microsoft word 1 bangladesh journal of bioethics 2011 vol 2 issue 1 page 4 4 ethical poems ¯’cwz bqv‡dm imgvb ¯’cwz bqv‡dm imgvb ¯’cwz bqv‡dm imgvb ¯’cwz bqv‡dm imgvb gvbbxq cöwzgš¿x weávb ges z_¨ i †hvmv‡hvm cöhyw³ gš¿yvjq evsjv‡`k mwpevjq, xvkv, বাংলােদশ (architect yeafesh osman, honorable state minister, ministry of science and information & communication technology, government of the people’s republic of bangladesh). ávb eo m¤ú` pp©vq †e‡o hvq b`xi †mªv‡zi gz ‡_‡g †m‡j g‡i hvq|| (knowledge is wealth, increases with practice; it dies like a stagnant river, if there is no practice.) nvw©iq¨vi mdiq¨vi wndg¨vbiqvi wzb wgj‡j nq werq gvbylb avmj zey bq‡j cy‡iv acpq| (hardware, software and human ware, constitutes triumph, but man is the central theme, otherwise all in vain.) kvb kikz †fvmwejvm hlb cöej uv‡b av`k© hvq gvwbe¨v‡m bxwz kei ’̄v‡b|| (too much luxury and comfort, replaces idealism by money, morality goes to the grave.) uvkvkwoi uvbuv cöej mwzuv zvi i‡ku fy‡jb e‡m me gnvrb kvd‡bi bvb c‡ku| (the attraction for money is as speedy as rocket, but all the money hoarders forget that there is not pocket in the coffin. dead body is wrapped by unstitch cloth.) microsoft word pdf 1 1 bangladesh journal of bioethics 2010; 1(2):1 editorial our global village is becoming terribly aggressive. the ongoing economic crisis, poverty, environmental pollution and the looming dangers of climate change threaten the progress towards millennium development goal. extreme materialism the immediate product of the technological advancement has created a tendency towards following an ‘aspire and achieve’ philosophy. unfortunately serviceoriented institutions are also turning into moneyproducing machine. bangladesh bioethics society wants to bring a gradual positive change of this unfavorable climate. this idea is prompted by aspiration of humanity. articles of the second issue of journal of bangladesh bioethics society depict an idealism of promotion and protection of human dignity and pursuit of peace and social justice. this journal contains plato’s notion of human nature and morality; relation of bio-ethics with agricultural and environmental ethics, ethical issues related to informed consent whether informed consent is a moral obligation, legal necessecity, patient’s rights and autonomy. we feel that medical establishment needs the discipline of systematic consumer input in order to function as an accountable and responsive health care system. the journal also covers ethical aspects of tissue banking in bangladesh which must follow the elimination of the trauma and morbidity of the patients. in order to build a just, sustainable and healthful society practice of bio-ethics is essential. the faculty of bioethics may be developed in a community through education, practice and research. article on animal research in diabetes and ethical consideration depicts that all scientific research involving the use of animals should begin with an ethical focus by examining the risk-benefit ratio. our collective pursuit for peace and justice will continue. peace is the necessary prerequisite for sustainable human development and for equitable access to resources and services. we must cultivate the spirit of optimism, a feeling of hope in the future that is to come. rowshan ara ph.d professor department of philosophy university of dhaka bangladesh bangladesh journal of bioethics 2010; 1(1):9 gender equity and economic empowerment: women and ethical/religious family law in bangladesh prof dr taslima monsoor, professor, dept. of law, dhaka university email: taslima_monsoor@hotmail.com women suffer the denial of land and property rights in bangladesh. they are severely restricted to acquire property although they have the ability. the core of the problem is that many women in bangladesh today are deprived of the rights granted by the ethical/religious and statutory family laws. prominently, women are deprived of their rights of inheritance, maintenance and dower. the study of gender and property rights under islamic and ethical law is a complicated one, which has been hardly explored; an attempt is however, made in this article. the constitution of bangladesh gives gender equality but the personal laws give gender equity, then how can the personal laws exist? first, article 149 states that all existing laws shall continue to have effect, second, the constitutional clause of sexual equality [under article 28(2)] only applies to the public sphere third, article 28(1) provides freedom of religion. finally, the directive principles of state policy, gives preference to islam as state religion. thus, the constitution itself protects religio-personal laws. the primacy given to custom has worked to the detriment of muslim women and a shift to ethical and religious sharia law of property and succession would be a positive step. in a legal project, it seems appropriate to conclude that a better-sensitised judiciary could empower and protect women from economic deprivation. 9 mailto:taslima_monsoor@hotmail.com bangladesh journal of bioethics 2010; 1(1):1 editorial twenty first century is a period of momentous transition in human civilization. the creative power of mankind is being gradually lost under the pressure of technology. people are facing a grave danger of the crystallization of human society into a mechanized social living without a moral ideal. now the highly materialistic world comes to place an exaggerated importance on the material things of life to the utter neglect of the moral and spiritual values. fundamental human values are ignored. a creative renaissance of human civilization needs reverence for life and love. only moral ideal cannot make men grow unless they are translated into practice. bio-ethics can pave the way to keep its ideal for the welfare of the mankind. the field of bioethics has addressed a broad swath of human inquiry, ranging from debates over the boundaries of life (e.g. abortion, euthanasia) to the allocation of scarce health care resources (e.g. organ donation, health care rationing), reproductive rights, recreational drug use, surrogacy, population control and many other issues with practical moral values. bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, philosophy, and theology. as philosophy in britain and elsewhere moved away from the influences of logical positivism and emotivism, the development theories of ethics and their application to practical problems gained in interest. the publication of principles of biomedical ethics by james f. childress and tom beauchamp —the first american textbook of bioethics—marked a transformative moment in the discipline. some bioethicists would narrow ethical evaluation only to the morality of medical treatments or technological innovations, and the timing of medical treatment of humans. others would broaden the scope of ethical evaluation to include the morality of all actions that might help or harm organisms capable of feeling fear and pain, and include within bioethics all such actions of a bear in relation to medicine and biology. the field contains individuals trained in philosophy such as peter singer of princeton university and daniel brock of harvard university, medically-trained clinicial ethicists such as mark siegler of the university of chicago and joseph fins of cornell university, lawyers such as jacob appel and wesley j. smith, political economists like francis fukuyama, and theologians including james childress. bio-ethics can enhance world peace through practical application of ethical theories. peace encompasses all aspects of social cohesion including equality, freedom and the rule of law. it is the necessary prerequisite for sustainable human development for equitable access to resources and services. all the articles of this journal cover the issues related to environment, energy, gender, which affect the lives of mankind. these articles were presented in the first unesco ethics education workshop in bangladesh held in dhaka on 17 and 18 march 2009. i like to express my thanks to the chairman of the editorial board prof. taslima mansoor, assistant editor prof. shamima parvin laskar and the members for their sincere cooperation. we hope our search for practical morality or ethics will continue. editor rowshan ara ph. d professor of philosophy, university of dhaka 1 http://en.wikipedia.org/wiki/abortion http://en.wikipedia.org/wiki/james_childress http://en.wikipedia.org/wiki/james_childress http://en.wikipedia.org/wiki/francis_fukuyama http://en.wikipedia.org/wiki/wesley_j._smith http://en.wikipedia.org/wiki/joseph_fins http://en.wikipedia.org/wiki/daniel_brock http://en.wikipedia.org/wiki/peter_singer http://en.wikipedia.org/wiki/technology http://en.wikipedia.org/wiki/tom_beauchamp http://en.wikipedia.org/wiki/james_f._childress http://en.wikipedia.org/wiki/theology http://en.wikipedia.org/wiki/philosophy http://en.wikipedia.org/wiki/law http://en.wikipedia.org/wiki/politics http://en.wikipedia.org/wiki/medicine http://en.wikipedia.org/wiki/biotechnology http://en.wikipedia.org/wiki/life_sciences http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/euthanasia bangladesh journal of bioethics 2010; 1(1):8 intellectual property rights prof shah mohammad keramat ali, senior consultant, department of epidemiology and biostatistics, bangladesh institute of diabetes endocrine and metabolism (birdem). email: keramatinfs@yahoo.com medical research done in collaboration with its host institutions is engaged in the direct active conduct of research in conjunction with hospitals. scientific research in the public interest and its objective with respect to intellectual property arising from its research activities is the dissemination of such property for public use on a nondiscriminatory basis. the host institution should adopt policies and procedures to govern the ownership, assignment, and dissemination of its intellectual property. its policies and procedures relating to institute intellectual property generally are set forth in this intellectual property policy (the policy). further policies and procedures relating to scientific research collaborations, materials transfer agreements, consulting, and other issues are set forth elsewhere and are not included in this policy. but this is practically not practiced in bangladesh. bioethics in biotechnology bangladesh perspective dr. r.h. sarker, department of botany, university of dhaka, dhaka 1000 email: rhsarker2000@yahoo.co.uk biotechnology consists of a gradient of technology, ranging from long established and widely used techniques of traditional biotechnology through to modern biotechnology based on the application of recombinant dna technology. the advent of genetically modified crops with pest and disease tolerance, efficient recombinant vaccines and waste-detoxifying bacteria has become a reality. application of biotechnology has lead to the improvement in lives of people from both developed and developing countries. the economic potential of biotechnology in agriculture, health, energy and environment is well recognized. on the other hand there also exists apprehension as modern biotechnology may pose certain risks to human health and environment. bangladesh is relatively new in the field of biotechnology research and development. many research institutes and universities in the country are currently involved in various plant and microbial biotechnological research. bangladesh is a signatory of cartagene protocol on biosafety to the convention on biological diversity. in recognition of the importance of ensuring the safe application of biotechnology bangladesh has developed biosafety guidelines as well as a biosafety framework. biotechnological research is being carried out following these biosafety guidelines. in these biosafety documents concerns of ethical issues related to biotechnology has been raised. however, bangladesh is yet to develop policies on bioethics related to biotechnology. moreover in general bioethical education is very limited in various phases of science education and research in bangladesh. 8 mailto:rhsarker2000@yahoo.co.uk mailto:keramatinfs@yahoo.com bangladesh journal of bioethics 2010; 1(1):8 intellectual property rights prof shah mohammad keramat ali, senior consultant, department of epidemiology and biostatistics, bangladesh institute of diabetes endocrine and metabolism (birdem). email: keramatinfs@yahoo.com medical research done in collaboration with its host institutions is engaged in the direct active conduct of research in conjunction with hospitals. scientific research in the public interest and its objective with respect to intellectual property arising from its research activities is the dissemination of such property for public use on a nondiscriminatory basis. the host institution should adopt policies and procedures to govern the ownership, assignment, and dissemination of its intellectual property. its policies and procedures relating to institute intellectual property generally are set forth in this intellectual property policy (the policy). further policies and procedures relating to scientific research collaborations, materials transfer agreements, consulting, and other issues are set forth elsewhere and are not included in this policy. but this is practically not practiced in bangladesh. bioethics in biotechnology bangladesh perspective dr. r.h. sarker, department of botany, university of dhaka, dhaka 1000 email: rhsarker2000@yahoo.co.uk biotechnology consists of a gradient of technology, ranging from long established and widely used techniques of traditional biotechnology through to modern biotechnology based on the application of recombinant dna technology. the advent of genetically modified crops with pest and disease tolerance, efficient recombinant vaccines and waste-detoxifying bacteria has become a reality. application of biotechnology has lead to the improvement in lives of people from both developed and developing countries. the economic potential of biotechnology in agriculture, health, energy and environment is well recognized. on the other hand there also exists apprehension as modern biotechnology may pose certain risks to human health and environment. bangladesh is relatively new in the field of biotechnology research and development. many research institutes and universities in the country are currently involved in various plant and microbial biotechnological research. bangladesh is a signatory of cartagene protocol on biosafety to the convention on biological diversity. in recognition of the importance of ensuring the safe application of biotechnology bangladesh has developed biosafety guidelines as well as a biosafety framework. biotechnological research is being carried out following these biosafety guidelines. in these biosafety documents concerns of ethical issues related to biotechnology has been raised. however, bangladesh is yet to develop policies on bioethics related to biotechnology. moreover in general bioethical education is very limited in various phases of science education and research in bangladesh. 8 mailto:rhsarker2000@yahoo.co.uk mailto:keramatinfs@yahoo.com bangladesh journal of bioethics 2011 vol 2 issue 1 page 5-6 5 unesco core curriculum and teaching resources darryl macer phd regional advisor, regional unit for social and human science in asia and the pacific, bangkok, thailand email: d.macer@unesco.org the task of a teacher includes empowering their student to develop their maturity as individuals as well as being able to cooperative members of changing societies. student need to be prepared so they are able to apply knowledge to make good decisions during their life. basic to fulfilling many tasks, teachers themselves need to be in the right situation. how can we train teachers and sustain their motivation to take upon this sacred vocation? how can create communities that tolerate these goals? this paper will look at the roles and challenges for teachers and institutions, with some comparisons between countries and trends. there will be examples of some training strategies and methods being used in the multidisciplinary area of bioethics. bioethics is looking at ethical issue relating to life science and technology, or could even be called the love of life. ethics is a concept balancing benefits and risks of choice and decisions. the underlying heritage of ethics can be seen in all cultures, religions, and in ancient writings around the world. the turbulent times of today have challenged some of the traditional structures in the relationships between human beings within their society, with nature and god. how can we empower teachers to make a special contribution in the wider context of constructing a mature society. mature means a person, or a society that can balance the benefits and risk of alternative options, and make well considered decisions, and talk about it. there are at least four strategies that thinking person need to cope with the turbulent times. 1. descriptive ethics to enable people to accurately assess the situation. people need to understand the way they and other people view life, their moral interactions and responsibilities with other in their life. 2. prescriptive ethics is to tell others what is ethically good and bad, or what principles are the most important in making such decisions. it may also be to say something or someone has rights, and others have duties to them. it is a basic for sound policy making, and law, and empowering people to make decision in their life. 3. interactive ethics is decision and debate between people, groups within society, and communities. such dialogue skills are necessary to live harmoniously with others. the tensions in turbulent times are even more stretched yet we must continue to teach people to get along, and empower teachers to interact across perceived boundaries of discipline, culture, religion and ideology. 4. practicality is essential if teachers are expected to continue teaching, and students will continue their interest in the matter. this paper will gives some examples of teaching critical thinking through both environmental and medical ethics issues. critical thinking is essential for empowering person to cope with changing times. how do we promote the creation of ideas, and individuality in an era of bangladesh journal of bioethics 2011 vol 2 issue 1 page 5-6 6 globalization? the rapid progress of technology has led to challenges in the way that we live. the systems and the patterns that are seen in the relationships between patients, families, health professionals, and the society in general changed. appropriate education requires teachers to apply methods and resources appropriately and to develop the decision making ability in students, teachers and policy makers so our society can evolve with the demands of the times. the unesco bioethics core curriculum sets out to introduce the bioethical principles of the universal declaration on bioethics and human rights to university students. bioethics teaching has not introduced in many universities in many countries. the unesco core curriculum can provide an incentive to start introducing such teaching. its contents are based on the principles adopted in unesco. it therefore does not impose model or specific view of bioethics, but articulate ethical principles that are shared by scientific experts, policymakers and health professionals from various countries with different cultural, historical and religious backgrounds. however, the core curriculum should not be treated as a comprehensive curriculum in bioethics. it is recognized that the content of the core curriculum does not necessarily cover all aspects of bioethics. traditional issues that have not been included could be incorporated as examples that are pertinent to one or several of the declaration’s principles within the curriculum’s framework. we are working with institutions that have varying levels of experience with bioethics education, some of them at the early stage to introduce new bioethics courses, while others, are reviewing their curricula with a view to enriching it from cultural perspectives, taking into account the unesco bioethics core curriculum. also we are gathering feedback from bioethics education efforts, and examining existing bioethics curriculum developed at national and international level, so to decide either to follow transdisciplinary curricula across medical, environmental and science ethics or independent curricula specific for each discipline. bangladesh journal of bioethics 2010; 1(1):4 review of bioethics education in bangladesh prof. shamima parvin lasker, professor of anatomy, city dental college, dhaka. arif hossain, phd fellow, washington university, usa email: splasker04@yahoo.com a survey has been carried out from 1st november to 30th december 2008 in different institutes of dhaka city to evaluate the current status of bioethics education in science in bangladesh under the auspices of united nations educational, scientific and cultural organization (unesco), dhaka. people face dilemma with advancing science and technology along with enormous health and environmental problems. bioethics may make bridge between science, technology, social, cultural and spiritual values. there is huge gap in teaching of ethics in undergraduate level. moreover, demand for health research in this country is constantly increasing and international collaboration is growing rapidly in bangladesh. recently each faculty try to establish own ethical review committee. although there are a few training programmes on research ethics has been conducted but these are still not enough to meet the growing need for research and an ethical review process. increasing awareness, sensitivity, research and practice of bioethics in various disciplines of medical science, science and social sciences are required. ethical problem can not be resolved if not first noticeable. thus bioethics education / activity is essential in bangladesh. governments can create a national bioethics commissions by which they can bridge on issues of both scientific and moral complexity in health, science, environment and social science. environmental pollution dr khandaker rashedul haque, director general, academy for planning & development, ministry of planning email: rashedul.haque@yahoo.com protection of environment through enforcement of environmental law in bangladesh is a real challenge; especially for those who are mandated to do it. this is really a defining moment for government, whose priority for development is driven by decisions to balance pressure groups and environmental activists, as well as for the officials, who are very often in between two fires because of baffling instructions from the government. it requires high amount of moral courage for the government official to be ready to take challenge to fight for the environment, even sometimes risking career. along with that is the temptation in more than one form that comes through tantalizingly. the businessmen whose industries and plants need to be run in compliance with the obligation they need to fulfill do make commitment only to be broken in the process making the life of the officials all the more difficult and challenging, especially these people have high clouts in the society to buy decision in their favour. 4 mailto:rashedul.haque@yahoo.com mailto:splasker04@yahoo.com bangladesh journal of bioethics 2010; 1(1):5 however, it’s not only enforcement; there need to be strong collaboration between the officials enforcing legal provisions and the business community as well as other stakeholders who are ever vigilant to see sustainable development. the element of reciprocity and complementarity needs to be in place towards ensuring appropriate environment for sustainable development. above all, it’s the leadership of the officials who make the difference in the enforcement of environmental law in the country by sheer courage and steadfastness in decision-making and implementation. ethics of energy technologies prof. darryl macer, ph.d., regional adviser for social and human sciences in asia and pacific, rushsap, unesco bangkok email: d.macer@unesco.org the regional unit in social and human sciences in asia and the pacific (rushsap) at unesco bangkok launched the ethics of energy technologies in asia and the pacific project in september 2007. the launch conference was held also with the cooperation of the ministry of energy and ministry of science and technology of thailand. a full report of that conference is available on the web, as well as the abstracts of the three day meeting, attended by a hundred people from about 20 countries from many sectors and backgrounds. since then there have been a number of subsequent conferences and working group sessions organized in different countries, and a summary of these will be presented. following on from that conference fourteen working groups have been formed on the following topics (more details appear in the project introduction document) [http://www.unescobkk.org/index.php?id=energyethics]: • universalism and environmental values • ethical worldviews of nature • visions and hopes of the future • representation and who decides • community engagement • stakeholder responsibilities • energy equity and human security • cost-benefit analysis and economic constructions • adoption & development of energy technologies (state of the art review) • ethical frameworks for research agendas and policy • educational frameworks for environmental ethics • nuclear dialogues • energy flow, environment, and ethical implications of meat production • water ethics and water resource management the aim of the working groups is to develop dialogue around these particular issues with a focus on environmental ethics and human security. each group will produce a report with policy options that can be used by policy makers, philosophers, scientists and researchers to consider the ethical dimensions of energy policy. all can follow the report development through the individual websites. the reports will also feed into the comest considerations on the ethics of climate change. there are approximately 200 persons who are currently members of the working groups, from young and old, many disciplines, professions and country. this overview will introduce some of the working group results, and progress. more members are invited to join. 5 http://www.unescobkk.org/index.php?id=energyethics arif hossain,bangladesh bioethics society, religious denominations vs ethical models in beginning of life bangladesh journal of bioethics 2012; 3(2):31-34 31 comment on editorial religious denominations vs ethical models in the beginning of life arif hossain, vice president bangladesh bioethics society. email: ykhsmh@yahoo.com abstract: an article was published at editorial of bjb in 2012 vol. 3 issue 1, page 3 entitled” challenge of 21st century to integrate the reproductive technologies concerning the beginning of human life” written by associate editor of bjb. i would like to comment on article that the religions those have holy book from god have almost the same notion regarding the beginning of life. they are involved with biblical account of the creation of human and prefixed notion on procreation and families. from a bioethical point of view, religions seem to favor “deontological” models. it may hinder the proper ethical incorporation of reproductive technologies. stewardship or divine providence leads to a fixed creational view, pessimist as basic attitude and dependence. on the other hand, other distinguished ethical models (consequentialism or utilitarianism) are “creativity”, e.g. models of responsibility (personalism), models of caring (care ethics) etc. these models are anthropo-centric, optimistic, evolving creation (created co-creator) and have open future. therefore, it is crucial to understand how 21st century will integrate the new technologies concerning the beginning of human life. discussion: all the religions have almost the same notion on beginning of life. according to hinduism human animating spirit is present from fertilization. so the embryo is given the status of person throughout pregnancy. hindu concern with moral attitudes toward research on the preembryo is exploitation of the vulnerable. islamic code of medical ethics gives the moral status of the human embryo from the current fixations of movement (14th day after fertilization). according to islamic jurisprudence (shari’a law) procreation and parenting relationships are lawful between valid spouses because of designated role-responsibilities. use of third party gametes for reproduction violates precepts concerning legitimacy, lineage, and inheritance. roman catholic bans all types of reproductive technology. in school of protestant accept the expansion of human freedoms and control over human reproduction. mailto:ykhsmh@yahoo.com bangladesh journal of bioethics 2012; 3(2):31-34 32 the themes of theological bioethics are “deontological” models. they are involved with biblical account of the creation of humans and prefixed notion on procreation and families. they consider human dominion over nature as playing god. sometimes, it violates the human dignity (contrary to declaration on human rights and biomedicine). in addition, there is a challenge of pluralism for religious denominations. the basic respect is that everyone’s religious belief. stewardship or divine providence leads to a fixed creational view, theo-centric, pessimist as basic attitude and dependence. it may hinder the proper ethical incorporation of reproductive technologies. on the other hand, other distinguished ethical models e.g. consequentialism or utilitarianism (actions are right or wrong according to the balance of their good and bad consequences), models of responsibility (personalism-act is good if the gain aimed at outweighs the damage incurred), models of caring (care ethics-relationship-based accounts: caring in these accounts refers to care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship) etc are “creative” model. these models are anthropocentric, optimistic, evolving creation (created co-creator) and have open future. some examples are given below. in vitro fertilisation (ivf) or test tube baby is a process by which an egg is fertilized by sperm outside the body and latter transferred to the womb of mother for further development of baby. since the fallopian tube is the only place in the female body where normal fertilization can occur, if both tubes become blocked, pregnancy becomes difficult or impossible. ivf is a major treatment for infertility when other methods of assisted reproductive technology have failed. ivf is designed for the treatment of severe tubal disease, infections, inflammations, endometriosis and other conditions may cause irreparable damage to the fallopian tubes. ivf allows for successful fertilization outside the fallopian tube, thus bypassing the problem area. another common indication for ivf is low sperm counts. in recent years a process has been developed where a single sperm can be injected into an egg to cause fertilization in the laboratory, a procedure called intracytoplasmic sperm injection (icsi). surrogacy: if the embryo is transferred to the womb of other lady is called surrogacy. women, with congenital absence of the uterus or who have had a hysterectomy for carcinoma or haemorrhage, but who all still have functioning ovaries or who have suffered repeated miscarriages and for whom the chance of ever carrying a baby to term is remote, women who repeatedly fail to implant normal healthy embryo in her uterus and who have certain medical condition, such as cancer, heart or renal disease which might threaten the life of a woman are considered to be suitable candidates for this type of surrogacy. when a woman/man is incapable of producing ova/sperm as a result of disease e.g. cancer, injury, congenital absent of gamet or normal aging, a donor ovum/sperm may be fertilized in vitro and implanted in her uterus and she bangladesh journal of bioethics 2012; 3(2):31-34 33 then gestates the baby to term. the couple may choose this type of surrogacy with the hope that the kid will be at least half-related to them. cloning is the process of producing similar populations of genetically identical individuals that occurs in nature. therapeutic cloning is achieved by creating embryonic stem cells in the hopes of treating diseases such as diabetes and alzheimer’s, cancer, cosmetic surgery. dolly, a finndorset ewe, was the first mammal to have been successfully cloned from an adult cell. if the cloned human is born, beginning of life human will be redefined. pre-implantation genetic diagnosis (pgd) is essentially who have been confronted with serious genetic risks in their family and want to prevent further problems in the future. it offers concrete problem solving for couples confronted with serious risks of genetic abnormalities for their children. from above mentioned examples, it is understandable that incorporation of these reproductive technology needs ethical models e.g. utilitarianism or personalism. conclusion: a careful balancing of values and disvalues in concrete clinical cases can help to integrate ethically the possibilities of ivf, surrogacy, cloning and pgd in such a way that this integration promotes the humanly possible. the linkage with ethical models is in many cases more important than the linkage with religious denominations. so, it is crucial to understand how 21st century will integrate the new technologies concerning the beginning of life. moral sensitivities are essential concerning a medical reality. references: brinsden rp. gestational surrogacy. human reproduction update 2003. 9;5:483-91. beauchamp ti. & childress jf. principles of biomedical ethics. fourth edition, oxford, oxford university press, 1994. böckle f. fundamental moral theology. dublin, gill and macmillan, 1980. cloning. http://en.wikipedia.org/wiki/cloning (access on 22 august 2012) human cloning. http://en.wikipedia.org/wiki/human_cloning (access on 22 august 2012) http://en.wikipedia.org/wiki/cloning http://en.wikipedia.org/wiki/human_cloning bangladesh journal of bioethics 2012; 3(2):31-34 34 in vitro fertilization. http://en.wikipedia.org/wiki/in_vitro_fertilisation (access on 22 august 2012) lasker s. challenge of 21st century to integrate the reproductive technologies concerning the beginning of human life. bjb 2012; 3 (1):3. schotsmans p. responsible involvement and conscientious freedom: a relational approach to medical ethics' in j. selling (ed.), personalist morals. leuven, university press, 1988, p. 167184. schotsmans p. personalism in medical ethics. ethical perspectives 6 (1999)1, p. 10-20 conflict of interest: no conflict of interest http://en.wikipedia.org/wiki/in_vitro_fertilisation intellectual property and developing country bangladesh journal of bioethics 2010; 1(3):43-46 intellectual property rights and developing countries arif hossain1 shamima parvin lasker2 1. vice president, bangladesh bioethics society, bangladesh. email: ykhsmh@yahoo.com 2. professor & head, department of anatomy, city dental college, dhaka, bangladesh. email: splasker04@yahoo.com abstract: knowledge is the multidimensional outcome of human intellect. intellectual property rights system (iprs) is considered from economic and legal aspect as the ownership rights for the excessive use of innovation and creative work. iprs are measured to encourage innovation, promote investment in s&t and make the technologies for public benefit. but history shows that from the time of industrial revolution in europe and during twentieth century in the north america and japan, iprs contribute to the s&t driven economic growth. therefore, there is a fair and consistent relationship between strength of iprs and per capital income. a recent study of world bank suggested that the major beneficiaries of iprs in terms of enhanced value of patents are the developed countries with usa along made an annual gain of us $ 20 billion while developing country face an annual loss of 7.5 billion on royalties and license fees. moreover, for the developing county, while indigenous technological capability is a significant determinant to economic growth and poverty reduction, no exact relationship has been established between the iprs and economic growth. developed countries and business corporations who are benefited directly from iprs regime insist on implementation of strong iprs for all countries. need for strong iprs for developing and least developed countries are discussed. strong iprs for all countries whether it leads to transfer of wealth from poor countries to rich countries to further widen the economic divide is a major ethical concern. introduction: knowledge is the multidimensional outcome of human intellect. intellectual property rights (iprs) is the legal protection over scientific and technological knowledge through the patents, copy writes and other novel legal means. iprs are considered to encourage innovation, promote investment in science and technology (s&t) and make the technologies work for public benefit. in economic growth and development the power of the knowledge has come into sharp focus since the days of industrial revolution and more recently with the advance in science & technology. iprs usually have seen from economic and legal perspective as the ownership rights for the excessive use of innovation and creative work. science and technology activity is the engine to economic development in the contemporary world. according to the classical theory on s&t and iprs, s&t is the machine and iprs is the fuel. history shows that from the time of industrial revolution in europe and during twentieth century in the north america and japan shows that iprs contribute to the science and research (s&r) driven economic growth. 43 mailto:splasker04@yahoo.com mailto:ykhsmh@yahoo.com bangladesh journal of bioethics 2010; 1(3):43-46 however, in case of developing counties indigenous technological capability is a critical determinant to economic growth and poverty reduction, but no precise relationship has been established between the iprs and economic growth. conflicts about iprs: the present conflict of iprs is sharpened by the increase presence of private sector in s&t and its rush for establishing exclusive rigid, legal ownership on the knowledge intensive modern technological service in order to leverage such ownership for exclusive trade and other strategic advantages. developed countries and business corporations who may benefited directly from iprs regime insist on strong iprs for all counties in the globalization process under trips (trade related aspect of intellectual property rights), established in 1994 that wto members countries have to abide by within specific deadlines. as many of the ip protected technologies are owned by the private sector in the developed countries, they are the major beneficiaries of trips mediated strong patent regime. when most of the innovation (97%) in the hand of developed countries. only 3% of global patents are owned by developing countries of the 93% patents on biotechnology in usa, european union and japan and rest 7% from other countries. hence the criteria for measuring the social benefit of iprs are deferent. a recent world bank analysis suggests that the major beneficiary of trips on term of enhanced value of patents are the developed countries with usa alone expected to make an annual gain of us$ 19 billion while developing countries face loss of us$ 7.5 billion on royalties and license fees. strong iprs and developing countries: strong and uniform iprs regime prescribe under the “one size fits all “principal may essentially hinder development in developing countries. this particulate form of iprs would exploit the developing countries by exorbitant price being levied for licensing and consequent social losses in economic welfare. therefore the major ethical issues are that strong iprs led to transfer of wealth from the poor to the rich which widen the economic divide. developing countries participate in global intellectual property systems as 'second comers' in a world that has been shaped by the 'first comers'. they are now being urged to adopt a complex set of rules more suited to advanced economy is a major ethical concern. developing countries are the late comer in the world economy are also disadvantaged bearing disappropriate share of cost with respect to the benefit is an another concern. strong iprs may facilitate technology transfer under licensing it may not promote investment and growth of indigenous s&t. it rather chokes the domestic r&d in developing counties. the deficiency of the human and technical capacity to innovate also irrelevant to strong iprs in stimulating r&d in many developing country. 44 bangladesh journal of bioethics 2010; 1(3):43-46 protection is not necessarily better. developing countries should not be encouraged or coerced into adopting stronger ip rights without regards to the impact this has on their development and poor people. they should be allowed to adopt appropriate rights regimes, not necessarily the most protective ones." iprs, as a whole is less advantageous for developing than for developed countries in many areas of importance to development, such as health, agriculture, education and information technologies. the system increases the costs of access to many products and technologies that developing countries need. weak ip and developing countries: before implementation of trips, in 1995 it was the strength of iprs which determines the growth of the indigenous s&t and economy in the developing countries. without strong ip regime many countries has developed economy. for example without strong ip protections as well as no protection for pharmaceutical products, south korea achieved economic growth which led to their economic transformation from developing to developed country. similarly switzerland , holland and japan benefited from their ability to technology catch up without patent law for many years after founding the paris convention. japan introduced the product patent only in 1976. in india a weak ip protection contributed to rapid and significant growth of india’s pharmaceutical industries particularly a low cost generic medicine and intermediates. weak iprs existed in some east asian and latin american countries also encourage fdi (fireign direct investment). indications are that the economic development in developing counties are not essentially require strong ip protection and most of these countries tend to apply a less stringent iprs regime until their per capital income is by and large above the uds$ 8000. conclusion: the right to human and economic development, the right of access to food, medical care, health and well being and right to social security shall stand denied or limited in a global iprs regime under trips and it violates the universal declaration of human rights (udth) as well. there is also need for more intense debate and discussion on the ethical aspect of the trips. references: 1. ethics of information communication technology in ethics in asia pacific , unesco bankok, 2004. 2. who 2002. genomics and worldhealth organization. www3.who.int/whois/genomics/genomics_report.cfm 45 bangladesh journal of bioethics 2010; 1(3):43-46 . 3. kumar n 2002 intellectual property rights, technology and economic development; experience in asian countries. commission on intellectual property rights background paper. london. 4. maskis k 2000. intellectual property rights and global economy. institute for international economic, washington dc. 5. world bank 2002. global economic prospects and the developing countries 2002. www.worldbank.org/prospactys/gep2002 6. world bank 2002. world development indicators 2001 www.worldbank.org/data/wdi2001/ 7. roderick rl 1995. the libertarian case against intellectual property rights. liberal national foundation. http://www.libertariannation.org/a/f31l1.html 8. alan rp 2007. information technology intellectual property ethics; issues and analysis. issue in information system, 8(2). 9. wipo . intellectual property and bioethics-an overview. 10. intellectual property rights –ii. iprs and economic development. 11. strong domestic iprs may spur domestic innovative activity, and thus affect ... patented (from an ethical point of view—these ethical issues are ... www.ww.uni-magdeburg.de/bwl2/lehre/wto/wto-l6 _2004 12.whyte wolf 2010. is intellectual property itself unethical? http://www.iacis.org/iis/2007_iis/pdfs/peslak.pdf 46 http://www.iacis.org/iis/2007_iis/pdfs/peslak.pdf http://www.ww.uni-magdeburg.de/bwl2/lehre/wto/wto-l6%20_2004 http://www.libertariannation.org/a/f31l1.html packiaraj asirvatham ma bangladesh journal of bioethics 2012; 3(2):27-30 27 your consent and my decision – a case study packiaraj asirvatham an independent researcher india. email: packiaraj.a@gmail.com case: raju was a 30 year old male from tirunelveli, india. he was running a small business enterprise in his town. he married latha in may 1990. they lead a happy and peaceful life. in december 1990 he had a mild stroke. immediately he was taken to the hospital and his family doctor suggested further investigation. so raju underwent a scan and the primary result was not good. he was diagnosed with a tumour in his brain. a grade 2 glioma developed in his brain and started to spread. after ct scan, he was asked to go for an mri scan to exactly locate the tumour and its spread and the doctor found out that the tumour has spread a bit to the nearby part, that is, cerebrum to cerebellum. since it is type two tumour he decided to remove the tumour by surgery. however, its not going to be easy. the doctor invited the siblings and parents of raju to decide on the treatment. he presented the treatment options to the family members. first option is to remove the tumour completely but the possibility of brain damage during surgery is 90% which may lead him to coma/paralysis/handicap. the second option is to remove 90% of the tumour and proceed with radiation therapy. in this way though he is not going to remove 100% of the tumour he will have a safer surgery and after the surgery a normal life span of 10 more years without any problems at least. in this context, the doctor asked the parents about their opinion and they opted for the second option of partial cure and safer surgery. after hearing their opinion the doctor proceeded with first option. personally he took this case as a challenge and performed the surgery. the result was surprisingly positive, raju was cured completely. with the successful outcome, the doctor proclaimed himself as a “miracle surgeon” and the family too are happy. case analysis problem: i have analysed this case by using the nijmegen method of case deliberation systematically. as a starting point, the moral problem can be stated by the following question. is the act of doctor ethically justifiable in pursuing his own line of option in curing the patient? facts: raju is diagnosed with cancer, a life threatening disease. though the diagnosis came as a shocking news for raju and his family, they are optimistic in saving raju's life since it’s an early stage of cancer. after regular scan the tumour is located and the surgeon observed and decided about the possibility of the treatment. there are two possible ways of treatments: first is to remove mailto:packiaraj.a@gmail.com bangladesh journal of bioethics 2012; 3(2):27-30 28 the tumour completely with the possibility of brain damage during surgery being 90% and this may lead to coma/paralysis/handicap. second option is removing 90% of the tumour and proceeding with radiation. in this way though the surgeon is not going to remove 100% of the tumour raju will have a safer surgery and after the surgery a normal life span of 10 more years without any problems at least. so the first option has 90% risk and 10% complete cure whereas the second option has less risk as well as moderate cure which will give at least 10 more years of life span to raju. so it is very important to decide whether the doctor and the patient are going to take risk or play safe. raju and his family members are so concerned about the welfare of raju where doctor is so concerned about his duty of curing raju to a maximum. however, since raju is relatively young, recently married and the breadwinner of his family the whole issue of his surgery has multiple consequences. so raju's came back with the first option where there is less risk as well as less harm to during surgery. the doctor is an experienced surgeon; he knows the social background of raju and his family as well as the condition of raju's disease. however, he goes with the second option where the risk is more as well as the cure is more. in the indian context, paternalistic approach of doctor is inevitable. basically doctors discuss with the family and the patients, however, predominantly they decide. in this case, though raju and his family opted for the safer option the doctor went on with second option which is completely against the wish of the patient. the whole medical system is led by doctors where his healthcare team members and nurses have no say. the doctor clearly understands the case of raju and realises the needs of family but he took a calculated risk to save raju’s life, but at what cost? assessment: raju is a young person and recently married who is at the peak of his life but cancer shatters the hope of raju. here, the doctor is the great hope of raju and his expertise is remarkable. the complicated location of the tumour places a vital role and it increases the risk of surgery. if raju develops any handicap/coma because of surgery then that is an ultimate loss to his family as well as for him. in the meantime, the doctor approaches the case in a more optimistic manner and he realised the risks as well. in this context, who decides what is good and what is not good for patient? the doctor or the family (raju)? the doctor knows the condition of the patient and the informed choices to his family however; he takes his own decision to save raju's life. he is an expert in surgery however the perception of raju's family and the doctor is differed consequently the doctor decided against the interest of the patient; however he is with good motive. the autonomy of the patient is violated though he was informed about the various choices but his consent was not been executed. another argument is that the instrumentalisation of the patient. doctor would have liked to develop himself and his knowledge on surgery by doing more risky surgery where it is inevitable. meantime, he could have thought of saving raju's life perfectly since he is full of life. but the family of raju is worrying much about the consequences. for them the bangladesh journal of bioethics 2012; 3(2):27-30 29 safety of raju is more important than cure whereas for doctor cure is more important with safety. on the other hand, if anything goes wrong with surgery the doctor is not going to be held responsible as well as he is not going to suffer like raju and his family. although, the whole issue is centred around raju, however he does not have any authority over the doctor as well as his family. when a person is affected by a disease he automatically loses his social authority to his family members/caretakers consequently his autonomy is a threat. though the autonomy of the person is more important it is hard to prove that a patient is really exercising his autonomy when he is making crucial decisions at the hospital context in india. in addition the patient doctor relationship is very hierarchical in india where absolutely the doctor decides what he thinks is right for a patient along with patient and his family members some extent. this is because medical fraternity predominantly think that many of the lay people lack medical knowledge and on the other hand people also think that the doctor is more wise and knowledgeable so they can make better decision than patient. decision making: this incident took place in 1990. the doctor treated raju with his own decision and took a calculated risk and remarkably the surgery went well. now raju is surviving with two children and his wife without any problem. he is completely cured. his family has deep gratitude towards the doctor. in this context, can we justify the act of the doctor? at least he could have described his decision to the family of raju and would have undertaken the surgery. the conflict of interest between patient and doctor is always at crossroads. there is no consensus all the time. however, people believe more in doctor’s decision than their own. they strongly believe that doctors decision would be alright in medical context and they strongly believe that no doctor will do harm to their patient. obviously, the question of who decides is at stake? is it the patient, the family of the patient or the doctor? here it is the doctor who decides. the paternalistic approach of doctors is very much part of indian health care system which often surpasses the autonomy of the patient. in the meantime with regard to beneficence and non-maleficence the doctor is abiding with ethical fibre. because of the doctors treatment the patient is cured and the family also benefited by the service of the doctor and he did not harm the patient though he put the patient under risk. in addition, since it’s a private hospital he provided a maximum best service for what he is paid. on the whole he abode with the ethical practice on ground however, it is very hard to understand why he acted against the interest of the patient and his family? he could have understood that the family is very much worried about the possibility of bad consequences and analysed the possibility of complete cure and the maximum risk. ultimately, the real wish of the patient is cure. to be more specific, with regard to the surgery the patient wished a safer surgery. it is a normal precautionary step . the doctor would have focused much about the ultimate wish of cure then subsidiary wish of safer surgery. again the responsibility of the doctor always pushes him to proactively engage in medical practice. it is bangladesh journal of bioethics 2012; 3(2):27-30 30 always very evident that many a times doctors proactively save life of a patient where the patient himself/herself has different opinion (for example a failed attempted suicide persons wish is to die but once he is taken to hospital and consequently his/her life is saved, which is completely against the interest of the patient.) to conclude, the doctor’s act of saving the raju's life from cancer is respectable and also he followed the necessary procedures of informed consent however, he treated the patient in his own way and saved his life. can autonomy be violated if it is beneficent to the patient? when we weigh the case in the light of all four parameters of autonomy, beneficence, non-maleficence and justice we can argued that the doctor respected all other norms, however, he is proactively decided to take calculated risk which led to a complete cure. however since the patient is autonomous his consent matters a lot however his ultimate wish is cure. since he is cured completely it can be ethically justifiable because the doctor followed another three important parameters of beneficence, non-maleficence and justice along with autonomy of the patient. the doctor might have focused more on the real wish of the patient, that is, to be cured at any cost! so on the whole contexts and consequences ultimately decide than autonomy of a person or the authority of a doctor in indian medical contexts though everything is interlinked! bangladesh journal of bioethics 2010; 1(1):6 ethical aspects of sharing international river water: the case of teesta river md. fakrul islam, ph.d., professor and chairman, department of social work, university of rajshahi rajshahi, bangladesh wardatul akmam, ph.d., professor, department of sociology, university of rajshahi, bangladesh email: hiraharati@yahoo.com all riparian states have the right to use international river water. this right is equally recognized for all riparian states on the basis of ethical principles and laws on international water sharing. however, sharing of river water has become one of the issues of conflict between neighboring states. various claims and counter claims are heard of and in order to resolve these issues many cooperative bilateral treaties have also been signed. but politically induced treaties that neither include provisions for economic benefits nor follow ethical principles on humanitarian grounds of the riparian states are not likely sustain for long. continuity of such treaties is indispensable for the sustenance and development of the riparian states and ethical principles and humanitarian grounds should be the basis for these treaties. nowadays, it is observed that states situated at the upstream control the water flow of rivers for their own benefits without considering its consequences on the downstream state. as a result inhabitants of the downstream countries suffer untold miseries. nevertheless, there are some good examples of international water sharing. in this paper, i discuss these examples along with the case of sharing of the teesta river water between india and bangladesh. some policy proposals are also made in this regard. the paper emphasizes the necessity of upholding morality and ethical principles in formulating and implementing policies regarding sharing of international river water. riparian states must cooperate and be sympathetic for the cause of one another. ethics and integrity in public service in bangladesh: institutional and comprehensive approach iftekharuzzaman, executive director, transparency international bangladesh email: email: edtib@ti-bangladesh.org this paper is an attempt to examine the challenges to prevent erosion of ethics and integrity in public service in bangladesh. it first presents an overview of corruption as a development and governance challenge. we then identify the entry points of erosion of integrity which account for the depth and breadth of corruption in public service. in the next section the paper goes on to examine the prospect of preventing erosion of integrity and ethics, and propose a few tools and processes. finally the paper proposes an institutional and comprehensive approach without which ethics and integrity in public service will be hard to promote and institutionalize. the main theme of the paper is that corruption exists everywhere in the world; it also involves every sector and level where there is scope of abuse of power. the public sector tends to be exposed to erosion of ethics because of institutional and individual factors. when depth and breadth of corruption are associated by a growing culture of impunity and erosion of values and ethics, corruption threatens to become a way of life. policies, decisions and actions of public interest at national level are taken in private interest, while at the local level citizens' access to basic rights and entitlement become contingent upon the capacity to make unauthorized payments. the issue of ethics and integrity in public service is crucial to addressing corruption. whatever well-meaning may be reforms in other sectors, these cannot bear fruits nor can any of those be sustained without establishing that appointments, promotions, postings and transfers in public service are based on performance and merit and not on 6 mailto:edtib@ti-bangladesh.org mailto:hiraharati@yahoo.com bangladesh journal of bioethics 2012; 3(1):3 3 editorial challenge of 21st century to integrate the reproductive technologies concerning the beginning of human life religion is significantly important to understand how the 21st century will integrate the new reproductive technologies concerning the beginning of human life. as religious interpretation of “creation” has a strong impact on society, therefore, the influence of religion may limit the proper ethical incorporation of reproductive technologies. as for example, according to hinduism the “self” (atman) is part of the creative force (brahman) and life energy residing in all creation. a person cannot “play god”, because in an ultimate sense of the “self” is god. hindu thinks human animating spirit is present from the fertilization. so the embryo is given the status of personhood throughout the pregnancy. therefore, hindu thought is concerned with moral attitudes toward research on the pre-embryo is exploitation of the vulnerable. on the other hand, islamic code of medical ethics gives the moral status of the human embryo from the current fixations of heart beat (14th day after fertilization). majority scholars say embryo as human at the end of the fourth month or around 120 days when self movement of embryo is established. it is an important consideration in discussions regarding termination of pregnancy, chorionic villous biopsy (in first trimester) and prenatal screening. further, all muslim authorities agree that termination of pregnancy is justified if the continuation of pregnancy places a mother’s life in danger. termination for any other reason is strongly and consistently discouraged, particularly after ensoulment. however, it seems that the use of third party reproduction in islam is problematic. according to islamic jurisprudence (shari’a law) procreative and parenting relationships are lawful between valid spouses because of designated role-responsibilities, legitimacy, lineage, possible incest and inheritance. roman catholic bans all types of reproductive technologies. even if among catholic believers there is a wide variety of attitude and ideas about it, showing a complex reality more or less close to the vatican's teachings. in school of protestant accept the expansion of human freedoms but control over human reproduction (joseph fletcher). paul ramsey thinks risk for compromising humanity and basic concepts of human procreation. the anglican church is less rigid in its views and has not condemned the practice of surrogacy. different religions have different notions regarding the beginning of life. it may limit the access of benefits of the technology. so it is crucially important for the researchers to incorporate religion in such a way that all the people of globe can get benefit from the new reproductive technology. shamima parvin lasker professor and head of anatomy, city dental college, bangladesh associate editor bangladesh journal of bioethics issues of research ethics and clinical ethics in developing world, possible solution: a way forward bangladesh journal of bioethics 2012; 3(3):12-15 12 issues of research ethics and clinical ethics in developing world, possible solution: a way forward muhammad waseem khan 1 , imrana niaz sultan 2 , afrasiab khan 3 muhammad bilal khan 4 department of biotechnology & informatics, faculty of life sciences & informatics, balochistan university of information technology engineering & management sciences (buitems), quetta balochistan, pakistan. email: mwaseem.tareen@yahoo.com abstract: research plays a pivotal role in the progress of inventions in medicines and medical technology. it is noticed that researchers from developing world or multinational companies are interested to conduct their research studies in developing countries, in doing so sometimes it is noticed that rather benefiting the participants it causes significant harm to the research study participants of developing countries. ethical lapses in research can significantly harm human subjects. in research ethics the basic aim of ethics is distinguishing between right and wrong, to recognize the wrong doings and try to avoid them from harming research subjects in any research study whether that is done in developing country or developed country. it must follow the principle of non malefiecence or do no harm. introduction: there are many ethical issues regarding research ethics in developing countries that need to be addressed. the issue of study design, independent ethical review, valid inform consent, respect for individual’s autonomy and dignity, social value of research, scientific validity of research, fair subject selection, risk benefits ratio, standards of care, socioeconomic deprivation inequities and post trial benefits to host community are largely have been highlighted but mostly ignored by researchers in developing countries. 1,2 one central ethical concern when conducting research on human subjects in developing countries is to avoid research which has been rejected as unethical or of no value in the developed country. many research studies that are conducted in developing countries are of no value and sometimes they are scientifically invalid, but still they are conducted by multinational companies in resource poor developing countries. these studies are largely conducted for financial gain rather than for the health care of human beings. it is noticed that such studies are conducted in areas where participants are heavily paid for their participation; the participants being very poor and illiterate tend to participate in large numbers regardless of their health as they receive enough amount to serve their needs. 3 the issue of scientific validity and social value of any research study is important that lacks in developing countries research studies. before conducting any research study the scientific validity must be ensured with the social value for the research participants, the primary beneficiaries of the research. the research study and design must be feasible within the social, political, and cultural context of the research participant’s society. in developing countries it is noticed that the research studies are not carried out on the diseases which are causing more mortality and morbidity in developing countries rather it is largely conducted on the issues which are prevalent in the researcher’s society from developed countries, which seems benefiting developed world and harming the participants from developing countries. the impact of research study needs to be addressed for the research participants rather than research conducting countries. 4 mailto:mwaseem.tareen@yahoo.com bangladesh journal of bioethics 2012; 3(3):12-15 13 a research study should advance scientific knowledge, should lead to improvements in health and should have social, scientific and clinical value. the research studies carried out in most developing countries are sometimes aimed for academic success, institutional demands, success and promotion and to secure research grants. the researchers tend to achieve relevant reports and results rather than improving the health of society. the researcher main aim should be the impact of research study for the improvement of health standards which must be above such kinds of selfish motives. 5 the issue of involuntary participation is common in developing countries in which people from developing countries are forced to participate in any research study. involuntary participation is linked with the issue of inform consent which is rather forced informed consent due to any reason. inform consent means that research participants must be fully informed about the procedures, interventions and risks involved in research participation and must give their consent to participate. by complete consent it is meant that the five components of valid inform consent must be fulfilled which includes, disclosure (participant must be informed as fully as possible of the nature and purpose of the research, the procedures to be used, the expected risks and benefits to the participant/society, stresses, and discomforts, and alternatives to participating in the research), understanding (participant must understand what has been explained and must be given the opportunity to ask questions and have them answered by one of the investigators), voluntariness (participant’s consent to participate in the research must be voluntary, free of any coercion or promises of benefits unlikely to result from participation), competence (participant must be competent to give consent. if the participant is not competent surrogate may provide consent if it is in the participant's best interest to participate), consent (potential human subject must authorize his/her participation in the research study). in developing countries informed consent is considered just as singular event and a mere formality to be followed by researchers. the issue of standard of care is of great debate in recent years. in research studies in developing countries placebo has been used in control arms instead of universally accepted standard of care. it is mainly used in studies which are of no value to the society of research participants rather it is just for the registering of me too drugs and achieving financial gain and registering their products. the issue of exposing vulnerable population is another issue that needs to be addressed in developing countries research studies. the study participants are not fairly selected and the procedure of randomization is not followed. participants are recruited on subject of their easy availability which exposes vulnerable population to great risk and harm. research ethics demands that study participants should be fairly selected without any biasness. favorable risk-benefit ratio that determines the risks associated with conducting the trial should be clearly mentioned and the study participants should be given more benefit than the associated risks. 4, 6 another important issue is the post trial benefits that should be focused and given importance especially once the research is over, pointing out that the new intervention proves to be effective and functioning then it should be offered to those in the control arm of the study subjects once the research is over. research sponsored in developing countries by developed countries raises ethical issues not only during research but also once the research study is over. researchers and sponsors should be bound by ethical committees to guarantee access to interventions to the research participants and to the local community when an intervention is found to be efficacious. the health care teams involved in research studies irrespective of being in develop or developing country is morally and ethically bound to respect human life, dignity and autonomy. they are morally bound to follow the principles of autonomy, beneficence by doing good, nonmaleficence by doing no harm to the research participants which requires investigators to minimize the harm and enhance benefits to the study participants and justice which requires priority to be given to the interests of research participants over his own. how can clinical research be made more ethical in developing countries? clinical research also called clinical investigation is testing new drugs and compounds in human subjects for discovering potential beneficial effects. clinical research is increasingly supported and bangladesh journal of bioethics 2012; 3(3):12-15 14 conducted by multinational pharmaceutical companies. as clinical research involves patients, researchers are ethically and legally obligated to protect them. in clinical practice a physician would be expected to use interventions that have a reasonable expectation of success and are designed solely to enhance the well being of an individual patient. government hospitals and private hospitals in developing countries are aimed for better quality and affordable care to the masses. patients in most developing countries choose public hospitals because they cannot afford treatment in private hospitals but even in public hospitals they pay for some drugs, tests and procedures, and this constitutes a burden that many cannot afford. public hospitals in many developing countries are considered as clinical trial sites. in a clinical setup of developing country the patients enters the trial because of their primary care physician is involved in research study. as physicians are highly respected and included by patients in their decisions in fact they are given the authority to make decisions for their patients. patients are not able to question their doctor’s judgment. they may be easily influenced by the doctor’s advice. it is widely thought and believed that their refusal to follow their doctor’s advice to enter a trial would affect their access to care. when the trial’s principal investigator is also the patient’s primary physician, there is scope for a direct conflict of interest. it becomes more suitable for conflict of interest when physicians are paid recruitment fees to recruit their patients into trials by the pharmaceutical companies conducting the research study. 6 for any research to be ethical the ethics review committee has to play its role not to allow the research which has no impact, which is exploiting human population or causing harm to the participants. the ethics review committee should be independent bodies and the committees should be allowed to function in unbiased environment. the committee should focus the issues that are involved off the field and during the field when the study is conducted. the physicians should be ethically and morally bound to protect his patient from harm and should not participate in trials which causes conflict of interest between his patient and the research, his primary aim should be his patient care rather than research. 5 the physician participating in clinical research should be ethically and legally bound not to accept any gift, package and any benefit from pharmaceutical companies as it causes conflict of interest between the research and his patient care. the issue of therapeutic misconception may be found in clinical research in developing countries where the patients are looking for cure while he is participating in research. the physician carrying the research should inform his patient before involving him in research. being the patient’s primary physician, he should protect him from risks regardless of valid inform consent which he must obtain from his patient. the physician should only advise his patient to enter in trial if it is in patient’s benefits rather than receiving money for his participation. the impact of research should be thoroughly analyzed and only those studies should be allowed by ethical reviews committees which have good impact for the society. it is noticed that many research studies conducted in developing countries are of no impact; they are only for financial gain, personal or degree and project requirements. another issue is of wild lab referrals and unnecessary lab procedures. in developing countries it is considered due to the physician having share in such procedures which may be demanded by pharmaceutical companies or lab owners. there should be double check on such procedures to ensure that poor patients are not exposed to expensive wild procedures. the privacy and confidentiality is considered of no use in a clinical setup of many developing countries. physicians and researchers must be sensitive to not only how information is protected from unauthorized observation, but also if and how participants are to be notified of any unforeseen findings from the research that they may or may not want to know. the investigator must enumerate how privacy and confidentiality concerns will be approached. bangladesh journal of bioethics 2012; 3(3):12-15 15 conclusion: ethical guidelines and rules can be set easily but it is difficult to ensure that they are duly followed. we have to educate the inner human of individuals, the physicians and the researchers to act morally and ethically. we have to make it our habit and not to compromise on anything less than morality and virtuous values benefiting our fellow human beings. references: 1. bhutta, z, a. ethics in international health research: a perspective from the developing world. bulletin of the world health organization. 2002; 80:114-120. 2. emanuel e j. et al. what makes clinical research ethical? jama. 2000; 283(20):2701 2711. 3. kiatboonsri p, richter j. ‘unethical trials of dipyrone in thailand’. lancet, ii. 1988. 1491. 4. emanuel ej. et al. what makes clinical research in developing countries ethical? the bench marks of ethical research. perspective. jid 2004 march 01:189.935. 5. kalantri sp. ethics in clinical research. indian j. anaesth. 2003; 47 (1): 30-32. 6. benatar sr. reflections and recommendations on research ethics in developing countries. social science & medicine. 54. 2002. 1131–1141. competing interests: the authors declare that they have no competing interests. authors’ contributions: all authors have contributed substantially to the conception and design of the manuscript. muhammad waseem khan is the 1 st and corresponding author. imrana niaz sultan, afrasiab khan and muhammad bilal khan are 2 nd authors and they have contributed equally. muhammad waseem khan has critically revised the manuscript. all authors have read and approved the final manuscript. funding: the authors declare that the current study was not funded. bangladesh bioethics society 2011 vol 2 issue 2 page 30 30 society’s news: youth leadership training workshop on bioethics for ensuring human rights a day long training workshop for students of various disciplines was organized by bangladesh bioethics society in collaboration with bangladesh national commission for unesco (bncu) on 13th september, 2011 at 9.30 am at bncu auditorium, 1 asian highway, palassy, dhaka to promote strong ethical values, practice of ethics and morality among the young generation in their professional and social life to lead the nation for upholding the human rights and long term sustainability of the country. architect yeafesh osman, honorable state minister, ministry of science and information & communication technology government of the people’s republic of bangladesh was the chief guest. selina hossain, bengali fiction writer, essayist and editor was also present in the occasion as special guest. members of bbs in different course and conferences: bioethics conference: vii world conference on bioethics september, 2011. shamima parvin lasker, professor and head, department of anatomy, city dental college, dhaka & general secretary of bbs. erasmus mundus master of bioethics 2011-2012 shamima parvin lasker, professor and head, department of anatomy, city dental college, dhaka & general secretary of bbs. dr abu sadat mohammad nurunnabi, lecturer of anatomy, dhaka medical college, dhaka & life member of bbs. microsoft word pdf 3 7 bangladesh journal of bioethics 2010; 1(2):7-10 informed consent: protecting patients or salvaging physicians inayat ullah memon chief pathologist, peoples medical college hospital, nawabshah, sindh, pakistan abstract: history of tradition of following ethical code in medical practice is very ancient and it could be traced as back as 3500 year old document of ebers papyrus (berdon 2000). later greek and egyptian teachings also emphasized upon ethical practices in medicine. but the concept of formally taking consent (and informed consent) with emphasis on patients’ rights and his/her autonomy emerged in early 20th century when some law suits were filed in courts, particularly in usa. later the well known infamous atrocities carried out by nazi doctors on prisoners during second world war and consequent verdict by nuremberg tribunal and milestone declaration of nuremberg made a land mark in the history of medical ethics and provided a ground on which the doctrine of ‘informed consent’ is built. this paper discusses and analyzes various ethical issues related to informed consent. how the obligation of taking informed consent was established in the clinical practice and biomedical research. discusses whether informed consent is a moral obligation or legal necessity with reference to various historical cases and presentation of views by some authors. this paper also analyzes famous legal litigations that helped to provide foundations for the patients’ rights and autonomy in clinical, such as cases of shoendorff v. new york hospital of 1914; prince v. massachusetts litigation of 1944; canterbury v. spence lawsuit of 1972; large v. superior court of arizona legal case of 1986 and younts v. francis hospital suit of 1986. a discussion is also made regarding five universally accepted components of informed concept (disclosure to the patient/research subject, comprehension by the patient, his/her competency, voluntariness and willingness), which are variously and sometimes conflictingly interpreted in different contexts and situations. situations are highlighted where these problems create ethical dilemmas and legal conflicts in clinical and research environment and a reference is made to ongoing discussion whether informed consent has been primarily devised for protection of the patients or it is a tool to rescue physicians when they are brought to courts to face law suits. keywords: informed consent, autonomy, ethical principles introduction: this article highlights and analyzes various ethical issues relating to one of the fundamental element of contemporary bioethics i.e. principle of informed consent. beginning with the historical background of this principle, a discussion will be made about reasons that prompted the practice of obtaining informed consent; arguments will be analyzed if informed consent is a moral obligation or legal necessity. and a discussion about various issues related to descriptive ambiguity of five universally accepted components of informed consent will be made which are differently interpreted in changing contexts and situations. history: concept of bioethics can be traced as back as 4000 bc but the oldest documentary evidence of code of medical ethics is found in 3500 years old ebers papyrus (berdon 2000). earliest code of medical ethics that was enunciated during the period of hammurabi (encyclopedia medicine, history), oath of hippocrates and all other ancient as well as modern teachings stress upon the end of human sufferings in a disinterested manner, irrespective of remuneration, status and personal reputation. these early teachings reflect the honesty of physicians and advocate the paternalistic attitude of physicians in a noblesse oblige manner. but in the ancient code of medical practice no mention of consent (or informed consent) was made including that of greek period and the egyptian civilization (kour and rauff 1992), strongly leading to the presumption that patients were submissive to physicians’ authority. a little more than two centuries ago with us revolution (us declaration of independence) there was emphasis on human rights (and consequently those of patients’). later, the concept of informed consent emerged during post-second world war era when the war tribunals discovered indiscriminate use of human subjects in brutal experimentation and stressed upon rights of human subjects in biomedical research. the idea of written consent (not the informed consent) roots in the famous case of schoendorff v. society of new york hospital, 211 n.y 215, 105 n.e. 92, 1914 (murray, 1999 and lombardo 2005), which made the basis of necessity of consent in clinical practice, wherein justice benjamin cordozo, stressed heavily on the participation of patient in the decision making process and made the verdict: “every human being of adult years in sound mind has the right to determine what shall be done with his own body; and the surgeon who performs operation without his patients’ consent commits a battery for which he is liable in damages” the imbalance of power between physician and patient in clinical situations or between researcher and research participant is multiplied by circumstances when patient or research subject belong more vulnerable group of population who are deprived of basic rights (zion, gillam & loff 2000). this happened in world war ii when 8 bangladesh journal of bioethics 2010; 1(2):7-10 extreme cruelties were made on the prisoners of war in the name of medical research. this made the beginning of the end of long-practiced trust of patients in the physicians and weakened the till-respected principle of paternalism. nuremberg tribunal not only convicted the nazi physicians but to avoid such brutalities in future set a code of ethics for medical research in the form of nuremberg code. similar type of codes and declarations (helsinki declarations, belmont report) stressed upon the need of voluntary participation of human subjects in experiments besides setting other codes of conduct. these steps provided basis for necessity of informed consent in biomedical research and formed fundamental milestones for this moral necessity. with this, the notion of consent was changed to doctrine of informed consent promoting the need to fully inform the patient about the treatment procedure (such as surgery), explain available treatment alternatives and probable risks and benefits without implicit or explicit coercion. in contrast to informed consent, some of the authors mention valid consent (singh 2008), wherein the burden of explaining the details of procedure does not lie on the physician. but most of the literature uses the term informed consent wherein by letter and spirit physician carries the onus of explanations to the patient. informed consent, moral or legal requirement: though the roots of informed consent are based in legal happenings such as nuremberg code but still there is debate whether it is legal necessity to be fulfilled by the physicians or of moral obligation to be discharge by health care professionals. most of authors are in favor of its moral side but recent publications of indian journals heavily support the idea that it is primarily a legal document (singh 2008 and bastia 2008). besides this difference of opinion, both of these authors argue that the informed consent is a document and a tool to rescue physicians in situations where they are entangled in court litigations. their position is strongly contended by farhat moazam (2008), arguing that neither it is one-step and get-signed document nor it solely carries the legal importance. but it is an on-going process between patient and physician and has more moral value than the legal importance. there is almost universal consensus to ensure the fulfillment of five elements of informed consent (disclosure, competency, comprehension, voluntariness and decision-making) amongst the medical and legal fraternity. here is analysis of few issues that would help us to dis-entangle the dilemma arising from practical application of informed consent and its ramifications in various contexts (geographic locations, cultures and religions). extent of disclosure: not infrequently it remains unclear how much information is to be disclosed to the patients by a physician to comply with requirements of moral informed consent. frequently it is considered unnecessary by the physician to disclose remote possibilities and least probabilities to the patient and these are usually preferred to be ignored. reference to an important case (canterbury v. spence case 1972) is worth mentioning here as this indicates how much burden lies on the physician with regard to disclosure of information. canterbury a minor child suffered from backache that was diagnosed by dr spencer (the neurosurgeon) as having ruptured disc of vertebral column and recommended surgery (laminectomy). he gave brief description of the surgical procedure to child’s mother but did not mention that paralysis was known complication of this type of surgery (whose probability was 1% as testified by dr spencer later during proceedings). though the surgery was uneventful but sometime after operation, the patient fell, lost bowel functions and developed paraplegia. in this case, court held dr spencer guilty of not obtaining complete informed consent. according to the court: “1% chance of such a grave consequences as paralysis was reasonable to disclose, and a hypothetical reasonable patient would likely consider that information as significant while making his decision of whether or not to consent to the operation”. this is the case of a time (year 1972) when bioethics and tradition of taking informed consent was in early years of its practice. today when medical science and biomedical technology has shown tremendous development, the complications of treatment and resultant responsibilities of taking full informed consent pose great responsibility on the shoulders of physician. according to this case there are two exceptions to full disclosure of information by the physician. one, when the patient is unconscious and potential harm resulting from failure of the treatment is more than potential harm from initiating the treatment. secondly, when the patient is so emotionally unstable that full disclosure would prevent the patient from making a rational decision as to his/her treatment (canterbury v. spencer case, high court summaries). patient’s competency in clinical settings and other legal environments: standards of giving legal consent differ from that of discharging informed consent for medical purposes. in this regard a case is mentioned here i.e. large v. superior court of arizona, 714 p.2d 399, 1986 (murray 1990). a woman with organic brain syndrome with resultant poor brain function was admitted to a hospital with hip fracture. the attending physician before undertaking surgery obtained informed consent after explaining expected outcome of the surgical procedures and probable risks. simultaneously she also executed will in the presence of a lawyer about her properties. after the surgery the patient died and the court reviewed her consent for surgical procedure and the executed will. the court found that her will was invalid due to the reason that she lacked testamentary 9 bangladesh journal of bioethics 2010; 1(2):7-10 competence, while surgical consent was considered valid because the patient was able to understand the surgical procedure and the associated risks and benefits. evaluation of comprehension: to assess whether the patient is able to understand the details explained to him/her for the intended medical procedure as part of informed consent, besides sound mental health the age is one of the important factor. a mature minor (say about 15 years age), though younger than the legal adult age (say 18 years, thought varies in different countries) creates legal complexity regarding his/her capacity to give informed consent and this becomes more problematic when the parents or guardians are not available. i would like to present here a case in this regard. a 17 year old girl was visiting hospital to see her unconscious mother who had undergone major surgery. during her visit the girl got her finger injured in the hinge while closing the door of her car. the injured girl was taken to the emergency room and operated upon after obtaining her consent (hartman 1999). though the procedure was successful but later her mother objected upon the surgery and brought suit in the court on the grounds that the obtained consent was not valid as the girl had not attended the legal age. she further contented that had she been consulted for the consent she would not have given the same, instead she would have sought the opinion of family physician. the court remarked that as the patient was 17 years old (the legal adult age being 18 years) and had apparent ability to understand the complexities of the situation, the patient was reasonably able to comprehend the nature and consequences of procedure and was mature enough to “knowingly consent to the beneficial surgical procedure made necessary for accident”. here is an important point to be noted, i.e. court remarked that the situation was not life-threatening emergency but the consent was valid under mature minor exception. voluntariness: as is apparent, any consent given under force or coercion is not valid. but not infrequently the compelling force is not apparently visible. in washington dc a lady patient was advised that if she did not undergo procedure of tubal ligation (sterilization) she would suffer her welfare benefits. the district court of washington considered it as duress and deemed any consent given under these circumstances for tubal ligation as invalid and not a voluntary one (murray 1990). authority of decision making: supreme authority and importance of autonomy of patient regarding his/her own body is exemplified by judgment of natanson v. kline case (murray pm, 1990), where the judge declared: “a man is master of his own body and he may expressively prohibit the performance life-saving surgery or other treatment”. this is a situation when patient’s decision is against one of the basic principle of bioethics i.e. non-maleficence. physicians find themselves in real ethical dilemma in situations like this. in fact the principle that patients has authority on his own body is based on the doctrine that a person has right to choose about his person or body, whether he has chosen correctly or incorrectly (englehardt 1986) i.e. his decision might be incorrect in physician’s view. informed consent in special situations: proxy consent given on behalf of children has some limitations. this particularly applies on parental authority to refuse to consent in clinical settings where because of certain beliefs the parents refuse to certain treatments and thus their children are put into danger. examples are refusal of jehovah’s witness refusing blood transfusion and fundamentalist christians in southern west virginia requiring children to handle snakes during worship services and refusing them medical attention when bitten. in this regard a judgment was declared by supreme court of usa in 1944 in case prince vs. massachusetts, 321 us 158, 1944 (prince vs. massachusetts case, 1944) and said: “parents may be free to become martyrs themselves, but it does not follow that they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves” conclusion: it should be appreciated that the principle of informed consent has legal foundations but it is the reflections of both the moral obligation and legal necessity. informed consent obtained in clinical practice has more legal worth as has been discussed above in various court suits. while the consent in perspective of biomedical research has roots in moral and ethical codes (carmen & joffe 2005). through the informed consent, both in clinical and research environment patients’ autonomy is respected and he/she is given full right and provided options to proceed with, but it has some inherent limitations i.e. available choices in particular situation may not be the all possible choices offered in other contexts. also socio-cultural differences may not allow any patient to exercise his/her autonomy particularly in asian and african countries where extended families give this right to the family head or women may not be fully empowered to deliver their consent without spouse’s will. lastly by virtue of the codes and oaths of the medical practice physicians are the trustees of the patients’ possessions including the informed consent, therefore it should not be devised or constructed with an intention to rescue physicians when they are brought to court litigations. rather its primary spirit of practice is to respect patients’ autonomy thus it is the instrument to protect their rights. 10 bangladesh journal of bioethics 2010; 1(2):7-10 references: bastia bk, 2008, ‘consent to treatment: practice vis-à-vis principle’, indian journal of medical ethics, vol. 3, pp. 113-114 berdon, v, 2000, codes of medical and human experimentation ethics <http://wisdomtools.com/poynter/codes.html> canterbury v. spence case, 464 f2d 772, washington d.c., 1972, high court case summaries, pp. 15-16 canterbury v. spence case, quimbee, ‘the case brief database’ <http://www.quimbee.com/index.php/quimbee/case_detail/canterbury%20v.%20spence/> carmen mg, jofee s, 2005, ‘informed consent for medical treatment and research: a review’, the oncologist, vol. 10, pp. 636-641 encyclopedia medicine, history, <http://www.allrefer.com/medicine-history> englehardt ht, 1986, ‘suicide and cancer patients’, a cancer journal for clinicians, vol. 36, no. 2, pp. 105109 hartman km, liang ba, 1999, ‘exceptions to informed consent in emergency medicine’, hospital physician, pp. 53-59 kour nw and rauf a, 1992, ‘informed consent – historical perspective and clinician’s view’, singapore med j, vol. 33, pp. 44-46 lombardo pa, 2005, ‘phantom tumors and hysterical women: revising our view of the schoendorff case’, journal of law medicine and ethics, vol. 791, pp. 791-801 moazam f, 2008, ‘comment on: consent to treatment: practice vis-à-vis principle, by bk bastia’, indian journal of medical ethics, vol. 3, pp. 115-116 murray pm, 1999, ‘history of informed consent’, iowa orthop. j, vol. 10, pp. 104-109 singh d, 2008, ‘informed vs. valid consent: legislation and responsibilities’, indian journal of neurotrauma, vol. 5, pp. 105-108 us supreme court, prince vs. massachusetts, 321 us 158, 1944 <http://supreme.justia.com/us/321/158/case.html > us declaration of independence, < http://www.pavisnet.com/declaration/> zion d, gillam l, loff b, ‘thje declaration of helsinki, cioms, and the ethics of research on vulnerable populations, nature medicine, vol. 6, no. 6, pp. 615-617 editorial bjb nov. 2010, vol.1 issue3 editorial there are certain ideas which have universal message for the welfare of mankind. these ideas must be dedicated to a noble cause, entirely selfless, free from all narrowness and fearless. bangladesh bioethics society is trying to work some such pertinent ethical issue gradually. but it is impossible to deal with existing socio-ethical problem individually. we should proceed in a concreted manner. an article of this issue made an attempt to understand the lesson of ethics in the existing primary education. because moral education in early life will build up their future character. there is a discussion on the problem of moral deviation in young people of bangladesh, gravity of the situation and its possible solution. an important article deals with organ transplantation and donation under ethical compulsion. it elaborately analyzes a case of live donor (un-married girl), where orally consent to donate kidney to the brother who is bread earner of their joint family. by consenting to donate kidney, the girls jeopardizes her matrimonial purpose as her finance is uncertain about her post-donation health status. intellectual property right is a very important issue in developing countries. iprs is considered from economic and legal aspect as the ownership rights for the excessive use of innovation and creative work. the paper has presented an elaborate discussion on the iprs. the present issue analyzes the sector where ethical improvement is immediately needed. morality should be started and practiced from the family. an other paper assesses the stem cell treatment as well as it impact in human life. a discussion explains the ethical issue of stem cell research and therapy which focuses how recent biotechnology and biological understandings of development narrow the debate. public health is the societal approach to protecting and promoting health. a framework of ethics analysis geared specifically for public health is needed to provide practical guidance for public professionals and researches in bangladesh. technical and ethical perspectives of egyptian health websites are discussed elaborately, based on a pilot study. in short, appeal of bioethics is to the noble-instinct of the people. we should realize once duties and responsibilities outside the sphere of once own lives based on bioethical perspective. rowshan ara phd (professor of philosophy, university of dhaka, bangladesh) editor bangladesh journal of bioethics bangladesh journal of bioethics 2011 vol 2 issue 1 page 3 3 editorial right to life is our fundamental human right. but rundown conditions of road across the country have come to such condition that we can call it nothing but death trap. bus and truck drivers have no mercy for the passengers. safe and sound journey become impossible. according to news paper source, there are 3.5 lakh non professional drivers in the country. about 10 lakh drivers in total have license. massive killing in road accident recently awakened the people in all strata of life. now we question the skill of the drivers and the flaws of law. according to the world health organization four thousand persons are killed every year in the country due to road accident. most of the road–crashes are caused by untrained, desperate and crazy drivers. these are not accident, we can call it murder. unsafe journey leads us to valley of death. media and civil society leaders have started campaign against the irregularities of issuing driving license without testing their skill and abilities. on behalf of the bangladesh bioethics society we express our solidarity with this movement to ensure right to life. this issue of the journal contains few ethical poems representing golden rules of bioethics. it has an article on unesco bioethics core curriculum and training recourses. the paper discuss the roles and challenges for teachers and institutions to empower the students to be matured enough to be able to participate in decision-making process. another paper discusses the ethical and policy concerns pertaining to rice landraces in asia. an article depicts the picture of gender imbalance in policy making level in science and ethical issue. mdg will not be attained unless there is active participation of women in science and ethical education. biomedical considerations in the manufacture, clinical trails and bioequivalence studies of pharmaceuticals emphasizes the establishment the clinical trail and bioequivalence norms in the manufacturing processes. i hope theses will enrich the knowledge of the readers. rowshan ara professor of philosophy university of dhaka bangladesh journal of bioethics 2011; 2(2): 20-23 what makes multinational clinical research ethical & how to minimize possible exploitation in host country? dr. md. ashraf ali former consultant, health & population sector program of bangladesh, dfid, british council, dhaka background: in recent years there has been substantial debate about the ethics of research in developing countries. the controversies have been centered on (i) standard of care that should be used in research (ii) reasonable availability of interventions that are proven to be useful and (iii) quality of informed consent. clinical research is different from clinical practice in ethically important ways where each has different goals, different methods and different justification for risk to individuals. the goal of clinical research is to generate useful knowledge about health and illness. benefit to participants is not the purpose of research, although it does occur. here people are the means to develop useful knowledge; and are thus at risk of exploitation. possible exploitation of host country: in developed countries, the risk of exploitation of human research subjects or host communities is minimized, because (i) society funds research to improve health (ii) researchers and research institutions are part of the larger community and (iii) there is an infrastructure, even if imperfect, translates research results into health-care practices for the benefit of the larger community. but multinational clinical research in developing countries creates a greater risk of exploitation due to (i) poverty, (ii) illiteracy, (iii) limited health care services, (iv) cultural and linguistic differences and (v) less understanding of the nature of scientific research. moreover regulatory infrastructures that might minimize the risk of exploitation are less established, less supported and less effective in developing countries. as a consequence, individuals or communities in developing countries assume the risk of research, but most of the benefits may accrue to people in developed countries. how to minimize exploitation: to minimize the possibility of exploitation, previously, there was delineation of a framework for ethical research that included 7 principles. later on an 8th principle ‘collaborative partnership’ was added and elaborated these principles through 31 benchmarks that systematically specify practical measures to determine the extent to which the research satisfies the principles. the principles are as follows: collaborative partnership: a collaborative partnership between researchers & sponsors in developed countries & researchers, policy makers & communities in developing countries helps to minimize the possibility of exploitation by ensuring that a developing country determines for itself whether the research is acceptable & responsive to the community’s health problems. moreover without the engagement of the researchers & host communities in the developing country, a study is unlikely to have any lasting impact, and without the investment of makers of health policy, the research results are unlikely to influence policy making & the allocation of scarce health care resources. social value: it is widely recognized that ethical clinical research must have social value, through generation of knowledge that can lead to improvement in health; without social value, research exposes participants to risks for no good reason & wastes resources. scientific validity: science & ethics do not conflict; valid science is an ethical requirement. unless research generates reliable & valid data that can be interpreted & used by the specified beneficiaries of the research, it will have no social value & participants will be exposed to risks for no benefits. fair subject selection: historically, populations that were poor, uneducated, or powerless to defend their own interest were targeted for high risk research, whereas promising research was preferentially offered to more privileged individuals. a challenge for research in developing countries is fair selection of target villages, tribes or city neighborhoods from which individual participants will be recruited. 20 bangladesh journal of bioethics 2011; 2(2): 20-23 the delineated ethical principles are elaborated through benchmarks which are as follows: principles benchmarks collaborative partnership • develop partnerships with researchers, makers of health policies, and the community. • involve partners in sharing responsibilities for determining the importance of health problem, assessing the value of research, planning, conducting, and overseeing research, and integrating research into the health-care system. • respect the community’s values, culture, traditions, and social practices. • develop the capacity for researchers, makers of health policies, and the community to become full and equal partners in the research enterprise. • ensure that recruited participants and communities receive benefits from the conduct and results of research. • share fairly financial and other rewards of the research. social value • specify the beneficiaries of the research—who. • assess the importance of the health problems being investigated and the prospective value of the research for each of the beneficiaries—what. • enhance the value of the research for each of the beneficiaries through dissemination of knowledge, product development, long-term research collaboration, and/or health system improvements. • prevent supplanting the extant health system infrastructure and services. scientific validity • ensure that the scientific design of the research realizes social value for the primary beneficiaries of the research. • ensure that the scientific design realizes the scientific objectives while guaranteeing research participants the health-care interventions to which they are entitled. • ensure that the research study is feasible within the social, political, and cultural context or with sustainable improvements in the local health-care and physical infrastructure. fair selection of study population • select the study population to ensure scientific validity of the research. • select the study population to minimize the risks of the research and enhance other principles, especially collaborative partnership and social value. • identify and protect vulnerable populations. favorable risk-benefit ratio • assess the potential risks and benefits of the research to the study population in the context of its health risks. • assess the risk-benefit ratio by comparing the net risks of the research project with the potential benefits derived from collaborative partnership, social value, and respect for study populations. independent review • ensure public accountability through reviews mandated by laws and regulations. • ensure public accountability through transparency and reviews by other international and nongovernmental bodies, as appropriate. • ensure independence and competence of the reviews. informed consent • involve the community in establishing recruitment procedures and incentives. • disclose information in culturally and linguistically appropriate formats. • implement supplementary community and familial consent procedures where culturally appropriate. • obtain consent in culturally and linguistically appropriate formats. • ensure the freedom to refuse or withdraw. respect for recruited participants and study communities • develop and implement procedures to protect the confidentiality of recruited and enrolled participants. • ensure that participants know they can withdraw without penalty. • provide enrolled participants with information that arises in the course of the research study. • monitor and develop interventions for medical conditions, including research-related injuries, for enrolled participants at least as good as existing local norms. • inform participants and the study community of the results of the research. favorable risk-benefit ratio: a clinical research should offer participants a favorable risk-benefit ratio, or, if potential risks outweigh benefits to participants, the social value must justify these risks. only benefits that accrue to 21 bangladesh journal of bioethics 2011; 2(2): 20-23 participants from the interventions necessary to achieve the research objectives or those deriving from the knowledge to be gained by the research should be used to justify risks to participants. independent review: to minimize concerns with regard to researchers’ conflicts of interest & to ensure public accountability, independent ethical review of all clinical research protocols is necessary. in multinational research, there is a special need for transparency. transparency enhances accountability by assuring the public that the research is not exploitative. informed consent: individual informed consent has been recognized as a principle of ethical clinical research for more than a century. the concept of formally taking consent with emphasis on patient’s rights & his/her autonomy emerged in early twentieth century when some law suits were filed in courts, particularly in usa. later the well known infamous atrocities carried by nazi doctors on prisoners during second world war & consequent verdict by nuremberg tribunal & milestone declaration of nuremberg made a landmark in the history of medical ethics & provide a ground on which the doctrine of informed consent is built. respect for recruited participants & study communities: the ethical conduct of clinical research does not end when informed consent is obtained. researchers have ongoing obligations to participants, former participants & the host community. discussion & conclusion: together, these principles & benchmarks constitute a systematic framework that specifies core practical considerations necessary to ethically justify research in developing countries. this framework functions within general ethical values, such as honesty, that are relevant to scientific integrity and avoidance of fraud. application to actual research studies may suggest refinement or the need for additional benchmarks. for a developing country to minimize the risk of exploitation it is necessary to apply a previously proposed ethical framework for clinical research within developed countries to developing countries, explicating a previously implicit requirement for collaboration. application of ethical framework of principles and benchmarks in designing and conducting clinical research is essential to minimize the risk of exploitation. to apply these ethical principles and benchmarks in clinical research the host country has to build capacity of its researchers and research institutions for (i) establishment of a system for independent ethical review of research proposals and (ii) development and implementation of standard operating procedures for both clinical research and ethics review. references: 1. angell m. the ethics of clinical research in the third world. n engl j med 1997; 337:847-9. 2. wilmshurst p. scientific imperialism: if they won’t benefit from the findings, poor people in the developing world should not be used in research. bmj 1997; 314:840-1. 3. del rio c. is ethical research feasible in developed and developing countries? bioethics 1998; 12:328-30. 4. glantz lh, annas gj, grodin ma, mariner wk. research in developing countries: taking ‘benefit’ seriously. hastings cent rep 1998; 28:38-42. 5. angel m. ethical imperialism? ethics in international collaborative clinical research. n engl j med 1998; 319:1081-3. 6. wertheimer a. exploitation princeton, nj: princeton university press, 1999:3-15 7. emanuel ej, wendler d, grady c. what makes clinical research ethical? jama 2000; 283:2701-11 8. stephens j. the body hunters: as drug testing spreads, profits and lives hang in balance. washington post, 17 december 2000:a 1. 9. weijer c, anderson ja. the ethics wars: disputes over international research. hastings cent rep 2001; 31:1820. 10. shapiro h, meslin e. the ethics of international research. n engl j med 2001; 314:139-42. 11. black n. evidence based policy: proceed with care. bmj 2001; 323:275-8. 22 bangladesh journal of bioethics 2011; 2(2): 20-23 12. daniels n, sabin je. setting limits fairly. in: justice, security, and public accountability for limits. new york: oxford university press, 2002:13-14. 23 microsoft word pdf 2 2 bangladesh journal of bioethics 2010;1(2):2-6 ehical reading of platos’s the republic jose ma. ybanez tomacruz, phl., emmb professor of philosophy, philosophy division, ateneo de davao university, e. jacinto street, davao city philippines abstract: the last four books of plato’s the republic manifest fecundity, not simply in terms of books or pages but in terms of topics or themes. plato in this opus, true to the form of a socratic disciple, uses the method of the catena -chain. that is, one topic is nexated or interconnected to the other. this is also the reason why i have decided to delve into this paper not in terms of books but thematically, more specifically, those i consider to be major ones. these themes that i deem to be major ones contained in the four books are plato’s notions of human nature and morality, socio-political philosophy, the process of education or learning, and then his epistemology. however, here i have decided to tackle only one, i.e., plato’s notions of human nature and morality. lastly, let it also be pointed out that all the expository work and critique shared here are all mine, and thus, for any error or shortcoming, the burden is solely mine and not of plato nor of any other person. key terms: human nature, morality, virtue, evil on human nature and morality plato expounded on his view of human nature through the story of er (2). er was a warrior who, people thought, died in battle. however, when his body was recovered ten days after the battle, it was still undecomposed. subsequently, his family first held a wake for him and set to burn his body after two more days. however, two days later, as his body was already on the pyre to be burned, er revived. thereafter, er recounted that during those days when people thought him to be dead, his soul actually went on a journey in the afterlife. he said that his soul was made to come back to his body because he was entrusted with the mission that “he must be the messenger to mankind to tell them of the other world”(3) and that he was commanded “to give ear and observe everything”(3) that he will witness. it is important to note that plato, in recounting the tale of er is using a “myth” to explain his view of human nature. “myth” not in the usually-conceived sense that a story is simply fictional, ergo not true. plato uses the “myth” here in the sense that, granting that the story itself may be imaginary, yet the message it conveys carries with it what he considers as a universal truth -i.e., true to everyone and in every manner-. and conveying a universal truth, therefore, the story carries with it, authority. and that because it has authority, ergo, it should/is ought to be believed. thus, here we can see, that from plato’s perspective, his view of human nature is not just a fallible theory but is already an ex cathedra ideology. that er is a harbinger of a sacrosanct decree which humanity should/ought to heed for it is for the sake of humanity’s own good: in it lies humanity’s salvation and doing otherwise would be damnation. in other words, plato’s view regarding human nature is not only on the factual level but already on the normative or practical. it takes on the force of law, thus it should be obeyed, a categorical imperative. and thus, after er’s account is over, plato says: and so, glaucon, the tale was saved, as the saying is, and was not lost. and it will save us if we believe it, and we shall safely cross the river of lethe, and keep our soul unspotted from the world. but if we are guided by me we shall believe that the soul is immortal and capable of enduring all extremes of good and evil, and so we shall hold ever to the upward way and pursue righteousness with wisdom always and ever, that we may be dear to ourselves and to the gods both during our sojourn here and when we receive our reward, as the victors in the games go about to gather in theirs. and thus both here and in that journey of a thousand years, whereof i have told you, we shall fare well.(4) indeed, in other words, plato in a sense, by appealing to the authority of the myth, is putting a stamp of unimpeachable imprimatur on his view regarding human nature. 3 bangladesh journal of bioethics 2010;1(2):2-6 plato says that according to er, the souls of those who die initially go either to the upper or lower regions the former, heavenly; the latter, still earthly. those who lived good or virtuous lives are judged to go to the upper region, and those who lived evil lives are adjudged to the lower region. the two groups will stay in their respective regions for a thousand years. on the upper region, the virtuous souls are to enjoy all the heavenly delights as their reward, and those on the lower rungs are also to stay in their region so as to be punished and also to be reformed/or purged of their past evils. when the thousand years have come to pass, those of the two groups are to emerge out of their respective regions so as to be brought to an ascendant level. the virtuous ones will immediately be admitted into the next ascendant level, albeit, those of the lower regions is another case. as previously stated, those relegated to the lower regions are sent there to be punished and purged of their evil. however, the story says that there are those in the lower regions who “are incurably wicked or... those who have not completed their punishment”(5). these souls, according to the story, will not be allowed to automatically leave their lowly abode even if the prescribed millennial penalty has already elapsed. the ones who will be allowed to leave the lowly regions -for the higher level or heavenupon completion of the penal term of a thousand years are only those who have been purged of their evil. as the story progresses, it will be seen that only the said already-righteous and purged souls will be the ones who will be allowed once again to go through another cycle of birth in our temporal world.(+) or that, for a soul to be temporally reanimated or be subjected through another cycle of temporal life, it should have qualified to do so: the soul is one of virtue. this point is important, for it shows that plato believes that all living creatures -at least the sentient ones, i.e., human beings and animalshave-temporal-lives/are-able-to-be-born-in-the-temporal-world precisely because they have good souls in their heavenly existence. however, another nuance is needed. that is, because the souls have been of virtue prior to their temporal rebirth, it necessarily follows that they also are temporally born of virtue. not so, according to plato, as per er’s story. er recounted that the righteous and purged souls, upon the passage of a millennium staying in their designated habitations, are subjected to another process before they are again reborn in the world here and now. the said process is somekind of a half-way house. now, in their new heavenly residence, after their emergence from their respective regions, they are made to individually choose as to what kind of life they individually would want to have in their approaching earth-bound rebirth. i highlighted the word “individually” to emphasize the point that it is each soul who makes the choice for him/herself. ergo, inasmuch as no one compels anyone to make that specific choice, the individual soul bears sole responsibility for what it will become in its temporal rebirth. thus the story says: “souls that live for a day, now is the beginning of another life cycle of mortal generation where birth is the beacon of death. no divinity shall cast lots for you, but you shall chose your own deity. let him who falls the first lot first select select a life to which he shall cleave of necessity. but virtue has no master over her, and each shall have more or less of her as he honors her or does her despite. the blame is his who chooses. god is blameless.”(6) it can also be noted that i also highlighted the term “necessity” in the above citation. i did so because the story is also saying that one is also bound to one’s individual choice. thus, whatever one’s choice was ante-birth, consequently that is what one shall also necessarily become in the temporal life. simply put, plato is saying that what one is in this world, one has become so because one has priorly decided to become so in the ante-life. this point is germane because its implication is that, if one made a bad or wrong choice in the ante-birth, one cannot anymore have the chance to lead a virtuous life here in the temporal sphere. one can only change again for the better only after one dies and his/her soul is sent to that earlier mentioned lower region and its subsequent possible release to the heavenly abode upon completion of a millennial purgation. thus this also implies that one who leads a life of evil is worthless, i.e., negated of any positive value. inferentially, therefore,it can be claimed that to kill evildoers or other evil sentient creatures is outrightly justifiable, or could even be considered as an act of charity because by doing so, the said evildoers are even helped to have their chance of redemption hastened. thus, if one is born evil, one will always be evil, at least until one is still alive in this world, for in such life one “shall cleave of 4 bangladesh journal of bioethics 2010;1(2):2-6 necessity”. redemption for evildoers is simply not possible in this temporal existence. only after death could one have the chance of redemption. such view has another side to it. that is, only those who made the right choices in the ante-life therefore have lives worth living and cultivating in this space-time dimension for they are the only ones who are not predestined or fated to live evil lives. however, as the story of er unfolded, upon their rebirth, all the souls -both those who made the right and errant choices in the ante-birthhave already forgotten their previous existence. thus because of such existential amnesia, if persons -whose souls made the right choices in the ante-lifeare not properly guided/properly “awakened” as regards their previous lives, they may also become evil, whether caused by human beings or other circumstances. ergo, evil is not only predestined, but it could also be a result of non-cultivation of the predetermined goodness. however, of course, if one is already priorly evil, one will always be evil despite any guidance in this spatio-temporal existence. this view of predestined goodness or evil, as the case may be, has another quite ominous implication: that is, therefore everyone is not born equal. what makes the said congenital inequality more sinister is that it is something from which one cannot escape while one is still alive in the here-and-now. another onerous implication is that, it follows from the preceding implication that therefore the human being is not necessarily born free (and be-free), good (and be-good). that only some are. that there really are human beings who are therefore born evil and thus will always be evil throughout their temporal lives. and this has at least two further severe implications. firstly, this might eventually prove that one should not necessarily be responsible for one’s actions, specially if they are evil. fate -though of his own ante-life choicehas destined one to be so in this existence. and so no one should even blame the evildoer anymore. he/she is simply perfecting what he/she has started even before he/she was conceived. the evildoer’s existence is a mistake. the evildoer does not only have a tragic flaw here. he/she is tragedy itself. and it was not his/her fault to that he/she was made to proceed to rebirth despite such fateful affliction. as er’s tale goes, he/she was simply made to proceed to rebirth despite of making the aforementioned wrongful choice. and such mistake cannot be rectified here and now but only in the afterlife. ergo, the best resort for such an hopeless temporal existence is to kill the evildoer -and with the further implication that through the said death the predestined evil is redressed and the a-priori error in the ante-life is once again in the process of being rectified. the second severe implication has to do with the existing cornerstone of human jurisprudence: that is, one should not anymore be presumed innocent unless proven otherwise, but instead the reverse. that because one has committed an evil action, therefore one is evil, unless he/she proves otherwise -again with the implication that one is able to do evil because one is of a soul who made the wrong choice in the ante-life. another insidious consequence of predestined goodness or evil is the justifiability of the preferential treatment to a group of people on the assumption that they are the ones who are born to be virtuous because they are also deemed to have made the right choice in the ante-life. ergo, discriminations resulting from such preferential treatment are also warrantable. therefore, only those who have been deemed to have been born to be good are to enjoy rights and privileges in this world. on the other hand, those considered base-born, therefore, based on the preceding arguments, will only have two rights: either to live a life of contempt, or to die. to live a life of miserable contempt for he/he deserves because it is what he/she actually is in the first place. to die, so as to be able to have the chance again to be purged in the after-life, so as to be subsequently able to hopefully make right choices in the following ante-life, so as to subsequently be able to have the chance to become virtuous in one’s next cycle of life. at this juncture, one might already have the impression that i might simply be putting words into plato’s mouth, or charging him with ideas which he himself does not espouse. let us see. the story of er said that the souls made their choices in heaven, and that such choices were irrevocable. thus being irrevocable, the souls who made wrong choices should be/are destined to live evil temporal lives. and being irrevocably evil lives, thus nothing will ever change it except death. i find such flow of the story logically implausible. the story would have been more sensible if it should have gone in such a manner that the souls should have corrrected or should have been allowed to correct their egregiously erroneous choices in the ante-life. otherwise, the worldly existence of such er’s story’s characters is meaningless, absurd. meaning that, a storyteller does not put such a situation in a story unless either he/she does so by mistake -a mental lapseor that she has the deliberate purpose for doing so. but, i would like to give plato the benefit of the doubt: that he was not stupid, and thus he did not make a mistake/mental lapse, but instead has some very deliberate purpose in mind. i say very deliberate, for i 5 bangladesh journal of bioethics 2010; 1(2):2-6 can’t seem to conceive that a person of plato’s caliber, whose extant works are nothing less than brilliant, can make an error in such crucial a point. i think he simply literally meant what he said through the story of er. i would like to surmise that plato was indeed simply saying that if one is being so predisposed -ergo in a sense predestinedto evil, therefore one simply makes one’s life nothing but being akin to a goingthrough-the-motions-existence, ergo, meaningless/absurd. that having already accepted that one has indeed been predisposed/fated to such, one also at the same time has ceased to struggle to ask, to question such kind of never-ending existential gloom. therefore, by thinking so, plato was simply trying to keep faith with his mentor socrates’ credo that “an unexamined life is a life not worth living.” in fairness to socrates however, i think here plato might have taken his mentor’s words to their extreme. methinks that i should, and i think so too socrates would, agree with plato that indeed an evil life is a meaningless life. however, i would like to disagree -and maybe socrates also wouldwith plato that there should only be two options that his paradigm should offer to an evildoer: one, a life worthy solely of contempt, or two, death. ergo, again, i think by presenting his notion of human nature through the myth of er, plato could have either been culpably stupid -made a monumental mistake-, or that plato being the classic genius that he was, was simply brilliantly deliberate. in addition, based on my previous discussions, whichever of the two plato may have been, his appeal to the story of er as a myth-expressing-universal-truth-ergo-beingauthoritative is now highly suspect. the way i see it, the myth of er as such is more of the fictional variant. therefore, i conclude that plato’s view on human nature -i.e., one is predestined to be either good or evil even before one is conceivedis also of the of the same kind: at minimum, highly questionable. finally, through the story of er, plato, undeniably, however, also presented something worth positive merit. the story tells here of those souls who made the wrong choices in heaven: he was one of those who came down from heaven, a man who lived in a well-ordered polity in his former existence, participating in virtue by habit and not by philosophy, and one may perhaps say that a majority of those who were thus caught (i.e., making wrong choices) were of the company that come from heaven, inasmuch as they were unexercised in suffering. but those who came up from the earth, since they themselves suffered and seen suffering of others, did not make their choice precipitately...(7) the above citation tells us several things. firstly, that “habitual virtue” is not enough. habitual virtue, meaning unreflectively repeatedly doing something precisely because we consider it to be ethically good or sought-for, thereby making the said action almost part of our so-called second nature. plato here shows an insight into the human tendency to do things based on established pattern -and the pattern in turn already unquestionably considered as safe. at the same time, he however posits a challenge to the said habits by saying that one could be “... participating in virtue by habit and not by philosophy...”, thereby implying that even our so-called habitual virtues should also be adequately checked or examined either for further buttressing, or for possible amendments, or even for total change. secondly, that what can really guide to make such checking and correcting is “philosophy” or simply put, reflection. plato seems to be saying that habits at times could also lead us to selfdeception, and unfortunately at times with dire consequences. ergo, if ever there is a habit which should be so consistently nurtured and cultivated it is that of selfexamination, self-reflection, because as plato’s paragon socrates said, “an unexamined life is a life not worth living.” thirdly, that as our comfort zones -brought about by habitual inclinationscould dull our capacity for right judgment, inversely, difficulties could hone it. thus the citation says that “but most of those who came from earth, since they themselves suffered and seen sufferings of others, did not make their choice precipitately...” my observation and experience confirm plato’s point. i have seen that the people who usually panic or wilt in crisis or extreme situations are the ones who lived protected lives. to a large extent, quite a number of people who are products of sheltered upbringing lack that toughness to make even simple decisions, and more so, hard decisions. simply as a university professor, i have witnessed quite a number of students coming from really prominent families who lived directionless lives. students who are more focused in their studies -and later in their careersare usually the ones who come from lower and middle income backgrounds, backgrounds usually characterized by resiliency, hard work, competition. 6 bangladesh journal of bioethics 2010;1(2):2-6 references 1. shorey, p, translator. plato: the republic, 2 vols. first printed, 1930. cambridge, mass., and london: loeb classical library; 1953, 1956. * this paper should not in any way be reproduced without explicit permission or proper citation of the author. 2. plato: republic, 614b-621b. 3. 614d. 4. 621c-d. 5. 615e. + the greeks also believe in reincarnation. 6. 617d-e. 7. 619c-d. bangladesh bioethics society 2011 vol 2 issue 2 page 3 3 editorial infertility treatment in developing country western countries believe that overpopulation is the major problem of developing countries. they think that contraception and fertility control should be policy of resource-poor countries. this conviction was and still is the main barrier to consider infertility treatment in resourcepoor countries. but in developing country having children is a social obligation, due to the family (-in-law) and the community. in these countries children secure one’s marriage, confer social status, guarantees rights of property and inheritance, assist with labor, offer social security in old age and provide continuity by maintaining the family name. egalitarian societies, people want children as part of their life plan and they suffer when they cannot fulfill this wish. however, because parenthood has deeper social rooted in developing countries, the social and psychological consequences of involuntary childlessness are often more severe and largely impact on the lives of men and especially women. in a conference on population and development in 1994 in cairo adopted a dentition of reproductive health that integrates both fertility control and infertility treatment in family planning. reproductive health therefore implies that people are able to have a safe sex life and that they have the capability to reproduce and the freedom to decide on it. family planning implies both avoiding unwanted children and having wanted children. so the infertility treatment in the context of reproductive health and family planning is crucial for the ethical evaluation. a utilitarian could defend that it is the best to cure infertility by providing art in developing countries to maximize happiness and well-being. other perspective can be taken for these negative consequences of infertility in developing countries. these are – 1. focus on changing the existing moral and social order so that infertile people will no longer be ostracized and discriminated. 2. measures should be adopted to diminish the pronatalist ideology and its undesirable consequences. this can be done by providing education to women to obtain a job which gives them an alternative route to increase their self-esteem and to ensure economic independence and security. like infertility, in india, china and some other countries, mother who has only daughter are often undergo ostracism, a reason for a man often divorce to his wife, face beating, risk for suicide or fatal accidents. the main argument against this analogy is that wanting a child is acceptable while wanting a child of a certain sex is unacceptable. shamima parvin lasker (professor & head of anatomy. city dental college, dhaka) associate editor bangladesh bioethics society bangladesh journal of bioethics 2010; 1(1):2 introduction of bioethics and its necessity in bangladesh arif hossain, phd fellow, international studies and diplomacy, washington university, usa. shamima parvin lasker, professor of anatomy, city dental college, dhaka, bangladesh email: ykhsmh@yahoo.com bioethics is the understanding of rights, responsibilities, justices and moral interaction in living beings. it includes medical ethics, environmental ethics, legal ethics, business ethics and ethics in human rights & politics. legal ethics, business ethics and ethics in human rights & politics. since its inception in 1970, the field has grown exponentially in its scope and importance. many hospitals now employing bioethics experts to guide on such issues as allocation of scarce resources, how to care for terminally ill patients and dilemmas of doctors facing everyday for advancement of new technology. there are at over 95% of u.s. hospitals has ethics committees for helping physicians, nurses and families on bioethical issues on a case-by-case basis at present. thus today bioethics is not only a reasoned discourse but a matter of crisis management. bangladesh is a pluralistic society with a wonderful diversity of values and ethical ideals. but poverty, natural calamities, lack of proper and substantial education and rapidly advancing technology people are forced to deal with one crisis after another. in a result bio-ethical decision, sanctity of life is deemed to be less important than the quality of life. corruption, nepotism, selfishness, misconduct and malpractice are becoming the common phenomena in bangladesh. it gives the impression that we don't able to tell which values need to be employed when and which ethical dilemmas need our most immediate attention in our society. thus implementation of bioethics is needed urgently in bangladesh to make the country peace and prosperity. bioethics in bangladesh prof hasna begum, honorary professor, department of philosophy, dhaka university. email: lala_rukh_selim@yahoo.com this presentation aims at showing i) poverty level, ii) environmental pollution level, iii) outdated education system, and iv) inadequate health services for over (estimated) 14 crore people in bangladesh, in order to evaluate the possibility of bioethics practice and research within the country, and also to find the reasons why bioethics activities have not yet found ground here by. bioethics is a multidisciplinary approach to evaluating bioethical issues. thus, the main reason for a meager presence of bioethics activities in this country is the education system, which is not multidisciplinary enough to encourage bioethics activities. apathy among the academicians and professionals in the absence of a national education policy is causing full implementation of a multidisciplinary system impossible. consequently, students and professionals educated in the present system are generally disinterested in other disciplines. there are bioethical issues present in bangladesh , e.g., indirect coercion and absence of informed consent in the field of population control, exploitation of people in the name of treatment of infertility, environmental pollution in the absence of law enforcement, exploitation of people by health insurance companies, unethical practices by care-givers in the health sector, etc. in conclusion it is stated that bangladesh is an untrodden and rich ground for a bioethicist to do research on many relevant issues present in the country. the need for a national bioethics association to be formed by academicians and professionals, and a national bioethics commission to be formed by the government of bangladesh has also been emphasized. 2 mailto:lala_rukh_selim@yahoo.com mailto:ykhsmh@yahoo.com bangladesh journal of bioethics 2010; 1(1):3 ethical issues in social research prof. ahmadullah mia, ph.d. dean, faculty of sciences and humanities, american world university, dhaka campus, email: amia1941@gmail.com the aims of social research include broadly understanding and explaining human behaviour and relations, influences of social institutions on behaviour, interactions between individuals’ innate tendencies and social institutions, behaviour changes and conditions that lead to changes, scope of manipulations of the environment for positive social outcome, and impact of social interventions on individuals and groups or communities, etc. varied methodologies are applied in social studies for theoretical development as well as advancing social inventions contributing to improvement of the living conditions of human population. forms of studies are planned to suit the purpose. also, methodology used in a study determines the type of study. ethical issues in social studies emanate from the debate on the purpose of social studies – whether studies should primarily focus on building knowledge or application for change in the social conditions. similarly methods applied to investigating into human life as making scientific exploration or influencing social conditions invite ethical controversy. values that guide social research contain ethical elements, which are unavoidable, like research in any other field. social research concerned with human being is always likely be plagued by controversy on ethical judgment. the only way to bypass the problem is to give priority consideration to ‘those who the research is meant for’. the goals of bioethics education prof. darryl macer, ph.d., regional adviser for social and human sciences in asia and pacific, rushsap, unesco bangkok, email: d.macer@unesco.org the rationale for bioethics education is in the asia-pacific regional action plan, “joint plan of action for regional networking in bioethics education towards better bioethics education”, developed at the unesco asia-pacific conference on bioethics education in 2006. please refer to the goals there for a discussion. the international bioethics education network was also launched. the current strategies will be discussed including: 1) use of on-line teaching materials for bioethics education in different countries. production of cross cultural materials. improvement via expert meetings. adapted and translated in different languages to teach school and university classes about bioethics. 2) a network of teachers in different countries , sharing bioethics curricula for schools, bioethics clubs and other endeavours. 3) implementation of the joint regional action plan (july 2006) 4) mapping of bioethics teaching programs in global ethics observatory (geobs) 5) sharing of museum displays and over stimuli to enhance classroom interactions 6) development of moral games and participatory methods 7) conducting teacher training workshops with unesco national commissions and colleges 8) curriculum review and development 9) unesco core curriculum on bioethics and mous with pilot institutions 10) mainstreaming of ethics, integration into professional educational review and training 11) evaluation of teaching bioethics. 3 bangladesh journal of bioethics 2012; 3(1):4-12 4 transcending gender and sex: ethical implications for identities, ambiguities and interrelations oluwaseun adeola adenugba department of philosophy olabisi onabanjo university ago-iwoye, ogun state, nigeria. email: seunfunmiade@yahoo.com abstract: this paper examines the moral issues involved in the acts of transcending gender and sex. attempts are made in answering such fundamental questions as: is transgenderism necessary and beneficial? does transsexualism necessarily imply transgenderism? are natural rights violated by the acts of transcending sex and gender? what implications do development in trangenderism and transsexualism hold for our conventional linguistic resources, identity and interrelationships? ought humans to be allowed freedom to choose to transcend gender and sex? what criteria should be used in avoiding bigotry against androgynous and in harmonizing relationships with their physician? we review the current state of clinical research with transsexualism and transgenderism, the history of transsexual research, the major moral arguments for and against the practices of transcending gender and sex, and the new ethical dilemmas sprawled as aftermath. the paper critically assesses the arguments on the dividing line of the debate. this paper establishes that the reasons offered for artificial intervention in traversing sex and gender are not sufficient and morally convincing enough. it concludes that instead of the predominant current attitude of aggressive intervention with naturally unique sexuality, together with its attendant discrimination and moral resentment against transsexuals and transgenders, it is more ideal to engage on the one hand, in an in-depth discussion with the concerned people, listen to their worries and see ways in which their problems could be addressed through counseling. an on the other hand, there is a need for public discourse and public awareness on the fluidity in gender and sexual orientation so that people’s attitude to this new development can be better sharpened. keywords: transgender, transsexualism, gender dyphoria. introduction: transgenderism and transsexualism are relatively new issues generating opprobrium in contemporary ethical discourse. these acts generate some new worries beyond the conventional issues in gender and sexism discourses; this accounts for why we have divergent opinions as to the morality, immorality or amorality of transgenders and transsexuals. starting off from a conceptual angle, this paper provides some analysis of related concepts that can enhance our subsequent understanding of the moral issues raised in this paper: transgenderism and transexualism. as a prelude to this, is a historical exposition of the genesis to the practices of transgenderism and transsexualism. the third section of this paper is a critical x-ray of the apologist arguments and the non-apologist stance on the ethics of transgenderism and transsexualism. the last section of the paper systematically evaluates the dividing line in the debate with some noteworthy concluding remarks. bangladesh journal of bioethics 2012; 3(1):4-12 5 historical analysis of transgenderism: the history of transgenderism shows that it was already in existence before it was diagnosed in the 19th century. history reveals that modern diagnosis started back in 1880s in germany. dr. magnus hirschfeld was the true pioneer in the field of transgenderism and he was also the first to coin the two popular terms used in describing transgender: transvestism and transexualism. though cauldwell was quoted in about 98 % literature as the first to use the word, hirschfeld wrote his first monograph about this phenomenon in 19101. hirschfeld’s curiosity and interest for transgender made him explore the idea of a surgical solution to some of the cases of transgender. he also reported that the first incomplete surgery in female to male patient was performed in berlin in 1912.this surgery involves the removal of the sexual organ of the patient. the most notable attempt at vaginosplasty was initially performed using skin graft from the legs. however, in 1931, the first male-female was again reported. this success was made possible with hirschfeld’s recommendation. this patient, named ritchter rudolph, underwent castration (penectomy) and an artificial vagina was constructed for hir. in 1930, lili elbe who was referred by hirschfeld had sexual re-assignment surgery under gohrbandt, and died the following year from the complications that resulted from the surgery. the death of lili elbe caused fear to the people as a result of which magnus hirschfeld institute for sexual science was raided and destroyed by nazis. magnus hirschfeld died two year after the incidence. the reaction of people to transgender prompted them to burn writings in sexology and this accounted for the reason why sexologists were persecuted during the nazi holocaust. it is also very interesting to note that transexualism that was halted by german society was embraced by some countries in europe. in demark and norway, this activity is being referred to as ‘therapeutic penectomies’ and castration’. history recorded that transsexualism moved into public spotlight in late 70s and early 80s. this became very more evident when the first american named christine jorgensen had srs (sexual reassignment surgery) in 1952 which was done in copenhagen. this incident attracted the attention of the public and it was also reported in new york daily news. this publicity of the sexual reassignment of christine jorgensen made the practice to grow dramatically. as a matter of time passage, transsexuals began telling their own stories without any fear of contradiction or molestation. however with the growing prevalence of srs in europe, the us was still hesitant to the operation. this was because transgender individual were afraid of being persecuted by law. srs would remain a crime as long as there is no officially recognized diagnosis that makes it a valid cause. srs finally came to america and the first gender identity clinic was opened; but it was done after getting permission from baltimore court. srs today is a wider practice outside the continent of europe to every part of the world. transgender and transsexual: a conceptual clarification: karl h. ulrichs once voiced that: our character, the manner in which we feel, our entire temperament is not masculine, it is feminine. we only act male. we play the male just as an actress plays a man on stage…. it is impossible for us to transform our female instinct into a male instinct2. bangladesh journal of bioethics 2012; 3(1):4-12 6 the above alarm of karl ulrichs shows that transgender individuals are just unfortunately caught in a wrong body. as a transgender hirself and hir assertion represents the contradiction between hir sex assigned at birth, and hir gender disposition. there are a host of people who from an early childhood stage in life often show a desire to express themselves in ways that are not socially acceptable for their naturally assigned sex. if this true, what then is transgender? transgender can be described as a general term applied to a variety of individual behaviors and groups centered on the full or partial reversal of gender role 3 . transgender individuals are people who by all known biologic measure are male or female yet feel like a member of the opposite sex4. transgenderist are therefore people who freely and fully live in opposition to their anatomy. they are said to suffer certain discomfort and as a result of this may need their sex changed. this discomfort is called ‘gender dysphoria’. however, transgender may or may not had medical re-assignment surgery called srs i.e. sexual re-assignment surgery while transsexuals are individuals who desire to have or have achieved, a different physical sex from that which they were assigned at birth. transsexuals are those who had surgery or hormones enhancement in an attempt to traverse the boundary of their physical sex. they were assigned at birth. “a transsexual man may be referred to as ftm (female to male), f2m, or mtm, the latter used in recognition of the fact that they had not ever felt female in their lives”4. we can therefore say that all transsexuals are transgender but not all transgender are transsexual. transgenderists are said to have long faced discrimination in medical institution, including physician’s offices and hospitals 5 . more critical is the societal opprobrium against them; they are seen as outcast in many societies. there are divergent views as to what may have caused a person to feel highly uncomfortable with the sex which hir/sie belongs. can we simply say that transgender have a uniquely wired brain? what exactly is the cause of this? are they different being entirely? these are some of the questions that lingers the mind of concerned persons about transgender. a recent study showed that “the nucleic of transgendered male to female (mtfs) is the same size of the nuclei of genetic females” 6. this position is further supported by an earlier study that reveals that female hormones have been used in treating prostate cancer for years so also is female dying of virilizing adrenal tumors has nucleic consistent with their genetic sex 7. this is a way of saying that the hormonal exposure of both female and male has no effect on the gender specific nuclei of their brains. in the psychiatric diagnosis coding manual dsm-iv, gender dysphoria is listed as a psychiatric condition. psychopharmacologic medication is given to individual who has not had surgery. this medication i.e. psychopharmacologic medication may no longer be necessary once surgical intervention has taken place. as earlier mentioned, transgenderists do not feel fit in the body they find themselves and nearly all transgendered adults feel this discomfort right from their childhood. this feeling comes from within and this is very difficult to say as a child. some children even make effort to dress and act like a man secretly. the stage of acknowledgement of themselves as not being in the right body varies from mid childhood to middle age. transgender people failed to acknowledge this fact because of the fear of being stigmatized in the society or the possibility of being rejected by their family, friends and even at their places of work. it seems this act naturally sounds absurd and difficult to convey proudly in the society. many have mixed up transgenderism with homosexuality. homosexuals are individual who are sexually attracted to members of the same sex and may not have the desire to have their sex changed. some of bangladesh journal of bioethics 2012; 3(1):4-12 7 them are desirous of a change in sex. those who have their sex changed (mtfs) still are attracted to men; much as ftms are also attracted to women. richard green hypothesized that homosexual identity disorder is etiologically related to homosexuality without gid (gender identity disorder) it is worth noting that majority of the children who express interest in being the opposite sex are not transgender though many of them become homosexual and less than 20% of this children want to be called a name consistent with their gender identity 8. this goes with their way of dressing, the kind of friends they move with and the kind of activities they engage in. many of them are also afraid of the age of puberty because the irreversibility of this change is seen as a threat to the way they are perceived. the rate at which medical practice is advancing is amazing and that is why “medicalization” of transgenderism is possible. "medicalization" has helped transgendered people to acquire therapy and social acceptance, transgenderism is part of a larger social struggle between defenders of the "natural" and "god-given" and the right of individuals to control their own bodies and define their own lives 9 . whether the individual has a sole right to intervene with the natural is another question entirely. in order to have a sex changed either from male to female or female to male required certain medical intervention. estrogen is required from mtf and testosterone is required for ftms. these interventions have their side effects. this shall be discussed later when pointing out the risks of srs and treatments. biomedical ethics, transsexualism and transgenderism: in this session, effort will be made to analyze very critically, the practices of transexualism and transgenderism, using the principles of biomedical ethics as propounded by tom beauchamp and james childress which are: the principle of respect for autonomy, the principle of beneficence, the principle of non-maleficence and the principle of justice. our aim in this regard is to justify and defend acts in transsexualism and transgenderism. transgenderism, transsexualism and the principle of respect for autonomy: autonomy is derived from the greek word autos and nomos meaning selfrule or self-governance 10. initially, this principle was directed only in relation to self-rule of independent city or state; but now, it is extended to individuals. the autonomous individual acts freely without interference from the other. s/he chooses what s/he sees as being right. the conception of the scope of autonomy differs among scholars. some recognize it as the capacity for selfgovernance such as understanding, reasoning, deliberating, managing, and independent choosing. at the level of the individual, the non-coerced demonstration of these capacities is seen as the trait of an autonomous person11. being autonomous is to respect the moral agency of an individual; respecting individual agents is to acknowledge that they have a right to hold a view, make a choice and take actions based on their personal values and beliefs10. if the principle of respect for autonomy is rightly taken, then an individual agent who has chosen a medical intervention for his/her discomfort should not be hindered in anyway. a transgender who suffers gender dyphoria has the moral right to determine what hir/sie wants to do with the body. as long as a discomfort is evident, no one should stand against the actualization of the desired goal of either an intending transsexual or a transgender. denial of such is an infringement of the person’s right and disrespecting his autonomy. such an endeavor can be term as cruel. how do we know when an individual is indeed autonomous to make such big decision? this would raise further question on the criteria for autonomous being. transsexualism, transgenderism and the principle of beneficence: it is one thing to respect individual autonomous decision; it is another to help others in the attainment of a beneficial end by contributing to their welfare. beneficence refers to the character traits or virtue of being disposed to act for bangladesh journal of bioethics 2012; 3(1):4-12 8 the benefit of others. the principle of beneficence therefore refers to a statement of moral obligation to act for the benefit of others10. with the principle of beneficence, one is not only refrained from harming, but also to make effort in doing what will benefit others. by implication, the principle of beneficence recognizes the moral obligation a person with the intent of transsexing owes others by self-querying whether the act will benefit others or not. to a transgenderist, the question is raised if the act of gender fluidity will be beneficial to other concerns, even if not selfbeneficial to the transgendered. the principle of beneficence has an altruistic appeal though with modification. this principle of beneficence raises some questions, which if not cleared, may affect the right application of the moral principle to the acts of transcending sex and gender. what is best, and even beneficial, is itself, a problematic concept. it is arguable to say that i can only know what is best for me and not for others. what is beneficial to me may not be beneficial to others. in fact, the word ‘others’ is ambivalent as one may ask, what is the scope of the ‘others’? in any case, conscious effort should be made to support an individual in actualizing what is beneficial to him and no effort should be made to hinder him from what he thinks benefits him. a transsexual who succeeds the surgical operation and hormones enhancement may want to belief hir/sie has benefited by being in the desired body. transsexualism, transgenderism and the principle of non-maleficence: this principle imposes an obligation not to inflict harm on others. this principle in a way expresses an obligation of non maleficence and an obligation of beneficence which goes thus: “i will use treatment to help the sick according to my ability and judgment, but i will never use it to injure or wrong them”12. this principle can be simply stated thus: one ought not to inflict evil or harm, either on self or others. the denial of a transgendered individual the avenue to have srs may be termed as doing harm to the other. the discrimination and resentment to health care that transsexual are prey to in the hands of the society and medical personnels are morally condemnable on the basis of the principle of non-maleficence because the transsexual or transgendered are psychologically and medically harmed. there are different ways in which an individual can be harmed. harming could be psychological, emotional, physical and institutional. the strong feeling of being in the wrong body is a feeling that no one can assist another to explain with adequacy. it is a feeling that could be tagged with the psyche even emotional and this may affect the relationship of such individual with the other members of the society. how can we be sure that granting the request of transexualist is not more of infliction of harm on the concerned individual? transsexualism, transgenderism and principle of justice: various philosophers have used terms like fairness; desert and entitlement in an attempt to explicate justice10. justice guarantees what is due or owned to a person. an act is considered as injustice if it involves a wrongful or an omission that denies people resource or protection to which they are due. injustice is said to occur when some benefits to which a person is entitled are denied without good reason or when a burden is imposed unduly. the endeavor to kick against transsexualism could be said to be denying the concerned individual resource and the protection they are due for. in order to ensure that justice is done to everyone, transgender should not in any way be prevented from what he so desire to have or to be in life. our in-depth understanding of the analysis of the principles of biomedical ethics vis a vis transgenderism shows that it favors the act. why not transsexualism and transgenderism: we shall critically present the ethical problems generated by the acts of transsexualism and transgenderism, which are arguments posed against the practices. some arguments have been posed against the veracity and meaningfulness of the practice of transsexualism, be it male to female (mtf) or female to male (ftm): bangladesh journal of bioethics 2012; 3(1):4-12 9 evident danger: in traversing sex, (both in ftm or mtf), supraphysiologic doses of cross hormones is required for its effectiveness. for mtf, estrogen is required and ftms, testosterone is required. the danger in this intervention is that the administration of high dose of estrogen poses the risk of blood clots. this is said to be very fatal if it travels to the lungs. testosterone use for ftm is also with its risk. testosterone is meant to prevent menses but this drug also induces hypertension. irreversibility: it may be important at this point to note that srs is not just about changing sex, gender role or name. it involves changing everything that makes one either man or woman. for instance, the administration of estrogen to male changing to female has the effect of producing breast enlargement and also helps to diminish sperm production. this is the reason why some have decided to have their sperm stored in the sperm bank in order to maintain and retain their productive capacity. so also is ovulation and menses lost when testosterone is used. the unfortunate thing is that eggs cannot be stored but it is not impossible that it may be technologically possible in the nearest future. our worry with this practice is that the change as a result of srs is irreversible. intervention in children: intervention in children also constitutes a very serious problem. there is the problem of when and how to intervene with children evaluated to be transgendered. there is no consensus as to what should be done to children with gender dyphoria. the worry is whether the intervention should come up at early age or withhold till when we can be sure that the child really wants it. some have argued that such should be delayed until the completion of puberty because children are likely to have their minds changed about their sex; some others have argued that the earlier it is done, the better. this argument is defended on the ground that it will help to prevent severe depression and it will also help to avoid psychological effects resulting from painful procedure during and after intervention. integration in the society: many are faced with the problem of how to address transgender individual. since it is not the case that all transgender are transsexual, one may therefore be a transgender and not transsexual. the implication of this is that the practice creates ambiguity of identity. one may not find it funny making mistake in addressing transgender when only their gender role has been transitioned to a role consistent with their gender identity. this is because their name and gender have not been legally changed. in some states, before allowing a name and gender changes, “genitoplasty” or “mastectomy” may be required. this is a serious confusion caused by transgenderism. cost of treatment: this intervention is costly and most insurance companies do not cover this treatment. many save for many years in order to have necessary treatment for the discomfort they suffer. in the netherlands and belgium, national health insurance covers treatment related to transgender individual. in short, the unequal access to treatment of transgender as it is not covered by all countries strengthens the harm done to the individual who could not access such13. playing god: the idea of playing god is prominent in arguing against all forms of human enhancement technologies. activities such as genetic engineering, cloning, and reproductive technologies such as ivf, artificial insemination etc. are argued to be playing on god, or put mildly, rubbing shoulder with god in the act of creation. there is no doubt that activity such as this involves series of manipulations. in the other way, a counter argument can say that we are not playing god but assisting god to perfect the imperfection in what he has created. . since we are ordinarily meant to be creative and productive, there is no point waiting for god for remedies. instead, conscious effort should be given in service to humanity in order to bring about perfection. bangladesh journal of bioethics 2012; 3(1):4-12 10 unnaturalness: there is also the argument that says it is naturally wrong to go against nature 14 . it is a traditional part of catholic moral theology15. since transsexualism is an act against the natural way in which the person has been created, conscious intervention is therefore morally wrong. transsexualism is a form of enhancement. it is to make people be in their best. there is a counter argument against this position because defining “natural” itself is a difficult task to embark on. almost all the technology we benefit from will be termed as unnatural. for instance, the use of mobile phone, airplanes etc. will all count as unnatural. other argument is that it increases inequality because not every transgender will be able to afford the cost of treatment and solutions to the discomfort suffer. srs also opens up the opportunity for misuse to the extent parent can desire the opposite for their children especially when there are existing treatments to it. having carefully discussed the arguments against transsexualism, we have seen very clearly the problems with the practice. additionally, dr. paul mchugh, a psychiatrist-in-chief of johns hopkins hospital said: i have witnessed a great deal of damage from sex-reassignment... we psychiatrists have been distracted from studying the causes and natures of their mental misdirection by preparing them for surgery and for a life in the other sex. we have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it 15 . mchugh realizes that efforts in the past made damaged their credibility by getting involved in preparing transgender individual for surgery. elliot on the other hand compared srs to a psychiatric condition. like the conservative critique, elliot argues that sex re-assignment is a sign that we are using inappropriately to cure spiritual and psychiatric ailments 16 . all these arguments show the controversial nature of transsexualism. evaluation: considering the arguments for and against earlier presented, it is crystal clear that the debate around transgenderism is an enigmatic one. aside these arguments, there are certain cultural issues which seems not to be too evident for some culture but dominant in some others. for instance in an african culture specifically some parts of the yoruba land (a tribe in south west, nigeria) importance is placed on a male child. if transgenderism is culturally and generally accepted by the society, there is no doubt that members of the society may want their sex changed so that they can perfectly fit in. this, no doubt, may give them the necessary treatment they deserve as member of the desired sex. cultural issues may be part of the reasons why some transgenders wants sexual reassignment surgery. besides cultural bias in the assessment of transgenderism and transsexualism, some scholars have based their arguments on freedom and autonomy of decision making of the concerned person. we become more disturbed whether autonomous decision should extend to sensitive and controversial issues such as the one we have. we also have to take cognizance of misuse of the available medical intervention by parents and individual who intentionally want to hide under the pretense of having a gender dyphoria. the worries of this paper can therefore be captured by this question: to what extent are individual said to be autonomous or are there limit to our freedom? our conviction is that an individual has bangladesh journal of bioethics 2012; 3(1):4-12 11 an autonomous right to do and make decision about his life and situation but this right should not be void of sanity. issues about transgender do not necessitate surgery or other aggressive form of intervention. it is on this ground that this paper is proposing an alternative to total transexualism. conclusion: transsexualism is a very controversial issue. it is controversial because one cannot argue that it harms the other person. for instance, a conscious effort to spread hiv to the other can be said to have a direct effect on the potential victim and also the society at large but transsexuals are satisfying their interests; getting themselves involve in aggressive intervention such as surgery and etc. in order to ensure they are in the body compatible with their gender identity. yet, we are still worried about the problems generated by this practice, most especially, intervention in children who have the tendency of having a change of mind in the future. the irreversibility of this practice is also a good reason to be worried. having seen the medical possibility of assisting the concerned individual and the risk it poses, it may be necessary to find an alternative to transsexualism, specifically srs. the alternative this paper suggests is to enter into a care relationship with the individual, listen to their worries and see ways in which they can be counseled and assisted. this cannot be successful if their pains and suffering are not shared with them. in fact, there may be need to acknowledge that their pains is evident; this will stimulate the process of interaction and it will help in the counseling process. indeed, it is an issue that needs to be tackled in order to ensure that the processes and outcome of sexual and gender transcendence are not misused by individuals in the society (especially parents who prefer their child to be in the other body different from the so called natural body), medical practitioners, social crusaders among others. moreover, there is a need for public discourse and public awareness on the fluidity in gender and sexual orientation so that people’s attitude to this new development can be better sharpened. i am not morally convinced that the sole solution to this discomfort is total transition to the desired body or a change in gender status. in other words, the discomfort they claim to suffer is not a good reason to have sexual re-assignment. references 1. hirschfeld m. die intersexuallekonstitution, sexualle zwischentufen. 23: 2-27. 2. ulrichs kh. forschungenüber das räthsel der mannmännlichenliebe. trans.1994. p. 1864-79. 3. transgender, transsexual, gender identity disorder, http://www.web4health.info/en/answers/sexgender-what.htm. 4. feinberg l. transgender warriors, boston: beacon press, 1996. 5. feinberg l. trans liberation: beyond pink or blue, boston: beacon press; 1998, p. 43. 6. kruijver fp, zhou jn, pool cw, hofman ma, gooren lj, swaab df. male-to-female transsexuals have female neuron numbers in a limbic nucleus. j clin endocrinol metab 2000; 85(5): 2034-41. 7. zhou jn, hofman ma, gooren ljg, swaab df. a sex difference in the human brain and its relation to transexuality. nature 1995; 378(6552): 68-70. 8. green r. a typical psychosexual development. in: rutter m, hersov l, taylor e. eds. child and adolescent psychiatry. london: blackwell scientific; 1994. 9. zuckerand ks, bradley sj. gender identity and psychosexual problems in children and adolescents. london: the guilford press; 1995. 10. beauchamp tl, childress jf. principles of biomedical ethics. new york: oxford university press; 2009. p. 99. bangladesh journal of bioethics 2012; 3(1):4-12 12 11. rebecca k. consciousness autonomy: displacing decisions in health care. hasting center report 2005. p.34-44. 12. jones whs. hippocrates. vol. 1. cambridge: harvard university press; 1923. p. 165. 13. cohen-keltenis pt, pfafflin f. transgenderism and intersexuality in childhood and adolescence, making choices. london: sage publication; 2003. 14. baron j. against bioethics. cambridge: the mit press; 2006. 15. finnis j. natural law and natural rights. oxford: clarendon press; 1980. 16. elliot js, better than well. new york: norton & co; 2003. bangladesh journal of bioethics 2011; 2(3):19-20 19 short communication public responsibility and shortage of resource in healthcare shamima parvin lasker professor & head department of anatomy, city dental college, dhaka, bangladesh health is the basic human right. it is the moral obligation of the society to ensure everyone to access some level of health care service for living as a human life, functioning normally and pursuing many other values in life. since 1980, contemporary health care has become sophisticated and expensive in order to exponential advance in diagnostic capabilities and related therapeutic possibilities. due to the shortage of recourse, something is needed to plays a powerful role in political dialogue that may have moral and ethical value. traditionally, in medical model of disease, patients are usually not held responsibility for the genesis of their illness. when a person becomes ill, the medical judgment implies that he can not be blame for his condition. the treatment and care are appropriate and morally desirable for him. western philosopher john rawlsian said basic social justice is resulting from a social contract between the society and institutions in where the parties (people) come together to achieve the benefits. the parties are imagined as normal and fully cooperating members of society and possessing the two moral powers – capacity for a sense of justice and conception of the good. norman daniels shifts rawls theory in health care. health as a primary social good and people are normal and fully functioning individuals. therefore, people should make significant contribution to protect the normal function by limiting attitude as much as possible. moreover, human right to healthcare implies that the individual has obligation for healthy behavior and the restriction of unhealthy choice as an autonomous individual. in addition in a liberal society, individual are normally free to do as they choose. in this respect caring for health is not different from other dimension of personal life. but when the individual choices turn out badly and when individual remain uninfluenced by moral appeal of health education e.g. a drunk driver bear the costs of medical care that he needs after a car accident, a smoker have lung cancer, heart attack who is seriously over weight, alcohol and the liver disease, aids with unsaved sexual activity, skiing, top-class sports, and other hazardous activity etc., the legal and financial sections may be think of justification. if an individual has a health problem he is causally responsible due to his unhealthy life style or the risky behavior in the past. since the person himself is the cause of his present problem, he is also answerable for the consequence of his prior behavior. retrospective concept of responsibility is therefore retrievable. this attempt may guide and change the individual’s behavior for his future health and may reduce the bangladesh journal of bioethics 2011; 2(3):19-20 20 cost of healthcare. research is needed to find out the relationship between major expenditure with certain pattern of behavior. references: daniels, n. justice, health, and healthcare. american journal of bioethics 2001; 1: 2–16. have hamj ten. genetics and culture. bioethics in uropean perspective, netherlands. kluwer academic publishers.2001. have hamj ten and loughlin m. responsibilities and rationalities: should the patient be blamed? healthcare analysis 1994; 2(2):119-127. rawls, j. political liberalism. new york: colombia university press. 1996, yvonne denier. mind the gap! three approaches to scarcity in health care. med health care and philos 2008; 11:73–87 on the myth called ‘african bioethics’: further bangladesh journal of bioethics 2012; 3(3):4-11 4 on the myth called ‘african bioethics’: further reflections on segun gbadegesin’s account fayemi, ademola kazeem 1 , akintunde, folake adeogun 2 1, 2 department of philosophy, lagos state university, ojo, lagos email: kcaristotle@yahoo.com, adeogun2020@yahoo.com abstract: this paper examines, and further reflects, on segun gbadegesin‟s position on the question of african bioethics. in an attempt to situate bioethical discourse within the garb of cultural appropriateness, gbadegesin gives an african perspective of bioethics by exploring the attitudes of the yoruba people (an example of an african culture) towards bioethical issues. through this, he calls for a transcultural bioethics, which will underscore the universality of bioethics without undermining the significance of cultural identities. this paper challenges as a „myth‟, the assumptions and positions of gbadegesin in his recent discourse on african bioethics. by raising and adducing reasons to fundamental questions (such as: how authentic is gbadegesin‟s reportage on the yoruba attitude to bioethical issues? how plausible is the possibility of a universal/global bioethics that is anchored on the recognition of all cultures in bioethical discourse? is there a distinctive african bioethics? if yes, what is the nature of such an inquiry? what are the bioethical principles employed in solving bioethical issues in african culture?), this paper defends the position that there is not yet an african bioethics. keywords: bioethics; african bioethics; ikuyaj’esin; culture; yoruba. introduction: bioethics is an aspect of applied ethics which studies ethical issues in all forms of life. it concerns ethical issues arising from healthcare and the biomedical sciences 1 . it is an interdisciplinary field of study that addresses adverse set of ethical questions associated with biomedicine, life sciences, most broadly regarded public health, environmental issues, as well as issues relating to all integrated aspects of life. bioethics accommodates different disciplines (and not only medical field) to be equipped with the tool of offering sharp critique to the activities of medical, biological and technological researches and innovations as they affect „life‟. bioethics, in its present form has been criticized for its strong footing in western culture. this is on the ground that bioethics developed in the west in response to the impact of development in biomedical technology. not only that, different approaches (such as principlism, consequentialism, deontologism, ethics of care etc.) employ in evaluating bioethical issues are limited to a string of biomedical problems that do not have their roots in non-western contexts. in other words, bioethics in its present form is yet to undertake a comprehensive exploration of the social and cultural realties that shape so many bioethical conflicts. one of the scholars blazing the trail of looking at the possibility of having an african cultural account, both in theory and practice, is gbadegesin. besides him, cletus andoh 2 , godfrey tangwa 3 , kaori mbugua 4 , t. metz 5 , c. onuoha 6 , t.o ogundiran 7 , m. murove 8 , etc. are other african scholars that have defended the notion of african bioethics. they have put forward different arguments has to why bioethics in its present form is not adequate. their arguments challenge bioethics deep entrenchment in a domineering culture, its footing in ethical values that reflects western tradition. for these scholars, bioethics as practiced in modern context, the argument goes, has been portrayed as being eurocentric in nature. the reasons for this state of affair are not unconnected to the argument that bioethics ignores moral traditions whose roots and ways of thinking lie outside western philosophy, political and social theory 9 . western culture in which bioethics in its present form is deeply entrenched is characterized by the attitude of spreading its tentacles towards other cultures. this is done through the encroachment of mailto:kcaristotle@yahoo.com mailto:adeogun2020@yahoo.com bangladesh journal of bioethics 2012; 3(3):4-11 5 their way of life in order to make them its prototypes without a reservation of being influenced by such cultures. also, there is the supposition that the assemblage of bioethics in the western and philosophical and cultural context may not fit in other cultures of the world 10 . this is because for example, bioethics (western) focuses on individual, ignoring who are intimately affected such as the family and the community 11 . this focuses on individual is based on a philosophy that regards the self as the end per se 12 . much as this is axiomatic in the west, in the african perspective for example, the reliance on the self and ethical egoism is misplaced 13 . thus, bioethical principles (of the west) are questioned for not reflecting the cultural experiences of what constitute the value of life in other cultures. thus, leading to the affirmation of areas like „african bioethics‟ and „asian bioethics‟. such phrases, it is argued, encapsulate the incorporation of cultural worldviews into the evaluation of bioethical issues as lived moral experience in different socio-cultural contexts. it is in the light of the above reasoning that gbadegesin presents an affirmative response to the question of african bioethics. in the rest of this paper, we shall be discussing gbadegesin‟s views on yoruba (african) bioethics which he explores under the umbrella of „transcultural bioethics‟. we think his account of yoruba ethics is more of a myth. his conviction on african bioethics, as presently constituted, is a fiction, a figment of the imagination. to defend this position, we think it is apposite to first discuss gbadegesin on yoruba (african) bioethics. gbadegesin on yoruba-african bioethics: gbadegesin calls for „transcultural bioethics‟ which is characterized by: (a) serious effort to understand the cultures and values of other peoples; (b) development of a compendium of values and belief system across cultures; (c) promotion of intercultural dialogue on the critical analysis of those values and belief systems; (d) identification of set of common values that transcend particular cultures; ;and (e) utilization of this set of common values in the development of bioethical principles and standards that all cultures can embrace 14 . from the above, we glean that trans-cultural bioethics aims to achieve a field that is characterized by cultural appropriateness at the base, which builds up and gets to its peak to shed off the cultural fabric for a common bioethical principles and standard for evaluating bioethical issues for all cultures. gbadegesin explores yoruba-african bioethics as a cultural building block of „transcultural bioethics‟. gbadegesin‟s subscription to cultural approach to bioethics propels him to present a yoruba-african stance on bioethical discourse as a response to the question, is there african bioethics? he presents a bioethics rooted in yoruba (african) culture by beaming the search light on the inextricable link between the yoruba cultural beliefs (on personhood and causality) and their attitude towards bioethical issues such as euthanasia, infertility, adoption and surrogate pregnancy and transplantation. according to gbadegesin, yoruba conceptualize a person (i.e. „eniyan‟ in yoruba language) in normative and ordinary dimensions 15 . he notes that strong emphasis is laid on the former than the latter. the ordinary dimension encapsulates the „ara‟ (i.e. body), which is the psysio-material part of the human body that houses internal components such as „ifun‟ (intestine) „opolo‟ (brain), „okan‟ (heart), flesh, bone and „ori‟ (which presupposes the outer head as well as destiny) 16 . there is also the part of „emi‟, (the spirit, active element of life that guarantees conscious existence) which is the most important and it is understood as part of the divine breath of olodumare (the supreme being). in the words of gbadegesin: bangladesh journal of bioethics 2012; 3(3):4-11 6 it is this that make everyone a child of god. thus, in virtue of this heritage, there are things you cannot do to a human person. you cannot take their lives arbitrarily; you cannot make use of them as objects and you cannot make them objects of contempt and ridicule 17 . on the other hand, the normative dimension of „eniyan‟ which really determines the personhood of an individual is premised on the idea of communitarianism (i.e. a perspective that recognizes both individual dignity and the social dimension of human being). that is, an individual is both an autonomous individual (who possesses rationality, moral sense, capacity for virtue and capacity for free choice and responsibility to the community) and a communal being (who is only a person in relation to others). thus, gbadegesin asserts that: being a person means that one has certain rights and responsibilities … including the responsibility to be useful to the community and to be of good behaviour. the training needed for this is provided from the beginning of life and it is expected that the grown up person will have internalized society‟s norms by adulthood. if for some reason, this expectation is not realized, efforts are made to make amend by every of further training, socialization and rituals. personhood is denied to an adult who, after all, still does not live up to expectation. she/he is treated as a child, with sympathy but without responsibilities 18 . the above assertion implies that the yoruba confer personhood only after a process of incorporation into a community through rights and responsibilities. it also shows that a child, an insolent adult, a vagabond etc. cannot be called a person in yoruba traditional culture on the ground that such set of individuals do not meet up to the expectation of the community through rights and responsibilities. thus, personhood can either be denied or conferred in the light of this standard in yoruba traditional culture. consequently, gbadegesin summarizes the beliefs of the yoruba traditional culture on the idea of personhood as follows: (1) individuals are creatures of olodumare (the yoruba supreme deity) and are endowed with dignity and worth, with a capacity for a moral reflection and virtuous life. (2) it is wrong to cause unnecessary harm to creature of olodumare, including non-humans. (3) a person who is a member of a community must not be sacrificed to the deities of the community. (4) personhood is constituted by communal relationship through the articulation of values shared with other members and the actualization of individual potentials in response to, and by active participation in the community 19 . from the idea of personhood in yoruba traditional culture as presented by gbadegesin, we glean that they frown at total autonomy of an individual as it is in western culture. rather, they conceptualize the individual as a relational self to the „others‟ in the community who is saddled with rights and responsibilities of being useful to that community. thus, the realization of potentials for both „self‟ and „community‟ is strongly based on the inextricable link between them. thus, the defining characteristics of „african (yoruba) bioethics‟ which distinguishes it from „western bioethics‟ are: communalism (which emphasizes the sense of fellow-feeling, solidarity and selflessness), sanctity of life and religiosity. gbadegesin explores the yoruba understanding of causality in relation to bioethics. this idea of cause in yoruba traditional culture stems from the observation of disruption of order in a word that ought to move smoothly in a straight line. this disruption is perceive as a problem that may lead to misfortune, illness etc. whenever this disruption occurs, the yoruba make attempt to search for explanation and solution from two perspectives which are the natural realm and supernatural realm. according to gbadegesin: bangladesh journal of bioethics 2012; 3(3):4-11 7 the first level of explanation is the natural realm where natural laws are operative when a solution proposed from this realm does not appear effective, then further questions are raised and further answers are sought beyond the realm of nature where spirits, deities and powerful forces are in control of human destinies 20 . from the above assertion, we understand that the yoruba do not only limit the cause and solution of illness for instance to the natural realm. rather, they extend it to the supernatural realm (i.e. the abode of unseen forces that controls the world and human destines) with the belief that evil forces could be the cause. and that powerful deity can be consulted in turn to heal such patient. having described the idea of personhood and causality in yoruba traditional culture, we shall delve into how gbadegesin shows the link between these cultural beliefs and the disposition of the yoruba to bioethical issues such as euthanasia, infertility, adoption, surrogate pregnancy and transplantation. euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering 21 , according to gbadegesin, the disruption of the yoruba to the above idea of euthanasia is embedded in their reluctant attitude towards it. they frown at the idea of mercy killing in this form because; (1) we are not in a position to know for sure that a miracle cannot happen and (2) we are not responsible for giving life; therefore, we should not be responsible for taking it 22 . however, the yoruba concept of euthanasia which is acceptable “is captured in the idea of „ikuyajesin‟ (which means death is preferable to loss of dignity)” 23 . this concept permits an average yoruba woman to refuse surgical operation for the treatment of breast cancer that would save her life. this is on the ground that it would leave her without a breast. thus, she refuses the treatment base on loss of dignity and not because of pain. also, the idea of euthanasia is permitted amongst the yoruba, if the patient is schizophrenic (which is an example of mental disorder). in the words of gbadegesin: in some cases, (mercy?) killing is excused when it is determined that the individual is not only suffering pain, but that the illness is also affecting his/her mental functioning. for instance, in some cases, an infirm old man or woman may become schizophrenic and may start uttering incoherent statement which may cause embarrassment to the family. in such a case, the family may take a painful decision to end her life before an irreparable harm is done to them 24 . the above assertion implicitly explains the attitude of yoruba to mercy killing as evaluated in the light of their idea of personhood. it shows that the rightness and wrongness of mercy killing is dependent on any case of illness that can lead to loss of personhood. bioethical issues such as adoption and surrogate pregnancy is acceptable in the yoruba traditional culture. the yoruba embrace them as solution to the problem of infertility (i.e. the biological inability of a woman to conceive or carry pregnancy to full term). adoption and surrogate pregnancy‟s acceptance rest on the belief that having children is one of the determinants of conferring personhood on an individual. according to gbadegesin, adoption and surrogate pregnancy are also associated with the belief that “the spirit of the child the woman in question loves and cares for will eventually attract her own natural child to her” 25 . it is important for us to note that the description of adoption and surrogate pregnancy is practiced not in the same way as it is in western culture. for instance, a child is adopted in yoruba traditional culture from a close relation whereby the child is still recognized as the child of her biological parents. surrogate pregnancy on the other hand is described through a scenario whereby the “husband is advised, sometimes by the first wife, to marry a younger woman in the hope that the spirit of the child bangladesh journal of bioethics 2012; 3(3):4-11 8 so born into the family, will attract a child for the first wife too” 26 . surrogate pregnancy is also evident in a situation whereby the woman who finds it difficult to get pregnant “arranges for her husband to marry another woman of her choice on the understanding that she will carry the first wife‟s child” 27 . thus, this arrangement makes the woman married only the genetic mother of the child to be born. transplantation on the other hand is frowned at amongst the yoruba. the reflection of organ transplantation is associated with their disposition towards organ donation. their attitude has to do with the: cultural belief that dealt is a transition from one form of existence to another and that therefore if one does not depart from here as a complete person, one may not enjoy one‟s existence in the next world 28 . from the foregoing, we applaud the effort of gbadegesin to present a bioethics that is rooted in an african (yoruba) culture. however, it raises some fundamental questions: what constitute the „africaness‟ of gbadegesin‟s account of bioethics? is gbadegesin‟s account participating in professional bioethics? do the concepts „ikuyaj‟esin‟, „surrogacy‟ and „adoption‟ as presented by him hold water in the lives of contemporary yoruba people?‟ how plausible is his participative perspective in „transcultural bioethics‟? some problems in gbadegesin’s account: according to gbadegesin‟s account of yoruba bioethics, the humanistic and social understanding of personhood that characterizes african bioethics does not accommodate individualism as it is in the west. consequently, we observe that the bioethical reflection of the yoruba on bioethical issues according to gbadegesin is guided by the yoruba mindset on the concept of personhood and social relationship shaped by the belief in communitarianism. implicitly, his account describes the yoruba attitude to bioethical issues as basically determined by the service to community. in relation to the foregoing, we argue that there is nothing unique about communitarianism in african (yoruba) bioethics that makes it peculiar to africa. this is because communitarianism possesses a utilitarian undertone which is also presented as an approach to bioethics in the west. this undertone informs us of the attitude of the yoruba towards the evaluation of bioethical issues. this principle is evident in the concept of „ikuyaj‟esin‟ as reported by gbadegesin. „ikuyaj‟esin‟ according to him permits the yoruba to kill a schizophrenic old parent if he or she is uttering embarrassing words that could harm the reputation of the lineage. thus, in this scenario, it is justifiable and morally right to kill (for mercy) such adult. in other words, it is permissible through the lens of utilitarian undertone to end the life of an individual. this is on the ground that his or her actions harm (short and long term) the greatest number (i.e. the children or progeny) by deterring their happiness. from the above, it shows that the communitarian nature of african (yoruba) bioethics devalues the individual for the greatest good of the greatest number without paying attention to the individual‟s wellbeing whenever there is conflict of interest. consequently, this debunks the insistence of bioethicists in africa that communitarianism (whether radical or most especially moderate which gbadegesin subscribe to) encapsulates the respect of the individual dignity and moral worth. in other words, the autonomy of an individual through the lens of utilitarian under is determined by the amount of happiness it contributes to the wellbeing of the community. thus, the communitarian african (yoruba) bioethics does not proclaim the inherent moral worth of all people just like it is in the west through the utilitarian approach to bioethics. in consequence of the above analysis, we think that communitarianism is not peculiar to bioethics in africa. thus, we admonish bioethicists such as gbadegesin to desist from the enterprise of misinforming africans and non-africans about the peculiar characteristic of the entirety of bioethics in africa, likewise for the west. this is because they fall into the trap of thinking that the entirety of bioethics in west sees man as an isolated individual in search of pursuing self-interest. however, our research shows that there are different approaches to the evaluation of bioethical issues in the west. bangladesh journal of bioethics 2012; 3(3):4-11 9 consequently without prejudice to gbadegesin‟s account, we ask these mind puzzling questions concerning the authenticity of his account in the light of the attitudes of yoruba towards bioethical issues: what are the sources of his claim on the yoruba disposition? is it from an oral tradition or his assumptions? is gbadegesin‟s account not assuming yoruba attitudes to bioethical issues from heterogeneity to homogeneity (i.e. are these attitudes generally accepted by all subcultures under yoruba culture)? how relevant is his account to the evaluation of bioethical issues in contemporary times? the relevance of gbadegesin‟s account may perhaps be examined through the concept of „ikuyaj‟esin‟, surrogacy and adoption. in traditional times, the concept of „ikuyaj‟esin‟ is relevant in a scenario whereby an individual opts for suicide as the only choice in the face of shame. that is, the concept from traditional perspective as presented by gbadegesin is meaningful only in the light of suicide and not euthanasia. however, if we are to ascribe the concept of „ikuyaj‟esin‟ in the evaluation of euthanasia in contemporary times, then the scenarios painted by gbadegesin will not hold water. this is because, it implies that the yoruba are not receptive to change in the face of technological advancement and the emergence of stronger dimensions to the bioethical issues in biomedical field. for example, we do not think a contemporary yoruba woman will refuse a surgical operation that will save her life and still give her an opportunity to be useful to herself and the community due to loss of breast. this can happen in most cases due to financial constraints and probably not for the loss of breast. to our mind, we think gbadegesin appears not to have made empirical studies on the idea of life and death amongst contemporary yoruba people before presenting the argument based on traditional perspectives in relation to evaluating bioethical issues in modern times. we therefore argue that for „ikuyaj‟esin‟ to be relevant as a principle for evaluating euthanasia in modern times, then it must be contextualized in strong or irreversible scenarios which the concept implies. in order for the concept to be sustained, it must incorporate the consideration of issues of life and death such as neo-critical death (i.e. the chronic vegetative state which is characterized by unconsciousness with retained physiological functions and open eyes of the patient), a kinetic mutism (a condition whereby the frontal region of the brain is impaired which makes the patient aware of his environment but unable to establish a contact), lethargy sleep (which may last over a decade), irreversible ailment like cancer etc. these cases have recently called for special concern due to a high incidence of severe diseases such as cancer or perturbations of cerebral blood circulation which leads to an incurable, irreversible state associated with prolonged period of sufferings. put succinctly, the yoruba describe these cases as “ko j e ara aiye, ko je ero orun” (i.e. neither an inhabitant of earth nor heaven). thus, we reflect that an average contemporary yoruba will employ the concept of „ikuyaj‟esin‟ as modified due to the pain and suffering of the patient. consequently, our modification of „ikuyaj‟esin‟ is more cogent in the context of active euthanasia (i.e. terminating a person‟s life in a painless way, at his request or with the intention of preventing someone from suffering) in contemporary times. surrogacy and adoption as presented by gbadegesin in traditional yoruba culture presupposes so many complications if it is adopted in contemporary times. this is because the rationale behind these issues in traditional setting cannot hold water in contemporary times. for instance, the probability of requesting for the child back by the genetic mother is very high in modern times. thus, conforming to surrogacy has practiced in modern could be detrimental. consequently, gbadegesin fails to take cognizance of the guideline concerning the procedures and the enactment of laws to reduce chances of occurrences before making case for a traditional african understanding and practice of surrogacy in modern times. if this unrealistic in practice in the light of contemporary times, then it is incapacitated in principle. having questioned the relevance of gbadegesin‟s account, we shall turn to the problems inherent in his cultural approach to bioethics. cultural approach to bioethics has a global promise, which is characterized by diverse cultural interpretations of normative principles employed in evaluating issues in bioethical discourse. however, cultural approach to bioethics assumes that culture is static. that is, it does not consider the profound and constantly transforming sources of cultural differences. this is evident in the account of bangladesh journal of bioethics 2012; 3(3):4-11 10 gbadegesin where he romanticized the attitudes of traditional africans in evaluating bioethical issues for contemporary framework. in consonance with this, he identifies the entirety of bioethics in africa with traditional african thought based on communitarianism. this is done in order to exhibit a peculiarity in identity which is in contrast with the western option. kwasi wiredu warns against this attitude of „mummifying‟ our thought because it is detrimental to our development in modern times. in his words, africans are apt to identify african thought with traditional thought. the result has not been beneficial to the movement of modernization usually championed by the same class of african 29 . given that every culture undergoes consistent change whether slow or rapid, we think that no culture conforms to particular norms and worldviews forever but only for a period of time. the „transcultural bioethics‟ proposed as the end in view of cultural approach to bioethics by gbadegesin can be limited by the fact that it is not all cultures that will participate in it. we conceptualize „transcultural bioethics‟ as a „sisphysian‟ task. it is described thus in the words of albert camus because, it could be difficult to incorporate the principles put forward by different cultures without excluding some. also, we are faced with the problem of effecting changes in the construction of transcultural bioethics whenever culture evolves. it is no gainsaying that comparative study is at the heart of african philosophy. this is because most african philosophers tend to present the peculiarity of african philosophy through comparison of western conception and african conception. thus, there is a tendency of comparing philosophy encapsulated in the communal worldviews of the people called ethno-philosophy with professional philosophy. wiredu admonishes us to desist from such attitude in his article “how not to compare african thought with western thought”. he harps that philosophies should be compared on epochal sameness. consequently, this has been imported into bioethical discourse in africa through cultural approach to bioethics. this is evident in gbadegesin‟s account which is premised on the importation of traditional african cultural worldviews hook, line and sinker in the evaluation of bioethical issues in contemporary times. this implies that his account is at the ethno-stage. the bone of contention here is how can there be a sound foundation for a building of „transcultural bioethics‟ that includes the „western bioethics‟ that consistently meets the challenges of bioethical dilemma in the face of technological advancement ad they emerge. thus, can the account presented by gbadegesin and his african counterparts be relevant in the light of contemporary bioethical issues such as blood/blood plasma trade, medical malpractice (i.e. professional negligence by a medical officer which results in harm to the patient), transhumanism? a positive response to this poser is perhaps, very doubtful. conclusion: although, there appears to be agreement about bioethics as a field of study, there is much less consensus about the applicability of principles that can be implemented in diverse cultural settings. it is the lack of consensus that led to the many examples of western, african and eastern dichotomy in bioethical discourse. in the cause of carving a unique identity for respective cultures in bioethical field, scholars sometimes fall into the trap of overzealously accounting for „african bioethics‟, „asian bioethics‟ which they claim are radically different from „western bioethics‟. gbadegesin‟s account of yoruba (african) bioethics suffers seriously from this defect. conclusively, on the bases of our exposition of the limitations of gbadegesin‟s cultural approach and constitution of bioethics, we argue that his account has not presented a distinctive african bioethics. neither has he put forward any peculiar methodology for this discourse, nor does his claim about the defining communitarian character of african bioethics unique. his reference to communitarianism in african bioethics has been identified and discussed by bioethicists in the west such as ezekiel emmanuel 30 and daniel callahan 31 without much underlying difference. no unique african bioethical principle (s) for evaluating issues in bioethical discourse in african cultural world or beyond has been bangladesh journal of bioethics 2012; 3(3):4-11 11 presented. rather, what gbadegesin engages in is merely a description of attitudes to bioethical issues (such as euthanasia, surrogacy and adoption and transplantation) in yoruba traditional thought. thus, his so called „african bioethics‟ is more of a myth, and not yet an african bioethics. references: 1. kuhse, h, singer, p. what is bioethics? a historical introduction. in kuhse, h, singer, p. eds. a companion to bioethics. malden: blackwell publishing ltd.; 2009, p. 3. 2. andoh, ct. bioethics and the challenges to its growth in africa. open journal of philosophy 2011; 1 (2): 67-75. 3. tangwa, gb. bioethics: an african perspective. bioethics 1996; 10 (3): 183-200. 4. mbũgua, k. is there an african bioethics? eubios journal of asian and international bioethics 2009; 19 (4): 2-5. 5. metz, t. african and western moral theories in a bioethical context. developing world bioethics 2010; (10): 49-58. 6. onuoha, c. bioethics across borders: an african perspective. uppsala studies in social ethics 2007; (34): 1-342. 7. ogundiran, to. enhancing the african bioethics initiative. bmc medical education 2004; 4 (21). 8. murove, m. african bioethics: an exploratory discourse. journal for the study of religion 2005; (18): 16-36. 9. randall, v. slavery segregation and racism, trusting the healthcare system ain‟t easy: an african american perspective on bioethics. st. louis: u publications; 1996, p. 191. 10. randall, v. 1996, p. 200. 11. cate, fh. emerging paradigms in bioethics. post humans autonomy, revisited work. supranote, 1994. 12. thomas, l. the morally beautiful in black. in pellegrino, e.d. ed. african american perspective on biomedical ethics. george town: university press; 1992, p. 123. 13. thomas, l. 1992, p. 124. 14 gbadegesin, s. bioethics and culture. in helga, k and singer, p. eds. a companion to bioethics. maiden: blackwell publishing ltd.; 2009, p. 32. 15. gbadegesin, s. eniyan: the yoruba concept of a person. in coetzee, p.h., roux a.p.j. eds. the african philosophy reader. london: routledge; 1998, p. 149. 16. gbadegesin, s. 1998, pp. 150-153. 17. gbadegesin, s. bioethics and culture: an african perspective. bioethics 1993; 7 (2-3): 257. 18. gbadegesin, s. 1993: 258. 19. gbadegesin, s. 2009, p. 33. 20. gbadegesin, s. 1993: 258. 21. wikipedia. euthanasia. retrieved on 1st of june, 2012 from http://en.m.wikipedia.org/wiki/euthanasia. par 1. 22. gbadegesin, s. 1993: 259 23. gbadegesin, s. 2009, p. 31 24. gbadegesin, s. 1993: 259. 25. gbadegesin, s. 1993: 260. 26. gbadegesin, s. 1993: 260. 27. gbadegesin, s. 1993: 260. 28. gbadegesin, s. 1993: 260. 29. wiredu, k. how not to compare african thought with western thought. in eze, e.c. ed. african philosophy: an anthology. u.s.a: blackwell publishers; 1998, p. 194. 30. emmanuel, ej. the ends of human life: medical ethics. in a liberal polity. cambridge: harvard university press; 1991. 31. callahan, d. communitarian bioethics:a pious hope. the responsive community 1996;6 (4):26-33. http://en.m.wikipedia.org/wiki/euthanasia eve-teasing has been identified as the beginning of violence against women bangladesh journal of bioethics 2010; 1(3); 58-62 moral deviation in young people of bangladesh rowshan ara ph.d1 tanha mahjabeen2 1. professor, department of philosophy, university of dhaka, 2. ph.d. student, curtin university of technology, perth, western australia abstract: youths of bangladesh (18-35) constitute one-third of the total population. in this article, young people imply both adolescents and youth. there are 28 million adolescent populations in bangladesh. approximately there are sixty million young people in bangladesh the vast majority of them are illiterate, and handicapped with severe poverty. because of lack of family control, proper education, poverty, unemployment and peer pressure a significant portion of them are deviated from the norm of the society. in this paper four issues of moral deviationeve teasing, drug and substance abuse, juvenile delinquency and access to pornography will be discussed. juvenile delinquency: juvenile delinquency is a major concern in bangladesh where the number of youth involved in anti-social activities appears to be on the rise. with the advancement of industrialization and urbanization, juvenile delinquency is gradually rearing its ugly head and making the problem more acute day by day. the new manifestations of juvenile delinquency take such characteristic forms as gang activities, purposeless offences, acts of vandalism, joy-riding, terrorism, eve-teasing and the like which can be serious from the point of public order without necessarily being an indication of serious anti-social behavior. brought up in an unwholesome environment they develop wrong norms and values and it becomes difficult to bring them back to the right path. studies on criminal behavior has shown that a good percentage of adult criminal committed first offence in their childhood long before their first conviction. a study titled “under-aged prison inmates in bangladesh: a sample situation of youthful offenders in greater dhaka”, (actionaid, november 2008) found that the dominant agegroup of the inmates having committed crime is between 12 and <16 years (64.58%), and it was found that 31.25% did not attend school. in this area, there is an improvement over the study conducted during the year 2003, when 41% were found to have not attended school at all. out of whole of the inmate population, the representation of the dhaka metropolitan area was more than 61%, and mirpur police station area appears to be the first among the police station to have contributed largely to the sample within the city. among the 5 districts, narshingdi has the highest numbers. the important charges/complaints against the inmates were theft (22.92%), murder (18.05%) as against 15.57% during the year 2003, drug related offence (13.19%) and possession of illegal arms (10.14%) as against 27.33 % during the year 2003. situation regarding other offences remained almost static. the inmates of prison and correctional homes have been staying for a period of about 3 months (almost 50%). the inmates of jail and kishore unnoyon kendra (kuk) mostly come of poor family. due to poverty they have to face they are habituated in different adventures. due to struggle for existence they are fond to be adventurous. about 39% admitted that they had adventurous incidents in their life. they gave 27 kinds of adventurous activities. different information comes out from them and its degree was also different. those who disclosed about their adventurous activities, like association with friends, free movement and also want to work 58 bangladesh journal of bioethics 2010; 1(3); 58-62 outside family disciplines. they become easily involved with crime in absence of family governance and bad companion. they are organized adventures whereas their works are such as :rescue a child from fire, coming to the town alone, elopement, stealing of fruits from garden, inscribing names by cutting own skin, climbing the hills, salvaging from drowning, catching and charming snakes, weight lifting, breaking hands by falling from tree, crossing river, rape, carrying arms, hijacking, throwing stones to police etc. it seems the petty crimes from childhood lead them to bigger crimes. eve-teasing by the young people: constant eve teasing by way ward naughty young people become an issue of grave concern to the society throughout the country. eve-teasing has been identified as the beginning of violence against women. according to the press reports during 2001 to 2006, a five-year period, ten girls committed suicide owing to harassments by local young hoodlums, goons, and terrorists. eight of them were 9–16 years, the rest two were 21/22 years old. the most tragic incidence happened when trisha, a 9-year old girl, jumped into a pond and drowned as she was chased by three local goons on her way back home from school. another fatal incidence can prove the unsafe and insecure condition of the female adolescents. rumana parveen (teethi), (age-13) of savar girl’s high school committed suicide because of constant verbal and physical abuse by some hoodlums of her locality. rumi, trisha, shimi, sopura and some other girls also have the same fate because of constant eve-teasing by some derailed young people (prothom alo, september 20, 2006). despite enactment of the suppression of violence against women and children act 2000 (amended in 2003) the country has made very little progress particularly with respect to protecting the adolescent girls outside home. a research conducted on a very large sample of 203077 households covering various rural and urban areas of the country reveals that about 6.0 per cent of the dropout children were such cases that their parents had to stop sending them to school because they felt “insecure” (mia and hassan 2008). while law and law enforcement is inadequate to address the issue, social mobilization and protest against such heinous atrocities is so far absent. ngo’s campaign against violence against women and adolescent girls has had only small effect given their limited scale of operation and coverage. the government machineries including the state run media have not been sufficiently effective in mobilizing all social agencies and the law enforcement system has not had its proper application to stop gendered violence by the deviated young people. recently the girl student of sunamganj and fulpur of mymensingh abstain from attending class as a protest against the torture of the eve teasers (prothom alo, july 7, 2009). the people of sunamganj caught hold of an eve-teaser who manhandled a school girl and handed him over to the police. these type of eve teasers always block the road of their school going girls and disturb them by abusing words and obscene gesture. young people need proper guidance, counseling, develop livelihood skill so that they do not waste their time and strength by teasing the girls. if we can not save the girls from these eve teasers and ensure their security how can we expect a civilized society? drug and substance abuse: drug abuse is a gruesome menace in the society today-with grave biological, social, economic and security implications on the individual, family, community and the country. the alarming speed, with which the drug scourge has ravaged the whole country, particularly over the last two decades, has brought the threat of the menace to every door step. adolescents’ and youth’s drug use fits a “cultural deviance model of behavior”. for young people reliance of drugs may reflect emotional disturbance of varying degrees of severity 59 bangladesh journal of bioethics 2010; 1(3); 58-62 and an inability to cope with the demands of living or to find a meaningful personal identity. these may be profound disturbance in family relationship or disadvantaged adolescents facing a future without hope and confronted with economic, social discrimination with inhuman living conditions, often with untreated physical needs and a breakdown in their family social relationship may give up a sense of ego-identity and try to escape in the oblivion of drugs. drug abuse, criminal and other antisocial behavior has been attributed to peer group influence and pressure. juvenile delinquency is very much co-related with drug addiction. the real scenario of drug abuse is indeed a frustrating one. according to the statement of department of narcotic control, about 100,000 people, including 30,000 women and children, are involved in illegal drug trade in bangladesh. drug dependents spend at least 460 million3 taka (about 6.57 million u.s. dollars) on narcotics every day. there was no specific government data on the number of drug addicts or drug use in the country. according to the fhi in 2004 there were some 4.6 million drug addicts in the country. heroin is the most widely abused hard drug and around 75 percent of the dependent are 15-30 years old. a rapid situation assessment on drug and substance use was conducted by unicef in 2008. the study is focused in selected divisional cities and convergence districts of bangladesh namely dhaka and gazipur in dhaka division, chittagong and cox’s bazar in chittagong division, khulna and kushtia in khulna division, barisal and barguna in barisal division, sylhet and moulavi bazar in sylhet division and rajshahi and chapainawabganj in rajshahi division. findings from the rapid assessment revealed that the average age of the drug users is 16 years, with 42 % of them being below the age of fifteen years. 17% of the injecting drug users have shared syringe/ needles. the main initiation age 11 years to 15 years, during this age 79% of the children had initiation to sex. 82% of the girls had ever sold sex for buying drugs. the vulnerability of both the boys and girls is very obvious as 68% of the boys had sex with sex workers in one or more of their last three sexual intercourses, and 59% of the girls had sex with their clients in the same number of sex occasions. majority (59%) of the young people faced harassment due to taking drugs. according to the assessment, conducted in dhaka city from april 2006 to june 2006 (unicef, 2008). the study team found out total 229 drug users spot, among them 21 of the injecting drug users spot, 77 of the heroin smokers spot and other 131 spot where drug users take other drugs. other types of drugs include ganga, sleeping pill, glue inhale, phensidyle, etc. the study shows the estimated size of high risk population in terms of 75 to 90 injecting drug users, 565 to 775 heroin smokers and around 2075 to 2760 other types of the drug users (except cigarette smokers). 71 percent of children and adolescents coming in contact with drugs through peer pressure. further, the more drugs adolescents use, the more likely they are to have friends who use not only those drugs but other drugs as well. though there are some programs for young and adolescent children, drug use prevention or harm reduction focused interventions are not seen with national commitment. in this regard, policy initiative, implementation structure and capacity are lacking. govt. of bangladesh set up a specialized drug addiction treatment hospital at tejgaon, dhaka under the administrative control of dnc. drug addiction treatment programs in bangladesh are limited within the process of detoxification. rest of the programs is not supported by appropriate after care, follow up motivation, counseling, skill development training, rehabilitation and social re-integration program. a country wise study is needed to assess the situation and combat this rehabilitation of the addicts and introduce preventive education for the adolescents on an urgent basis. in order to combat this dangerous situation community leaders, parents and teenager counselors who are willing to serve as “preventive agent” should be involved in this process. 60 bangladesh journal of bioethics 2010; 1(3); 58-62 access of young people to pornography: most of the adolescents especially the adolescent boys use to watch porno film on compact disc (cd). the pirated copies of these cds are very cheap and available throughout the country. in all metropolitan cities the roadside stores sell these cds and most of the sellers are adolescent boys. when someone visits these stores the seller talks with local sign languages to inform that he has those porno films. in interviews with different cd sellers it is found that large numbers of consumers are both school going and non-going adolescents. they exchange cds, one with others among the friends. many of these students preserve porno mp4 and porno images in their cell phone and enjoy these in a group. sometimes they send these to their friends and other girls through sms and make them embarrassed. uncontrolled access to internet and satellite tv channels is promoting this trend among the adolescent population. root causes of moral deviation the following:  lack of proper education, drop out.  unemployment and poverty.  lack of family control.  urbanization and slummization.  lack of provision for meaningful utilization of leisure time.  broken and troublesome family.  ineffective role of law enforcing agency.  influence of alien culture and media exposure to obscene film and culture of violence.  peer pressure.  political exploitation of young people. suggested recommendation: • to strengthen interpersonal communication and conflict resolution in the families by increasing moral values and increase family bondage. • to include the drug use prevention information including negative consequences of drug use in the formal education text book starting from class four to ten • easy supply and availability of drugs should be stopped and exemplary punishment to the drug traffickers should be given. • promotion of moral values in the family. • provide marketable entrepreneurships for the dropout youths. • ensure life-relevant education curriculum at secondary level, and widen the provisions for well-managed technical-vocational education appropriate for employment market. • life skill education should be incorporated with formal education. particularly on adolescent relevant issues like coping with stress, coping emotions, self-awareness building, empathy etc. that would ensure smooth transition of adolescents to adulthood and enhance capability to play effective role in family, community and social life. • family life education should be included in the syllabus of formal and non formal education. values are of vital concern for youth. now there is no moral radar to guide young people. in midst of rapid social change the difference between right and wrong has been blurred. adult people are formulating their own code of conduct in order to fulfill their selfish motive and demands. unless the socioeconomic problems of the young people can be resolved, until some better match can be found between vocational opportunities and the needs, talents, skills and values of young people, both society and youths are likely to be in serious trouble. 61 bangladesh journal of bioethics 2010; 1(3); 58-62 responsibility of the parents, community leaders, teachers and the ngo and go are of utmost importance to save the future citizens from the moral erosion therefore, healthy environment must be created in which young people will find encouragement to achieve real heroism to eradicate evil and corruption from the society. the youth should not be identified as a symbol of terrorism, violence, indiscipline and destruction. they were the hope of yesterday, joy of today and the guarantee of a better tomorrow. 62 bangladesh journal of bioethics 2011 vol 2 issue 1 page 7-12 7 ethical and policy concerns pertaining to rice landraces in asia abhik gupta professor, dept. of ecology & environmental science, assam university, silchar 788011, india email: abhik.eco@gmail.com abstract: domestication of rice (oryza sativa l.) from the wild species o. rufipogon and o. nivara by neolithic asian farmers more than 10,000 years ago represents one of the most important events in human history, as this crop is the major staple food of over one-third of the world’s population, meeting around 20 % of the global calorie intake. the asian rice, o. sativa, which is grown worldwide, has three major “variety groups” or subspecies: indica varieties of the indian subcontinent; tropical japonica or javanica varieties very common in southeast asia and southern china; and temperate japonica varieties predominantly cultivated in northeastern asia. furthermore, cultivation and farmer selection over a long period of time have given rise to over 120,000 varieties or farmer’s landraces of rice. these include glutinous and non-glutinous landraces, aromatic landraces; those taking different times to mature; with different levels of tolerance to abiotic stresses like cold, drought, submergence and salinity; and even differing in their resistance to pests and diseases. however, a few hundred “high-yielding” “improved” varieties have largely replaced these traditional landraces, with the latter finding their place of preservation in the rice germplasm banks. while it is true that various genes of the traditional landraces have been incorporated into many modern varieties, questions arise as to the ethical propriety of banishing ‘live’ and ‘flourishing’ life forms that are also integrally linked to the culture of many communities, to a ‘synthetic, and overtly utilitarian existence. the present paper aims to discuss these issues in the light of ethical principles as well as policies pertaining to traditional knowledge and practices. introduction: rice has two cultivated species of which oryza glaberrima, the african rice is grown only in west africa, while oryza sativa, the asian rice is grown worldwide and is the staple food for over one-thirds of the world population (kush, 1997). in many eastern indian languages such as ‘bangla’ or ‘axomiya’ (the former spoken in bangladesh and west bengal and parts of assam in india; the latter in assam, india) the word bhat which means steamed rice, is synonymous with food or meal. in fact, rice is one of the oldest domesticated crops – with archaeological evidence of its domestication by asian neolithic farmers some 9000-11,000 years ago (olsen et al., 2006). three major “variety groups” or subspecies of o. sativa are recognized: (i) indica group of varieties – typically found in the indian subcontinent; tropical japonica (javonica varieties) in southeast asia and south china; and temperate japonica varieties in northeast asia (kush, 1997). in terms of rice-production ecosystem types and agricultural technologies, irrigated lowlands occupying c 79 m ha of land produce 75 % of the world rice production; followed by rainfed lowland (54 m ha and 19 % of production); upland (14 m ha and 4 % of production; and flood-prone deepwater rice occupying 11 m ha of land with a production of 1.5 t ha -1 (bouman et al., 2006). the landraces of rice: long period of cultivation and farmer selection has resulted in the production of a large number of varieties or landraces of rice, of which an estimated 120,000 are known to exist. about 80,000 are preserved in international rice research institute (irri), philippines, and about 40,000 and 25,000 in chinese and indian gene banks, respectively. other countries, including bangladesh, also have smaller national collections. these landraces show a wide divergence of properties, with some glutinous, others non-glutinous, some aromatic, fine grained, some fast growing, with deepwater varieties like rayada taking longer to mature (kush, 1997). however, the green revolution has resulted in the widespread introduction of around 300 high-yielding varieties in the rice fields all over the world, accompanied by severe erosion of the traditional landraces. traditionally, a bangladesh journal of bioethics 2011 vol 2 issue 1 page 7-12 8 vast amount of genetic diversity was distributed among the numerous landraces in different parts of the rice-growing areas of the world. in japan, for instance, more than 1000 landraces are conserved in the germplasm banks, but not found in their natural habitats any more. more than 100 o. japonica landraces once found in taiwan are now confined to the laboratory. similar erosion has occurred in the mekong delta of vietnam, and in thailand, where a high-yielding glutinous variety has replaced several traditional glutinous landraces. a study conducted there revealed that the 27 traditional varieties cultivated in a thailand village in 1981 had dwindled to a mere 4 in 1991. the most pronounced erosion has occurred in china, indonesia, india and bangladesh, where several thousands of landraces conserved a high degree of genetic diversity, but are rapidly vanishing or drastically dwindling in the farmers’ fields. in bangladesh, this erosion is taking place in all the three seasonal groups of rice aus, aman and boro (morishima and chitrakon: http://www.aseanbiodiversity.info/abstract/ 53000315.pdf; irri, 1994). in india, rice is grown as early kharif, medium kharif and rabi seasonal crop (maclean et al., 2002), and genetic erosion is evident in all the three ecotypes. in jeypore in orissa, india, which is considered to be a secondary centre of the origin of cultivated rice, especially its aus ecotype, about 1750 landraces had existed even in the 1950-‘60s. however, only 324 varieties were found in 1995-’96, of which only 83 varieties were in cultivation, as revealed by a 1998 study by the m.s. swaminathan research foundation, chennai, india. introduction of high-yielding varieties along with low productivity of the traditional landraces were inferred to be the main reason behind this erosion (mssrf-fao, 2002). a study conducted in the seti river valley of nepal, which is traditionally a rice-growing area, observed that of the 75 landraces known to have originally existed, only 11 were widely grown, 47 were under threat, while 17 were totally lost from the area. besides other factors, introduction of hyvs was important in causing decline of traditional landraces (rijal et al., 1998). in garhwal himalayas, india, diversity declined from 65 crop landraces before 1970s to 39 in 1990s. the area under traditional landraces, especially of paddy, also declined during the same period. the government promoted a high-yielding aromatic variety along with fertilizer subsidies. this led to farmers replacing their traditional aromatic mukhmar landrace with the hyv whose initial high yields declined after the fertilizer subsidy was withdrawn. the traditional landrace, however, became extinct in the process (chandra et al., 2010). value of agrobiodiversity: protection of agrobiodiversity is considered important in the context of conservation of wild relatives of important crop plants as well as traditional and threatened landraces, especially those linked to traditional cultural practices (phillips and stolton, 2008). erosion of the landraces of an important crop such as rice, therefore, assumes special significance. besides the high “use value” (pardey et al., 1998, quoted in love and spaner, 2007) by virtue of their contribution to the genetic variability of the species, the diverse landraces are also important in providing food security to poor and marginal farmers, and are integral components of many religious-cultural events in the life of the people. farmers in india often harvest aus paddy landraces in certain months like september, when all rice from previous harvests get exhausted (arunachalam et al., 2006). these landraces, therefore, are very important from a food security point of view, and linked to the collectivedevelopmental human rights of the marginal and tribal farmers in many areas. the other aspect is the exclusive use of certain rice landraces in various religious rites and ceremonies. for example, in the jeypore area of orissa, india, some aromatic varieties were used in a broad range of festivals, while a few aromatic forms and non-aromatic but delicious landraces were earmarked for specific deities or religious rites (arunachalam et al., 2006). the iban tribe of sarawak, malaysia, practice a special ritual in the centre of the rice field, where a specific rice variety is planted (bellon et al., 1996). in the barak valley region of assam, india, a traditionally rice-farming community cultivated over 50 landraces including aus, shali and boro varieties, of which several were meant for religious occasions (guha et al., 1999). thus the traditional religious-cultural importance placed by the farmers and other members of the community imparts a kind of intrinsic value in addition to the instrumental or extrinsic use value of the landraces. this cannot be substituted by any hyvs. this is somewhat synonymous with “existence value”, which is associated with the satisfaction derived by the people from the existence of biodiversity in their environment (bellon, 1996, quoted in love and spaner, 2007). bangladesh journal of bioethics 2011 vol 2 issue 1 page 7-12 9 the governments and national and international scientific organizations have tried to address the genetic erosion in rice and other crop species by resorting to various ex-situ conservation methods comprising maintenance of plants in open plots and glasshouses, followed by the sophisticated cold preservation facility emerging in 1960-‘70s. in long-term gene banks, seeds preserved at -10 0 to – 20 0 c can be stored for several decades or potentially up to 100 years, if maintained properly; in mediumterm gene banks, up to 20 years at 0 0 to 50 c; and in short-term facilities, up to a decade or less at ambient temperature or cold temperatures above 50 c (plucknett et al., 1983). this was a technologydependent reductionist approach which only took into account the objective material aspect of rice landraces in terms of their genetic diversity and potentially useful characters that could be harnessed in future for the benefit of the consumers and society at large. nevertheless, the gene banks are particularly valuable when it contains materials that have vanished from its original habitat or locality. for instance, a virus-resistant oryza wild relative found in taiwan is only available now in the irri gene bank and no longer found in its original place of occurrence; several cambodian landraces were lost during the war there, and could since been reintroduced only because these had been previously stored in gene banks (plucknett et al., 1983). the international rice genebank (irg) at irri has more than 80,000 accessions of cultivated rice and wild species (bellon et al., 1996). without undermining the utility of modern gene banks, it can, however, be said that they supplement, but do not necessarily replace in-situ – including on-farm conservation and perpetuation of landraces. compared to ex-situ conservation, in-situ conservation of rice species and landraces has received very less attention. one important aspect here is the conservation of the wild species of the genus oryza. ethically speaking, human societies in a large part of the world owe to these wild species the very basis of their survival and flourishing. the growth and perpetuation of human civilization in large parts of south, southeast and east asia have been possible due to the occurrence of these wild rice species, from which the numerous cultivars had evolved due to human ingenuity to feed the millions over ages. apart from the fact that we need to conserve these species from narrow anthropocentric considerations of human health, nutrition and welfare, we also ought to pay attention to their ‘intrinsic’ value. on-farm conservation of rice varieties has received the least attention from established rice germplasm conservation programmes, although its importance is recognized by all in principle. the age-old practice of planting several varieties simultaneously by the asian farmers represent an adaptation, a strategy evolved over a long time. it provides them security against uncertain weather, pest outbreaks and food shortage. furthermore, it allows them to have some variety in an otherwise monotonous and often nutrient-deficient diet by having some aromatic or otherwise good-tasting, finegrained rice. some fine-grained aromatic landraces in bengal (historically including the whole of present-day bangladesh, west bengal and parts of assam in india), such as gobindobhog in west bengal, kalijeera in bangladesh and joha in assam, are made into payesh or paramanno after boiling with milk and addition of sugar, raisins, nuts, special jaggeries, etc. this is a very special food that brings joy to the members of farmers’ families, especially children. at the same time, such special rice or the food items prepared from them are also offered to propitiate the gods and in gratitude. these were also offered to the zeminders (landlords) in bengal to receive favours and to keep them in good humour. and not the least, the rice landraces find ample mention in the rich literature of bengal, both in its early and modern forms. thus rice and its numerous landraces in bengal is more than just food, as it also stores the chequered history of its farmers, traders, landlords and the people in general. conserving rice germplasm in refrigerated gene banks and ex-situ plots cannot respect or preserve or do justice to this history. the answer perhaps lies in on-farm conservation, which is a “dynamic” form of conservation in which the varieties that the farmers select and plant continue to evolve, thereby retaining their future adaptive potential (bellon et al., 1996). the various programmes of rice landrace conservation cannot enjoy ethical fulfilment without vibrant on-farm conservation with full and voluntary farmer participation. it is essential that the ethical principle of informed choice and not the paternalistic imposing of rice varieties by the agricultural scientists and policy-makers should govern rice cultivation in asia. to make the choice truly ‘informed’, great emphasis and effort need to be given towards education of farmers about the pros and cons of selecting a specific landrace. the extinction of a himalayan aromatic landrace mukhmar described in the previous section, shows that while the scientists and policy-makers were insensitive to traditional knowledge and cultural legacy of the people in that area, their emphasis on production and development was also defeated in the long run, with the option of returning to the traditional landrace being closed due to its extinction. this is a typical case of bangladesh journal of bioethics 2011 vol 2 issue 1 page 7-12 10 paternalism where the ‘enthusiasm’ of agricultural scientists in introducing a new variety that combines high yield with aromatic property overlooked the long-range ethical and socio-cultural considerations. the issue of on-farm conservation is further complicated by the land-holding size available with the farmers. it has been observed that when the farmers first took to cultivating high-yielding varieties, they also simultaneously planted some traditional forms in spare plots of land. however, this was not possible for many farmers with small land-holdings, and over time they continued to plant only the hyvs. this is an issue that needs to be addressed in a larger socio-economic context and has profound ethical implications. participatory management: participatory crop improvement has been proposed as an incentive for farmers to conserve crop diversity on farms and is a non-market or supply intervention. two methods of participatory crop improvement have been outlined: 1) participatory varietal selection, where the farmers evaluate the different varieties available; and 2) participatory breeding, where the farmers select within highly variable populations (reviewed in love and spaner, 2007). exchange of seed materials among farmers have greatly contributed towards maintenance and distribution of a wealth of agrobiodiversity, a process in which women’s social networks played significant roles. this age-old scenario is fast changing though, and as padmanabhan (2008) has shown, the traditional system of agrobiodiversity exchange and maintenance by the women of the kurchiya tribe in kerala, india, has lately been threatened by the newly introduced system of peoples’ biodiversity registers (pbrs) maintained by the panchayats (local self-governments). this new system also diminished reciprocity with an element of altruistic act of the kurchiya women towards each other. the ecological theoreticians and conservationists, who were instrumental in lobbying for and introducing pbrs, did not take into consideration the ethical superiority of the traditional system that was more participatory and led to improved social bondage among the members of the community and increased cooperation. participatory plant breeding have been shown to be a possible methodology to resolve the conflict between introduced programmes promoting hyvs and the traditional small farmer, especially tribal farmer, preference of locally adapted landraces that satisfied taste and other cultural requirements and at the same time ensured food security under uncertain weather conditions. the latter also becomes particularly relevant under the scenario of global climate change. acknowledgements: i thank the bangladesh bioethics society, which was kind enough to invite me to present a part of these thoughts at an international conference at dhaka, and for kindly admitting me as an international member. references: 1. arunachalam, v., chaudhury, s.s., sarangi, s.k., ray, t., mohanty, b.p. and mishra, s. 2006. rising on rice: the story of jeypore. m.s. swaminathan research foundation, chennai, india. 2. bellon, m.r., brar, d., lu, b.r. and pham, j.l. 1996. ii. rice genetic resources. in: fisher, k.s. 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(1999): indigenous conservation initiatives in barak valley, assam. in: kharbuli, b., syiem, d. and kayang, h (eds.): biodiversity: north-east india perspectives, pp. 42-46. north eastern biodiversity research cell, north-eastern hill university, shillong. 5. i.r.r.i. 1994. safeguarding and preservation of the biodiversity of the rice genepool. report of an action plan meeting at los banos, philippines. international rice research institute (irri), manila, philippines. 6. kush, g.s. 1997. origin, dispersal, cultivation and variation of rice. plant molecular biology 35: 2534. 7. love, b. and spaner, d. 2007. agrobiodiversity: its value, measurement, and conservation in the context of sustainable agriculture. journal of sustainable agriculture 31: 53-82. 8. maclean, j.l., dawe, d.c., hardy, b. and hettel, g.p. (eds.). 2002. rice almanac. international rice research institute, manila, philippines. 9. mssrf-fao. 2002. rural and tribal women in agrobiodiversity conservation. rap publication 2002/08. m.s. swaminathan research foundation, chennai, india and fao regional office for asia and the pacific, bangkok, thailand. 10. olsen, k.m., caicedo, a.l., polato, n., mcclung, a., mccouch, s. and purugganan, m.d. 2006. selection under domestication: evidence for a sweep in the rice waxy genomic region. genetics 173: 975-983. 11. padmanabhan, m.a. 2008. collective action in agrobiodiversity management: gendered rules of reputation, trust and reciprocity in kerala, india. journal of international development 20: 83-97. 12. phillips, a. and stolton, s. 2008. protected landscapes and biodiversity values: an overview. in: amend, t., brown, j., kothari, a., phillips, a. and stolton, s. (eds.): protected landscapes and agrobiodiversity values. vol.i. protected landscapes and seascapes. iucn & gtz, kasparek verlag, heidelberg. 13. plucknett, d.l., smith, n,j.h., williams, j.t. and anishetty, n.m. 1983. crop germplasm conservation and developing countries. science 220: 163-169. bangladesh journal of bioethics 2011 vol 2 issue 1 page 7-12 12 14. rijal, d.k., kadayat, k.b., joshi, k.d. and sthapit, b.r. 1998. inventory of indigenous rainfed and aromatic rice landraces in seti river valley, pokhara, nepal. li-bird technical paper no.2. local initiatives for biodiversity, research and development (li-bird), pokhara, nepa microsoft word pdf 6 24 bangladesh journal of bioethics 2010; 1(2):24-30 bioethics: awakening and changing of human life ferdousshi begum, phd professor of philosophy, jagannath university,dhaka ethics is primarily a part of the quest for truth and motive for standing . it is the desire for knowledge. in this respect it is more akin to philosophical subjects than the natural sciences where the practical applications are many and attractive.ethics is one of the important branches of philosophy which started from the ancient time. ethics started through the philosophy of sophists in ancient greece.this culture later expanded through continuous process. the ethical culture has been expanded from socrates, plato, aristotle till today. ethics can be defined as a science that appreciates human conduct in the light of moral ideal. the english word ‘ethics’is derived from the greek word ‘ethica’ meaning matters pertaining to ‘ethos’ or character, that is, remarkable manners, customs and habits of men.1 there are three trend or dimension through the attentive observation of ethical history: such as traditional ethics, meta-ethics and practical-ethics. traditional ethics deals with justice – injustice, good-bad, right-wrong of human conduct in the light of the moral ideal.2 meta-ethics is mainly concerned with conceptual and linguistic analysis with moral language which is used in theoretical ethics. on the other hand practical ethics evaluate the social and moral problems of both individual and society regarding the logical uses and implementation of moral standard.3 bio-ethics is a part of practical ethics. bio-ethics is the study of moral problems in the area of life sciences and health care and insofar these problems are related with the study of social, legal and economic problem.now a days there arises some bio-ethical problems,without relating health care and treatment. but these problems are co-related to life. the main aims and objects of treatment are to cure and strengthening of human being .many treatments are related to lives like animal in modern age. but it is only possible for the treatment of the living being and nothing else. so it is impossible to make differences between bio-ethics and medical science. bio-ethics is the systematic study of moral problems of human conduct in the society. bio-ethics is the philosophical study of the ethical controversies brought about by advances in biology and medicine.bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology,medicine,politics,law,philosophy and theology.4 bio-ethics is such type of branches of practical ethics that deals with the study of human conduct and inner-relation with each other in the light of moral values and principles. few days ago, bio-ethics was mainly concerned with medical ethics. but now a days it is related to agricultural and environmental ethics too. from this point of view it has been discussed the ethical problem of health care or medical ethics changing the human live,which should be acceptable and beneficiary to the whole world. 25 bangladesh journal of bioethics 2010; 1(2):24-30 the term bioethics (greek bios, life; ethos, behavior)was coined in 1927 by fritz jahr, who “anticipated many of the argument and discussions now current in biological research involving animals”. in an article about the “bioethical imperative,” a he called it, regarding the scientific use of animals and plants, in 1970, the american biochemist van rensselaer potter also used the term with a broader meaning including solidarity towards the biosphere, thus generating a “global ethics,” a discipline representing a link between biology, ecology, medicine and human values in order to attain the survival of both human beings and other animal species.5 medical ethics or bioethics is study of moral issues in the fields of medical treatment and research. the term is also sometimes used more generally to describe ethical issues in the life science and the distribution of scarce medical resources. the professional fields that deal with ethical issues in medicine, nursing, law, sociology, philosophy and theology though today medical ethics is also recognized as its own discipline.6 medical ethics traces it root to several early codes of ethics such as the ancient greek hippocratic oath, which required physician above all to “do no harm.” firstly ,bioethics was learned by the side of the epistemology, metaphysics and axiology as the media of learning bio-medicine. ultimately with the gradual development of medical science and medicine-science bio-ethics reveals as the fundamental subjects. the objects of bio-ethics and medical ethics are so cordially related with one another that it is difficult to make a great differences between these two. according to pitersinger bio-ethics is the lesson of moral problem regarding sciences. but there are some bio-centric problem which are not related to health care and medical treatment. the main aim of treatment is to care and strengthen the human body with long life. recently many living beings including animals are treated. but there is no scope of treatment for the non-living. so there is no scope to make a difference between bio-ethics and medical-ethics. for a long time medical-ethics was the main object of bio-ethics. but there has been great changes in the educational contents of bio-ethics in last three or four decades and also expanded and extended the scope of it.7 very recently environmental ethics and genetic engineering and applied ethics has been included in bioethics and it has been extended and expanded with the scope of new subjects. there arises the question of ethics in the agricultural field after the extension agricultural bio-ethics and foodbiology. there arises some ethical problems due to the extension of bio-technology in agriculture sector. food technology has been developed regarding the different technique of food processing ; different machineries has been used for food processing to make nutritious and quality foods . the time has come to observe deeply whether these foods are helpful for health or indulgence for human body. the question has also arisen to explain newly about the usefulness of these food. the method of hi-breeding is being examined ,which is being used for production of vegetables, corns, fishes and animals. for the double or triple production various artificial and bio-chemical manure has been used. as a result it has been dangerous for maintaining the human and animal health .the buyers and cultivators has been faced with the various moral question regarding the mechanical process of production,such as : 26 bangladesh journal of bioethics 2010; 1(2):24-30 1. whether the productive corn or food is suitable for the health care of man and animal. 2. whether it is capable for the development of health 3. whether the environment is free from danger 4. whether the role of these technologies to eradicate poverty is satisfactory 5. whether it will only help the rich o the poor will be also be benefited 6. whether it is humane and ethical regarding the animal that has been used as food or for the experiment in research centre, and if it is regarded as ethical, is there any reason for ethical purpose. firstly agricultural and food technology has to face various ethical question, but it has been agreed regarding the usefulness of these. considering its necessity, it has been accepted. but regarding environmental balance, economic advancement, social justice and animal rights it has given birth to a moral debate and public opinion has been formed against it. physician and bio-scientists tried to cure various health problem with medicine. most modern equipment is very much helpful for correct diagnosis. most modern technological treatment regarding healthcare is very helpful for right measurement of health related area. invention of new medicine for prevention of disease also depend on technology. for acute diagnosis to the patient, physician has to depend on pathology. and pathological research also depend on technology. but there arises some health related problems due to uses of most modern equipment in medical science. but though these problems are included in medical science ,there is a clue of ethical solving for these problems. such problems deal with duty, good or bad – which are the object of ethics; and bio-ethics is also related to ethics. bio-ethics make decision and judges moral standard for every issues regarding healthcare. medical science and biological-science discuss about the difference aspects of human body; sometime there arises some problems which are responsible for moral conflicts. regarding health, various issues are concerned with duty. so to overcome the hard problem it is very much important to explain values. so to get rid of difficult or critical problems of medical sciences it is the duty of bio-ethics to explain and to make a decision morally i.e. what is good or bad. bio-medical ethics has been created due to ethical problem and crisis of human medical science. modern and new technology of medical science ensure for the good human-health on the other hand there arises some problems beyond medical science. for example the most modern invented medicine is good to cure epidemic diseases; on the other hand there arises a question whether it is moral or immoral for inventing this medicine when men are used as an experimental case. thus bio-ethics as a part of practical science has been turned into an important subject . medical science and bio-logical science is descriptive science of fact; ethics is a evaluative science. there are various aspects of medical science. such as there should be: 1. an honest relation between physician and patient 2. whether there should be implementation of any technical stress upon patient for the implementation of different new technology. 27 bangladesh journal of bioethics 2010; 1(2):24-30 3. whether it is ethical to use the patient as a research subject. varieties of medical programs mainly with experimental case of patient has been faced with ethical question. there arises a conflict in the medical area regarding the responsibility and duty of physician. for example it may be mentioned about euthanasia . the term euthanasia may be defined to accept the death for relieving the severe pain. euthanasia indeed is a kind of mercy killing or plenty of death. the question now arises whether we should accept mercy killing, the killing of disable child and incurable old people. regarding these matter, there arises such type of conflict which can be accomplished by ethical knowledge. so bio-ethics deals with the accomplishment of different problem of medical science and biological-science. with the welfare of the patient there arises responsibility about the qualitative stage of life. health care must be related to moral consciousness ; so that , the notion of ‘life’ and ‘death’ can be defined and analyzed to a new era. medical science has been rapidly developed and changed at the beginning of 1970. because from this time the knowledge of different types of medicines such as antibiotic medicine, medicine of birth control, mental health and life saving drugs and technology (i.e., machinery of artificial breathing, dialysis) replacement of kidney ,hart, cornia, fertility process i.e. test-tube-baby ,surrogative mother, genetic engineering i.e. cloning, human jenome has been developed rapidly.8 except medical science, newly invented technology of biology added a new trend to the field of man’s will, linking, freedom and selection. so the traditional value has become weak to some extent. the new technology and use of it , has made a conflict to the old value. on the other hand the field of social justice has been extended. women freedom is being observed due to the advantage of birth control technology. thus different technology of medical science and biological science related to medical science has already improved our daily life; on the other hand created a new conflict. though there arises some social problems in medical science and there arises a conflict in the field of fact and value – it would be solved in the light of ethics. the commonly accepted principles of health care ethics include: 1. the principle of respect for autonomy 2. the principle of nonmaleficence 3. the principle of beneficence 4. the principle of justice respect for autonomy in health care decision respect for the autonomy of the patient is a very important factor. german philosopher emanuel kant and british philosopher stuart mill highlighted the individual freedom. they have joined the individual dignity with the individual freedom. as the human posses the right to selfcontrol, she/he has power of possessing the same right .so regarding the treatment of a patient we should consider the willingness and unwillingness of a patient. but in some stages such as the patient of c. c.u or i.c.u 28 bangladesh journal of bioethics 2010; 1(2):24-30 is unable to follow the principle of autonomy. in such case when principle of autonomy become inactive , there required some side principle – such as respect for the person and informed consent. respect for the person means to save the secrecy of the patient with dignity and sense of value.9 principle of nonmaleficence the principle of nonmaleficence means that we should not intentionally create a needle harm or injury to the patient. it must occur either through acts of commission or omission. in case of professional model of care, one may be morally and legally blameworthy if one fails to meet the standards of due care. the legal criteria for determining negligence are as follows: 1. the professional must have a duty to the affected party 2. the professional must breach that duty 3. the affected party must experience a harm 4. the harm must be caused by the breach of duty. this principle affirms the need for medical competence. it is clear that medical mistakes occur, however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.10 principle of beneficence this principle is mainly based on utilitarianism of jeremy bentham and john stuart mill.there are two aspects of this principle ,one is the duty of health care with welfare benefit to the patient as well as to take positive steps to prevent and to remove harm from the patient these duties are applied both to individual patients and to the good of society as a whole. a physician has a duty to seek benefit of any or all of his/her patient.this duty becomes complex if two patients appeal for treatment at the same moment. in these case some criteria of urgency of need might be used. or there should be some principle of first come first served, to decide who should be helpful at the moment.11 principle of justice justice in health care is usually defined as a form of fairness, or as aristotle once said, "giving to each that which is his due." this implies the fair distribution of goods in society and requires that we look at the role of entitlement. it is generally held that persons who are equals should qualify for equal treatment. this is borne out in the application of medicare, which is available to all persons over the age of 65 years. this category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. in fact, our society uses a variety of factors as a criteria for distributive justice, including the following: 29 bangladesh journal of bioethics 2010; 1(2):24-30 1. to each person an equal share, 2. to each person according to need, 3. to each person according to effort, 4. to each person according to contribution, 5. to each person according to merit, 6. to each person according to free-market exchanges.12 at first the decision of professional was accepted for the health care and medical treatment.but at present the importance has been given to the patient and to the freedom of patient .such as the treatment of patient depends on the approval ,view and confession of the patient and the doctors. principles in current usages in the health care ethics seems to be of self-evident value. before implementing the medical care plan, it is now commonly accepted that the patient must indicate a willingness in writing to accept the proposed treatment. the physician should develop a care plan designed to provide that is most beneficial to the patient. in the history of recent period bio-ethics as a part of the practical ethics played an important role . duty toward patient of the physician is the central point of bio-ethics. there are two aspects of duty ,one is positive dealing with direct part, other is negative dealing with indirect part. main general and principle responsibility of the physician to the patient is to ensure the welfare of the patient ,to respect all the patient, to restrain from deception with patient, to take proper care of the patient , to utilize health welfare incase of full cure, to give importance regarding mental and religious field, medicine should be applied skillfully with no harm etc. adding to these they should gain skillful professional knowledge and expand the outlook through whole life learning. they should also confess and respect the others capability in case of necessity. society for bioethics and humanities should promote multidisciplinary, interdisciplinary professional development and inter professional. the study of bioethics enhances our knowledge of the world of possibilities and thereby broaden our vision and outlook. this in turn can lead to increased tolerance that is indispensable for democracy. bioethics can greatly enlighten us on living moral issues on gender discrimination, reverse discrimination, affirmative action, fundamental human rights, political rights , civil disobedience, environment, equality, equity, fairness, justice, war and peace. so by executing bioethics we will get a fine society ,at the same time a fine world to live in. references: 1.john s. mackenzie,a manual of ethics,university tutorial press ltd, london,1964.p.1 2.william lillie, an introduction to ethics, allied publihers pvt.ltd,new delhi, 2003,p.3 3. a .s.m.abdul khalek, praogic nitibiddya, annanya, dhaka, p.introduction 4. bioethics – wickipedia, the free encyclopedia, http://en.wikipedia.org/wiki/bioethics 5.terminology,wickipedia, the free encyclopedia, http://en.wikipedia.org/wiki/bioethics 6. arther caplan,glenn mc gee, bioethics for beginner, http//www.acgme.org/outcome. 30 bangladesh journal of bioethics 2010; 1(2):24-30 7. a .s.m.abdul khalek, praogic nitibiddya, annanya, dhaka, p.introduction 8.bioethical issue: cloning: in the minds of many people the word cloning generally conjures up pictures of identical human beings, created without using normal reproductive processes. however cloning is more surrogacy surrogacy involves a woman (the surrogate mother) carrying a child for someone else, usually an infertile couple or sometimes a gay couple. before she becomes pregnant the surrogate mother agrees to more genetic engineering genetic engineering and genetic modification are terms used for genetic techniques which can be used to transfer genes from one organism to another move, delete, modify, or multiply genes within a more euthanasia. from the catechism of the catholic church catholic teaching labels euthanasia as 'murder' while making a clear distinction between euthanasia and refusing 'overzealous' or 'extraordinary' medical more 9. souvenir unesco philosophy day, department of philosophy, universityof dhak 18. november.2004 p.13 10. ibid 11 thomas r. mc cormike, d min,principles of bioethics.faculty,mdical histor and ethics., 12. ibid institutional ethical review board (ierb) : concept & context bangladesh journal of bioethics, 2011; 2(2):24-25 institutional ethical review board (ierb): concept & context dr. md. humayun kabir talukder1, dr. md. zakir hossain2 , dr. nasrin ahkter 3, ismat ara perveen4 1. associate professor & course director, centre for medical education, dhaka 2. registrar, sapporo dental college, dhaka 3. asstt. prof, dhaka medical college, dhaka 4. instructor, nursing college, dhaka abstract: according to modern concept of institutional review board, all proposal of biomedical research involving human participants should be cleared/approved by an institutional review board (irb) is mandatory. competence and independence are the two hallmarks of an irb. the responsibilities of an irb are protection of dignity, rights and well being of potential research participants. all research projects do not pass through irb in bangladesh. many researches have been performed without ethical clearance. young healthcare professionals are scare about irb as they have little ides about irb. structure of irb, review procedures and irb in bangladesh are discussed in this paper to better understanding of ethical process of research paper to the health care professsionals. introduction: the modern concept of institutional review board originated in 1970s.1 it is mandatory that all proposal on biomedical research involving human participants should be cleared/approved by an appropriately constituted institutional ethical review board (ierb)/ institutional ethic committee(iec), also referred to as institutional review board (irb) ethics review board (erb) and research ethics board(reb) in other countries.2 competence and independence are the two hallmarks of an (ierb)/ (iec) .the responsibilities of an (ierb)/ (iec) are protection of dignity, rights and well being of potential research participants; ensuring that universal ethical values and international scientific standards are expressed in terms of community values and customs and assistance in the development and in the education of a research community responsive to local health care requirements.2 the boards are responsible for review of the proposed research proposal prior to initiation of the project. they also have the responsibility of regular monitoring of the approved research project to foresee the compliance of the ethics during the period of the project.2 actions of ierb are approvalapprove without stipulation, approve with stipulations. they enforce rules regarding noncompliant investigations by rejecting a proposal or termination of an investigation1. in composition the (ierb)/ (iec) should be multisectorial and multidisciplinary. institutional ethical review board (ierb) is a body consisting of concerned odd number of persons (9-11). the (ierb)/ (iec) may be comprised of a chairperson; one or two persons from basic medical science; one or two clinicians from various institutes ; one legal experts; one social scientist or representative of non governmental voluntary agency; one philosopher /ethicist/theologian ; one lay person from the community 2,1. the (ierb)/ (iec) members should be encouraged to be updated of all national and international developments in ethics through orientation courses on related topics by its own members or regular training organized by constituted body.2 review procedures by (ierb)/ (iec): for a research proposal on human participants a scientific evaluation by a appropriate scientific review committee has been completed before ethical review is taken up. a 24 research proposal should be screened by the (ierb)/ (iec) secretariat for their completeness and depending on the risk involved categorizes into three types , namely , exemption from review , expedited review and full review 2, 1. a proposal which present less than minimal risk fall under the category of exemption from review and administratively reviewed does not require board review. the proposal having no more than minimal risk to research participants may be fall under the category of expedited review and usually reviewed by sub committee. all research presenting with more than minimal risk , or those proposal/ projects which do not qualify to fall under the category of exemption from review , expedited review and proposal/ projects that involve vulnerable population and special groups shall be subjected to review by all members of the (ierb)/ (iec). research intended for publication are generally subjected to be reviewed by institutional review board.(2,1) completion of irb process is time consuming and expensive . the bell report for the national institute s of health described annual work load facing 491 irbs including an estimated 284,000 reviews.3 ethics review committees in bangladesh: bangladesh is a developing country in the south asia region. health research demand is increasing as there are huge health problems. in bangladesh there is one central ethics review committee and nine institutional committees. the bangladesh medical research council ethics committee is considered as the central/ national ethics review committee4. the nine other ethics review committees are functioning in seven postgraduate medical institutes and two medical college. the institutes are bangabandhu sheikh mujib medical university, national institute of preventive and social medicine, national institute of the kidney diseases and urology (nikdu), institute of child and mother health (icmh), bangladesh institute of child health (bich), chittagong medical college (cmc), sir salimullah medical college (ssmc), rajshahi medical college (rmc) and bangladesh institute of research for promotion of essential and reproductive health and technologies. icddr’b has its own ethics review committee. bangladesh medical research council (bmrc) was established in1972 as an autonomous body by order of the president under the ministry of health and family welfare. the central ethics review committee was established in 1979. at present committee consists of 11 members5. the clinicians, lawyers, laypersons and religious leaders are included as members. the committee is formed by the executive committee of the bmrc and has tenure of three years. the committee is registered in the office for human resource protection in the usa as an official institutional review board and it has federal wide assurance. about 100 research proposals are reviewed by central ethics review committee of bmrc. references: 1. parviji j, tarity d, conner k, smith b, institutional review board approval: why it matters? journal of bone and joint surgery .2007; 89: 2. institutional ethical review board jawaharlal nehru university http://www.jnu.ac.in/ierb/icmr guideline 3. a central institutional review board for a multi – institutional trials. n engl j med 2002;346(18) www.nejm.org 4. rashid ha, regional perspectives in research ethics : a report from bangladesh eastern mediterranean health journal, 2006 ;12 (1) 5. bangladesh medical research council www.bmrcbd.org 25 http://www.nejm.org/ http://www.jnu.ac.in/ierb/icmr bangladesh journal of bioethics 2011; 2(3):10-15 10 ethics in dissection of cadaver in teaching and learning of anatomy abu sadat mohammad nurunnabi 1 , shamim ara 2 , mohsin khalil 3 , mansur khalil 4 1. dr. abu sadat mohammad nurunnabi, lecturer, department of anatomy, dhaka medical college, dhaka. cell phone: +8801712290608, email: shekhor19@yahoo.com (corresponding author). 2. dr. shamim ara, professor and head, department of anatomy, dhaka medical college, dhaka. 3. dr. mohsin khalil, professor and head, department of anatomy, mymensingh medical college, mymensingh. 4. dr. mansur khalil, professor and head, department of anatomy, chittagong medical college, chittagong. abstract: dissection of dead body is a time honoured part of medical education. undergraduate and postgraduate students do dissection as a part of the learning human anatomy. according to the state regulations, most of the cadavers are obtained from the forensic mortuary declared as ‘unclaimed body’. some are collected through ‘body donation’ as well. however, use of human tissue for research and the use of human cadavers for teaching and training purposes are surrounded by ethical uncertainties. moreover, the main ethical concern of cadaver dissection lies in respect to human life. this writing has been aimed to put a nominal guideline how to act in an ethical way in cadaver dissection by the medical students in medical colleges and pave the way for better understanding how to respond in an ethical manner in medical professional life. some rules and regulations have been recommended for maintaining the highest standard of a dissection hall as well as the dignity of the cadavers. key words: ethics, dissection, cadaver, teaching and learning anatomy. introduction: the most important book in the history of medicine is an anatomical treatise published in 1543, ‘de humani corporis fabrica’, based on dissections of the human body. the illustrations in the seven volumes of this work by andreas vesalius are exquisite for their beauty, complexity and humanity1. prior to vesalius anatomical texts were based largely on dissections of nonhuman animals. however, cadaver dissection was not new in the time of vesalius, where there was a physician-teacher performed dissection in the theatre surrounded by the students1,2. bangladesh journal of bioethics 2011; 2(3):10-15 11 cadaveric dissection has been the paradigm of anatomy teaching since the renaissance, and the defining experience of medical teaching since the 16th and 17th centuries3,4. subsequently, cadaveric dissection featured regularly in medical training, although often in an informal, semi-official manner 5 . even with the current tools available to the western countries such as the visible human project, students still begin the study of human anatomy at the dissecting table both in eastern and western world. dissection of cadaver ― essential part of teaching and learning anatomy: cadavers are required for studying the human anatomy in all disciplines of medical science. as medical institutions of various specialized disciplines have overgrown, the need for cadavers has also increased proportionately 6 . cadavers used by these institutions are usually unclaimed bodies obtained by the police in our country. occasionally they are donated by relatives of the deceased, to teaching institutions, according to the dead person's wishes7,8. donating one's body for dissection meets the criteria for the highest levels of charity as set forth by the 12 th century philosopher, physician, and rabbinic scholar moses maimonides 9 . ethical concerns in dissection of cadavers: anatomical dissection is a time honoured part of medical education5. however, like the use of human tissue for research purposes, the use of human cadavers for teaching and training purposes is surrounded by ethical uncertainties 9-12 . ethical problems are recognized as one of the reasons for thinking to take decision to abandon anatomical dissection altogether in the u.k. (e.g. newly founded peninsula medical school in plymouth) as stated by mclachlan et al.13. at the heart of such uncertainties lies the ambiguous status of the cadaver, which carries at the same time personal and material qualities10. this ambiguity is not easily resolved, which explains why the dissecting room experience can be frightening and fascinating 14 . the main ethical concern of cadaver dissection lies in respect to human life. rules and regulations for working in the dissection hall: the students in our country have got enormous opportunity of dissecting cadavers and learning themselves, especially in government medical colleges, where there are morgues for medicolegal autopsy purposes. therefore, it is a great opportunity to participate in a rich tradition and experience a privilege shared by only few. cadavers are referred to as ‘human anatomical specimens’15, a description that seems inadequate for such a valuable gift to medical bangladesh journal of bioethics 2011; 2(3):10-15 12 education. working with human material requires respect and sensitivity16. the following information and rules will help the students and the teachers understand their responsibilities regarding the use of human material. here are some rules and regulations for maintaining the highest standard of a dissection hall as well as the dignity of the cadavers: 1. human anatomical gifts: we stated earlier that the most of our cadavers were obtained from the college mortuary declared as ‘unclaimed body’, according to the state regulations. some are collected through ‘body donation’. persons donating their body receive no financial compensation; this is truly their ultimate gift17. hence, it is imperative that proper respect be paid to the cadaver at all times. any disrespect for the cadaver will be shameful as a human being 18 . the teachers and the students should observe professional conduct while in the dissection hall and outside of the hall, particularly if anyone wants to discuss anything related to the cadaver in a public place. photographs of the cadaver or any parts should not be taken inside the dissection hall without prior permission. 2. care of cadavers: the cadaver has to be kept moist at all times. the cadaver is covered with towels moistened with embalming fluid. the students should only uncover the area they are studying. 3. laboratory access: the dissection hall should have got a limited access and needs to be locked when not in use. only students enrolled in the course are allowed in the dissection hall. the students should not bring in friends or visitors! of course, this may differ in accordance with different institutional rules. 4. laboratory safety: cadavers are embalmed with a fluid containing glycerin, ethyl alcohol and phenol. physical contact of one’s skin and clothing with the cadaver should be avoided. the students are required to wear disposable gloves at all times while working in the dissection hall. non-latex/powderless gloves should be available for dissection. however, in our country, dissection is done without wearing hand gloves in many medical institutions. a long-sleeved white coat/apron should be worn while working with the cadaver. lab coats may not be worn outside of the lab. dirty coats are a health hazard and are offensive. no open-toed shoes or sandals are allowed. the students should wear shoes that cover their entire foot. contact lenses should not be worn in the dissection hall, because the lenses can absorb bangladesh journal of bioethics 2011; 2(3):10-15 13 chemical vapours. if anyone must need to wear contact lenses, he/she is required to purchase and wear vapour proof goggles. only textbook and dissection manual are allowed in the dissection hall. all backpacks or other personal items should be left at a corner. food and drinks are not allowed in the dissection hall. proper use and handling of the dissection instruments should be carefully maintained. the ventilation system in the hall is designed to remove air at the level of the cadaver and to reduce exposure to the embalming chemicals and odours. the ventilation system should remain on at all times. there is a negative air flow to keep odours from leaving the hall. the door to the hall should be closed at all times. 5. preservation of the tissues and organs: all tissues removed from the cadaver must be collected and placed in the designated containers or tray. no body parts, tissue, etc. should be removed from the dissection hall. the excess liquid that has accumulated on the dissection table should be drained into the bucket located under the table. the last word lost in translation: anatomy is a rigorous course requiring great dedication and devotion. just as dissection remains an essential technique to teach three-dimensional concepts, the cadaver dissection hall is an ideal place to introduce concepts of humanistic care14. the dissection hall evokes the students' memories, speculations, and fears about serious illness in themselves, their families, and loved ones19. the attitude of the lecturers/curator (as they are engaged in dissection classes for the students in our country) in ministering to the students' needs as they undertake the emotionally charged task of dissection can provide a model for how the students will respond, in turn, to the hopes and fears of their patients and to their own reactions to dying. this approach will allow students to implement and practice humanistic values immediately, laying a foundation for their clinical training20. we are actually not in a position to judge whether the ethical approach will produce better doctors in the end. however, we like to think that it allays some of the ethical difficulties in dealing with human cadavers. of course, medical practitioners face many ambiguities, including the need to show both detachment and empathetic care in the treatment of patients 21 . therefore, learning how to deal with such ambiguities is in itself an important aspect of medical education and training13. in this respect, everyone engaged in teaching and learning should follow the ethical ways. this writing was aimed to put a nominal guideline bangladesh journal of bioethics 2011; 2(3):10-15 14 for ethical way of act in cadaver dissection and pave a way for better understanding how to respond in ethical manner in medical professional life. last but not the least, we want to share a quote from the students’ words of condolence for their body donor, experienced in thailand, where the cadavers are always referred to as ‘ajarn yai’ (great teacher), never as ‘sop’ (cadaver). “i would like you to know that to me and many others you are a hero. your sacrifice is silent, most people don't know about it. but i promise, i will never forget you. you have taught me everything there is to be learnt both in the book and in the facts of life. i will remember you as my great teacher forever.” [from a booklet for a cremation ceremony at mahidol university, bangkok, thailand – the original text in english]14. references: 1. rath g, garg k. inception of cadaver dissection and its relevance in present day scenario of medical education. j indian med assoc 2006; 104(6): 331-3. 2. hildebrandt s. capital punishment and anatomy: history and ethics of an ongoing association. clin anat 2008; 21: 5-14. 3. richardson r. death, dissection and the destitute. london: penguin; 1988. 4. persaud tvn. the early history of human anatomy: from antiquity to the beginning of the modern area. illinois: thomas books; 1984. 5. mclachlan jc, patten d. anatomy teaching: ghosts of the past, present and future. med educ 2006; 40(3): 243-53. 6. pampilly vs. cadavers for anatomical dissection. indian j med ethics 2005; 2(1): 16-7. 7. dyer gs, thorndike me. quidne mortui vivos docent? the evolving purpose of human dissection in medical education. acad med 2000; 75(10): 969-79. 8. furness p. consent to using human tissue. bmj 2003; 327: 759-60. bangladesh journal of bioethics 2011; 2(3):10-15 15 9. sukol rb. building on a tradition of ethical consideration of the dead. hum pathol 1995; 26(7): 700-5. 10. hafferty fw. cadaver stories and the emotional socialization of medical students. j health soc behav 1988; 29: 344-56. 11. tuffs a. von hagens faces investigation over use of bodies without consent. bmj 2003; 327(7423): 1068. 12. shaffer k. becoming a physician: teaching anatomy in the digital world. n engl j med 2004; 351: 1279-81. 13. mclachlan jc, bligh j, bradley p, searle j. teaching anatomy without cadavers. med educ 2004; 38(4): 418-24. 14. winkelmann a, güldner fh. cadavers as teachers: the dissecting room experience in thailand. bmj 2004; 329(7480): 1455-7. 15. baumel jj. donation of bodies for medical education. nebr state med j 1968; 53(3): 90-2. 16. pawlina w, hammer rr, strauss jd, heath sg, zhao kd, sahota s, et al. the hand that gives the rose. mayo clin proc 2011; 86(2): 139-44. 17. yeager vl. learning gross anatomy: dissection and prosection. clin anat 1996; 9(1): 57-9. 18. pawlina w, lachman n. dissection in learning and teaching gross anatomy: rebuttal to mclachlan. anat rec b new anat 2004; 281(1): 9-11. 19. rizzolo lj. human dissection: an approach to interweaving the traditional and humanistic goals of medical education. anat rec 2002; 269(6): 242-8. 20. bertman sl, marks sc, jr. the dissection experience as a laboratory for self-discovery about death and dying: another side of clinical anatomy. clin anat 1989; 2(2): 103-13. 21. rosenfield pj, jones l. striking a balance: training medical students to provide empathetic care. med educ 2004; 38: 927-33. bangladesh journal of bioethics 2011; 2(3):16-18 16 breach of confidentiality: unintentional common practice due to misunderstanding and unawareness mohammad waseem khan master student of bioethics, aga khan university hospital, karachi, sindh, pakistan. email: mwaseem.tareen@yahoo.com abstract: advancement in medical technology has helped man kind in several ways and no one can deny the contribution of medical technology in the field of medicine. on the other hand technology has also given rise to some ethical issues. the issue of confidentiality is one of those issues. patients keeping their trust on physician reveals all concerned confidential information to their physician with surety that physician will not reveal it to other person and will keep it confidential. it has been common in practice that, physicians unintentionally breach their patient’s confidentiality by discussing cases and history of their patients in public places, hospital elevators, and with their students. in a busy hospital setting it can be difficult to maintain confidentiality for patients. increasing workloads lead to discussions of patients in public areas which is not an acceptable excuse. the very next person present there listening the discussion could be a patient's friend, relative, or media member that is not entitled to this privileged information. in all these cases permission must be received from the patient prior to any disclosure. introduction: the principal of confidentiality involves sharing of information with the expectation that it will not be revealed to third parties, or that it will be revealed under restricted circumstances with consent of the owner. the principal of confidentiality is usually applied to private information of the patient which is an important aspect of privacy between patient-physician relationships. health care professionals have a legal and ethical duty to keep patient’s medical information private. physicians and nurses, along with hospital staff are required by law and professional codes to practice confidentiality. 1 patients have right to expect that information about them will be held confidential in confidence by their doctors that is central to trust between doctors and patients. in our environment we see many tertiary care hospitals following the policy of confidentiality but still unable to follow it in practicality. there are number of cases in which patient’s confidential information are shared in hospitals and public places by the physicians and the healthcare team. the duty of physician includes the confidentiality of their patients which need physician not to disclose any medical information which is discovered by physician or revealed by patient to physician. the obligation of confidentiality can be breached in specific situation where benefit gain is greater than breach of confidentiality. situations where confidentiality can be breached include public welfare and concern for the safety of other specific person. as far as the case which includes the breach of confidentiality for education and teaching purpose, care needs to be taken by avoiding common practice mentioning patient names. patient’s confidentiality can be maintained by not disclosing patient name and allotting identification numbers to patients and discussing each case by their identification number. identification number will help maintaining patient confidentiality and achieving desired purpose of education to the medical students. case study: in a tertiary care hospital (quetta) a patient (x) after visiting his physician (d) came to know that his physician has breached his confidential information to the people while discussing the case with medical students for teaching purpose in consulting clinics. in consulting clinics there were some other patients with their relatives waiting for their meeting with the physician. the patient was told by one of his family member (f) who was present in consulting clinic's waiting area as the physician was pointing him out with his name. the information revealed was meant to be confidential which the patient was unwilling to share with anybody else other than his physician. ethical issue: maintaining patient confidentiality is one of the most important columns in clinical practice. physicians and health care providers have the duty of protecting the private details of their patient. maintaining patient confidentiality is not just a matter of moral respect but is an essential element in retaining the important bond of trust between the physician and patients. physicians are bound to obey and are governed by the rules of confidentiality. physicians and health care providers can not reveal a patient's medical history, even to their closest family members or friends, without the permission of their patient. bangladesh journal of bioethics 2011; 2(3):16-18 17 analysis in norman daniels framework: now, i will try to unfold and asses the above case by following accountability for reasonableness approach presented by norman daniel which is mainly based on justice and fair selection. four main postulates of afr include: 1. publicity 2. relevance 3. appeals and revisions 4. regulative (enforcement) publicity condition: as it is claimed by norman daniels that accountability for reasonableness makes decisions in healthcare legitimate and fair. the first condition of priority setting states that decisions and their rationales must be accessible to public. applying accountability for reasonableness we see that in cases of protecting patient’s confidentiality the hospitals has clear cut policy of applying the principal that follows the first condition of accountability for reasonableness and the policy is sometimes accessible and understand able to the public and some time it is not. it may be made easily accessible to the public by creating awareness programs to the public. 2, 3, and 4 relevance condition: applying the second condition of a for r in priority setting which states that rationales for priority setting and decisions making must rest on valid reasons. the patient’s confidentiality is sometimes overruled by health care professionals which might not always be legal. firstly it should be done with the permission of concerned patient and should be justified with greater ratio of benefits to risks. the relevant condition needs to be explained with reasonable explanation by health care provider to the patient whether that is to be discussed with another physician, family members or to the students for teaching purpose. 2, 3, 4 appeals and revisions condition: moving to the third condition of a for r, appeals and revisions should be welcomed by the organization in any case where the affected body thinks that the breach of confidentiality is not justified or if he shows any concern. for any process, appeals and revisions plays a pivotal role for future betterment of decision making. there must be mechanisms for challenge and dispute resolution regarding limit-setting decisions. 2, 3, 4 regulative condition: as for as the fourth condition of a for r is concerned a lot of mishaps occur there. health care organizations do make the policies to follow the principal of confidentiality and to safeguard their patients, but it is not ensured that they are applying that policy in their day to day practice. in many cases it has been seen that health care professionals some way the other do breach their patient’s confidentiality without knowing themselves. in many cases the confidential information has been discussed widely in public areas of the health care hospitals by the health care professionals and the team working in health care hospitals. 2, 3, 4 observational studies in tertiary care hospitals have shown that breaches of patient’s confidentiality by healthcare professionals occurred by discussing patients by name at parties or even in hospital elevators or cafeterias. most healthcare professionals know the limits of confidentiality well but they have trouble applying them to their behavior as they are unintentionally involved in breaching their patient’s confidentiality. 5, 6 beside the conditions of accountability for reasonableness for any action to be reasonable it must pass through relevant phases of responsibility, authority and accountability. as in cases of confidentiality the physicians are responsible for their patient confidentiality and if they are given the suitable environment and authority to accomplish their job then they should be accountable for the protection of their patient’s confidentiality. conclusion: maintaining confidentiality is increasingly difficult in modern medicine as many people have access to medical records, including the attending physician, house staff, medical students, consultants, nurses, social workers, pharmacists, billing staff and medical records but all possible measures should be taken to safe guard patient’s confidential information to maintain the value of trust between patient and physician. as confidentiality is not only between the individual and the advisor but it is also between the individual and the organization for this reason a clear cut policy should be made by health care organization following the four conditions of accountability for reasonableness which will be helpful in avoiding breach of confidentiality and will ensure that decisions are made fairly. bangladesh journal of bioethics 2011; 2(3):16-18 18 references: 1. majumder m. “cyberbanks and other virtual research repositories”. journal of law, medicine & ethics 2005. 33, 31. 2. daniels n. “accountability for reasonableness: establishing a fair process for priority setting is easier than agreeing on principles”. bmj 2000;321:1300-1. 3. daniels n, sabin je. “limits to health care: fair procedures, democratic deliberation, and the legitimacy problem for insurers”. philos public aff 1997;26:303–50. 4. rid a. “justice and procedure: how does ''accountability for reasonableness'' result in fair limit-setting decisions”? j med ethics 2009 35: 12-16. 5. vigod, sn. et al. “privacy of patient’s information in hospital lifts: observational study”. bmj 2003; 327:1024– 5. 6. bernard, lo. “resolving ethical dillemmas, a guide for clinicians”. 4th edition. chapter 5. pp4-48. 7. beauchamp tl, childress jf. “principles of biomedical ethics”, 4th ed. new york: oxford university press, 1994: 418-42. bangladesh journal of bioethics 2011 vol. 2 issue 1 page 18-21 18 bioemedical consideration in the manufacture, clinical trail and bioequivalence studies of pharmaceuticals a b m faroque professor and dean, faculty of pharmacy, university of dhaka, bangladesh. abstract: bangladesh pharmaceutical sector has been growing at a remarkable speed since 1982. from the meager 30% national market share, now it is supplying 97% of our annual demand. around 1,100 generics are now available in a total of around 12,000 trade name products. the national market size has crossed 6,000 crore taka per annum, where the local multinational share is only 7%. our industries are now exporting drugs to 72 countries. but just because our pharmaceutical sector has developed its own backbone does not meant that our pharmaceutical industries have solved the relevant bioethical questions. there are complaints that some companies do not pursue necessary bioethical norm as at various levels of its manufacturing processes. still a good number of small companies sell sub-standard and counterfeit drugs, and yet some are not following accepted gmp standards. moreover, for capturing foreign markets we need clinical trials and bioequivalence study results. these study needs human subjects as volunteers. in a poverty-stricken country like us, if we do not establish these clinical trial and bioequivalence norms, everything becomes irrelevant. if we can establish theses norms, this could be the beginning of a new era for further growth of our pharmaceutical industries vis-à-vis our public health national economy. introduction: bangladesh has a severely war-torn economy, seriously disrupted infrastructure and a huge deficit in foreign currency when it earned independence in 1971. all these factors aggravated the overall health care situation of the country. at that time, country’s health care facilities, including the supply of medicines, were mostly depending on import. at that time more than 80% drugs of our annual demand were being imported. in 1982, a national drug policy was announced that largely encouraged local production in our pharmaceutical sector. under the umbrella of this drug policy, a large number of local companies invested in creating local pharmaceutical manufacturing facilities. this trend still continues. the present government is also encouraging these local investors and our hon’ble bangladesh journal of bioethics 2011 vol. 2 issue 1 page 18-21 19 prime minister her excellency sheikh hasina has also declared her policy to restrict import of drugs that are locally manufactured. this market protection stimulated the growth of our national pharmaceutical companies and has led to a national aspiration towards selfsufficiency in pharmaceutical sectors. pharmaceutical sector of bangladesh: in today’s bangladesh, the pharmaceutical sector has emerged as one of the fastest growing business sector, its current annual market size is about 6,000 crore taka, it is the second highest contributors to our national exchequer, and it is the largest white collar labor intensive employment sector. in 1982, market share of the multinational pharmaceutical companies was 75%, only 25% was contributed by our national companies. but today our pharmaceutical market is dominated by local manufacturers and the top 10 pharmaceutical companies are mostly local companies. today we are moving towards self-sufficiency in medicine by getting 97% our drugs that are consumed annually from local manufacturers and only 3% from import. these very meager imported items are vaccines, anticancer drugs, insulin etc. whereas, drug import figures for singapore is 75%, myanmar 90% and shri lanka 85%. another very import point regarding our pharmaceutical industries is that our pharma companies are heading towards self-sufficiency without compromising the quality. bangladesh is now capable of producing high quality pharmaceutical products. this was possible because our industry now uses state-of-the-art manufacturing technology, very sophisticated qc equipment and apparatus, and highly skilled human resource. a good number of these plants have achieved mhra, eu, gcc, tga and anvisa certifications. now some of them are improving themselves further and trying to obtain the fda certification too. moreover, our pharmaceutical industries are achieving self-sufficiency without affecting the consumers’ affordability. before drug policy in 1982, price of one amoxicillin capsule was tk. 7, now it is tk. 3.60; doxycycline capsule was tk. 3.95, now it is tk. 2 ; and diclofenac tablet was tk. 9, now it is tk 0.50 only. in this way another national aspiration has developed in our pharmaceutical sector i.e. turning an import-based pharmaceutical industry into an exporter of quality medicines. today, bangladesh is successfully exporting its quality products to 87 countries in asia, africa, latin america and europe. the drugs we are exporting are a wide range of pharmaceutical products covering all major therapeutic classes and doses forms. besides bangladesh journal of bioethics 2011 vol. 2 issue 1 page 18-21 20 conventional products we are exporting high-tech specialized products like inhalers, nasal spray, infusions etc. the quality and efficacy of the products being exported from bangladesh have been highly appreciated in all the countries we are exporting. bangladesh now has become one of the cheapest sources of quality medicines in the world. so the generic pharmaceutical market of the world is now open for bangladesh. bioethics: but just because our pharmaceutical sector has developed its own backbone does not mean that all our pharmaceutical industries have solved the relevant bioethical questions. though we are proud of many of our pharmaceutical companies; still there are complaints that some other companies do not pursue necessary bioethical norms at various levels of their manufacturing processes. still a good number of companies sell sub-standard and counterfeit drugs, and yet some are not following the accepted gmp standards. this is very much unfortunate and need to be addressed properly both for the sake of public health and for the interest of the pharmaceutical companies. the deviations that some companies of our country are showing in general are : not employing enough qualified pharmacists, absence of regular health check-up of the personnel directly in contact with the manufacturing process, not having formal gmp training for all personnel of vital departments, not following proper in-process quality control measures, not having proper qc instruments, not using appropriate reference standards, not having any authorized vendor list for procurement of raw materials, not performing 100% sampling for identification of apis and excipients, not having standard cleaning schedules for production machineries and surroundings , not rotating the disinfectants for cleaning of floors, not validating the production equipment and processes properly, not having acceptable waste disposal system etc. these variations are neither acceptable nor good for developing a positive image of our overall pharmaceutical manufacturers. ethical selfregulation could be a means to minimize such deviations. though these companies are not competing in the export market but their products are being sold in the local market. this is an important concern for us because these companies are not gmp-compliant. fortunately market share of these companies is negligible. if we consider exporting our medicine to the world market, it needs clinical trial and bioequivalence studies. as clinical trials and bioequivalence studies are experiments on human subjects, this means that ethical issues are always to be considered. these bangladesh journal of bioethics 2011 vol. 2 issue 1 page 18-21 21 experimental subjects are assigned either to receive the experimental intervention, or to receive an already established treatment product. who’s approach to bring all clinical trial data including trial conducted by private pharmaceutical companies, into a clinical trial registry is an excellent idea. poor counties like bangladesh will be benefited from this approach because we have a very large poor population that might be used as guinea pigs if appropriate national bioethical principles are not there. right to informed consent and getting unbiased scientific health information about any experimental product is most important. it is an issue if global justice too. conclusion: in a poverty stricken country like bangladesh, if we do not establish these clinical trial and bioequivalence study norms nationally, everything else becomes irrelevant. growth of our national pharmaceutical industry or earning a huge foreign currency without bioethical considerations is absolutely impossible and unacceptable. if we can establish these national bioethical norms, this could be the beginning of a new era for future growth of our pharmaceutical industries vis-á-vis our public health and national economy. we want to keep it in mind that ethical behavior is essential if a business is to function effectively. policing through self-regulation is a good idea where bioethics can play a vital role. we need proper national ethical guidelines and this ultimately will be a right step in the right direction for further advance of our pharmaceutical industries, for better health care coverage of our poor people and for a potentially remarkable growth of our national economy. bangladesh journal of bioethics 2011;2(3):2 editorial should nursing ethics be distinguished from medical ethics? medical care is much boarder than simply restoring normal function. it is the interaction between care and cure characterizing by care and trust, constitute the essence of doctor patient relationship and nurse-patient relationship. a book entitled “extending the boundary of care: medical ethics and caring practice” introduce the limit between the care and cure. medical ethics exclusively focus on medical decision where care is relatively neglected. medical decision of care is taken by nurse. in a nursing home dimension, care for older person, person suffering from chronic condition, mentally incorporated older person, dying patients etc are responsible for nurse. in curative medical care, care for these people is limited. for them role of nursing care is more important. nurse usually confronts ethical problem arise in their practice. so this care needs different type of ethics. on the basis of philosophical analysis, concept of care is the reflection of value of nursing profession. ethics of care is emphasis on responsibility, solidarity, finitude, morality and communication. it is long tradition nurse has been demonstrating the value of ethics of care. in addition, nursing profession is largely feminine, care oriented, virtue and emotional then the medical ethics which is masculine, cure oriented including principal and rational. therefore there is room for thinking to distinguish nursing ethics from medical ethics. research on this arena is needed. shamima parvin lasker (professor & head of anatomy, city dental college, bangladesh) associate editor bangladesh journal of bioethics bangladesh journal of bioethics 2012; 3(1): 23-29 23 ethical case deliberation involving the end of life decision oduwole ebunoluwa department of philosophy, olabisi onabanjo university, p.m.b.2002, ago-iwoye, ogun state, nigeria. email: ebunoduwole2k2@yahoo.com abstract: end of life decisions involving the patients who are in unbearable, intense suffering are often not easy to make especially when there are moral dilemmas or conflicts. the patient, physician and care givers may have to come together to decide on a reasonable course of action. however, in arriving at a moral course of action a moral conflict may arise between all concerned parties. in resolving such a conflict there is a need to adopt a method. here, a brief set of questions has been used as a method that can help to structure a case deliberation following a set of carefully separated steps. this paper adopts the nijmegen method of case deliberation to analyse a case that involves a moral conflict. in addition to the method adopted the paper gives a careful consideration to the cultural underpinnings of the case. the choice of this method does not indicate that it is the best of all existing method but that the whole exercise is an attempt to point out how a moral conflict may arise in a case and how such conflict can be resolved by using a structured method. key words: moral conflict, ethical case deliberation, method of deliberation introduction: there are a lot of dilemma that faces patients, family and the medical professions towards the end of life. for example a physician may be faced with taking decisions concerning the life of a patient who may be suffering from an incurable disease and whose case is seen as hopeless and in intense suffering as he is expected to save life at all cost and at the same time to do their best to relieve suffering and pain. since the days of the hippocratic oath the doctors have always been in a dilemma not to harm a patient and doing their best to relieve suffering. besides, there are some principles that tend to be a guide to health care providers, care givers and family in an attempt to help a patient. the principles of autonomy, beneficence, nonmaleficence and justice add fidelity to it 1 . these principles though appear very easy to understand but their applications are not the easy because they are thick concepts that require careful analysis and applications to particular issues and situations. the context of each case thus matters in ethical deliberations and decision making in all medical procedures. thus as cavalieri 2 rightly observed, physicians and other healthcare professionals providing care for dying patients will confront many ethical dilemmas and challenges. providing good care to dying patients requires physicians to be knowledgeable of potential ethical dilemmas and be aware of strategies and interventions aimed at avoiding conflict. cavalieri 2 further states that it is important for the physician to be proactive with regard to decision making and have good communication skills. keeping the patient central in all decision making, that is, respecting patient autonomy is thus very essential. it follows that ethical issues may arise at end of life of a patient when the attending physician thinks that treatment if futile and the family or care givers may differ and hold the view that treatment is not futile as such both parties differs on the next line of action. the idea of futility thus may give rise to conflict because there is no consensus between the doctors’ opinion and the family or even between members of the family. in some other cases the financial and monetary aspect is given a priority in moral considerations especially when the family cannot afford to continue with treatment. the cultural underpinning of a case also is of paramount important when a case is another factor that is of paramount importance in a case of moral conflict or dilemma. this paper thus tries to analyse a case of chief mrs omojakande, a 90 year old yoruba woman using the nijmegen method of ethical bangladesh journal of bioethics 2012; 3(1): 23-29 24 deliberation. in order to put the case in its proper cultural perspective the paper will give a brief analysis of the nijmegen method of ethical deliberation and how an ethical conflicts in the case can be solved given the various cultural factors that underscores the case . the yoruba on death: the yoruba are from the western part of nigeria, west africa. they have a rich culture and they are deeply rooted in their idea about life and death. for the yoruba death can be either good or bad depending on the age, situation and circumstances surrounding a person’s life and death. examples of bad death include when a young person dies or a woman who dies in child birth or during pregnancy, and accidents. bad death is regarded as ‘iku ofo’ – mourning death. so, young age is one of the main characteristics of bad death. misfortunes, accidents, unpalatable events in life are also included in the factors that label a death as bad. good death is characterised by old age, accomplishment of dreams, hopes and aspirations in life. if a person lived to old age, living behind lots of children and grandchildren then he will be seen as having lived a good life and dying a good death 3 . the death of this nature is an occasion for celebration and grand burial ceremonies. in this case, the children of the dead do take their time before they bury the corpse. they make adequate preparation so as to give the dead a befitting burial. in the traditional yoruba thought it is the belief that people that fall under the group of “bad death” will not be accepted in the abode of the ancestors, it is said that, they become wandering spirits and some may reincarnate. however, those who die a “good death” live on in a blissful life in the company of the ancestors. thus, among the yoruba, death is the means of transforming from mortality to immortality 3. these are traditional ideas and meaning of life that shapes the people’s perception about life and death even despite the exposure to christianity, islam and western values and ideals. they are cultural markers that can be described as lived experiences that affect decisions in end of life. the nijmegen method of case deliberation: several methods such as the socratic dialogue, the hermeneutic method, the clinical pragmatism can also be proposed in solving ethical conflicts and moral uneasiness concerning a case. the nijmegen method of case deliberation is also one of the methods developed to discuss ethical conflicts on the ward. it was developed for the use of clinical practices in cases of moral conflicts and uneasiness. in this method, case deliberation is seen as a team based multidisciplinary endeavour, with a professional ethicist as both a critical tutor and a facilitator 4 . the nijmegen method consists of a brief manual of questions, which can be used to enact the method, and to help structure a case deliberation following a set of carefully differentiated steps 4. it is designed to integrate the process of argumentation and the structure of ethical judgement with each other. in the deliberation consensus is thus seen as a relative value 4. while not denying that there may be immoral consensus the method considers of very seriously that the most important criteria of the rightness of a judgement are coherent, acceptable ethical reasons. common sense, consciousness and consensus are important aspects in ethical case deliberation. however they claim that even this cannot be the criteria for the rightness of actions nor can the responsibility of a physician in charge be replaced by a procedure of democratic decision making 4 . it follows that in the deliberation, instead of taking on the responsibility of health care providers they are being supported in deliberating about the moral problems they endeavour in patient treatment. the major concern of this method then is on team deliberation and consensus without jeopardising moral uprightness. the basic paradigm of a protocol of the nijmegen method thus comes in four major steps which comprise of the following: the moral problem, the facts of the case, the assessment and decision making. the first crucial question is: what is the moral problem in this case? in consideration of the moral problem it is important to make an inventory of the problems that may emerge from the team and decide on which one is the most important. in other words, the team needs be specific so as not to lose focus in the midst of the varying problems that may emerge. this will help to make a concrete bangladesh journal of bioethics 2012; 3(1): 23-29 25 formulation of the most important problem that may emerge in the case. the formulation usually takes the form of a question. following the identification of the moral problem, there is a need to take an inventory of the facts starting from the medical dimension that is, the diagnosis, therapy, and prognosis of the patient. next is the nursing dimension which includes the perspective of the nurses and activities of daily living of the patient. having considered the nursing dimension there is a need to consider the patient’s values and social dimension, the organisational and juridical dimension. the third step consist of considerations of the various assessment starting from the well-being of the patient, respect for autonomy of the patient and informed consent, respect for life, representation by proxy, responsibility of the health care professionals and the team. the final step involves the conclusion and decision making. in this step, the moral problem has to be recapitulated and other unknown details given to help in the deliberation and decision making. the various relevant arguments will then be summarised and an evaluation that can lead to a decision will be made. it is important to have a consensus within the team 4 . the advantage of the nijmegen method is that it is not based on a single philosophical approach. it is a combination of clinical practice, hermeneutic reflection, and analytical bioethics. it also reflects patients’ treatment in the clinic and the multidimensional team spirit. it is also facilitated by a moderator who is from outside the team and can provide a structure, guidance and procedural authority. as a result this method improves communication, creates space for deliberation, improves decision making and it develops reflection as an attitude that is paramount for deliberations on ethical conflicts in cases 4 . in addition to the procedure of the nijmegen method this paper considers it appropriate to give the cultural dimension an important attention in the ethical case while not been unmindful of the problems that moral relativism can generate. this is because some moral conflicts may have cultural underpinnings which cannot be ignored and which may lead to communication break down between patients and the care providers. such cultural assumption may shape the judgement of care givers and even health professionals directly or indirectly and this will arouse conflicting moral judgements of a case. the cultural factors determine the lived experiences of the people and they cannot be ignored in understanding, evaluation and decision making in a case. thus, in using the nijmegen to evaluate the case below, attention will be given to the cultural issues that may emerge in the course of deliberation. the case of mrs omojakande: chief (mrs) adetutu omojakande, a 90 year old yoruba woman from nigeria and a mother of four children (three of which are female and one male), having several grandchildren and great grandchildren, has lived a very normal life till her 85 th birthday when she developed diabetes mellitus, renal insufficiency, anemia, cerebrovascular accident, coronary artery disease and parkinsonism. besides, she broke her hip. prior to surgery, she experienced multiple grand mal seizures. afterwards, was posturing, rigid, unresponsive to noise or pain. reviewed by a neurologist, it suggests a slim chance of reasonable recovery. her children are of the opinion that their mother had lived a very good life and her life should not be full of indignity at the latter stage of life. to die at this moment will be most dignifying to their mother as she has done quite a lot of fulfilling things in life especially the birth of the new great grandchild which she witnessed before hospitalization. their mother also was fond of telling them that she will rather die in dignity than lose her dignity. her point of reference most times is the yoruba adage that it is better to die than to lose one’s dignity (iku ya j’esin) she kept on asking for prayers as a support from her children. mrs omojakande’s doctor came to discuss with relatives about treatment options and their challenges and that some medication could be terminated. the following day before adetutu was brought into discussion for her decision, she went into coma. mrs omojakande, was moved to intensive care unit bangladesh journal of bioethics 2012; 3(1): 23-29 26 being sustained with ventilator and maintained on total parenteral nutrition, but more seizures, arrhythmias, gastrointestinal bleeding, disseminated intravascular coagulopathy where muscle wasting also occurred. her chance of neurological recovery was nil. the doctor insisted on doing his best for mrs omojakande as she is a woman that deserves to die in dignity because of her status in the society. he said she can continue with the ventilation and other medication until she comes into partial consciousness, after 6 months may be to full consciousness but her muscular activities won’t be sustained. the first son wanted their mother weaned off ventilator so she can die peacefully and in dignity as she had wished before. the other daughters reacted to the elder one after noticing something can still be done for their mother having in mind she was a bit confused before going into coma. the insisted that whatever could be done should be achieved so that their mother will still live a more dignified life and invariably death. they discussed with the nurses on the possibilities of retaining their mother in the hospital. however, the nurses commented that after ventilation, mrs omojakande will only need palliative care which can be done at home otherwise it will be a waste of money keeping her in the hospital. the children of mrs omojakande are praying for her with a faith that she will be doing well. they have decided to continue with medication. the first son withdrew himself from the plan and commented that they are putting their mother in more unnecessary pain, suffering and indignity. ethical analysis of the clinical case: following the nijmegen protocol of case analysis we shall then analyse the case of mrs adetutu omojakande as follows: what is the moral problem? should the doctor preserve the life of the patient? inventory and interpretation of facts: 1. medical dimension (diagnosis, therapy and prognosis): the patient had diabetes mellitus, renal insufficiency, anemia, cerebrovascular accident, coronary artery disease and parkinsonism. besides, she broke her hip and had a surgery. prior to the surgery she experienced multiple grand mal seizures and afterwards, was posturing, rigid, unresponsive to noise or pain. from this assessment the patient is in intense suffering and pain. the neurologist was invited to assess her and a review shows that there is a slim chance of reasonable recovery. hence, from the experts view her case was futile medically and it was not something to be discussed within the limits of curative treatment. after this, she went into coma and was moved to intensive care unit being sustained with ventilator and maintained on total parenteral nutrition, but with more seizures, arrhythmias, gastrointestinal bleeding, disseminated intravascular coagulopathy where muscle wasting also occurred. all indications based on the experts’ advice shows that the chance of neurological recovery was nil. the co-morbidity assessment at this point shows that she is in great pains and her medical condition is not within curative limits. however, the doctor thought the best method of dealing with mrs omojakande’s case is to continue ventilation and other medication until she comes into partial consciousness, after 6 month may be to full consciousness. at this stage her muscular activities won’t be sustained. on the whole the wellbeing of the patient is not within the limits of curative treatment because the trajectory of the illness and the comorbidity indicate that doing everything possible to cure the patient is a kind of misdirection and will lead to therapeutic obstinacy. her quality of life is thus decreasing rapidly. 2. nursing dimension: the nursing team seem to have a different opinion from the doctor. they are of the view that after ventilation, mrs omojakande will only need palliative care which can be best bangladesh journal of bioethics 2012; 3(1): 23-29 27 achieved at home. they foresaw the therapeutic obstinacy in the patient’s case and are of the opinion that palliative care at home is a better option. in short, the nurses have a plan for the patient but they seem not to want to disagree with the doctor because he has the professional duty to take a decision. 3. patient’s view (values, religious, cultural and social dimension): the patient is a deeply religious person. she kept on asking that her children should pray for her. this could be interpreted in two ways bearing in mind the christian nature of the average yoruba and the cultural underpinnings. it could mean that the prayers will bring a miracle and heal her, or it may be that the prayers will hasten her towards dying a painless death. in this case, bearing in mind the cultural underpinnings the latter is likely to be the case. mrs omojakande as the case indicates is a great grandmother, with a lot of life fulfilling ambitions. for example, her last wish was to see the great granddaughter and she did. when a yoruba woman of her age has accomplished so much it will bring a sense of fulfilment and she will pray that death should take her speedily without pains and suffering or deterioration of the body. her chieftaincy title indicates that culturally and socially her status is high. such a title indicates that she is a public figure. the life and death of such a person is expected to be couched in social dignity. 4. social dimension: this is a very important aspect of the case in that the children of the patient did not agree on their views. there is a conflict in the decision of the family. the ladies suggest continuation of the treatment as long as this can still be done as this will lead to dignity. the son is against such a decision because in his view it will cause pain and indignity to their mother. however, a critical look will show that the argument from both ends can be reduced to the concept of dignity though interpreted from different perspectives. this then gave rise to a communication problem in the family. secondly, the division between the daughters and the son gives a very interesting cultural dimension. in the nigerian culture the first son has a prerogative of decision making. if he happens to be the first child then this duty becomes stronger. so considering this aspect of the culture the decision of the first born who happens to be the first son should prevail. since both parties rely on the concept of dignity though from different perspectives, the doctor should have taken a professional position in the interest of the patient along a dignified death. the nigerian yoruba culture also recognises futility of medical treatment. in this case the concept of death is better than loss of dignity will apply (iku ya j’esin). life as the yoruba view it should not be preserved at all cost especially when the treatment is futile and when prolongation of life will lead to great and intense suffering. thus, the yoruba will advise that optimising quality of life and a painless death will be a more dignified death for a woman of her social status and age. for a woman who has accomplished so much in life, and considering her age which will be described as a “ripe age” for the yoruba, if she dies the burial will be tinged with rejoicing and feasting to express her fulfilled, accomplished and dignified life. so not prolonging her pains will make the process and state of dying a dignified one. it will be interpreted as a fulfilled life, dignified life, dignified process of death and dignified state of death will follow with the burial ceremonies. if the doctor continues prolonging her life with intense suffering and pain then apart from the somatic suffering and harm he will bring a social harm to her. at such a ripe age the yoruba fear illness and suffering not death. most yoruba people in such a situation would seriously object to being kept alive on life support or have life prolonged at all cost. the financial aspect also comes in because the nurses implied that her prolonged stay in the hospital will lead to wasting of financial resources. in the nigerian context it will be more prudent to take a patient home for palliative care if the illness trajectory shows that the patient cannot be cured. this will then be morally acceptable. bangladesh journal of bioethics 2012; 3(1): 23-29 28 organisational dimension: the patient’s need would be better met at home as the nurses indicated. the juridical aspect: there is no law in nigeria that suggests euthanasia or physician assisted suicide both the nigerian criminal code and the penal code prohibit killing of human being no matter the intent, as a result suggesting both procedures will not be an option. however, medical care recognises futility of treatment and that end of life care should be beneficial and proportionate. in this case the doctor’s action is not proportionate. since there is no legal procedure to follow and considering the futility of the illness the doctor should have used the available professional training and medical ethics to take a decision in the interest of the patient. moral values and norms: 1. well-being of patient: there is intense pain and suffering and loss of dignity. the concept of dignity in death which matters to the patient and her children even with their disagreements is been violated by the actions taken by the doctor. the well-being of the patient is not taken into consideration by the physician. 2. autonomy of the patient and informed consent: up to the point that the patient was conscious she was well informed of her prognosis but just before the final decision was to be taken she went into coma. it can then be argued that the patient’s autonomy is not very clear. it is clear from the statements of the daughters that she considers dignity in death as not suffering and been in pains. she can be said to have given a verbal advanced directive. since the patient’s autonomy could not be explicitly decided before she went into coma and given the communal nature of the yoruba, her children should give proxy consent based on her earlier wish. 3. representation by proxy: there is no doubt that this case needs a representation by proxy since she is in coma, consequently, the family in this case, the children of mrs omojakande are the next of kin. there is an obvious disagreement between the children and this has created a communication gap between them. coincidentally the two sides are trying to protect the interest of their mother by respecting her dignity but from two different perspectives. the need to have a consensus between the children is very important as this may help the doctor and the team take a decision in the interest of the patient without a conflict. 4. responsibility within the team of health care professionals: there does not seem to be a good team approach between the health care professionals. the doctor did not consider the neurologist’s expert advice in his decision making. there is also a subtle indication of disagreement between the doctor and the nurses. this indicates that there is lack of team work in care giving between the nurses and doctors and other professionals. conclusion and decision making on the case: given all the facts at hand, it can be argued that the doctor did not consider `the expert advice of the neurologist in his actions. he should have based some of his decisions on the early assessment of the neurologist. furthermore, mrs omojakande’s case can be interpreted on one hand as a moral problem on the duty of the doctor not to prolong life in the face of medical futility and communication problem on the side of the children thus not making a concrete proxy consent upon which the doctor could have acted possible. the doctor should have frankly discussed the trajectory and prognosis of the illness of mrs omojakande with the family and advise them professionally on the medical futility of the case. a realistic dialogue between the doctor and the family may have given a better focus on the quality of life and not prolonging life at all cost. the continued over zealousness on the path of the bangladesh journal of bioethics 2012; 3(1): 23-29 29 doctor invariably may not be a beneficent for the well-being of the patient but may be maleficent in that her life was been prolonged in pain and unnecessary suffering. she would have died a more dignified death in terms of less suffering and pain than the on-going and future suffering. the patient should have been given a comfort therapy with the intention to reduce her pains. dying should not be the intention of such a therapy but the avoidance of harm and pain. conclusively, the patient should have been taken outside the context of curative care to palliative care with the aim of giving her comfort and ensuring a more dignified death. if invariably she dies the principle of double effect and wish to die with dignity would have been a good moral justification for the action. conclusion: this paper has identified a method that is the nijmegen method of case deliberation among several methods in deliberating upon a case that posed a moral conflict on the ward. the preference for this method does not foreclose the efficiency of other methods and the line of deliberation and decision making is not just the only one that can be arrived at by other committees that try to evaluate the moral problem another ethical committee may deliberate on the case and come up with different ethical question as the most important. consequently, their line of deliberation will shift. the most important idea is that a case deliberation follows a protocol that can be used to structure a case deliberation following a set of carefully differentiated steps 4 and following the suggested steps that they come out with a moral course of action or a useful moral action guide. acknowledgements: i thank dr norbert steinkamp the coordinator of bioethics training at the erasmus mundus masters in bioethics program at the radboud university nijmegen, the netherlands, in the 2011-2012 session of which i was a part. i also thank the entire radboud university department of iq scientific institute for quality health care and section ethics, philosophy and history of medicine, especially prof dr evert van leeuwen (chair), drs. wim dekkers, martien pijnenburg, simone van der burg, and simone naber for facilitating the ethical deliberation sessions during the program. references: 1. beauchamp tl, childress jf. the principles of biomedical ethics. new york: oxford university press; 2001,57-272. 2. cavalieri ta. ethical issues at the end of life. j am osteopath assoc 2001; 101(10): 616-22. 3. labeodan h. death is not the end: a review of the concept of immortality among the yoruba. kinaadman 2008; 19(2). 4. steinkamp n, gordijn b. ethical case deliberation on the ward: a comparison of four methods. med health care philosophy, 2003; 6(3): 235-46. title:*published criteria for evaluating health related websites: an egyptian pilot study bangladesh journal of bioethics 2010; 1(3):2-14 a pilot study for evaluating egyptian health websites: technical and ethical perspectives nahed m. ali1, amira gamal2, and amr a. mohamed3 1. professor of forensic medicine and toxicology, faculty of medicine, suez canal university, egypt. (corresponding author) email: nmoustafa2004@yahoo.com 2. assistant prof of community, environmental and occupational medicine, faculty of medicine, suez canal university, egypt. email: gamalamira@gmail.com 3. it department director, egyptian diabetes center, egypt. email:aibrahim@onlinediabetes.net keywords: e-health ethicshealth website. abstract: background: the growing popularity of the internet has made it easier and faster to find health information. much of this information is valuable; however, the internet also allows rapid and widespread distribution of false and misleading information. aim of the work: to evaluate some of the egyptian health websites from the technical and ethical perspectives and to compare the reliability of the different types of egyptian health websites. materials and methods: this is a descriptive study. search engines (eg. google.com and yahoo.com) were thoroughly searched for egyptian health websites. some of these websites were not accessible. out of thirty two health websites, thirteen internet health websites were randomly selected and evaluated twice in this study. they were classified into 4 categories, official, professional, educational and private. the tool used in this study was a questionnaire developed by the research team depending on ehealth code of ethics, 2000 and international technical guidelines. the questionnaire consists of two main categories (technical and ethical). the technical evaluation includes (authority, objectivity, coverage, currency, design, privacy and security). the ethical evaluation includes (quality of information, informed consent and professionalism). a score for the questionnaire was developed by the research team to assess the websites. all statistical analyses were performed using the statistical package for social science (spss) version 11.0. comparisons between ethical and technical categories were done using the student’s t-test and anova test for continuous variables and pearson’s chi square test for categorical variables. results: on evaluating the quality of information of the health websites, it is noticed that in 92.3% of the sample, medical care is provided by professionals and their information based on scientific studies. around forty six percent (46.2%) of the health websites do not mention the date of publication, date of recent update and the source of the information. concerning the professionalism, 100% of the sample obeys laws and regulation in identifying themselves and mentioning the limitation of online consultation. 76.95% of the sample states clearly the purpose of the health website. only 38.5% of them were recently updated. privacy policy evaluation shows that 33.3% 2 mailto:aibrahim@onlinediabetes.net mailto:gamalamira@gmail.com mailto:nmoustafa2004@yahoo.com bangladesh journal of bioethics 2010; 1(3):2-14 mentions if the system prevents unauthorized access to personal data while only 16.7% states how the user's personal data is stored and for how long. there is a statistically a significant change (p<0.05) on comparing the quality of information between the different types of websites. both of the official and professional websites are better than educational and private websites. conclusion: some of the egyptian health websites are reliable and up-to-date; some are not. most of them are technically satisfactory. evaluation of the health websites faces difficulties due to continuous updating. recommendations: we should teach the health seekers to trust what they see or read on the internet only if they can validate the source of the information and the authors and contributors should always be identified. it is necessary to establish mechanisms of accreditation of egyptian health websites. e-health ethics training is very essential for the health professionals. introduction: ethics can be viewed as a prerequisite for the success of medical practice. if the prerequisite is not in place to ensure trust of product or services provided, consumers will not utilize the product or services. in case of medical field, the public trusts the medical profession to regulate its own practices1. knowledge and capabilities of new technology or an area of study often develop faster than the guidelines and principles needed for practitioners to practice ethically in the new arena. one area of rapid technological and economic expansion was that of the internet, in particular how quickly the internet is impacting and changing the practice of medicine in the 21st century2. internet health seekers may be healthy citizens with an enquiring mind, newly diagnosed or chronically ill patients and carer for a diagnosed person. different factors affect the patient's safety on the internet as the quality of information, privacy of information, professionalism in online health care and informed consent. the internet has become and will continue to be a significant means by which individuals self educate with respect to health, and this self education has the potential to result in important changes in the dynamics of the physician-patient relationship3. concern has been expressed about the quality of medical information displayed generally on the internet. some sites provide inaccurate or misleading information4&5. the quality of information in health website plays a pivotal role in patient's safety. it is extremely variable from evidence based health care to practice of fraud and dangerous claims. sometimes the medical care or advice is provided by a non professional person who does not state if this info based on scientific studied, expert consensus or personal experience or opinion. many health websites do not mention the source the site or content provider has used with references or links to sources. us food and drug administration (2005) advised the health seekers to pay close attention to where the information on the site comes from. many health and medical web sites post information collected from other web sites or sources. if the person or organization in charge of the site did not write the material, the original source should be clearly identified6. we should to be careful of sites that don't say where the information comes from. in case of drug or products, some health websites do not inform health seekers if they are approved by authorities or not. fox, (2007) mentioned that eighty percent of american internet users have searched for health information online. 3 bangladesh journal of bioethics 2010; 1(3):2-14 they are called "health seekers". three quarters of health seekers said that they did not consistently check the source and date of the health information online. this translates to about 85 million americans gathering health advice online without usually examining the quality indicators of the information they find. one possible reason for this diminishing diligence in checking sources and dates might lie with health websites themselves7. these concerns have led to the development of the ethical codes for the providers of medical information on the internet (health internet ethics). although these vary depending on the specific purpose and context of the proposed codes, there are common themes between many of them. there are also several, international ethical standards and guidelines for internet health sites. e-health code of ethics is the one of the commonest guidelines which ensures that all people worldwide can confidentially, and without risk, realize the full benefits of the internet to improve their health8. the large volume of health information resources available on the internet has great potential to improve online health services, but the critical question is how to differentiate between the appropriate and inappropriate information on both medical specialists and patients, many of health field members are trying to find an accredited criteria to evaluate the wide range of medical information available on the world wide web (www). now we have a question, are the egyptian websites providing health services reliable regarding ethical and technical criteria or not? to our knowledge, there may be no attempt made to evaluate the egyptian health websites from the technical and ethical perspectives. so the aim of this paper was to evaluate the ethical and technical aspects of some egyptian websites providing health services in the form of medical consultation, health related information and selling or advertising health products. materials and methods: the study design of this work was a descriptive study. search engines (eg. google.com and yahoo.com) were thoroughly searched by entering the key words healt websites, and egyptian. thirty two health websites were found, some of them were not accessible. thirteen internet health websites were evaluated in this study. they were classified into 4 categories, official, professional, educational and private. table (1) shows the evaluated egyptian health websites. there are 2 educational health websites, 3 official health websites which includes two for ministry of health & population and one for the egyptian medical syndicate, 4 professional health websites which are developed by scientific societies, and 4 private health websites which are developed by doctors or health centres. health websites were evaluated twice (february and june, 2007 respectively). the aim of the first evaluation was to test the validity of the tool while the aim of the second evaluation was to detect the changes in the previous evaluation due to update of the health websites. masrawy website was omitted during the second evaluation due to removal of the health sector from it by the authors. 4 bangladesh journal of bioethics 2010; 1(3):2-14 table (1): the evaluated egyptian health websites type name link 1. official 2. official 3. official 4. professional 5. professional 6. professional 7. professional 8. educational 9. educational 10. private 11. private 12. private 13. private ministry of health& population of egypt ministry of health& population of egypt egyptian medical syndicate heart journal, cardiology dep, cairo u egyptian hypertension society egypt’s medical portal egyptian society of paediatric allergy faculty of med. ain shams u medical education online the ultimate health portal for egypt consultant of plastic surgery e-males online diabetes.net www.mohp.gov.eg www.drguide.mohp.gov.eg www.ems.org.eg www.hearj.com, www.ehs-egypt.net www.egydoc.com www.espai-eg.org www.com-med.ikalogic.com www.medicaleducationonline.org www.abcseha.com www.gamalekonline.com www.erajol.com www.onlinediabetes.net the tool used in this study was a checklist that consisted of two main categories: technical and ethical. the technical category evaluated 6 items including authority, objectivity, coverage, currency, design, privacy and security. the ethical category evaluated the quality of information, informed consent and professionalism, the tool was developed by the research team depending on: e-health code of ethics, 20008 for the ethical part and the several international guidelines which are used in evaluating health websites as health on the net foundation ( hon code of conduct for medical and health web sites9 ,health information technology institute, british healthcare internet association, us national institute of health and others. all questions were answered as yes, no and not applicable, which equal to 0 and 1 for no and yes respectively and omitted from the score if not applicable. a score for the checklist was developed by the research team. for example, the quality of information item included 9 questions which means that the total score is 9, if we have only 7 answered yes, then dividing 7/9 will give us the score and if we wish to express it as score percent we multiply it by 100 (7/9 x 100). the same process was repeated to calculate the total score for each of the ethical and technical categories. then data was carried out and statistical analysis was performed using the statistical package for 5 http://www.onlinediabetes.net/ http://www.erajol.com/ http://www.gamalekonline.com/ http://www.abcseha.com/ http://www.medicaleducationonline.org/ http://www.com-med.ikalogic.com/ http://www.espai-eg.org/ http://www.egydoc.com/ http://www.ehs-egypt.net/ http://www.hearj.com/ http://www.ems.org.eg/ http://www.drguide.mohp.gov.eg/ http://www.mohp.gov.eg/ bangladesh journal of bioethics 2010; 1(3):2-14 social science (spss) version 11.0. data was presented as proportions and percentages, mean and standard deviations. anova test for continuous variables was used. figure (1) summarized the process of evaluation of the health websites. figure (1): summary of health websites evaluation process results: the ethical and technical criteria were applied to 13 egyptian health websites. table (2) shows results of the thirteen egyptian health websites accessed by frequency with which the criteria are met. the evaluation of the quality of information shows that 92.3% of the sample provided medical care by professionals and the information is based on scientific studies, while 46.2% of the health websites do not mention the date of publication, date of recent update and the source of the information. 69.2% states that the 6 13 egyptian health websites are randomly selected literature review to develop the tool classification of health websites (educational, official, professional and private) use of e-health code of ethics &international health websites evaluation guidelines to develop the tool 1st evaluation to test the tool development of the scoring system 2nd evaluation to detect the changes due to updating bangladesh journal of bioethics 2010; 1(3):2-14 table (2): results of the thirteen egyptian health websites accessed by frequency with which the criteria were met parameter proportion % quality of information: medical care is provided by professionals information is based on scientific studies information is controversial language is clear mention the date for published information mention the date for review information recently mention the source website used with reference there is an evaluation of contents of website state if the products are approved by authorities informed consent type of data clear who collects data how website use data professionalism fees for online consultation obey laws and regulation professional identify themselves limits of consultation online authority: authors clearly identified is there any institutional affiliation can easily contact authors for clarification objectivity is the purpose of the website clearly stated are the information presented relevant to the objective of the website coverage is the website bilingual is the website divided into sections which cover most of topics does the website satisfy the needs of its targeted visitors currency is the website updated recently is the revision date recent enough to account for the changes in the field are the links kept up to date design can the website be accessed reliably& easily navigated is there any visual effects do visual effects enhance the resource, banners are there interactive features that increase usability can the website be accessed without additional viewer or plug in does the website provide the links for the software needed for opening the website pages privacy does the system prevent unauthorized access to personal data does the system tell how the user personal data is stored and for how long 12/13 12/13 9/13 13/13 7/13 7/13 7/13 11/13 8/13 4/5* 2/5** 1/5*** 2/4• 4/4• • 4/4• • • 4/4•••• 13/13 8/13 12/13 10/13 13/13 6/8♦ 13/13 12/13 5/13 5/13 10/13 13/13 10/13 7/10♣ 9/13 5/13 1/ 8♣♣ 2/6♠ 1/6♠♠ 92.3 92.3 69.2 100 53.8 53.8 53.8 84.6 61.5 80.0 40 20 50.0 100.0 100.0 100.0 100.0 61.5 92.3 76.9 100.0 75.0 100.0 92.3 38.5 38.5 76.9 100.0 76.9 70.0 69.2 38.5 12.5 33.3 16.7 n.b: percent calculated from the total number of no and yes, np= not applicable * np= 8/13 (61.7%), ** np=8/13 (61.5%),*** np=8/13 (61.5%),• np=9/13 (69.2%), • • np=9/13(69.2%),• • • np= 9/13 (69.2%),•••• np= 9/13 (69.2%),♦ np= 5/13 (38.5%) ♣ np= 3/13(23.1%),♣♣ np= 5/13 (38.5%),♠ np= 7/13 (53.8%),♠♠np= 7/13 (53.8%) 7 bangladesh journal of bioethics 2010; 1(3):2-14 presented information may be controversial and 61.5% mentions that their products are approved by the authority. on evaluating the informed consent, 40% of the sample states who collects the data while only 20% mentioned how the websites uses data. concerning the professionalism, 100% of the sample obeys laws and regulation in identifying themselves and mentioning the limitation of online consultation. regarding the technical evaluation: 100% of the sample identifies the authors, 76.9% of the sample states clearly the purpose of the health website, 75% of the sample is bilingual and only 38.5% of them are recently updated. the design evaluation shows that all the websites are accessed and navigated easily, but 69.2% of them have interactive features and only 12.5% provides the links for the software needed for opening the website pages. privacy policy evaluation shows that 33.3% mentions that the system prevents unauthorized access to personal data while only 16.7% states how the user's personal data is stored and for how long. table (3) shows the frequency distribution of the 13 egyptian internet health websites according to the score of the technical and ethical evaluation. it is shown that quality of information in 7 health websites is 100%, while it is 37.5% in 3 health websites. authority is 100% in 8 health websites and coverage is 76.9% in 10 health websites. design item shows that only 2 health websites have a design score of 83.3% and privacy shows that 4 out of 6 health websites have no privacy policy. there is a significant change (p<0.05) on comparing the quality of information between the different types of websites. both of the official and professional websites are better than educational and private websites as shown in (table 4). discussion: the internet can be a valuable source of health information, but not all sites are equally worthy or reliable. information on the web may be incomplete, inaccurate, or overly simplified. the web lacks peer review or quality control; many sites are trying to sell a product, and are biased or out of date; and anyone can publish on the web whether they are an expert, or not10. in this study, the evaluation of the quality of information shows that 92.3% of the sample provided medical care by professionals and the information is based on scientific studies, while 46.2% of the health websites do not mention the date of publication, date of recent update and the source of the information, 69.2% states that the presented information may be controversial and 61.5% mentions that their products are approved by the authority. on evaluating the informed consent, 40% of the sample states who collects the data while only 20% mentioned how the websites uses data. concerning the professionalism, 100% of the sample obeys laws and regulation in identifying themselves and mentioning the limitation of online consultation. 8 bangladesh journal of bioethics 2010; 1(3):2-14 table (3): frequency distribution of the thirteen health websites according to the score of technical and ethical evaluation frequency of web sites (n= 13) score percent quality of information informed consent* professionalism** authority objectivity coverage currency design privacy 3 2 1 7 1 2 1 1 2 2 1 4 8 3 10 3 10 2 5 3 3 3 3 5 2 4 1 1 37.5 50.0 62.5 100.0 0.00 25.0 50.0 100.0 75.0 100.0 33.3 66.7 100.0 50.0 100.0 66.7 76.9 0.00 33.3 66.7 100.0 33.3 50.0 66.7 83.3 0 50 100 *not applicable 8 websites; **not applicable 9 9 bangladesh journal of bioethics 2010; 1(3):2-14 table (4): comparison of quality of information among the different types of health websites n mean ±sd official professional educational private 3 87.5±21.7 4 100±0.0 2 68.8±44.2 4 43.7±7.2 * anova test was used in this table f= 6.84 p value= 0.011 the national cancer institute (2005) and medical library association (2008) mentioned that any web site should make it easy for people to learn who is responsible for the site and its information. if the person or organization in charge of the web site did not write the material, the original source should be clearly identified. health-related web sites should give information about the medical credentials of the people who prepare or review the material on the site. any web site that asks users for personal information should explain exactly what the site will and will not do with that information. it added that the federal trade commission and the food and drug administration are government agencies that help protect consumers from false or misleading health claims on the internet11&12. so it is important to mention that authors and contributors should always be identified and we have to avoid any online physician who proposes to diagnose or treat persons without a proper physical examination and consultation regarding our medical history. according to fox (2006) about 85 million americans gathering health advice online without consistent examining the quality indicators of the information they found. three quarters of them said they checked the source and date "only sometimes", hardly ever, or never. one possible reason for this diminished diligence in checking sources and dates might lie with health websites themselves. just 4% of "frequently visited" health websites disclosed the source of information on their pages and 2% disclosed how the content is updated13. in the present study, it is noticed that the quality of information of both of official and professional websites is better than the educational and private websites (p> 0.05) which means that both of the official and professional health websites follow the criteria of international guidelines. this result shows that it is necessary to establish mechanisms of accreditation of egyptian health websites. aeree and mee-kyungs (2001) stated that anyone with a computer and internet access can publish on the web, so judging the trust worthiness of scientific and health related web sites becomes the responsibility of each individual user14. 10 bangladesh journal of bioethics 2010; 1(3):2-14 it is worthy to mention that in the academic community, the peer review process is used to ensure the validity and quality of the information presented in papers and reports. the general public, however, is more likely to understand a "seal of approval" from an individual or group commonly perceived as credible. sites should indicate whether the information provided has been subjected to review, and if so, describe the process and the individuals involved. in the present study, 4 out of 6 health websites have no privacy policy, 33.3% of the sample mention that the system prevent unauthorized access to personal data while only 16.7% states how the user's personal data is stored. winker et al, (2000) stated that medical websites, more than any other type of site on the internet, should ensure visitors' personal privacy and prevent personal medical information, including patterns of use and interests, from being sold, purchased, or inadvertently entering the hands of marketers, employers, and insurers15. the national consumers league (1999) stated that health care websites have access to an unprecedented amount of personal information about consumers. the public's concerns about internet privacy are significant, and heightened with regard to safeguarding their personal health information online16. a survey of 1009 adults released in january 2000 by the california health care foundation and the internet health care coalition found that 75 % of people were concerned about health websites sharing information without their permission and 17% of people did not even go online merely to seek health information due to their concerns over privacy. the good news is that nearly 80% of people said that the existence of a privacy policy that provides them with the ability to make choices about how and whether their information was shared had a positive impact on their willingness to engage in online health activities17. there was much work needed to provide consumers with an acceptable level of trust and confidence in the privacy safeguards and practices of health websites. goldman et al, (2000) mentioned that at best, the privacy policies of health websites were confusing, inconsistent, weak, and often misleading when measured against the site's actual practices. a site with a privacy policy that disclaims liability for the actions of third parties on the site in effect negates the privacy policy18. the present study shows that 100% of the sample identifies the authors, 76.9% of the sample states clearly the purpose of the health website, 75% of the sample is bilingual and only 38.5% of them are recently updated. the design evaluation shows that all the websites are accessed and navigated easily, but 69.2% of them have interactive features and only 12.5% provides the links for the software needed for opening the website pages. eysenbach (2000) found that consumers assessing the credibility of a website primarily looked for the source, a professional design, language and ease of use, study participants never checked any "about us" sections of websites, disclaimer or disclosure statements. the average consumer paid far more attention for the superficial aspects of a site, such as visual cues, than to its content. the consumer assessed the credibility of sites based in part on the appeal of the visual design, including font size and color schemes19. griffiths and christensen (2000) evaluated the quality of web based information on treatment of 11 bangladesh journal of bioethics 2010; 1(3):2-14 depression to identify potential indicators of content quality and they found that although the sites examined contained useful information, their overall quality was poor20. sites typically did not cite scientific evidence in support of their conclusions. measures of quality such as display of authorship, attribution or references, currency of information and disclosure did not differ between popular and less popular sites21. in similar findings, kunst et al (2002) found that while there is a correlation between credibility features and accuracy of information, the associations is relatively weak22. in this study, as the health websites are evaluated twice, some changes have been noticed due to continuous updating. at last, physicians, nurses, pharmacists, therapists, and all other health care professionals who provide specific, personal medical care or advice online should abide by the ethical codes that govern their professions as practitioners in face-to-face relationships. they should also mention the limitations of online consultations. conclusion: some of the egyptian health websites are reliable and up-to-date; some are not. most of them are technically satisfactory. evaluation of the health websites faces difficulties due to continuous updating. recommendations: we should teach the health seekers to trust what they see or read on the internet only if they can validate the source of the information and the authors and contributors should always be identified. it is necessary to establish mechanisms of accreditation of egyptian health websites. e-health ethics training is very essential for the health professionals. study limitations: the present study is a pilot study to measure the adherence of the egyptian health websites to the ethical criteria of e-heath code of ethics. it did not evaluate the quality of health related websites in a certain discipline or certain health topic, so our results cannot be generalized. also since it is a pilot study, the sample size was rather fair and further studies with larger sample size are needed targeting certain disciplines and different types of health websites. references: 1. kassirer j p. pseudoaccountability. ann intern med. 2001 apr 3;134(7):587–90. 2. dyer ka. ethical challenges of medicine and health on the internet: a review. j med internet res, 2001, 3(2):e23. 3. broom, a. “virtually he@lthy: the impact of internet use on disease experience and the doctor-patient relationship,” qualitative health research (2005), volume 15, number 3 (march), pp. 325-345. 4. eysenbach, g. and diepgen, t.l. ‘towards quality management of medical information on the internet: evaluation, labelling, and filter of information’, british medical journal, (1998) vol. 317, no. 71, pp.1496–1499 12 bangladesh journal of bioethics 2010; 1(3):2-14 5. shepperd s, charnock d, gann b. helping patients access high quality health information. br med j 1999; 319: 764-766 6. us food and drug administration: how to evaluate health information on the internet. december 2005. http://www.fda.gov/default.htm 7. fox, s. online health research is widespread, but few check the source and date. medscape general medicine (2007); 9(1): 30. 8. rippen h and risk a: e-health code of ethics. j med internet res. 2000; 2(2):e9 9. boyer c, selby m, scherrer jr, appel rd.the health on the net code of conduct for medical and health websites. comput biol med. 1998 sep;28(5):603-10 10. health affair report: untangling the web: how to find quality health information. published by the university of washington retirement association http://www.washington.edu/admin/uwra 11. national cancer institute (2005): how to evaluate health information on the internet: questions and answers www.cancer.gov 12. medical library association: a user's guide to finding and evaluating health information on the web, 2008. http://www.mlanet.org/resources/userguide.html 13. fox, s. online health search. most internet users start at a search engine when looking for health information online. very few check the source and date of the information they find. washington dc: pew internet and american life project, 1615 l st., nw-suite 700 washington dc. 20036, 2006. 202-419-4500 http:// www.pewinternet.org/. 14. aeree s, mee-kyungs. evaluating health information sites on the internet in korea: a cross-sectional survey. asia pacific j public health, 2001; 13 suppl:s19-22 15. winker m a, flanagin a, chi-lum b, white j, andrews k, kennett r l, deangelis c d, musacchio r a. guidelines for medical and health information sites on the internet: principles governing ama web sites. american medical association. jama. 2000;283(12):1600–6. doi: 10.1001/jama.283.12.1600. 16. national consumers league, “consumers and the 21st century,” (1999): for additional information on consumer attitudes about internet privacy see “beyond concern: understanding net users’ attitudes about online privacy,” at http://www.research.att.com/projects/privacystudy 17. goldman j.;hudson, z.; smith, rm. privacy: report on the privacy policies and practices of health web sites. california healthcare foundation. 2000 jan [2001 apr 18]. 18. goodman kw, miller ra. ethics and health informatics: users, standards and outcomes. in: shortlife eh, perreauit le, editors. medical informatics: computer application in health care and biomedicine. new york: springer-vertag; 2000.p chap.7. 19. eysenbach g. consumer health informatics.bmj. 2000, 24;320(7251):1713-6. 20. griffiths km, christensen h. quality of web based information on treatment of depression: cross sectional survey.bmj.2000, 16;321(17275): 1511-5. 13 http://www.research.att.com/projects/privacystudy http://www.pewinternet.org/ http://www.mlanet.org/resources/userguide.html http://www.cancer.gov/ javascript:al_get(this,%20'jour',%20'comput%20biol%20med.'); http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22appel%20rd%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22scherrer%20jr%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22selby%20m%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22boyer%20c%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://medgenmed.medscape.com/medgenmed http://www.fda.gov/default.htm bangladesh journal of bioethics 2010; 1(3):2-14 21. meric, funda.;bernstam, elmer v.;mirza, nadeem q.;hunt, kelly k.;ames, frederick c.;ross, merrick i.;kuerer, henry m.;pollock, raphael e.;musen, mark a.; singletary, s eva. breast cancer on the world wide web: cross sectional survey of quality of information and popularity of websites. bmj. 2002 mar 9;324(7337):577–81. doi: 10.1136/bmj.324.7337.577. 22. kunst, heinke.;groot, diederik.;latthe, pallavi m.;latthe, manish.; khan, khalid s. accuracy of information on apparently credible websites: survey of five common health topics. bmj. 2002 mar 9;324(7337):581–2. doi: 10.1136/bmj.324.7337.581. competing interests the authors declare that they have no competing interests. authors' contributions nahed ali helped conceived the idea of the study, contributed to the design of the study tool and evaluating the health websites. she wrote the manuscript amira gamal contributed to the design of the study tool and evaluating the health websites. she did the data analysis. amr mohamed conceived the idea of the study, contributed to the design of the study tool and evaluating the health websites from the technical point of view. all authors read and approved the final manuscript corresponding author: prof. nahed ali is the head of the department of forensic medicine and clinical toxicology, faculty of medicine, suez canal university, egypt. she is a certified trainer of research ethics, maryland university, usa, and an ethics expert among global ethics observatory (geobs), unesco nmoustafa2004@yahoo.com 14 mailto:nmoustafa2004@yahoo.com summaries of articles bangladesh journal of bioethics 2010;1(3) :35-42 organ transplantation and vulnerable donors: donation under emotional compulsion inayat ullah memon chief pathologist, peoples medical college hospital, nawabshah, sindh, pakistan. email: memon.inayat@gmail.com abstract: during last few decades advancements in medical knowledge and technologies have increased the practice of organ donation. organ transplantation, on one hand gifts renewed life to the donors, while on the other hand unwanted ethical practices in the field exploit vulnerable donors, such as trend of ‘transplantation tourism’ involving non-related live donors. beyond this, some delicate and intriguing situations bring the physicians at cross-roads in cases of live related donors’ transplantation. in this paper, i would like to discuss and analyze a case of live donor (un-married girl), where overtly consents to donate kidney to her brother who is breadearner of their joint family. by consenting to donate, the girl jeopardizes her matrimonial proposal as her fiancé is uncertain about her post-donation health status. the transplant clinician, aware of this fact faces ethical dilemma, whether to perform transplantation surgery so as save the life of ailing patient or to abandon it in order to save the future marriage of the girl from being broken. the case highlights multiple ethical issues in asian socio-cultural context. i have attempted to disentangle the dilemma by applying mc donald and rodney’s framework of ethical decision making. introduction: since the first kidney transplantation in early fifties of twentieth century, that was associated with some complications, the practice of kidney transplantation have progressively increased due to development of interventions that increased acceptability of foreign organ, introduction of leading-edge surgical procedures that are more comfortable as well as safer for both donor and recipient, with subsequent improvement in quality and increased volume of transplantation procedures in coming years.1,2 from ethical perspective, though cadaveric organ donation is less problematic than acquisition of organs from live donors, but this category of donation alone can’t meet the growing demands for the end-stage renal failure patients.3 much has been debated about ethics of non-related organ donation. in developing and poor countries, extreme poverty, non-existence or ineffective legislation governing this procedure and presence of influential organ-trade brokers in collaboration with some medical professionals have opened the avenues leading to ‘transplantation tourism’, which is coupled with overt and undesirable unethical practices.4,5 alternatively, the ethically preferable and medically favorable mode of transplantation i.e. live-related donation is not absolutely free from ethical downsides. on one hand the related donors have technically more chances of compatibility than non-related donors, while on the other hand some subtle ethical intrigues are frequently encountered in this type of donation than more obvious moral problems associated with non-related type. acquisition of genuine, valid, truly voluntary and coercion-free informed consent from donor is ethical pre-requisite.6 role of compelling emotions by the donor towards related organ recipient is not only natural, provides psychological satisfaction to the donor as sharing the illness of the patient and is commendable act as well. living organ donation has 35 bangladesh journal of bioethics 2010;1(3) :35-42 unique characteristic i.e. for the well being and life of the ailing person, a healthy donor is put at potential risks.1,2 witnessing by the transplantation team the impulsive and hurried decision of relatives to donate organs generates concerns about the validity of consent. some authors argue that participation in clinical trials have similarities with donating organs for nears and dears but there are unjustifiable differences while obtaining informed consent from these two groups of altruistic people. in organ donation the members of transplantation team have conflict of interest in the form of inherent sympathies for the organ recipient that makes the consent taking procedure questionable. 1,6 the most worrisome factor in the process of donor’s consent in transplantation procedure is whether it is free from impulsive and compelling emotional forces generated due to the close relationship with prospective recipients and sympathy toward them. does the donor ignore associated risks because of these forces? does the donor’s decision–making ability is adversely affected because of financial dependence (as in the following case) on the recipient? does the donor, being close relative of the recipient have no alternative but to submit herself to the wishes of the family (which is not uncommon phenomenon in eastern context) so as ‘save the face’? 6,7 moreover is the donor fully aware of all the possible outcomes of the proposed transplantation, including failure of the procedure or possible death of the recipient and potential risks and hazards resulting from his/her nephrectomy? 1,2 uncertainty in the medical fraternity about the risks associated with kidney donation, particularly the long-term long term such as hypertension, diabetes and chronic kidney disease, with ethnic variations, further compounds the issue. 2,8,9 to address these questions, an environment is required to exclude the potential weaknesses associated with procedure of obtaining informed consent by the transplantation team and offered by the donor in these special circumstances. in eastern socio-cultural context, where transplantation team is more trusted by the donors as well as recipients who customarily exercise lesser autonomy in contrast to rights-based western society, the responsibilities of the transplantation clinician are enhanced in order to resolve ethical issues and help both partners of the transplantation procedure and their families to arrive at morally acceptable outcomes. following case explains a situation, similar to which are not infrequently encountered in developing countries where the transplantation teams face a dilemma. cases like these need to be assessed by some recognized frameworks of ethical decision-making. i have made an attempt to disentangle the issue by using mc donald and rodney’s framework.10 case study: mr. “p” (patient) suffering from renal failure is admitted to specialized transplantation hospital, ktc (karachi transplantation centre, not the real name) in karachi, pakistan, where he is undergoing hemodialysis. he is 42 years aged man, belongs to poor socio-economic group. his father mr. “f” (father) is 65 years old and alive, while had mother has passed way a few years ago. mr. “p” is married, his wife mrs. “w” (wife) is happy and healthy, has two children, one boy and one girl. mr. “p” has one sister miss “s” (sister), who is unmarried (her marriage is planned after about six months), aged 25 years and has one brother “b” (brother) 35 years old. miss “s” is illiterate house woman, not engaged in any job. being a joint family, all live together and are financially dependent on “p” who has/had been the bread-winner. doctors have advised “p” for renal transplantation. as an initial step “s”, “b” and “w” were investigated for compatibility to donate kidney to “p”. the workup reveals that only his sister “s” is compatible, the results were communicated to the family. after a few days, 36 bangladesh journal of bioethics 2010;1(3) :35-42 the dr. “u” (urologist, member of transplantation team) called a meeting with all concerned people in this case i.e. miss “s”, mr. “f” and mrs. “w” and mr. “b”. “s” was informed that she has been found the appropriate person amongst the three to donate kidney to her brother. she does not show any sign of apparent displeasure or disagreement for the procedure, her father “f” also agrees for her kidney donation. after three days, a person mr. “fi” (fiancé) came in the office of dr “u”, introduced himself as fiancé of miss “s”, informed dr “u” about his concerns regarding kidney donation of “s” for “p”. he raised objection on the willingness of the family of “p” for the transplantation. he politely informed dr. “u” that if her kidney is removed for donation, he will not marry with “s” because her health would deteriorate. doctor listened to him carefully and told that his views will be given due consideration, doctor “u” also discussed with him about his (“fi”) fears of health deterioration after kidney donation and explained that so far no major adverse health consequences have been reported by kidney donation, if the donor is carefully looked after. mr “fi” did not make any comment after dr “u” ‘s explanation, but dr “u” guessed from his nonverbal behavior that “fi” has not changed his views even after the explanation. dr. “u” faces ethical dilemma in this case. he wonders what he should do. should he accept the kidney of “s” for “p” (to save the life of patient) despite objection of her fiancé? or advise the relatives of “p” to seek and arrange some other compatible donor. the family is not financially sound to compensate un-related donor for kidney donation. the family is unable to bear the expenses of long-term haemodialysis. neither, “p” is insured for his health, nor there is state social welfare system to bear the financial cost of dialysis. at the same time, he is aware of the fact that if kidney of “s” is removed “fi” would not marry with her. moreover he is familiar with local customs and traditions that once her engagement is broken with bearing this stigma the chances for her matrimony are very bleak and he is aware of the fact the prospective donor (“s”) is financially dependent on recipient (“p”) that further deepens ethical issue. dr “u” is under pressure from the family of “p” to perform transplantation surgery early so as “p” returns to routine life and provide earnings for the family. to resolve this issue and in the best interest of “p” and prospective donor “s”, dr “u” thought it better to arrange a meeting with “s” and her father “f” so as to disclose and discuss with them views expressed by “fi”. meeting was held and dr “u” came to know that “f” and “s” were already aware of “fi”’s disagreement and both were overtly happy if “s” s kidney is transplanted to “p”. dr “u” attempted to have meeting with miss “s” in privacy, so as to assess her free will of donating kidney and exclude the factor of coercion by her relatives, if any, but he couldn’t succeed because of cultural inhibitions. ethical analysis of the case: first, i would like to identify the ethical issues in the case followed by their analysis using the framework of mcdonald and rodney, which includes within its larger framework the ‘four boxes’ clinical ethical analysis of jensen et al. this framework has four components i.e. a. collection of information and identification of the problem. this includes four factors of jonsen, siegler and winsdale 11 (medical indications, patient’s preferences, quality of life and contextual factors) b. specification of feasible alternatives c. use of ethical resources to identify morally significant factors in each alternative 37 bangladesh journal of bioethics 2010;1(3) :35-42 d. making the choice ethical issues: 1. is the donor (being a lady/a vulnerable member of the community and financially dependent on prospective recipient) truly autonomous, genuinely free and emotionally neutral to give voluntary informed consent? 2. is she able to make her own decisions in the background of the fact that her father and brother would be unhappy, if she declines to donate kidney? 3. if she donates the kidney, what would be the fate of her prospective marriage? 4. is she well informed about the possible adverse consequences of the kidney donation? let us discuss each issue separately: 1: given the fact that “s” is financially dependent on his brother “p” and is part of an intricately woven joint family, it appears very impracticable for her to decline to donate kidney (to genuinely exercise her autonomy), even if she decides to do so. now let us further explore this issue in context of developing countries. presuming that donor is male, bread-winner of the family and financially supporting joint family, then what would hypothetically be the voluntary decision of a brother for his sister who needs kidney for transplantation. in general no brother or sister having equal social or financial standing will disagree for organ donation for his/her brother/sister, if this process has no bad health consequences for donor. that is demand of the doctrine of “ethics of care”2. it is the brother-sister relationship (like any other close bondage) which attracts more care for each other out of love. these situations do not involve any apparent influencing / coercing factors on close relatives to donate the organs. but when viewed in context of poor developing countries, the read-winning brother would hardly sacrifice his precious organ to save the life of his sister having low financial value. 2: is she emotionally neutral to make decision about kidney donation (neuroethics). this aspect of the case needs further exploration. it can be appreciated that one’s emotional situation, previous experiences and context do affect the decision-making ability. as described by moll and crafman12 in their “event-feature-emotion” complex, interplay of different parts of brain (i.e. pre-frontal lobe, temporal lobe and limbic system) results in ethical decisions making. limbic system being concerned with emotions does affect the ultimate decision. moreover, they assert that person’s background (exemplified by orphan child) will affect the decision as well. likewise in this case, she can’t be considered emotionally neutral. prospective kidney recipient is the bread-earner of the family and his sister is the only compatible match amongst three available donors. will not this situation compel her to donate? moreover process of decision making varies with social and cultural context.13 i mean to say that western individual-based autonomy can neither be expected from eastern society nor it is practiced to that extent as in the west. in eastern culture a man is considered superior while women is given secondary status, this fact becomes even harder where the literacy rate and socio-economic condition go down. in this background and the fact that she is not earning member of the family, if she declines to donate kidney, there are strong fears that her father and brother would not only be unhappy but angry. she being a part of this culture would be aware of this fact. will this affect her ability of decision making? 38 bangladesh journal of bioethics 2010;1(3) :35-42 3: another factor is fate of her matrimony. if she donates kidney there are strong chances that her fiancé would refuse to marry with her as her fiancé has already expressed his views about the proposed transplantation. this is generating producing conflict in her mind (a conflict of interest), either to save the life of her ailing brother and ‘save her face’ in family and society or for the sake of her matrimony refuse to donate. 4: the root problem that created the dilemma is the issue of adverse consequences on donor’s health after nephrectomy, because this is the issue that prompted “fi” to contact dr “u”. according to canadian scientist, issue of knowledge and assessment of medical consequences of organ donation is important one, as he said: “a more precise understanding of the long-term medical outcomes is critical for improving donor selection, informed consent and follow-up”14. though there are few post-donation risks of lesser gravity, but still there is no complete and high-volume studies available on record for the ethnic minorities in usa and for the people of developing countries; that hinders the ethically compete disclosure of information to the donors so as to allay their fears if any. while analyzing the issue of girl’s consent for donation, it is important to assess the validity of her informed consent, to inform her about health related consequences of kidney donation, available alternatives and possible chances success/failure of transplantation surgery. i am afraid this issue is not faithfully dealt with at least in developing countries. the legal formalities are fulfilled, donors’ willingness is taken just in the form of signature (or thumb impression) but requirements of understood and informed consent are not met. i would like to refer here two episodes of program televised about kidney selling/donation, shown on local tv network in pakistan on 14th and 21st april 2007 (08-05 pm), wherein surgeon said that he used to tell to the donors all the things about removing kidney and further explained that he had documentary proof of that. he stressed on documents but gave very little importance to the ongoing process of informed consent.15 analysis in mc donald and rodney’s framework: a. collection of information and identification of the problem: it will be appropriate to apply the ‘four boxes’ of jensen et al on both the patient (organ recipient) and donor. regarding medical indications, from the patient’s perspective, the process of kidney transplantation fulfils the goals of medical treatment i.e. there are bright chances of recovery of the patient from renal failure while from the donor’s perspective in general there are only few (if any) chances of damage to her health and these are same to as to any other donor in case of kidney transplantation. but lack of data and absence of studies regarding long-term post-nephrectomy consequences for donors of developing countries makes the issue more problematic. as far patient’s preferences are concerned, the he wishes with his full senses, to have the kidney transplanted to him and it is informed, understood and voluntary. while it is uncertain if the donor’s consent is genuine and informed or given under emotional coercion, duress or family compulsion. regarding patient’s quality of life, it would improve both in the view of patient and the caregiver (transplantation clinician), moreover it is worthwhile to perform this process as it is internationally recognized mode of treatment for the end-stage renal failure. but from the donor’s perspective it is doubtful, being a 39 bangladesh journal of bioethics 2010;1(3) :35-42 woman she has slightly more chances of developing hypertension related disorders of pregnancy moreover belonging to poor socio-economic group makes it uncertain that she would be properly looked after in case her health deteriorates.2 regarding contextual features, transplantation will improve the economic condition of the recipient’s family, as he is the bread earning member. but it is doubtful if the family would be able to bear the expenses of ongoing treatment of the recipient after transplantation. from the donor’s perspective, she will be in a fragile situation, as recipient being the bread-winner will be preferentially looked after than the donor in case of illness. b. specification of feasible alternatives: for the patient the possible alternatives are either to have transplantation performed or to continue the haemodialysis. but the second option because of economic constraints is not feasible for the family. this factor also applies to the physician, if he performs the transplantation surgery he will knowingly jeopardize the matrimonial proposal of the donor but on the other hand if he doesn’t, then he will increase the miseries of the renal failure patient. this situation brings the physician at cross-roads. c. use of ethical resources to identify morally significant factors in each alternative: when physician applies four founding bioethical principles of beauchamp and childress, he faces a dilemma. veracity of informed consent of the donor is tinted due to many reasons, including disclosure of insufficient and uncertain information about post-donation risks for donor,2,8,9,16-18 she, because of her peculiar position in the society and in the family is unable to exercise her innate autonomy. as the donor will benefit from the process of transplantation, thereby physician fulfils requirement of beneficence, but lesser attention is paid to the women folk in our society will make the donor medically more vulnerable which will negate non-meleficence, another principle of bioethics. regarding justice, what the society and the medical profession will do in case the donor is brother and the recipient is sister who is not in a position to bring monetary benefit to the family. will the members of the society permit this transplantation if some important event of life (such as marriage) of the male donor is at risk due to this process? d. making the choice: in this case the transplantation clinician has two choices, either to perform the surgery for the health of the patient or to refuse the procedure due to ethically questionable consent of the donor. to pave the way for decision the surgeon utilized his efforts to persuade the fiancé of donor not to object and by explaining that there are minimal chances of adverse effects to the donor’s health of donor. this framework, fortunately allows the decision maker (transplantation surgeon) to select a better choice amongst the available ones, the chosen one may not necessarily be the best, but transplant clinician still has to decide which is better choice in eastern perspective. dilemma has still remains un-resolved! though mc donald and rodney’s framework has obvious and convincing strengths in the process of ethical decision-making but it is not free from weaknesses. application of the framework in this particular case, though involves all the stakeholders in decision making which is ethically required19 but the particular situation where parents of donor and recipient are not only willing but eager for early procedure with questionable consent of the vulnerable donor brings the onus of ultimate decision on the shoulders of transplantation surgeon. this framework does allow the clinician to 40 bangladesh journal of bioethics 2010;1(3) :35-42 make choices between available options, as well as taking the responsibility of decision. therefore by using this framework, one can reach at some conclusion. in cases of live related donor transplantation, the four boxes of jonsen et al ought to be applied in both involved persons i.e. patient and donor. the results of application of two boxes amongst the four i.e. preferences and quality of life, four boxes, on two persons (donor and patient) are inherently opposing and conflicting (when donor’s interests are protected the recipient’s interests are jeopardized) as it involves a process of organ transfer from one member of the pair to another, that makes the decision difficult. this requires more suitable frameworks that can meet the needs of dilemmas like one presented in this paper. conclusion: this case presents one of the many unique issues characteristic of developing, particularly poor countries, where specific cultural traditions, tribal customs, societal factors, poverty and legislative weaknesses facilitate undesirable and unethical practices to flourish. the vulnerable groups of the population are easy prey to undesirable organ transplantation practices, a ethical problem shared by clinical research mal-practices. more obvious, overt and loudly heard issues like ‘transplantation tourism’ have attracted the attention of clinicians and bioethicists since many years but subtle ethical issues attached to live-related organ donations by weak and silent family members or relatives such as mentally retarded or unknowledgeable females deserve attention of society leaders, clinicians and other stakeholders. mere obtaining of documentary informed consent is neither sufficient nor the required condition. we need to as sincerely and honestly safeguard the donors’ interests as we ethically protect the wellbeing of our organ-recipient patients. references: 1. perrir a, ‘ethic committee validation of live donor consent: is it any use?’bioethica forum, 2009, vol. 2, no. 2, pp. 92-97 2. reese pp, friedewald jj, ‘profiling live kidney donors in america: cause of optimism and concern’, clin j am soc nephrol, 2010, vol. 5, pp. 1732 – 1733. 3. truog rd, ‘the effects of organ donation by living donors’, n eng j med, august 2005, vol. 353, no. 5, pp. 444-446 4. world health organization (who) bulletin, ‘dilemma over live-donor transplantation’ http://www.who.int/bulletin/volumes/85/1/07-020107/en/# 5. denneman l, mol m, is legalizing commercial kidney donation medically-ethically justifiable?, organ trade: a win-win situation or exploitation in disguise? ‘global medicine’, http://globalmedicine.nl/index.php/currentedition11/206-organ-trade-a-winwin-situation-or-exploitation-in-disguise 6. truog rd, ‘consent for organ donation: balancing conflicting ethical obligations’, n eng j med, march 2008, vol. 358, no. 12, pp. 1209-1211 41 http://globalmedicine.nl/index.php/currentedition11/206-organ-trade-a-win-win-situation-or-exploitation-in-disguise http://globalmedicine.nl/index.php/currentedition11/206-organ-trade-a-win-win-situation-or-exploitation-in-disguise http://www.who.int/bulletin/volumes/85/1/07-020107/en/# bangladesh journal of bioethics 2010;1(3) :35-42 7. abecassis m, adams m, adams p, robert m, arnold, carolyn r, et al, ‘consensus statement on the live organ donor, jama, 2000, vol. 284, no. 22, pp. 2919 1926 8. drukker a, ‘unilateral nephrectomy: the adverse effects of live kidney donation’, assia, jewish medical ethics, feb 2001, vol. iv, no. 1, pp. 7-8. 9. lentine kl, schnitzler ma, xiao h, saab g, salvalaggio pr, axelord d et al, ‘racial variation in medical outcomes among living kidney donors’, n eng j med, august 2010, vol. 363, no. 8 10. mcdonald m, ‘a framework of ethical decision-making: version 6.0 ethics shareware. jan 200. <www.ethics.ubc.ca/.../a%20framework%20for%20ethical%20decision-making.pdf similar> 11. jonsen ar, siegler m, winslade wj. “clinical ethics: a practical approach to ethical decisions in clinical medicine’. 2006, 6th ed. new york: mcgraw-hill. 12. moll j, 2005 ‘ethical decision-making’, a new review, brain ethics, <http://brainethics.wordpress.com/2005/11/> 13. jennifer mencl, 2007, ‘moral emotions and ethical decision making’, presentation at: business ethical in a global world: china, india and beyond. markkula centre for applied ethics, santa clara university, march 10, 2007. http://www.scu.edu/ethics/practicing/focusareas/business/conference/2007/presentation s/ 14. lawson in the news, “study to look at long-term implications of becoming a kidney donor”, may 12, 2005. http://www.lhrionhealth.ca/lhri/news/news_articles_2005/news_05_12_05.htm 15. tv talk on ‘geo’ television network, with transplant surgeons on 14th and 21st april, 8-00 pm, 2007. 16. petrinin c, ‘ethical issues in informed consent from potential living kidney donors’, may 2010, transplantation pro, may 2010, vol. 42, no. 4, pp. 1040-1042. 17. national health and medical research council (nhmrc), australia, ‘some important ethical issues to be considered’, ethical issues in organ donation, discussion paper no. 2. 18. fazel i: ‘renal transplantation from living related and unrelated donors, transplant proc, 1995, vol. 27, pp. 2586–2587. 19. american medical association (ama), professional resources, medical ethics, clinical case 3, ‘finding the balance in shared decision making’, <http://www.ama-assn.org/ama/pub/category/11848.html> 42 http://www.lhrionhealth.ca/lhri/news/news_articles_2005/news_05_12_05.htm http://www.scu.edu/ethics/practicing/focusareas/business/conference/2007/presentations/ http://www.scu.edu/ethics/practicing/focusareas/business/conference/2007/presentations/ http://www.google.com.pk/search?hl=en&biw=1003&bih=306&rlz=1r2rntn_enpk376&q=related:www.ethics.ubc.ca/upload/a%2520framework%2520for%2520ethical%2520decision-making.pdf+mcdonald+rodney+framework+ethical+decision+making&tbo=1&sa=x&ei=ilostooogjhnswbyqkcyba&ved=0cboqhzaa recent articles have included conceptual frameworks of public health ethics and overviews of historical developments in the field [7,8,11] bangladesh journal of bioethics 2010; 1(3):15-21 ethical issues in public health research abu sadat mohammad nurunnabi1, mahmood-uz-jahan2, shaorin tanira3 1. dr. abu sadat mohammad nurunnabi, lecturer, department of anatomy, dhaka medical college, dhaka. email: shekhor19@yahoo.com. (corresponding author) 2. dr. mahmood-uz-jahan, deputy director, bangladesh medical research council (bmrc), dhaka. 3. dr. shaorin tanira, coordinator (health), mch-fp clinic, manabik shahajya sangstha (mss), dhaka. abstract: public health is the societal approach to protecting and promoting health. public health ethics can be defined as the identification, analysis, and resolution of ethical problems arising in public health practice and research. the emerging interest in ethical issues in public health research and practice reflects both the important societal role of public health and the growing public interest in the scientific integrity of health information and the equitable distribution of health care resources. this article provides an overview of ethical issues in public health research for young researchers and readers who do not necessarily have an in-depth knowledge of public health ethics. a framework of ethics analysis geared specifically for public health is needed to provide practical guidance for public health professionals and researchers in bangladesh. bangladesh medical research council is playing a role in setting a standard in the field of biomedical research including public health concerning its strategy and ethical issues and by helping different health institutes to build up a research environment. though public policy is based on many factors in addition to public health goals and ethical reasoning, it should not lead to the politically preferable option for a given time. key words: public health, public health research, ethical issues, national health research strategy, bangladesh medical research council. introduction: in 1923, the great public health scholar c.s. winslow stated that public health is “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts”1. public health is the societal approach to protecting and promoting health. generally through social, rather than individual, actions, public health seeks to improve the well-being of communities2. public health activities include community collaborations and partnerships for health and the identification of priorities for public health action. recent articles have included conceptual frameworks of public health ethics and overviews of historical developments in the field3,4. the emerging interest in ethical issues in public health research and practice reflects both the important societal role of public health and the growing public interest in the scientific integrity of health information and the equitable distribution of health care resources. attention to ethical issues can facilitate the effective planning, implementation, and growth of a variety of public health programs and research activities5. public health 15 mailto:shekhor19@yahoo.com bangladesh journal of bioethics 2010; 1(3):15-21 ethics, which can be defined as the identification, analysis, and resolution of ethical problems arising in public health practice and research, has different domains from those of medical ethics. ethical concerns in public health often relate to the dual obligations of public health professionals to acquire and apply scientific knowledge aimed at restoring and protecting the public's health while respecting individual autonomy6. amartya sen, a nobel winner economist, emphasizes the importance of health to justice by saying that “health is among the most important conditions of human life and critically significant constituent of human capabilities which we have reason to value”7. public health professionals must go through the steps of an ethics analysis to assure the public of their integrity. the public must feel confident that public health professionals will offer only those proposals that will improve the health of the public, that proposed measures are minimally burdensome, and that a fair procedure has determined that the magnitude of the problem and the ensuing benefits justify overriding conflicting moral claims8. ideally, the government would set a public health policy which include research strategies, ethical concerns, priority of public demand, cost-benefit ratio and, of course, “by reference to scientific or objective knowledge, maximizing the value of health and well-being within the population”9. moral reasoning in public health: moral reasoning involves ethical questions and reaching a decision with the help of judgment and rational analysis. among different methods of moral reasoning, the following two are considered to be more pronounced5. 1. princple-based approach: the principles of beneficence, nonmaleficence, autonomy, and justice, as explained by beauchamp and childress10, seek to reduce morality to its basic elements and to provide a useful framework for ethical analysis in the health professions. however, those principles do not provide a full philosophical justification for decision making. in situations where there is conflict between principles, it may be necessary to choose between them or to assign greater weight to one. practical problems in public health ethics require that these principles be made more applicable through a process of specification and reform11. 2. case-based approach: sometimes, the specific decisions that emerge in particular cases may remain unaddressed by the principles. such decisions are often made by focusing on the circumstances of the case at hand and the moral context in which the case rests. case-based methods such as casuistry are grounded in analogical reasoning, appeal to paradigmatic cases, and practical judgment11,12. here, decision making takes place at the level of the particulars of the case itself. given a case and a particular decision to be made, maxims are identified that have bearing on the case. other approaches to moral reasoning, such as rights-based theories, duty-based theories, contractarianism, ethics of care, narrative ethics, and communitarianism have not been widely applied in public health5. 16 bangladesh journal of bioethics 2010; 1(3):15-21 public health research: ethical concerns: a framework for public health ethics will help public health professionals recognize the multiple and varied moral issues in their work. public health ethics must emphasize positive rights as well. public health has affirmative obligations to improve the public’s health, ensure ‘health for all’ and to reduce certain social inequities. hence, a code of public health ethics is also needed to address such social justice. some emerging issues related to ethical aspects of public health research are discussed below. ethical issues in public health surveillance: public health professionals have ethical obligations to both maximize the potential benefits of routinely collected surveillance and disease registry data and minimize risks and potential harms. steps taken to assure the quality of data collected by public health surveillance systems and disease registries maximize the potential benefits of the data. registry data must be accurate, complete, and timely5. minimizing risks and providing benefits: ethical concerns in epidemiology and public health practice often relate to the obligations of health professionals to acquire and apply scientific knowledge aimed at maintaining and restoring public health while respecting individual rights5. potential societal benefits must often be balanced with risks and potential harms to individuals and communities, which is particularly important in epidemiologic studies of vulnerable populations e.g. children, prisoners, old people, and populations that are socioeconomically disadvantaged13. obligations to communities: these obligations include communicating the results of public health/epidemiologic studies at the earliest possible time, after appropriate scientific peer review, so that the widest range of readers are able to get benefit from the information. researchers should strive to carry out studies in a way that is scientifically valid and interpret and report the results of their studies in a way that is scientifically accurate and appropriate5. moreover, they should respect cultural diversity in carrying out studies and in communicating with members of affected communities14. informed consent, privacy and confidentiality: informed consent provisions in public health studies ensure that research participants will make a free choice and also give institutions the legal authorization to proceed with the research15. this includes the purpose of the research, the scientific procedures, anticipated risks and benefits, any inconveniences or discomfort, and the participant's right to refuse participation or to withdraw from the research at any time. seeking and updating informed consent is fundamental to good practice in research involving human participants16. special considerations for obtaining informed consent may arise in public health studies of socioeconomically deprived people. people who have limited access to health care may misunderstand an invitation to participate in a study as an opportunity to receive medical care. in addition, they may be reluctant to refuse participation when the researcher is viewed as someone in a position of authority, such as a physician or university professor. socioeconomically deprived people may also be more motivated to participate in studies involving financial incentives for participation17. a further issue is that there is often a need to translate informed consent statements into a language other than english18. 17 bangladesh journal of bioethics 2010; 1(3):15-21 another important way in which public health researchers reduce potential harms and risks to participants in research is by protecting the privacy of the participants and the confidentiality of their health information19. specific measures taken by researchers to protect the confidentiality of health information include keeping records under lock and key, limiting access to confidential records, discarding personal identifiers from data collection forms and computer files whenever feasible, and training the staff about the importance of privacy and confidentiality protection20. other measures that have been employed to safeguard health information include encrypting computer databases, limiting geographic detail, and suppressing cells in tabulated data where the number of cases in the cell is small21. avoiding and disclosing conflicts of interest: other ethical issues that arise in the professional practice of epidemiology relate to how to deal with potential conflicts of interest, in order to ‘maintain public trust in epidemiology and sustain public support for health research’22,23. conflicts of interest can affect scientific judgment and harm scientific objectivity16. studies have suggested that financial interests and researchers’ commitment to a hypothesis can influence the reported research results23,24. hence, researchers should disclose financial interests and sources of funding when publishing research results. it may also be important to disclose information about potential or actual financial conflicts of interest when obtaining informed consent from research participants. the role of the institutional ethical review committee (erc): the purpose of research ethics committees or institutional ethical review committees (ercs) is to ensure that studies involving human research participants are designed to conform the relevant ethical standards and that the rights and welfare of participants are protected25. research ethics committees should not function under political control or one’s sweet will26. ethics committees must be independent of research organizations. this independence relates to their decisions, not their operating processes16. a methodical review by such committee ensures that studies have a “favorable balance of potential benefits and risks, and that the participants are selected equitably, and that procedures for obtaining informed consent are adequate”27. it is praise-worthy that national institute of preventive and social medicine (nipsom), all the government medical colleges and different specialized government health institutes have got their own ethical review committees (ercs). moreover, bangladesh medical research council (bmrc), the focal point for health research in the country, has got a strong ‘national research ethics committee’ to review the ethical aspects of a research project28. the first and foremost addressed issues are informed consent, privacy and confidentiality of data, risk-benefit ratio of the community/participants29. other issues concerned in the guidelines include those pertaining to scientific misconduct, intellectual property and data sharing, publication of research findings, and cross-cultural or international health research30. however, any research now requires only a single ethical review, irrespective of the authority concerned (but preferably done by the parent institution) and number of sites involved. what is needed in our country is that all research ethics committees in 18 bangladesh journal of bioethics 2010; 1(3):15-21 bangladesh should operate in a standard fashion, providing an impartial, unbiased review and quick decision. directorate general of health services (dghs), bangladesh has already published a ‘national health research strategy’ with technical assistance from bangladesh medical research council (bmrc) and world health organization (who) featuring different aspects of biomedical research which include institutional framework, priority setting, ethical clearance, financing, monitoring and evaluation, capacity development, dissemination and utilization of research results31. conclusion: bioethics, as a discipline, helps health care professionals identify and respond to moral dilemmas in their work. public health is what we, as a society, do collectively to assure the conditions for people to be healthy1. hence, a framework of ethics analysis geared specifically for public health is needed, both to provide practical guidance for public health professionals and to highlight “the defining values of public health, values that differ in morally relevant ways from values that define clinical practice and research”8. besides, conflict of interest of the researchers, indemnity for the protection of participants, and confidentiality of data are widely accepted as core ethical issues in any research. therefore, we should look into these matters seriously in the field of public health research. of course, public policy is based on many factors in addition to public health goals and ethical reasoning, but it should not lead to the politically preferable option for a given time. references: 1. beaglehole r, bonita r. public health at the crossroads: achievements and prospects. 2nd ed. cambridge: cambridge university press; 2004. 2. institute of medicine. committee for the study of the future of public health. the future of public health. washington, dc: national academy press; 1988. 3. callahan d, jennings b. ethics and public health: forging a strong relationship. am j public health 2002; 92: 169-76. 4. kass ne. public health ethics: from foundations and frameworks to justice and global public health. j law med ethics 2004; 32: 232-42. 5. coughlin ss. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology 2006, 3: 16-. 6. coughlin ss, beauchamp tl, weed dl. historical foundations. in: ethics and epidemiology. 2nd ed. new york: oxford university press; 2009. 7. sen a. why health equality. in: anand s, peter f, sen a. editors. public health, ethics, and equity. 1st ed. new york: oxford university press; 2004. 8. kass ne. an ethics framework for public health. am j public health 2001; 91(11): 1776-82. 9. gostin lo. editor. public health law and ethics: a reader. 1st ed. berkeley: university of california press; 2002. 19 bangladesh journal of bioethics 2010; 1(3):15-21 10. beauchamp tl, childress jf. principles of biomedical ethics. 5th ed. new york: oxford university press; 2001. 11. beauchamp tl. moral foundations. in: coughlin ss, beauchamp tl, weed dl. eds. ethics and epidemiology. 2nd ed. new york: oxford university press; 2009. 12. coughlin ss, soskolne cl, goodman kw. case analysis and moral reasoning. in: coughlin ss. editor. case studies in public health ethics. 2nd ed. washington, dc: american public health association; 2009. 13. coughlin ss. ethically optimized study designs in epidemiology. in: coughlin ss, beauchamp tl, weed dl. editors. ethics and epidemiology. 2nd ed. new york: oxford university press; 2009. 14. public health leadership society. principles of the ethical practice of public health. version 2.2. 2002. 15. shulz m. legal and ethical considerations in securing consent to epidemiologic research in the united states. in: coughlin ss, beauchamp tl, weed dl. editors. ethics and epidemiology. 2nd ed. new york: oxford university press; 2009. 16. pattison j, stacey t. research bureaucracy in the united kingdom: seeking a balance: response from the department of health and corec. bmj 2004; 329(7466): 622. 17. smith nl. the context of investigations in cross-cultural evaluations. studies in educational evaluation 1991; 17: 3-21. 18. macklin r. against relativism: cultural diversity and the search for ethical universals in medicine. 1st ed. new york: oxford university press; 1999. 19. parmet we. populations, public health, and the law. 1st ed. washington, dc: georgetown university press; 2009. 20. coughlin ss. ethically optimized study designs in epidemiology. in: coughlin ss, beauchamp tl, weed dl. editors. ethics and epidemiology. 2nd ed. new york: oxford university press; 2009. 21. wynia mk, coughlin ss, alpert s, cummins ds, emanuel ll. shared expectations for protection of identifiable health care information: report of a national consensus process. j gen intern med 2001; 16(2): 100-11. 22. centers for disease control and prevention (cdc). framework for program evaluation in public health. mmwr 1999; 48(rr11): 1-40. 23. seigel d. clinical trials, epidemiology, and public confidence. stat med 2003; 22: 3419-25. 24. jamrozik k. research ethics paperwork: what is the plot we seem to have lost? bmj 2004; 329: 286-7. 25. fairchild al, bayer r. ethics and the conduct of public health surveillance. science 2004; 303: 631-2. 26. wald sd. bureaucracy of ethics applications. bmj 2002; 329: 282-4. 27. jones am, bamford b. the other face of research governance. bmj 2004; 329:280-1. 28. bangladesh medical research council (bmrc). rich. 2008; : . 20 javascript:al_get(this,%20'jour',%20'bmj.'); bangladesh journal of bioethics 2010; 1(3):15-21 29. council for international organizations of medical sciences. international guidelines for ethical review of epidemiological studies. law med health care 1991; 19: 247-58. 30. beauchamp tl, cook rr, fayerweather we, raabe gk, thar we, cowles sr, et al. ethical guidelines for epidemiologists. j clin epidemiol 1991; 44(suppl.1): 151-69. 31. directorate general of health services (dghs). national health research strategy. ministry of health and family welfare, government of the people’s republic of bangladesh, 2009. 21 bangladesh journal of bioethics 2011;2(2):26-29 justification of participation of human subjects in phase 1 clinical trials: an ethical analysis dr. inayat ullah memon chief pathologist & incharge bioethics unit, peoples medical college hospital, nawabshah, pakistan email: memon.inayat@gmail.com abstract: in the process of clinical trials, after ascertaining the safety of drugs or other therapeutic interventions in animals or in vivo, phase i clinical trials are conducted as initial step on healthy human volunteers (or patients with specific disease) to observe pharmacokinetics, safety and side effects associated with escalating doses of the drugs. participation of human subjects having different biological system than animals is not without risks in these trials; this fact raises some important ethical issues. in the light of international research ethics guidelines, this paper analyses moral justification of use of humans as research subjects in phase i clinical trials, discusses what groups of participants should be involved, their economic status, questionable coercive effect of monetary remuneration on the subjects and soundness of informed consent obtained for the trials. these issues are also discussed in the perspective of four founding principles of bioethics i.e. autonomy, justice, beneficence and non-maleficence. keywors: phase i trials, human subjects, ethics, participants’ protection introduction: tremendous development in medical science and consequent discoveries resulting into successful prevention and cure of various diseases are shared by the clinical research involving human participants. preceding the trials in human subjects, to ensure safety the proposed drug or any other intervention is either tested in laboratory (in vitro) or in animals (in vivo) to assess initial safe starting dose for human beings and to identify the benchmarks for clinical monitoring for potential unfavourable effects.1 but these pre-human trials may not necessarily safeguard against untoward effects in human beings, as happened in case of thalidomide tragedy, which disabled and killed thousands of babies born to mothers taking this medicine. 2,3 use of healthy human subjects in preliminary experiments (phase i clinical trials) reduces or excludes the risks of subsequent unwanted effects in future trails and use in respective patients. participants of phase i trials (or phase 0 trials) in some cases are the victims of such unpredictable and life-threatening effects as in case of tg1412.4,5 apart from this ethically questionable situation, history of clinical trials reveals that either investigators or the research sponsors camouflaged the information conveyed the to prospective subjects or exploited either their social vulnerability or economic and intellectual poverty to lure them to the study. 6,7 regular and frequent visits by the researchers to specific geographic location on international level or particular communities within a country or region not only stigmatize them but target research subjects because of financial incentives offered to them rely on remunerations for their livelihood and welcome future researchers without need of knowing consequent ill-effects. spirit of non-coercive and fully informed willingness does not absolve the researchers from the ethical responsibilities even when the documentary consent was obtained from participants, as participants have no knowledge of possible adverse effects of on-going research. cases of tainted consent in research negate the principle of respect for autonomy. moreover the fact that there are only meagre probabilities of benefit to the participants of phase i trials, except the financial remuneration offered to them, while future users of that particular intervention would benefit from such trials, negates the principle of justice and beneficence. the principle of non-maleficence is violated when vulnerable groups of the communities are favourite subjects for the studies, resulting into their addiction for the participation in the trials with potential of harmful effects. this paper discusses following issues from ethical perspectives. 1. whether is it justifiable to involve human volunteers in phase i trials? 2. if yes what groups of human volunteers be involved, casual participants or those who meet their living expenses from monetary remuneration or reward earned from such studies. 3. how much the subjects be paid for participating in these trials? isn’t the paid amount so voluminous that it deceives subjects’ decisional capacity to participate? 1 bangladesh journal of bioethics 2011;2(2):26-29 4. issue of perception of phase i trials by the participants and ethical soundness of the obtained informed consent. justifiability of involving human beings: a necessary but not the sufficient requirement of justifying human involvement in clinical trials is that experiment has to be scientifically valid, based on reasonable hypothesis and should have a research methodology that can be expected to reach its stated endpoint.8 if we apply this requirement on phase i clinical trials (as well as phase 0 trials), then we do not have difficulty to justify the involvement of human models. but we have difficulty in meeting this requirement in oncology phase 0 trials as we do not have capabilities to measure the effects of the drug on its targets. another requirement which is necessary and sufficient one to justify human involvement in clinical trials is that research needs to be of benefit to participants. accepting the practices of clinical research the benefits include direct or indirect to participants and to others as well.8 the phase i trials carried out on healthy human volunteers are not coupled with any direct or indirect benefit to them. but those carried on patient volunteers such as suffering from cancer have a component (though a small one) of benefit to them directly as there is small chance of therapeutic benefit from these trials. moreover the pro-phase i commentators may make their argument worthier and ethical by adding the factor of ‘benefit to others’ as a result if phase i trials prove successful. additional component in favour of involving human models in these trials is participants’ wish to help others (altruism). what group of human beings should be involved: careful selection of human participants is needed to justify their involvement in phase i trials to ensure avoidance of their exploitation. in the past, poor and desperate-formoney people were recruited to participate in these trials such as in eli lilly case, where homeless alcoholics were recruited for these studies.6 while in some other investigations, immigrants with doubtful health condition were recruited who later developed tuberculosis and contracted same to some others as well.7 another factor augmenting exploitation is practice of involving for-profit institutional review boards (irb) as supervisory and overseeing bodies for the research trials.6 monetary status of paid volunteers and volume of financial remuneration: a study carried out in recent past regarding socio-economic status of the participants revealed that financial incentive was one of the strong motivating factor as well as the most valued one for low income people while had no or opposite influence on people with higher earnings. moreover lower educational level played a role to attract such people to participate in the phase i trials.9 to pay for participation in clinical trials is neither a new practice nor it is controversial.6 moreover it is not unlawful to offer payments for research participation.10 but core issue is the volume of the monetary need of the prospective phase i participants and the influence of financial inducement on various strata of the society resulting into possible deception of their decisional capacity. same volume of money may not be tempting for a wealthy person but that could be very attractive for economically less privileged person of the society.6 this fact leads to the undue inducement for the participants and ethically undesired exploitation by the investigators or research sponsors. as a result, more will the chances that poorer become research participants and lesser will be the probabilities that they would benefit from such trials if the drug under question becomes available in the market (after successful trial and approval) but beyond the purchasing power of the poor. this situation negates one of the seven requirements (social value) of ethical research trials9 and violates the article 19th of the declaration of helsinki which requires that medical research is ethically justifiable, only if there is a reasonable chance that the population in which it is conducted will benefit from the results. origin of some of these issues is based on the fact that clinical research has been changed into business adventure. as a consequence the research participants, taking part in phase i trials perceive it as a sort of job or employment. their perception is not based on false beliefs but is truly based on offer of high remuneration for participation, which in many cases is more than minimum job wages and is consequently sufficient to mislead them. this situation also plays a part in distortion of medical history as because of temptation of disproportionately high incentives the prospective participants conceal their illnesses so as to avoid their disqualification from taking part in the trials.6 beside the financial incentives for the participation in phase i trials there is ongoing discussion about relationship between the risks and hazards associated with phase i trials. some commentators argue that not only the participants be paid but the volume of benefits and incentives be related to the degree of the risks.10 they argue that in today’s rights-based society and value for individual autonomy it would be unduly paternalistic to set limits for financial inducements offered for the trials and they corroborate their position by the fact that monetary benefits do not affect the understanding of risks by the participants.10,11 an analogy has been offered by jones and liddell10 in this regard, where comparison of high-risk phase i trials is made with high-risk financial investments. i strongly disagree with their stance, contending that risk to life (or health) can’t be legally and ethically compared with risk to financial investment, they are entirely different and unmatchable entities. financial loss can be regained while human loss is irrecoverable. they also justify high incentives for risky and hazardous associated with phase i trials by exemplifying the high wages for dangerous industries or fire-fighting services10 again, i argue against them, as in dangerous industries and fire fighting, the risks are more or less predictable and reasonably assessable, while in these trials the situation is entirely different. if it were the situation (predictability, even of high risk) in case of tgn1412 trials carried out by parexel international, none of the six participants would have adventured to take part in the trials like this one, where their heads and necks swelled three times their normal 2 bangladesh journal of bioethics 2011;2(2):26-29 size.12 i am with saunders’s opinion who rightly argue that ‘level of the risk should not be so high as to necessitate payments in the first place’.13 moreover the financial benefits offered should not be of such degree as to encourage people to take part in risky trials. perception by the phase i participants and soundness of informed consent: as has already been argued that poverty of the participants and the high financial benefits distort participants’ perception as they take their involvement in the research trials as some sort of job.6,9 this misperception coupled with incomplete disclosure of the research risks and hazards, make the informed consent tainted with consequent disrespect and negation of the spirit embodied in the doctrine of informed consent. four founding ethical principles of beauchamp and childress and phase i clinical trials: the four founding principles i.e. autonomy, beneficence, non-maleficence provide some valuable guidance in resolving the ethical issue of human participation in phase i clinical trials. research participants are fully autonomous to take part (or not) by virtue of their self-governance but at the same time there should be some limits of governance. if the western right-based society considers the ‘right-to-die’ as entirely and solely personal affair and confers this right to individuals such as in cases of euthanasia and pas (physician assisted suicide), then how many such countries have so far legally conferred their citizens the right-to-die? the situation is so such complex and controversial that in the northern territory (nt) of australia, euthanasia legitimized by ‘rights of terminally ill act 1995’ was overturned by federal parliament just after 9 months of its enactment. 14 while in other instances, because of difference of opinion amongst jurists, legal battles pertaining to mercy killing lingered for as long as seven years, as in case of terri schiavo.15 therefore, supporting the issue of participating in phase i clinical trials with crunches of autonomy and self-governance is not without legal and moral weaknesses and shortcomings. regarding the principle of beneficence; though these trials, meet the seven requirements of ethical conduct of the research set by emmanuel et al 16, but need balancing of the principles and rules as suggested by beauchamp and childress, keeping in view the nature of individual research. there is almost no benefit to the research participants in phase i trials except a minor fraction anticipated in those trials conducted on cancer patients. but benefit to others (for the society in future) provides reason for ethical justification of phase i trials. the scope and quantity of maleficence is low but its degree / severity might be high in some cases, like tgn 1412 cases. depending upon the nature of cases, again decision should be made on case to case basis. one may infer from the basic notion of justice i.e. treating like situations in like ways, that no one should be preferentially or discriminately induced to take part in phase i trials. then there should not be undue financial inducement or other forms of benefits for these trials to allure participants. neither poor financial situation nor low educational level be exploited to tempt individuals to participate in these experiments.6 as the beneficiaries of the research results are the affluent people, therefore same group of people should offer themselves for the studies rather than guinea pigging the resource-starved communities. conclusion and suggestion: there are no unequivocal guidelines by the international ethics organizations to set limits for the financial inducements offered to participations in research trials, particularly phase i. there are recommendations by some national organizations, but these are either vague or controversial such as those of british pharmaceutical industry (delinking benefits to the risks) and royal college of physicians (linking benefits to degree of inconvenience and incurring risks). there is need for some consensus principles on which ethics committees could base their decisions. there is need to set, define and explain the responsibilities of monitoring bodies engaged in overseeing the phase i research trials, so that no such events occur in future like tgn1412, moreover establishment of for-profit irbs should be discouraged in order to make justice with research participants. there is no disagreement with the fact that scientific, including medical knowledge can’t grow without research including phase i trials, but tremendous scientific development requires balancing with increased sensitivity for bioethics with its broadened and deepened dimensions there is need to completely identify, understand and resolve these issues without the judges (such as bioethicist and members of irbs and review boards) being unduly influenced by the glamorous temptations offered by the some stakeholders such as powerful pharmaceutical. in these situations we need to protect the most vulnerable subjects of the research trials (phase i trials), particularly when their vulnerability is compounded by economic or intellectual poverty. references: 1.sellers em, souich pd, ‘phase i trials’ human pharmacology. http://www.iuphar.org/pdf/hum_40.pdf 2. thalidomide victims association of canada, thalidomide: the canadian tragedy http://www.thalidomide.ca/the-canadian-tragedy/ 3. the thalidomide tragedy: another example of animal research misleading science http://www.pnc.com.au/~cafmr/online/research/thalid2.html 3 http://www.iuphar.org/pdf/hum_40.pdf http://www.pnc.com.au/~cafmr/online/research/thalid2.html http://www.thalidomide.ca/the-canadian-tragedy/ bangladesh journal of bioethics 2011;2(2):26-29 4. hawkes n, ‘the drug trial that went horribly wrong’, sunday times, march 16, 2006, http://www.timesonline.co.uk/tol/news/uk/health/article741405.ece 5. suntharalingam g, perry mr, ward s, brett sj, castello-cortes a, brunner md, panoskaltsis n, ‘cytokine storm in a phase 1 trial of the anti-cd28 monoclonal antibody tgn1412’, new eng j med,sept. 2006, vol. 355, pp. 1018-1028. 6. elliot c, abadie r, ‘exploiting a research underclass in phase 1 clinical trials’, n eng j med, 2008, vol. 358, no. 22, pp. 2316-2317 7. evans d, ‘sfbc drug testers have tuberculosis after exposure at center’, http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a90ozzprlkae&refer=columnist_evansredirectoldpage 8. hill tp, ‘phase o clinical trials: are they ethically challenged?’, editorial, clinical cancer res, 2007, vol. 13, no: 3, pp. 783-784 9. almeida l, azevedo b, nunes t, vas-da-silva m, soares-da-silva p, ‘why healthy subjects volunteer for phase 1 studies and how they perceive their participation’, european journal of clinical pharmacology, 2007, vol. 63, no. 11, http://www.springerlink.com/content/0lu6704568434874/ 10. jone e, liddell k, ‘should healthy volunteers in clinical trials be paid according to risk: yes’, 2009, bmj, vol. 339, b4142 11. bentley p, thacker pg, ‘the influence of risk and monetary payment on the research participation by healthy volunteers in clinical trials’, j med ethics, 2004, vol. 30, pp. 293-298 12. six healthy volunteers in phase i drug trial critically ill uk, 2005. <http://www.ahrp.org/cms/content/view/110/84/> 13. saunders j, ‘should healthy volunteers in clinical trials be paid according to risk: no’, 2010, bmj, vol. 339, b 4145 14. grey w, ‘right to die or duty to live? the problem of euthanasia’, journal of applied philosophy, 1999, vol 16, no 1, pp. 19-32. 15. quill te, ‘terri shiavo – a tragedy compounded’, n eng j med, 2005, vol. 352, no. 16, pp. 1630 1633 16. emmanuel je, wendler d, grady c, ‘what makes clinical research ethical’, jama, 2000, vol. 283, no. 20, pp. 2701-2711 4 http://www.springerlink.com/content/0lu6704568434874/ http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a90ozzprlkae&refer=columnist_evans-redirectoldpage http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a90ozzprlkae&refer=columnist_evans-redirectoldpage http://www.timesonline.co.uk/tol/news/uk/health/article741405.ece microsoft word abstract_mehedi.doc bangladesh journal of bioethics 2010; 1(2): 34-36 ethics in the judiciary system of bangladesh mehedi imam, managing director, adhuna bangladesh limited abstract in bangladesh, demand for judicial independence in practice has been a much debated issue and the demand is fulfilled but expectation of people is not only limited to have an independent judiciary but to have an impartial system and cadre of people, which will administer justice rationally being free from fear or force. the independence of judiciary and the impartial judicial practice are related concepts, one cannot sustain without the other and here existence as well as the need of practicing impartiality is well recognized. but the art of practicing impartiality does not develop overnight as it’s related to development of one’s attitude. it takes a considerable time resulting from understanding, appreciating and acknowledging the moral values, ethics and professional responsibility. the judiciary includes judges, advocates mostly who are expected to demonstrate a high level of moral values and impartiality towards people seeking justice and ‘rule of law’. this is true that bench officers and clerks are also part of the process to ensure rule of law with same level of participation by the law enforcing agencies such as police. however the paper includes only those who either join judiciary as judge/magistrate or advocate to explore level and extent of ethical knowledge they receive being key role players of the system. introduction the people at the bench are individuals whom we expect to practice impartiality in administering justice without being pressurized by any restriction, influence, inducement, threat or influence. the vast majority of judges and judicial officers are appointed from either the members of legal profession with long professional standing or the law graduates by way of judicial service examination intake. judicial officers/judges • judicial administration training institute (jati) arranges for training of persons appointed in the judicial service, lawyers and some other professionals connected with the judicial system in order to increase their professional efficiency. • the judicial administration training institute (jati) runs a 60 day basic course for newly appointed assistant judges, 21 day courses (and sometimes, 3 day short courses) for senior assistant judges, joint district judges and district judges. 34 bangladesh journal of bioethics 2010; 1(2): 34-36 • the curriculum for the "basic course" does not include any lecture on ethics or professional responsibility. • but, the curriculum for judicial administration training course for the district and session judges have a module on "judicial ethics and code of conduct of judicial officers". advocates • as per rule 10 of the bangladesh legal practitioners and bar council rules 1972, the functions of the bangladesh bar council includes, is to  admit persons as advocates on its roll;  hold examinations for purposes of admission;  remove advocates from such roll;  lay down standard of professional conduct and etiquette for advocates;  entertain and determine cases of misconduct against advocates on its roll and to order punishment in such cases;  promote legal education etc. • as per bangladesh bar council, every person shall, before being admitted as an advocate, pass a written examination, viva voce ‐ and a vocational training course of approx. 7 weeks. • the syllabus for the written examination for enrolment includes a topic, "rules of professional etiquette" which is examined by assessing a candidate's knowledge on bangladesh bar council canons of professional conduct and etiquette. canons of professional conduct and etiquette states about an advocate's duty towards the court, his/her clients, colleague advocates and towards the public generally. • these canons were framed in exercise of the power conferred on the bangladesh bar council by section 48(q) of the legal practitioners and bar council act 1965 and are crucial for any legal practitioners of bangladesh as they (advocates) are expected to discharge certain high duties in the society. • according to bar council enrolment examination policy, every candidate is expected to be familiar with these canons and is examined by way of answering a given hypothetical problem of ethical conflict situation. but this is simply not enough to ensure the target result of having an overall ethical and professionally responsible legal profession. • every successful candidate who have passed the written examination and viva voce,‐ would need to go through a compulsory training course known as bar vocational course (bvc) to get a call to the bar and the 'certificate'. the bvc is conducted by the legal education and training institute (leti) of bangladesh bar council. within a span of 7 weeks, the students of bvc have approximately 80 84 c‐ lasses and unfortunately, only 3 classes (each with approx. one hour duration) are allocated to have a discussion on the topic of professional ethics. the discussion is of general type and there is no specific syllabus available for those sessions. bangladesh journal of bioethics 2010; 1(2): 34-36 35 observation in a bid to understand the level of professional ethics we can explore the answers of the following questions that are directly linked to ethics and we have to take note that the existing legal education system do not teach the law students or graduates te ethics or professional responsibility. there is no conceptual framework that to be a good lawyer a student needs to learn and develop good ethics and as such, there is no subject called legal ethics in the official curriculum of any of the law degree of our country. 1 • do the judges get any systematic training during their process of making to build up a state of mind or attitude whereby they become committed to uphold the moral and ethical values which help them to ensure the rule of law? 2 • what level of care are our legal professional bodies and the legal education system is providing to produce a lawyer or a law graduate to practice and appreciate the ethics to ensure the ‘rule of law’? conclusion the need for independent judiciary is no doubt a cornerstone of democratic practice all over the world and in bangladesh, demand for judicial independence in practice has been a much debated ‐ issue among policy reformers, democratic philosophers and legal academics for a long time and it has been achieved so far, though there are still some conflicts. many a people have raised this issue at various national levels and demanded a positive change to ensure independence of judiciary at the earliest but expectation of common men is not only limited to have an independent judiciary but also, to have an impartial one, which will administer justice rationally being free from fear or force. the independence of judiciary and the impartial judicial practice are related concepts, one cannot sustain without the other. the art of practicing impartiality does not develop overnight rather it results from understanding, appreciating and acknowledging the moral values, ethics and professional responsibility over a considerable period of time. it is basically a question of developing an attitude. in developing that attitude, there is a need for the development of an ethical framework in our entire legal and judicial arena and for which there is no other alternative but raising the knowledge of our legal and judicial professionals with regard to ethics, professional responsibility and accountability. ensuring of such knowledge will help the society with long time benefit in general and particularly for the legal and judicial professionals. 36 bangladesh journal of bioethics 2010; 1(1):7 political influence, bribery and other means of subjective influence. so long as discretion is wide and the scope remains for abuse of power with impunity, and as long as effective legal and ethical standards are not in place with enforcement mechanisms for zero tolerance to corruption, no true results can be expected or sustained in enhancing ethical and moral standards. no less important is the issue of salaries and benefits, which must be viewed as investments for future. much would definitely depend on the extent to which anti-corruption values and ethics can be mainstreamed in the public service. a key role would be played by preventive measures against erosion of public service integrity and honesty by enforcing public service code of ethics including positive and negative incentives. ethics and integrity in public service are more than a project of value or moral education, however well-designed it may be. it cannot be viewed in isolation from systemic challenges, and must be part of a holistic institutional structure and process that would promote and sustain integrity in the public service as well as other aspects of life in a holistic infrastructure of integrity. a comprehensive and institutional approach strongly backed by highest level political commitment is indispensable. ethical dilemma and research methodology of social sciences prof. ahmad a.n. neaz, dssc., american international university-bangladesh , email: aneaz@aiub.edu today, when the galaxy of knowledge, be it social, political, economic or scientific is expanding at an unprecedented pace, new questions and new interests require us to enter into a new search for a new answer. for many millennia knowledge was exclusively confined under the grip of subjectivity and pre-conceived ideas. although, greek scholars started to think objectively the newtonian paradigm came as a major breakthrough in this regard. the ultimate outcome turned out to be the development of a ‘positivistic methodology’, solely relying on empirical evidence. social scientists also pretended to follow scientific method and their search for objectivity was the foundation of research endeavor. they also followed newtonian philosophy by considering a closed autonomous system, ruled by endogenous factors of highly selective nature, self regulating and moving to a determinate predictable point in terms of linear, stable and equilibrium analysis. social science, particularly economics ahead of others, claims itself as a ‘value free science’ in order to follow positivistic methodology, depended solely on empirical evidence. consequently, it discards ethics, values and any subjective involvement as idealistic rather than realistic. for nearly a century, in order to become increasingly scientific, ethics has been abandoned by many disciplines and ultimately, ethics has been tethered around and nurtured by philosophy only. einstein tried to synthesize the positivist accommodating the ‘world of idea’ in the field of research. m.k gandhi was the first person to challenge economists as a ‘value free’ subject. bioethics could be termed as a landmark in order to rehabilitate ethics. it is for sure that within near future ethics will be the guiding philosophy of all the disciplines of knowledge. in order to achieve that, education and research method need to be redesigned to developed epistemology. it is a fallacy of the positivistic methodology that there will be no subjective involvement. in the field of social sciences where events or phenomena have unique particularity and have no scope for repeated experiment, empirical evidence must be supported by rational thinking. otherwise it will lead to empiricism which may not be considered as knowledge even. application of intensive observation, rra, pra and other methods have been supplementing and complementing the limitations of positivistic approach. amartya sen tried to introduce values in economics but in vain. development economics initially considered ‘economic growth’ or gni as the yardstick of development. since mid 1970s it has been shifted to ‘human development’ which has been intensified under millennium development goals. economists yet to conceive ethics as a guiding philosophy which may further shift the discipline from human development to ‘humane development’ emancipating human civilization from the realm of poverty, greed and inhumanity to the arena of welfare, peace and global harmony. 7 bangladesh journal of bioethics 2012; 3(1):13-18 13 ethics in stem cell research md. fakruddin scientific officer, industrial microbiology laboratory, institute of food science and technology (ifst), bangladesh council of scientific and industrial research (bcsir), dhaka. email: fakruddinmurad@gmail.com abstract: stem cells have constituted a revolution in regenerative medicine and cancer therapies by providing the possibility of generating multiple therapeutically useful cell types that could be used for treating some of genetic and degenerative disorders. however, human embryonic stem cell research raises few ethical and political controversies because of its involvement in destruction of human embryos. the ethical issues in human embryonic stem cell research encompasses not only with question of the ethics of destroying human embryos, but also with questions about complicity of researchers in destruction of embryos, moral distinction between creating embryos for research purposes and creating them for reproductive ends and the permissibility of cloning human embryos to harvest stem cells. bangladesh should formulate its own regulations justifying its stand regarding this matter. key words: stem cells, applications, prospects, ethics. introduction: few technologies spark as much interest, hope and controversy as stem cell technology. many people have strong opinions about the morality of stem cell research, but few have a strong understanding of the science and its potential. the excitement about stem cell research and its potential therapeutic applications is clearly evidenced by the large investments into research that have been made by corporations, governments and universities around the globe. tempering the exuberance, however, are the myriad ethical, legal, and political challenges that face this field of research. the eventual resolution of these conflicts will determine the success of the research and potentially the face of medicine in the future 1 . what is stem cell? stem cells are unspecialized cells with remarkable potentiality to develop into many different cell types. they are capable of renewing themselves through cell division 2 . under special condition they can be induced to become tissue or specific cell with defined function, these distinguishing features make stem cell different from other types of cell. stem cells are undifferentiated cells that through replication have the capability of both self-renewal and differentiation into mature specialized cells 3,4 . properties of stem cell: stem cells have some unique properties compared to normal cells. first, they have longevity. they divide and replicate under laboratory conditions for long periods of time without differentiating until induced to do so. second, they have plasticity. they are able to differentiate into different types of specialized cells, such as cardiac muscle or pancreatic cells 5,6 . history of stem cell research: since their discovery in the early 1900s, stem cells have captured the imagination of scientists. interest intensified, however in 1998, when professor james thomson at the university of wisconsin isolated and grew stem cells derived from human embryos7. soon thereafter, researcher from johns hopkins university achieved similar results with human germ stem cells 8 . these advances impelled a wave of stem cell research around the world, focusing on three areas: human development, birth defects and therapeutics. bangladesh journal of bioethics 2012; 3(1):13-18 14 ethical issue of stem cell research: ethical challenges are not new to medicine and medical research. stem cell research raises the concern that humans are "playing god". this concern is particularly relevant when discussing the cloning of human embryos for research purposes. there is also the possibility of inadvertent germ-line (reproductive cells) manipulation, even with the use of adult stem cells. germ-line manipulation would result in the genetic modification of the offspring and would have a permanent impact on the human species 9,10 . as therapies are developed and commercialized, society will have to consider the ethical implications of not only science but also the management of the corporations that bring such treatments to market 11,12 . the source of tissues used to obtain stem cells in one of the most incendiary topics surrounding stem cell research. the president's council of bioethics suggested three primary and recurring points of contention with regard to the issue of tissue sources: the moral status of human embryos, complicity and the "alternative of adult stem cells" 13,14 . stem cell research is controversial not because of its goals, but rather because of the means of obtaining some of the cells. the crux of the debate centers around embryonic stem cells, which enable research that may facilitate the development of medical treatments and cures, but which require the destruction of an embryo to derive. in addition, because cloning is one method of producing embryos for research, the ethical issues surrounding cloning are also relevant15,16. table-i. ethical issues at different phases of stem cell research17 phase of research ethical issues donation of biological materials informed and voluntary consent research with hescs destruction of embryos creation of embryos specifically for research purposes 1. payment to oocyte donors 2. medical risks of oocyte retrieval 3. protecting reproductive interests of women in infertility treatment use of stem cell lines derived at another institution conflicting legal and ethical standards stem cell clinical trials risks and benefits of experimental intervention informed consent a discussion of ethics in stem cell research cannot however be limited to the research arena. as therapies will be developed and commercialized, society will have to consider the ethical implications of not only the science but also the management of the corporations that brings such treatments to market 18,19 . several of these issues are discussed in more detail in the following. tissue source: the source of tissue used to obtain stem cells is one the most incendiary topics surrounding stem cell research. three primary and recurring points of contention with regard to the issue of tissue sources arethe moral status of human embryos, complicity and the “alternative of adult stem cells” 13,20 . moral status refers to the inherent worth of something from a moral standpoint (rather than economic, technical or other standpoint) 21 . the key question is, when does an embryo become a human? some argues that to destroy a fetus in the course of research is simply to take the life of an innocent human bangladesh journal of bioethics 2012; 3(1):13-18 15 individual. this unambiguous assertion holds that all embryonic stem cell research is morally wrong, regardless of potential benefit 22 . some other argues that becoming human requires more than the potential to develop into a human child. following this logic, it is morally acceptable to destroy surplus or cloned embryos for the greater benefit of society 23 . complicity relates to the question of who is responsible for embryo destruction. the third point of contention is “the alternative of adult stem cells”. some contend that therapies derived from adult stem cells are not sufficient to advance research and innovations24,25. hence research using stem cells from all sources including embryo should go forward. legal issues: a report issued by the nih in 2000 stated that “congressional prohibition does not prohibit the funding of research utilizing human pluripotent stem cells because they are not embryos”26. however, the report also stated that appropriations law (p.l. 105-277, section 511,112 stat, 2681-386) prohibits funds “for the creation of a human embryo or embryos for research purposes, or research in which human embryos are destroyed, discarded or knowingly subjected to risk of injury or death” 27,28 . the problem, of course, is that human embryonic stem cells are derived from early embryos. the proposed nih answer is to permit funding for pluripotent stem cell research while denying funding for deriving stem cells from embryos29,30. according to them, fund can be used “only if the cells were derived from early human embryos that were created for the purposes of infertility treatment and were in excess of clinical need of the individuals seeking such treatment”31,32. worldwide regulation scenario: policies on stem cell research vary greatly from nation to nation. britain is leading the drive for acceptance of stem cell research. in early 2001, the u.k. parliament approved the amendment of the 1990 human fertilization and embryology act governing research on human embryos, which allows the use of embryos up to fourteen days old for research on the derivation and potential of human stem cells. in israel, a national bioethics committee in 2001 approved the derivation of embryonic stem cells and research into therapeutic cloning. the bioethics committees of australia, canada and japan have also allowed stem cell research. in germany, parliament voted in january 2002 to allow research on imported human embryonic stem cell lines that had been created before january 20, 2002. these cell lines can only be used for research projects approved by regulatory body. but, in china, research on embryonic tissue is generally banned, according to the chinese health ministry. however, the study of stem cells drawn from the umbilical cord and afterbirth is permitted33-35. bangladesh scenario: no such research using stem cells have been known to be performed in bangladesh so far, though in-vitro fertilization and storage of germ cells is not new here. government and policy makers still are not aware of this matter, hence no government regulation and policy on the acceptability and use of stem cell in research is yet to be formulated. strict but rational regulations should be prepared and be in place for prospective stem cell research in this country to preserve ethical and moral values of the country people and to prevent unethical, unauthorized and unscientific use of stem cells in future. a national bioethics committee should be formed to guide the government in this issue. bangladesh being a muslim country, it will be difficult to gain acceptability of this type of research from common people. considering all the facts, government should make its stand clear with appropriate logic in this ground. today or tomorrow, the wave of stem cell research will reach bangladesh due to its immense commercial potential. so, we should be prepared well ahead of the time. conclusion: stem cell research has the potential to lead to the development of novel cellular and gene therapies that could be translated into effective and safe clinical treatments of numerous genetic and degenerative disorders in humans. although stem cells are highly unlikely to contribute to human fantasies of immortality and eternal youth, tremendous progress has been made in the past few years in the potential use of these cells as therapeutic agents, which may lead to prolonged life with less suffering and higher quality. in order to safely use stem cells or their differentiated progeny, methods of purification bangladesh journal of bioethics 2012; 3(1):13-18 16 and methods of cell-death control will need to be developed. another important aspect of stem-cell-based therapies will be the necessity of preventing the rejection of the donated cells by the immune system. in summary, much basic research lies ahead before application of a stem cell therapy to patients in a rigorous therapeutic manner is realized. however, mankind will surely benefit enormously by conducting research in this important area. references: 1. mezey e, key s, vogelsans g, szalayoua i, lange gd, crain b. transplanted bone marrow generates new neurons in human brains. proc natl acad sci usa 2003; 100(3): 1364-9. 2. barry fp, murphy jm. mesenchymal stem cells: clinical applications and biological characterization. int j biochem cell biol 2004; 36(4): 568-84. 3. burt rk, loh y, pearce w, beohar n, barr wg, craig r, et al. clinical applications of blood-derived and marrow-derived stem cells for nonmalignant diseases. jama 2008; 299(8): 925-36. 4. pera mf, trounson ao. human embryonic stem cells: prospects for development. development 2004; 131(22): 5515-25. 5. chapman ar, frankel ms, garfinkel ms. stem cell research and applications monitoring the frontiers of biomedical research. american association for the advancement of science and institute for civil society. 1999. 6. bobis s, jarocha d, majka m. mesenchymal stem cells: characteristics and clinical applications. folia histochem cytobiol 2006; 44(4): 215-30. 7. thomson ja, itskovitz-eldor j, shapiro ss, waknitz ma, swiergiel jj, marshall vs, et al. embryonic stem cell lines derived from human blastocytes. science 1998; 282(5391): 1145-7. 8. gearhart j. new potential for human embryonic stem cells. science 1998; 282(5391): 1061-2. 9. bobrow jc. the ethics and politics of stem cell research. trans am ophthalmol soc 2005; 103: 13842. 10. lo b, parham l. ethical issues in stem cell research. endocrine reviews 2009; 30(3): 204-13. 11. macdonald c. stem cell ethics and the forgotten corporate context. am j bioeth 2002; 2(1): 54-6. 12. robertson ja. ethics and policy in embryonic stem cell research. kennedy inst ethics j 1999; 9(2): 109-36. 13. outka g. the ethics of stem cell research. meeting of the president's council on bioethics, april, 2002. available at http://www.bioethics.gov/topics/stemcells_index.html. (accessed on january 22, 2011). 14. lodi d, iannitti t, palmieri b. stem cells in clinical practice: applications and warnings. j exp clin cancer res 2011; 30(1): 9. bangladesh journal of bioethics 2012; 3(1):13-18 17 15. williams ed, johnson ja. stem cell research: ethical issues. crs report for congress. congressional research service. 2008. 16. davila jc, cezar gg, thiede m, strom s, miki t, trosko j. use and application of stem cells in toxicology. toxicol sci 2004; 79(2): 214 -23. 17. pellegrini g, luca md, arsenijevic y. towards therapeutic application of ocular stem cells. semin cell dev biol 2007; 18(6): 805-18. 18. wobus am, boheler kr. embryonic stem cells: prospects for developmental biology and cell therapy. phys rev 2005; 85(2): 635–78. 19. dor y, brown j, martinez oi, melton da. adult pancreatic β-cells are formed by self-duplication rather than stem cell differentiation. nature 2004; 429: 41-6. 20. lennard al, jackson gh. stem cell transplantation. bmj 2000; 321: 433-7. 21. brock dw. bioethics: messing with mother nature, review of our posthuman future, by francis fukuyama. american scientist online, september. 2002. available at http://www.americanscientist.org (accessed on january 23, 2012). 22. ivanovic z. hematopoietic stem cells in research and clinical applications: the “cd34 issue”. world j stem cells 2010; 2(2): 18-23. 23. farley m. roman catholic views on research involving human embryonic stem cells. [conference abstract]. presented at the 42 nd national bioethics advisory commission meeting. bethesda, md, usa. july, 2000. 24. ramón-cueto a, cordero mi, santos-benito ff, avila j. functional recovery of paraplegic rats and motor axon regeneration in their spinal cords by olfactory ensheathing glia. neuron 2000; 25(2): 425-35. 25. liras a. future research and therapeutic applications of human stem cells: general, regulatory, and bioethical aspects. j transl med 2010; 8(1): 131. 26. national institutes of health. guidelines for research involving human pluripotent stem cells. 2001. available at http://www.hhs.gov/news/press/2001pres/01fsstemcell.html (accessed on january 25, 2012). 27. mimeault m, hauke r, batra sk. stem cells: a revolution in therapeutics recent advances in stem cell biology and their therapeutic applications in regenerative medicine and cancer therapies. clin pharmacol ther 2007; 82(3): 252-64. 28. krause k, schneider c, jaquet k, kuck kh. potential and clinical utility of stem cells in cardiovascular disease. stem cells and cloning: advances and applications 2010; 2010(3): 49–56. 29. bjorklund lm, sánchez-pernaute r, chung s, andersson t, chen iy, mcnaught ks, et al. embryonic stem cells develop into functional dopaminergic neurons after transplantation in a parkinson rat model. proc natl acad sci usa 2002; 99(4): 2344-9. bangladesh journal of bioethics 2012; 3(1):13-18 18 30. zoloth l. stem cell research: a target article collection: part ijordan's banks, a view from the first years of human embryonic stem cell research. am j bioeth 2002; 2(1): 3-11, 30. 31. kimbrel ea, lu sj. potential clinical applications for human pluripotent stem cell-derived blood components. stem cells int 2011; 2011: 273076 32. hughes sm. muscle development: reversal of the differentiated state. curr biol 2001; 11(6): 237-9. 33. tonti ga, mannello f. from bone marrow to therapeutic applications: different behaviour and genetic/epigenetic stability during mesenchymal stem cell expansion in autologous and foetal bovine sera? int j dev biol 2008; 52(8): 1023-32. 34. velasco i, mayani h. stem cells: basic aspects and possible therapeutic applications. in: chimalmonroy j. ed. topics in animal and plant development: from cell differentiation to morphogenesis. kerala: transworld research network; 2011. p.163-80. 35. power c, rasko je. promises and challenges of stem cell research for regenerative medicine. ann intern med 2011; 155(10): 706-13. bangladesh journal of bioethics 2012; 3(1):19-22 19 consequential approach of islamic bioethics arif hossain vice president, bangladesh bioethics society abstract: bioethics is the understanding of right, responsibility, justices and moral interaction in living being. it is the corner stone to guide the society for righteous action. due to the enormous innovation of sciences and technology, wide-ranging ethical issues have been raised in biotechnology, nanotechnology, assisted reproductive technologies (art) and stem cell research. these advancements could lead to irreversible disasters if not limited by ethical principles and similarly society can not gain the benefit from this new technology if not addressed by the philosophical reflection. to date few attempts appear to have been made at a critical interpretation of the philosophical reflection on islamic bioethics. this article shows that the islamic medical ethics is a virtue ethics, deontological ethics (moral duties and obligations) and a consequential approach. it may help the health professionals, educator and the policy maker to get insight the knowledge of new application of art in their practice for the welfare of the society. key words: consequential approach and islamic bioethics historical background of islamic medical ethics: the code of hammurabi in babylonian may the first clearly outlined medical code for the controlled medical malpractice. in 1790 b.c, the most famous mesopotamian law, “codex hammurabi” that attempted to regulate medicine and to protect patient’s rights. the codex hammurabi described “if a surgeon performs a major operation on a nobleman with a bronze lancet and caused the death of this man, they shall cut off his hands” (halwani and takrouri, 2007). the code is engraved on a slate which is kept at the louvre museum in paris. persian history says that the sassanian encyclopaedic (dinkard) and zoroastrian’s holy book (vendidad of the avesta) have mentioned the characteristics of a good physician (zahidi et al 2009). during late 600 ad the qur’an and the traditions of the prophet have laid down detailed and specific ethical guidelines regarding various medical issues. consequently, muslim physicians paid special attention to ethics in their professional practice (daar and khitamy 2001). in 807-861 ad, a number of books related to medical ethics have been written to guild the physician in their practice e.g. spiritual medicine (teb e rohani), ethics of a physician (adab al-tabib), the paradise of wisdom (ferdous al hekmat) and the perfect art of medicine (kamel al-sanaatal-tibbia). in 931 a.d. the caliph al-mugtadir from the abbasid dynasty, ordered the chief court-physician sinan ibn-thabit to screen the 860 physicians of baghdad and only those qualified were granted license to practice (al-ghazal, 2004 cited in waber 2010). isalmic bioethics: islamic jurists pronounce opinions align to biomedical innovations based on shari’ah(quran, hadit, ijma and qiyas). islam put a great emphasis on moral virtues, and the completion and perfection of moral ethics. the widely applied principle of shari’ah law la darar wa la dirar (there shall be no harm inflicted or reciprocated) which similarity in basic principles can be seen in hippocrates’ dictum primum non nocere (first do no harm). finally if these four sources do not answer the question, it invokes the principle of maslaha (public benefit) by ijtehad (fadle 2002). islamic bioethics is based on duties and obligations (e.g. to preserve life, seek treatment, rights of community and the individual) do feature in bioethics, as does a call to virtue (ihsan) (daar and khitamy 2001). ali bin sahl rabban at-tabari (died 855) wrote in his “the paradise of wisdom in medicine”, the five qualities of medical ethics, e.g. first continuous care, second battle with illness, bangladesh journal of bioethics 2012; 3(1):19-22 20 third respect for kings and the common people agreement and respect to their skill, fifth name of god (waber 2012). similarly, al-ruhawi in his “ethics of a physician” stated “train by employing good morals and actions with sympathy, mercy, gentleness, chastity, courage, generosity, justice. do not aim for an excess of worldly riches (waber 2010). aristotle is concerned with social relations and his ethical approach is characterized as a virtue ethics e.g. how do goods such as friendship, pleasure, honor and wealth contribute to a good or virtuous life (waber 2010). islam has a tradition of professional medical ethics adab (etique) or akhlaq (ethics) which is both analogous and historically related to aristotelian virtue ethics (waber 2010). thus, many moral dilemmas or moral problems in medical praxis can be solved, or will never arise, simply by visiting a virtuous physician as outlined in the islamic virtue ethics tradition. in islam, rights are coupled with responsibilities and the collective rights of the society (maslahah alummah). communitarian right must always be given priority over individual rights (zawawi 2012). therefore, in the muslim context, the primacy appears reserved for the principle of public benefit (maslaha) and the principle of justice as the collective interest takes precedence over that of the individual autonomy (daar and khitamy 2001). furthermore, the family often remains the important subject for the patient’s decisions in relations with the doctor. families and the male guardians expect to be part of the medical decision making process. therefore, family concerns can take precedence over autonomy of patient to medical decision-making about their own bodies. this can be a limit to the patient’s autonomy (atighetchi 2007). another important principles of islamic bioethics are necessity (darura), public benefit (maslaha), local custom (urf) and justice (atighechti 2007, daar and khitamy 2001). principle of maslaha (public benefit) is consequentialist ethics. abdulaziz sachedina provides the following case illustrating the use of consequentialist ethical reasoning in islam: a muslim before dying has swallowed a valuable object belonging to a muslim orphan. is it permissible to dissect the cadaver to retrieve the object? many jurists have said ‘yes’ because of the consequences. the swallowed object may form part of the orphan’s inheritance. the consequences to the orphan, the loss of his right to his inheritance, outweigh the foundational islamic moral principle of not violating the dignity of the dead the rights of orphans, the subject of several passages in the qur’an, form a strong concern in islam, undoubtedly because prophet muhammed himself was an orphan and knew that they needed special protections (sachedina, 2009). in islam new medical technologies, such as art is employed by consequential arguments with weighing the public benefit by necessity. infertility is believed as a disease and desire for a cure in principle by means of art due to the importance of family. a basic tenet of islam is that prohibited actions, if performed out of necessity, become permissible even it violet the primary source. as for example, the majority of scholars declared collection of sperm for artificial insemination is through masturbation is prohibited as qur'an mentions [the successful believers] who abstain from sex, except with those joined to them in the marriage bond, or (the captives) whom their right hands possess, for (in their case) they are free from blame, but those whose desires exceed those limits are transgressors … (qur'an, sura almuminul 23: 5-7). however, masturbation is permitted by public interest with condition that it can be done in order to collect sperm for artificial insemination of husband (alh) within the marriage bond and in disease condition. aih does not create any ethical problem vis a vis islamic guidelines (sharmin 2007). in the case of absolute necessity, where religiously lawful alternatives do not exist, islamic teaching allows for sacred law to be suspended, temporarily if possible. the use of pork insulin and heart bangladesh journal of bioethics 2012; 3(1):19-22 21 valves from pigs has been ruled on the basis of this principle of necessity, when consumption of pork is forbidden by qur’an (gatrad and sheikh 2001). maslaha appears to have points in common with bentham’s principle of utility or aggregate good. bentham’s (1748–1832) philosophy of utilitarianism forms the basis of health care economics (costbenefit, cost effectiveness analyses). a utilitarian action is good to the extent that it maximizes aggregate utility (benefits) to the community. on an individual level, utility can be measured by feelings of pleasure and pain. a good act is one that maximizes pleasure, and minimizes pain. but in islamic medical ethics a pragmatic (utilitarian) argument will never take precedence over a clearly articulated principle originating in the qur’an. new medical technologies, such as art is employed by consequential arguments with weighing the benefits to society by necessity in islam. in instance, infertility is believed as a disease and desire for a cure in principle supportive of art due to the importance of family. but has forbidden certain art such as surrogate motherhood as well as sperm and ova donations between non-related donors because this violates the injunction of mixing lineages (nasab) and therefore would technically result in adultery or fornication (zina) (islamic medical association of north america, 2005). conclusion: therefore, islamic medical ethics is a virtue ethics, deontological ethics established on foundational moral duties and obligations and a consequential approach. to date few attempts appear to have been made at a critical interpretation of the philosophical reflection on islamic bioethics. due to the rapid advancement of science and technology society can gain the benefit from this new technology if the ethical principles are correctly addressed. references: 1. al quran sura al mu’minun 23, v. 5, 6, 7. 2. atighetchi d. problems of islamic bioethics and biolaw. derecho y religion 2007; 2:221-229. 3. daar sa and khitamy aba. bioethics for clinicians: 21. islamic bioethics. cmaj 2001;164(1):60-63. 4. fadel he. the islamic viewpoint on new assisted reproductive technologies. fordham urban law j 2002; 30(1):147-157. 5. gatrad ar and sheikh a.medical ethics and islam: principles and practice. arch dis child 2001; 84:72–75. 6. islamic medical association of north america (imana). islamic medical ethics: the imana perspective 2005. http://www.imana.org/ethics.html. (accessed on april 2012). 7. halwani, t., m. takrouri.. medical laws and ethics of babylon as read in hammurabi's code (history). the internet journal of law, healthcare and ethics 2007; 2:4. 8. sharmin i, rusli bn, rani a and hanapi bmn. ethics of artificial insemination: an islamic prospect. jima 2007; 39: 29-32. 9. sachedina aa. islamic biomedical ethics: principles and applications. oxford: oxford up. 2009 bangladesh journal of bioethics 2012; 3(1):19-22 22 10. weber as. bioethical reasoning in islam. intern j of arts and science 2010; 3(15): 607-617. 11. zahedi f, razavi she and larijani b. a two-decade review of medical ethics in iran. j publ health 2009; 38 (sup 1):40-46. 12. zawawi m. third party involvement in the reproductive process: comparative aspects of the legal and ethical approaches to surrogacy. eubios ethics institute. http://www.eubios.info/abc4/abc4389.htm (accessed on may 01, 2012). bangladesh journal of bioethics 2010; 1(1):5 however, it’s not only enforcement; there need to be strong collaboration between the officials enforcing legal provisions and the business community as well as other stakeholders who are ever vigilant to see sustainable development. the element of reciprocity and complementarity needs to be in place towards ensuring appropriate environment for sustainable development. above all, it’s the leadership of the officials who make the difference in the enforcement of environmental law in the country by sheer courage and steadfastness in decision-making and implementation. ethics of energy technologies prof. darryl macer, ph.d., regional adviser for social and human sciences in asia and pacific, rushsap, unesco bangkok email: d.macer@unesco.org the regional unit in social and human sciences in asia and the pacific (rushsap) at unesco bangkok launched the ethics of energy technologies in asia and the pacific project in september 2007. the launch conference was held also with the cooperation of the ministry of energy and ministry of science and technology of thailand. a full report of that conference is available on the web, as well as the abstracts of the three day meeting, attended by a hundred people from about 20 countries from many sectors and backgrounds. since then there have been a number of subsequent conferences and working group sessions organized in different countries, and a summary of these will be presented. following on from that conference fourteen working groups have been formed on the following topics (more details appear in the project introduction document) [http://www.unescobkk.org/index.php?id=energyethics]: • universalism and environmental values • ethical worldviews of nature • visions and hopes of the future • representation and who decides • community engagement • stakeholder responsibilities • energy equity and human security • cost-benefit analysis and economic constructions • adoption & development of energy technologies (state of the art review) • ethical frameworks for research agendas and policy • educational frameworks for environmental ethics • nuclear dialogues • energy flow, environment, and ethical implications of meat production • water ethics and water resource management the aim of the working groups is to develop dialogue around these particular issues with a focus on environmental ethics and human security. each group will produce a report with policy options that can be used by policy makers, philosophers, scientists and researchers to consider the ethical dimensions of energy policy. all can follow the report development through the individual websites. the reports will also feed into the comest considerations on the ethics of climate change. there are approximately 200 persons who are currently members of the working groups, from young and old, many disciplines, professions and country. this overview will introduce some of the working group results, and progress. more members are invited to join. 5 http://www.unescobkk.org/index.php?id=energyethics bangladesh journal of bioethics 2010; 1(1):2 introduction of bioethics and its necessity in bangladesh arif hossain, phd fellow, international studies and diplomacy, washington university, usa. shamima parvin lasker, professor of anatomy, city dental college, dhaka, bangladesh email: ykhsmh@yahoo.com bioethics is the understanding of rights, responsibilities, justices and moral interaction in living beings. it includes medical ethics, environmental ethics, legal ethics, business ethics and ethics in human rights & politics. legal ethics, business ethics and ethics in human rights & politics. since its inception in 1970, the field has grown exponentially in its scope and importance. many hospitals now employing bioethics experts to guide on such issues as allocation of scarce resources, how to care for terminally ill patients and dilemmas of doctors facing everyday for advancement of new technology. there are at over 95% of u.s. hospitals has ethics committees for helping physicians, nurses and families on bioethical issues on a case-by-case basis at present. thus today bioethics is not only a reasoned discourse but a matter of crisis management. bangladesh is a pluralistic society with a wonderful diversity of values and ethical ideals. but poverty, natural calamities, lack of proper and substantial education and rapidly advancing technology people are forced to deal with one crisis after another. in a result bio-ethical decision, sanctity of life is deemed to be less important than the quality of life. corruption, nepotism, selfishness, misconduct and malpractice are becoming the common phenomena in bangladesh. it gives the impression that we don't able to tell which values need to be employed when and which ethical dilemmas need our most immediate attention in our society. thus implementation of bioethics is needed urgently in bangladesh to make the country peace and prosperity. bioethics in bangladesh prof hasna begum, honorary professor, department of philosophy, dhaka university. email: lala_rukh_selim@yahoo.com this presentation aims at showing i) poverty level, ii) environmental pollution level, iii) outdated education system, and iv) inadequate health services for over (estimated) 14 crore people in bangladesh, in order to evaluate the possibility of bioethics practice and research within the country, and also to find the reasons why bioethics activities have not yet found ground here by. bioethics is a multidisciplinary approach to evaluating bioethical issues. thus, the main reason for a meager presence of bioethics activities in this country is the education system, which is not multidisciplinary enough to encourage bioethics activities. apathy among the academicians and professionals in the absence of a national education policy is causing full implementation of a multidisciplinary system impossible. consequently, students and professionals educated in the present system are generally disinterested in other disciplines. there are bioethical issues present in bangladesh , e.g., indirect coercion and absence of informed consent in the field of population control, exploitation of people in the name of treatment of infertility, environmental pollution in the absence of law enforcement, exploitation of people by health insurance companies, unethical practices by care-givers in the health sector, etc. in conclusion it is stated that bangladesh is an untrodden and rich ground for a bioethicist to do research on many relevant issues present in the country. the need for a national bioethics association to be formed by academicians and professionals, and a national bioethics commission to be formed by the government of bangladesh has also been emphasized. 2 mailto:lala_rukh_selim@yahoo.com mailto:ykhsmh@yahoo.com bangladesh journal of bioethics 2010; 1(2):31-33 education & practice of bioethics: an initiative to build a just, sustainable & healthful society dr. md. ashraf ali associate professor of family medicine, bangladesh college of general practitioners & president, taposhi bangla, community health care & social work organization. introduction: morality is a unique feature enabling human life to differentiate right-wrong, good-bad and just-unjust. ethics is the science of morality. bioethics is the study of moral principles governing behavior, action and choice of individuals, institutions and societies and influencing everyday decision and policy making in personal and social life. in practice bioethics is the art of logical application of acquired knowledge-skill and science-technology of a society for greater good of humankind. bioethics conducts research on issues arising from application of knowledge-skill and science-technology in the society and intends to resolve those issues to make the world a better place to live in. the aim of bioethics is highest attainable wellbeing but not at the expense of environment and other forms of life. the objective of bioethics is to build a socio-economically productive and ecologically sustainable community that strives for ethical-cultural-political efficiency. the goal of the discipline is production of rational individual and promotion of bioethical maturity of society. the philosophy of bioethics is that the medical profession has scope of greater contribution to social progress by innovative service-mix which builds capacity of human life to cope with environment and maintain a state of equilibrium on which health/wellbeing depends. aim: the faculty of bioethics may be developed in a community through education, practice and research. it is essential to maintain unity of education-practice-research for logical development of the faculty. it is also necessary to achieve a consensus on definition as well as educational materials of bioethics so that practice of the discipline can address bioethical issues of both personal and social life. newly developing faculty of bioethics has the scope of (i) understanding human life and knowing its relationship with environment and (ii) finding out root causes of loss of health/wellbeing and making plan for combating those causes. method: the discipline of bioethics in collaboration with un-fragmented medical science, environmental health science, behavioral sciences, biomedical science and other health related sciences intends to organize biomedical-social action in a community to ensure greater good of the society. bangladesh journal of bioethics 2010; 1(2):31-33 discussion: scientific study reveals that human life is a product of gene and environment. interaction of gene with environmental components gives rise to bio-molecule, cell, tissue, organ and body which are biological existence of human life. human body with integration of mind develops into an individual who behaves as a member of family, local-national-global community, society and the world order constituting psycho-social existence of human life. the biological and psycho-social existence of human life together constitutes human system. health/wellbeing depends on capacity of different components of human system to cope with environment and attain a state of equilibrium. loss of health/wellbeing means loss of the state of equilibrium. the principal causes of loss of health/wellbeing are disease, environmental crises and psycho-social problems. the later two environmental crises and psycho-social problems arise from irrational human behavior. therefore it is obvious that disease and irrational human behavior are root causes of loss of wellbeing. practice of bioethics intends to maintain the state of equilibrium between human life and environment by organizing biological, medical and social action which together could be called bio-medical-social action. biological action influences the control mechanism of different components of biological existence of human system. we should think about biological action seriously but proceed cautiously by analyzing the risks and benefits of the action critically. medical action has to reduce burden of disease through (i) hospital based personal health service approach ensuring highest good of the diseased individual (ii) public health institution based impersonal service approach ensuring maximum benefit of the greatest number and (iii) community based unitary family health service approach ensuring ethical provision of health care and medical social work for a defined community. social action has to address (i) environmental crises e.g. pollution, loss of biodiversity, global worming and climate change and (ii) psycho-social problems e.g. poverty, illiteracy, corruption, crime, terrorism, injustice, inequality, child abuse, gender discrimination, political instability, conflict, violence, misuse of knowledge-skill and science-technology. well-developed faculty of bioethics in a society has the ability to reduce burden of disease as well as irrational human behavior that causes environmental crises and psycho-social problems. conclusion: the faculty of bioethics is supposed to facilitate education, promote practice and conduct research in a planned way to bring a change in the state of health/wellbeing of the people living in the community. in doing so bioethics faculty has to form bioethics associations and committees at different level of the society to protect human research participants, to improve patient-centered care, to establish sound professional practices and to establish sound science and health policies for citizens. therefore it may be said that education and practice of bioethics in a community is an initiative to build a just, sustainable and healthful society where people have opportunity for enjoying the highest attainable physical-mental-social wellbeing. bangladesh journal of bioethics 2010; 1(2):31-33 references: 1. darryl r.j. macer. moral games for teaching bioethics. bangkok. regional unit for social and human sciences in asia and pacific (rushsap), unesco; 2008. 2. julia cheftel. bioethics core curriculum section 1: syllabus ethics education programme. paris. unesco; 2008. 3. darryl r.j. macer, ph. d. a cross-cultural introduction to bioethics. bangkok. eubios ethics institute; 2006. 4. jerome lo monaco. establishing bioethics committees. paris. unesco; 2005 5. leonardo d. de castro, peter a. sy, allen andrew a. alvarez, regina v. mendez and james kevin rasco. bioethics in the asia-pacific region: issues and concerns. bangkok. unesco asia and pacific regional bureau for education. 2004. pp.1-90 bbs news: bangladesh journal of bioethics 2012; 3(3):27 bbs news: two members of bbs awarded erasmus mundus master of bioethics shamima parvin lasker, professor and head, department of anatomy, city dental college, dhaka & general secretary of bbs and dr abu sadat mohammad nurunnabi, lecturer of anatomy, dhaka medical college, dhaka & life member of bbs awarded master of bioethics in 2012. both they are the scholars of erasmus mundus master of bioethics. degree was awarded by k.u.leuven, belgium, radboud universiteit nijmegen, netherlands and università degli studi di padova, italy. prof shamima’s research was on “attitudes toward surrogacy around muslim world” under supervision of dr marcello ghilardi, university of padova , italy whereas dr nurunnabi worked on prospects and problems of stem cell research in bangladesh: can equity and justice be maintained in context of public health demand? under supervision of professor evert van leeuwen, chair of the section ethics, iq healthcare, philosophy and history of medicine, radboud university, nijmegen medical centre, netherlands. thanks and congratulations for them and for their outstanding achievements on behalf of all the members of the bangladesh bioethics society. bangladesh journal of bioethics 2011; 2(3):3-9 3 nurses lived experiences of conscience reaction: a qualitative phenomenological study parkhideh hasani 1 rostam jalali 2 zhila abedsaeedi 3 1. assistant professor, phd of nursing, shahid beheshti university of medical sciences. 2. msn, phd student of nursing. shahid beheshti university of medical sciences. nursing department, shahid beheshti's faculty of nursing and midwifery, taqatoae niayesh-vali asr, tehran-iran. ks_jalali@yahoo.com cell phone +989181324821 (corresponding author) 3. assistant professor, phd of management in health services, shahid beheshti university of medical sciences. abstract: background and objectives: conscience is a cornerstone of ethics, affecting both our private and professional lives. everyday health care practice raises questions about conscience and how to understand its role. conscience has also been described as inducing self-growth and protecting personal integrity. nurses views on their reactions to behaviors consistent or contrary to conscience could therefore help us to understand the meaning of the reactions of conscience. this study aimed to illuminate meanings of nurses lived experience of conscience reaction in their daily practices. material and methods: interviews with nine nurses were interpreted using a phenomenological hermeneutic (colaizzi, 1978) method. data was collected in 2010 among nurses working in various hospitals in kermanshah. the nurses were selected for participation purposively. results: the nurses lived experience of conscience reaction was formulated in three themes and ten sub-themes. the first theme is ‘being peace, which includes three sub-themes: being calm, being pleased, and being satisfying. the second theme is ‘trouble conscience’ which includes four subthemes: guilt, thinking engagement, discomfort, and fretfulness. the third theme is responding which includes three sub-themes: expressing, compensation, and lack of repeat. conclusions: the nurses lived experience of conscience reaction showed that nurses considered conscience reaction to be an important factor in the exercise of their profession, as revealed by the descriptive categories: being peace when they act consistent with conscience; trouble conscience when they act contrary on conscience; and responding after doing an anti conscience practice. they perceived that conscience played a role in nursing actions involving patients and next of kin, and guided them in their efforts to provide high quality care. keywords: phenomenology, conscience reaction, nurses, lived experience. introduction and statement of the problem: nurses are considered as the conscience of health care systems. thus, they not only have positive effect on public health, but also play a key role in improvement of health care systems. they are responsible for fulfillment of the methods that enhance access to safe, high quality, and competent heath care (sincox, 2005). moreover, they are in charge of providing nursing care to all patients without any prejudice and judgment, in a direct and timely manner with high quality. respecting people’s rights and treating people with regard to their dignity is an inseparable part of heath care systems (jansen and lidell, 2009). in nursing, moral topics point to the values that govern the relationship of nurses and patients (fawcett, 2005). to direct the relationship and moral acts, a sensitive conscience is needed; thus it is an important item for health care providers, and violating it without bringing about major adverse effects on moral integrity is not possible (dahlqvist et al. 2009). conscience is the foundation of morality and influences private and professional life (dahlqvist et al. 2007). when nurses are taking care of critically ill patients, they remember the patients they did not sufficiently take care of. sorlie quoting from ricoure discusses bangladesh journal of bioethics 2011; 2(3):3-9 4 morality memory. according to him, people never want or never can, and in fact should not, forget good or bad events in their life. thus, nurses do not forget the patients whom they did not sufficiently look after (sorlie et al. 2003). conscience originates from the living experience and is a part of our daily and professional life and we cannot get rid of or escape from it (kulka, 2002). when a nurse stands contrary to his/her interest, there are conflicts of value, that mean; the nurses prohibited to delivery care appropriately, or when they haven't choices and must participate in caring that is contrary to human dignity, and also may emerge when the nurses can't defend for his/her ideals (post, 1998). conscience conflict can lose the individual integrity. nurses coercion to engaging in activities that is inconsistent with conscience, cause to desertion nursing profession. although protecting of nursing conscience must be guarantee against professional coercion (curtin, 1993). otherwise cause troubled conscience and shame and guilt for not following conscience (post, 1998). if we do not follow conscience, blaming and expostulation phenomenon seen clearly. clearance and consistency of this phenomenon is more than other conscience phenomena. absolutely blaming is the aspect of conscience that protects our ideal personality, and promotes it more ever is an antecedent for psychological development. this phenomenon is the greatest humanistic condition that human being has a clear conscience. these people benefits of all conscience activities (jafari, 2009). guiltiness and conscience permit us to promote our actions; now, past and in the next. in continuum we decide, which of the actions must be accepted or rejected. inability in balancing can cause guilty in persons that they are susceptible to guiltiness. if we have guiltiness and blaming, then we left animal hostility and entering to humanity domain (gaylin, 1994). in contrast, when a nurse practice accordance with his/her conscience, he/she hasn't anxiety, and with resolve the cause of anxiety and comprehension, the conscience become calm and find normal condition (jafari, 2009). the morally sensitive and susceptible individuals have grief when they act against their conscience, but the others hadn't (may, 2001). having conflict before or after doing an action and nurse's reaction to consistency with conscience practice must be investigated precisely. nurse's experiences from their reactions to consistent and inconsistent behaviors can help us to understand meaning of conscience reaction. in his working experience, the author has observed how nurses encounter conscionable issues during care providing, and due to different reasons they cannot act in accordance with their conscience. thus, the current study was carried out with a qualitative approach, which is suitable for evaluation of individuals’ experience, beliefs, and priorities. by understanding the experience of nurses, the study would be helpful to elucidate the nature of conscience's reaction in nursing. methodology: the current study was carried out to perceive the nurses’ living experience of conscience with a phenomenological method. it is a study with a qualitative approach. phenomenological research is a type of qualitative research with philosophical roots focused on the experience of man’s life (polit et al., 2005). phenomenology is in fact an attempt to describe living experience without previous theories about their objective reality (strubert and carpenter, 2007). in phenomenology, the context of the event and the occurrence of the phenomenon are the interpretational factors in understanding the world of participants or the events and phenomena under evaluation. with the language of participants, the qualitative researcher associates the practical items and the living experience of the individual by rational involvement and entering the unique world of the participant of the study (benner, 1994). the participants were chosen purposively and their number was determined by data saturation criterion, and the task was consequently repeated until the data saturated and the themes repeated (strubert and carpenter, 2007). characteristics of data gathering tools and method of data gathering: the main tool for data gathering was extensive, in-depth, unstructured, and interactive (face-to-face) interview. the interviews were recorded, transcribed at the earliest possible time, and then immediately encoded and analyzed. moreover, the goal-oriented observation of phenomenon under study (observation of verbal and non-verbal behaviors) in the natural context and in appropriate time by the observer as a participant were performed, recorded, encoded, and then analyzed. inclusion criteria: the participants were selected from among the individuals who have direct experience of nursing conscience (the background of working as a nurse) and were willing to attend the study. the lowest educational level was b.sc. of nursing. the participants did not have speaking or hearing problems. furthermore, they were willing to narrate their perceptions (experience). the participants were informed and attended the program voluntarily. bangladesh journal of bioethics 2011; 2(3):3-9 5 sampling method: the participants were asked to attend the study by an invitation letter. after returning the invitation letter and accepting to participate the study, the time of interview was set by telephone or in person. following the signing of an informed written consent, according to the schedule, the participants attended an unstructured interview at their working place or whenever they preferred. face-to-face interview provides first hand information by discovering the real experience and brining the researcher to the context of the topic. moreover, during the interview, the participant is given feedback, and thus verifying and additional data can be obtained. the interviews were recorded and then transcribed. combination of in-depth interview and observation increase the validity of data and weakness of a data gathering method is covered by another method. each interview took 20 to 60 minutes. if needed, the interview with a single participant carried out in several sessions. after performing each interview, the recorded interview was carefully listened several times. then, word for word, the interviews transcribed with microsoft word software and then printed. the procedure performed for all interviews. after transcription, the researcher reviewed the texts when listening the recorded interviews. this was carried out to enhance the preciseness of transcribed data and to increase the researcher’s comprehension of the data. after carrying out these steps, the transcribed data was considered as the raw data to be analyzed. general steps of data analysis: the data were analyzed according to the steps of colaizzi’s data analysis (1978). the method includes nine steps as follows: 1describing the interested phenomenon, 2gathering the participants’ description of the phenomenon, 3reading all the participants’ description of the phenomenon, 4return the original transcripts and extract significant statements, 5trying to spell out the meaning of each significant statements, 6organizing the aggregate formalized meaning into clusters of themes, 7write an exhaustive description, 8return to the participants for validation the description, and 9if new data are revealed during the validation, incorporate them into an exhaustive description (colaizzi, 1978). in the current study, we followed the stages of data analysis step by step. moreover, for recording behaviors, non-verbal communications, appearance, facial expression, and eye contact of participants, we used observation and note taking during the unstructured interview with the unstructured observation method. to do so, the observations were recorded if possible during the interview, or immediately after that. the data was used in transcription of interview data and its analysis. trustworthiness of research data: common methods of qualitative studies were used to verify the trustworthiness of the data. in the current study, the method suggested by guba and lincoln (1994) was used. to verify the creditability of the data, we used a combination of data collection method (unstructured interview, field note taking, and memoing), revision by participants, and revision of codes and categories by professionals. to verify the reliability and dependability of the data, we used detailed description of the study. thus, it can be evaluated by external observers. to justify the confirmability of the research, all steps of the study, including data collection and analysis and extraction of codes and categories were described such that other people could judge them by reading the descriptions. to check the transferability, the results were given to three nurses who did not attend the study and their experience was compared with the results of the current study. ethical considerations: after receiving the approval of observation of ethical issues from the ethics committee of research department of shahid beheshti medical university, all participants signed an informed written consent and then we came to an agreement with the participant on the time and place of the interview. after describing the objectives of the study and the voluntary involvement in the study, the permission to record the interviews was taken. findings: in general, nine participants from among the nurses working in educational hospitals of kermanshah attended in-depth interviews (table 1). if there were any ambiguity in content analysis of the interview, we removed the ambiguity by re-visiting the participant or calling him/her. the interviews were carried out by the researcher (the first author). encoding and extraction of main items was also done by the researcher and the main coworkers, and then the results were revised and modified by external observers and the participants. with continuous analysis of the data and analysis of the interview notes on the experience and beliefs of nurses about the reaction of conscience was bangladesh journal of bioethics 2011; 2(3):3-9 6 formulated in three themes and ten sub-themes. the first theme is ‘being peace, which includes three sub-themes: being calm, being pleased, and being satisfying. the second theme is ‘trouble conscience’ which includes four sub-themes: guilt, thinking engagement, discomfort, and fretfulness. the third theme is reaction which includes three sub-themes: expressing, compensation, and lack of repeat (table 2). table 1: characteristics of the participants educational level bs 8 nurse, ms 1 nurse sex female 6, male 3 age mean 32.5 range 26-45 yrs nursing experience mean 9.5 range 2-22 yrs interview duration 20´ to 60 ´; mean =35´ nursing role head nurse 1, supervisor 1, clinical nurse 7 being peace: one of the major concepts extracted from the data was the peace of conscience, which includes three sub-themes: being calm, being pleased, and being satisfying. most participants talked about being peace of conscience. however, they mentioned that being peace is as being calm, being pleased and being satisfying. in this regard, the nurses mentioned: "often occurred these things, i have a sense of calming, often occurred that i say, i do widget; i have calming sense, i sense today is a day that go on to my willingness…" "… if i do some things accordance to my conscience; i'll very glad …" "in the time of acting accordance with conscience; i sense satisfying, that mean; i do correct action …" trouble of conscience: a pivotal concept extracted from the data and on the basis of experience of the participants was trouble of conscience. this concept consist four sub-themes: guilt, thinking engagement, discomfort, and fretfulness. regarding this fact, nurses mentioned that: "if i do some things against my conscience … i think; i am not appropriate for this job and i have an internal sense of discomfort …" "… but i have a challenge with myself; i am engaging in my inward; there is more conscience engagement …" "if i do some things against my conscience; i am discomfort; because it is different from happiness. it cause more discomfort for me" "if i do some things against my conscience; the first thing for me is a blaming condition and internal discomfort …" reaction of conscience: of the main concepts extracted by the data analysis were reaction of conscience, which included three sub-themes; expressing, compensation, and lack of repeat. in this regard, the nurses considered that: bangladesh journal of bioethics 2011; 2(3):3-9 7 "… because i do a positive action; and … i have a good sleep after it, fortunately or regret; i express always and very soon in my home; i say: i do a good action today …" "if i being the cause of this encounter; i try to compensate anyways; to convince them… but anyway i do to compensate it…" "if i do some things against my conscience; i try to don't repeat in the next time… but i don't repeat this wrong action never … i try to don't repeat in the next time forever". table 2: major and minor categories of reaction of conscience theme sub-theme codes being peace being calm "… i have a sense of calming, … i have calming sense, …" being pleased if i do some things accordance to my conscience; i'll very glad being satisfying i have a complete satisfying with acting accordance to conscience; i sense that lost my exhaustion. trouble of conscience guilt, thinking reaction to work against conscience! sense of guiltiness… engagement i have a challenge with myself; i am engaging in my inward discomfort if i do some things against my conscience; it cause more discomfort for me fretfulness the first thing is blaming; you ashamed yourself anyway reaction of conscience expressing i express always and very soon; i say: i do a good action today compensation i compensate it as soon as possible lack of repeat i try to don't repeat in the next time discussion : the findings showed that reaction of conscience in nurses’ experiments include three pivotal concept; the being peace, trouble conscience, and reaction of conscience. one of the findings was the being peace. participants expressed their experience on acting accordance with conscience as calming, pleased and having satisfied. in this regard, jafari wrote; the human conscience has capacity to accepting authenticity, and good practices followed by conscience satisfaction. really, the conscience has a sense of satisfaction on justice and fairness. he says; our relative knowledge doesn't give us the peace that we expect it, but, only conscience can create the calming (jafari, 2009). on the basis of the dictate of conscience, a person can perform an action that will provide the basis for the development of the relevant virtues (stanford university, 2011). the calm conscience presents us certainty and calming. one of the amazing phenomenon in our inside is that, this certainty from the view of exploration is marked, but, when created by conscience; is the same as seeing it and still, higher than seeing, can sensed as the component of the our body(jafari, 2009). participant in this study, paid attention to calming, satisfying and pleased after following their conscience. another theme that emerged from analysis of data was trouble of conscience; because of threatening of moral integrity. nurses have reported feeling of trouble conscience in situation in which they felt unable to provide the quality of care they believed their duty required for them. nurses feel guilty and inadequate when they fall short of perceived performance standards (sorlie et al., 2003). troubled conscience has been described as a positive force that develops our moral values; it makes us aware of our values, even though its negative consequences are more frequently described. for nurses, an inability to act according to their conscience is associated with several phenomena: decreased wellbeing in nurses and patients, high turnover rates and shortage of nurses, burnout, and distancing from patients (glasberg et al., 2006). troubled conscience, such as feelings of guilt, is experienced by care providers, for instance, when not fulfilling their perceived obligations to patients. these obligations can be dictated either by oneself or by others, such as patients, management or the organization (juthberg et al., 2007). circumstances and demands may conflict with the care providers’ moral values. conscience can be understood as a person’s integrated moral values and discrepancies between circumstances, demands and the care providers’ moral values may trouble the care providers’ conscience (juthberg & sundin., 2010). conscience relates to moral responsibility. failing one’s moral responsibility, whether related to personal failures or to situational constraints may bangladesh journal of bioethics 2011; 2(3):3-9 8 lead to moral distress and stress of conscience (stress related to troubled conscience) which are both related to burnout. stress of conscience is found to be associated with factors such as not being able to follow one’s conscience and of being morally burdened (glasberg et al., 2008). the nurses try to resolve these stress and burden simultaneously with having discomfort, guiltiness and blaming; by performing several actions such as compensating, don't repeating and expressing under the name of reaction of conscience theme. consciences call the people to left wrongness and attend to rightness and establish a level of selfish and authenticity (lederman, 2003). conscience acts as; internal restrain and individual moral authority (johnston, 2006). conscience has also been described as inducing self-growth and protecting personal integrity. it can be consulted in care situations with the intention of protecting the integrity and dignity of all individuals involved (dahlqvist et al., 2007). guilt helps to shape the morality or character of a person, and anticipation of guilt prevents wrongdoing. ricoeur points to the warning function of conscience and underlines its significance for being and acting ethically. in the dialectics between attestation and suspicion, coming from questioning what is good, we develop as moral beings (glasberg et al., 2008). in health care, conscience perceived as a warning against doing wrong helps to protect the fundamental integrity, wholeness and harmony of persons involved in care. nurses refer to their previous experiences of troubled conscience to help them make decisions in future situations and to teach them to use their conscience to make controversial decisions (post, 1998). conclusion: the lived experience of nurse on reaction of conscience was specified in three categories; being peace, trouble of conscience, and reaction of conscience. though the nurses in this study showed troubled conscience; when acting against their conscience and being peace; when acting consistent with conscience, but, they told; troubled conscience is a developing factor for conscience. although the results were consistence with those of other studies, the emphasis of participants on different aspects of conscience was different from the findings of other studies; such that the item of the highest importance in another study did not have the same level of importance in the current study. furthermore, the participants were nurses of different wards, while it seems that the nurses’ perception of conscience in various wards or different hospitals can be different. thus, besides providing some mechanisms to reinforce nursing conscience or removing the factors that impair the nursing conscience, it is suggested to carry out some more specific studies in specialized wards or hospitals. references: benner p, (1994). interpretive phenomenology: embodiment, caring, and ethics in health and illness. thousand oaks, ca: sage publication; new york. colaizzi pe (1978). psychological research as the phenomenologist views it. existential phenomenological alternative for psychology. new york: oxford university press. curtin l.(1993). conscience and clinical care. nursing management,; 24(8): 26-9. dahlqvist v, eriksson s, glasberg an, lindahl e, lutzen k, strandberg g, soderberg a, sorlie v, norberg a (2007).development of the perceptions of conscience questionnaire. nursing ethics; 14(2)181-193. dahlqvist v, soderberg a, norberg a, (2009).facing inadequacy and being good enough: psychiatric care providers’ narratives about experiencing and coping with troubled conscience. journal of psychiatric and mental health nursing; 16, 242–24. fawcett j( 2005 )analysis and evaluation of contemporary nursing knowledge :nursing models and theories .canada, f.a.davis co. gaylin w. conscience: knowing good and doing good. the hastings center report, 1994; 24(3): 36. glasberg an, eriksson s, dahlqvist v, lindahl e, strandberg g, soderberg a, sorlie v, norberg a (2006).development and initial validation of the stress of conscience questionnaire. nursing ethics;13(6)633-648. bangladesh journal of bioethics 2011; 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(2008). factors associated with ‘stress of conscience’ in healthcare. scandinavian j of caring sciences; 22; 249–258. guba eg, lincoln ys. (1994). competing paradigms in qualitative research. handbook of qualitativr research. thousand oakes, ca: sage.jafari m.t. (2009). conscience, fourth edition. institute for the publication of allameh jafari’s works, tehran, (persian). jensen a, lidell e (2009).the influence of conscience in nursing. nursing ethics; 16(1)31-42. johnston m-j (2006). bioethics: a nursing perspective. 4 th edition, churchill livingstone, london. juthberg c, eriksson s, norberg a, sundin k (2007).perception of conscience in relation to stress of conscience. nursing ethics; 14(3):329-343. juthberg c, sundin k (2010). registered nurses' and nurse assistants' lived experience of troubled conscience in their work in elderly care-a phenomenological hermeneutic study. international journal of nursing studies; 47:20-29. kukla r. (2002). the ontology and temporality of conscience. continental philosophy review; 35: 1– 34. lederman e. (2003). conscience and bodily awareness: disagreements with merleauponty. journal of the british society for phenomenology; 13(3): 286-295. may t. (2001). rights of conscience in health care. social theory & practice. 27(1): 111-118. polit d.f, beck c.t, hungler b.p (2005) essentials of nursing research :methods, appraisal, and utilization .5 th edition .usa, lippincott co. post, i. (1998). perioperative nurses’ encounter with value conflicts: a descriptive study. scandinavian journal of caring sciences, 12 (2): 81-88. sincox k (2005) the conscience of the health care system. michigan nurse, august: available at: www.minurses.org. -sorlie v, jansson l,norberg a (2003). the meaning of being in ethically difficult care situations in paediatric care as narrated by female registered nurse. scandinavian journal of caring sciences;17:285-292.. -streubert h, carpenter dr (2007). qualitative research in nursing., 4 th edition lippincott william and wilkins, philadelphia. www.plato.stanford.edu/enteries/conscience-medieval/ bangladesh journal of bioethics 2010; 1(1):6 ethical aspects of sharing international river water: the case of teesta river md. fakrul islam, ph.d., professor and chairman, department of social work, university of rajshahi rajshahi, bangladesh wardatul akmam, ph.d., professor, department of sociology, university of rajshahi, bangladesh email: hiraharati@yahoo.com all riparian states have the right to use international river water. this right is equally recognized for all riparian states on the basis of ethical principles and laws on international water sharing. however, sharing of river water has become one of the issues of conflict between neighboring states. various claims and counter claims are heard of and in order to resolve these issues many cooperative bilateral treaties have also been signed. but politically induced treaties that neither include provisions for economic benefits nor follow ethical principles on humanitarian grounds of the riparian states are not likely sustain for long. continuity of such treaties is indispensable for the sustenance and development of the riparian states and ethical principles and humanitarian grounds should be the basis for these treaties. nowadays, it is observed that states situated at the upstream control the water flow of rivers for their own benefits without considering its consequences on the downstream state. as a result inhabitants of the downstream countries suffer untold miseries. nevertheless, there are some good examples of international water sharing. in this paper, i discuss these examples along with the case of sharing of the teesta river water between india and bangladesh. some policy proposals are also made in this regard. the paper emphasizes the necessity of upholding morality and ethical principles in formulating and implementing policies regarding sharing of international river water. riparian states must cooperate and be sympathetic for the cause of one another. ethics and integrity in public service in bangladesh: institutional and comprehensive approach iftekharuzzaman, executive director, transparency international bangladesh email: email: edtib@ti-bangladesh.org this paper is an attempt to examine the challenges to prevent erosion of ethics and integrity in public service in bangladesh. it first presents an overview of corruption as a development and governance challenge. we then identify the entry points of erosion of integrity which account for the depth and breadth of corruption in public service. in the next section the paper goes on to examine the prospect of preventing erosion of integrity and ethics, and propose a few tools and processes. finally the paper proposes an institutional and comprehensive approach without which ethics and integrity in public service will be hard to promote and institutionalize. the main theme of the paper is that corruption exists everywhere in the world; it also involves every sector and level where there is scope of abuse of power. the public sector tends to be exposed to erosion of ethics because of institutional and individual factors. when depth and breadth of corruption are associated by a growing culture of impunity and erosion of values and ethics, corruption threatens to become a way of life. policies, decisions and actions of public interest at national level are taken in private interest, while at the local level citizens' access to basic rights and entitlement become contingent upon the capacity to make unauthorized payments. the issue of ethics and integrity in public service is crucial to addressing corruption. whatever well-meaning may be reforms in other sectors, these cannot bear fruits nor can any of those be sustained without establishing that appointments, promotions, postings and transfers in public service are based on performance and merit and not on 6 mailto:edtib@ti-bangladesh.org mailto:hiraharati@yahoo.com bangladesh journal of bioethics 2010; 1(1):7 political influence, bribery and other means of subjective influence. so long as discretion is wide and the scope remains for abuse of power with impunity, and as long as effective legal and ethical standards are not in place with enforcement mechanisms for zero tolerance to corruption, no true results can be expected or sustained in enhancing ethical and moral standards. no less important is the issue of salaries and benefits, which must be viewed as investments for future. much would definitely depend on the extent to which anti-corruption values and ethics can be mainstreamed in the public service. a key role would be played by preventive measures against erosion of public service integrity and honesty by enforcing public service code of ethics including positive and negative incentives. ethics and integrity in public service are more than a project of value or moral education, however well-designed it may be. it cannot be viewed in isolation from systemic challenges, and must be part of a holistic institutional structure and process that would promote and sustain integrity in the public service as well as other aspects of life in a holistic infrastructure of integrity. a comprehensive and institutional approach strongly backed by highest level political commitment is indispensable. ethical dilemma and research methodology of social sciences prof. ahmad a.n. neaz, dssc., american international university-bangladesh , email: aneaz@aiub.edu today, when the galaxy of knowledge, be it social, political, economic or scientific is expanding at an unprecedented pace, new questions and new interests require us to enter into a new search for a new answer. for many millennia knowledge was exclusively confined under the grip of subjectivity and pre-conceived ideas. although, greek scholars started to think objectively the newtonian paradigm came as a major breakthrough in this regard. the ultimate outcome turned out to be the development of a ‘positivistic methodology’, solely relying on empirical evidence. social scientists also pretended to follow scientific method and their search for objectivity was the foundation of research endeavor. they also followed newtonian philosophy by considering a closed autonomous system, ruled by endogenous factors of highly selective nature, self regulating and moving to a determinate predictable point in terms of linear, stable and equilibrium analysis. social science, particularly economics ahead of others, claims itself as a ‘value free science’ in order to follow positivistic methodology, depended solely on empirical evidence. consequently, it discards ethics, values and any subjective involvement as idealistic rather than realistic. for nearly a century, in order to become increasingly scientific, ethics has been abandoned by many disciplines and ultimately, ethics has been tethered around and nurtured by philosophy only. einstein tried to synthesize the positivist accommodating the ‘world of idea’ in the field of research. m.k gandhi was the first person to challenge economists as a ‘value free’ subject. bioethics could be termed as a landmark in order to rehabilitate ethics. it is for sure that within near future ethics will be the guiding philosophy of all the disciplines of knowledge. in order to achieve that, education and research method need to be redesigned to developed epistemology. it is a fallacy of the positivistic methodology that there will be no subjective involvement. in the field of social sciences where events or phenomena have unique particularity and have no scope for repeated experiment, empirical evidence must be supported by rational thinking. otherwise it will lead to empiricism which may not be considered as knowledge even. application of intensive observation, rra, pra and other methods have been supplementing and complementing the limitations of positivistic approach. amartya sen tried to introduce values in economics but in vain. development economics initially considered ‘economic growth’ or gni as the yardstick of development. since mid 1970s it has been shifted to ‘human development’ which has been intensified under millennium development goals. economists yet to conceive ethics as a guiding philosophy which may further shift the discipline from human development to ‘humane development’ emancipating human civilization from the realm of poverty, greed and inhumanity to the arena of welfare, peace and global harmony. 7 title: ethics in clinical research bangladesh journal of bioethics 2012; 3(3):16-20 16 ethics in clinical research md. fakruddin 1 , abhijit chowdhury 1 , md. nur hossain 1 , khanjada shahnewaj bin mannan 2 1 institute of food science and technology (ifst), bangladesh council of scientific and industrial research (bcsir), dhaka, bangladesh 2 center for food & waterborne diseases, icddrb dhaka, bangladesh. email: fakruddinmurad@gmail.com abstract: history of unethical clinical research practice date back to a very long time, though the most remarkable unethical clinical research was those by the nazis during second world war, which eventually shaken the scientific community and gives birth to the first guideline of ethics in clinical research, the nuremberg code. following nuremberg code, a number of ethical guidelines has been formulated most important of which are the declaration of helsinski. to make any research involving human subjects or samples ethically acceptable, a number of key features have to be considered by the scientists. these guidelines are internationally accepted and without following these guidelines, no clinical research is acceptable in the world. though, there are many countries in the world like bangladesh, which don’t have any ethical guidelines of their own and thus scientists in those countries do not adhere the any ethical guideline while conducting their research. each country should have their own ethical guidelines and each clinical research institutes should have own ethical review committee to ensure ethical clinical research. key words: ethics, clinical, human, bangladesh introduction: the ethics of contemporary research practice, especially with respect to the design and conduct of clinical trials, has been subjected to considerable scrutiny in recent years 1 . issues related to informed consent, the use of placebo controls and the tension between the requirement for scientific evidence on the one hand and for patient autonomy on the other have all generated heated debate 2 . in this editorial i review some recent controversies that highlight the fractious nature of the debate and point to the watershed we are approaching in clinical research ethics. although there are no obvious solutions, it is clear that there is a need for increased patient participation in any attempt to achieve consensus on the ethical conduct of medical research 3 . history of unethical clinical research: history of unethical clinical research and trials dates back to ancient times. many of the early advances in medicines have been developed at the expense of many marginal groups such as asylum inmates and prisoners. these test subjects were involved in these clinical trials without being informed or even asked 4 . the most horrifying example of unethical clinical trials and research was that done by the nazi doctors in germany. they conducted clinical research trials with prisoners of concentration camp against their consent and most of the prisoners died due to such trials. not only in germany, has unethical clinical trials also been performed in united state and britain 5 . revelation of these unethical trials have shaken the public and research communities and aware them of the necessity of bioethics and guidelines. the nazi doctors were trialed at nuremberg court and this trial gives birth to the world’s first guideline for ethical medical research, the nuremberg code in 1948 6 . but ironically, unethical clinical practice does not end right then. many unethical clinical trials have been revealed time to time till 1990s. the most remarkable of those were the tuskegee syphilis study mailto:fakruddinmurad@gmail.com bangladesh journal of bioethics 2012; 3(3):16-20 17 conducted from 1932 to 1972 by the united states public health service. as many as hundred men were died in that trial from syphilis as the doctors willingly refrained from treating them with penicillin, the most effective drug till then against syphilis, for the sake of research. when revealed in 1972, whole world was shacked with terror and us president clinton had to formally apologize for the study 7 . nuremberg code: the nuremberg guidelines paved the way for the major initiative designed to promote responsible research with human subjects. the nuremberg code consisted of ten basic ethical principles that have been violated previously 8 . the 10 guidelines were as follows: 1. research participants must voluntarily consent to research participation. 2. research aims should contribute to the good of society. 3. research must be based on sound theory and prior animal testing. 4. research must avoid unnecessary physical and mental suffering. 5. no research projects can go forward where serious injury and/or death are potential outcomes. 6. the degree of risk taken with research participants cannot exceed anticipated benefits of results. 7. proper environment and protection for participants is necessary. 8. experiments can be conducted only by scientifically qualified persons. 9. human subjects must be allowed to discontinue their participation at any time. 10. scientists must be prepared to terminate the experiment if there is cause to believe that continuation will be harmful or result in injury or death 9, 10 . ethics principles: there are four principles of biomedical ethics: 1. autonomy (respect for the person a notion of human dignity). 2. beneficence (benefit to the research participant). 3. nonmaleficence (absence of harm to the research participant). 4. justice (notably distributive justice equal distribution of risks and benefits between communities) 11, 12 . ethical considerations in clinical research involving human: the following should apply to any research programme: i. the participant as a person respect for the autonomy of the participant, whether patient or volunteer, demands that the participant must be treated as a unique human person within the context of his or her community system. freedom of choice must be safeguarded. ii. human rights respect for the basic rights of the individual as a human being as well as the rights of groups and communities. iii. the ethic of justice, fairness and objectivity research should always respect the dignity of people involved and should never expose them to intentions and motives not directly attached to the research project, its methodology and objectives 13 . iv. competence researchers must be professionally and personally qualified. in all circumstances they must be accountable and act in a responsible manner. professional standards should be upheld in accordance with academic training. v. integrity integrity should be promoted by being honest and fair. researchers must be honest about their own limitations, competence, belief systems, values and needs. vi. sensitivity sensitivity in research implies balancing scientific interest (the research) with general values and norms affecting the human dignity of the people involved 14 . vii. confidentiality confidentiality must be respected under all circumstances. documentation should be safeguarded and viewed as strictly private in terms of the limits set by the research project. viii. demarcation of roles there should be mutual understanding of the roles and interests of investigators and participants in research. ix. communication bangladesh journal of bioethics 2012; 3(3):16-20 18 clear and understandable verbal communication is required, with factual data. emotional and cultural values should be considered. x. possible dangers to be taken into consideration (a) the danger of objectification and fragmentation special care must be taken not to treat a participant as a mere object. research objectives are subordinate to the following principle: to treat human beings with respect. (b) the danger of direct or indirect coercion direct or indirect coercion of people in the name of research must be avoided under all circumstances. coercion may include the exploitation of vulnerable people; taking undue advantage of a participant, volunteer or any other person; or the misuse of the authority and influence of the research 15 . how to make clinical research ethical? many believe that informed consent makes clinical research ethical. however, informed consent is neither necessary nor sufficient for ethical clinical research. drawing on the basic philosophies underlying major codes, declarations, and other documents relevant to research with human subjects, 7 requirements can be proposed that systematically elucidate a coherent framework for evaluating the ethics of clinical research studies: (1) value— enhancements of health or knowledge must be derived from the research; (2) scientific validity—the research must be methodologically rigorous; (3) fair subject selection—scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should determine communities selected as study sites and the inclusion criteria for individual subjects; (4) favorable risk-benefit ratio—within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks; (5) independent review unaffiliated individuals must review the research and approve, amend, or terminate it; (6) informed consent— individuals should be informed about the research and provide their voluntary consent; and (7) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored. fulfilling all 7 requirements is necessary and sufficient to make clinical research ethical. these requirements are universal, although they must be adapted to the health, economic, cultural, and technological conditions in which clinical research is conducted 16, 17 . research ethics committees: the role of research ethics committees, the history of their origin and details of their composition and organization, has been provided by the royal college of physicians of london. research ethics committees are of crucial importance in the proper regulation of research involving humans and animals, since investigators should not be the sole judges of whether their research conforms to generally acknowledge ethical codes 18 . all research involving humans, whether patients or healthy volunteers, must be referred to a research ethics committee. sometimes class approval may be given in advance to applications for minor research, or a series of studies of a particular type carried out as a regular feature of a research or training programme. even in these circumstances, the committee will wish to be informed of each individual study by title at least 19 . the objectives of research ethics committees are the following: i. to maintain ethical standards of practice in research; ii. to protect research participants and investigators from harm or exploitation; iii. to preserve the research participant's rights, which take preference over society's rights; iv. to provide reassurance to society that this is being done 20 . the research ethics committee should see to it that the responsible investigator is appropriately qualified and experienced. the research ethics committee should also ensure that: i. adequate preliminary literature has been consulted and experimental studies have been undertaken. ii. every reasonable effort has been made to inform prospective participants of the objectives and consequences of their involvement and particularly of identifiable risks and inconvenience. informed consent should be obtained, bangladesh journal of bioethics 2012; 3(3):16-20 19 iii. any arrangement to delegate consent has adequate justification, and that appropriate safeguards have been instituted to ensure that the rights of participants will not be abused. iv. appropriate measures have been adopted to ensure the confidentiality of data generated in the course of research, through the use of coding or anonymity of participants, for example. v. every effort has been made to ensure that participants have an opportunity to comment on and, if they wish, to decline to participate, or to withdraw from a research project easily without having to give a reason, and without any adverse consequence 21, 22 . bangladesh perspective: though ethical considerations in clinical research are a big issue in developed world, it is not the same in bangladesh. even, neighboring country, india is also far ahead in this regard. in 2006, indian council of medical research has published ethical guidelines for biomedical research on human participants as guideline for indian researchers, where no such guideline is still formulated in bangladesh. every research organization should have an ethical review committee comprised of qualified ethical reviewer, but unfortunately except icddr,b, no organization have ethical review committee. bangladesh medical research council is mandated by govt. to monitor and maintain the quality and ethical status of clinical research, its activity is not satisfactory till now. again, most of the clinical researcher and other researchers are not aware of the importance of ethical clearance of their research. as a result, they face difficulty in publishing scientific article is reputed and international journals. again, due to lack of ethical guidelines, participants or volunteers do not get back the feedback of the research. it is high time that the country formulate a national guideline on ethics for biomedical and clinical research involving human participants or involving samples from human such as blood. involved scientists and workers as well as common peoples should be aware of the applicability of the guideline. conclusion: contemporary research ethics are intricate enough to defy consensus even on longestablished features of randomized trials. clearly, ethical research practice extends far beyond obtaining institutional review board approval and informed consent. these maneuvers, while designed to protect patients’ rights, can only serve as components of a more comprehensive system of safeguards 23 . these safeguards include the investigators’ commitment to maintaining the highest ethical standards and the inclination of other researchers to criticize unethical studies. recent discussions on the ethics of clinical research have benefited from increased input from patients. although such input may tend to make an already complex situation more contentious, the added perspective is clearly necessary. closer scrutiny of established practices, with input from increasingly concerned and informed patients, should serve to further what has been described as the search for absolutes in a secular and ambiguous age. references: 1. beecher hk. ethics and clinical research. the new england journal of medicine 1966; 274(24): 1354-1360 2. angeles-lierenas a, bello ma, dirce g, salinas ma. argentina, brazil and mexicobiomedical research and the defence of a single standard of attention in developing countries. review investigations clinical 2004; 56(5): 675-685. 3. joseph ks. ethics in clinical research: searching for absolutes. cmaj 1998; 158:1303-1305. 4. bhutta za. why regulate? ethical regulation of health research. journal of college of physicians & surgeons 2001; 11: 537-540. 5. memon iu. justification of participation of human subjects in phase 1 clinical trials: an ethical analysis. bangladesh journal of bioethics 2011; 2(2): 26-29 6. brody ba, mccullough lb, sharp rr. consensus and controversy in clinical research ethics. jama 2005; 294(11): 1411-1414 bangladesh journal of bioethics 2012; 3(3):16-20 20 7. kapp mb. ethical and legal issues in research involving human subjects: do you want a piece of me? j clin pathol 2006; 59:335–339. doi: 10.1136/jcp.2005.030957 8. kottow mh. who is my brother’s keeper? journal medical ethics 2002; 28(1): 24-27. 9. pandey a, aggarwal a, seth sd, maulik m & juneja a. strengthening ethics in clinical research. indian j med res 2011; 133: 339-340 10. ogundiran to. enhancing the african bioethics initiative. bmc med education 2004; 15(4): 21. 11. rivera r, borasky d, rice r, carayon f. many worlds, one ethic: design and development of a global research ethics training curriculum. developing world bioethics 2005; 5(2): 169-175. 12. hyder aa, wali sa, khan an, teoh nb, kass ne and dawson l. ethical review of health research: a perspective from developing country researchers. journal medical ethics 2004; 30(1): 6872 13. coughlin ss. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology 2006; 3:16. doi:10.1186/1742-7622-3-16 14. macklin r. bioethics, vulnerability, and protection. bioethics 2003; 17(5-6): 472-486. 15. gilman rh, gracia hh. ethics review procedures for research in developing countries: a basic presumption of guilt. canadian medical association journal 2004; 171(3): 248-249. 16. emanuel ej, wendler d, grady c. what makes clinical research ethical? jama 2000; 283: 27012711 17. ali ma. what makes multinational clinical research ethical & how to minimize possible exploitation in host country? bangladesh journal of bioethics 2011; 2(2): 20-23 18. talukder mhk, hossain mz, akhter n, perveen ia. institutional ethical review board (ierb): concept & context. bangladesh journal of bioethics 2011; 2(2): 24-25 19. cowell hr. ethical responsibilities of editors, reviewers and authors. clin ortho.2000; 378: 205218 20. gilman rh, anderton c, kosek m, garcia hh and evans ca. how many committees does it take to make a project ethical? lancet 2002; 60: 1025-1026 21. macpherson cc. ethics committees. research ethics: beyond the guidelines. developing world bioethics 2001; 1(1): 57-68. 22. kalantri sp. ethics in clinical research. indian j. anaesth. 2003; 47 (1): 30-32 23. verweij m, dawson a. public health research ethics: a research agenda. public health ethics 2009; 2(1): 1–6 bangladesh journal of bioethics 2010; 1(1):4 review of bioethics education in bangladesh prof. shamima parvin lasker, professor of anatomy, city dental college, dhaka. arif hossain, phd fellow, washington university, usa email: splasker04@yahoo.com a survey has been carried out from 1st november to 30th december 2008 in different institutes of dhaka city to evaluate the current status of bioethics education in science in bangladesh under the auspices of united nations educational, scientific and cultural organization (unesco), dhaka. people face dilemma with advancing science and technology along with enormous health and environmental problems. bioethics may make bridge between science, technology, social, cultural and spiritual values. there is huge gap in teaching of ethics in undergraduate level. moreover, demand for health research in this country is constantly increasing and international collaboration is growing rapidly in bangladesh. recently each faculty try to establish own ethical review committee. although there are a few training programmes on research ethics has been conducted but these are still not enough to meet the growing need for research and an ethical review process. increasing awareness, sensitivity, research and practice of bioethics in various disciplines of medical science, science and social sciences are required. ethical problem can not be resolved if not first noticeable. thus bioethics education / activity is essential in bangladesh. governments can create a national bioethics commissions by which they can bridge on issues of both scientific and moral complexity in health, science, environment and social science. environmental pollution dr khandaker rashedul haque, director general, academy for planning & development, ministry of planning email: rashedul.haque@yahoo.com protection of environment through enforcement of environmental law in bangladesh is a real challenge; especially for those who are mandated to do it. this is really a defining moment for government, whose priority for development is driven by decisions to balance pressure groups and environmental activists, as well as for the officials, who are very often in between two fires because of baffling instructions from the government. it requires high amount of moral courage for the government official to be ready to take challenge to fight for the environment, even sometimes risking career. along with that is the temptation in more than one form that comes through tantalizingly. the businessmen whose industries and plants need to be run in compliance with the obligation they need to fulfill do make commitment only to be broken in the process making the life of the officials all the more difficult and challenging, especially these people have high clouts in the society to buy decision in their favour. 4 mailto:rashedul.haque@yahoo.com mailto:splasker04@yahoo.com microsoft word editorial(1) bangladesh journal of bioethics 2015;6(3) editorial dear readers, welcome to this issue of our beloved bangladesh journal of bioethics! in this sweltering heat we are all seeking for some cool and comfort. we bring this issue of bjb on different ethical practices and bring up related questions. are we respecting the rights of every human being when we are either doing research or practicing health service provision? what are the minimum norms and standards to be maintained or are we circumventing those? the issue looks into different issues and provides us with indepth information, queries, fears and reservations. in the article on knowledge, attitude and practice of medical ethics among medical intern students in a medical college in kathmandu, ramesh p aacharya and yagya l shakya , report on a knowledge attitude and practice survey of 46 medical undergraduate interns of maharajgunj medical campus. the result of the survey is quite interesting. ‘doctors know the best irrespective of patients’ opinion was agreed upon by 35 %, ‘confidentiality cannot be kept in modern era and should be abandoned’ was strongly disagreed by 34.8% and disagreed by 60.9%. the authors hope that the findings will assist the faculties to strengthen the teaching of medical ethics and guiding the interns for ethical professional conduct. in the article titled organizational justice and employee’s service behavior in the healthcare organizations in bangladesh is an agenda for research, md. nuruzzaman and md. humayun kabir talukder present a conceptual framework and a set of hypotheses regarding the relationships among distributive justice, procedural justice, interactional justice, employee’s citizenship behaviour, role prescribed behaviour and counterproductive behavior in the healthcare organizations in bangladesh. the authors state that the purpose is to assist the policy makers and service providers in identifying desirable and undesirable hrm practices in order to maintain optimum level of employee commitment for ensuring quality and efficient service delivery to the communities. though the article is theoretical it may be useful for the policy makers and service providers. if an operational research could be carried out to test the hypothesis the practical utility of the concept could be tested in bangladesh. zoheb rafique in the article ethical justification of conducting research trials in lower and middle income countries including pakistan: the responsibilities of research enterprises explores the ethical aspects of research sponsored by commercial agencies. he looks into the factors that influence selection of a study site for a sponsored trial particularly in traditional countries like pakistan where cultural values add to the problem in assuring that research is conducted in an ethical manner. in this paper, the author discusses the responsibilities of researchers and funders in low and middle income countries like pakistan and the ethical justifications of doing research trials in developing countries. he concludes that research participants should be fully informed about the research trial and their participation and it is their right to know all risks and benefits so that they have the option of rejecting participation. the article on ethical aspects of dhaka university tele-medicine system by ahmed raihan abir provides and analysis of the telemedicine system in dhaka university. the author is a member of an extended group at dhaka university (du) which has been developing telemedicine equipment and data acquisition software to promote telemedicine practice in bangladesh. recently the telemedicine group of du and a local ngo named samama with support from service innovation fund (sif) of the prime minister office (pmo) of bangladesh took the initiative to establish eight rural telemedicine centers and bangladesh journal of bioethics 2015;6(3) one expert center for the field trial of telemedicine in bangladesh. the aim of this paper is to examine the ethical challenges of such health care system and the effort to overcome these problems before starting the field trial. the author looks into the details of data confidentiality and security, responsibilities of doctor and rural technician, quality of service and implications of telemedicine in bangladesh. he concludes that du telemedicine project will essentially bring the services of qualified medical experts to the doorsteps of the common people throughout the country, even in the remote rural areas. although a telemedicine cannot match a face to face consultation, du tele-medicine system is much better than no consultation at all. sifat rahman in the article on ethical issues of fair subject selection in research provides an overview of the criterion for maintaining ethical standards for conducting research. the author reviews the three fundamental conditions to be met for adhering to strict ethical standards which are: respect for persons by protecting the autonomy of people, treating them with courtesy and respect and obtaining informed consent.; beneficence which incorporates the philosophy of "do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; and justice by ensuring that reasonable, non-exploitative, and well-considered procedures are administered fairly. finally the author concludes that researchers must be truthful and conduct no deception. dear readers, as you can see from the above ethics and maintaining the values in research and services are of utmost importance in the improvement of the quality of life. through our queries, questions and sense of respect for every living being can our endeavors to ensure ethics in all spheres of development be successful. dear readers, please keep on sending your articles, notes or thoughts to us. your participation will make a difference in the quality of our lives. best regards tahera ahmed editor understanding lessons of ethics in the primary education of bangladesh bangladesh bioethics society 2010; 1(3):47-51 understanding lessons of ethics in the primary education of bangladesh alamgir kabir1 mehedi imam2 director, a k & associate, adakapn@gmail.com 2 managing director, adhuna bangladesh ltd. m.imam@adhunabangladesh.com abstract: in a bid to understand the lesson of ethics in the existing primary education according to government approved syllabus in bangladesh, a survey was carried out in dhaka and kushtia for students studying at class 1 to class v, teachers and guardians. it has found that majority students are aware of ‘right and wrong’. their source of learning are parents as mostly found, followed by teachers and both. majority of guardians think text books contain ethical knowledge and they are insufficient. all the teachers found the textbooks contain ethical knowledge and education but only one forth of them found those as insufficient. on appropriateness of the lessons, only a few teachers were satisfied but majority felt the need of ethical knowledge according to age and psychology. in the text books, moral lessons are found in religion, social and environmental context as a mere advice. they are available in the form of do’s and don’ts. stories carry ethical lesson but no individual lesson/chapter was found to be available in any books. the paper has tried to understand the existing syllabus in government run primary schools up to class v through interviewing students, teachers and guardians so that the level of lessons taught, and the need to learn the ethical knowledge can be assessed. key words: lessons of ethics, primary education and bangladesh introduction: primary level of education in bangladesh is provided in various schools rather than a unified system in parallel with government approved/run syllabus. there are other syllabuses also to teach in primary level. class v is the last step of primary education. recently the national education policy has been drafted and introduces a new primary level of education where class viii will be regarded as the last tier for entering into next level of education. in this background, this is an effort to understand the existing ethical lesson in the syllabus in government run primary schools up to class v through interview students, teachers and guardians so that the level of lessons learnt in terms of acquiring ethical knowledge and the need for learning the lessons can be assumed. this is also can lead a wider research involving experts from various disciplines. objective: to study the lessons of ethics in the primary level of exiting education and their extent in the textbooks and teaching systems. 1 2 47 mailto:m.imam@adhunabangladesh.com mailto:adakapn@gmail.com bangladesh bioethics society 2010; 1(3):47-51 methodology: the study adopts a triangular methodology which includes a) reading of the books of the primary level b) interviewing of students, teachers and guardians, particularly parents and c) secondary data analysis through a number of sources such as web, papers and other printed materials. the survey was conducted in june july 2010 in two towns – dhaka and kushtia to catch up two different geographic locations. it should be noted here that no personal information/socio-economic information was collected/recorded in terms of interviewees name, address, gender, age etc. all statistical analyses were performed using the statistical package for social science (spss)3. sample number: a total of 93 persons were interviewed through a structured questionnaire and those include the following categories of respondents. respondent no percentage teachers 15 16.13 students 55 59.14 guardians 23 24.73 total number 93 100 limitations of the study kindergarten and english medium school syllabus were not studied which is being taught in a large number of kg and english medium schools. further, no interview was taken of trainers of the primary school teachers. findings: findings of the questionnaire survey from three groups are summarised below separately followed by findings of the books of the primary level of education. students – out of 55 students, 43 students are aware of ‘right and wrong’. it has also found that they can differentiate among these two. – their source of learning are parents as mostly found (27 students), followed by teachers (13 students), both (8 students). – it is importantly noted that a few said about learning from relatives such as grand parents, other relatives in a close family. – the highest response (36) on ‘what lessons you have learnt’ was received by ‘always speak the truth’, followed by ‘never tell a lie’ (3). but ‘read timely’ was also received response from 5 students. – telling lie has been the most received response (37) as an unethical act, followed by disobeying parents (3), misbehaving with people (2). – the study team was interested to inquire what sort of stories these students are fond of – 28 students love to listen ghost story, followed by fantasy (22). – fairy tale received the 2 responses while stories with moral lessons were liked by 3 students. 3 version 11.0 48 bangladesh bioethics society 2010; 1(3):47-51 – 83.6 % of students (46 students) feel guilty after doing a wrong and they all are ready to ask forgiveness. guardians – 39 % respondents as guardians (9 persons) think text books contain ethical knowledge and they are sufficient while 69.6 % (16 persons) find the knowledge is appropriate. – they have expressed they provide ethical knowledge to their children at home through advising them to speak truth, practical experience etc. this is also supported by their family members. – all the guardians feel the necessity of learning and teaching ethical knowledge through providing more suitable knowledge on ethics with particular focus on making a habit by practice. – 21 guardians admits of social anarchy can be linked any way with the teaching of education and ethics as well. teachers – all the 15 teachers found the textbooks contain ethical knowledge and education but only 26.7 % (4 persons) found them as insufficient – those who do not find they are sufficient, feel the need of more lessons, constant care form family and relatives. – on appropriateness of the lessons, only 6 teachers was satisfied but others feel the need of more knowledge according to age and psychology, practice both in the school and home. – most of the teachers (12 persons) received training on ethics and 13 teachers informed that they used to provide ethical knowledge outside the textbooks – the need of ethics and spreading of its knowledge was felt by all the teachers and expressed that the knowledge should have to be spread in a better way, utilising up-to-date methodology – the teachers mostly unwilling to make any link of social anarchy with the lack of ethical knowledge (12 teachers) and the three teachers find that knowledge, family and society can mould children mind. books • it has found from studying the text books that such lessons are found in religion, social environment as a mere advice. they are available in the form of do’s and don’ts. • stories carry lesson but no individual lesson/chapter was found to be available in any books. • also, illustration is not that much attractive. major findings the summarized findings from all the sources provide the following points in general; • there is still a gap in understanding the ethical knowledge as mostly found with ‘speak the truth’. • moreover, the lessons are practice oriented, that is to say, they require practice and provided as moral. 49 bangladesh bioethics society 2010; 1(3):47-51 • understanding of the guardians and the teachers contradicted in some issues on text books. • most important, the study finds that family members care to the children is becoming less in learning/spreading ethical knowledge. discussion: mahatma gandhi once said: “education means all-round drawing out of the best in child and man – body, mind and spirit.”4 as such, education becomes the basis of personality development on all dimensions – moral, mental and emotional. therefore, we all understand the need in the long run, education forms the foundations on which the castles of peace and prosperity can be built. since ancient times, it is said that with education we finally attain salvation. this essentially contains the thought and essence of value education that is relevant in all perspectives. this very concept, when applied to the simple but refined approach to the children, these is sure to provide us with a new dimension of educational development, benefit of which will be immense in the future to come. as such, while analyzing the views expressed by the respondents in three categories, we can observe them under two main points: educate teachers, students and guardians (particularly parents) to inform them of their rights, their obligations, like the standards of service to be expected of teachers or the duty to send children to school, and of who to turn to in case of perceived wrongdoing. since it is important to address issues relating to corruption and moral behaviour during the formative years, measures should be taken to address this, and to aim at creating a cultural sensitivity to all sort of unethical activities from an early age. conclusion: the survey found that ethical knowledge are mostly confined to understanding ‘wrong and right’, ‘always speak the truth’ etc. both for students and teacher’s perspective. the guardians also fall in this understanding and ensure practices at home. but, it is understood that the level of ethical knowledge is a broad issue, practicing of which should be started at home with support from education materials and supported by the education institutions. role of teachers in this regard is very important to understand those lessons and focus on the need. development and inclusion of proper knowledge of lessons and teaching materials is thus be sought by the teachers with comments from guardians so that an appropriate system can be introduced and run effectively for shaping the mind of the future leaders. references: 1. all text books of class i – v, national textbook and curriculum board (eg., bangla, english, sociology, religion, general mathematics etc.) 4gandhi on value education, by dr. ravindra kumar (dr. ravindra kumar is a universally renowned gandhian scholar, indologist and writer. he is the former vice-chancellor of university of meerut.) 50 bangladesh bioethics society 2010; 1(3):47-51 2. [draft] national education policy 2010, gob. 3.http://www.u4.no/helpdesk/helpdesk/queries/query25.c fm 4.‘green signal to unified education system’, the daily star, june 1, 2010. 51 bangladesh journal of bioethics 2011 vol 2 issue 1 page 13-17 13 gender imbalance in policy making level in science and ethical issue shamima parvin lasker professor and head department of anatomy, city dental college dhaka, bangladesh. abstract: when the achievement of women leadership in science and technology (s&t) is heighten in developed nations in comparison to women in developing countries, it is unfortunate that women are invariably left below, rarely reaching decision-making positions in s&t in bangladesh. in bangladesh, prime minister and leader of opposition are female but when it comes to leadership in science, it is difficult to find a marie curie in bangladesh. men are twenty times more likely than women to reach the top level positions in research. women are underrepresented in almost in all scientific boards. the scarcity of women in senior positions in such bodies inevitably means that their opinions are less likely to be voiced in policy and decisionmaking processes, which may lead to bias decision-making and priority setting in scientific research. the causes of lower representation of women in s&t are discussed. all the causes raise ethical questions and violate the universal declaration of human rights (udth). millennium development goals can never be accomplished without the active participation of women who represent 50 percent of the population, particularly their involvement in science education. based on this analysis, a change of culture is required to improve gender imbalance in decision-making level in science. key words: gender imbalance, policy level, science and ethical issue introduction: it is true that women representation in top positions or policy making levels in science are less through out the world. women hold less than 15% of the full professorships in europe, even though more than half of the european student population is female. american women earned over 67 percent of ph.d.s in graduate schools of medicine, dentistry and engineering. but the percentage of women in decision making levels in science departments are still less then 20%. there have been 513 winners of the nobel prize in the science, only about 44 (6%) have been women. a study commissioned by the organization of islamic conference (oic) standing committee on scientific and technological cooperation found that there are only 18 (4%) women scientists among the top 381 oic scientists. there are also very bangladesh journal of bioethics 2011 vol 2 issue 1 page 13-17 14 few women elected members in islamic world academy of sciences or the academy of sciences for developing world (twas). in india, women are increasingly adopting science careers, although their ratio to the total higher position is still in single digit. according to pakistan council for science and technology, the representation of women in r&d organizations is hardly 2.7 percent of the existing manpower. when the achievements of women leadership in s&t is heighten in developed nations in comparison to women in developing countries, it is unfortunate that women are invariably left below, rarely reaching decision-making positions in s&t in bangladesh. in bangladesh, prime minister and leader of opposition are female but when it comes to leadership in science, it is difficult to find a marie curie in bangladesh. although the involvement of women in science education are increasing but it is not impressive. women are rarely included in the boards of scientific organizations and academic councils of universities. the scarcity of women in senior positions in such bodies inevitably means that their opinions are less likely to be voiced in policy and decision-making processes, which may lead to bias decision-making and priority setting in scientific research in bangladesh. this article examines the ethical concern for gender imbalance in top position in science that world needs to overcome violation and ensure human rights and achieve millennium development goals. are females intellectually weak? literature depicted that the first technical name in science was male imhotep the architect of the first pyramid. the second technical name was female en hedu'anna (c.2354 bc). certainly women were questioners and thinkers long before 4,000 years ago. in most myths and religions preserved that the beginning of agriculture, civilization, mathematics, calendars, time keeping, laws, and medicine were in the hands of women. scientifically men and women had the same amount of grey matter in their heads and a nation has to utilize the intellectual capacity of them for its own good as they could contribute to conservation of biodiversity, protection of the environment and ensuring food security. the majority of women sees and feels reality in a way different from men. of course, there are exceptions but because of gender and because of historical and social compulsions, women tend to view the world in a more holistic way and more spontaneously see and feel interbangladesh journal of bioethics 2011 vol 2 issue 1 page 13-17 15 dependence. director, canadian international development agency said that women have the capacity to create bridges more easily than empires, hierarchies and walls. more women in all fields of science will probably usher a new scientific era, a new kind of science that recognizes the validity of a different approach. cause of lower representation of women in science: 1. women traditional roles in the home 2. patriarchal society 3. lack of family support 4. a heavily male-dominated field 5. culture of negative bias 6. socio economic factors 7. misattribute personal or professional conflicts to sexism. 8. fear of science 9. recognition 10. barriers to entry 11. socialization barriers 12. professional support 13. networking 14. education system 15. schooling system ethical issue: the above mentioned causes of lower representation of women in science are true for each woman in every corner of the word. if we go in depth clarification for individual cause, we will see that discrimination is the main cause behind this which is not scientific and it raises ethical questions. this discriminations cause large levels of widespread deprivation that make the women more vulnerable, subjecting them to silent suffering. article 19 of the universal declaration of human rights in 1948 stated that “freedom to hold opinions without interference.” article 21 of universal declaration on the human genome and human rights in 1997 stated “states should also undertake to facilitate on this subject an open international discussion, ensuring the free expression of various socio-cultural, religious and philosophical opinions” and “freedom to be a scientist from any group of persons with no discrimination”. bangladesh journal of bioethics 2011 vol 2 issue 1 page 13-17 16 from above article, it stands that, science needs a foundation for scientific thought not based on discrimination. both the men & women scientists should give equal incentives for their hard work. discussion: since forty years ago (development decade), it was considered that the poverty, hunger and unemployment are the problem for the development. this concept has proved to be an oversimplification on the context what is happening in the real life in the area of gender, economic equity, environment degradation and jobless economic growth. from 90s, it is witness of gender, economic equity and environment in ethical point of view. the millennium declaration and millennium development goals (mdgs) also identify gender equality and women empowerment as central cross cutting goals. but the current system is that a large percentage of graduate women are not reinvesting their skills in the economy, owing to traditional gender roles that are no longer in accordance with the demands of modern women and men. employers, policy-makers, scientists and society all need to consider whether we can afford to lose such a large number of trained specialists from the workforce. conclusion: a change of culture is required to improve gender imbalance in research and decision-making level in science. we need to ensure that men and women who want to have families are not prevented from having careers and contributing to society in every way that they can. this can only be achieved by a significant change in the way that the society and individuals think about the roles of men and women and by taking positive action to improve the working conditions and favorable support at all stages of their careers. millennium development goals can never be accomplished without the active participation of women who represent 50 percent of the population, particularly their involvement in science education. references: 1. 4000 years of women in science: how long have women been active scientists? http://www.astr.ua.edu/4000ws/newintro.html 2. en hedu'anna http://www.astr.ua.edu/4000ws/en.html 3. kyaw myo lwin frank. a recent graduate’s perspective. asia life science council. http://asialifesciencecouncil.net/forum 4. akhtar mahmud faruqui. a new scientific era? editor, pakistan link. june 11, 2004 http://www.pakistanlink.com/editorial/06112004.html bangladesh journal of bioethics 2011 vol 2 issue 1 page 13-17 17 5. suresh menon. where are the women? of the 513 nobel winners in the sciences, only 11 have been women. why? the hindu newspaper, 28 october 2007. 6. wagdy sawahel. new network to raise profile of muslim women scientists. science and development network. 4 august 2008. http://www.scidev.net/en/news/new-network-to-raise-profile-of-muslim-women-scien.html 7. s. nagesh kumar. 'women must be encouraged to take up science' “the hindu” online edition of india's national newspaper. thursday, october 19, 2000 8. cecily cannan selby. does bias in science hold women back? the faseb journal 2006;20:1284-1287. 9. anna ledin, lutz bornmann, frank gannon & gerlind wallon. a persistent problem: traditional gender roles hold back female scientists. european molecular biology 2007; 8 (11): 982-987. 10. hasina akhter. http://agora.forwomeninscience.com/index.php/2008/07/more-women-scientistsin-bangladesh/ 11. sex and science. are women discriminated against in the lab? or are gender imbalances due to intellectual differences? academia , 2001 http://www.salon.com/life/feature/2001/04/12/science_women 12. henry etzkowitz, carol kemelgor, michael neuschatz & brian uzzi. barriers to women in academic science and engineering. who will do science? educating the next generation, baltimore: johns hopkins university press, 1994. http://people.mills.edu/spertus/gender/eknu.html bangladesh journal of bioethics 2015; 6(1):40 40 news of bbs course on guidelines for ethical research with human subjects: 2 weeks course on “guidelines for ethical research with human subjects” was organized by bbs in march 2015. research ethics, medical mistakes and misconduct, informed consent, conflict of interest, fair subject selection, coercion and undue inducement, confidentiality, vulnerability, qualitative and quantitative research; irb, preparation for protocol writing, project proposal for ethical clearance; publication ethics were the topics of lectures. prof dr akhtarun naher, director, nipsom; dr ma shakoor, associate professor, bsmmu; prof shamima p lasker, secretary general, bbs; prof m kabir, professor of statistics, jahangir nagar university and prof ziaul islam, professor of epidemiology, nipsom were recourse persons respectively. ten participants from different medical & dental colleges attended the course. members of bbs in conferences in abroad: prof shamima parvin lasker, general secretary, bbs & vice president for south asia attended the survey of research ethics committee, faculty of medicine, chiang mai university, thailand in march 2015 as a evaluator on behalf of farcap. dr arif hossain, vice president of bbs attended the international conference on building the collaborative research platform and professional training workshop for cancer treatment, hospice/palliative care and bioethics in southeast asian countries in taiwan in 2014. he presented article “good death” which was highly praised by audience. key words: commercialization, confidentiality, human tissue sample, informed bangladesh journal of bioethics 2010; 1(2):11-19 ethical perception of tissue banking in bangladesh hasan m. zahid*, kanchan chakma, mamun miah and azizun nessa tissue banking and biomaterial research unit, atomic energy research establishment (aere), gpo box-3787, dhaka-1000, bangladesh bangladesh atomic energy commission has initiated the processing of human tissue for utilization in reconstructive surgery as allograft in cooperation with the international atomic energy agency (iaea). tissue donation and grafting has comprehensive and versatile role in the health care sector. iaea programmes to develop a series of tissue banks throughout south east asia by having great significance for improving basic health care in other developing countries. utilization of human tissues has been practicing in many countries and it has a long history. bangladesh is somewhat new in the field of tissue banking activities to treat degenerative bone diseases, congenital deformities, bone fractures, gap non-union from traumatic accidents, dental defects, different type of burns, acid violence, leprotic ulcer, bedsore, traumatic open wound, diabetic wound etc. several hospitals and clinics throughout the country are currently involved in tissue procurement and grafting though some of intricate ethical problems (ideological, cultural, psychological, and religious) and conflicts stay behind this field. for ethical and legal concern, the healthcare personnel have been working under the law of “human organ / tissue donation and transplantation act”, as the national parliament of the people’s republic of bangladesh has approved the declaration on 13th april-1999 requiring consent from the donor or next of kins. before considering the legal and ethical questions associated with tissue banks, several functions must be identified and followed: improvement of the patient care, elimination of the trauma and morbidity associated with secondary surgical procedures, reduction of the prolonged hospital stays and medical costs etc. although ethics, moral principles, and legal aspects are practicing within some degree of people, it should disseminate enormously to the general public of the country as they could be more aware and interested to tissue donation thereby more people will contribute to alleviate sufferings and more lives will save. key words: amniotic membrane, bone, confidentiality, informed consent, organizational policies, standards, and tissue banking. * correspondence: hasan m. zahid, scientific officer, tissue banking and biomaterial research unit, bangladesh atomic energy commission, gpo box-3787, dhaka-1000, bangladesh, e-mail: zahid_bmb@yahoo.com introduction radiation sterilized human amniotic membrane and bone allografts have been using successfully in different types of clinical disorders and injuries in bangladesh. to rehabilitate and treat these sorts of health problems in our country, such as different type of burns, acid violence, leprotic ulcer, bed-sore, traumatic open wound, diabetic wound, degenerative bone diseases, congenital deformities, bone fractures, gap non-union from traumatic accidents, oral and maxillofacial defects ‘‘tissue banking and biomaterial research unit’’ of bangladesh atomic energy commission regularly providing radiation sterilized amnion membrane and 11 bangladesh journal of bioethics 2010; 1(2):11-19 bone allografts to different hospitals and clinics throughout the country. at present, 109 hospitals and clinics and more than 300 surgeons & physicians are involved with this unit through utilization of radiation sterilized tissue allografts. by following scientific procedure, gamma radiation (co60) is used for tissue graft sterilization. this unit is also undertaken research activities on both the fundamental and applied / clinical areas of tissue banking. photograph 1 & 2 represent processing and use of human tissue (amniotic membrane & bone). tissue banking research progressively more is accomplished in partnership between the forprofit and not-for-profit spheres, lifting up many ethical considerations (1). in part, this change can be attributed to the growing sophistication of genomic technology and, in particular, the new interest it has fueled in human tissue (2). in addition, tissue banks in the non-profit sector are often supported by the pharmaceutical and biotech industries that help fund academic research and rely on human biological samples recovered and banked by these institutions (3). some contend that the current system of safeguards (at least in the us) will become increasingly obsolete in protecting tissue donors; others point to a variety of cultural, organizational, and professional issues that question the ethical appropriateness of for-profit tissue banks and academic-industry relationships (4). in these regards, various governments, non-governmental organizations, and other institutions have been planning and promulgating policies to regulate tissue banks and their relationships with industry. these policies represent the consensus of private associations (such as the american association of tissue banks), reflect the national policies of certain governments (such as spain), and are the products of various international bodies (such as the european union). thus, these policies are broad in scope; we have not surveyed the institutional policies of individual banks, academic medical centers, or other institutions. moreover, the enforcement mechanisms will similarly reflect the authority of the bodies that produce such policies. for instance, a private association will have relatively little authority to sanction individual banks for violations of certain policies; on the other hand, governments will have appropriate enforcement mechanisms to ensure compliance (although resources to achieve such compliance will vary from country to country). wherever tissues are removed from human beings, and possibly transplanted into other human beings, the activities involved in the collection and use of such tissues are subject to ethical requirements intended to safeguard respect for human beings, their dignity and 12 1amnion membrane 2 human femoral head bangladesh journal of bioethics 2010; 1(2):11-19 autonomy, and for the common good. as the issue of safety is vital, the protection must extend to tissue donors and recipients, and to all health care professionals whose work involves collecting, manipulating and using human tissues. laws and regulations: bangladesh 1. a bill on “human organ/tissue donation and transplantation act” has been passed by the national parliament of the people’s republic of bangladesh on 13th april 1999 (5/1999) requiring consent from the donor or next of kin. (5/1999) 2. a bill on “safe blood transfusion act, 2002” (12/2002) has been passed by the national parliament of the people’s republic of bangladesh making serological screening mandatory for tissue/ organ donation. (12/2002) viability of human tissues a number of potential benefits stem from the commercialization of human tissues. for industry, the likelihood of profit based on medical products derived from human tissues is an effective incentive to invest in related academic research. with the judicious use of patents and other forms of intellectual property rights, industry has added reason to support cuttingedge and sometimes financially risky academic research involving human tissues. from the perspective of academic centers, the infusion of capital by industry can help to fund innovative research and support the training of researchers. perhaps the most important benefit associated with the commercialization of human tissue comes from the successful interchange between the two spheres, toward a more efficient transmission of knowledge from academic based tissue banks to industry, facilitating the development and delivery of medical products to the public. there is, however, a potential downside to the commercialization of human tissues. specifically, the growth of for-profit tissue banks and augmented academic-industry partnerships increase the likelihood of conflicts of interests. for example, financial incentives to academic researchers (e.g., stock options and royalties) could undermine scientific standards of integrity by promoting secrecy, data hoarding, and even the manipulation of research outcomes. if this occurs, the commercialization of human tissues could have the unintended consequence of compromising human tissue research and subordinating the health of the public to profit maximization. beyond concerns regarding conflicts of interests, the commercialization of human tissues also raises a host of broader social, cultural, religious, and psychological issues on the meanings we assign to the human body and, in particular, on how we treat it during life and after death (5). table 1 and 2 represent non-profitable collection, processing and supply of amniotic membrane and bone allografts those were being prepared by the tissue banking and biomaterial research unit of bangladesh atomic energy commission in 2008. these grafts were used to treat different types of diseases throughout bangladesh. 13 bangladesh journal of bioethics 2010; 1(2):11-19 table1 type of tissue collected number number of grafts prepared number of grafts supplied patients treated human amniotic membrane 389 (foetal sacs./ placenta) 1901 pieces 1751 pieces heat burn 146 acid burn 05 diabetic wound/ diabetic foot ulcer 01 leprotic ulcer 03 abdominal wall reconstruction 04 total :159 154 pieces (eye graft) 136 pieces (eye graft) chemical (acid) burn (corneal surface rt.) 01 chemical (lime) burn 01 pterigium removal site 05 peripheral corneal ulcer 01 orbit reconstruction 01 total : 09 preparation and uses of human amniotic membrane (in 2008) table2 type of tissue collected number number of grafts processed number of grafts supplied patients treated human femoral head 423 3810 (chips/segments) 3172 (chips/segments) giant cell tumor (gct) 76 aneuroysmal bone cyst (abc) 18 simple bone cyst (sbc) 13 fibrous dysplasia (fd) 19 gap non-union 27 bone fracture 66 spinal fusion/scoliosis 02 osteomyelitis & other bone defects. 03 total: 229 preparation and uses of human femoral head (in 2008) 14 bangladesh journal of bioethics 2010; 1(2):11-19 many people conceptualize the transfer of human organs and tissues during life or after death as a gift motivated by altruistic feelings, not economic incentives. u.s. federal law prohibits the buying and selling of human organs, it does allow fees for the recovering, processing and transporting of human tissue (6). the exportation of blood from the u.s. alone is a multibillion dollar industry (7); other human tissues such as hair and corneas play an important role in commerce. the american association of tissue banks (aatb) (8) provides even less guidance, as it has no explicit statement, general or specific, about the commercial aspects of tissue banking. unlike the batb and the aatb, two reports from the health and human services/food and drug administration/office of inspector general (hhs/fda/oig) provide guidelines that address some of the commercial aspects of tissue banking (9). confidentiality confidentiality, which refers to the promise not to disclose information that the donor does not want disclosed, is treated by all the organizations and countries that were surveyed as an important value to be protected. different levels exist among methods to curtail breaches of confidentiality. commentators have outlined a useful taxonomy of: • identified: the tissue source is known and the individual’s identity is tied to the sample. • identifiable: the tissue source is tied to the specimen through the use of a link (e.g., a code number), but the identity of the source is not directly known without tracing the link. • anonymized: the tissue source’s identity is irrevocably unlinked from the specimen, so that the individual’s identity cannot be discerned (i.e., the tissue is not identifiable). • anonymous: the tissue source’s identity is never known, since the specimen is collected with no identifiers at all (i.e., the sample is unidentified) (10). protection of the donor and recipient with regard to the removal of tissues, the main ethical principles from the donor’s point of views are the respect for the human body, even after the person’s death; for the autonomy of the donor; thus, tissue may not be removed whenever the person refuses. for deceased persons, this implies that tissues may not be removed if the person refused consent during her/his lifetime. it is required to protect vulnerable people, namely people unable to give consent; respect for private life and medical confidentiality, which is a fundamental right; the right to prior information on the conditions of removal and the expected use of the tissues; the right not to be subjected to unfair discrimination, which could result from the revelation of data collected from the donor, or the family, to third parties (e.g. employers and insurance companies). the main principles affecting recipients of allografts are the respect for the autonomy of the person concerned, which requires clear information on the risks and advantages of the proposed transplant; respect for private life and medical confidentiality, which applies to all medical treatment; the right to safety, which requires prior verification of the quality and safety of the tissue to be transplanted with regard to the risk of transmission of infectious diseases, neoplasms and immunological diseases; the right of patients to have fair access to the therapeutic possibilities offered by the transplantation of human tissues; the effectiveness of this right depends partly on the greater or lesser availability of tissues. 15 bangladesh journal of bioethics 2010; 1(2):11-19 informed consent informed consent serves as a safeguard for individuals’ rights and welfare, by providing them the opportunity to understand an intervention, its scope, and its implications, before they decide whether to agree to it. in the context of this discussion, the intervention is the collection of tissue samples by a tissue storage facility for the purpose of research. what should the informed consent process for the collection of tissue samples include? this question pertains to tissue samples that have yet to be collected. it needs to be distinguished from a related but separate matter: what should be done with collected tissue samples that were obtained with informed consent that would not meet current standards? the latter question is not directly addressed in this paper, which concerns itself with the collection of tissue, except to say that the more rigorous alternative of going back to donors or donors’ families to obtain consent for unanticipated uses is the gold standard: it provides assurance that the donor’s wishes will be respected. unless donors (or their families) understand the specific nature of a research protocol in which they are enrolling, they neither can assess adequately whether participation in the overall investigation is consistent with their values, nor freely and deliberately refuse participation in certain aspects of a study. role and responsibilities of tissue bank activities of procurement, which are non-commercial, as well as activities carried out by tissue banks require an authorisation. this authorisation must be subject to compliance with basic ethical principles and with health safety standards, which themselves are an ethical imperative. safety rules must be uniform throughout the country. tissue banks have an eminent responsibility to monitor implementation of these rules and principles. they should refuse to accept tissues the procurement of which does not satisfy ethical principles and safety rules. tissue banks also have specific responsibilities as regards protecting the confidentiality of the personal data they keep on donors and their families. in view of their responsibility for the quality and safety of the tissues they provide to third parties, banks should be obliged to keep a register of the tissues stored and distributed. this register should be available for presentation to the national inspectorates at all times. photograph 3 & 4 represent the processing of amniotic membrane and bone allografts 16 3gamma radiation sterilized amnion membrane 4 human femoral head cancellous bone segments bangladesh journal of bioethics 2010; 1(2):11-17 findings from research on tissue samples it seems best to discuss at the time consent is sought what will later become of information derived from tissue samples. two major questions arise with regard to findings. should they be communicated to the donor (or donor’s family)? it may be feasible for the facility to contact the donor (or donor’s family) with findings that pertain to them, where the samples were identified. so, it is important for potential donors to contemplate whether this is information they would welcome – and in what detail. knowledge regarding the risks and benefits associated with learning this sort of information – and what it means that it is familial in nature – can help inform this decision. where tissue samples are anonymized, general findings are the only kind of information the donor (or donor’s family) can consent to receive. the other question that arises from the findings is whether the donor (or donor’s family) can share in any profits from products, tests, or discoveries that result from the research. while it seems easiest to preclude this sort of sharing, some organizations allow it. details of how the donor (or donor’s family) will benefit are worked out during the consent process. in these latter cases, it is helpful to determine conditions as part of the informed consent process. several of the european policies rely on notions of presumed consent for organ and tissue retrieval from deceased individuals (belgium, european commission, france, and spain), while british and american policies stress informed consent with different levels of specificity. collected tissue samples: anticipated uses tissue storage facilities receive donations and make samples available to investigators for research purposes. the donor (or donor’s family) may want to know whether the facility has ties with commercial, as well as non-commercial, companies. does it stand to benefit financially? what criteria does the facility use to determine to whom to provide tissue samples? the party making the donation may be able to limit or suggest to what sort of company the samples should be provided. along similar lines, the donor (or donor’s family) might have the opportunity to specify or recommend toward what type of research the tissue may be used. the risk is that people with insufficient scientific grounding will participate in complex research decisions and that they may request limits that are difficult, unfeasible, or impossible to implement. 17 5dressing of burn wound with amnion membrane 6transplantation of massive bone allograft in resected bone gap. bangladesh journal of bioethics 2010; 1(2):11-19 photograph 5 & 6 represent the use of amniotic membrane and bone allografts to rehabilitate burn and bone injured patient discussion in bangladesh, we believe that tissue banks systematically should consider the following requirements: first, each tissue bank should have a mission statement, against which it can assess the merits of proposed uses of donated tissue. developing such a document will serve to provide a definition of what constitutes high quality research in the eyes of the particular bank. second, financial conflicts of interest can be addressed, in part, by ensuring that those making tissue allocation decisions do not have personal financial stakes in potential recipient organizations, or by sharply circumscribing such relationships. third, tissue banks should be explicit about their standards of ‘‘confidentiality:’’ are tissues identified, identifiable, anonymized, or anonymous? they should develop adequate methods to limit breaches of confidentiality, which are made known. tissue banking guidelines and policies need be specific about the conditions under which donated tissues will be deemed confidential. by doing so, tissue banking guidelines will be more effective in minimizing potential harms to donors, donor families, as well as to future tissue research and product development. fourth, tissue banking guidelines and policies should specify what information to address as part of the informed consent process. to do this, tissue banks will already need to be clear about their mission, financial arrangements, and level of confidentiality protections they intend to use. it is only after receiving the required information that the donor (or donor’s family) can arrive at an informed decision about whether to provide tissue samples to the facility. toward this goal, the information to be addressed should be presented in clear and understandable language. these four main requirements are meant to offer general guidance regarding ethical considerations that deserve to be examined. they are neither exhaustive, nor absolute. rather, they relate to the four factors (commercialization, confidentiality, informed consent, and quality of research) that emerged from the authors’ review. institutional review boards, or corresponding bodies, the purview of which is to ensure the protection of research participants, must be involved to aid tissue banks by providing appropriate oversight and monitoring of their activities that relate to research, as well as assistance with specific ethical issues as they arise. conclusion in different hospitals and clinics throughout the country, the legal and ethical questions associated with tissue banks and their function must be identified : these are to provide improved patient care through tissue transplantation; to abolish the trauma and morbidity associated with secondary surgical procedures used to harvest autografts; to reduce prolonged hospitals stays and reduce medical costs; to avoid the sacrifice of the patient’s normal structures; to provide unlimited quantities of grafts in suitable sizes and shapes. some organizational policies do not address commercialization, while others fail to consider confidentiality and quality of research. however, even in those instances where one of the four factors is recognized by all policies (commercialization, confidentiality, informed consent, and quality of research); there is often a lack of uniformity in its meaning, scope, 18 bangladesh journal of bioethics 2010; 1(2):11-19 and ethical significance. until uniform ethical guidelines regulating the storage, distribution, and use of human tissues for research are established, the international transfer of human tissues and multinational research involving industry will not only remain cumbersome but, in many instances, ethically problematic. we propose that in bangladesh, governments, nongovernmental organizations, and other institutions further collaborate and harmonize policies regarding human tissue. references 1. deborah josefson, ‘‘human tissue for sale: what are the costs?’’ western journal of medicine 5 (2000): 302–303. 2. ted t. ashburn, sharon k. wilson, barry i. eisenstein, ‘‘human tissue research in the genomic era of medicine: balancing individual and societal interests,’’ archives of internal medicine 160 (2000): 3377–3384. 3. joseph b. martin, dennis l. kasper, ‘‘in whose best interest? breaching the academicindustrial wall,’’ new england journal of medicine 343 (2000): 1646– 1649. 4. deborah josefson, ‘‘us hospitals to ask patients for right to sell their tissue,’’ british medical journal 321 (2000): 653. 5. dorothy nelkin, lori andrews, ‘‘homo economicus: commercialization of body tissue in the age of biotechnology,’’ hastings center report 28 (1998): 30–39. 6. national organ transplant act, 1984. pub l. no. 98–507, 3 usc 301. 7. danielle m. wagner, ‘‘property rights in the human body: the commercialization of organ transplantation and biotechnology,’’ duquesne law review, 33 (1995): 931–958. 8. american association of tissue banks, ‘‘ethical guidelines for commercial activities and advertising,’’ (sept. 11, 1996). 9. department of health and human services, ‘‘human cells, tissues, and cellular and tissue-based products; establishment registration and listing,’’ federal register 66 (jan. 19, 2001). 10. curtis naser and sheri alpert, ‘‘genetic information, ethics, ethical issues in tissue banking and human subject research in stored tissues,’’ in: encyclopedia of ethical; legal; and policy issues in biotechnology, eds. t.h. murray and m.j. mehlman (new york: john wiley & sons, 2000), p. 365. 19 ethical case deliberation: bangladesh journal of bioethics 2012;3(3): 21-26 21 ethical case deliberation: breast cancer with pregnancy in cross cultural setting shamima p. lasker fellow of erasmus mundus master of bioethics university of padova italy email: splasker04@yahoo.com case: nadia, a 28-year-old muslim woman from bangladesh, is a phd student at university of padova, italy. she used to feel a small lump at her breast. sometimes it disappeared. sometimes she had slight pain. due to her busy schedule with study she ignored it and thought that she would have checked with doctor latter or going back to country of residence. her be-husband alam is as an engineer, was working at a multinational company in canada. recently he got confirmation latter of immigration to italy. two families arranged the marriage ceremony soon. about 6 month latter nadia admitted to hospital in padova, italy. after repeated investigation, doctor found to have a rapidly growing carcinoma of the breast. she said to doctor that she has been feeling a small mass at the 1 st year of her phd study. now she requires surgery and postoperative chemotherapy. but she is 5 weeks into her first pregnancy. attending gynecologist prescript her for early surgery. she is advised to terminate the pregnancy before the chemotherapy as well. she does not want to terminate pregnancy. her fear is if she never be pregnant again. but she wants to do surgery and chemotherapy. dr. martha faced some ethical dilemma based on the best interest of patient. dr martha new that abortion is permitted in islam by 1 st trimester of pregnancy. she realized that this is the right time for termination of pregnancy as a muslim and do surgery as early as possible for saving the patient. she asked nadia about her decision on abortion and surgery. she had an extensive discussion with the patient about the possible risk of fetus as well. she advised nadia for cryopreservation of ovum for letter ivf and surrogacy. nadia let alam know what doctor proposed to her to do and seek his permission. he did not agree about the termination of pregnancy as it is his first baby and he dream and crave to be father for long time. neither has he accepted the concept of cryopreservation of ova and surrogacy as it may violate the islamic regulation. but he agrees with the treatment. the case was placed at hospital ethical committee and asked to review the situation and make recommendations. introduction: with globalization, doctors and patients alike are moving around to different parts of the world. it becomes common that physicians may have to provide medical services to patients with ethical precept which are different from that of their own. therefore, medical professions patients and family may face a lot of dilemma for cultural difference. as for example a physician may be faced moral conflict to take decisions concerning the beginning of life who may be suffering from a disease of cancer couple with pregnancy in different cultural and religious context. doctor is expected to save life of patient at all cost and at the same time not to do any sort of harm of patients. avoiding cultural, religious aspect of patient may violate the patient’s dignity. physicians, healthcare professional need to be sensitive to this diversity and avoid a stereotyped approach aimed at good care to patients and to avoid conflict before making their judgment on medical practice. thus the case of nadia, a 28 year old muslim woman is analyzed in ethical deliberation using by padova method developed by prof. corrado viafora. the choice of this method does not signify that it is the best of all existing method. but this paper will analyze how a moral conflict may arise in a case and how an ethical issue can be solved given the proper cultural importance by this structured method. mailto:splasker04@yahoo.com bangladesh journal of bioethics 2012;3(3): 21-26 22 islamic perspective on artificial reproductive technology (art) autonomy: person has right to choose freely his or her reproductive performance including his or her reproductive potential. though reproductive choice is basically a personal decision, in fact it is not totally so. this is because reproduction is a process which involves not only the person who makes the choice, but it also involves the other partner, the family, society and the world at large (serous 2012). however, in islam, rights are coupled with responsibilities and the collective rights of the family and society. communitarian right must always be given priority over individual rights (zawawi 2012). family often remains the important subject for the patient’s decisions in relations with the doctor. consequently families and the male guardians demand and expect to be part of the medical decision making process. therefore, family concerns can take precedence over autonomy of patient to medical decision-making process. this can limit the patient’s autonomy (atighetchi 2007). abortion: there are two anthropological models with major consequences on the bioethical positions concerning the start of life in islam. according to majority scholar status of embryo as human is alleged to take place about 120 days after fecundation (4 lunar months plus 10 days) when self movement of embryo is established. on the other hand, according to a minority thesis, embryo as human around the 40th day from fecundation is acknowledged. therefore, life can be divided into two clearly distinct phases: without a soul and with a soul. the consequences can be very important on several levels, including the bioethical and criminal law levels. the abortion of a foetus without a soul should not be considered as equivalent to killing a human being (with a soul). however, the embryo or the foetus has a soul can offer them better protection (atigatchi 2007). in some juridical or medical reasons, abortion is allowed after implantation and before ensoulment e.g. rape, mother’s life is in danger. if a choice has to be made to save either the fetus or the mother, but not both, then the mother’s life would take precedence. she is seen as the root, the fetus as an offshoot. some modern islamic opinions and rulings have also accepted prenatal diagnosis and accept abortion in severe congenital anomalies and malformations per se as a reason (daa r and khitamy 2001). at the practical level, physicians who are aware of islamic bioethics will understand that the provision of simple measures can make big differences for their muslim patients. invitro fertilization (ivf): islam permits in-vitro fertilization, cryopreservation of gamete and artificial insemination with the husband. in vitro fertilization of an egg from the wife with the sperm of her husband and transfer of this fertilized embryo(s) back to the uterus of the wife is allowed, provided that the procedure is indicated for a medical reason and is carried out by an expert physician in order to reduce the chances of failure. if the marriage contract has come to an end because of divorce or death of the husband, medically assisted conception cannot be performed on the ex-wife even if the sperm comes from the former husband (el ghar, and serour 2000 cited in inhorn 2006; abduljubbar 2009). according to islamic jurisprudence (shari’a law) procreative and parenting relationships are lawful between valid spouses because of designated role-responsibilities (lasker 2012). surrogacy: all type of third-party reproductive assistance (ovum or sperm donation) is prohibited in islam (inhorn 2006). introduction of sperm/ova other then husband/wife is as adultery (zina). according to sharia law, procreation is only allowed within a legally binding marriage and a child from without a valid marriage is illegal (inhorn et al 2010). use of third party gametes donation for reproduction is problematic as these violate the precepts of islam concerning legitimacy, lineage, inheritance and incest. gestational surrogacy is not permissible as it involves introducing the sperm of a man into the uterus of a woman to whom she is not married. furthermore, confusion can be resulted from surrogate motherhood: who is the real mother, the genetic mother or the birth mother? for the definition of motherhood qur’an says: their mothers are only those who conceived them and gave birth to them (al quran surah al-mujadalah 58: 2). thus, this ayah categorically denies any rights of motherhood to the bangladesh journal of bioethics 2012;3(3): 21-26 23 genetic mother. since neither the biological mother nor the surrogate has comprehensively fulfilled the definition of motherhood. there is problem to determine who the mother is in gestational surrogacy that will definitely lead to dispute and harm. in genetic gestation surrogate arrangement the child may be a source of perpetual stress for all parties involved which will invariably cause harm to the child also. “harm is to be avoided before benefit is derived” is a well established maxim in islamic law (kholwadia 2012). prenatal diagnosis: first trimester chorionic villous biopsy (performed before ensoulment) is allowed. therapeutic foetal medicine may lead to a greater willingness to engage in genetic counseling and prenatal screening (shaikh and grady 2001). case analysis this methodology evaluates the ethical issues arising from clinical practice based on respect of human dignity. its structure aim to organize the ethical analysis of case along the following steps: 1. collecting clinical data (the essential starting point in the ethical analysis of a clinical case consists in collecting clinical data, adopting a model if clinical analysis that considers not only strictly medical aspect but also personal, relational and cultural ones). 2. assessing responsibilities 3. identifying the ethical problems 4. proposing alternative solution and justifying ethical judgment 1. collecting clinical data a) medical aspect (diagnosis, prognosis and potential treatment): patient nadia, had rapidly growing carcinoma of breast. according to medical history she has been suffering from breast lump for about four years. it is assumed that she is at stage iii of breast cancer. she requires surgery and postoperative chemotherapy. as she is pregnant, termination of the pregnancy is advisable before the chemotherapy. chemotherapy itself causes the foetal abnormality. b) personal and relational aspect: nadia is well educated. it is important to point out here that she is newly married. there has psychological tension as she fears that if she never be pregnant again. it may hamper personal happiness. she did not want to terminate pregnancy but she wants to do surgery and chemotherapy according gynecologist. her husband, alam is also well educated. he did not agree with the termination of pregnancy. he can not accept the loose of his baby as it is his first baby. from this point of view alam is emotional in nature about the family. he has some religious misinterpretation on cryopreservation. but hehas right understanding on surrogacy in his religion. this misconception has risks to compromise with the medical benefit. c) cultural aspects: nadia’s case take place in cultural context (bangladeshi muslim). culturally, husband has all responsibility and liability to take care of wife. moreover, as a muslim, communitarian right is given priority over individual rights. consequently families and the male guardians demand and expect to be part of the medical decision making process. however, bangladeshi women do not usually go beyond the husband decisions. it is very import point to make note that alam should be included in all medical decision making process. 2. assessing responsibilities a) what are the specific responsibilities of health care professional in this given case? considering the nature of disease the responsibility of healthcare professional are 1. to alleviate suffering based on the best interest of patient. 2. to communicate about the possible risk of the patient’s health and possible risk of foetal health after chemotherapy e.g. malformation. b) has the patient (or his/her legal guardian) been adequately informed? bangladesh journal of bioethics 2012;3(3): 21-26 24 patient is clearly well informed about the disease, prognosis and therapeutic possibility. but the legal guardian seems totally ignored. c) has the family been adequately involved? it seems family is adequately involved since (1) he is providing the emotional support to the patient (2) taking care of his wife. (3) he continuously supports the patients and dreaming for new life. d) what are the possibilities of social bodies (social service. etc)? patient’s husband has some religious misinterpretation on art (e.g.cryopreservation is not accepted in religion). the gynecologist only has concrete religion knowledge on abortion but has not complete information on religious verdict on art. therefore, there is short come of religious interpretation on art. both the doctor and patient need help of social service e.g. spiritual. counseling of by theologian/religious clergy in present of both doctor and patient and his family may support for the better understanding to get/provide the utmost medical benefit. 3. identifying the ethical problems what ethical problems are involved in the evaluation of given case? a) conflict of interest between doctor and patient and patient’s family. pregnancy terminate or not b) patient is informed and patient’s autonomy is only considered. husband is ignored totally. c) roll and responsibilities of the health care provider, the patient and the family are not clearly stated to avoid confusion and conflict. d) surrogacy is advised that is against the precept of patient’s religion. e) misconception of religious notion on abortion, cryopreservation and surrogacy of the legal guardian and attending doctor. what is the case, the main ethical problem? the clinical context of the case is the progressive, degenerative breast cancer couple with pregnancy of 5 th week. doctor advises to terminate the pregnancy on the medical ground for the best interest of the patient before the surgery and chemotherapy. patient does not want to terminate pregnancy due to emotional and social cause. there is conflict of interest between doctor and patient regarding termination of pregnancy due to miscommunication and religious misinterpretation of art. 4. proposing alternative solution what are the possible choices for this case? 1. termination of pregnancy and do surgery as early as possible for saving the patient. 2. cryopreservation of ovum for letter ivf for future pregnancy, in possible case by surrogacy. 3. communication between the doctor, patient and patient family to achieve the foreseen medical benefit. 4. group discussion with social body (theologian/religion scholar) and different stake holders e.g. doctor, patient and family 4. do surgery and go with pregnancy and then start chemotherapy after delivery. justifying ethical judgment: among the above identified possible choice, which one better promotes in principle, the human dignity of the patients? why communication between the doctor, patient and patient’s family as well as group discussion with social body will remove the knowledge gap of medical and religion that may influence to change the decision of patient and patient’s family. this way, autonomy, beneficence, non maleficent and justice will be restored and better promotes the human dignity in the given case. bangladesh journal of bioethics 2012;3(3): 21-26 25 argument 1. termination of pregnancy and go for surgery as early as possible for saving the patient. the case presented here the chemotherapy is necessary for the patient’s health. if cancer spread her body it may kill the patient that is not desirable. chemotherapy might cause a miscarriage of baby and severe developmental abnormalities in the fetus. the pregnancy itself may worsen her prognosis. therefore, abortion would be advisable. counter argument 1. family is the network of relationship. if discuss with family, he got the more responsibility and cannot take decision that is not good for patient health and future baby. termination of pregnancy with the consent of not only patient but also her husband is needed. answer to counter argument 1. because, culturally her all social and medical responsibility on her husband’s shoulder and it is emerge that he is the only close relative of patient in foreign country. argument 2. the couple says that they would dearly love to have a child in the future and inform the physician that as well. cryopreservation of ovum for letter ivf for future pregnancy by means of surrogacy may be good alternative this particular case. counter argument 2. to retrieve and freeze her ova, before chemotherapy to be fertilized later would be permissible in patient religion provided the sperm, with certainty, came from her husband, and that at the time of fertilization they are still married and the husband is alive. answer to counter argument 2. the option of surrogacy is broached by the physicians as an alternative. but problem is with the definition of legal mother in patient’s religion. the birth mother is the real mother, not the ovum donor. surrogate cannot fulfill their desire to be mother. surrogacy is therefore excluded. argument 3. do surgery and go with pregnancy and then start chemotherapy after delivery. doctor’s duty is to serve the patient. so do surgery for the best interest of patient. and continue the pregnancy as the patient wishes. respecting patient’s wish in principal better promote patient personal dignity. in this way family wish can be restored as well. counter argument 3. anesthesia during surgery have some complication on baby e.g. fetal syndrome distress and kill the baby within womb. answer to counter argument 3. it is true that there will have complication of anesthesia during surgery on baby but it may be medically manageable. however, the drugs itself have possibility on serious affect on fetal development and growth. this may cause patient and her family especially for child burdensome and unbearable in future. which choice actually better promote the human dignity of this patient in this particular case? why? a) facts related to this clinical contest termination of pregnancy and do surgery as early as possible for saving the patient. preservation of life means preservation of human dignity. b) facts related to this particular patient c) communication between the doctor, patient and patient’s family as well as group discussion with social body may remove the information gap of medical and religion that may influence to change the decision of patient and family. this way, autonomy, beneficence, non maleficent and justice will be restored and promotes the human dignity. bangladesh journal of bioethics 2012;3(3): 21-26 26 references 1. abduljabbar s.a., and amin r., assisted reproductive technology in saudi arabia. saudi med j 2009; 30(4):461-464. 2. atighetchi d., problems of islamic bioethics and biolaw. derecho y religion 2007; 2:221-229. 3. al quran surah al-mujadalah 58: v. 2 4. al quran surah al-mujadalah 58: 2 5. daar s.a., and khitamy a.b.a., bioethics for clinicians: 21.islamic bioethics. cmaj 2001; 164(1):6063 6. gatrad a. r. and sheikh a., medical ethics and islam: principles and practice. arch dis child 2001; 84:72–75. 7. inhorn m.c., patrizio p., serour g.i., third-party reproductive assistance around the mediterranean: comparing sunni egypt, catholic italy and multisectarian lebanon. reproductive biomedicine online 2010; 21, 848– 853 8. inhorn m.c., making muslim babies: ivf and gamete donation in sunni versus shi’a islam. culture, medicine and psychiatry 2006; 30: 427–450. 9. kholwadia s.m.a., the islamic ruling on surrogate motherhood, http://www.ilmgate.org/the-islamicruling-on-surrogate-motherhood/ (accessed on 27 th feb 2012) 10. lasker s., challenge of 21st century to integrate the reproductive technologies concerning the beginning of human life, bangladesh journal bioethics 2012; 3(1) 3. http://www.banglajol.info/index.php/bioethics/article/view/10865/7966 (accessed on 27 th oct. 2012) 11. serour g.i., bioethics in infertility management in the muslim world, 2012 http://www.islamicworld.net/sister/h12.htm (accessed on feb 2012) 12. zawawi m., third party involvement in the reproductive process: comparative aspects of the legal and ethical approaches to surrogacy. eubios ethics institute. http://www.eubios.info/abc4/abc4389 (accessed on may 01, 2012) competing interests: the authors declare that they have no competing interests. acknowledgements: it has been a tremendous privilege to work on this case under the supervision of dr enrico furlan, course coordinator, emmb, university of padova. i express my sincere thanks for his constant criticism with support that provides me the way of thinking philosophically on this case deliberation breast cancer with pregnancy in cross cultural setting.. my deepest gratitude to dr. marcello ghilardi, lecturer, university of padova, italy for all the advice, attention and encouragement he has given me and the knowledge he has shared with me in this field. i express my sincere thanks to prof. corrado viafora, professor of moral philosophy, chair of bioethics, department of philosophy, sociology, educational sciences and applied psychology, university of padova for his every cooperation. http://www.ilmgate.org/the-islamic-ruling-on-surrogate-motherhood/ http://www.ilmgate.org/the-islamic-ruling-on-surrogate-motherhood/ http://www.banglajol.info/index.php/bioethics/article/view/10865/7966 http://www.islamic-world.net/sister/h12.htm http://www.islamic-world.net/sister/h12.htm http://www.eubios.info/abc4/abc4389 bangladesh journal of bioethics 2014 vol.5 (2) editorial the bangladesh journal of bioethics is an open access journal and open to all interested and involved persons in this or related fields. the journal seeks to bring to the forefront current challenges and issues within this important sector. as a result research articles from many different countries depicting current or ongoing research, latest technological breakthrough, experiences from the field or literature reviews are shared with all. with the millennium development goals (mdg) coming to an end in 2015, the need to assess and evaluate the progress in the 8 goals is being undertaken by different countries. at the same time global discussions are underway on sustainable development beyond 2015. the journal of bioethics society looks forward to submission of articles on these areas and the role played by bioethics. the current issue presents the following articles: zoheb rafique describes experiences of teaching bioethics in different institutes and degree courses at undergraduate level. bioethics is being taught to improve the understanding of the ethical issues in the field of medicine. bahareh heydari and najmeh razmkhah study the increasing importance of intellectual property rights (ipr) over the area of seed production, is radically transforming agricultural production relations. mohammad manzoor malik delves into the different problems of patient autonomy to euthanasia. patient autonomy has a critical role in making decisions in medical practice and it is accepted by international conventions on health care and various national medical codes. muhammad waseem khan etal studies the different standards of care in clinical research in countries. standard of care followed in one country may not suit other countries; the reason may involve economic conditions, certain norms, beliefs, tradition and culture of that society. the issues of conducting research in developing countries will remain and one has to try sincerely to sort out the ethical problems while conducting a research study. fayemi ademola kazeem studies the the nijmegen method of case deliberation and clinical decision in a multicultural society. ethical case deliberation is a method of reflecting, clarifying, evaluating and making decisions about moral problems, conflicts and dilemmas in the clinical settings. the nijmegen method helps to motivate rational decision and reasoned responsibility in healthcare through consensus building which does not attenuate moral uprightness. the nijmegen method is part of the healthcare process and aims at improving communication among patient, family and the healthcare team as well as enriching the decision making process. as the new editor of this journal , i seek cooperation and involvement of all members to provide state of the art information on the important topic of bioethics which has a tremendous impact in all spheres of our lives. warm regards to all our readers and authors! tahera ahmed consultant, reproductive health, unfpa, faculty, north south university, former assistant representative, unfpa editor, bangladesh journal of bioethics bangladesh journal of bioethics 2010; 1(1):3 ethical issues in social research prof. ahmadullah mia, ph.d. dean, faculty of sciences and humanities, american world university, dhaka campus, email: amia1941@gmail.com the aims of social research include broadly understanding and explaining human behaviour and relations, influences of social institutions on behaviour, interactions between individuals’ innate tendencies and social institutions, behaviour changes and conditions that lead to changes, scope of manipulations of the environment for positive social outcome, and impact of social interventions on individuals and groups or communities, etc. varied methodologies are applied in social studies for theoretical development as well as advancing social inventions contributing to improvement of the living conditions of human population. forms of studies are planned to suit the purpose. also, methodology used in a study determines the type of study. ethical issues in social studies emanate from the debate on the purpose of social studies – whether studies should primarily focus on building knowledge or application for change in the social conditions. similarly methods applied to investigating into human life as making scientific exploration or influencing social conditions invite ethical controversy. values that guide social research contain ethical elements, which are unavoidable, like research in any other field. social research concerned with human being is always likely be plagued by controversy on ethical judgment. the only way to bypass the problem is to give priority consideration to ‘those who the research is meant for’. the goals of bioethics education prof. darryl macer, ph.d., regional adviser for social and human sciences in asia and pacific, rushsap, unesco bangkok, email: d.macer@unesco.org the rationale for bioethics education is in the asia-pacific regional action plan, “joint plan of action for regional networking in bioethics education towards better bioethics education”, developed at the unesco asia-pacific conference on bioethics education in 2006. please refer to the goals there for a discussion. the international bioethics education network was also launched. the current strategies will be discussed including: 1) use of on-line teaching materials for bioethics education in different countries. production of cross cultural materials. improvement via expert meetings. adapted and translated in different languages to teach school and university classes about bioethics. 2) a network of teachers in different countries , sharing bioethics curricula for schools, bioethics clubs and other endeavours. 3) implementation of the joint regional action plan (july 2006) 4) mapping of bioethics teaching programs in global ethics observatory (geobs) 5) sharing of museum displays and over stimuli to enhance classroom interactions 6) development of moral games and participatory methods 7) conducting teacher training workshops with unesco national commissions and colleges 8) curriculum review and development 9) unesco core curriculum on bioethics and mous with pilot institutions 10) mainstreaming of ethics, integration into professional educational review and training 11) evaluation of teaching bioethics. 3 bangladesh journal of bioethics 2014; 5(3):18-22 18 case study jahi mcmath and the ethics of the brain death standard norman k. swazo, ph.d., m.h.s.a. department of history and philosophy north south university bashundhara r/a 1229, dhaka, bangladesh email: nswazo@northsouth.edu abstract: how does one account for “the discrepancy” between the evidence of total and irreversible brain death and the current evidence of recovered brain function? this is the question that is raised by recent legal action in the case of 13-year old jahi mcmath, certified dead on the basis of neurological criteria but maintained in mechanical ventilation and medical/nursing care since then at the insistence of the parents who claim she is alive. in this brief discussion, the medical and legal issues are reviewed. here the argument is advanced that this is not a case that means there should be a re-evaluation of the neurological criteria for determination of brain death. instead, this case is to be understood as the exception that proves the rule. case scenario: in late 2013, then 13-year old jahi mcmath underwent complicated throat surgery, suffered severe blood loss that lead to an anoxic-ischemic event, and was declared “brain dead” while a patient at children’s hospital in oakland california (usa). she was pronounced “dead” on the basis of brain death (neurological) criteria valid in the state of california. jahi’s parents and loved ones objected to the declaration of death because of what they believed to be the presence of cardiopulmonary function; and they requested that jahi be kept on a respirator with tracheotomy performed for prospective transfer to another hospital and nasogastric tube inserted for feeding and nutritional support to her body. the latter procedures were refused by the hospital medical staff because of the declaration of brain death and likewise not supported by court judgment, despite a series of intervening court injunctions not to withdraw mechanical ventilation. in what has turned out to be a totally unique case, the family of jahi insisted that, despite the medical evidence and professional judgments of numerous physicians and specialists in neurology, the young girl is alive and, therefore, deserving of continued medical and nursing care. despite the issuance of a death certificate, jahi’s “body” was “transferred with the permission of the coroner to be taken out of state,” the family then moving her to a facility in the state of new jersey that was willing to accept jahi as an in-patient for the purpose of continued medical and nursing care. after mailto:nswazo@northsouth.edu 19 approximately eight months in this facility, jahi was transferred to a home environment in that state, where she continues to receive what the family has determined to be acceptable medical/nursing care. christopher b. nolan, legal counsel for the family, has now, one year later, filed a petition (a “writ of error coram nobis”) in the superior court of california, county of alameda, seeking reversal of the judicial determination of brain death.1 based on evidence and testimony before it at the time one year earlier, the court determined that mcmath “met the standard and criteria to be determined brain dead.” this meant that the court affirmed the professional medical judgment and diagnosis, which concluded that mcmath suffered “total and irreversible cessation of all neurologic activity, including the brain stem.” key to this assessment is the judgment that the cessation is understood to be both total and irreversible. in the intervening time (01 september and 26 september 2014), jahi’s parents permitted additional testing to assess jahi’s brain structure and function. accordingly, dr. d. alan shewmon, professor emeritus of neurology and pediatrics (with board certifications in pediatrics, neurology, and electroencephalography and recently retired), from the david geffen school of medicine of the university of california at los angeles, submitted legal testimony on 03 october 2014 in support of the petition to reverse the judgment of brain death.2 referencing “mri/mra studies, records, and reports, as well as viewing two videos of jahi mcmath moving her body parts (foot and arm) following her mother’s commands,” and also accounting for “discussions with dr. calixto machado, a world renowned expert on brain death” and dr. philip defina, “a neuroscientist with the international brain research foundation,” dr. shewmon has found sufficient reason to assert “unequivocally” that jahi “does not [in october 2014] fulfill diagnostic criteria for brain death.” attorney nolan asserts in his petition before the court that independent medical judgment and “objectively verifiable diagnostic measurements” now allow for the conclusion that the claim of total and irreversible cessation of brain function in jahi that was the basis of the declaration of death is to be construed as an error in fact. indeed, nolan asserts furthermore, “what may have appeared to be fact was actually prediction which has turned out to be wrong.” as far as nolan is concerned, jahi’s family has succeeded in keeping jahi “alive” to date, in which case the court must now provide legal remedy for its “flawed, unjust” judgment of death and correct the legal record. this petition for reversal is quite extraordinary both as a matter of law and as a review of a medical certification of death in this patient. however, there is an epistemological assessment here that needs clarification. it is one thing to declare an error in fact and another to assert that a determination of brain death is to be construed as a prediction. a declaration of brain death is a consequence of a medical diagnosis and judgment issued according to both medical and legal criteria. it requires independent confirmation according to those criteria, to assure as high probability as is reasonable on the facts in question. the court-appointed neurologist in this case concurred with the physicians of record that jahi indeed met the state of california’s neurological criteria for the determination of brain death. under no bangladesh journal of bioethics 2014; 5(3):18-22 20 circumstances, either medically or legally, would a declaration of death and a certification of death with disposition of the “body” to the office of the coroner be issued were it construed by anyone as a “prediction.” hence, nolan’s statement is entirely problematic both as a statement evaluated from the point of law and from the point of clinical judgment. if the evaluation of facts is grounded in a different set of facts, then there is no prediction involved at all. it is simply a matter of a medical evaluation and clinical judgment differently grounded. thus, in contrast to nolan, dr. shewmon opines that the available evidence, i.e., the evidence available at least 10 months after the initial declaration of death, “proves that she is not brain dead, not even comatose, but very severely disabled.” in other words, despite this severe disability, jahi can today be diagnosed to be “conscious” and, therefore, “responsive” (the latter evidence contrary to one of “the cardinal parameters” required in the determination of brain death). dr. shewmon is clear in his clinical judgment that “spinal reflex” (as an alternative causal explanation for motion in jahi’s body) is ruled out—“the quality” of jahi’s movements have “the appearance of volition,” are “reliably reproducible,” and “do not occur at random” as would be expected in a spinal reflex motion. additionally, dr. shewmon remarks on the assessment of jahi’s “heart rate variability,” which is such as to provide “objective corroborating evidence that jahi not only has spontaneous modulation of heart rate by the autonomic nervous system (such variability should be completely absent in brain death), but even more impressively that her heart rate changes in response to her mother’s voice.” dr. shewmon accounts it as “hard evidence of auditory processing by the brain, if not also of registering of the emotional valence of those auditory signals and frank conscious awareness of them, and it is not a matter of interpretation.” further, citing nursing records, dr. shewmon underscores the fact of presence of brain function given that jahi has had two menstrual periods: “the female menstrual cycle involves hormonal interaction between the hypothalamus (part of the brain), the pituitary gland, and the ovaries. corpses do not menstruate. neither do corpses undergo sexual maturation.” these facts indicate that jahi has brain function. hence, argues dr. shewmon: “hypothalamic function is a brain function, and california’s statutory definition of death by neurological criteria requires irreversible absence of all brain functions, so even apart from her responsiveness, she would not fulfill the statutory definition of death on the basis of hypothalamic function.” dr. shewmon is careful to clarify that he does not imply “that her hypothalamus is functioning normally: it is not. the point is that there is some preserved hypothalamic function, and a rather remarkable one at that).” given the additional evidence of a low-voltage eeg rather than an isoelectric (flat) eeg reading, and accounting for “some obviously artifactual waveforms,” dr. shewmon opines, “there appears to be genuine electrocerebral activity…” this does not mean that the medical judgment given a year ago was in error as to the facts contributing to the determination of death. rather, “with the passage of time,” dr. shewmon judges, jahi’s “brain has recovered the ability to generate electrical activity, in parallel with its 21 recovery of ability to respond to commands.” an mr angiogram supports the assessment that there is intracranial blood flow, in which case her brain has not succumbed to necrosis or liquefaction; on the contrary, “much of it is structurally intact.” this claim of brain “recovery,” however, places the previous determination of death at children’s hospital in california in question on the issue of whether jahi’s brain suffered “total” and “irreversible” brain damage. hence does dr. shewmon remind that, “a dead brain cannot spontaneously recover electrical function,” in which case the implication is clear that jahi’s brain was not totally and irreversibly dead at the time the medical declaration of death was given nearly a year ago. in other words, were jahi today located physically in a health care facility in the state of california, there is sufficient medically relevant evidence such that the criteria for brain death would not be met, in which case there would be no medical declaration of death issued on the basis of neurological criteria. therefore, there is both medical and legal basis for reversal of a declaration of death. such is the current claim of jahi’s family. dr. shewmon, however, makes a statement that is contrary to attorney nolan’s claim that the original declaration of death is to be considered a mere prediction: “clearly, jahi is not currently brain dead. yet i have no doubt that at the time of her original diagnosis, she fulfilled aan [american academy of neurologists] diagnostic criteria, correctly and rigorously applied by the several doctors who independently made the diagnosis then.” thus, one cannot conclude that the physicians in the case at children’s hospital are by any means either morally or legally blameworthy for errors in medical judgment. after all, as dr. shewmon reminds, “that diagnosis was even backed up by two ancillary tests: an eeg that was reportedly isoelectric and a radionuclide scan that reportedly showed no intracranial blood flow.” the foregoing assessment presents a medical conundrum: how does one account for “the discrepancy” between the evidence of total and irreversible brain death and the current evidence of recovered brain function. dr. shewmon proposes one plausible explanation: “(1) the standard clinical diagnostic criteria are not as absolutely, 100% reliable as commonly believed, and (2) radionuclide blood flow studies are not sensitive enough to distinguish no flow from low flow—in technical terminology, from ischemicpenumbra-level flow, i.e., flow that is too low to support brain functioning but just enough to maintain tissue viability.” discussion: this is a hypothesis, and it is at this point unclear how this might be falsified except insofar as additional testing might be done to evaluate as carefully as might be done with the latest technology what is the functional status of jahi’s brain, and thereby how this may translate to determinations of “conscious” responsiveness. that said, it is important, as a matter of scientific assessment, that no one should expect “absolute, 100% reliability” in any medical judgment and assorted technological evidence given for such functional analyses and determinations of brain death. bangladesh journal of bioethics 2014; 5(3):18-22 22 neurological criteria aim to yield medical judgments that are admittedly inductive rather than necessarily certain. this means that we have determinations of brain death and certifications of death on that basis issued with “high probability” rather than with certainty. was it not for the unusual circumstances in which jahi’s family insisted on continued medical/nursing care and support of jahi’s body? there would be nothing at issue today whether jahi is “alive” and “conscious” and thus meriting the court’s reversal of the declaration of death. this is not a case that means there should be a re-evaluation of the neurological criteria for determination of brain death. on the contrary, this is very much a case of “the exception proving the rule” (in the latin, “exceptio probat regulam in casibus non exceptis”). both medical practitioners and the courts are permitted discretionary judgment on the basis of the evidence available at the time a judgment is to be issued. richard holton3 has written concerning the point of the maxim, re-stating it to say, “exception (i.e., the fact of excepting) proves (establishes) the rule in the case not excepted.” thus, some explain the maxim to mean that while one may be able to point to an exception to the rule “the rule still stands; and furthermore, that, rather than undermining the rule, the exception serves to confirm it.” how can this be so? holton clarifies: this second claim may seem paradoxical, but it should not, once it is realized that what does the confirming is not the exception itself, but rather the fact that we judge it to be an exception; and that what is confirmed is not the rule itself, but rather the fact that we judge it to be a rule. to treat something as an exception is not to treat it as a counterexample that refutes the existence of the rule. rather it is to treat it as special, and so to concede the rule from which it is excepted. what is important here is to recognize that “the rule” that counts in a case such as that of jahi mcmath is a set of neurological criteria, all of which when applied yield empirical evidence incomplete and subject to error, these criteria together thus counting as the equivalent of a defeasible rule (to use holton’s term here)—i.e., a rule “to which exceptions can be made without rejection.” references 1. latasha winkfield v children’s hospital & research center, case no. pr13-707598, “declaration of christopher b. nolan in support of plaintiff’s writ of error coram nobis and request for reveres [sic] of judicial determination of brain death of jahi mcmath,” superior court of california, country of alameda, 03 october 2014. 2. declaration of d. alan shewmon, m.d., olive view-ucla medical center, los angeles, california, as submitted to mr. christopher dolan (sic: nolan), dated 03 october 2014. 3. holton, r. the exception proves the rule. the journal of political philosophy, 2010; 18(4):369388.http://onlinelibrary.wiley.com/doi/10.1111/j.1467-9760.2009.00358.x/abstract, accessed 16 november 2014. http://onlinelibrary.wiley.com/doi/10.1111/j.1467-9760.2009.00358.x/abstract bangladesh journal of bioethics 2015; vol 6 issue 1 editorial heartiest eid mubarak to all our readers, authors and well wishers! this issue of the bangladesh journal of bioethics has a unique combination of papers focusing on rights – human and animal. the papers search deeply into the ethical issues related to scientific research and raises pertinent questions. another critical topic addressed is the mutually beneficial relationship between the pharmaceutical industry and the physicians and possible impact on the services to patient. all the papers are important and highly relevant to the principles of bioethics. shahinul alam, et al in their paper on the ethical relation between physicians and pharmaceutical industries in the perspectives of bangladesh , have reviewed guidelines in different countries on gifts provided to physicians , cash back, samples, industry sponsored scientific meetings, research and hospitality by the pharmaceutical industry. the authors conclude that bangladesh is lagging behind in protecting the patient’s rights properly with regard to update regulations, adherence to existing guidelines and lack of guidance from statutory bodies. the current situation in bangladesh does not address the rights of the patients and needs attention from both professionals and pharmaceutical associations. dr. nahid ferdousi examines the ethical issue of using children as research subjects. the study explores some of the major ethical issues that arise in research involving children during and after the research in terms of the best interests of the children. the paper is particularly important not only in terms of research ethics but also whether the un convention on the rights of the child and the international covenant on civil and political rights has been respected or transgressed. zoheb rafique in his paper on animal rights and use of animals in biomedical research discusses in detail that how animals should be handled while doing research and what are animal rights and their uses in biomedical research. ali jamkarani expresses the thought of the human rights in shiite perspective in his article entitled human rights: illusion or reality; theological (shiite) perspective. this article has two parts. part 1 of this article publishes in this issue. part 2 of this article including conclusion and full bibliography will be published in bjb 2015; vol 6 issue 2. norman k. swazo in his comments on crispr/cas9-mediated editing of human β-globin gene in human cells discusses the recent chinese research using a gene-editing technology on abnormal human zygotes. this research has prospective clinical application. this paper reviews the ethical issues of the research report and come to the conclusion that the chinese research team did not meet the standards of scientific responsibility. jaime a. teixeira da silva in his commentary on pay walled retraction notices questions the morality of whether a cope (committee on publication ethics) member should be charging money for access to retraction notices. the author queries whether this would this not be a direct violation of cope’s code of conduct. a retraction of a scientific paper is made, most often due to errors or lack of publishing ethics on the part of authors, or, on occasion, duplicate publication by a publisher in error. the retraction notice that accompanies the retraction is important document that bangladesh journal of bioethics 2015; vol 6 issue 1 provides a background to the public regarding the reason why the manuscript was retracted. as several journals and publishers, some of which are cope members, are selling the retraction , the author questions the ethical side of it. dear readers, as we all know, to make the world more livable and more rights based, the importance of bioethics cannot be over emphasised. this interesting and relevant field of ethics and ethical rights encompasses a huge, comprehensive arena from robotics and genetics to exploring the universe. let us all, through this journal, strive towards greater equality and equity. looking forward to your papers. best regards tahera ahmed former chief, sexual and reproductive health, unfpa, faculty, north south university, and editor, bangladesh journal of bioethics bangladesh journal of bioethics 2014; 5(2):80-81 bbs news: award ceremony and seminar on practicing bioethics in bangladesh bangladesh bioethics society in collaboration with bangladesh bureau of statistics organized the “award ceremony and seminar on practicing bioethics in bangladesh” on 4th june, 2014 at 10 am at bangladesh bureau of statistics auditorium, agargoan, dhaka. hasanul haq inu, honorable minister, ministry of information, people’s republic of bangladesh was the chief guest in this programme. ifftekharuzzaman, executive director, tib; k siddique-e-rabbani, professor & chairperson of biomedical physics & technology, university of dhaka and prof. ahmad a.n. neaz, professor of economics, american international university-bangladesh delivered lecture in the seminar. sa tv and radio aamar were the media partners of this programme. programme was sponsored by marcel and bangladesh ayeen samity. art / photography competition on ethics bangladesh bioethics society organized an art / photography competition on ethics to develop ethical values among young generation. the theme of the competition was “ethics and life”. sub themes were what is good and bad; beauty of good behavior; appreciation of human life; discover truth about humanity and recognize inherent dignity of human. undergraduate and postgraduate bangladeshi students of age between 18 to 25 years were the participants in this competition. md. reaz mahmood, mba student, northerrn university, dhaka; kaniz fatema, bba, 5th semister, northerrn university, dhaka and samina ferdousi, 2nd year, bds student, city dental college, dhaka were adjusted 1st, 2nd and 3rd position respectively in fine art / cartoon category. tofazzal hossain (sourav), student of ll.m, department of law, university of dhaka stood 1st in photography category. bioethics awards: bbs recogniges those who have efforts to promote bioethics in bangladesh and have outstanding contribution to bbs from 2014. in appreciation of dedicated work for the society prof taslima monsoor, professor & dean, faculty of law, du & president, bangladesh bioethics society; dr arif hossain, founding chairman & vice president, bangladesh bioethics society and prof shamima lasker, professor & head of anatomy, city dental college, dhaka & founding bangladesh journal of bioethics 2014; 5(2):80-81 chairman & secretary general, bangladesh bioethics society were awarded bioethics award for the year of 2014. best volunteer award: in recognition of dedicated work & organization skills, bangladesh bioethics society awarded best volunteer award to atia mannan bushra, 4th year bds student; farin binte rahman, 3rd year bds student; ataur rahman bhuyan, 3rd year bds student and taslim bin hasan, 2nd year bds student for the year of 2014. they all are the students of city dental college, dhaka. bbs news bangladesh journal of bioethics 2013; 4(1):35 bbs news prof shamima parvin lasker, general secretary of bbs has been elected as vice president of asian bioethics association for south asian region. congratulations to her from bbs on her achievement. study and analysis of stem cell therapy and its ethical consideration bangladesh journal of bioethics 2010;1(3):22-34 study and analysis of stem cell therapy and its ethical consideration m.ullah 1, vidyanath chaudhary 2, nurul absar, ph.d.3 1, 2 department of biochemistry and biotechnology, university of science and technology chittagong, (ustc), foy’s lake-4202, bangladesh. 3prof. and head, department of biochemistry and biotechnology, university of science and technology chittagong, (ustc) foy’s lake-4202, bangladesh . 1email: babugene11@yahoo.com abstract : the controversy surrounding stem cell research led to an intense debate about ethics. up until the recent years, the research method mainly focused on embryonic stem cells, which involves taking tissue from an aborted embryo to get proper material to study. this is typically done just days after conception or between the 5th and 9th week. since then, researchers have moved on to more ethical study methods, such as induced pluripotent stem cells (ips). ips is artificially derived from a non-pluripotent cell, such as adult somatic cells. this is probably an important advancement in stem cell research, since it allows researchers to obtain pluripotent stem cells, which are important in research, without the controversial use of embryos. nowadays stem cell treatment has been spreaded throughout the world. it has also been grown commercially in developed countries. this paper assesses the stem cell treatment as well as its impact in human life. it also examines specific stem cell therapy market that proves far reaching effect in world economy. though various organizations have made it as a controversial issue the analysis shows that stem cell treatment has brought positive dimension in human society. a discussion has been made about the ethical issues of stem cell research and therapy; which focus how recent biotechnology and biological understandings of development narrow the debate. it is thought that one day it may be the major key to treat various diseases. key words: stem cells, stem cell treatment, leukemia, cardio vascular diseases, ethical issues, stem cell therapy business. literature search: the paper has been made based on study and analysis of various research papers, articles, books, news on stem cell and stem cell therapy. here a discussion is made on stem cell and its therapeutic role in human society. some stem cell treatments are discussed on the basis of case analysis of different experiments on different parts of the world. the demand of stem cell treatments is increasing with time. the analysis seeks to address this issue in this paper. 22 http://en.wikipedia.org/wiki/induced_pluripotent_stem_cell http://en.wikipedia.org/wiki/induced_pluripotent_stem_cell mailto:babugene11@yahoo.com bangladesh journal of bioethics 2010;1(3):22-34 introduction : this study presents the stem cell therapy and its impact in modern society. nowadays stem cells become a tool for therapeutic purposes. various types of work are carried out in different parts of the world on the basis of stem cell therapy. stem cell technology becomes the hope for the patient. medical researchers believe that stem cell research has ability to dramatically change the approaches to understanding and treating various diseases. though it has an immense role in the therapeutic purposes, it has some limitation also. scientists are trying to find out the appropriate solution of those limitation .some groups considered it as controversial issue. researchers have already developed the stem cell technology. so its positive site is opened in front of the world. but stem cell is not only enough to develop successful treatment. to develop successful l treatment, the importance is on technology and experienced doctor. stem cell therapy is considered as like a soldier with a weapon. only if the soldier (experienced doctor ), weapon (technology) and bullets (stem cells) all are in our hand than the fight will turn in our favor. literature review : the human body has a variety of 220 different cells types. stem cells are master cells that act as foundation cells for every organ, tissue and cell in the body. they differ from other cell by their remarkable properties to develop into many different cell types. they are considered as a blank microchip that can be programmed to perform particular tasks. they serve as a repair machine for the body. at present, scientists worked with two broad classes of stem cells from animals and human: embryonic stem cell (isolated from inner cell mass of blastocysts) and non-embryonic “somatic” or “adult” stem cells (stem cells taken from adult tissue). in 2006, researchers made another breakthrough by identifying new type of stem cell, called induced pluripotent stem cells (ipscs) thorough genetically reprogramming of specialized adult cell. last year jaenisch's group successfully treated transgenic mice carrying the human gene for sickle-cell anemia by giving them hematopoietic stem cells derived from those mice's gene-repaired ips cells1. human embryonic stem cells were isolated relatively recently, in 1998. by transplanting cells generated from human embryonic stem cells in to the patient diseases might be treated like parkinson's disease, diabetes, heart disease, and vision and hearing loss etc. embryonic stem cells are derived from embryos through fertilization of egg in vitro in an in vitro fertilization clinic and then donated for research purposes with informed consent of the donors. they are not derived from eggs fertilized in a woman's body. now a day human embryonic stem cells are cultured in plastic laboratory culture. scientists have already established some basic protocols for embryonic stem cells to become some specific cell types. adult stem cell also known as somatic (from greek σωματικóς, "of the body") stem cells and germ line (giving rise to gametes) stem cells, they can be found in children, as well as adult 2.one supply of adult stem cell is from human fetal tissue. the first human stem cells were extracted from "primordial gonadal tissue which was taken from a non-living fetus" 3.the primary function of adult stem cells is to maintain and repair the tissue in which they are found. research on adult stem cells has generated a great excitement. scientists have found adult stem cells in many more tissues than they once thought possible. this finding 23 javascript:glosspop('invitro') http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm bangladesh journal of bioethics 2010;1(3):22-34 has led researchers and clinicians to use adult stem cell as therapeutic purposes. adult stem cells have already produced therapies, while embryonic stem cells have not 4, 5. moreover, there have been many advances in adult stem cell research, including a recent study where pluripotent adult stem cells were manufactured from differentiated fibroblast by the addition of specific transcription factors 6.for example bone marrow transplants are a type of adult stem cell therapy. for more than 20 years, patients with leukemia have been treated by introducing hematopoietic (blood forming) stem cells through bone marrow transplantation. adult stem cells are also used in veterinary medicine to treat tendon and ligament injuries in horse’s 7.the use of these stem cells in research and treatment is not as controversial as embryonic stem cells. nowadays scientists' enthusiasm grows for induced pluripotent cells when shinya yamanaka of kyoto university reported his transformation of cultured mouse skin cells into a state approximating that of embryonic stem cells 8, he was met with plenty of skepticism. other scientists hadn't anticipated that such a feat was possible. "nobody else was even close to doing the same experiment," says richard young of the whitehead institute in cambridge, massachusetts. "that was a very special breakthrough." by inserting just four genes -oct4, sox2, klf4 and mycinto fibroblasts (cultured skin cells); yamanaka's group had achieved the biological equivalent of making water flow uphill. the resultant induced pluripotent stem (ips) cells proliferate indefinitely in culture and differentiate into all the tissues necessary to generate a live mouse. 9, 10. there are lots of advantages and disadvantages in case of adult and embryonic stem cells. embryonic stem cells are pluripotent, means they are able to form all cell types of the body. on the other hand, adult stem cells do not show the same capabilities. because they are considered as a tissue-specific stem cell. rejection is common in embryonic stem cell therapy but it is less of a concern with adult stem cell therapy. this is due to a patient's own cells could be used in culture, a specific cell type produced (differentiation), and finally reintroduced into the patient. the reason of transplant rejection by tissues derived from embryonic stem cell is not clear, since the united states food and drug administration has only recently been approved (fda). moreover embryonic stem cells do not participate in the destruction of an embryo but embryonic stem cells have to face this ethical problems .though both types of stem cells play important role in medical sciences, but there are some limitations to using adult stem cells. adult stem cells may exhibit dna abnormality during the course of a lifetime. these potentials might limit the usefulness of adult stem cell in therapy. for this reason, human embryonic stem cells are thought to have much greater developmental potential in comparison to adult stem cells. in 1998, a group led by dr. james thomson at the university of wisconsin developed a technique to isolate and grow the human embryonic stem cells. from then scientists have completed experiments with human embryonic stem cells. in late january 2009, geron california based company get clearance from fda to begin the first human clinical trial of human embryonic stem cells. in spite of having some disadvantages, stem cells are used in therapeutic purposes. these activities arise new area in medical technology, called stem cell treatment. stem cell 24 http://en.wikipedia.org/wiki/embryonic_stem_cell http://en.wikipedia.org/wiki/stem_cell_controversy bangladesh journal of bioethics 2010;1(3):22-34 treatments are also familiar as therapy, where new cells are introduced into damaged area to treat a disease or injury in a patient similar to organ transplantation. these treatments are potential enough to change the face of human disease. in medical science, stem cell treatments provide both help and hope to the patients. in may, 2009, dr. kameshwar prasad of the all india institute of medical sciences (aiims) gave a presentation on his stem cell study at the european stroke research conference. in his speech he said, “the stem cells had excellent safety profile. after carrying out pet scans and mris thrice in a year on patients who received stem cells, we found no side-effects. this study shows that stem cells are a safe and feasible therapy in acute stroke. this holds promise and needs to be confirmed in a bigger study’’11.so diseases which can not possible to treat those are treatable and even curable through stem cell treatment. there are some groups that arise questions about the potentiality of stem cell. there are some obstacles that must be overcome before the potential uses of stem cells in cell therapy .these are – find out stem cell source and provide right conditions to differentiate cells into the specialized cells. the most potential application of human stem cells is the formation of cells and tissues that can be used for cell-based therapy. researchers are delivering the stem cells intravenously, because they believe the cells naturally migrate to an injury site. researchers from the medical college of georgia (mcg) injected human stem cells (200,000 to 400,000) into the brain of animals. the stem cells used in this purpose were multipotent adult progenitor cells. at least 25 percent treated animals shown greater improvement in neurological performance than controls. this result was published by cesario borlongan, phd, a neuroscientist at mcg and the veterans affairs medical center in augusta, ga. the findings are important recovery advances in humans. researchers think stem cell therapy, aggressive physical therapy and possibly the clotbusting drug tissue plasminogen activator (tpa) decrease the rate of stroke. this is major problem among american adults. national institutes of health stated that: "...there is evidence that adult stem cells may have more limited potential than hpscs [human pluripotent stem cells]. first, stem cells for all cell and tissue types have not yet been found in the adult human. significantly, cardiac stem cells or pancreatic islet stem cells have not been identified in adult humans. second, stem cells in adults are often present in only minute quantities, are difficult to isolate and purify, and their numbers may decrease with age" 12 . on the other hand another group think adult stem cells offer greater potential than originally believed in early 2002, new scientist magazine reported that catherine verfaillie's team at the university of minnesota had found stem cells in the bone marrow of adults that may be capable of becoming almost any of the 220 tissue types in the human body. these "multipotent adult progenitor cells" or (mapcs) might match the flexibility and potential of stem cells derived from embryos. verfaillie's team was able to isolated mapcs from about 70 of the approximately 100 people who donated samples of their bone marrow 13. stem cells are important because human development occurs from stem cells. scientists have created many ways of using stem cells to develop into human cells, researchers are confident to treatments many diseases by stem cells bone loss, leukemia, broken bones, 25 bangladesh journal of bioethics 2010;1(3):22-34 lou gehrig's disease brain damage due to oxygen starvation, severe burns, cancer (some forms), type 1 diabetes mellitus, cardiac failure , hepatitis, osteoarthritis, incomplete bladder control, missing teeth, huntington's, lupus, spinal cord injuries ,muscular dystrophy, blindness and vision impairment, multiple sclerosis, stroke etc . leukemia is one of the life threatening diseases in human life. the leukemia’s are neoplastic disorder of hemopoitic tissue where an uncontrolled, abnormal and wide spread proliferation of the leucocytic cells (white blood cells) is occurred. every year a huge number of people around the world are attacked by these diseases. a common treatment for these diseases is chemotherapy. but it has some problem also. at first most growing cells like leukemia or neoplastic cells are destroyed by the cytotoxic agents, due to chemotherapy. these agents also kill the hematopoietic stem cells within the bone marrow. unfortunately this side effect arises a question about the use of the chemotherapy. to solve this problem scientists use stem cell as a therapeutic purposes. for over many years bone marrow stem cells have been used by the scientists to treat patients with leukemia and lymphoma. news published in the famous new england journal of medicine that stem cells collected from the umbilical cords of newborn babies are viable and valuable transplant source for thousands of leukemia patients who haven’t any other treatment option. every year leukemia patients require a bone marrow transplant, but it is difficult to find out matched relative bone marrow. umbilical cords are normally discarded after birth can be used to provide real hope for the leukemia patients. researchers conducted an investigation and comparison of leukemia treatment results in more than five hundred adult patients with stem cells transplant. the research was conducted in the united states during a six-year period ending in 2001, where patient's ages were 16 to 60 years. the survival rates were maximum (33 percent) for bone marrow transplants with matched unrelated donors. survival rates were the same (22 percent) for cord blood and one antigenmismatched unrelated bone marrow transplant patients-results that clearly indicate the efficacy of cord blood stem cells when bone marrow donors are unavailable, according to dr. laughlin, an associate professor of medicine at case western reserve university school of medicine 14. the donated cord blood can be used for any patient for future transplantation. cord blood transplantation provides stem cell to the patient, help to produce mature blood cells. as comparison to stem cell umbilical cord blood is not controversial; and in fact, it is normally discarded after birth. so new mothers can donate this immediately after delivery. when the doctors cannot find any matching bone marrow, they choice cord blood for their availability. which is now become the key tool to treat leukemia and other associated diseases. according to science daily (june 2, 2004) maywood, ill. more than 106,000 people in the u.s. each year are diagnosed with these life threatening diseases. various clinical trials have proved adult stem cell therapy is safe and effective to treat heart disease. this therapy is available for heart disease on at least five continents. for example, now it is possible to generate healthy heart muscle cells in the laboratory and then transplant into patients with chronic heart disease. in preliminary research of transplantation of bone marrow stromal cells in damaged heart of mice and other animals indicates beneficial effects. cardiovascular disease (cvd) includes coronary heart disease, 26 http://en.wikipedia.org/wiki/leukemia http://en.wikipedia.org/wiki/haematopoiesis http://en.wikipedia.org/wiki/cytotoxic http://en.wikipedia.org/wiki/heart_failure http://en.wikipedia.org/wiki/diabetes bangladesh journal of bioethics 2010;1(3):22-34 congestive heart failure, hypertension, and stroke. cardiovascular disease is a leading cause of death worldwide killing 17 million people each year15, especially due to heart attack and stroke. in the united states, heart disease is the number one cause of death. the high rate of mortality associated with heart diseases is the inability to repair damaged tissue 16. therefore a potentially new strategy to treat heart failure is restoring damaged heart muscle tissue, through repair or regeneration .the use of adult and embryonic stem cells for cardiac repair is a dynamic area of research. the umbilical cord blood cells have also been investigated as possible sources for regenerating damaged heart tissue. a recent report used a swine model of atrioventricular block and transplanted human es cellderived cardiomyocytes into the pig's heart to work as a pacemaker 17. the es cells survived, functioned and integrated well with the host cells. a new research on stem cell shows that partial paralysis of stroke patients can be cured by a person’s own adult stem cells. for example a stem cell study took place in new delhi, india, there 12 stroke patients were treated with their own stem cells within 1 month after a stroke. as a control group 3 stroke patients were used without stem cell transplantation. however after year, 70% (7 or 8 of the patients) were able to overcome their handicaps and successfully return to their normal life .only 1 out of the 3 in the control group were able to go back to their normal routine. there was no side effects from own stem cells transplantation. another study shown that transplantation of embryonic stem cells to mouse embryos in the earliest stages of development demonstrated a capacity to recover from cardiac injury in adulthood. this study provides the first regenerative medicine can successfully treat myocardial infarction through prophylactic intervention. eye is the important organs in human life. there are many reasons for blindness and vision impairment .but these are not curable by current medical technology. stem cells also play a vital role in this field. researchers have already transplanted human retinal stem cells to restore vision into damaged eyes. scientists grown a totipotent stem cells in the laboratory and then transplanted this sheet over the damaged retina, this stem cells stimulate repair mechanism, eventually restoring vision .the latest such development was in june 2005, when researchers at the queen victoria hospital of sussex, england were able to restore the sight of forty patients using the same technique. the group, led by dr. sheraz daya, was able to successfully use adult stem cells obtained from the patient, a relative, or even a cadaver. further rounds of trials are ongoing 18. moreover the university hospital of new jersey claims a success rate growing the new cells from transplanted stem cells varies from 25 percent to 70 percent 19. a degenerative disease called keratoconus which causes vision impairment arises due to corneal transplants and has no known cure. researcher hoped that one day stem cell research will provide a treatment to such devastating corneal disorders. stem cells are also used in the treatment of multiple sclerosis (ms), an autoimmune disease that affects about 85,000 people in the uk. dr doug brown, research manager at the ms society, said, “stem cells are showing more and more potential in the treatment of ms and the challenge we now face is proving their effectiveness in trials involving large numbers of people" 20. a clinical trial investigating the treatment of patients with multiple sclerosis (ms) using bone marrow stem cells has produced encouraging results, researchers at bristol university have reported. in the phase i clinical trial, six ms patients were 27 http://en.wikipedia.org/wiki/keratoconus http://en.wikipedia.org/wiki/the_university_hospital_(newark,_new_jersey) http://en.wikipedia.org/wiki/cadaver http://en.wikipedia.org/wiki/sussex,_england http://en.wikipedia.org/wiki/queen_victoria_hospital http://en.wikipedia.org/wiki/retina bangladesh journal of bioethics 2010;1(3):22-34 injected with stem cells harvested from their own bone marrow. the main aim of the study was to determine whether this procedure was safe and free from side effects. the study, carried out at frenchay hospital, found no serious side effects associated with the procedure. it also found that the ms was stable in five out of the six patients receiving bone marrow stem cells, and did not deteriorate over the twelve month period. dr claire rice, research fellow at the university of bristol, said: 'the results are very encouraging. we would have expected these pathways to get worse but they have actually got better. it is exciting because the treatment is relatively pain free and patients do not need to stay overnight in hospital' 21. scientists in berlin "cure" patient of hiv disease is supported by a report published in the new england journal of medicine in february of 2009. in this report, berlin doctors describe a male patient who has both hiv infection and leukemia. in order to treat this patient's leukemia, doctors transplanted stem cells from a donor who was naturally resistant to the hiv virus. such naturally resistant people to the hiv virus comprise approximately 1% of the general population and are deemed such as they have a genetic mutation of the ccr5 gene which is required for susceptibility to hiv infection. after the stem cell transplant for the patient’s leukemia was performed with the hiv resistant cells, the patient was able to discontinue taking all anti-hiv medications and remained without detectable hiv virus in his blood for the 20 consecutive months he was monitored. in effect, this patient was “cured” of his hiv disease 22. besides this stem cell also replace missing teeth. in theory, stem cells taken from the patient could be coaxed in the lab into turning into a tooth bud which, when implanted in the gums, will give rise to a new tooth, which would be expected to take two months to grow 23. researcher are trying to use stem cell treatment in parkinson’s disease which is the second neurodegenerative disease following alzheimer's. approximately 1.5 million people in the united states suffer from parkinson's disease 24. another focusing site of stem sell transplant is in veterinary animals .research currently conducted on horses, dogs, and cats can benefit the development of stem cell treatments in veterinary medicine, but may also contribute to developing those in human medicine for a range injuries and diseases such as myocardial infarction, stroke, tendon and ligament damage, osteoarthritis, osteochondrosis and muscular dystrophy 25,26,27,28 . though stem cell therapy plays remarkable role in medical science it has also some limitation. adult stem cells are not yet a permanent solution for diseases. it is difficult to judge its therapeutic potential. some patients show a noticeable improvement after treatment with these stem cells, but the same treatment will have no effect on others patient. so more research is needed on this field. ethical issues: now a day’s ethics is the important topics in case of biological research. stem cell research is monitored by various groups. they have raised their voice against stem cell research. though embryonic stem cells have greater plasticity, potentially 28 http://en.wikipedia.org/wiki/muscular_dystrophy http://en.wikipedia.org/wiki/osteochondrosis http://en.wikipedia.org/wiki/osteoarthritis http://en.wikipedia.org/wiki/ligament http://en.wikipedia.org/wiki/tendon http://en.wikipedia.org/wiki/stroke http://en.wikipedia.org/wiki/myocardial_infarction bangladesh journal of bioethics 2010;1(3):22-34 allowing them to treat a wider range of diseases29. but in recent years human embryonic stem cell research is controversial because, to create a stem cell line a human embryo has to destroy. opponents of stem cell research also say this technology devalue human life. many pro-lifers like roman catholics and conservative protestants raised their vice against embryonic stem cell research (escr). they claim that embryo is human being. during stem cell extraction, the embryos are killed. they compare the method as murder of human. if the basis for protecting embryos is that they have the potential to become reasoning beings, then, some argue, we have reason to ascribe a high moral status to the trillions of cells that share this potential and to assist as many of these cells as we reasonably can to realize their potential (sagan & singer 2007, savulescu 1999). but it is morally permissible to kill an individual who is about to be killed by someone else where killing that individual will help others (curzer, h. 2004)30. on the other hand researcher proved that stem cells are unable to grow in to a complete person except an organ. so stem cell cannot create a human life. some parties contend that embryos are not humans, believing that the life of homo sapiens only begins when the heartbeat develops, which is during the 5th week of pregnancy 31, or when the brain begins developing activity, which has been detected at 54 days after conception 32. moreover in many countries abortions are legal. so a logical argument is why not using them for stem cell research or treatments? the us government has declared embryonic stem cell research legal in this year. this order will give motion in embryonic stem cell research. the importance of embryonic stem cell research can be understood from president barack obama speech. in a speech before signing the executive order, president obama noted the following: “today, with the executive order i am about to sign, we will bring the change that so many scientists and researchers; doctors and innovators; patients and loved ones have hoped for, and fought for, these past eight years: we will lift the ban on federal funding for promising embryonic stem cell research. we will vigorously support scientists who pursue this research. and we will aim for america to lead the world in the discoveries it one day may yield” 33. by executive order on march 9, 2009, president barack obama removed certain restrictions on federal funding for research involving new lines of human embryonic stem cells. not onlyin u.s.a but also other developed countries take initiative step about stem cell research.they make different types of law to control the stem cell researchfor their country. austria, denmark, france, germany, and ireland do not allow the production of embryonic stem cell lines, the creation of embryonic stem cell lines is permitted in finland, greece, the netherlands, sweden, and the united kingdom 34. according to a january 9,2007 daily telegraph (london) article reporting on a statement by dr. anthony atala of wake forest university, the fluid surrounding the fetus has been found to contain stem cells that, when utilized correctly, "can be differentiated towards cell types such as fat, bone, muscle, blood vessel, nerve and liver cells", according to the article. the extraction of this fluid is not thought to harm the fetus in any way. "our hope is that these cells will provide a valuable resource for tissue repair and for engineered organs as well," said dr atala 35. the developed countries also involved in embryonic stem cell research. in 23 january 2009 the united states food and drug administration approves clinical trials for human embryonic stem cell therapy 36. in case of extraction of adult stem cells there are 29 http://www.religioustolerance.org/res_stem12.htm http://en.wikipedia.org/wiki/food_and_drug_administration_(united_states) http://en.wikipedia.org/wiki/wake_forest_university http://en.wikipedia.org/wiki/united_kingdom http://en.wikipedia.org/wiki/sweden http://en.wikipedia.org/wiki/netherlands http://en.wikipedia.org/wiki/greece http://en.wikipedia.org/wiki/finland http://en.wikipedia.org/wiki/ireland http://en.wikipedia.org/wiki/germany http://en.wikipedia.org/wiki/france http://en.wikipedia.org/wiki/denmark http://en.wikipedia.org/wiki/austria http://en.wikipedia.org/wiki/homo_sapiens http://en.wikipedia.org/wiki/embryo http://en.wikipedia.org/wiki/stem_cell_line http://en.wikipedia.org/wiki/embryonic_stem_cell http://en.wikipedia.org/wiki/embryonic_stem_cell bangladesh journal of bioethics 2010;1(3):22-34 no major ethical concerns. bioethicist dr. nigel cameron said, "we know that adult stem cells, which have no ethical problem, can do the job, as well" 37. however, recently it has been shown in principle that adult stem cell lines can be manipulated to generate embryonic like stem cell lines using a single-cell biopsy similar to that used in preimplantation genetic diagnosis that may allow stem cell creation without embryonic destruction 38. it can be said easily stem cells have a huge promise to help mankind. it saves life and cure diseases. this creates a very strong moral demand to explore their potential. stem cell therapy business is becoming a key factor in economy in developed countries. in u.s.a this business is increasing day by day. this is shown in following chart: fig : stem cell market analysis fact sheet of the 2nd annual stem cell summit, february 12-13 at san diego 39, on the above chart it has been shown clearly that stem cell therapy business has far reaching effect in u.s.a. economy. result and discussion: at present creating a new stem cell line for mammals is difficult; for primates including humans it is particularly difficult. in spite of that stem cells treatment has shown a hope for the patient. in future it may be the key tools for treating various diseases .future stem cells study could also increase our knowledge about abnormal cell division and differentiation, which causes cancer and birth defects. however, ips (induced pluripotent stem cells) will maybe be the wave of the future. they have various similar properties as embryonic stem cells. news was published in the healthy day news paper in april 23, 2009 that scientists have already converted adult cells into 30 http://www.stemcellsummit.com/ http://www.stemcellsummit.com/stem-cell-fact-sheet.pdf http://en.wikipedia.org/wiki/preimplantation_genetic_diagnosis bangladesh journal of bioethics 2010;1(3):22-34 embryonic-like stem cells by using chemical programming. this may permit adult stem cells to work as embryonic stem cells without significant ethical concerns. stem cell acts as a renewable source of replacement cells and tissues. this would greatly diminish the risk of rejection in any form of transplant operation. for unique properties, stem cell therapy is important for today’s medical technology. through research on this topic it is found that there is a significant mis-information about the stem cell research because some opponents of stem cell research are misguiding the public for their own political agendas. there exists a social and scientific uncertainty about stem cell research, which could possibly be overcome through future study, and further education of the public. by allowing research and increasing funding the public will be informed more accurately and the true benefits of stem cells research will be more clearly realized. and that will make stem cell more beneficial for mankind. references 1. hanna, j. et al. treatment of sickle cell anemia mouse model with ips cells generated from autologous skin. science 318, 1920–1923 (2008). 2. jiang y, jahagirdar bn, reinhardt rl, et al (2002). "pluripotency of mesenchymal stem cells derived from adult marrow". nature 418 (6893): 41–9. doi: 10.1038/nature00870. pmid 12077603 . 3. anon, "human embryo research/fetal experimentation," focus on the family, policy statement dated 1997-dec-15.see:http://www.family.org/ 4. clarke, michael f. and michael w. becker. (july 2006). "stem cells: the real culprits in cancer?" scientific american. retrieved on august 8, 2006. 5. anonymous (september 24, 2006) "cloning/embryonic stem cells." national human genome research institute. retrieved september 24, 2006. 6. cyranoski. "simple switch turns cells embryonic". nature 6 june 2007. 7. kane, ed (2008-05-01). "stem-cell therapy shows promise for horse soft-tissue injury, disease". dvm newsmagazine. http://www.dvmnews.com/dvm/equine+medicine/stemcell-therapy-shows-promise-for-horse-softtis/articlestandard/article/detail/515503.retrieved on 2008-06-1. 8. takahashi, k. & yamanaka, s. induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. cell 126, 663–676 (2006). | article | pubmed | isi | chemport | 31 http://chemport.cas.org/cgi-bin/sdcgi?app=ftslink&action=reflink&origin=npg&version=1.0&coi=1:cas:528:dc%2bd28xpt1aktbs%3d&pissn=%7bprintissn%7d&pyear=2008&md5=307b9fa40168d18e8e9adcd61d9c1b3b http://links.isiglobalnet2.com/gateway/gateway.cgi?&gwversion=2&srcauth=nature&srcapp=nature&destlinktype=fullrecord&keyut=000240276700016&destapp=wos_cpl http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=retrieve&db=pubmed&list_uids=16904174&dopt=abstract http://dx.doi.org/10.1016/j.cell.2006.07.024 http://www.dvmnews.com/dvm/equine+medicine/stem-cell-therapy-shows-promise-for-horse-soft-tis/articlestandard/article/detail/515503 http://www.dvmnews.com/dvm/equine+medicine/stem-cell-therapy-shows-promise-for-horse-soft-tis/articlestandard/article/detail/515503 http://www.genome.gov/10004765 http://www.sciam.com/article.cfm?chanid=sa006&colid=1&articleid=000b1bed-0c0a-1498-8c0a83414b7f0000 http://www.sciam.com/article.cfm?chanid=sa006&colid=1&articleid=000b1bed-0c0a-1498-8c0a83414b7f0000 http://www.family.org/cforum/research/papers/a0001013.html http://www.ncbi.nlm.nih.gov/pubmed/12077603 http://dx.doi.org/10.1038%2fnature00870 http://en.wikipedia.org/wiki/digital_object_identifier bangladesh journal of bioethics 2010;1(3):22-34 9. okita k., ichisaka, t. & yamanaka, s. generation of germ line-competent induced pluripotent stem cells. nature 448, 313–318 (2007). | article | pubmed | isi | chemport | 10. wernig, m. et al. in vitro reprogramming of fibroblasts into a pluripotent es-cell-like state. nature 448, 318–324 (2007). | article | pubmed | isi | chemport | 11. repairstemcell.wordpress.com/2009/04/20/ stem cell research shows adult stem cells help stroke victims posted 20 april, 2009 in stroke | 12. national institutes of health guidelines for research using human pluripotent stem cells," at: http://www.nih.gov/ . 13. sylvia pagan westphal, "is this the cell that could revolutionize medicine?" 2002-jan26, new scientist (http://www.newscientist.com) online at: http://www.eurekalert.org/ 14. university hospitals of cleveland (2004, november 30). leukemia patients survive with stem cell transplant. science daily. retrieved april 16, 2009, from http://www.sciencedaily.com /releases/2004/11/041129112109.htm 15. http://www.who.int/cardiovascular_diseases/resources/atlas/en/. 16. jackson, k.a., goodell, m.a. (2004) generation and stem cell repair of cardiac tissue. stem cell handbook, edited by sell, s. 259-266.] 17. kehat, i., khimovich, l., caspi, o., gepstein, a., shofti, r., arbel, g., huber, i., satin, j., itskovitz-eldor, j., gepstein, l. (2004) electromechanical integration of cardiomyocytes derived from human embryonic stem cells . nature biotechnol. 22, 1282-1289. 18. bbc news | england | southern counties | stem cells used to restore vision . 19. the university hospital of new jersey, 2002. 20. http://news.bbc.co.uk/2/hi/health/7858559. 21. rachael panizzo-multiple sclerosis stem cell therapy trialed. bionews 557 (10 may 2010) http://www.bionews.org.uk/page_59801.asp 22. robert maietta, md.can stem cell therapy cure hiv and aids? www.suite101.com/content/can-stem-cell-therapy-cure-hiv-and-aids-a201245 23. teeth from scratch . 24. www.parkinson.org/site/pp.asp?c=9djfjlpwb&b=71125. 32 http://whyfiles.org/shorties/147tooth/ http://news.bbc.co.uk/1/hi/england/southern_counties/4495419.stm http://www.who.int/cardiovascular_diseases/resources/atlas/en/ http://www.eurekalert.org/pub_releases/2002-01/ns-itt012302.php http://www.newscientist.com/ http://www.nih.gov/news/stemcell/stemcellguidelines.htm http://repairstemcell.wordpress.com/2009/04/20/ http://chemport.cas.org/cgi-bin/sdcgi?app=ftslink&action=reflink&origin=npg&version=1.0&coi=1:cas:528:dc%2bd2sxnvveqslg%3d&pissn=%7bprintissn%7d&pyear=2008&md5=a915b013e29d5a91742b7a0135550c5b http://links.isiglobalnet2.com/gateway/gateway.cgi?&gwversion=2&srcauth=nature&srcapp=nature&destlinktype=fullrecord&keyut=000248118300050&destapp=wos_cpl http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=retrieve&db=pubmed&list_uids=17554336&dopt=abstract http://dx.doi.org/10.1038/nature05944 http://chemport.cas.org/cgi-bin/sdcgi?app=ftslink&action=reflink&origin=npg&version=1.0&coi=1:cas:528:dc%2bd2sxnvveqsl0%3d&pissn=%7bprintissn%7d&pyear=2008&md5=04b23ef6bcce1997b01b987c397871e4 http://links.isiglobalnet2.com/gateway/gateway.cgi?&gwversion=2&srcauth=nature&srcapp=nature&destlinktype=fullrecord&keyut=000248118300049&destapp=wos_cpl http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=retrieve&db=pubmed&list_uids=17554338&dopt=abstract http://dx.doi.org/10.1038/nature05934 bangladesh journal of bioethics 2010;1(3):22-34 25. chen j, li y, wang l, zhang z, lu d, lu m, chopp m. therapeutic benefit of intravenous administration of bone marrow stromal cells after cerebral ischemia in rats. stroke. 2001; 32: 100 26. assmus b, schachinger v, teupe c, et al. transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction (topcare-ami). circulation 2002 dec 10; 106(24):3009-17 27. murphy jm, fink dj, hunziker eb, barry fp. stem cell therapy in a caprine model of osteoarthritis. arthritis rheum 2003 dec; 48(12):3464-74 28. sampaolesi m, et al. mesoangioblast stem cells ameliorate muscle function in dystrophic dogs. nature. 2006: 444:574-579. 29. "arguments for stem cell research". spinney press. 2006. http://web.archive.org/web/20080201224807/http://www.spinneypress.comau/178_book_d esc.html.retrieved on 2007-12-26 30. ethics of stem cell research. stanford encyclopedia of philosophy. fri apr 25, 2008 31. greenfield, marjorie. “dr. spock.com".retrieved 2007-01-20. 32. singer, peter. rethinking life & death: the collapse of our traditional ethics, page 104 (st. martins press 1996). retrieved 2007-03-04 33. a debt of gratitude to so many tireless advocates. 34. as noted before, the production of hesc lines is currently illegal in germany; the 1990 embryo protection act prohibits any utilization of the embryo that does not serve its preservation. ... ireland, austria, denmark and france prohibit any production of hesc lines...finland, greece, the netherlands, sweden and the uk allows the production of hesc lines from surplus ivf embryos."peter m. wiedemann, judith simon, silke schicktanz & christof tannert (2004). "the future of stem-cell research in germany". nature and the european molecular biology organization. 35. clout, laura; and agencies (2007-09-01). ""scientists report alternative stem cell source"". dailytelegraph(uk).http://www.telegraph.co.uk/news/main.jhtml? xml=/news/2007/01/08/ustem108.xml.retrieved on 2007-09-20 36. "green light for us stem cell work". bbc news. http://news.bbc.co.uk/2/hi/health/7847450.stm 37. steve jordahl, "calif. governor signs stem cell bill," at: http://www.family.org/ 33 http://www.family.org/cforum/fnif/news/a0022396.html http://news.bbc.co.uk/2/hi/health/7847450.stm http://news.bbc.co.uk/2/hi/health/7847450.stm http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/01/08/ustem108.xml http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/01/08/ustem108.xml http://en.wikipedia.org/wiki/2007 http://books.google.com/books?vid=isbn0312144016&id=d5w1xe1gm2ec&pg=ra1-pa104&lpg=ra1-pa104&ots=kg4pxgcqdg&dq=%22human+life+must+be+protected+from+fifty-four+days%22&num=100&sig=pwh7kepjvwhxakfwtawd3dwuyb0#pra1-pa104,m1 http://en.wikipedia.org/wiki/january_20 http://en.wikipedia.org/wiki/2007 http://www.drspock.com/article/0,1510,9851,00.html http://web.archive.org/web/20080201224807/http:/www.spinneypress.com.au/178_book_desc.html bangladesh journal of bioethics 2010;1(3):22-34 38. nell greenfieldboyce (23 august 2006). "firm creates stem cells without hurting embryos".national public radio. http://www.npr.org/templates/story/story.php? storyid=5696557. 39. pimm.wordpress.com posted by attilachordash on february 13, 2007. 34 http://pimm.wordpress.com/ http://www.npr.org/templates/story/story.php?storyid=5696557 http://www.npr.org/templates/story/story.php?storyid=5696557 http://www.npr.org/templates/story/story.php?storyid=5696557 http://www.npr.org/templates/story/story.php?storyid=5696557 islamic bioethics of pain medication: an effective response to mercy argument bangladesh journal of bioethics 2012; 3(2):4-15 4 islamic bioethics of pain medication: an effective response to mercy argument mohammad manzoor malik assistant professor department of general studies kulliyyah of islamic revealed knowledge and human sciences, international islamic university malaysia e-mail: philomalik@iium.edu.my / philomalik@gmail.com abstract: pain medication is one of the responses to the mercy argument that utilitarian ethicists use for justifying active euthanasia on the grounds of prevention of cruelty and appeal to beneficence. the researcher reinforces the significance of pain medication in meeting this challenge and considers it the most preferred response among various other responses. it is because of its realism and effectiveness. in exploring the mechanism and considerations related to pain medication, the researcher briefly touches the catholic ethical position on the issue, a position that cannot be ignored in the development of contemporary bioethics. the researcher particularly deliberates on the contemporary islamic discourse on the issue; by furthering the debate in line with the islamic legal maxims and general guidance from the primary sources of islamic law and ethics. the resolution on the issue is sought by synthesizing the views and legal maxims (al-qawaid al-fiqhiyyah) on the issue, which in conclusion provide justification for pain medication by considerably regarding pain as “necessity” and “pressing need”. however, such resolution allows pain medication to the limit and proportion that removes the pain and prohibits overdosing the patient with medication that may directly cause the death. key words: mercy argument, euthanasia, pain medication, doctrine of double effect, islamic bioethics introduction: mercy argument is at the heart of discussions that support legalizing active euthanasia. various versions of the argument defend permissibility of mercy killing by highlighting essential aspects related to patients and the nature of medication. in brief, the argument is used to justify mercy killing of the patients who request so on the grounds of avoiding unnecessary pain and suffering. after exploring the mercy argument and briefly mentioning the popular responses against it, i would argue that among these responses, pain medication is the most effective solution and the best response because it helps in coping with the pain and suffering of the patients and avoids active euthanasia. most importantly, this solution is realistic as it does not ignore the actual harm of pain that some patients suffer because of serious diseases. in understanding the ways this pain medication is suggested to be implemented, catholic ethical position on the subject is briefly mentioned to show its importance in western bioethics, thus showing its similarity with islamic discourse. the crucial part of the article deliberates with adequate discussion on formulation of islamic position on pain medication within the contemporary discourse on the issue that is in line with the legal maxims and general guidance from the primary sources of islamic law and ethics. mailto:philomalik@iium.edu.my mailto:philomalik@gmail.com bangladesh journal of bioethics 2012; 3(2):4-15 5 mercy argument for active euthanasia: mercy argument is among a few powerful arguments that proponents of euthanasia make and it is “central to the libertarian viewpoint” 1 . it is based on prevention of cruelty and it appeals to the principle of beneficence. according to this argument “it is cruel and inhumane to refuse the plea of a terminally ill person that his or her life be mercifully ended in order to avoid unnecessary suffering and pain” 2 . utilitarian moral philosophers such as peter singer, john harris, marvin kohl, and jonathan glover have arguably defended this argument on the consequential basis. the same argument is restated by james rachels; he believes that the single most powerful argument in support of euthanasia is the argument from mercy. he claims that, it is also an exceptionally simple argument, at least in its main idea, which makes one uncomplicated point that terminal patients sometimes suffer pain so horrible that it is beyond the comprehension of those who have not actually experienced it. their suffering can be so terrible that we do not like even to read about it or think about it; we recoil even from the descriptions of such agony. the argument from mercy says: euthanasia is justified because it provides an end to that 3 . however, to what extent this argument can appeal is very succinctly described by ruth chadwick as follows: “this argument is used not just in relation to actual physical suffering, but also mental suffering, the frustration of being unable to perform everyday tasks for oneself, and the erosion of dignity as personal and previously private tasks have to be performed by someone else as one reverts to behavior not experienced since infancy. the argument from beneficence or utilitarianism will be strongest where there is no alternative but death to the misery that one is witnessing, both when the period of suffering is likely to be unremitting and prolonged or when death is fairly imminent” 4 . popular criticisms of mercy argument: the responses to mercy argument are various. j. p. moreland and norman l. geisler believe that the critics have made responses at least in four ways. first, there are very few cases where modern medicine cannot alleviate suffering and pain, building an ethical doctrine on such few cases is not a right moral methodology. second, suffering as itself is not a bad thing; it has many positive aspects. third, instead of killing in severe circumstances, pain medication could be done even it causes death as an unintended effect. four, life is like a gift and human beings are not the absolute owners of their lives 5 . defense of pain medication against mercy argument: among the above counter arguments, the most important argument in my view is that which proposes pain medication as a solution to pain and suffering. though other arguments have their meaning and significance, however, if a patient is not to be killed, the patient deserves to live painlessly; pain and suffering are real harm. there is no other way but to resort to pain medication if severe and unbearable pain of patients is to be removed. arguments that downplay pain that many ill people suffer are made by people who i think have never suffered the acute pain or fail to estimate rightly the intensity of the pain that occur in some diseases. the realism regarding terminally ill patients is that some of them do go through a lot of pain and between killing them and pain medication, the choice which stays on life saving side is, indeed, pain medication. with highly effective painkillers, now bangladesh journal of bioethics 2012; 3(2):4-15 6 available, great pain that terminally ill patients suffer could be prevented. therefore, use of painkillers, not euthanasia, is the answer to painful terminal illness. however, enhancing pain medication management is in need of a continuous effort because “[i]n up to 90 percent of [cancer] patients, the pain can be controlled by relatively simple means. nevertheless, under treatment of cancer pain is common because of clinicians’ inadequate knowledge of effective assessment and management practices, negative attitudes of patients and clinicians toward the use of drugs for the relief of pain, and a variety of problems related to reimbursement for effective pain management” 6 . on the basis of mercy argument, in a restrict sense, when the case is related to terminally ill patients, proponents of active euthanasia argue that the patients whose death is foreseen instead of killing them they are left to die and their dying process takes days and weeks in suffering, such patients could have been better off by active euthanasia by putting end to their suffering. against this thinking, i argue in two ways. the first is that pain killers coupled with efficient palliative care help minimizing unbearable pain and save people from committing to act of killing which is an undesirable solution on many grounds and an option disfavored by majority cultures and countries of the present world. the second is that for those patients who are terminally ill and their life may be miserable due to the pain which is caused by illness, removing their immediate harm should be first priority; therefore, providing pain medication to such patients in a careful manner without crossing the appropriate bounds by overdosing them ought to be allowed, even that may have side effects leading to hastening death as an unintended consequence. pain medication has been regarded by catholic and islamic bioethicists as a solution and right alternative to active euthanasia while treating painful, suffering terminally ill patients. in catholic bioethics, the issue is discussed under various applications of doctrine of double effect (dde). in islamic writings on the issue, discussions have in various ways tackled issues, some have even rejected such pain medication and some have allowed it without setting any definite guidelines. after some scrutiny of the views, i argue that the discussion in line with the broader guidelines set in the primary sources of islamic law and ethics i.e. the quran and sunnah, the issue could be refined with a decisive stance within a careful discussion that undertakes study of various legal maxims (al-qawaid al-fiqhiyyah) relevant to the issue in their applications. the legal maxims retain their due justification because of their derivation from the primary sources of islam and their widely acceptance as guiding principles in debates wherein their application is invoked such as ethical discussions including the issues related to bioethics. the purpose of discussing islamic and catholic positions on the issue of pain medication opens up a venue of dialogue between two ethical traditions which share many common points. doctrine of double effect (dde): catholic principle for pain medication: there are many names for doctrine of double effect (dde) such as principle of double effect (pde), rule of double effect (rde), double-effect reasoning (der), and simply double effect. “the words "double effect" refers to the two effects that an action may produce: the one aimed at, and the one foreseen but in no way desired” 7 . the distinction is between “direct and indirect agency” 8 . intentions or their lack make moral difference and likewise morality of means that are used to accomplish an act are also considered 9 . the doctrine of double effect holds that there is difference between “what one aims at (one's direct intention) and what is foreseen bangladesh journal of bioethics 2012; 3(2):4-15 7 but is not intended (one's oblique intention)” and “it is always wrong to do an action whose intended consequences are bad for the sake of foreseen consequences that are good, but that it may be permissible to perform an action whose intended consequences are good even though the foreseen consequences are bad” 10 . the principle of double effect beside its various applications in moral issues is of practical significance in many bioethical issues including its use and significance of justifying pain medication. it is one of “the most significant principles proposed by all catholic medical ethicists” 11 . thomas aquinas is credited with introducing the principle of double effect in his discussion of the permissibility of self-defense in the summa theologica 12 . according to him, “nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention” 13 . the classical formulation of the principle requires fulfillment of four conditions if the action in question is permissible: “(1) the act is good or at least indifferent regarding the end that one directly intends. (2) the good and evil effects follow immediately from the act; that is, the good effect is not obtained by means of the evil effect. (3) one only intends the good effect but merely tolerates the bad effect, even if that bad effect was foreseen prior to the act. (4) there is a proportion between the good and bad effects; that is, the good must be at least equal to the bad” 14 . “sometimes a fifth condition, “there must be a grave reason for permitting the evil effect” is added, but this is already covered by the third condition. because it is not possible to avoid all harmful side effects and at the same time to fulfill our obligations to do the good from which these harmful effects also result, we need a principle to guide us in such dilemmas” 15 . in brief, “all authors agree on four conditions to justify an act under the principle of double effect, although all do not follow the same order in proposing the four conditions” 16 . thought the doctrine has many applications; in particular, its application in treating terminally ill is widely accepted and traditionally practiced by clinicians. the principle is used to justify the case where a doctor gives drugs to a patient to relieve distressing symptoms even though he knows doing this may shorten the patient's life. this is because the doctor is not aiming directly at killing the patient the bad result of the patient's death is a side-effect of the good result of reducing the patient's pain. many doctors use this doctrine to justify the use of high doses of drugs such as morphine for the purpose of relieving suffering in terminally-ill patients even though they know the drugs are likely to cause the patient to die sooner. the double effect doctrine, as applied in medicine, is based on two basic presuppositions: the doctor's motivation is to alleviate suffering; and the treatment must be proportional to the illness. the doctrine applies if 1) the desired outcome is judged to be good e.g., relief of suffering; 2) the bad outcome e.g., death of patient is not intended; 3) the good outcome is not achieved by means of the bad, and 4) the good outcome outweighs the bad 17 . these conditions of the principle are well elaborated on practical grounds by wanzer et al. (1989/1990); they suggest that in the patient whose dying process is irreversible, the balance between minimizing pain and suffering and potentially hastening death should be struck clearly in favor of pain relief. they recommend that pain medication should be given in whatever dose and by whatever route is necessary for relief. they further suggest that in extreme cases it is morally correct to increase the dose, even though the medication may contribute to the depression of respiration or blood pressure, the dulling of consciousness, or even death, provided the primary goal of the physician is to relieve suffering. they bangladesh journal of bioethics 2012; 3(2):4-15 8 suggest that however the proper dose of pain medication is the dose that is sufficient to relieve pain and suffering, even to the point of unconsciousness 18 . it is therefore an accepted practice to use doctrine of double effect in such cases which contain suffering. even in cases where death is imminent and pain cannot be minimized or eliminated through normally accepted dosages of medication, active euthanasia is not the only option. a doctor can give the necessary pain medication if the intent is solely to alleviate pain and not to kill, even if it can be foreseen that such an action will hasten death. in this case death is a foreseen, tolerated, but an unintended effect. contemporary islamic discourse on pain medication: pain medication is one of the new bioethical issues; therefore, discussions on it are contemporary in islamic writings and no outright guidance on the issue is found in the traditional writings. generally, pain medication and palliative care is a medication option. the traditional islamic guidance on medication is based on different opinions of jurists on nature of permissibility of medication in islam. the discussion is stuffed with many opinions from many jurists based on their (ijtihad) and preferences of evidences present in the recorded traditions of the prophet muhammad called as hadith and sunnah. in brief, the conclusions on islamic stance on medication were made in the resolution that was passed in the seventh session of majamul fiqh al islami held in jeddah on 7-12, 11, 1412 h. according to the resolution, medication in light of the quran and sunnah is permissible because it guards the self of a person and its protection is one of the aims of islamic shariah. however, injunctions regarding medication are types according to cases. medication is obligatory (wajib) if its abandonment leads to the fatality of the life or an organ or causes its inability or the disease transmits to others such as communicable diseases. medication is commendable or recommended (mandub) if its abandonment leads to weakness of the body with the abovementioned. it is permissible (mubah) if above two categories are excluded. it is reprehensible (makruh) if by doing medication there is worry of having more trouble than the disease itself that is considered to be cured 19 .however, the statement has not touched pain and suffering of patients who are mostly terminally ill and their pain is sometimes unbearable. should they do pain medication? especially, when their pain makes them unable to do the daily functions and leaves them like disabled persons with cries and tears. the traditionalist scholars have not addressed this issue because the issue is itself new. because of modern advanced developments in medical sciences that lead to development of pain killers that can minimize pain of a patient and in face of emergence of various new diseases and identification of unknown diseases in a rampant manner that cause immense pain to patients, the islamic response to the issue has become necessary. therefore, this issue has been discussed by contemporary muslim scholars and professional bodies concerned with bioethical issues. the contemporary discourse on pain medication among muslims is part of fatwas and statements made by scholars. these statements are with both conflicting and complimentary material. islamic medical codes have concisely touched the issue with indefinite precision. the fatwas and statements on pain medication are two types. the first type supports prohibition of pain medication that may enhance death and the second type supports permission. the first type disallows pain medication that may hasten death; these fatwas are based on those prophetic traditions which encourage bangladesh journal of bioethics 2012; 3(2):4-15 9 patience with greater reward in hereafter. for example, the prophet said, “no fatigue, nor disease, nor sorrow, nor sadness, nor hurt, nor distress befalls a muslim, even if it were the prick he receives from a thorn, but that allah expiates some of his sins for that” 20 . in addition, these fatwas take justification from the legal maxims that say, “harm is not eliminated by the similar harm” (ad-dararu la yuzal bi mithlihi). in line with this, some similar fatwas allow pain medication in the general sense that do not mention hastening death even though the medication is based on substances that are prohibited in islam by taking justification from the legal maxim , “necessity makes the unlawful lawful” (al-darurat tubih al-mahzurat). the works on legal maxims that are related to their application to bioethical issues mostly written in arabic have not deliberated on pain medication that is under consideration here. the second type of fatwas and statements allow pain medication for terminally ill patients, even though it hastens their death, without explaining more on the quality and quantity of medication. for example, the islamic code of medical ethics, issued by the first international conference on islamic medicine held in kuwait, in 1981, in its article sixty-two, it states that among “examples of what is not covered by the term “mercy killing” and, therefore, permissible is “the intensified administration of a strong medication to stop a severe pain, although it is known that this medication might ultimately end the patient's life” 21 . in answer to the question, “should cancer patients' requiring heavy pain medication take the medication or be in pain patiently and remember god”, the answer given to the question states : “they must be given pain medication, remember god, and be patient about residual inevitable pain that cannot be relieved medically. a heavy dose of is permitted if necessary provided the intention (niyyah) is not to kill the patient” 22 . islamic medical association of north america (imana) also states that terminally ill patients “… should be treated with full respect, comfort measures and pain control” 23 . hassan hathout, md, phd answers the question “ for a patient who has cancer with bone metastasis and is in constant pain, is it better that he takes strong pain killers all the time or be in pain and remember god?” by stating “he should take pain killers as god does not want him to suffer. in severe pain he may not have the strength to remember god” 24 . islamic code of medical ethics states, “the claim of killing for painful hopeless illness is also refuted, for there is no human pain that cannot be conquered by medication or by suitable neurosurgery” 25 . rationale of islamic discourse for pain medication: muslims in regards to bioethical issues turn to islamic guidance on the related issues and in response to demanding nature of the subject, few medical codes have been drafted, conferences are being organized, and fatwas are being written in response to ever growing new issues and demands of guiding decrees from public on the related matters. from western muslim minorities to eastern majority muslim countries the fact remains that muslims as being communities are collectively unanimous on upholding legal, ethical religious sources in resolving the bioethical issues rather than considering seriously any other moral basis of resolution such as utilitarianism or virtue ethics. some writings by muslim scholars on bioethical issues are sympathetic to virtue ethics with religious justification that is in line with western biomedical virtue ethics that includes respect for “autonomy, nonmaleficence, beneficence, and justice” 26 as expounded by tom l. beauchamp and james f.childress in their pioneer work, principles of biomedical ethics; however, majority works written by muslim scholars prefer to base their resolutions on original sources of islam. therefore, these writings stick to the islamic juristic methodology (usul al-fiqh), both in loose and strict manner, with considerations of the higher bangladesh journal of bioethics 2012; 3(2):4-15 10 intentions of shariah (maqasid shari'ah) and applications of some relevant maxims of islamic laws (alqawaid al-fiqhiyyah). pain medication is among the difficult issues in islamic bioethics because no clear and direct statement from the quran and sunnah on the issue could be stated, except that islam clearly prohibits killing and suicide. the subject is in need of ijtihad on the issue which vacillates between the clear guidance of islam on prohibition of killing on one hand and permissibility of removal of harm and difficulty in matters connected to muslims. therefore, the case of pain medication has to be understood in the discourse that is conditioned with prohibition of killing and permissibility of removing harm. quranic verses on the prohibition of killing are clear and comprehensive in principle. they include: prohibition of killing, prohibition of helping on prohibited acts, consenting to self destruction, and suicide. regarding the prohibition of killing, the quran prohibits unjustified killing: “and do not kill anyone whose killing allah has forbidden, except for a just cause….” 27 . furthermore, intentional killing is extremely prohibited: “and whoever kills a believer intentionally, his recompense is hell to abide therein, and the wrath and the curse of allah are upon him, and a great punishment is prepared for him” 28 . the quran prohibits resorting to self destruction and suicide: “... and do not kill yourselves (nor kill one another). surely, allah is most merciful to you” 29 . the quran prohibits helping and cooperating on conducting sinful acts: “and do not help each other in sin and aggression” 30 . killing an innocent human being is one of the major sins in islam. these injunctions derived from the very first source of islamic guidance and legislation i.e. the quran clearly prohibit killing, and these injunctions in an aggregated manner prohibit all types of killings. on the other hand, in cases of pain medication, some patients go through lot of pain which is clear harm. regarding any kind of misery and harm, islam encourages its adherents to remove harm and difficulties. the quran clearly states that “allah intends for you ease, and does not want to make things difficult for you” 31 ; and “allah does not want to place you in difficulty” 32 .this ease is linked with the weakness that human beings have in their very nature; the quran states “god desires to lighten things for you, for the human being has been created weak” 33 . in a consistent manner, the quran shows the manifestation of god’s desire to ease as a reality in religious matters, the quran states “he has chosen you, and has imposed no difficulties on you in religion” 34 . in the similar way, the prophetic traditions also restate the same message: “religion is easy...” 35 . without any doubt, human element of creating ease or difficultness has no role to play in the formulation of issues and injunctions that are clearly stated in the quran and sunnah. however, the human nature and its inclination towards difficultness or ease may sometimes inaptly play its role in the process of comprehension and interpretation. against this possibility, evidences for justification for any decision or position are to be understood in a holistic manner, keeping the overall sprit of islam in mind, relying on proper methods, and working through evidences in reaching conclusions that seem on scrutiny in line with obviously understandable easy nature of religion. keeping this in mind, the prophetic traditions indicate to the probable extrinsic role of human element and desire in understanding nature of religion and the obligations which come with it. the prophet states “the best of your religion is that which is easiest...” 36 . he further states, “religion is very easy and whoever overburdens himself in his religion will not be able bangladesh journal of bioethics 2012; 3(2):4-15 11 to continue in that way. so you should not be extremists, but try to be near to perfection and receive the good tidings that you will be rewarded; and gain strength by worshipping in the mornings, the nights” 37 . therefore, those in position of expounding religion and guiding masses to it have to steer clear on this stance of islam, the prophet clearly guides, “facilitate things to people (concerning religious matters), and do not make it hard for them and give them good tidings and do not make them run away (from islam)” 38 . the central to the easiness of islam on removing harm and difficulty is the consideration which god gives to the human capacity, as he clearly states “la yukallifullahu nafsan illa wus'aha” , allah does not burden a person with something more than he can bear 39 . islamic legal maxims and pain medication: rethinking and resolution: the doctrine of double effect according to catholic ethics in regards to pain medication gives a clear premium to intentionality. the islamic moral principle among maxims of islamic jurisprudence (al-qawaid al-fiqhiyyah) that is close to the matter is (al-umur bi maqasidiha) which means “matters shall be judged by their objectives” or “acts are judged by the intention behind them”. the principle is without dispute applicable to almost all moral actions. this principle is well founded on the sound tradition of the prophet in which he states: “actions are but by intention and each person will have but that which he intended” 40 . however, application of such a principle is not without qualifications when applied to ethical issues. any adequate qualification of the principle has to be understood in line with other maxims of islamic jurisprudence. in regards to the issue of pain medication, the qualifying and conjunctive maxims are: “harm shall be removed” (al-darar yuzal) ; “harm must be eliminated but not by means of another harm” (ad-dararu yuzalu wa lakin la bi-darar); “harm is not eliminated by another harm” (ad-dararu la yuzalu bid-darar); “harm is not eliminated by the similar harm” (ad-dararu la yuzal bi mithlihi) ; “a greater harm is eliminated by means of a lesser harm” (ad-dararu alashadd yuzal bid-darar al-akhaff); “harm is eliminated to the extent that is possible” (al-darar yuzal bi-qadr al imkan); and “necessity is measured in accordance with its true proportions” (al-darurat tuqaddaru biqadriha). none of these maxims certainly lead to permissibility of pain medication that may result in death; therefore, we find the writings on the issue of applicability of these principles to the pain medication have altogether missed the point. those who allow pain medication have resorted to other famous maxim i.e. “necessity makes the unlawful lawful” (al-darurat tubih al-mahzurat); however, their use of the maxim in an unqualified manner is not justifiable. in seeking a resolution of the issue in light of the broader guidelines of islamic shariah and application of islamic jurisprudential maxims, first of all, the issue of pain medication has to be made clear. to do so, a subject case or problem for pain medication is formulated: suppose a person who is terminally ill or nonterminally ill experiences a great deal of pain that besides creating unbearable pain also renders conducting daily tasks difficult. patience on enduring such pain is not possible to live with because of the intensified nature of the pain and its hampering a person’s ability to conduct daily tasks. since killing such a person for the alleged reasons of mercy is prohibited on islamic guidance, whereas, on the other hand, living with pain and suffering is also not possible, the only option that remains open is to carry out pain medication. using pain medication, on one hand, controls the pain and, on the other hand, it shortens in some cases the life expectancy which comes as a side effect; in other words, it hastens death. to put it another way, there is bangladesh journal of bioethics 2012; 3(2):4-15 12 harm and that is pain and removing that harm leads to other harm and that is hastening death. sometimes overdose of the medication can cause a sudden death. in resolving the above issue, the question arises: what a muslim patient and a physician are supposed to do, in compliance with the islamic bioethical guidance, regarding the matter. when thinking about the case under consideration, there are obviously very important elements which need to be understood properly. they are: hardship (al-íaraj); intent (niyyah); and necessity (al-darurat). in the above-mentioned supposed case the patient undergoes a severe pain which could not be removed unless pain medication is applied, the juristic maxim “hardship shall bring alleviation”, (al-mashaqqatu tajlib al-tayseer) allows that such harm should be removed. this maxim is based on the injunctions of the quran which are aimed at removing harj. therefore, pain medication becomes a permissible option. however, this pain medication should be aimed at removing harm, not causing it. this is based on another juristic maxim “harm shall be removed”, (al-darar yuzal) as derived from the hadith that “harm may neither be inflicted nor reciprocated in islam” (la darar wa la dirar fil islam). therefore, it depends on the nature of intentionality of both the physician and the patient; if the right intentionality is present in both the physician and the patient that is aimed at removing the severe pain, it would turn pain medication into a permissible act. this is based on the other famous juristic maxim known as “matters shall be judged by their objectives”, (al-umur bi maqasidiha). this principle is without dispute applicable to almost all moral actions. this principle is well founded on the sound tradition of the prophet in which he states: “actions are but by intention and each person will have but that which he intended”. however, one can argue on the basis of other maxims that state, “harm must be eliminated but not by means of another harm” (ad-dararu yuzalu wa lakin la bi-darar); and “harm is not eliminated by another harm” (ad-dararu la yuzalu bid-darar). therefore, an injury should not be relieved by a medical procedure that leads to an injury of the same magnitude as a side effect, (addararu la yuzal bi mithlihi). and when choice is between two kinds of harm, the greater harm should be removed; it is based on another maxim, “a greater harm is eliminated by means of a lesser harm” (addararu al-ashadd yuzal bid-darar al-akhaff). in light of these maxims, it seems hastening death is a greater harm therefore removing small harm that causes it is not legitimized. therefore, pain medication should not be permissible. however, rethinking these maxims while including other relevant maxims such as “harm is eliminated to the extent that is possible” (al-darar yuzal bi-qadr al imkan) provides space for permissibility. furthermore, since pain is unbearable therefore it creates a necessity and the maxim which applies to necessity is “necessity makes the unlawful lawful” (al-darurat tubih al-mahzurat). and “pressing needs (hajat) are treated as necessities (daruriyyat)”. however, the permission on the basis of necessity should not exceed the due proportion and limits of permissibility. therefore, the necessity in case of pain medication has to be understood well and it should be applied to the legitimate and limited proportion; this insight is covered by other relevant maxim that states “necessity is measured in accordance with its true proportions” (al-darurat tuqaddaru bi-qadriha). the principle of necessity that implies the permission of unlawful in necessary conditions is beside many verses of the quran based on the verse from the chapter of the cow (al baqara) which states: “he hath only forbidden you dead meat, and blood, and the flesh of swine, and that on which any other name hath been invoked besides that of allah. but if one is forced by necessity, without wilful disobedience, nor transgressing due limits, then is he guiltless. for allah is oftbangladesh journal of bioethics 2012; 3(2):4-15 13 forgiving most merciful” 41 . in this verse, the necessity is conditioned with two conditions: the permissibility should not transgress due limits and it should not be a wilful disobedience. in light of the above discussion based on the quran and the legal maxims, it seems that statements and opinions made by muslim scholars in favor for pain medication have justification in islamic sources. therefore, given pain medication to a patient is allowed even if it hastens death as a side effect as an unintended consequence. however, it would not be permissible if the pain medication transgresses the due proportions and limits such as overdosing, in such case it would be prohibited. to illustrate this limit, overdosing a patient with pain killers that will result in abrupt death would be prohibited. furthermore, opinions which go against pain medication seem very unrealistic as they actually do not demonstrate realistic understanding of the levels of pain and its intensity that passes into the categories of “necessity” and “pressing need”. conclusion: pain medication is one of the responses to the mercy argument that is used by proponents of euthanasia, especially utilitarian ethicists. they argue that mercy killing should be allowed on the grounds of mercy. among the trends and traditions that oppose mercy killing are catholics and muslims. they base their approach on religious grounds beside other ethical principles derived from religious sources by theologians and jurists. islamic and catholic traditions allow pain medication. catholic approach to pain medication beside other reasons is in practical way treated as an application of principle of double effect. this principle with stipulated conditions allows pain medication even if it hastening death as an unintended consequence. the islamic discourse on pain medication is between denial and acceptance of pain medication. some statements of muslim scholars prohibit it and some allow it. the resolution on the issue is sought by synthesizing the views and legal maims on the issue, which in conclusion provide justification for pain medication by considering pain as necessity and pressing need. however, such resolution allows pain medication to the limit and proportion that removes the pain and prohibits overdosing the patient with medication that may directly cause the death. references 1. moreland jp, geisler nl. the life and death debate moral issues of our time westport, ct: praeger; 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(m. m. khan, trans.). book: 70, hadith : 545. available from: http://www.searchtruth.com/hadith_books.php. 21. the international islamic code for medical and health ethics the islamic organization for medical sciences (ioms) 1981. 22. hathout h. medical ethics questions from the audience during the medical ethics symposium at isna convention. shahid athar; 1997 [cited 2012 march 5]; available from: http://www.freepctools.com/ethics.htm. 23. islamic medical ethics islamic medical association of north america, committee ie. 24. hathout h. frequently asked medical ethics questions. islamic medical association of north america; [cited 2012 3 may]; available from: http://www.isna.net/leadership/pages/islamicmedical-ethics.aspx. 25. islamic code of medical ethics available from: www.emro.who.int/morocco/docs/en/islamic_ethics. 26. beauchamp tl, childress jf. principles of biomedical ethics. 5th ed. ed. oxford: oxford university press; 2001. 27. the quran, 17:33. bangladesh journal of bioethics 2012; 3(2):4-15 15 28. the quran, 4: 93. 29. the quran, 4: 29. 30. the quran, 5:2. 31. the quran, 2:185. 32. the quran, 5:6. 33. the quran, 94:28. 34. the quran, 22: 78. 35. al-bukhari. sahih al-bukhari. (m. m. khan, trans.). book, 2 hadith, 38. available from: http://www.searchtruth.com/hadith_books.php. 36. imam ahmad bin hanbal. musnad al-imam ahmad. vol. 3. 37. al-bukhari. sahih al-bukhari. (m. m. khan, trans.). book 2, hadith 38. available from: http://www.searchtruth.com/hadith_books.php. 38. al-bukhari. sahih al-bukhari. (m. m. khan, trans.). book 3, hadith 69. available from: http://www.searchtruth.com/hadith_books.php. 39. the quran, 2:286. 40. al-bukhari. sahih al-bukhari. (m. m. khan, trans.). book 1, hadith 1. available from: http://www.searchtruth.com/hadith_books.php. 41. the quran, 2:173. bangladesh journal of bioethics 2014; 5(3):28 26 news of bbs collaboration: bbs has established an academic scholarly exchange and collaborative agreement with american university of sovereign nation (ausn), arizona, usa to promote cooperation and scholarly advancements in the fields of education, academic research, bioethics, disaster prevention and mitigation, global studies, public health and medicine, and peace. as a first initiative, ausn took some bbs’s member for one year mbgph (master of bioethics and global public health) hybrid online and onsite master’s degree program. ausn provides scholarship to cover tuition. bbs has also established collaboration with college of medicine, national taiwan university & hospital to build collaborative research platform and professional training workshop for cancer treatment, hospice/palliative care and bioethics in southeast asian countries. intensive training workshop: bbs is going to organize three days intensive training workshop on bioethics and research: preparing ethical professionals to be held on dhaka, bangladesh, 2-4 january 2015, at centre for advanced research in sciences, dhaka university in collaboration between bbs and eubios ethics institute and ausn. all are requested to attend the workshop. speaker: professor darryl macer, director of the institute of indigenous peoples and global studies, and dean, masters program in bioethics and global public health (mbgph), ausn, usa. members of bbs in conferences in abroad: a team of two members attended the 15th asian bioethics conference, 19, november 2014 in japan. they contributed with their scholarly research paper in the conference and enhance the prestige of bbs. following papers were presented during the conference. public responsibility in healthcare. shamima parvin lasker professor & head of anatomy, city dental college, dhaka , bangladesh; general secretary, bangladesh bioethics society; vice president for south asia, asian bioethics association. ethical issues in biomedical research on human subjects in developing countries, dr. abdus shakoor, associate professor of physical medicine, bsmmu. challenge of palliative care bangladesh journal of bioethics 2013; 4(3):19-24 19 challenges of palliative care shamima parvin lasker professor and head of anatomy, city dental college, dhaka, bangladesh general secretary, bangladesh bioethics society. abstract: it has been moral duty of physicians to save and prolong patients‟ life for as long as possible. but the philosophy of treatment regime for terminally ill patients had been changed. to save and prolong human life if it is meaningful has got added value. many criticizes the modern way of death. palliative sedation, euthanasia as a good death model is criticized for medicalization of management of death. currently, end of life issues are one of the top 10 health care ethics challenges facing the public. there is a new ethical challenge that human life can be ended by a doctor, passively or actively or a doctor kills the patient. withholding and withdrawing, refusal of treatments, physician-assisted suicide, do not resuscitate (dnr) orders, advance directives, consent and quality of end of life care and are the main debates in this field. there are many complex ethical issues that can affect patients and families in the health care setting. good understanding of medical ethics will contribute to the health professional's decision-making and dayto-day practice of medicine for a terminally ill patient. key words: challenges, palliative care introduction: medicine or healthcare is not only to provide cure but also to offer comfort and empathy. palliative care creates an environment where healthcare providers, patients, and patient‟s families can consider what treatments will or will not be used to treat a life threatening illness. the goal of palliative care is to improve the quality of life of patients and reduce the burden of illness by reducing the use of aggressive treatment measures at end stage disease and reduce suffering of long-term illness through managing symptoms providing nursing care and psycho-social and spiritual support. but the people are not aware about this mode of treatment. it is still an emerging field even in developed countries. plan of palliative care is to make pain relief as a basic service only in most of the asian countries. unfortunately, care is merely limited to diseases like cancer. this policy is not translated into extensive service provision. history of death system: traditionally a man who suffered from end stage disease called not the doctor but the religious person. man was dying at home. he saw death as a spiritual passage. the authority of dying process was priest/ moulovi / purohit. funeral and mourning adheres to the family. due to the improvement of nutrition and medical technology death rate reduced dramatically. dying is no longer seen as spiritual but a medical condition. key person is the doctor. patient is hospitalized and dying bangladesh journal of bioethics 2013; 4(3):19-24 20 at hospital. family and close relative keep their grief privately. three quarter of british died in this modern system of death. of 70% death is britain is now followed by cremation. rising of individual and collapsing of community, dying person is the key person of the dying process. patient has right to dye without pain. dying person can take decision when and how he /she wants to die (euthanasia, assisted suicide). dying person can celebrate own funeral before death and get time to say goodbye to family members. relative can express grieve and talk how they feel to the dying person. patients suffering from pain for long time with cancer, hiv/aids, end stage cardiac or renal diseases, etc usually wish for postmodern system of dying. in usa, end-of-life care depletes 12% of total health care costs. many criticize the postmodern way of death. end of life issues are one of the top 10 health care ethics challenges facing people. challenges of palliative care: misconception: palliative care is applicable early course of illness, in conjunction with other therapies such as chemotherapy or radiation therapy, intending to prolong life and enhance the quality of life. according to definition of word health organization (who), palliative care is a n approach that improves the quality of life of patients and their family facing the problems associated with life threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical psychological and spiritual. but it is generally misconception that only people who are terminally ill and those whom doctors have given up hopes of any progress, need palliative care. information gap: death and dying is not a failure but the most natural things and sure event in life. but there is a custom not to talk about imminent death to a terminal ill patient in many society and culture. patients may not have discussed end-of-life decisions and wishes with their families while they were competent. family members often do not want to be the ultimate decision maker when death is inevitable. intensive care unit health care professionals may have challenged to support patients and families due to lack of information. pain: pain is the dominant symptom in advanced stage diseases. pain can make a patient anxious, discomfort and impatient. due to continuous pain patients accompany unhappy death. family members are repentant with sorrow due to miserable death of their love one. pain relief can be successfully achieved by the scientific and holistic approach of analgesic administration in palliative care. unfortunately, studies such as the large support trial have shown that 50% of patients still die in pain and 33% of these people experienced severe pain in the last days of their lives. lack of knowledge and skill in pain assessment, improper medication, unavailability of morphine and fear of opioid addiction are some of the complex hurdle of palliative care. there is fear that drugs (sedatives and opioids) prescribed in the terminal stage hasten the death process. research critics the dutch end-of-life (eol) policies and claimed that approximately 20.1% of all deaths were cases in which death occurred following an increase of medication to alleviate pain symptoms. study revealed that one the patient died after an increase of morphine at the request of the family with alleviation bangladesh journal of bioethics 2013; 4(3):19-24 21 of suffering and intention to hasten death. this case criticized practice of the use of increased morphine, with the intention to alleviate suffering and at the same time also shorten life. pain relieving medication has been administrated in the end stage disease for its “double effect principle”. in one hand it mitigates unrevealing pain and on the other hand it shortens life. the moral justification to provide analgesia at end stage disease for the noble intention of relieving distress provided that other conditions are satisfied. these conditions include, relevantly, that the physician must not intend to relieve distress by first killing the patient. the principle of double effect provides a basis for ensuring adequate symptom relief, even though this may hasten death, provided that this is not the physician‟s intention. the legal justification of use of analgesia for palliative care practices is less clear. physician value: the debate over influence of physician judgment on patient autonomy at end-of-life care has long been studied. study suggests that decisions regarding terminal patient care may be altered by a physician point of view and subjective attitudes toward dying patients. physician view on patient choice is more of an illusion than a reality. physician‟s anxiety towards death and their discomfort with dying patients reflect on their own past experiences, both personal and professional, impact on their feelings regarding the treatment options available to a given patient. study also shown that of 25 percent reported difficulty honoring advance directives if these went against what the physician believed was best for the patient. physicians picture the situation worse than it is in order to get the patient to decide what the physician feels to be in his/her best interests. goal is to hope for the best course of illness or for best quality of life for the longest possible time. physicians must be aware of their own values, beliefs and attitudes towards lifesustaining treatments as well as death and dying. ethics education should be intensify especially for physicians routinely involved in end-of-life care. do not resuscitation (dnr): some people believe that all attempts must be made to continue life since life is precious. family want to feel that they have tried “everything” for the patients. if heart of a patient stops, family members want to restart it with cardiopulmonary resuscitation (crp) using the paddles and electric shocks. this is not an easy or even very successful endeavour for the most of the cases. it may break some of ribs and bruise some of internal organs. if heart does not restart quickly, brain damage occurs. this may lead to loss of memory to paralysis. if heart restarts patient needs to be on life support afterwards. e. ezekiel, a bioethicist of nih, usa expressed concerns about the quality of care. physicians provide different aggressive therapy to who are not responding. “just to try something” is not only bad medicine, but also seriously unethical‟. in some cases, successful resuscitation is not possible as for example left ventricular dysfunction, advanced liver failure and metastatic cancer. in these cases physicians do not intent to offer cpr. in many countries of the world, patients and family members do not like to see the aggressive treatment at end stage disease on their love one and seek policy of do-not-resuscitate (dnr) in end-of-life care, even they may often seek to end his/her life quickly. decision making: decision making in terminal care is a demanding and stressful duty for all involved and in any setting (hospitals, nursing homes, hospices or at home). it needs of truth telling and patient's autonomy. every patient has the right to know about his illness (patient autonomy). physicians need to avoid giving bangladesh journal of bioethics 2013; 4(3):19-24 22 false hope of cure or of greater benefit than expected. palliative care team should nor hiding the truth neither telling the diagnosis abruptly, but gently breaking the news on a need to know basis. early and effective communications help both patient and family "digest" and accept the diagnosis and gives them a direction to move in. however, research has shown that patients and their families retain at best, 50% of the information they are provided. a competent patient can refuses unwanted medical treatment only. report says that nearly 6070% of seriously ill patients are unable to speak. capacity may be change over time due to delirium, drugs, lack of sleep, depression, emotions and the underlying illness itself may render a person incapable. therefore, capacity must re-evaluate time to time. unfortunately, capacity assessments have so far not been standardized. how capacity should be assessed, determinations of incapacity, who will give consent when patient is in incapable condition are challenged in palliative care. studies have shown that 62% of medical outpatients want to discuss their preferences in end-oflife care however only 10% of patients have completed an advance directive form in canada. decisions should be regularly reviewed in the light of changes in a person‟s condition or situation and review should always have as its aim the best interests of the patients. patient‟s beliefs and values should be respected in case of decisions making process in case of end of life issue even if these differ from the family or the health care professional‟s views. decisions also need to respect cultural or religious beliefs, and the specific needs of groups such as people from culturally and linguistically diverse communities. patients and their family will need time to think about their goals and expectations in light of diagnosis and expected disease course. they will need time to reflect on the treatment options, their risks and benefits in relation to their notion of quality of life, their life circumstances, past experiences, values, beliefs and in the context of their relationships with the patients. advance directives: the last period of life is much different from the rest of life, irreversible decay of bodily and mental capacities, pain and suffering, narrowing the consciousness and awareness, lack of time. may terminal palliative care patients like to avoid to being subjected to unnecessary tests, hospitalization, and intensive monitoring and resuscitation procedure. advance directive would be able to guide decisions in view of their previously expressed. advance directives aim to honor individual autonomy and respect individual wishes, values and beliefs irrespective of their background, condition or culture , way of dying (euthanasia, and to avoid the ethical conflicts associated with withholding and withdrawing medical treatment or assisted suicide). bioethics has placed a lot of emphasis on the principles of autonomy and self determination and value in decision-making. the patient, with the help of his/her health care providers, family members and loved ones, makes decisions about his/her diagnosis, prognosis, the expected course of the illness and the possible treatment alternatives, their risks bangladesh journal of bioethics 2013; 4(3):19-24 23 and benefits. however, confronted with dying patients may be seen as less important then relationships with loved ones and family and fears of burdening loved ones with their care. moreover, a person cannot know in advance his or her ability to cope and adapt to living with a disease and disability in real life. advance directives may improperly influence health care providers to limit the care. moreover, in some culture and religion advance directive is forbidden. palliative care is faced challenge to treat end stage diseased of these cultures as well. euthanasia: the practice of euthanasia is legalized in some countries (netherlands, belgium, some states of usa and australia). euthanasia poses an ethical dilemma in palliative care. recent dutch study, on 192 eol cases, where 2/3 of patients were not capable of making an explicit request for euthanasia. euthanasia predominantly the intention of the physician and not the patients wish. however, in some religion, terminating human life is unethical because it violates the moral belief that life should never be taken intentionally and the basic human right is not to be killed. how health services can go well beyond the biomedical model of health and treat the end stage patients with dignity is a great challenge. conclusion: good understanding of medical ethics and good communication may contribute to face some of these challenges. good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient's wishes and values. interdisciplinary seminar, conference and ethics training will provide valuable opportunities for participants to become involved in thoughtful, unique and creative dialogues with one another in terms of quality of care, professional and personal expectations, reluctance and resistance, institutional and individual. continued efforts are needed to overcome the barriers to successful implementation of palliative care. references: 1. alan meisel, lois snyder and timothy quill. seven legal barriers to end-of-life care myths, realities, and grains of truth. jama. 2000; 284(19): 2495-2501. 2. beckman m. 'rock star' of biomedical ethics tackles cancer. j natl cancer inst. 2007; 99:1426–7. 3. clare gardiner, sarah barnes, neil small, merryn gott, sheila payne, david seamark and david halpin. reconciling informed consent and‟ do no harm‟: ethical challenges in palliative-care research and practice in chronic obstructive pulmonary disease. palliative medicine 2010, 24(5) 469–472. 4. david j. casarett, ann knebel, and karin helmers, ethical challenges of palliative care research. journal of pain and symptom management 2003; 25(s3):4. 5. divya khosla, firuza d patel and suresh c sharma. palliative care in india: current progress and future needs. the indian journal of palliative care 2012; 18 (3): 149-154. bangladesh journal of bioethics 2013; 4(3):19-24 24 6.farzaneh zahedi, bagher larijani and javad tavakoly bazzaz. end of life ethical issues and islamic views iran. j allergy asthma immunol 2007; 6 (suppl. 5): 5-15. 7. frances norwood , gerrit kimsma and margaret p battin. vulnerability and the „slippery slope‟ at the end-of-life: a qualitative study of euthanasia, general practice and home death in the netherlands . family practice advance access 2009; 472-480. 8. ian anderson. end-of-life decision-making. continuing education program in end-of-life care. module 4. a joint project of continuing education and the joint centre for bioethics, university of toronto and the temmy latner centre for palliative care, mount sinai hospita. 9. joseph f. a palliative ethic of care: clinical wisdom at life's end. jones and bartlett publishers; 2006. 10. mousavi sm, akbari a, lotfi kashani f, akbari me, najd sepas h. euthanasia in cancer patients, islamic point of view iran j cancer prev 2011; 2:78-81 11. myers j, shetty n. going beyond efficacy: strategies for cancer pain management. curr oncol. 2008;15:s41–9. 12.monica k. crane, marsha wittink and david j. doukas. respecting end-of-life treatment preferences. am fam physician. 2005 oct 1;72(7):1263-1268. 13. nih-state-of-the-science conference statement on improving end-of-life care. nih consens state sci statements. 2004; 21:1–26. 14. national health and medical research council. an ethical framework for integrating palliative care principles into the management of advanced chronic or terminal conditions. national health and medical research council, australia 2011. 15. roger s. magnusson. the traditional account of ethics and law at the end of life and its discontents. bioethical inquiry 2009; 6:307–324. 16. rutecki gw, cugino a, jurjoura d, kilner jf, and whittier fc. nephrologists' subjective attitudes towards end-of-life issues and the conduct of terminal care. clinical nephrology. 1997;48:173-180. 17. scott y. h. kim. the ethics of informed consent in alzheimer disease research. nat. rev. neurol 2011;7:410–414. 18. van der heide a, onwuteaka-philipsen bd, rurup ml, buiting hm, van delden jj, hanssen-de wolf je, et al. end-of-life practices in the netherlands under the euthanasia act. n engl j med. 2007; 356:1957– 1965. bangladesh journal of bioethics 2015; 6(1):6-10 6 children as research subjects: the ethical issues dr. nahid ferdousi associate professor of law bangladesh open university email: nahid329@yahoo.com abstract: from the very beginning of civilization, children are made the subject matter of many social and clinical researches. due to the vulnerabilities of physical frailty and mental immaturity, children’s interests and rights need to be protected from the risks associated with any kind of research. recently, there has been increased global concern towards the involvement of children in research for the protection of their rights by the ethical research practice. it emphasizes upon the ongoing nature of ethical considerations that ethical issues need to be considered throughout the research process and even the post research ethical issues are equally significant. the study explores some of the major ethical issues that arise in research involving children during and after the research in terms of the best interests of the children. keywords: research; children; best interest; ethics; practice introduction: research stands for the systematic study of different social objects and phenomena which include human beings as they are the integral part of the society. there are so many vulnerable groups who have been being used as subjects of different kinds of research and the ethics of the research is required to uphold their rights, especially for the children. the basic principles of ethics ensure the principles of justice, mutual respect and the avoidance of doing harm to children subject to any research. as human beings, children are the beneficiaries of rights as articulated under a number of international human rights instruments for example, the international covenant on civil and political rights (iccpr) 1966 and united nations convention on the rights of the child (uncrc) 1989. these principles require that researchers attend to the relational as well as the procedural dimensions of research 1 . each state has a set of ethical rules as well as several international organizations and researchers have played a critically important role in developing ethical guidance for research involving children. the researchers must consider the potential negative impacts of research for the children’s lives, sense of identity and belongingness and the course of data collection, information gathering, interpretation and analysis of the collected data. in fact, the principle of beneficence refers to the actions that promote the well-being of children. rosie flewitt (2005) argued that researchers have a responsibility towards the participants of all ages not only to establish a robust and negotiated ethical framework for their research, but also to ensure that these ethical principles are applied throughout the stages of the research process. 2 from a historical perspective, research involving children have undoubtedly contribution to the generalization of knowledge and the construction of a body of information about the minds and behaviors of children. there are numerous ways of doing so. however, it is necessary for the researcher to recognize the reality of studying the children participants. research governance has expanded and a burgeoning literature is emerging that describes the processes, practices and difficulties that arise in social research in both developed and developing countries. 3 in europe and the usa, medical research has developed standards over several decades and the social researchers mailto:nahid329@yahoo.com bangladesh journal of bioethics 2015; 6(1):6-10 7 also agree to observe high ethical standards. in fact, children should not be placed at a disadvantage by being enrolled in a clinical trial, either through exposure to excessive risks or by failing to get necessary health care 4 . in practice, most of the research, children may be at the ethical questions that arise are about the best interests, the risks, the justification of a research for subjects along with the rights of the children and the authority of parents to give permission, the assent and consent which are related to children in research. similarly, the way in which these ethical issues are tackled in practice can be quite different from each other. often the way of conducting such researches could ignore, although most times unintentionally, the children’s rights. consequently, the children are presented as the silent victims of a tragedy, or are included in clinical research without their consent; whereas their human rights and their right to be protected are being jeopardized 5 . historical background: the historical origin of the ethical principles for research with children arose from the nuremberg trials, which took place after the second world war and the nuremberg code of 1947, which emerged first of these. the nuremberg code 1947 applied particularly to experimental research, although it had wider relevance to the key ethical principles in terms of voluntary consent, freedom to consent and avoidance of unnecessary pain or harm. the code sets out statements of certain moral, ethical and legal principles relating to the research involving human subjects. initially, these ethical guidelines were primarily concerned with medical research. however, they were subsequently used as a basis for guidelines for social research. thereafter, the emergence of the declaration of helsinki in 1964 which amended in 1989 and 1996 now includes an examination of the issue of children as research subjects in relation to informed consent in clinical research. the principles for conducting research contained in the declaration of helsinki apply to all human subjects, adults and children. the declaration indicated that adequate information must be provided to the research participants as well as participation in the research must be freely volunteered with the understanding that the participant can withdraw at any time. in addition, informed consent should be obtained, preferably in writing by the principles. there is one section, which refers specifically to research with children and states: “when the subject is a minor, permission from the responsible relative replaces that of the participant in accordance with national legislation. whenever the minor child is in fact able to give consent, the minor’s consent must be obtained in addition to the consent of the minor’s legal guardian. 6 however, there are different guidelines about the ethics of research with children, related to different disciplinary perspectives. 7 methods: this is a review article done during the participation in training course on ethical and regulatory aspects of clinical research, organized by bangladesh bioethics society in collaboration with department of bioethics, nih, usa through video conferencing on 01 october, 2014 to 12 november, 2014. the search was confined to google search and published articles. discussion: research in children is recognized as a moral duty based on several ethical principles. 8 these principles are universal, though there are of course many subtleties and diversities, and the contingent aspects of how principles are understood, interpreted and practiced can vary from place to place. in child research, the ethical questions about how to conduct research are deeply connected with the content of social or clinical theory. 9 however, many factors have to be taken into consideration so that the general research conditions are improved and not to the benefit of any particular party. 10 bangladesh journal of bioethics 2015; 6(1):6-10 8 ethical challenges during research: the general purpose of research that involves children is to obtain and produce scientific information about them. in this backdrop, the researchers should focus on the issues arising during research and take all reasonable precautions to ensure children will not be harmed or adversely affected by participating in the research. 11 similarly, researchers have to ensure that the children participating do so at their own volition and that the rights of the child are fully respected in the research process. the researcher is also obligated at all times to use the least stressful research procedure whenever possible. but the benefits of conducting such research must be balanced with ethical concerns. 12 the research in children has based its ethical guidance around some of the following principles: 1. informed consent: in every case informed consent must be obtained from the child’s legal representative and the child’s assent should be obtained through the provision of age-appropriate information. the application of general principles indicates that, where children have “sufficient understanding and intelligence to understand what is proposed”, it is they and not their parents whose consent is required by law 13 . the nuremberg code 1949 appears to introduce the concept of consent for the participation of children in research. according to the declaration of helsinki, even though a child may not be legally competent to give consent, researchers should gain informed consent. this means that parental consent is not enough and that both the parents and child should be informed about the implications of the research. parental and/or guardian’s (informed) consent is required for a child (a person below the age of 18) to participate in research. it is essential that the child has the full information about the research in order to give their ‘informed consent’ to take part, and that consent is ‘freely volunteered’ 14 . 2. assent and children’s indications of rejection: information presented to the child and parent, should explain: what will happen; what is being asked of the child; that the child can agree – or disagree to take part – without adverse consequences; and may withdraw at any time; and be given in clear language at a level that the child can understand, using visual aids if necessary. 15 if children are not fully informed of the research topic, informed consent is automatically denied even if the children are able to decide about participation, since informed consent exists only when one is fully informed 16 . 3. child protection and well-being: research involving children is important for the benefit of all children and should be supported, encouraged and conducted in an ethical manner. in the course of research, information comes to the researchers’ attention that may jeopardize the child's well-being. the researcher has a responsibility to discuss the information with the parents or guardians and with those experts in the field in order that they may arrange the necessary assistance for the child. thus, if at any time during the research process there is an indication that a child’s safety or well-being is being negatively affected; the research must be kept suspended until the issue has been addressed. if the child appears to be negatively affected by the research, the parent or guardian must be informed and the child and family must be offered with appropriate support. besides, extra time and support should be given for the children. similarly, dissemination of findings will need to be informed by an understanding of the specific communication needs of the children and their families 17 . 4. minimizing the risk of harm: ethical guidance and practices aim to minimize possible exploitation and ensure that the rights and welfare of children in research. accordingly, a key ethical consideration in research involving children is bangladesh journal of bioethics 2015; 6(1):6-10 9 the level of risk to which children may be exposed. risk refers to the potential harm (physical, psychological or social) that may arise from the research. the researcher should pose more identifiable risks of harm. similarly, researchers should not use those types of research procedure that may harm the child either physically or psychologically 18 . ethics after research: ethics after the research in children of equal importance like the ethics upheld throughout. the researcher has to ensure the ethical processing of data, the way this data will be stored and made available to others. personal data are usually protected by data protection laws, but there could be situations where a parent, who has provided consent, requires information about the research results, while the child participating in the research has been assured that her/ his answers will not be revealed. the topic of confidentiality is very problematic both for achieving the previously mentioned balance and protecting children participants from disclosure. one way of getting over this challenge is to ask for permission of the child subject to disclose information about the research afterwards although what the child understands can be very different 19 . hence, confidentiality is very important since the disclosure of information can put the children and their rights at risk. most of the researchers treat all information as confidential, but confidentiality cannot be guaranteed. so, in order to ensure the confidentiality of actual research, some researchers may think that compromising the results to parents and caregivers is not something that could harm the children subjects. the issue of privacy, for example, encompasses the trade-offs between confidentiality and child safety and the need to maintain confidentiality in the dissemination of research findings 20 . conclusions: in order to safeguard and promote the rights, dignity and well-being of children in and through research, it is important to promote more thoughtful attention to the complex ethical problems that arise when conducting research that involves children. before engaging in research on children it should first be clearly established that similar results could not possibly be obtained or derived from participants who are able to provide informed consent. even if this is established, the vulnerability of children must always be considered and they should not take part in research unless there is potential for the participating child to benefit from the results of that research. researchers should inform the children that they respect their right to withdraw from the research at any stage. thus, it is the obligation of researchers to protect both the rights and welfare of research subjects. hence, children should be given the chance to express their opinions, learn about themselves and their rights, while research activity must be regulated and the researchers must ensure that their rights of consent, confidentiality and unobstructed communication are protected at all times. references: 1 gerald p. koocher and patricia c. keith-spiegel, ethical approaches to gathering information from children and adolescents in international settings: guidelines and resources, the population council inc, usa, 2005, p. 3. 2 rosie flewitt, conducting research with young children: some ethical considerations, early child development and care, taylor francis group ltd, 175(6), 2005, p 554. 3 virginia morrow, the ethics of social research with children and families in young lives: practical experiences, working paper no. 53, department of international development, university of oxford uk, published by young lives, august 2009, p. 17. 4 md roth-cline, j gerson, p bright, cs lee & rm nelson, ethical considerations in conducting pediatric research, in h seyberth, a rane, m schwab, (eds.) pediatric clinical pharmacology, 1st edition, springer, 2011, p.1. bangladesh journal of bioethics 2015; 6(1):6-10 10 5 samantha punch, research with children: the same or different from research with adults?, childhood, department of applied social science, university of stirling uk, sage publications london, vol. 9(3), 2002, pp.321–341. 6 world health association: declaration of helsinki, paras i.9, p. 11. 7 shahanaz chowdhury, ethical considerations in research with children, bangladesh journal of bioethics, vol. 5(1) 2014, p. 37. 8 s j neill, research with children: a critical review of the guidelines, j child health care, vol. 9, 2005pp. 46–58. 9 pia christensen, “working with ethical symmetry in social research with children”, childhood, sage publications, london, vol. 9(4), 2002, p. 479. 10 g. p. koocher & p. c keith-spiegel, “children ethics and the law: professional issues and cases”, lincoln, nebraska: university of nebraska press, 1990, p. 11. 11 ma powell, rm fitzgerald, n taylor & a graham, “international literature review: ethical issues in undertaking research with children and young people”, the child watch international research network, southern cross university, centre for children and young people, lismore nsw and university of otago, centre for research on children and families, dunedin, nz, march 2012, pp. 1-51. 12 national institutes of health, office of human subjects research, the belmont report: ethical principles and guidelines for the protection of human subjects of research. <http://ohsr.od.nih.gov/guidelines/belmont.html> (accessed on 12 december 2014). 13 va miller, d drotar, e kodish, children’s competence for assent and consent: a review of empirical findings. ethics behav, vol. 14, 2004, p. 255. 14 s joffe, cv fernandez, rd pentz, et al. involving children with cancer in decision-making about research participation. j pediatr. vol. 149, 2006, pp. 862–868. 15 h.leonard & j.d glantz, conducting research with children: legal and ethical issues, sage publications, 1995, p. 19. 16 lovisa skånfors, ethics in child research:children’s agency and researchers’ ‘ethical radar’ childhoods today, vol. 3 (1), 2009, pp. 1-5. 17 guidance for developing ethical research projects involving children, department of children and youth affairs, ireland, april 2012, p.1.guidance for developing ethical research projects involving children. http://www.dcya.gov.ie/documents/publications/ethics_guidance.pdf. (access date:11/12/14) 18 virginia morrow and martine richards, the ethics of social research with children: an overview”, children & society, vol. 10, 1996, pp. 90-105. 19 katie schenk, and williamson jan, ethical approaches to gathering information from children and adolescents in international settings: guidelines and resources, population council. usa, 2005, pp.1-78. 20 cp merg, ethical principles, dilemmas and risks in collecting data on violence against children: a review of available literature, statistics and monitoring section/division of policy and strategy, unicef, new york, 2012, p. 1-61. conflict of interest: author declares no conflict of interest. children as research subjects: the ethical issues bangladesh journal of bioethics 2014; 5(1):5-10 5 institutional review board (irb): its role and responsibility in making research ethical dr. abu sadat mohammad nurunnabi bangladesh medical research council, dhaka, bangladesh. email: shekhor19@yahoo.com abstract: this is a review article prepared as a part of the assignment in the educational activity and training on research ethics titled “ethical and regulatory aspects of clinical research” arranged by the bangladesh bioethics society (bbs), dhaka, bangladesh, in collaboration with the department of bioethics of national institutes of health (nih), bethesda, maryland, usa, through video conferencing between september 25 and november 13 of 2013. the search was confined to ‘google’, ‘hinari’ and ‘pubmed’ published articles. besides, some guidelines on roles and responsibilities of institutional review board (irb) were taken into consideration. key words used for searching were ‘institutional review board’, ‘ethical review committee’ and ‘ethical research’. a total of 18 journal articles and some guidelines were selected for this writing. the systemic review from the databases revealed some important discussions on research, ethical research, roles and responsibilities of irb/erc and its challenges, and national/institutional research strategies. key words: institutional review board (irb), ethical review committee (erc), ethical research, research strategy. introduction: an institutional review board (irb), also known as an independent ethics committee or ethical review board, is a committee that has been formally designated to approve, monitor, and review biomedical and behavioral research involving humans 1 . they often conduct some form of risk-benefit analysis in an attempt to determine whether or not research should be done. the number one priority of irbs is to protect human participants from physical or psychological harm 2 . in the united states, the food and drug administration (fda) and department of health and human services (hhs) (specifically office for human research protections) regulations have empowered irbs to approve, require modifications in planned research prior to approval, or disapprove research. irbs are responsible for critical oversight functions for research conducted on human participants that are "scientific," "ethical," and "regulatory" 3 . although designed to protect the research participants, irbs have been criticized by bioethicists for conflicts of interest resulting in lax oversight. as of 2005, the for-profit western institutional review board claimed to conduct the majority of reviews for new drug submissions to the fda 4 . in a 2006 study of 575 irb members at university medical centers, over one-third reported industry financial ties and over one-third admitted they "rarely or never" disclosed conflicts of interest to other board members 5 . a 2009 sting operation by the government accountability office led coast irb to shut down after approving the fake product "adhesiabloc", called "the riskiest thing i’ve ever seen on this board" by one of the irbs not approving the fake products 6 . originally, irbs are committees at academic institutions and medical facilities to monitor research studies involving human participants, primarily to minimize or avoid ethical problems 7 . more accurately to say, conflict of interest of the researchers, indemnity for the protection of participants and confidentiality of data are widely accepted as core ethical issues in any research 8 . however, the belmont report 9 exists because of the unfortunate history of unethical mailto:shekhor19@yahoo.com http://en.wikipedia.org/wiki/committee http://en.wikipedia.org/wiki/biomedical http://en.wikipedia.org/wiki/behavioral http://en.wikipedia.org/wiki/research http://en.wikipedia.org/wiki/risk-benefit_analysis http://en.wikipedia.org/wiki/united_states http://en.wikipedia.org/wiki/u.s._food_and_drug_administration http://en.wikipedia.org/wiki/united_states_department_of_health_and_human_services http://en.wikipedia.org/wiki/united_states_department_of_health_and_human_services http://en.wikipedia.org/wiki/office_for_human_research_protections http://en.wikipedia.org/wiki/conflicts_of_interest http://en.wikipedia.org/wiki/conflicts_of_interest http://en.wikipedia.org/w/index.php?title=western_institutional_review_board&action=edit&redlink=1 http://en.wikipedia.org/wiki/government_accountability_office http://en.wikipedia.org/w/index.php?title=coast_irb&action=edit&redlink=1 http://en.wikipedia.org/w/index.php?title=adhesiabloc&action=edit&redlink=1 bangladesh journal of bioethics 2014; 5(1):5-10 6 research conducted on human participants in earlier times. this review has been prepared to highlight some of the key issues on roles and responsibilities of irb to make a research ethical. methods:this is a review article prepared as a part of the assignment in the educational activity and training on research ethics titled “ethical and regulatory aspects of clinical research” arranged by the bangladesh bioethics society (bbs), dhaka, bangladesh, in collaboration with the department of bioethics of national institutes of health (nih), bethesda, maryland, usa, through video conferencing between september 25 and november 13 of 2013. the search was confined to google, hinari and pubmed published articles. besides, some guidelines on roles and responsibilities of irb were taken into consideration. key words used for searching were ‘institutional review board’, ‘ethical review committee’ and ‘ethical research’. a total of 18 journal articles and some guidelines were collected and selected for this writing. results: the systemic review from the databases revealed some important discussions on research, ethical research, roles and responsibilities of irb/erc and its challenges, and national/institutional research strategies. research is defined as a systematic investigation designed to develop or contribute to generalized knowledge, or investigation designed to test a hypothesis 10 . the pursuit of new knowledge is considered one of the core missions of almost all institutions. to advance these missions, they must be committed to ensuring that research activities are conducted properly and consistently with the principles of openness, trust, and respect for the human participants. any systematic investigation (including curricular evaluation) that is designed to develop or contribute to generalized knowledge, and which uses living humans or identifiable private information about living humans, qualifies as human subjects research 11 . risk refers to the probability of harm or discomfort (these can be physical, psychological, social or economic) occurring as a result of participation in a research study. both the probability and the magnitude of possible harm may vary from minimal to significant 12 . however, a risk is minimal when the probability and magnitude of harm or discomfort anticipated in the proposed research are not greater than those encountered in daily life 13 . the department of health and human services [45 cfr 46.111(b)] and food and drug administration [21 cfr 56.111(b)] regulations require that additional safeguards be in place to protect the rights and welfare of research subjects "when all or some of the subjects are likely to be vulnerable to coercion or undue influence". the regulations do not provide a definitive list of vulnerable populations; they leave it largely to the discretion of the irb. some populations/groups that may be considered "vulnerable" include: pregnant women, children, prisoners, mentally challenged individuals, economically or educationally disadvantaged individuals and groups, etc. 14 . research that specifically targets a vulnerable population will receive a higher level of scrutiny than other protocols. this additional scrutiny is to insure that individuals are not being coerced into participation, that the consent process is culturally appropriate, etc. it is also important to remember that vulnerability must be considered in terms of the specific research proposed not all groups are vulnerable in all situations 15 . every research institute should formulate a policy statement, which should be made available to the irb. it should mention the type of research it will undertake, e.g. pre-clinical toxicology, animal studies in pharmacology or pathology, epidemiological surveys, clinical trials involving patients and studies using healthy volunteers, depending on its resources and infrastructure 16 . this will help in deciding the types of studies to be avoided. the purpose of research i.e. the benefits to be expected from the point of view of its staff, clients, students, society in general or the local community and the institute itself should be revealed in this policy 16 . bangladesh journal of bioethics 2014; 5(1):5-10 7 some irb reviews are conducted by for-profit organizations known as 'independent' or 'commercial' irbs. the responsibilities of these irbs are identical to those based at academic or medical institutions, and they are governed by the same federal regulations. the composition of an irb for the fda's requirements 17 is set in 21 cfr 56.107. (a) 1 the irb must have at least five members. (a) 2 the members must have enough experience, expertise, and diversity to make an informed decision on whether the research is ethical, informed consent is sufficient, and appropriate safeguards have been put in place. (a) 3 if the irb works with studies that include vulnerable populations, the irb should have members who are familiar with these groups. it is common for an irb to include an advocate for prisoners when considering research that involves them. (b) 1 the irb should include both men and women, as long as they aren't chosen specifically for their gender. (b) 2 the members of the irb must not be all of the same profession. (c) the irb must include at least one scientist and at least one non-scientist. these terms are not defined in the regulations. (d) the irb must include at least one person who is not affiliated with the institution or in the immediate family of a person affiliated with the institution. these are commonly called "community members." (e) irb members may not vote on their own projects. (f) the irb may include consultants in their discussions to meet requirements for expertise or diversity, but only actual irb members may vote. to vote on a proposal, more than half of the members of the board must be present and there must be a nonscientist present. exceptions for expedited review are available, where only the chair of the committee or a designee reviews research, but these are relatively narrow 17 . the primary ethical principles in human subjects review are outlined in the belmont report 9 , and include ‘respect for persons’, ‘beneficence’, and ‘justice’. it clearly explains the three principles that are the main tools that all irb members should use to evaluate the ethics of specific research proposals. respect for persons is the first principle which mandates that subjects voluntarily consent to participate in research, that they are adequately and thoroughly informed about the research and what is required, and that their privacy and confidentiality are protected. beneficence is the second principle which mandates the risks of research are justified by potential benefits to the individual or society and that those risks are minimized. justice is the third and final principle which mandates the equitable distribution of risks and benefits among those who may benefit from the research, meaning that one subset of a population should not take on all the burden of risk and reap all of the rewards; risks and rewards should be applicable and available to all subsets of a community. the irb may only approve research for which there is a bona fide informed consent process for participants, for which the risks to subjects are balanced by potential benefits to society, and for which the selection of subjects presents a fair or just distribution of risks and benefits to eligible participants 18 . the irb/erc should review a proposed clinical trial within a reasonable time and document its views in writing, clearly identifying the trial, the documents reviewed and the dates for the following 19 : http://en.wikipedia.org/wiki/belmont_report http://en.wikipedia.org/wiki/bona_fide http://en.wikipedia.org/wiki/bona_fide http://en.wikipedia.org/wiki/informed_consent http://en.wikipedia.org/wiki/clinical_trial bangladesh journal of bioethics 2014; 5(1):5-10 8  approval/favourable opinion  modifications required prior to its approval/favourable opinion  disapproval/negative opinion  termination/suspension of any prior approval/favourable opinion according to international conference on harmonisation good clinical practice (ich-gcp) 20 , an irb should safeguard the rights, safety, and well-being of all trial subjects. the irb should consider the qualifications of the investigator for the proposed trial, as documented by a current curriculum vitae and/or by any other relevant documentation the irb requests. moreover, the irb/iec should conduct continuing review of each ongoing trial at intervals appropriate to the degree of risk to human subjects, but at least once per year. the irb may request more information when in the judgment of the irb the additional information would add meaningfully to the protection of the rights, safety and/or well-being of the subjects. when a nontherapeutic trial is to be carried out with the consent of the subject's legally acceptable representative, the irb should determine that the proposed protocol and/or other document(s) adequately addresses relevant ethical concerns and meets applicable regulatory requirements for such trials. where the protocol indicates prior consent of the trial subject or the subject's legally acceptable representative is not possible, the irb/erc should determine that the proposed protocol and/or other document(s) adequately addresses relevant ethical concerns and meets applicable regulatory requirements for such trials (i.e., in emergency situations). the irb should review both the amount and method of payment to subjects to assure neither presents problems of coercion or undue influence on the trial subjects. payments to a subject should be prorated and not wholly contingent on completion of the trial by the subject. last but not the least, the irb should ensure the information regarding payment to subjects, including the methods, amounts, and schedule of payment to trial subjects, is set forth in the written informed consent form and any other written information to be provided to subjects. the way payment will be prorated should be specified. the purpose of institutional review boards or research ethics committees or ethical review committees is to ensure that studies involving human research participants are designed to conform the relevant ethical standards and that the rights and welfare of participants are protected 21 . research ethics committees should not function under political control or one’s sweet will 22 . ethics committees must be independent of research organizations. this independence relates to their decisions, not their operating processes 23 . in spite of the roles and responsibilities of irbs, the fact is that many are overloaded, understaffed and faced with a variety of skeptical criticism. many irbs are lacking the resources and staff to carry out the hefty task of reviewing research 24,25 . bangladesh scenario: it is praise-worthy that bangabandhu sheikh mujib medical university (bsmmu), the one and only medical university of the country, national institute of preventive and social medicine (nipsom), all the government medical colleges and different specialized government health institutes have got their own institutional review boards (irbs) or ethical review committees (ercs) for conducting research by the faculties, physicians, residents and students. however, several challenges have been identified in monitoring function of irbs on ongoing research in terms of annual review, consent, adherence to protocol, data integrity, auditing and quality assurance 2 . bangladesh medical research council (bmrc), the focal point for all biomedical research in the country, has got a strong ‘national research ethics committee’ to review the ethical aspects of a research project 26 . this committee was established in 1979. at present committee consists of 11 members. the clinicians, lawyers, laypersons and http://en.wikipedia.org/wiki/international_conference_on_harmonisation_of_technical_requirements_for_registration_of_pharmaceuticals_for_human_use http://en.wikipedia.org/wiki/good_clinical_practice bangladesh journal of bioethics 2014; 5(1):5-10 9 religious leaders are included as members. the committee is formed by the executive committee of the bmrc and has tenure of three years. the committee is registered in the office for human resource protection in the usa as an official institutional review board and it has federal wide assurance 2 . what is needed in our country is that all institutional review boards (irbs) in bangladesh should be operated in a standard fashion, providing an impartial, unbiased review and quick decision and thus facilitating a healthy atmosphere for ethical research in biomedical science in our country 8 . directorate general of health services (dghs), bangladesh, published a ‘national health research strategy’ in 2009 with technical assistance from bangladesh medical research council (bmrc) and world health organization (who) featuring different aspects of biomedical research which include institutional framework, priority setting, ethical clearance, financing, monitoring and evaluation, capacity development, dissemination and utilization of research results 27 . understanding the function of the irb requires an appreciation for the rules by which it is governed, as well as the history and circumstances that influenced the creation of those rules. researchers who appreciate the irb's purpose will be better equipped to navigate the labyrinth of research guidelines and regulations 28 . conclusion: biomedical 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environmental refugee: need for institution response and policy intervention bangladesh journal of bioethics, 2011;2(2): 4-19 riverbank erosion displacees in bangladesh: need for institutional response and policy intervention md fakrul islam, ph.d, and a.n.m. bazlur rashid, ph.d. 1. professor, department of social works, university of rajshahi, bangladesh 2. university of rajshahi, bangladesh abstract: environmental refugees are one of the most burning issues at this time throughout the world. bangladesh, a riverine country, is suffering from acquit riverbank erosion which compels millions of her population to be displaced from their place of origin. as such, 283 locations, 85 towns and growth centers, along with 2400 kilometers of riverbank line in bangladesh are vulnerable to erosion. the major rivers e.g., the padma, the jamuna, and the meghna, erode several thousand hectares of floodplain making thousands of people landless and homeless every year. along with the floodplain, bangladesh loses several kilometers of roads, railways, and flood-control embankments annually. no other disaster is as disastrous as riverbank erosion and ‘internally displaced populations’ (idp) face many unavoidable problems at different stages of displacement. displacement marginalized them in respect of livelihood patterns and psycho-physical troubles. such forty million homeless people in bangladesh are compelled to lead a floating life. riverbank erosion plays a major role in socio-environmental changes. the displaced people of riverbank erosion experience substantial socio-economic impoverishment and marginalization as a consequence of involuntary displacement from their original residence. findings of a social survey carried out in 2008 on the erosion-hit displaced people in chapai nawabganj and rajshahi districts are discussed in this paper. newly settled people along with the native inhabitants have been interviewed to reveal the problems associated with making rearrangements for the displaced people. besides these problems of displacement, adaptation strategies and relationships with the local people, their socioeconomic losses, sufferings, perception of natural disaster and psycho-physical problems, environmental ruins etc. have been revealed in this paper. there are no specific policies to rehabilitate the erosion-hit people. thus, it is time to formulate policies to address prevention of riverbank erosion as well as to rehabilitate the river-erosion refugees. 1.1 introduction bangladesh is a land of rivers. more than 700 rivers, with their tributaries and distributaries have criss-crossed the country forming a network of river system. it has about 2,400 kilometers of bank line and along with the bankline there are 283 locations, 85 towns and growth centers are vulnerable to erosion1. the padma (the ganges), the jamuna and the meghna, major rivers of bangladesh, erode several thousand hectares of floodplain, making thousands of people landless and homeless every year. in recent years, throughout the world, victims of environmental disasters are growing in number than the victims of war or other (man-made) forceful migration. victims of such political violence receive satisfactory media coverage along with different types of assistance from various national and international agencies. but the uprooted migrantscaused by environmental disastersfail to attract such level of local or international attention which tends them to be more vulnerable. according to the united nations university (unu), victims of political violence receive a lot of assistance from governments and international organizations in forms of financial grants, 1sustainable embankment maintenance through promoting settlers’ rights http://www.coastbd.org dated: 23 june 2007 4 http://www.coastbd.org/ bangladesh journal of bioethics, 2011;2(2): 4-19 food, tools, shelter, schools and clinics, but “environmental refugees” have not such access to receive aid.2 an empirical study conducted among the riverbank erosion displacees of rajshahi and chapai nawabganj, two districts of bangladesh, by writers in 2009. the respondents were displaced due to erosion of the padma and the mahananda, two rivers of the said two districts. 1.2 extent of bank-erosion and displacement rivers constantly alter their course, changing shape and depth, trying to find a balance between the sediment transport capacity of the water and the sediment supply. this process, called riverine erosion or riverbank erosion, is usually seen as the wearing away of riverbanks and riverbeds over a long period of time. riverbank erosion is often initiated by failure of a riverbank causing high sediment loads or heavy rainfall. this generates high volume and velocity run-off which will concentrate in the lower drainages within the river’s catchments area. when the stress applied by these river flows exceeds the resistance of the riverbank material, erosion will occur. as the sediment load increases, fast-flowing rivers will erode their banks downstream. eventually, the river becomes overloaded or velocity is reduced, leading to the deposition of sediment to further downstream or in dams and reservoirs. the deposition may eventually lead to the river developing a new channel. while all rivers change in the long-term, short-term rates of change vary significantly. in less stable braided channel reaches, erosion and deposition of material are a constant issue. in more stable meandering channels, episodes of erosion may only occur occasionally. the erosion rate depends on the sediment supply and amount of run-off reaching the river. these variables are affected by many things including earthquakes, floods, climatic changes, loss of bank vegetation, urbanization, and the construction of civil works in the waterway. there are varieties of natural and human-induced factors that influence the erosion process. for example, bankline orientation and exposure to prevailing winds and waves all influence erosion rates. bankline composition influences erosion rates as well. for example, riverbank composed of sand and silt are easily eroded whereas banklines primarily consisting of boulders or large rocks are more resistant to erosion. other factors may include: bankline type, geomorphology of the riverbank, structure types along the bankline, density of development, amount of encroachment into the high hazard zone, proximity to erosion inducing bankline structures, nature of the riverbank topography, elevation of riverbank dunes and bluffs, and bankline exposure to wind and waves. riverbank erosion has many consequences including the loss of land and any development on that land. it can cause increased sedimentation of harbors and river deltas. it can hinder channel navigation – affect marine transportation source. this char dynamics is related to the morphologic behavior of rivers and in particular to the bank erosion processes and the prevailing trends of widening and narrowing of rivers3. other problems include reduction in water quality due to high sediment loads, loss of native aquatic habitats, damage to public utilities (roads, bridges and dams) and maintenance costs associated with trying to prevent or control erosion sites. bangladesh is located at the confluence of the three mighty river systems of the world-the padma, the brahmaputra and the meghnarenders her one of the most vulnerable places to natural disasters. flood and riverbank erosion are the main disasters initiated from the river. during the last three decades (1970-2000), the padma and the jamuna have consumed 180,000 hectares of land. in 2008, bank erosion of the padma, forced about 200,000 people to be homeless4, along with 1630 acres of mainly agricultural land, 370 settlement areas, 3930 meters of road, 9 educational institutes, 5 hats and bazaars and 1 union parishad was eroded. satellite image studied on the ganges-brahmaputra-mehgna rivers showed that about 106,300 hectares of land was lost between 1982 to 1992, when the amount of accreted land was only 19,300 hectares. so, the net annual 2 http://environment.about.com/od/globalwarming/a/envirorefugees.htm 3 environment and gis support project for water sector planning, riverine chars in bangladesh (dhaka: the university press limited, 2000), p. 20. 4 the daily jugantor, 21.06.2008. 5 http://environment.about.com/od/globalwarming/a/envirorefugees.htm bangladesh journal of bioethics, 2011;2(2): 4-19 loss was 8,700 hectares during this period. it has estimated that about one million people become directly or indirectly affected by riverbank erosion every year. the ispan studied during 1981 and 1993, using satellite images and population data suggested that a total of 728,439 people were displaced from their original homestead by riverbank erosion. this also estimated that the annual number of displaced persons to be 63,722. estimation shows that, 50 percent of the total homeless people are victims of riverbank erosion and they cannot rebuild their home due to poverty and scarcity of resources. four million of such homeless people in bangladesh are compelled to lead a floating life5. report of the climate institute published in 1995, says that a growing number of people are displaced as a result of environmental problems such as drought, soil erosion, desertification and deforestation.6 it has further estimated that about 3.3 million people in indonesia and 7.1 million in india are at risk from flooding and inundation by 2070. it also expressed awareness of large-scale displacement in bangladesh caused by sea level rising and coastal or riverbank erosion. scholars are also predicting that 50 million people worldwide will be displaced by 2010 because of coastal/riverbank erosion, rising sea levels, desertification, dried up aquifers, weather-induced flooding and other serious environmental changes. the number of refugees worldwide grew from 9.9 million in 2007 to 11.4 million in 2008, according to a report by the united nations high commissioner for refugees (unhcr), which identified climate change as one of the leading causes of the global rise in refugees. geography and environmental science department of the jahangirnagar university presented a chart of the losses of riverbank erosion from 1996 to 2000, which is as follows:7 year financial loss affected areas affected population 1996 5809 m 71680.4 acres 10103635 1997 33012 m 7756 acres 173090 1998 2201 m 41519 acres 321000 1999 10535 m 227755 acres 899275 2000 3286 m 219310 acres 415870 from the above chart it is clear that the financial loss is not negligible, extent of riverbank erosion is high in the land-scarce country and displacement of people is needed to give maximum attention. to protect the lives and resources from erosion, there should be effective policy and programs of the government as well as nongovernmental organizations. 1.3 problems of the displacees riverbank erosion displacees face few unavoidable problems in different times of displacement, i.e. before displacement, during shifting household materials and family members and after displacement at their new settlement area. displacee households were living in a settled area from generation to generation. due to riverbank erosion, they were forced to migrate from their place of origin to other places, mostly unknown to them. displacement due to riverbank erosion marginalized them in respect of livelihood patterns and psycho-physical troubles. 1.3.1 losses for displacement riverbank erosion is such an environmental catastrophe which cannot be compared to other environmental disasters. in every disaster, other than earthquake, people lose their household structure at best but due to 5. coast trust, www.coastbd.org 6 http://www.climate.org/publications/environmental-refugees.html 7 ibid. 6 bangladesh journal of bioethics, 2011;2(2): 4-19 riverbank erosion people lose their land and become homeless. only the difference is, death counts less in number. riverbank erosion displacees’ losses are unbound. there are few losses, which can never be converted to money. besides the loss of land, they lose other things too. being homeless, they become assetless too. people of the study area have lost their agricultural and homestead land in one hand and on the other hand they became rootless, ousted from their community, broken down their family ties and social bondage. the effect was enormous and the loss was quite impossible to regain. 1.3.2 loss of land and changes in land holding capacity riverbank erosion aggravates land of the riparian inhabitants. it was found that, all of the respondents of study area had lost their land, either totally or partially. they were displaced from their original homestead, which was an unwilling displacement. impact of unwilling displacement is always negative, either economically or socially. land is fundamental for civilization, to build home and establish family followed by a society. from the study it was found that loss of land, as well as displacement, was the only reason for their present sufferings and other problems. they expressed that they followed their own strategy and system to mitigate needs and problems. but due to displacement and settling in a new area, things were out of their reach. searching for homestead land turned into priority and a few of them managed to become landowner. a number of respondents were found, determined not to make settlement in their present living place. 1.3.3 changes in economic activities and loss of income any kind of displacement has direct impact on regular sources of income and income generating activities of the displacee households. this change may be positive or negative but some sort of change is found in every situation faced by the affected people. if it was caused by a sudden forceful event which consequently causes unwilling displacement, the effect was counted severe. loss of income compelled them to live a sub-standard life and they could not continue their way of living even parallel to the way before displacement. displacement induced by natural disaster was different from other types of displacement. if it was due to any authority, the displacees were compensated and resettled by the authority. but displacement due to natural disaster did not make any room for the affected population rather they were victimized by several ill-motivated stakeholders. they faced difficulties to find new sources of income in new settlement area. riverbank erosion displacees took shelter in distant places or migrated to urban areas. the landless and jobless heads of the households under financial duress8 often deserted their families. left alone, women of those households had to struggle hard to maintain their family. from the collected data, it was found that about 75 percent respondents counted loss of income due to riverbank erosion induced displacement. on the other hand, the frequency of displacement had significant impact on income. it was found that number displacement played negative impact on total monthly income of the affected households. the households which were displaced more times became more affected in terms of total monthly income. once upon a time, during pre-displacement period, some of them provided jobs to their comparatively poor neighbors, in post-displacement time; bank erosion leveled them with others, who were living side by side at the present settlement area. these two groups were struggling for same goal. in the new settlements, they were searching for shelter and security, at the same time, they were eager to get a job to feed the dependant members of their family and buy daily needs. 8 nizamuddin, op.cit., p. 3. 7 bangladesh journal of bioethics, 2011;2(2): 4-19 1.3.4 loss of house-structure in rural areas of bangladesh, generally the houses are not constructed by modern architectural design or with modern building materials. most of the houses are designed by the household-head himself or other local laborer. unburned brick, straw, chatai and bamboo-chatai are used extensively for most of the houses in rural areas of bangladesh. a few are constructed by brick, or concrete materials. the roof is generally constructed by tin, straw, tiles, and a few are with concrete materials. it was found that all the respondents had lost their houses due to riverbank erosion. some of them managed to shift their movable house materials to the present location. when erosion took place and came towards their houses, they all together dismantled their houses themselves pursuing to shift household materials. but all of them did not get enough time to take house materials. they told during the fdg and interview that most of them sold their houses to vendors, who employed a number of laborers and took-off the materials. 1.3.5 loss of crop with the loss of land, a significant number of the riparian inhabitants lost their standing crops also. rich landowners suffered more loss of crops than relatively smaller landowners. crop was their main source of income and when they failed to harvest their crop in time, they suffered from shortage of money following unavoidable misery. they had to wait for next harvest, which was far away from present time. in the mean time, to meet daily expenditure they had nothing to do but to borrow money, in most of the cases, by lending their land to money-owners, locally known as mahajon. at the time of river bank erosion, if there were standing crop in the field, sometimes farmers harvest those knowing that they will not get food grain but may be used for fuel or animal food. loss of crop had direct impact on local as well as national production of crop. the study region was generally a surplus region in food production. but due to riverbank erosion, a large number of displacees faced food scarcity. many indigenous crops were being extinct due to loss of agricultural land and changing occupation of the farmers. dependency on others for food was increased in number. once upon a time, they were well set for rice and other cereals. but due to loss of land and displacement from their original homestead their dependency for food and cereals on others was remarkable. 1.3.6 loss of security security was another hazard faced by the displacees in the new settlement area. in the new settled area, some of them managed only a room for living but other homestead materials remained open under the sky. they identified five sectors of insecurity in the early days in new area. those were: valuable goods might be stolen, household goods might be lost, women and girls might be harassed, attack of animal or bite by snake, and infants or children might be missed. for this reason, they followed some indigenous strategies and measures to minimize the insecurity fear. they dug a hole inside the room, and kept valuable goods such as, cash, ornaments etc. inside the hole in a polythene bag. some of them, put valuables in a pot on reticulate bags9. they tied up and stacked other household materials. male members kept watching at night by turns. most of them had no enough money to light hurricanes at night. so, they managed to use torch-light at night. watching at night helped them to feel secured from danger. especially, they felt secured from thief or ill-motivated people. women and younger girls slept inside the room to be more secured. other members including males lied down on floor in front of the 9 reticulate bag made of jute strings, which is hanging from the wall or the ceiling. locally known as shika. it is used as a mini-storage of different things. many villagers use it as an alternative of chest-of-drawer. 8 bangladesh journal of bioethics, 2011;2(2): 4-19 door. sometimes, local union parishad member and chairman arranged special guarding by the village-police under their control. to remain safe from snakebite, they spread out leaves of neem around them. to save the children and infants from missing, the elder members compassionated them at daytime. beyond all these preventive measures, a few incidents happened at that period of instability. 1.4 immediate shelter after displacement shelter is one of the important basic needs at the time of displacement. as there was no government or nongovernmental steps to provide shelter to the displaced households, displacees themselves were eager to search their shelter to shift family members and other household materials. but at the time of displacement, it was not so easy to get a suitable land or house or place to resettle. it was found that their first choice was house or land of relatives or neighbors who were out of erosion risk. it was one kind of competition to get it. because, every families were on the track to get first welcome address by others. in some cases, river bank erosion displacees made innovative use of kinship10 and other ideologies legitimating reciprocity and mutual aid to re-establish themselves rent-free on the land of others. however, it did not show always a well-established way of living as entitlements and poverty tended to inter-household cooperative conflict and mutual aid among extremely poor people. it was evident that, most of the displacees were taken shelter to their relative or neighbor’s house just after displacement. the cause to choose this option was identified as safer place than others were. it was not needed to pay for stay and got help to collect food for family members. though many of them could not stay long time, but believers considered it as a grace of almighty to make them sympathetic to them. 1.5 frequency of displacement there are so many causes for displacement from one place to another. sometimes, people move willingly and sometimes it is caused by force. this involuntary or forced displacement may be categorized in three major11 groups: political displacement, environmental displacement and development-project induced displacement. forced migrant, inoduced by environmental change is termed as ‘environmental refugee’. in every case of displacement, an extreme form of marginalization of individuals and groups takes place12. in this study, respondent displacees experienced several times displacement from their living place. before settling in the study area, they built their house within the vicinity of riverbank erosion13. the reason behind was, they thought riverbank would not be eroded more and they would get back their land. however, every time, their dreams washed out with the bank erosion and they compelled to shift houses to another place. respondents told that none of them was ready to leave their beloved place of birth. some of them still hope to go back to their original land if land accretion happens. however, they agreed that it was not possible for them to go back and adapt again with new formation of land. as a last option, they settled in this place. from the study, it was found that a good number of respondents lived in the char areas. chars are more vulnerable to erosion and every year the inhabitants loss their land. this multiple shifting, took them quickly to under the poverty line. their living status 10 doreen marie indra and norman buchignani, “rural landlessness, extended entitlements and inter-household relations in south asia: a bangladesh case”, journal of peasant studies, vol. 24, issue 3, april, 1997, pp. 25-64. http://www.informaworld.com/smpp/content~content=a790270448~db=all~order=page dated: 24.07.2008. 11 heming and rees, op.cit., pp. 439-462. 12 ibid. 13 professor abdul baki (ed.), duryogbarta, disaster research training and management center, dept. of geology and environment, du, vol. 13, 2006, p. 6. 9 bangladesh journal of bioethics, 2011;2(2): 4-19 and livelihood pattern changed simultaneously. the rainy season, followed by flood is considered most vulnerable period for riverbank erosionwhich nature is not same. sometimes the rate of erosion increases, making a mass shifting of bank-inhabitants and aggravates maximum land. the maximum displacement found 12 times of displacement, which was the highest in number among the respondents. abrar and azad14 found 19 times of displacement in lalmonirhat from their study on the same. we may also identify them as a population of ‘living with hazard’. they had achieved this implanted force from their community. displacees lived in a society of strong ties, where collective force offered them some sorts of dependency. fdg members expressed this attitude as ‘die-to-die’ principle. ‘we are born here and want to die also; we can not live except this loving place’. that was the reason for shifting homestead with the encroachment of bankline. and, at the last time, community members left erosion prone vicinity to safer places. at present, they were living in different places of the country. in fdg, with other questions, they were asked also about the reasons behind living with the threat of erosion. the answer came from different corners of thought, but they believed that they would not be migrated. they believed that once upon a time the erosion would stop and they could get back their land. 1.6 problems for shifting family members at the time of displacement, a horrible situation arose over the erosion-affected area. every household of that locality tried to take all the household goods and other movable assets to their new shelter. in that situation, elder members, especially the women took care of children, not to leave away. respondents compared that situation with the wartime restlessness. they told that during wartime, when heavy bombardment happened, enemy soldiers were coming nearer; the residents had to leave within short time to save life. a very small amount of assets they could take with them. during riverbank erosion, almost the same situation arose. they got a very short time to leave. within that time, they had to shift or sell all the household goods as well as other movable things. 1.7 help received by the displacees for shifting in this situation, they sought and needed help from others. however, it was not possible for all to help others. because, all of them were busy with same circumstances. however, it was found that, though they were affected by same natural events and in a same vulnerable condition, they came with helping hands as much as possible. according to them, no other group could understand or could give prompt response other than neighbors. they shared their labor force and worked physically also for other households to shift household goods and family members. they responded quickly and shared all other facilities in that crucial time. that was because, from so many years, they were living side by side, shared their joy and sorrow and asserted security for each other. relatives were the next group to respond immediately on call of the affected members. relatives of most of the respondents of ranihati lived in distant places. therefore, they took more time to respond. it took time to reach help seeking message. distant relatives had no knowledge on what kind of support they could provide. at the time of migration, displacees felt unavailability of transport and labor force to shift household goods and family members easily and within short time. riverbank erosion caused a displacement of large population, who lived in same locality. they had own lifestyle and strong social ties. they had another identity on behalf of their society, which is known as samaj or gosthi. it is a predominant social heritage mainly in rural areas of bangladesh. members of a samaj or gosthi are more coherent among themselves, than others living in the same locality. a samaj is formed by one or more than one gosthi, where other members may be included sharing the same beliefs or values. a gosthi is identical by its clan. almost all the members of samaj or gosthi were affected 14 abrar and azad, op.cit., p. 32. 10 bangladesh journal of bioethics, 2011;2(2): 4-19 by riverbank erosion, when it took place. at the time of riverbank accretion, samaj or gosthi became mainly inactive as all were engaged in own purpose. so, help from samaj members was not so much expected. beyond that, memberswho were not within the erosion vicinity came to facilitate shifting activities. victims found no support from government or non-governmental organizations. 1.8 older members, women and children these three groups were found more vulnerable to natural disaster as well as riverbank erosion displacement. multistage troubles arose in the process of transferring these members. sometimes they suffered from various types’ of hardship or created problems to others. 1.9 problems related to older members at the time of leaving home for a new place, an emotional situation took place. all the family members were crying for their unfortunate displacement. older people were widely accepted as being a vulnerable or potentially vulnerable group15. older members created more complex situation for the young, who were engaged in shifting process. they had no time to waste for resettling family members. a large number of respondents replied that their older members were not willing to go another place leaving their forefathers homestead land. but lack of public awareness and information about older people’s contributions, circumstances, issues or needs created negative images of aged members. other family members were about to forget older peoples’ affliction to family in their early age. older members were so emotional that they wanted to die than to leave. they had spent their childhood in that place. mementos were touching in every corners of their house. most of the respondents realized that they had shown anger with their older family members in that situation. interestingly, they did not feel guilty for misbehaving with their older members. shifting of older members was another important problem faced by the displacees. elders, who were incapable to walk or too weak to walk or sometimes unable to climb into a truck or van or on a countryboats, they were taken up on the lap. in that vulnerable situation, they needed special care and attention from other members. on the transport, they occupied more space to lie-down. it was embarrassing for them, when they shared a transport with others or owned by others. sometimes, respondents had to manage a separate transport for them. problems concerned to elders did not end by shifting but in the new place, they found more troubles with the environment 1.10 problems related to women and girls women were one of the severe victims of riverbank erosion, which tended them to comparatively a vulnerable group16. women of the respondent households had reported17 their helplessness and vulnerability due to displacement induced by riverbank erosion. on the other hand, their male counterparts had expressed variably different attitude to few activities of female members on the eve of shifting. those comments and observations are stated below: a) the general comment of women on male members’ activities and attitude was that they were kept in the dark about things going on. they were eager to know about the rate of erosion, recent distance of river from 15 “older people in disasters and humanitarian crises: guidelines for best practice”, helpage international, london: na, pp. 1-20. 16 sharif a. kafi, disaster and destitute women (dhaka: bangladesh development partnership centre, 1992), p. 73. 17 their opinions on this issue were collected during focus group discussion meetings in the two study areas. a cross section (male and female) fdg was also arranged with the respondents and female members. 11 bangladesh journal of bioethics, 2011;2(2): 4-19 their place of living and selecting new place to resettle. but there was no direct information system to women to know about this. they were fully dependent on male members. b) at the time of disaster, pregnant women felt in a critical condition and they felt helpless. they could not move freely due to their physical inability. other members had to take special care for them, but in that terrible situation, members could do a little for them. if they were needed to take to hospital, it was almost impossible to do so due to unavailability of transport and hazardous communication. only traditional medicine and nursing facility could be provided for them. c) male members wanted to make safe shifting for their family. in that respect, they arranged transport and preparation. household heads expected to transfer household materials after sending family members. but most of the women desired to be present at the time of packing household goods, so that they could reopen those packs to get essential materials easily. male members forced them to leave immediately with other members. d) women and girls were found more exposed to insecurity, e, i; sexual and domestic violence in disaster contexts18. they became a vulnerable group in all respect. latha has identified several reasons for increased risk of sexual and domestic violence on women and children, in his study on aftermath of orissa cyclone and gujrat earthquake. women seeking shelter during cyclones had been exposed to sexual harassment and assault. concerns were raised that children misidentified as cyclone ‘orphans’ were trafficked into sex work. kafi’s19 work also supported this findings that girls and women affected by cyclones and floods followed by riverbank erosion, lack of protection from male relatives for widows and other sole women was cited as one of the factors increasing the rate and fear of sexual assault. girls in families forced by the losses of drought or cyclone to sell off dowry possessions may well be forced into early marriage and child labor increases when hard-hit families must send all members of the household out to work. families found ‘forced-marriage’ of their girls in early ages due to lack of security and providing of food. e) natural disaster induced displacement took displacees to the periphery of livelihood facilities. it was mentioned earlier that womenfolk of the society suffered more than the male from many purposes. more than 50 percent respondent families of the study areas did not get latrine facilities at their shelter for the first time. it got revealed that those female members could respond to their natural calls only at the very early in the morning or after evening. living without latrine facility, affected directly to the women, whereas, male members might not accept it as a severe problem. but they were concerned about that problem and managed latrine facility as soon as possible. f) it was another duty lies on the female members to look after children as well as older members. male members argued that they had to work outside to earn money for household expenditure and female members were traditionally accountable to look after other members. 1.11 impact on physical and mental health it is invariably true that everyone will experience physical or emotional and psychological distress during or in the immediate aftermath20 of a disaster or other large-scale traumatic event. acts of terrorism, natural disasters and other large-scale traumatic events typically result in tremendous loss of life, physical injuries and property damage. survivors of such tragedies invariably experience significant physical, emotional and psychological distress in the immediate days and weeks that follow. just after the disaster, respondents reported symptoms ranging from 18 prof dr krishnadas mazumder latha, “role of women in disaster preparedness”, www. authorsden.com. dated: 28.06.2008. 19 ibid. 20 matt j. gray, “acute psychological impact of disaster and large-scale trauma: limitations of traditional interventions and future practice recommendations”, prehospital and disaster medicine, vol. 19, no. 1 (march, 2004), pp. 64-72. 12 bangladesh journal of bioethics, 2011;2(2): 4-19 physical injury, intense fear, anxiety and despair to shock and disbelief21, which are compounded by legitimate concerns about safety, shelter and significant financial consequences of the event. every disaster left few signs over the affected locality. nirapad22 had found out five types impacts of disaster on the affected population as well as over the affected locality. from the figure 2.6, it was seen that respondents of both the study areas had suffered from physical trauma as well as psychological distress due to sudden dislocation and belief of being a permanent displacement from their homestead. these two types of trauma were discussed below. respondents and other family members got hurt in the process of shifting. physical accidents are as follows: a) injury: thirty six percent respondents were injured at the time of shifting of their household goods and family members. physical injury covers, bleeding or loss or damage of a limb. it was quite natural and unavoidable to be injured in any form of the hazardous shifting process. others experienced swelling or negligible hurts. b) disability: bone crack due to accident at the time of shifting was found in the 01 percent households of both the study areas. c) death: death due to riverbank erosion was not common like tornado, cyclone, earthquake or other natural disasters. every natural disaster left few psychological events for the affected population. for most of them, the adage “time heals all wounds”23 was an apt characterization of post-traumatic adjustment. however, after displacement from their homestead, they bore the psychological distress than did non-displacees24 though it was expected that they would show maximum resiliency. a thorough survey was done on the respondents of two study areas to find out the psychological impact of displacement. diversified expressions were observed over them. these are mentioned below briefly: a) fear: many of them feared that the river might grab their present homestead on day. they did not forget the fearful events-when they lived with threat of erosion. b) flashbacks: this type of emotional shock made people more vulnerable to be sick. they wanted to look forward but could not build new idea. all the time they thought about their past life, which they believed as a golden time. they remembered their childhood, joyful events, family-life etc. flashbacks made them emotional and consequently the became psychologically sick. c) feeling of pain: most of the displacees felt mental pain, when they thought about their fate and present situation. though it was reported as being impossible to describe in words, it was characterized by very painful emotions. d) feel helpless: displacees felt very helpless in the present place of living. in their earlier living area, they had a very strong association; neighbors were helpful to one another in every situation, especially in the emergency time. they had also a mutual understanding of their needs. but in the new settlement area, displacees felt themselves helpless in every situation, as they could not express their needs to the local people. e) loneliness: this was another symptom of distressed population. losing homestead, family members, friends and neighbors they became psychologically weak, and could not make relation with new neighbors. 21 ibid. 22 md. rezaul karim, post disaster psychological care manual (dhaka: nirapad, 2005), p. 9. 23 ibid. 24 http: //pdm.medicine.wisc.edu/hutton.htm dated: 30.06.2008 13 bangladesh journal of bioethics, 2011;2(2): 4-19 due to continuous emotional pressure, they became introvert and as a consequence of these matters, they preferred to stay alone and thought about their losses. f) disappointment: disaster victims always looks disappointed due to various reasons. and riverbank erosion displacees were victimized at the maximum that river can do. they looked just like a boat in a sea without sail. they found no light of hope to bear the needs. it was found that due to this displacement, total workhour of the displacees had reduced remarkably by 20-30 percent in both the areas, which varied from male to female also. g) low self-esteem: as a disappointed and hopeless man, they lost self-esteem to do something for the betterment of the family members. a number of respondents were found, who did not do anything. actually they had lost their inner energy and power to do something. in this connection, social workers had more space to gear up these people to start normal life. h) sleep disturbance: respondents reported on their changes in duration of sleep before and after displacement. it was found from their report that they were suffering from sleep disturbance due to migration in a new place and displacement from their original homestead. this may be clarified from the following table. i) crying: it was observed from fdgs that most of the displaced persons, especially the women and children cried for their present miserable condition. they could not forget their earlier happiness and way of living. ‘loss of land, loss of everything’ – this thinking made them emotional to cry out. j) feeling guilty: sometimes failure to manage situation professionally brought guilty perception to the head of the institution. the riverbank erosion displacees faced a crucial problem during and after displacement in connection with disposing or shifting household goods and family members. some of them expressed their concern over their land and other on movable assets, which they could sell out or bring with them. some of them felt guilty to compel family members to participate in the process of shifting who had been injured and disabled. k) addiction: it was observed that some of the household members became addicted to be forgetful of their personal and family depression. they were interviewed and agreed that addiction was not the solution but they had nothing to do to overcome sadness. l) suicidal tendency: disaster affected and psychologically distressed people may commit suicide any time after disaster. there are two final stages of psychological distresses, one is schizophrenia and the other is suicide. but it does not always happen to every affected person. in the two study areas, no incidence of suicide was found. displacees’ family ties and sharing family responsibilities by other members might have shown them the light of hope to start from the beginning. m) relationship problems25: relation with the local people sometimes might cause psychological distress to the displacees. the researchers came to know that though most of the local people accepted them cordially but some of them expressed negligence and criticized their sufferings as it was a punishment from allah for their unbound sins. sometimes they quote the qur’anic verses and try to relate with that. most of the local people identified displacees collectively as ‘refugee’. in this context, displacees suffered from relationship problem with local people. 1. 12 present policy and institutional setup 25 frndcine shapiro, “eye movement desensitization: a new treatment for post-traumatic stress”, disorder. mental research institute, inc., palo alto, california, vol. 10, no. 3 (1989), pp. 111217. 14 bangladesh journal of bioethics, 2011;2(2): 4-19 due to the geographical location, the country frequently suffers from devastating natural hazards of which, floods, cyclones, tornadoes, riverbank erosion, drought and earthquakes are the most disastrous to mention. flood, cyclone, tornado and drought are seasonal disasters in bangladesh. earthquakes happen rarely in this country. but only the riverbank erosion is recurrent and it happens throughout the year. riverbank erosion is a unique type of environmental disaster due to its destructive nature. in other disasters, resources may loss or people may displace for a short period of time but land exists. on the other hand, land, the primary component of civilization, is washed out, displacement occurs forever. so, no other disaster is as disastrous as riverbank erosion. unfortunately, it was not considered a specific disaster in bangladesh before 1993, rather thought to be a consequence of flood. but flood is not turns always a disaster. after continuous campaign and demand from concerned agencies and stockholders, in 1993, government of bangladesh declared riverbank erosion as a disaster. though riverbank erosion is a unique type of disaster but it is amalgamated with other disasters and affected people are entertained on the basis of the existing policies and programs of disaster management. ministry of water resources (mwr) and ministry of food and disaster management (mfdm) are two key ministries to work in this area. mwr is responsible for riverbank protection and management and mfdm has responsibility for coordinating the government disaster management efforts with two line agencies as the directorate of relief and rehabilitation (drr) and the disaster management bureau (dmb). the government of bangladesh has promulgated the national water policy in 1999 providing policy direction for water sector. planning and management of water resources under the policy (article4.2 q) provides directive to ‘undertake survey and investigation of the problem of riverbank erosion and develop and implement master plans for river training and erosion control works for preservation of scarce land and prevention of landlessness and pauperisation.’ mwr works individually to protect and manage riverbank from erosion without coordinating mfdm. the national policy on disaster management has emphasized a group of broad based strategies, i.e. risk management, community involvement and non-structural mitigation measures. in bangladesh there are three bodies for multi-sectoral coordination and collaboration at the national level26. a) the national disaster management council (ndmc) is headed by the prime minister, b) inter ministerial disaster management coordination committee (imdmcc), headed by the cabinet minister in charge of the ministry of food and disaster management (mfdm) and c) national disaster management advisory committee (ndmac) with memberships from both the public and private sectors. there are committees also in district, upazila and union level followed by the directives of national committees. the ministry of food and disaster management is responsible for building awareness in pre-disaster phase and distributing relief goods in post-disaster phase as well as rehabilitations in some extend. certain sections of the displacees are accommodated in allocation of khas land, adarshaya gram and abashon projects. ngos like care-bangladesh, oxfam, bdpc and rdrs are working with displacees in certain areas of bangladesh. 1.14 discussion on the policies and programs 26 national report and information on disaster reduction for the world conference on disaster reduction, ministry of food and disaster management , government of bangladesh. kobehyogo, japan, january 18-22, 2005. 15 bangladesh journal of bioethics, 2011;2(2): 4-19 it is common in bangladesh that the victims of riverbank erosion do not receive same response from the concerned authorities as received by the victims of flood, tornado and cyclonewho have secured important places in the list of disasters. because of its slow process and scattered incidences, displacees of riverbank erosion fail to draw attention successfully of the responsible authorities. riverbank erosion and displacees do not obtain also such media coverage as victims of other disasters get. as a result, almost a silent catastrophe is going on throughout the year to that unfortunate group of people. but there is no specific policy or program for the riverbank erosion displacees either in government or in non-government sectors. riverbank erosion victims are treated in same manner by the government as victims of other disasters. government has issued general principles for distribution of relief goods to the victims of disasters, which leaves unequal opportunities for the displacees due to few conditions for getting relief goods. in may 2007, four important government circulars have issued by the ministry of food and disaster management directing guidelines for distribution of ci sheets, general relief (cash), allotment (cash) for house building, and general relief (food) among the victims of cyclone/fire/flood/riverbank erosion/tidal wave/earthquake. riverbank erosion displacees do not get first two types of assistances because of the required qualifications. for getting ci sheets, victims have to have their own land. but ‘displacees became displacees’ after losing their land due to riverbank erosion. so, they fail to get ci sheets that is essential for building a temporary shelter. they do not get general relief (cash) also. if a person dies due to disaster then his family may get assistance as cash. fortunately, death is rare in case of riverbank erosion victims. twenty kgs of rice is distributed to each family only for once as general relief, with which a five-member family can go maximum ten days. three thousand taka is given to each family to repair their damage houses. problem also lies in selecting victim families. there are temporary shelters build by the government at cyclone prone areas, where people take shelter during cyclone-surge. authorities can easily get reach to them. they also can reach to those who do not come to the shelter, because they live in their own land. it is also the same for the flood affected people. but there is no temporary shelter for riverbank erosion victims or no early warning system or no early evacuation process to evacuate the inhabitants of erosion prone areas. as a result, after losing homestead, displacees leave the area on their own initiatives to distant safer places as there is no chance for early alluvial of their diluviated land. field level experience shows that most of them move to different administrative area. so, the officials of their original area cannot assist them and the officials of resettled area have limited scope to help them as they are not the victims of that administrative area. the consequence is that, these environmental refugees become more vulnerable in every sense and compel to live under the extreme poverty line. it is found that victims of sudden and highly-publicized disasters like the asian tsunami, bay of bengal cyclones (sidr, bizli, aila etc.) or the us gulf coast hurricanes are benefited from the mobilization of private and public sector generosity and humanitarian relief. on the other hand, millions of victims of disasters like coastal/riverbank erosion or sea level rising around the world are uprooted by gradual environmental changes, receive comparatively little support to cope and adapt and are not recognized as refugees with the benefits that grants. it is said that 50 million people worldwide will be displaced by 2010 due to different environmental disasters as scholars are predicting. developed countries has important role in this connection by providing financial assistance and logistic support. increasing number of internal displaced population is not only a problem for the affected country but it may also create extra-pressure through ‘inevitable migration’ to the developed countries. 16 bangladesh journal of bioethics, 2011;2(2): 4-19 therefore, some changes are needed in existing policies and initiatives of institutions to work for the victims of riverbank erosion. it is needed to consider riverbank erosion as a unique environmental disaster which not only makes people landless and homeless but it also changes the geographical map (by encroaching riverbank) of the land scarce country and increases the number of internal displaced population who finds no way but to live as slum dwellers. 1.15 recommendations on the basis of the above discussion, the following recommendations are made to reduce the vulnerability and improve the stability of the riverbank erosion induced displacees. the national disaster management council (ndmc) should enact the comprehensive riverbank erosion management policy: 1. to ensure the rights and protection of the displacees; 2. formation of ‘coordination council’ to coordinate bank-protection works and displacees’ livelihood development programs. these programs should include the following phases of erosion risk management at the national as well as local level: phase 1 – pre-displacement period 1. identifying, assessing and monitoring of the potential hazards, risks and vulnerabilities. 2. organization of effective early warning and information management systems. this guarantees timely and effective dissemination of early warning information to the community level. 3. building storage systems at district levels in order to effectively dispatch material resources for relief and rehabilitation. 4. identifying land/khas land to nearby safer zones to improve the management capacity of authority. 5. regional disaster management center of south asia for multilateral cooperation. phase 2emergency response 1. conducting rescue, evacuation and recovery operations as necessary. 2. determining temporary shelter and facilitate with transport may help the displacees to come to the shelter area. 3. activating evacuation points/areas and distributing relief and medical supplies to disaster victims. 4. undertaking rehabilitation activities. 5. developing recovery plans based on community needs and priorities. phase 3post displacement phase 1. providing “developmental relief” and recovery services as necessary. 2. allotment of khas land and providing accommodation in adarshya gram and abashon projects. 3. enacting banking policy to provide loan without interest and write off agricultural loan to the victims. 4. insurance schemes at soft premiums. 5. ensuring boundary conditions (river depth, flow velocities, water levels) for different design options (spurs, revetments) based on specific characteristics of major rivers. 6. introducing twoand three-layer bank protection systems. conclusion besides different bank protection works, riverbank erosion remains as a continuous threat to the riparian inhabitants and the land-scarce country. every year, a large number of its population is displaced due to 17 bangladesh journal of bioethics, 2011;2(2): 4-19 riverbank erosion. they loss their land and migrate to another place to make new settlement. these environmental refugees become vulnerable as a whole in every sense. before deteriorating situation to beyond control, it is high time to take necessary actions to stop forceful displacement and livelihood management of the victims. bibliography abrar, chowdhury r and azad, s nurullah, coping with displacement, dhaka: rdrs bangladesh, 2004. disaster report: 1997, bangladesh disaster preparedness forum, dhaka, bangladesh. -2000, bangladesh disaster preparedness forum, dhaka, bangladesh. doreen marie indra and norman buchignani, “rural landlessness, extended entitlements and interhousehold relations in south asia: a bangladesh case”, journal of peasant studies, vol. 24, issue 3, april, 1997, pp. 25-64. elahi, k. maudood et. al., (eds.). riverbank erosion, flood and population displacement in bangladesh. dhaka:riverbank erosion impact study, 1991. frndcine shapiro, “eye movement desensitization: a new treatment for post-traumatic stress”, disorder. mental research institute, inc., palo alto, california, vol. 10, no. 3 (1989), pp. 111-217. heming, li and rees, philip, “population displacement in the three gorges reservoir area of the yangtze river, central china: relocation policies and migrant views”, international journal of population geography, vol. 6, 2000. islam, m. zulfiquar ali. “social resilience of the riverbank erosion displacees in bangladesh”. ecology and human well-being. eds. by pushpam kumar and b. sudhakara reddy. new delhi: sage publications india pvt ltd. 2007. kafi, sharif a., what people can do to reduce the disastrous effects of river erosion, dhaka: pactbangladesh/prip, 1993. matt j. gray, “acute psychological impact of disaster and large-scale trauma: limitations of traditional interventions and future practice recommendations”, prehospital and disaster medicine, vol. 19, no. 1 (march, 2004), pp. 64-72. md. rezaul karim, post disaster psychological care manual (dhaka: nirapad, 2005), p. 9. ministry of food and disaster management , government of bangladesh, national report and information on disaster reduction for the world conference on disaster reduction,. kobe-hyogo, japan. national report and information on disaster reduction for the world conference on disaster reduction, ministry of food and disaster management , government of bangladesh. kobe-hyogo, japan, january 18-22, 2005. nizamuddin, k., ed., disaster in bangladesh, dhaka: disaster research training and management centre, undated. “older people in disasters and humanitarian crises: guidelines for best practice”, helpage international, london: na, pp. 1-20. professor abdul baki (ed.), duryogbarta, disaster research training and management center, dept. of geology and environment, du, vol. 13, 2006, p. 6. prof dr krishnadas mazumder latha, “role of women in disaster preparedness”, www. authorsden.com. dated: 28.06.2008. sharif a. kafi, disaster and destitute women (dhaka: bangladesh development partnership centre, 1992), p. 73. 18 bangladesh journal of bioethics, 2011;2(2): 4-19 the daily jugantor, 21.06.2008. www.coastbd.org environment.about.com www.climate.org http://www.informaworld.com/smpp/content~content=a790270448~db=all~order=page dated: 24.07.2008. http: //pdm.medicine.wisc.edu/hutton.htm dated: 30.06.2008 19 http://environment.about.com/od/globalwarming/a/envirorefugees.htm http://www.coastbd.org/ riverbank erosion displacees in bangladesh: need for institutional response and policy intervention 1.3 problems of the displacees bangladesh journal of bioethics 2015; 6(1):11-14 11 animal rights and use of animals in biomedical research zoheb rafique lecturer department of biochemistry, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: dr_zohaib@hotmail.com abstract: experiments on animals have always been considered as necessary for scientific research, both fundamental and applied. in addition to scientific suitability criteria, this practice also must be justified from a moral point of view. this concern arises from the demand of our civilization that a certain moral value be recognized to animals. in this paper it is discussed in detail that how animals should be handled while doing research and what are animal rights and their uses in biomedical research. key words: animal rights, biomedical research introduction: questions about the way animals are treated in research became more prominent in recent decades in a period which has been particularly favorable for freedom of research and science which promotes technological and scientific progress. at the start of the twenty-first century, it is obvious to the scientific community, as well as to the public, that science often raises some ethical questions. in the areas of animal-based research, teaching and testing, these include questions about the justification for studies involving distress and pain, which are detrimental to animal welfare. determining the behavioral and social needs of an animal and deciding how these needs can best be met are further concerns, arising from the of behavioral biology and animal welfare science, which should inform the debate about the use of animals. the research into and testing of almost every major medical treatment has involved the use of animals at different occasions. however, for as long as animals have been used to better understand the functioning of the animal and human body, the thoughtful researchers and general public have also concerned themselves with issues arising from that use. in particular, the question of distress and pain has been the main focus of concern 1 . in this paper, i will discuss the animal rights and the use of animals in biomedical research. this paper will focus on the way the animals should be handled ethically during the biomedical research. discussion: animal use as research subjects in medical investigations is widely condemned on two grounds. first, because it wrongly imposes on sentient creatures much avoidable sufferings. second, because it wrongly violates the rights of animals. neither of the above argument is sound. the first relies on a mistaken calculation of consequences; the second relies on a mistaken understanding of rights. it does not follows from this, however, that we are morally free to do anything we please to animals certainly not. a right, properly understood, is a claim that one party may exercise against another. the target against whom such a claim is registered can be a single person, a community, a group, or all humankind. immanuel kant was influential in his emphasis on universal human possession of uniquely moral will. humans confront choices which are purely moral. human beings are morally autonomous and self legislative. animals lack this capacity for free moral judgment. they are not capable of responding or exercising to mailto:dr_zohaib@hotmail.com bangladesh journal of bioethics 2015; 6(1):11-14 12 moral claims 2 . this importance of a humane care and treatment of animals used for research and teaching is increasing and constitutes a responsibility we all share. each time research and teaching involves animal participation, it is very essential that the welfare of those animals is properly considered. it places upon the researchers and investigators a primary responsibility to observe the professional, ethical and legal principles involved 3 . it is very important that the work involving animals within the research project proceeds in a way that is ethically acceptable. ethically acceptable research procedures must follow legislation for animal-based research: respecting the minimum requirements for animal housing, use of anesthesia, treatment procedures etc. for a researcher concerned with ethical aspects of his activity, it is important to strive to follow the general intentions of the law, such as attempting to find non-animal alternatives, and trying to minimize the number of animals used etc. it is essential that the intended experiments involving animals be subject to an ethics discussion beforehand. it is very important to demonstrate the potential benefit of the experiments and that reasonable measures have been taken to protect the welfare of the experimental animals 4 . every year more than 20 million animals are used in the biomedical research projects and from these 20 million more than 90 percent of them being rats, mice, and other rodents. from the other animal species, approximately 65,000 dogs, 23,000 cats, and 55,000 primates were used for research purposes only in the united states between the period october 1, 2003 and september 30, 2004 according to u.s. department of agriculture 5 . while not all biomedical researchers involve the use of animals, animals are essential in many areas. the short life span of research animals allows researchers and scientists to study them throughout the entire life cycle, and even through several generations-within a very short period of time. using laboratory animals in scientific studies allows researchers precise control over the animal’s environment (temperature, light, ventilation) to ensure that animals are healthy and thus keep experimental variables to a minimum. healthy, well cared-for, adequately housed animals are necessary to produce accurate research results. following examples are animal contributions to research. cats for studies of aids, eye and ear disorders, and the nervous system, armadillos for vaccine for leprosy, dogs for coronary bypass surgery; artificial heart valve insertion; pacemaker implantation; hip and other joint replacement surgery, chinchillas for studies on middle ear infections and hearing loss, ferrets for viral diseases such as influenza, fish for studies of vision, liver cancer, bacterial diseases, temperature regulation, and skin tumors, guinea pigs for nutritional studies such as vitamin c deficiency, lobsters for study of motor coordination diseases such as syphilis and parkinson’s disease, mice for studies of cancer, aging, aids, immunology, and genetics; embryo transfer techniques in humans and domestic and endangered animal species, nonhuman primates for treatments for polio and rh disease; studies of hiv and aids, cancer, heart disease, neurological disorders, and infectious diseases such as malaria, opossums for studies of the central nervous system, immune system, and bacterial endocarditis, pigeons for study of coronary heart disease, pigs for burn treatments; development of the cat scan; human heart valve replacements, rabbits for corneal transplant; drugs that lower blood cholesterol and help stop the development of hardening of the arteries; rats for studies to find treatment for paralysis caused by nerve damage; product safety tests; causes of some cancer; effects of nutrition on aging; understanding tissue rejection following transplant surgery, sheep for development of the arteriovenous shunt and testing of a device that assists lung functions in infants soon after birth, woodchucks for liver cancer and hepatitis b and slugs for studies of the short-and long-term memory 6 . the rationale for using animal models in biomedical research is scientific and animal models are likely to remain necessary until science develops other alternative models and systems that are equally robust and sound. the use of animal models in science, and biomedical research, is accepted by majority of lay people and scientists alike as being necessary to the advancement of useful knowledge that brings about relief from suffering. some outside of biomedical scientific community, however, have a clear understanding of why these animal bangladesh journal of bioethics 2015; 6(1):11-14 13 models are important. this is very unfortunate. man and animals are symbiotic in many ways and not just on an ideological level. arguments regarding whether biomedical science can advance without using animals are frequently mooted and makes as much sense as questioning if clinical trials are necessary before any new medical therapies are allowed to be widely used in the general population. while the use of animals has decreased in the last two decades, advances in genetic research and the demands of research to counter bio-terrorism are expected to reverse this trend and lead to an increase in use of animals. at the heart of it, all is the health and safety of humans 7 . since islam is predominant culture and religion in our country and according to islamic rules, life is divine present to all creatures, then, no one have authority to interfere animal’s life without their permission. animals are part of this truth of life; hence, we can use them only with respect for their status and dignity that has been created. animals should always be used in an ethical manner, because they are creatures which have pain and distress senses. according to islam, humans should know their limitations and positions in nature; therefore we are not allowed to use animals in the way we desire. our religious rules obligate us to avoid causing distress and suffering to animals, therefore, we should try to protect animal wellbeing in research, teaching and testing 8 . although the main principles of “western” bioethics (autonomy, beneficence, non-maleficence and justice) are acceptable according to islam, their interpretation can differ. for example, there is a limit on autonomy, because sometimes the interest of the society is preferred to individual rights. in muslim countries, in various discussions on medical ethics, we have a tendency to look towards religion. islam is believed to be able to fully restore the harmony between science and religion. the principles of bioethics and solutions to ethical problems are derived from the islamic legal rulings. the main principles of islamic ethics are the respect for human dignity, eternity of life and life after death, benevolence to fellow human beings, altruism, seeking perfection and eternal salvation. there is wide overlap between islamic bioethics, law and the islamic rulings, so that the religious principles such as the eternity of life could be very important in the ethical decision making in islamic setting 9 .the strong position implies that animals possess the right to respectful treatments, and this entails that they not be treated only as a means to some other end. they end in themselves, and this intrinsic worth makes it wrong to use animals as subject in research. the weak position on the animal rights would maintain that even for humans the right to life is not absolute, that rights frequently conflict, and that in circumstances where human rights conflict with animal rights, a judgment will be necessary. therefore, an animal’s right creates a duty, which to some degree restricts our behavior. since a person’s life is more important than any animal, the use of animals for medical purpose is morally acceptable. this position can be compressed to a claim that animals have some rights, without duties, and may justifiably be sacrificed for a variety of human purposes 10 . conclusion: although in this article i have focused on animal use in research, other areas also raise ethical concerns about animal rights and animal welfare. these include the use of animals as companions, in zoos, in agriculture, education, for entertainment or sport, and the treatment of wildlife and endangered species 11 . we should encourage others to become informed about the vital issue of using animals in biomedical research. as we begin to understand the facts more fully, we will agree that the judicious use of animals in research offers the greatest hope of improving the lives of both animals and humans. references: 1. gauthier c, griffin g. using animals in research, testing and teaching. rev sci tech. off. int. epiz. 2005; 24(2):735745. bangladesh journal of bioethics 2015; 6(1):11-14 14 2. cohen c. use of animals in biomedical research. new engl j med 1985; 315(14):865-870. 3. vieuille c, aubert a.. the human-animal relationship in higher scientific education and its ethical implications. animal bioethics: principles and teaching methods. binnenwerk bioethics. 2005; 173-182. 4. olsson a, sandoe p. guidelines for ethical conduct with animals-comparative genomics of man and pig. 5. u.s. department of agriculture: www.aphis.usda.gov/ac 6. use of animals in biomedical research. understanding the issues. american association for laboratory animal science. www.aalas.org. [retrieved] 7. chow p. the rationale for the use of animal models in biomedical research 2007; chapter 1.1:2-10 8. mobasher et al. proposing a national ethical framework for animal research in iran. iranian j publ health 2008; 37(1):39-46. 9. zahedi f, larijani b. national bioethical legislation and guidelines for biomedical research in the islamic republic of iran. bulletin world health organ 2008; 86:630-634. 10. lei rp. is the use of animal organs for transplants morally acceptable? debates over the use of animals in xenotransplantation. turkiye klinikleri. j med ethics. 2004; 12:242-247. 11. bishop lj, nolen al. animals in research and education: ethical issues. national reference center for bioethics literature. the joseph and rose kennedy institute of ethics. reprint issued march 2001; 1-19. conflict of interest: author declares no conflict of interest. professional boundaries and psychotherapy : a review bangladesh journal of bioethics 2012; 3(2):16-26 16 professional boundaries and psychotherapy: a review dr avinash de sousa consultant psychiatrist and psychotherapist private practice mumbai e-mail: avinashdes999@yahoo.co.uk abstract: psychotherapy is a vital component of any treatment programme in the management of psychiatric disorders. it is very essential that the therapist receives adequate training prior to embarking on therapy with patients. there are various ethical issues and boundaries that the therapist must be aware of when dealing with psychiatric patients. both experienced and novice therapist may experience confusion and dilemma when it comes across certain boundaries for the benefit of the patients. the present article introduces the readers the various boundaries that need to be maintained in psychotherapy and how the boundary is crossing or violations can lead to serious problems. the issue of gifts, fees, transference, physical contact between therapist and patient and sexual boundary violations are discussed. the need for focusing on boundaries in psychotherapy training is stressed. key words – professional boundaries, psychotherapy. introduction: psychotherapy is defined as a form of psychological treatment where a trained therapist enters into a professional relationship with the patient, with the aim of reducing certain symptoms, removing certain symptoms and bringing about overall growth and development of the personality of the patient 1 . psychotherapy is a professional relationship that helps patients in solving their own problems with their own efforts as well as that of the therapist. psychotherapy treatments occur within a construct that has been termed as the therapeutic frame. a simple definition of professional boundaries is that they are the parameters defining the limits of a relationship in which one person (a patient or client) entrusts his or her welfare to another (a psychotherapist), and where fees or payments are made for the provision of a therapeutic service 2 . these boundaries suggest professional distance and respect which is a prerequisite of ethical professional behavior. in the last decade, a renewed interest in psychotherapy has been seen in india. a larger number of psychiatric patients seek psychological interventions rather than medication as a cure for their problems. hence psychotherapy today has found a permanent place in all treatment programs of psychiatric disorders. psychotherapy pertains have not only had major psychiatric problems but also have various areas like school counseling in handling behavioral and parenting issues. many couples seek psychotherapy to find a solution to their marital problems. psychotherapists specialize in various forms of psychotherapy like cognitive therapy, rational emotive therapy and family therapy have increased in the last few years with more and more people realizing the long term value of psychotherapy in the treatment of psychological problems. mailto:avinashdes999@yahoo.co.uk bangladesh journal of bioethics 2012; 3(2):16-26 17 professional boundaries is a concept in psychotherapy which is essential, largely out of concern for the growing number of cases of sexual misconduct by therapists, which led to malpractice litigation and severe damage the reputation of mental health professionals 3 . there is a growing amount of cases of sexual misconduct being reported year after year where unqualified and untrained psychotherapists engage in both sexual and non-sexual boundary violations with their clients or patients 4 . this is more relevant in india, where patients present herself/himself whole heartedly to the therapist thinking him or her a knowledgeable and responsible for providing a cure for their problems. therapists in some quarters are known to take advantage of such vulnerable patients. the concept of boundary violation in psychotherapy: there are namely two types of boundary violations noted in psychotherapy viz. the non-sexual boundary violations which is milder and the graver sexual boundary violations. boundary crossings are benign phenomena that do not occur repetitively and are discussable between the therapist and the patient, while being non exploitative. psychotherapy is a process where both the patent and therapist observe each other and share emotions. in indian culture, the psychotherapist or doctor is often viewed as a demi-god who cures the patient. in such cases it is not unusual for patients to talk and enquire about the therapist’s likes and dislikes or ask certain questions that may be personal during the course of therapy. falling at the feet or touching the feet or sometimes kissing the hand of a doctor (who is perceived to be a healer) and cannot be viewed as a personal boundary crossing 5 . many patients in therapy often enquire about the therapist, his native place, his family, what they do and whether he has children and how old they are. this is normal social enquiry that is rampant in our culture and must not be viewed as with a boundary crossing mindset. it is normally seen that rigidity with respect to boundary crossings does no good for therapy. a good psychotherapist adjusts the treatment to the patient rather than expecting the patient to adjust to the treatment. novice psychotherapists are trained and taught so much about boundaries in courses, that they show great concern about maintaining proper boundaries thereby becoming cold, rigid, formal and inapproachable in their way of dealing with the patients or clients. some patients reject such therapists who behave more professional than human and do not generally follow up for therapy. rigidity about boundaries serves as hindrance in developing a good rapport with the patient in therapy 6 . this is a common reason why novice therapists complain of a lack of follow up amongst their patients. patients in india want a therapist who is friendly, homely and yet a guide and an advisor. in such cases the therapist has greater responsibility bestowed on him where he serves as an elder, friend, philosopher and guide for his patients. he may be looked upon in this role not only by the patients but also by the entire family of the patients. rigidity and unfriendliness by the therapist in such cases will result in the patients seeking therapy elsewhere where he finds a therapist with the qualities he desires. in psychotherapy, the beginning phase involves a period of adjustment where a sensitive psychotherapist needs to develop a comfort level of closeness or distance so that an appropriate bangladesh journal of bioethics 2012; 3(2):16-26 18 therapeutic frame and environment conducive for therapy is created. this phase needs joint efforts by both the patients and the therapists. some patients need a more talkative therapist, whereas others prefer a quiet and good listener. some patients may appreciate the use of laughter, jokes and metaphors while some may feel ridiculed by the therapist when this is done. good psychotherapists need an individualized approach with each patient throughout therapy. they vary their therapeutic style depending on the particular patient’s need 7 . indian patients may be shy and reserved when it comes to opening up and discussing intense emotional issues with a new member in their circle i.e. the therapist. in such cases a slow, friendly and steady approach by the therapist shall boost the confidence of the patient in the therapist and shall improve their relationship in therapy. a therapist who shall hurry his patients to open up shall end up losing such a patient who may feel that the therapist does not understand the gravity and nature of the problem. many life events that occur with patient may need professional as well as a personal outlook. sometimes there may be death of a figure to who he patient was extremely attached and the patient may expect a little extra sympathy or a patient listening from the therapist. lack of sensitivity at such points of time may destroy any rapport that has been established and affect therapy as well. sometimes therapy may seem to be going nowhere and therapists may get bored of their patients. at such times it may be seen that the therapist may seem disinterested in sessions and may look forward to hurry up sessions or prolong the time between consecutive appointments. all these phenomena may affect the patient who too observes therapist behavior just as the therapist observes patient behavior 8 . many of our patients in india need someone who would listen to them so that they may express their emotions. female patients coming from conservative and orthodox backgrounds often have problems expressing delicate issues and need a patience listening. at such times attitude like those mentioned above may be detrimental to the patients. boundary violations on the other hand, represent events or phenomena that are usually repetitive, harmful to the patient, and exploitative of the patient’s dependent position in therapy. sexual activity with the patient or engaging in a sexual relationship with a patient would be the gravest example. other examples would be exploiting the patient financially or emotionally 9 . the psychotherapeutic relationship is by definition a relationship where there must be equal power with both the therapist and patient 10 . the psychotherapist is trained and paid to deliver a service based on skills acquired by specialized training. the patients may assume that whatever the therapist says or does is designed to help of the patient. as a result, many patients innocently succumb to boundary violations under the feeling that it is for their own good 11 . a boundary transgression is used as an umbrella term that encompasses both boundary crossings and boundary violations 12 . another term of note is boundary blurring which is used to describe instances in which the boundaries are confused but not enacted in the form of a boundary violation 13 . bangladesh journal of bioethics 2012; 3(2):16-26 19 the setting of psychotherapy: in any consideration of psychotherapeutic boundaries one must take into account the setting in which therapy takes place. therapy usually takes place in an office, clinic or hospital that is sufficiently private so that the patients feel comfortable to disclose embarrassing, sexual and shameful content 14 . some patients prefer to sit on a comfortable chair or couch and talk while some prefer to walk while talking. water, tea or coffee may be offered to the patients in the therapy room. a medically or terminally ill patients in a general hospital may require therapy at the bedside. the psychotherapy setting may change if some form of behavior therapy such as an exposure therapy is being applied in case of phobias and panic attacks. this may be the case in animal phobia, bus phobia or fear of the dark 15 . the setting may also change in case of a behavior therapy termed flooding used in obsessive compulsive disorder where dirt may be used. in india, the doctor or therapist visiting the home of the patient is a common occurrence. the therapist as far as possible must conduct psychotherapy sessions in a clinic setting and must avoid visiting the house of the patient too often as chances of boundary violations occur. it happens many a time that a visit to the patient’s house results in the therapist being offered lunch or dinner and a session that should last 30-45 mins may extend to a few hours building the chances for boundary violations and relationships other than that in a therapeutic frame. the therapist should refrain from becoming associated with various family members and relatives of the patients and must focus on the patients concerned. even getting a rakhi tied by the patient though sacred as a relationship must be avoided as the therapist must maintain his frame of reference. even traveling on a vacation with the patients and his or her family for counseling sessions there must be avoided. the issue of confidentiality in psychotherapy: the fundamental principle in psychotherapy is one of confidentiality regarding what is spoken to the therapist. patients may speak out content that they may associate with shame, guilt, remorse, self-loathing, fears of disapproval, and a host of other anxieties. the confidentiality reassurance allows them to open up in a manner that they probably would not even to their family members. hence, confidentiality is regarded as the most important professional boundary 16 . the principle of confidentiality extends beyond not repeating what the patients say. numerous cases exist in which a third party realized that the only source of specific information could have been from the patient, and there were justifiable feelings of violation or breach of privacy. a breach of confidentiality can make one vulnerable to litigation or to action from professional bodies that govern therapists 17 . sometimes in order to protect confidentiality, the therapist may have to lie to others outside the consulting room. he may have to pretend that he does not know information which has learned of solely through a patient. over time, psychotherapists develop the capacity to compartmentalize certain information so as to keep it sequestered in a private sector of the psyche belonging to information heard during psychotherapy 18 . confidentiality is not an absolute boundary. one is required to break confidentiality to report child abuse or any form of sexual abuse. a threat of imminent violence or suicide to an individual requires a ‘duty to warn’ exception to confidentiality 19 . bangladesh journal of bioethics 2012; 3(2):16-26 20 psychotherapists may meet and speak about a patient when there is a secret pleasure of treating a celebrity or a public figure. however, the notion of confidentiality should be construed as meaning that one cannot even reveal whether a specific patient is in treatment or not. however, when one presents a psychotherapy case for educational purpose or research and publication, one must be careful to disguise the identity of the patients. moreover, even if consent is offered by the patient, identifying features must still be disguised so that an audience or reader does not recognize the patients 20 . in india, confidentiality becomes a difficult issue because there are relatives and family members who often believe that nothing should be hidden from them and thus want to know whatever the patient has mentioned in therapy. sometimes in cases of children and adolescents, the parents feel they have brought the child for therapy and actually pay the therapist his fees, hence they have a right to know what their child has disclosed. the same may be the case with the husband wife relationship in india. the therapist is sometimes in a quandary in such situations whether he must answer or not. the therapist must at such times not hurt anyone and keep in mind the sensitivity of both the patients and the relatives. the patients however, must be asked before disclosing anything to the relatives or family members. therapist self –disclosure in psychotherapy: therapists cannot be anonymous to the patient, no matter how hard they may try. the way they dress, the way they decorate their clinics, their facial expressions and the issues they choose to address when they speak all reveal a great deal about the therapist. the issue for the psychotherapist is not whether to self-disclose. the actual boundary concern is how much should one self-disclose. feelings that the therapist may experience provides useful feedback for the patient. it would be far better to be an honest therapist that expresses what he feels than to be deliberately deceptive. therapists often communicate feelings so that the patients may know what the therapist feels before the patients asks him or her 21 . one way of implementing a boundary on self-disclosure is to deliberately avoid sharing with the patients any details about one’s personal life or family. superficial elements like views on a political issue, a sport, a cricket match or studies may be needed at times. this may help in the rapport building process. self-disclosures about personal problems must be avoided. some personal disclosures may be initially received well by the patients and therefore may mislead the therapists into thinking that such information is productive and useful. small personal disclosures may often lead to greater intimacy and lead to the patients and therapists getting involved with each other either emotionally or sexually 22 . in india, the therapist is viewed as a learned person and hence certain insights from the personal life of the therapist may actually give strength and confidence in certain areas to the patients. thus therapists disclosure may be beneficial and must be used judiciously by the therapist. the professional attitude and psychotherapy: the concept of being a professional is fundamental to boundaries. the therapist is not a mother, father, priest, brother, son, lover or friend. bangladesh journal of bioethics 2012; 3(2):16-26 21 in the first session and initial therapist-patient meetings, it is prudent to clarify what therapy is and what therapy is not. the therapist’s professional role does not require that the therapist be excessively formal or inordinately depriving. the most important aspect is that psychotherapy is a scientific form of psychological treatment and this entails the professional aspect of the therapists, though in doing so therapy must not lose its humane touch 23 . another limit imposed on the professional therapist-patient relationship involves the duration of sessions. the time of the session is often 45-50 minutes but can be as brief as 15 minutes or as long as 90 minutes. in any case, the time parameters must be clear to the patient, and it is useful for the patient to understand from the beginning of the therapy that time constraints will always apply. patients generally understand if the therapist explains that the session cannot be extended because there are other patients waiting to be seen. sometimes one cannot be totally rigid, however, and occasionally may need to extend the time of sessions if the patient has just started to open out towards the end of a session or express an important facet of his or her problem or to accommodate an emotional reaction by a patient 24 . one must always have office assistants around when the patient is called as calling patients at odd hours may communicate to the patients that there is a potential for something other than a professional relationship. one must avoiding scheduling sessions on holidays or late at night and unless and emergent problems demands the same. therapy is hard work, and the therapist deserves to be paid. fees are another aspect that conveys the professional aspect of therapy. the fact of being paid further differentiates the therapist from parent, lover, friend, and so on. in any case, therapists should carefully monitor their attitude about the patient’s payment and the fee they are charging as a way of examining counter transference wishes to give the patient something for nothing. novice or beginner therapists are typically conflicted about deserving a fee or how much to charge and this may be resolved after consulting a senior colleague 25 . gifts and tokens of appreciation given by the patient: grateful patients may wish to express their appreciation by bringing gifts to their therapists. this may happen after they have had success at work which may be attributed to the therapy, found a new job or just returned from a vacation. some wealthy patients may wish to make a donation to the institution where a therapist works. patients may consciously or unconsciously feel that they are entitled to special dispensation because they have given money or other material gifts to a therapist. there are concerns about the potential of gifts to corrupt the therapeutic process and it is advisable to refuse all gifts. when a patient brings something handmade, a recommended book, a pen or a small memento, many therapists simply thank the patient for the gift and talk about the particular meaning or symbolism of gift. patients who may not be able to afford a gift or feel that gifts are inappropriate will sometimes offer to provide service for the therapist like painting the clinic, bringing something from a shop the patient owns or some other service. in general, services from patients blend into the area of business transactions and dual relationships, which are almost always problematic in psychotherapy 26 . bangladesh journal of bioethics 2012; 3(2):16-26 22 the use of appropriate dressing and language: both dressing sense and language are aspects of the psychotherapist role that are often not studied as part of professional boundaries. dressing in a professional manner conveys that the therapist is a professional. patients sometimes quit after an initial session of a therapist as he does not appear like a seasoned professional therapist to them. informal or crude language can also work against professionalism. the use of slangs may be problematic for some patients and one must exercise caution when using the same 27 . physical contact issues in psychotherapy: in general, psychotherapy avoids physical contact. there is generally a handshake when a therapist and patient first meet. there are exceptions, of course, often based on cultural practices, so that some patients will initiate a handshake at the beginning and end of each session. psychotherapists can return the handshake without concern about boundaries in most cases. some therapists argue that a hug is sometimes needed by a patient, but people’s capacity for self-deception is extraordinary. what a therapist may think is best for the patient may actually be a way of fulfilling the therapist’s own needs 28 . the concept of a nonsexual hug is usually in the mind of the therapist but not necessarily in the mind of the patients. professional boundaries after the termination of psychotherapy: although there is a broad consensus that sexual contact between the psychotherapist and a patient is always unethical, the idea of post termination sexual relations has been somewhat more controversial 29 the american psychiatric association determined in 1993 that any sexual relationship between a psychiatrist and former patient is unethical 30 . the american psychological association, on the other hand, allows for the possibility of a 2 year cooling-off period, after which it probably might be ethical for a therapist and a patient to begin a romantic or sexual relationship. psychotherapy may often be terminated for the specific purpose of embarking on a romantic relationship 31 . other critical issues in psychotherapy: transference involves the re-experiencing of the therapist and attributing emotions to the therapist was a powerful and authoritative figure from the past 32 . neurobiological studies demonstrate that representation of parents are laid down in neural networks that represent self and other from early in childhood, and then activated again and again by specific characteristics of current figures in one’s life 33 . transference may persist for a long time after therapy has been terminated 34 . in other words, the patient’s dependency and vulnerability to exploitation does not disappear at termination of therapy. as all experienced therapists know, patients who terminate psychotherapy frequently return for further therapeutic work in the midst of a life crisis or a struggle with a new developmental phase that must be mastered. hence, an argument for an absolute prohibition against romantic involvement following bangladesh journal of bioethics 2012; 3(2):16-26 23 termination is that the therapist may be needed again in the professional role of psychotherapist rather than as a friend, business partner, or lover. there may be areas of common interest that bring them together periodically as well. for example patients and mental health professionals may serve on committees together or be involved in organizing a conference or with social causes or non governmental organizations 35 . prevention and education regarding boundary violations: education about professional boundaries is essential in the training of psychotherapists. by its very, nature, psychotherapy involves a radical form of privacy. two people are meeting each other regularly behind closed doors, and one of them is confessing his or her darkest and most shameful secrets to the other. the atmosphere of emotional confession and acceptance fosters a rate kind of intimacy not often available outside of therapy. boundaries cannot be taught simply as a list of rules. they need to be taught as part of clinical wisdom, integrating boundary notions into discussions of technique and the choices a therapist must make. this can be done by an effective mentor or trainer who is there to guide and support the therapist. in any case, prevention depends to a large extent on what the therapist does in pivotal moments. in the final analysis, therapists must be their own watchdogs to avoid professional boundary violations 36 . conclusions: in this review, professional boundaries in psychotherapy have been dissected as issues that every psychotherapist must be aware of. different forms of psychotherapy are going to require different emphases on the way that the boundaries are implemented. within different techniques, whether one uses gestalt therapy or cognitive therapy or psychodynamic methods coupled with behavior therapy, one adjusts the boundaries to make the patient more capable of collaborating with the therapist. one of the most difficult aspects of psychotherapeutic practice is our incapacity to know the ultimate impact of departing from boundaries. nevertheless whenever boundary issues thwart psychotherapeutic practice they must be addressed. references 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5-12. 32. kernberg of, yeomans fe, clarkin jf, levy kn. transference focused psychotherapy : an overview and update. int j psychoanal 2008; 89(3): 601-620. 33. bateman a, fonagy p. the use of transference in dynamic psychotherapy. am j psychiatry 2007; 164(4): 680-682. 34. gabbard go. what is good enough termination? j am psychoanal assoc 2009; 57(3): 575594. 35. gabbard go bennett tj. dilemmas in the psychotherapy of sexually impulsive patients. am j psychiatry 2005; 162(5): 859-865. bangladesh journal of bioethics 2012; 3(2):16-26 26 36. douglas cj. teaching supportive psychotherapy to psychiatry residents. am j psychiatry 2008; 165(4): 445-452. conflict of interest: there is no conflict of interest. bangladesh journal of bioethics 2014; 5(2):44-48 44 bioethics teaching and assessment: my experience of three institutes zoheb rafique lecturer, department of biochemistry, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: dr_zohaib@hotmail.com abstract: this paper describes my experience of teaching bioethics in different institutes and degree courses at undergraduate level. bioethics is being taught to improve the understanding of the ethical issues in the field of medicine. the students are being trained in bioethics to recognize and resolve different ethical dilemmas and also to combat the situations where ethical analysis is needed. this paper also focuses on teaching and assessment methods for undergraduate courses. key words: bioethics, teaching, assessment introduction: while few would deny the fact that some attention should be given to the ethical issues as part of a medical student's education, it has never been clear how this could be best achieved 1 . bioethics is a necessary component of medical curriculum nowadays and it is being taught all over the world. it is not only included in medical curriculum, but also in dental, physiotherapy, nursing, biotechnology, residency programs and phd programs etc. the edinburgh declaration of medical education approved in 1988 requires that a future physician be trained as an attentive listener, a sensitive communicator, a careful observer and an effective clinician 2 . the practice of medicine is intrinsically an ethical enterprise because patients are vulnerable and suffering and medical treatments are not merely technical, they often invade patients’ bodies and engage their consciences 3 . pellegrino argues that the ethical decisions are an integral and essential part of being a good physician. the better the students’ prior ethical education the better they can appreciate nuances and complexities of medical ethical choices. the less that prior education, the more the student needs instruction in ethics in the medical schools 4 . from the developing world, countries such as pakistan, sri lanka, india and saudi arabia have been slow to respond to this universal need 5-7 . in pakistan bioethics was started in 1998 at aga khan university (aku) karachi and was included in undergraduate curriculum of community health sciences 8 . in our university liaquat university of medical and health sciences jamshoro (lumhs), bioethics teaching was started in 2007 and was included in mbbs undergraduate curriculum. bioethics is being taught in lecture format only because of huge number of students and shortage of faculty, so we are not able to arrange problem based learning and small group discussions. i have been teaching bioethics to first year and second year mbbs students since 2011. i have modified the curriculum and included more contemporary ethical issues and guidelines. bioethics is not a separate subject in our mbbs program, but it a tagged subject. mailto:dr_zohaib@hotmail.com bangladesh journal of bioethics 2014; 5(2):44-48 45 one of the affiliated institutes at our university iprs (institute of physiotherapy and rehabilitation sciences) has also started bioethics in their bsc physiotherapy program. they included bioethics as a separate subject in their final year. i am teaching in iprs along with their faculty. there are very few medical institutes in our city hyderabad and one of them is isra university. i am working as a visiting faculty member in isra university and i am involved in teaching bioethics. i am teaching bioethics to first year mbbs students and they have included bioethics as a minor subject. in this paper i will discuss my experience of teaching bioethics in these three institutes and i will also discuss the assessment methods in the exam. how do i teach bioethics: in our mbbs program at lumhs, there are twelve lectures of bioethics in their curriculum. i use to take three lectures in each semester so i cover 12 lectures in the initial 4 semesters of mbbs. the main subjects in the initial two years are anatomy, physiology and biochemistry and some of the other subjects are included as tagged subjects. they include bioethics, information technology and community medicine. community medicine becomes major subject in 4th year mbbs. the twelve lectures covers almost all major topic of bioethics and they include, introduction to bioethics, in which fundamental principles of bioethics and why there is need of bioethics, definition of ethics and bioethics, history of medical ethics and components of medical ethics are covered. physician-patient relationship is included in which all the doctor-patient approaches are covered such as consumerist, paternalistic, relationship of mutuality and finally default approach. one more important topic of bioethics confidentiality is also being taught in which definition of confidentiality, ethical basis of confidentiality, circumstances of breach of confidentiality, exceptions to the requirement of confidentiality, confidentiality in research i.e. benefits of maintaining confidentiality in research, how confidentiality can be maintained in the research setting and what researchers should do in this regard are covered. informed consent, its definition, five components, why informed consent is necessary, who cannot give consent and when proxy has to sign consent form, informed consent when doing research, informed consent form in detail are included. euthanasia, its definition, types, examples, case scenarios, islamic teachings regarding euthanasia and end of life issues are covered. brief account of organ donation and abortion are also included. medical error and its types, doctor guilt after making errors and strategies of avoiding medical errors and reporting them are also covered. one topic includes breaking bad news and why it is difficult to do it, abcde mnemonic of breaking bad news and what are the things to be avoided while breaking bad news are taught. professional ethics is also taught and it covers definition of professional ethics, the dual role of physician and investigator, ethical guidelines for research involving human subjects and nuremberg code. ethical dilemma, its definition, types, why does it exist and what are the steps for resolving ethical dilemmas are covered. privacy and veracity are also in the curriculum and they cover definition of privacy, privacy types, definition of veracity and arguments contributing to the justification of obligations of veracity. theories of bioethics are also included in the course 9 . one of the most important ethical issues which are often ignored is relationship of doctors/physicians with medical representatives of bangladesh journal of bioethics 2014; 5(2):44-48 46 pharmaceutical companies and includes levels of interaction, promotions, various gifts from pharmaceutical companies, drug samples and its purpose in the eyes of patients, doctors and manufacturers. the curriculum at isra university is same as in lumhs jamshoro, but at isra university bioethics in being taught only in 2nd semester mbbs. bioethics is major subject at iprs lumhs jamshoro and it is being taught in their 7th and 8th semester (final year). i use to teach the same topics which i teach at mbbs level and they include all the topics from general ethics and they form the base of physiotherapy students. the iprs have their own faculty also which is trained in ethics and they handle the ethical issues in the field of physiotherapy, organizational ethics and code of conduct in physiotherapy. we divided the topics into two and we cover them in both semesters (7th and 8th). as i earlier said in my paper that it is not possible for us to teach in any other format other than lectures, we do discuss case scenarios in our lectures and we make lectures interactive and we use power point presentations also in lectures. i always try to teach students the basic things so that they can learn and improve their future practices. the students do understand the ethical issues and they often ask questions regarding different ethical dilemmas. how do i assess in exam: my bioethics topics are same for the three institutes but the difference comes when doing final assessment. at the end of the semester classes and before exams, i give them handouts of all the topics covered in the lectures. the assessment tool is summative assessment (exam at the end of semester 10 . in lumhs mbbs program there is no separate paper of bioethics, instead we give one compulsory short essay question in anatomy paper. hence, anatomy paper consists of 95 marks and bioethics question contains 05 marks. if the students do not attempt the bioethics question they loss five marks because they don’t have any choice as it is compulsory question. due to the question being compulsory the students do read the handouts before the exam and generally they do perform well in exam. at isra university the subject as i said earlier is minor, but they do have full paper. the marks of the paper are included in the semester exam but not in final annual exam, as isra have both patterns of exam i.e., semester followed by annual. there is single paper which contains bioethics as well as skill. the skill here refers to skill lab procedures, methods and concepts and it is taught by the isra faculty themselves and i use to teach bioethics as visiting faculty member. the paper comprises of 100 marks with 50 marks reserved for each component i.e. bioethics and skill. there are 60 sbqs (single best questions) and 8 seqs (short essay questions). each (bcq) best choice question (contain one mark and each seq contain five marks. the students have to secure 50 marks out of 100 to pass the subject. in bs physiotherapy, the bioethics is compulsory subject and students have to pass the subject to clear their semesters. there is no annual system in iprs so students have to clear bioethics in both 7th and 8th semesters. there are 100 marks in bioethics paper and paper contains my component and other from the faculty of iprs. we have again divided our portions and we teach in the ratio of 75:25. in 7th semester i teach 75 percent of the course and the iprs faculty 25 percent. it is because the topics from general ethics helps the students and are like first step to understand ethical issues in physiotherapy in bangladesh journal of bioethics 2014; 5(2):44-48 47 the coming lectures. in 8th semester the ratio inverses and i teach 25 percent of the curriculum and they teach 75 percent. the physiotherapy component is mainly covered in 8th semester. there are 35 bcqs in the semester paper and contains 70 marks, while 30 marks are reserved for seqs and students have to attempt 6 questions out of 8 and each question carries 05 marks. we have the paper distribution also in the ratio of 75:25, in which 6 seqs and 27 bcqs are given to 75 percent weightage component and 2 seqs and 08 bcqs are reserved for 25 percent component and vice versa in other semester. in bcqs we include some case scenarios also which are discussed in the lectures. those students who get less than 50 percent marks are declared fail and they have to appear in re-sit exam. the performance of physiotherapy students is better than mbbs students in the exam. this is because bioethics is included in their final year and they are already familiar with the clinical subjects and clinical ward postings and being final year students their maturity and cognitive level is also higher than 1st year mbbs students. the other reason is that they have compulsory subject of bioethics and they have to pass it at any cost to get the degree. the time allotted for papers is 2 hours in physiotherapy paper and 2 and half hours in mbbs paper at isra university and lumhs anatomy paper is also of 2 hours where one compulsory question of bioethics is included. there is no ospe or osce exam included to assess the students. the students’ attendance is merged and counted in overall attendance with other major subjects and those students who have less than 75 percent attendance are not allowed to appear in exam. this rule applies to all three institutes uniformly. some students take bioethics seriously and try to understand the concepts and contemporary issues in the field, while other just tries to pass the exam and show superficial interest. conclusion: a good physician is one who is not only technically sound, but also ethically well-grounded. medical institutes in pakistan are providing technical training, but largely neglecting the ethical component. given the challenging environment of developing countries, it is imperative that structured education in bioethics with a proper evaluation and feedback system is developed. bioethics is currently being taught in almost all major medical institutes of our country and the smaller and newer institutes should also adopt this strategy. my current experience of almost 2 and half years of teaching bioethics is satisfactory and i hope the future generation of the doctors will practice their medicine in ethical way and they will implement bioethics in their clinical practices and research, whether it is informed consent or keeping confidentiality of the patient and the research subjects or avoiding unethical relationship with the representatives of the pharmaceutical companies. references: 1. d j weatherall. teaching ethics to medical students. journal of medical ethics.1995 21: 133-134 2. the edinburgh declaration. the world conference on medical education. 1988 august 7–12. edinburgh, scotland: world federation for medical education. 3. dubois jm, burkemper j. ethics education in us medical schools: a study of syllabi. acad med. 2002 77:432–437. bangladesh journal of bioethics 2014; 5(2):44-48 48 4. pellegrino ed. teaching medical ethics: some persistent questions and some responses. acad med. 1989 64:701–703. 5. al-shehri my. medical curriculum in saudi medical colleges: current and future perspectives. ann saudi med. 2001 21:320–323. 6. shiraz b, shamim ms, shamim ms, ahmed a. medical ethics in surgical wards: knowledge, attitude and practice of surgical team members in karachi. indian j med ethics. 2005 2:94–96. 7. al-umran ku, al-shaikh ba, al-awary bh, al-rubaish am, al-muhanna fa. medical ethics and tomorrow’s physicians: an aspect of coverage in the formal curriculum. med teach. 2006 28:182–184. 8. kulsoom ghias, syeda kauser ali, kausar s. khan, robyna khan, murad m. khan, arshi farooqui & parvez nayani. how we developed a bioethics theme in an undergraduate medical curriculum. med teach. 2011 33: 974–977. 9. tom l. beauchamp, james f. childress. principles of biomedical ethics. 2001; 5th edition, oxford university press. 10. k mattick, j bingh. teaching and assessing medical ethics: where are we now? j. med. ethics. 2006 32:181-185. conflict of interest: there is no conflict of interest. bangladesh journal of bioethics 2015; 6(2):15-22 15 undue influences on drugs and device industries distort healthcare research, and practice mohammad arifur rahman 1 , laila farzana 2 1. national institute of cardiovascular diseases, sher e bangla nagar, dhaka 1207, bangladesh. email: drarif79@yahoo.com 2. holy family red crescent medical college and hospital, dhaka, bangladesh. abstract: background: expenditure on industry products (mostly drugs and devices) has spiraled over the last 15 years and accounts for substantial part of healthcare expenditure. the enormous financial interests involved in the development and marketing of drugs and devices may have given excessive power to these industries to influence medical research, policy, and practice. material and methods: review of the literature and analysis of the multiple pathways through which the industry has directly or indirectly infiltrated the broader healthcare systems. we present the analysis of the industry influences at the following levels: (i) evidence base production, (ii) evidence synthesis, (iii) understanding of safety and harms issues, (iv) cost-effectiveness evaluation, (v) clinical practice guidelines formation, (vi) healthcare professional education, (vii) healthcare practice, (viii) healthcare consumer‘s decisions. results: we located abundance of consistent evidence demonstrating that the industry has created means to intervene in all steps of the processes that determine healthcare research, strategy, expenditure, practice and education. as a result of these interferences, the benefits of drugs and other products are often exaggerated and their potential harms are downplayed, and clinical guidelines, medical practice, and healthcare expenditure decisions are biased. conclusion: to serve its interests, the industry masterfully influences evidence base production, evidence synthesis, understanding of harms issues, cost-effectiveness evaluations, clinical practice guidelines and healthcare professional education and also exerts direct influences on professional decisions and health consumers. there is an urgent need for regulation and other action towards redefining the mission of medicine towards a more objective and patient-, populationand society-benefit direction that is free from conflict of interests. keywords: undue influence, conflict of interests, evidence-based medicine, healthcare industry, medication, pharmaceutical industry. introduction: a universal characteristic of most healthcare systems in developed countries is the heavy focus on pharmacological approaches for treating and preventing chronic disease and the considerable expenditure on hightech medical equipment, devices and technologies. this focus is often linked to astonishing financial interests, such as the $130 billion a single drug (lipitor) generated over 14 years 1 an amount that is higher than the 2010 gross domestic product of 129 of the 184 countries in the world 2 . besides traditional drugs, biologics and devices can also produce huge revenue. for example, the manufacturers of anti-tnf biological drugs and therapies have created a $10 billion annual market 3,4 even though these agents are used for indications with rather modest, incremental benefits. the market for drug-eluting stents for coronary artery disease is $4_6 billion per year in the united states alone 5 , even though a large share of the indications for which these stents are used (e.g. stable coronary disease) has no supporting evidence 6–9 . this excessive financial capacity and the associated political and lobbying power allow the industry to dictate the rules of the healthcare game to serve its interests at several levels. the industry‘s interests are often at stark contrast to those of the patients and the society. in this article, we try to analyse the multiple complex pathways through which the industry has directly or indirectly infiltrated healthcare systems including strategic direction, expenditure, research, medical education and daily clinical practice. how the industry influences healthcare research, strategy, expenditure and practice: the industry has created means to intervene in all steps of the processes that influence healthcare research, strategy, expenditure and practice. these include evidence base production, evidence synthesis, understanding of harms issues, cost-effectiveness evaluation, clinical guidelines formation, healthcare professional education and direct influences on healthcare professional decisions. mailto:drarif79@yahoo.com bangladesh journal of bioethics 2015; 6(2):15-22 16 evidence base production: industry funds and often designs and controls a large portion of the most influential medical studies. trials funded by for profit organizations are on average 4 times more likely than trials sponsored by non-for-profit organizations to favour the sponsored drug 10,11 . empirical evidence suggests that while methodological quality is the same in industry-sponsored and other trials 10 , industry-sponsored trials are more likely to compare the sponsored intervention against an inactive or straw man comparator 3,10 . an evaluation of over 600 trials registered in clinicaltrials.gov shows that with few exceptions, single trials address only products of a single company 12 . however, for most conditions, there exist many possible interventions, including lifestyle changes and products manufactured by diverse companies. finally, for many years now, the public sector has largely abandoned the conduct of randomized trials to the industry and thus, not surprisingly, the most cited trials are almost always industry sponsored, often exclusively so 12 . these trials then also guide the conduct of other clinical research. medical research is doomed to navigate only questions posed by the industry and their extensions. there is increasing direct evidence about the manipulation of reported results in industry-sponsored trials, which demonstrate favourable results and the avoidance of inconvenient findings, as in the case of gabapentin for off-label use 13 . in addition to these direct biases, the industry has a major impact on which research is published in the most influential medical journals through ghost authorship 14,15 , (i.e. raising the status of trial results by listing academically affiliated investigators as first or second authors in manuscripts) written by company staff or professional medical writers paid by the companies. it is possible that major journals have often undisclosed conflict of interests from publishing industry trials. journals also have conflicts themselves, because such industry trials generate considerable revenue from offprints and can boost the journal‘s impact factor by as much as 15% 6 . evidence synthesis: systematic reviews that summarize trials addressing the wrong questions (as above) will simply reinforce the wrong messages 17 , unless meta-analysts are astute to diagnose the problems in the generation of the evidence, let alone publication and other selection biases. access to raw data of clinical trials to date has been limited, and integration in systematic reviews of the data that are readily available may perpetuate and solidify the biases of the primary literature 18 . moreover, as systematic reviews and meta-analyses have grown in prestige and influence, the industry has also infiltrated this type of research. a systematic review comparing the methodological quality of meta-analyses of the same drugs by source of funding (industry-funded verses nonindustry funded) 19 concluded that the former type of study is of lower methodological quality and considerably more likely to omit reporting bias-relevant details (e.g. descriptions of the excluded patients/studies). although the estimated treatment effects were similar on average, 100% of industry-funded meta-analyses had conclusions recommending the experimental drug without reservations compared with 0% of the (independent) cochrane reviews 19 . in metaanalyses of antihypertensive drugs, financial ties to a pharmaceutical company were not associated with favourable results, but were linked to four times higher odds to report favourable conclusions 20 . furthermore, conflict of interests in the original studies included in meta-analyses are usually silenced and unreported 21 . for example, a recent study revealed that only 2 of 29 pharmacological metaanalyses reported the funding sources of the trials and none of them reported author–industry ties in the primary trials 21 . finally, content experts who co-author systematic reviews and meta-analyses may often distort the phrasing of the research questions, the results and the interpretation of these reviews in favour of industry products 22. understanding of harms issues: licensing for new products or indications requires demonstration of effectiveness and absence of major harms. however, the whole process allows plenty of room for serious harms to be unrecognized by the time licensing is granted. many interventions are withdrawn or acquire black boxes years after they are licensed and after they have already cost a fortune to the healthcare system 23 . recent drug withdrawals suggest that financial ties with the pharmaceutical industry can determine the orientation of the authors of trials and meta-analyses in drug safety issues. rosiglitazone, a multibillion selling drug for type 2 diabetes, was approved and prescribed to millions of patients worldwide for 10 years despite limited evidence on its benefits and,especially, safety 24 . rosiglitazone potentially increases the risk of cardiovascular disease and comorbidities such as weight gain and increases blood lipids. it has recently been withdrawn from both the eu and new zealand markets, and its indications have been severely restricted in the united states 25. among the many similar revelations, perhaps the best known case is rofecoxib (vioxx), a blockbuster non steroidal anti-inflammatory drug that nearly doubled the chances of both myocardial infarction and stroke 26 . data revealed during a litigation case suggested the manufacturer intentionally distorted the presentation of trial safety data 27 and trained its sale representatives to tactfully avoid physician questions on safety 28. bangladesh journal of bioethics 2015; 6(2):15-22 17 cost-effectiveness evaluation: cost-effectiveness of therapies is a major criterion when allocating scarce public resources and is directly influenced by commercial pricing strategies. most published analyses report favourable incremental cost-effectiveness ratios, and studies funded by industry are more likely to report ratios below required thresholds on cost-effectiveness 29 . studies funded by industry are more than twice as likely to report costeffectiveness ratios below $20 000 per quality-adjusted life year compared with studies funded by other sources [30]. there are many different methods by which industry-sponsored cost effectiveness analyses can achieve more favorable results, including but not limited to biased assumptions about the intervention, its comparators (e.g. underestimating the sensitivity/ specificity of the standard pap test for analyses of hpv vaccines or hpv dna tests for cervical cancer prevention) 31 or other parameters that need to be modeled (e.g. extent of indirect effects for vaccines) 32 . clinical practice guidelines: clinical practice guidelines are supposed to be based on best evidence. they are endorsed by recognized authorities, and to a large extent, they define daily medical practice. integrity, objectivity and independence are of paramount importance for a correct translation of the evidence into clinical guidelines. these three crucial attributes are difficult to safeguard. most (56%) scientists involved in the 17 most authoritative us cardiovascular clinical practice guidelines released between 2004 and 2008 received research grants, honoraria for speeches in drug-promoting events, stocks (shares) or consultancy fees by pharmaceutical and related industries 33 over 80% of the committee chairs had such conflict of interests. over 50% of guideline panel members in the united states and canada have conflict of interests while the respective figure for guidelines sponsored by nongovernment sources approaches 70% 34 . overall, between 56 and 87% of clinical practice guidelines, authors have been found to have at least a conflict of interest (consultancies, research support, equity/stock ownership) 35 . there is substantial margin for the members of these committees to input their subjective views through ‗expert opinion‘ (evidence level c), which represented nearly half of all major us cardiovascular clinical care guidelines published between 1984 and 2008 36 . even higher levels of interaction were noted between the authors of 44 clinical guidelines and the pharmaceutical industry in a previous publication 37 . given that the boundary between industry and academia has become so vague, it is hardly surprising that clinical practice guidelines often are heavily focused on new costly interventions and only loosely follow the available evidence. for example, current guidelines still advocate tight pharmacological glycaemic control for patients with type 2 diabetes, despite the best available evidence suggesting that there is no major benefit for patients 38 and possibly even deterioration of quality of life 39 . declarations of the conflict of interests of expert panels and researchers are thought to guarantee transparency and integrity in the evidence base and clinical recommendation generation process. nevertheless, there appears to be a gap between the intended purpose and practice as financial conflict of interests are severely under-reported in drug trial metaanalyses and panel guidelines 34 and practitioners very rarely discount for such conflicts when evaluating the evidence base 40 . besides clinical guidelines formation, narrative review and editorials by key opinion leaders also have a major impact on clinical practice decisions and the medical community in general 41,42 . an example of the influence of the conflict of interests of key opinion leaders is that although evidence does not support that brandname drugs are superior to generic drugs 4 3 , editorials often counsel against the interchangeability of generic drugs 43 . healthcare professional education: intense exposure to pharmaceutical marketing commences during undergraduate medical education for future prescribers. a study showed that third-year medical students are exposed to one industry-sponsored gift or activity per week and almost (93%) all have been asked or required to attend at least one industry-sponsored lunch 44 . the large majority (67 –92%) of medical students acknowledge that education from industry sources is biased and that pharmaceutical industry pressures increase over the course of medical school 45 . this exposure brainwashes medical students‘ attitudes towards the marketed products 46 . in the usa, 60% of medical school chairs have some form of personal relationship with industry (e.g. consultant, a member of a scientific advisory board, a paid speaker, an officer, founder or member of the board of directors) 47 . continuing medical education (cme) is an essential part of the development for practicing health professionals. in the united states, industry support for cme increased from $301 million per year in 1998 to $1_2 billion per year in 2007 accounting for approximately 60% of the total accredited cme costs (including advertising/exhibit payments) 48 . although there are signs of a reversing trend (due to regulatory restrictions and the economic trends), industry funded cme still accounted for approximately half of all cme by 2010 48 . industry sponsors have substantial influence over bangladesh journal of bioethics 2015; 6(2):15-22 18 the content of education programmes, which often involve heftily paid prominent medical figures presenting information about the company‘s latest products, often using slides provided by the company 49 . sponsored cme leads to increases in prescription rates by the attendant physicians of the promoted medication 50 . in the uk, most hospital educational ‗grand rounds‘ and many other medical education meetings are sponsored by the industry, with lunches provided in return for sales and marketing opportunities. in primary care, many staff events are sponsored by the pharmaceutical industry in return for a lunch and ‗educational‘ opportunities on pharmaceutical products. postgraduate education departments foster strong relationships with sales representatives, and educational meetings and conferences are nearly always industry financed 51 . direct influences on healthcare professional decisions: direct marketing pressures by sales representatives are substantial, for example, a us cardiologist meets with sales representatives nine times a month on average 52 . in 2004, over a third of the $57 billion that pharmaceutical companies spent on promotional activities went on visiting doctors to promote new drugs and establish relationships with health professionals in community or academic settings 53 . regular interactions with sales representatives increases the chances to add the drug company to a hospital‘s formulary by over 300%, and the combination of the physician receiving honoraria leads to even greater increases 54 .the culture of industry-offered ‗gifts‘ or equipment, educational textbooks, sponsorship or luxury travel 55 and free meals has been common across the entire spectrum of health practitioners. in many countries, most industries have a trade association representing their profit-orientated members, for example, the uk association of the british pharmaceutical industry (abpi) with 150 members, which has set up the prescription medicines code of practice authority to administer the pharma-ceutical industries‘ own code of practice. however, there has been a recent exodus of abpi members, with even fewer companies choosing to follow even this largely voluntary code [56]. surveyed patients consider the financial ties between practitioners and drug companies unacceptable and a compromise to their quality of care 57 ; however, patients are rarely aware of their doctor‘s ties with the industry, which may have biased their care plan. direct-to-consumer advertising: in the united states, where such marketing practices are permitted by law, directto-consumer advertising (dtca) is a major force of rising pharmaceutical costs 58 . industry spending on dtca for pharmaceuticals alone increased from $11 billion to $30 billion within the 1996–2005 decade 59 , about the same period of time when the total costs of prescription drugs were rising at a rate higher than 30% a year 60 . besides inflated costs for patients and healthcare providers [58], dtca is linked to concerns over the aptitude of the lay public to understand risks and benefits through a 30-s tv or a one page magazine advertisement. dtca typically commences one year after release of a new drug 59 , which is a very short time frame for many unwanted side effects to become apparent. the us senate has previously considered legislation prohibiting such advertising for at least two years 61. conclusions: given that many of the problems discussed above are closely linked to financial interests, we would argue that there is an urgent need to better deal with conflict of interests in medicine and healthcare. the institute of medicine has published a comprehensive set of recommendations on how to deal with conflict of interests in medicine so that the undue industry influences we describe above are eliminated 62. these recommendations cover general policy measures, medical research, undergraduate and continuous medical education, medical practice, as well as clinical guideline formation. the evidence we presented highlights the case for tighter regulation on how the healthcare industry designs, conducts, disseminates and publicizes their research, markets their products and interacts with medical students, health professionals and researchers. currently, industry expenditure influences and determines medical practice and attitudes at various levels at the expense of patients‘ health, healthcare budgets and medicine‘s integrity. there are positive signs of action taken in both united states and europe, for example, the sunshine act in the united states that requires drug companies to declare all payments and hospitality or gifts they give to doctors. in denmark, companies have been required to declare their payments to doctors since 2008, in scotland, doctors have to declare such transactions themselves, and france is currently preparing such legislation. the new england journal of medicine banned cost-effectiveness evaluations sponsored by product manufacturers almost two decades ago. these are some indicative steps towards redefining the mission of medicine towards a more objective and patient-, populationand society-benefit direction that is free from conflict of interests. conflict of interests: none of the authors have any conflict of interest to declare. bangladesh journal of 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miller lg, cleary pd, blumenthal d. a national survey of physician-industry relationships. n engl j med 2007; 356:1742–50. 53 gagnon m-a, lexchin j. the cost of pushing pills: a new estimate of pharmaceutical promotion expenditures in the united states. plos med 2008; 5:e1. 54 chren mm, landefeld cs. physicians‘ behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary. jama 1994; 271:684–9. 55 giannakakis ia, ioannidis jpa. arabian nights—1001 tales of how pharmaceutical companies cater to the material needs of doctors: case report. bmj 2000;321:1563–4. 56 norgine mp, martin p. norgine‘s reply to abpi. bmj 2010; 340:c1869. 57 licurse a, barber e, joffe s, gross c. the impact of disclosing financial ties in research and clinical care: a systematic review. arch intern med 2010; 170:675–82. 58 law mr, soumerai sb, adams as, majumdar sr. costs and consequences of direct-to-consumer advertising for clopidogrel in medicaid. arch intern med 2009; 169:1969–74. 59 donohue jm, cevasco m, rosenthal mb. a decade of direct-toconsumer advertising of prescription drugs. n engl j med 2007; 357:673–81. 60 kaiser family foundation [internet]. prescription drug trends. menlo park, california; c2010. available at: http://www.kff.org/ rxdrugs/upload/3057-08.pdf. access on 12 february 2013. 61 shuchman m. drug risks and free speech: can congress ban consumer drug ads? n engl j med 2007; 356:2236– 9. http://www.kff.org/ bangladesh journal of bioethics 2015; 6(2):15-22 22 62 institute of medicine. chapters 3–8. in: lo b, fields mj, editors. conflict of interest in medical research, education, and practice. washington, dc: national academy of sciences; 2009: pp. 62–229. bangladesh journal of bioethics 2015; vol 6 issue2 editorial greetings to all our readers and authors! the bangladesh journal of bioethics is gaining more popularity among all of us who are concerned about standards, norms, practices and ethics. this journal is our voice to share what is being practiced and what should be done. it will help to bring about equality and equity through an ethical rights based approach in all sectors of development touching our lives. this issue contains articles on diverse aspects of medical and social practices and will be very useful in ensuring that bioethical standards are complied with. some of the papers are discussed below: albert m. e. coleman in his paper discusses the challenges and implications of medical ethics and medical professionalism in low and middle income (lamic) countries. the article examines the ethical issues that may arise with regard to medical practice in low and middle income countries (lamic), and the challenges for medical regulatory bodies in upholding ethics in professional practice. the author recommends that lamic progress to improve the health of its population should synchronize with medical ethics theories. tahera ahmed in her paper on child marriage points out that it is still a massive problem in many developing countries. the paper reviews the current situation and existing programmes on reduction of child marriage. the paper discusses the consequences of child marriage such as risk of early and unwanted pregnancies, maternal morbidities and mortalities. the author recommends that each country set up its own mid-term and long-term goals to bring about significant reduction in child marriages. dr. mohammad arifur rahman et al looks into the influence of drugs and device industries on healthcare research, and practice. the authors through literature review and analysis have presented their findings at the following levels: (i) evidence base production, (ii) evidence synthesis, (iii) understanding of safety and harms issues, (iv) costeffectiveness evaluation, (v) clinical practice guidelines formation, (vi) healthcare professional education, (vii) healthcare practice, (viii) healthcare consumer’s decisions. they conclude that the industry influences evidence base production, evidence synthesis, understanding of harms issues, cost-effectiveness evaluations, clinical practice guidelines and healthcare professional education and exerts direct influence on professional decisions and health consumers. the authors recommend the need for regulation of medicine towards a more beneficial direction free from conflict of interests. zoheb rafique presents a case study relating to accountability for reasonableness, for priority setting and resource allocation. through a case study he examines the priority setting and resource allocation for scarce resources in a developing country like pakistan. he applies the four conditions of accountability for reasonableness for priority setting and resource allocation. these four conditions are publicity condition, relevance condition, revisions and appeals condition and regulative condition. in resource poor settings the four conditions of ‘accountability for reasonableness’ is a framework that can be used to guide priority setting in health care organizations. the author also recommends that more hospitals be set up, doctors trained, equipment and supplies provided. he concludes that even with scarce resources, the government hospitals in pakistan are providing excellent services. dear readers, your articles, reports or commentaries are welcome! in whatever field you are working in, bioethics play an important role, and we hope that through this journal you will share your thoughts and experiences for us to build a better and improved quality of life. best regards. tahera ahmed former chief, sexual and reproductive health, unfpa, faculty, north south university, and editor, bangladesh journal of bioethics bangladesh journal of bioethics 2014; 5(3):26-27 26 communication the bangladesh midwifery programme – a giant step towards safe motherhood tahera ahmed acting chief, sexual and reproductive health and rights unfpa, bangladesh email: tahera50@yahoo.com safe motherhood is not only a reproductive right but also a basic human right. provision of safe motherhood services like skilled attendants at birth reduces maternal deaths and morbidities. bangladesh has reduced maternal deaths from 540/ 100,000 live births in the nineties to 194 in 2010 1 . in a recent estimate by who, unicef, unfpa, the world bank and the united nations population division, the maternal mortality rate (mmr) has declined to 170 per 100,000 live births 2 in bangladesh. the honorable prime minister’s commitment at the un general assembly to accelerate progress to reach the mdg 4 and 5 was highly appreciated during the 2010 united nations summit on the millennium development goals (mdgs). bangladesh committed to: doubling the percentage of births attended by a skilled health worker by 2015 through the training of an additional 3000 midwives, staffing all 427 subdistrict health centers to provide round-the-clock midwifery services, and upgrading all 59 district hospitals and 70 mother and child welfare centers as centers of excellence for emergency obstetric care services. 3 to fulfill the commitment of the honorable prime minister at the 2010 united nations summit on the millennium development goals (mdgs), the government has introduced the midwifery programme and created 3000 post of midwives. this is the first time that a dedicated cadre skilled in the provision of safe motherhood services has been created and posted in the field to be available and accessible to all women when needed. the midwifery strategic directions document developed in 2008 with technical assistance from development partners like who and unfpa, as well as the bangladesh nursing council, the nursing directorate and other stakeholders including professional associations and ngos, provided guidelines for the development of the midwifery cadre including training of trainers and midwifery training. the training of the midwives is now ongoing in 2 pathways: a. 6-months advanced certificate in midwifery training for registered nurse-midwives -who have completed 4-year diploma in nursing & midwifery. b. 3-years diploma in midwifery -direct entry from hsc level. mailto:tahera50@yahoo.com bangladesh journal of bioethics 2014; 5(3):26-27 27 until now 1103 certified midwives have completed the 6 month training course and 700 students are studying for their midwifery diploma in 27 centers. as the situation has changed since 2008, a review and modification of the strategic directions 2008 has been made in consultation with all stakeholders to make it more effective and functional. the updated national strategic directions for midwifery in bangladesh, 2014 is focusing on 4 priority areas with strategic actions for each area. o policy and planning: o training, education and research. o deployment and utilization: o regulation monitoring and evaluation has been kept as an overall component of the document. the national strategic directions for midwifery in bangladesh, 2014 has been printed and will be shared by bangladesh nursing (and midwifery) council and unfpa. bangladesh has taken a huge step forward for ensuring safe motherhood and quality of care through the introduction of the midwifery cadre. with the timely implementation of the national strategic directions for midwifery in bangladesh, 2014 it is expected that maternal mortality as well as morbidity will come down to very low levels and bangladesh will be a shining example for others to follow. references: 1. bangladesh maternal mortality survey 2010. 2. united nations foundation. every woman every child-commitments. 2014. 3. world health orgamnization. trends in maternal mortality: 1990 to 2013, estimates by who, unicef, unfpa, 2014. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ (access on 27 th december 2014) http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ communication the bangladesh midwifery programme – a giant step towards safe motherhood o policy and planning: o training, education and research. o deployment and utilization: o regulation microsoft word research enterprise_1 bangladesh journal of bioethics 2015; 6(3):25-29 25 ethical justification of conducting research trials in lower and middle income countries including pakistan: the responsibilities of research enterprises zoheb rafique lecturer department of biochemistry, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: dr_zohaib@hotmail.com abstract: asia is the most diverse continent in the world in terms of culture, religion, population size, finance, education, health care, academic research, general population skills, and governmental drug regulations. each asian country has its own unique qualities when it comes to attracting industry sponsored clinical trials. factors that influence selecting location of a study site for a sponsored trial are mainly population size, infrastructure, education levels, and quality of health care, cost and drug regulatory platform. conducting research in traditional countries like pakistan adds another dimension to the problems in assuring that research conducted in an ethical manner. the indigenous layer of the cultural values makes it even more difficult task, but this is the task that we are morally and ethically bound to shoulder. key words: responsibilities, research enterprises, research trials lower and middle income countries, pakistan introduction: some asian countries such as japan, hong kong and singapore have among the longest life-expectancy, lowest infant mortality and highest per capita income worldwide, while others are in the lower end of such rankings. several, notably china and india, are amid rapid economic development, as the asian economy is more-or-less becoming the global axis, with the economies of us and europe slowing. asia has a population of 3.8 billion, at least ten times more than north america or europe. as the world’s most populous continent, asia has by no means reached full capacity in contributing with subjects in testing new medical products in collaboration with the international pharmaceutical industry. this trend will certainly direct more sponsored clinical trials to asia, but not necessarily benefit all asian countries. engaged in 18.1 % of all protocols globally asia is involved in more sponsored trials than any other region. india, korea and taiwan standout as the most active locations for multi-national trials in asia. when ranking is for cities seoul is the most active asia city, followed by taipei, hong kong, singapore and new delhi. the globalization process of sponsored clinical trials has provided an opportunity for asia to attract international companies to the region and also seemingly encourages development of local life-science industries1. we are beginning to see some bangladesh journal of bioethics 2015; 6(3):25-29 26 exponential growth in the clinical drug trials conducted in pakistan in which multinational drug manufacturing companies are major players. in majority of collaborative trials the sponsors are from countries of developed world while coinvestigators and research participants are drawn from asian and african countries2. in this paper, i will discuss the responsibilities of researcher/funder when the research trial is conducted in low and middle income countries like pakistan and i will also talk on ethical justifications of doing research trials in pakistan and other poor and developing countries. discussion: resource poor countries require a lot of attention from the medical research establishment in order to sustain the quest for treatments and remedies for diseases and other health-threatening conditions. however, the collaboration between rich countries and wellendowed agencies, on one-hand, and economically constrained research communities, on the other, requires a careful assessment of responsibilities and options for researchers and research subjects alike. major players in international research also include big pharmaceutical companies who seek people living in developing countries as subjects. safety and standard of care for human volunteers are also major issues. “i had not been exploring big pharma of third world ‘volunteers’ as cheap guinea pigs, observes writer john le carre (2001). “their role though they don’t even know this is to test drugs, which are not yet approved for the testing in us, and which they themselves never be able and possible to afford even if those tests turn out to be reasonably safe” (le carre, 2001). in us, it costs on an average $ 10,000 per participant to conduct one clinical trial, in russia it costs $ 3,000, and in poorest and remote parts of the world, it costs much less. this is among one of strong reasons why the clinical trials are now third world growth industry. in its may 2000 edition center watch, a newsletter for burgeoning clinical trials business, published an article under title latin american fever, in which it said that the continent “may offer a unique chance to reach larger numbers of the study subjects”. eli lilly tested some 590 patients, in 1994 across africa, middle east and the central and eastern europe. in 2001 the company expected to run the tests in those regions on 7,309 patients. in rush to market, poorly constructed, and weakly monitored drug trials are releasing the untried and untested drugs. the contemporary practice of biomedical research on a global scale has given rise to evolving forms of exploitation. standards of justice and equality tend to be put in question in the face of research practices that often put heavy burdens on poor people and poor communities in poor countries. there is a need to remain vigilant in the prior review of these activities and the monitoring of their implementation in order to ensure that biomedical research is conducted in accordance with universally acceptable standards. one of the most important requirements for the conduct of research in developing countries is emphasized in the who-council for international organizations of medical sciences’ guidelines for biomedical research involving human subjects: to guarantee that those communities where these new drugs have been tested will be given affordable access to the newly developed and approved drugs. otherwise, one might bangladesh journal of bioethics 2015; 6(3):25-29 27 rightly argue that people in developing countries have yet again been exploited by western researchers without benefiting from the positive results their risk-taking has yielded (del rio, kamarulzaman, and schuklenk, n.d.). ruth macklin observes that it is not just individuals who can lose out when big drug companies carry out their tests. when industrialized countries do research in a developing country, the developing country can’t afford the products of that research. the researcher’s pullout and the successful products then become available in the western industrialized countries and the population in the countries where the research was done get nothing. so that’s truly a question of justice, and we’re beginning to see a movement to rectify that injustice (2000). the wide disparities in resources that are available for biomedical research in developed and developing countries give rise to ethically relevant issues of research prioritization and collaboration. the international research community has to accelerate the shift to an environment where researchers from developing countries are recognized as full and equal partners in biomedical studies; where the technologies of developed and developing countries are integrated and made widely available; and where the benefits of biomedical research for participant communities can be ensured3. in resource-poor countries like pakistan and majority of developing countries, the two primary means of protecting participants-irb review and informed consent may be inadequate. irbs in low and middle income countries may lack training, experience, and resources. irbs in the united states are unlikely to be familiar with conditions in the host country. informed consent may be problematic in a country where people are poorly educated and lack health literacy, and where physicians in clinical practice usually do not tell patients their diagnosis, admit uncertainty, or obtain consent. participants may not accept western models of disease. furthermore, participants might hear rumors and other misinformation about a research study. in several highly publicized cases, researchers from developed countries have been harshly criticized for allegedly conducting inappropriately risk studies in resource poor counties without adequate consent. the other problem is health priority and it would be an imprudent use of limited health care resources in a developing country to conduct human-participants research that does not address a health or public health priority in the host country. because of scarce resources and logistical constraints, medical interventions that are standard in developed countries may not be available or feasible in resource poor countries where the trial is conducted. this creates an ethical tension between providing a benefit to research participants and obtaining generalizable scientific knowledge. according to the ethical obligation to minimize harm to participants, researchers should provide interventions that are known to be effective and feasible to prevent or treat the condition addressed in the clinical trial. because participants in a research study help researchers, sponsors, and society at large, they should receive some benefit in return as a matter of reciprocity. advocates contend that researchers and sponsors must avoid taking unfair advantage of participants and their communities by providing those who bear the risks of research appropriate benefits, in addition to the long-term benefit of generalizable knowledge. researchers and sponsors need to consider bangladesh journal of bioethics 2015; 6(3):25-29 28 whether the study intervention will be available in the host country if it is shown to be effective and safe. some ethics expert point out that providing reasonable access to study interventions after a trial may be an inadequate reciprocation for participation in research. first, it is too limited and weak an obligation. if the study is something other than a pivotal clinical trial (for example, an epidemiological study), no additional benefits will be required. even if the study is a clinical trial, it might be a negative study. second, other benefits might be more useful to participants or their communities than the trial drug. for example, they might benefit more from better primary care or better education for host country health care workers. third, the appropriate target group for benefits may be all persons in the community where the study is carried out, not just trial participants. providing benefits only to trial participants will widen health disparities in the resource-poor host country and therefore raise concerns about causing injustice. thus, providing benefits to the host country should be done in a way that ameliorates rather than worsens health disparities. for these reasons, some writers argue that researchers and sponsors from the developed world should provide fair benefits to the research participants and their communities in reciprocity for what they contribute to the research. researchers could provide benefits to research participants in a number of ways, such as by providing health education or some basic health services; training local health care workers, researchers, and irbs; donating equipment at the end of the study; and giving local investigators a key in analyzing data and writing papers. such contributions ensure that the community where the research is carried out will receive benefits in reciprocity for participating in the research. by building infrastructure, researchers can help provide sustainable improvements that will help to narrow health disparities between rich and poor nations4. pakistan is also among the poor and one of developing country and the health care conditions here are same as any south asian or african country. we will apply the same ethical and moral rules when we talk about research here in pakistan. added to this is other reality in pakistan i.e. weak, absent and only-on-paper accountability processes both at governmental and institutional levels. the lack of accountability processes and also the powerful power difference serve as a lethal combination for the human research participants and patients alike. through workshops held in our country pakistan, healthcare professionals and medical scientists are now becoming familiar with helsinki declaration and the council for international organizations of medical sciences (cioms) and some other research ethics guidelines. but the knowledge of such guidelines is one thing and application of this within the specificity and the context of existing professional and cultural practices quite another. ethical requirements for the clinical research don’t end when subjects either sign consent form or when they are enrolled in the research or they refuse enrollment. the individuals should continue to be treated and healed with respect and empathy right from the time they are approached and even if they refuse enrollment throughout the participation, and even after the participation ends5. the basic disclosure requirement for satisfying the informed consent provision in u.s. research regulations focus on information needed by a potential bangladesh journal of bioethics 2015; 6(3):25-29 29 participant to decide whether or not to participate in a study. of the eight basic disclosure requirements, one focuses on potential benefits: a description of any benefits to the subject or to others which may reasonably be expected from the research. traditionally disclosure is required to make sure that potential participants/subjects understand whether there is possibility that the procedure/intervention itself would benefit them when they are enrolled in research study. there is, however no any specific mention of any of post-trial benefits. those who may participate in the studies should be informed about the potential benefits if any. because this information is very relevant to the participants’ decisions to involve in research, ethical review committees should require the investigators to make those disclosures6. conclusion: biomedical research has provided huge benefits for the human, and it also offers good hope for the future. the problem arises when it is being high jacked by private and commercial enterprises those are willing to by pass the meticulous scientific methodology and the ethical standards. in the end i will conclude by saying that research participants should know each and every thing regarding their participation in the research trial or rejecting it, and it is their right to know all risks and benefits while participating in the research trials and this should be applicable to all countries around the world including all developing poor, middle and low income countries including pakistan. references: 1. johan pe karlberg. development of sponsored clinical trials in asia. clinical trial magnifier. 2008; vol. 1:5: 77-100. 2. farhat moazam. research and developing countries: hopes and hypes. east mediterranean health journal. 2006; vol. 12 (supplement no. 1): 30-36. 3. 3. leonardo d. de castro et al. bioethics in the asia-pacific region: issues and concerns. 2003; 1-108. 4. lo b. clinical research in resource-poor countries. ethical issues in clinical research: a practical guide. 2008; ch.22:194-210. 5. ezekiel j. emanuel et al. what makes clinical research ethical? jama. 2000; 283(20): 2701-2711. 6. ch 3; voluntary informed consent. national bioethics advisory commission. 35-53. conflict of interest: there is no conflict of interest bangladesh journal of bioethics 2014; 5(2):68-72 68 standard of care in clinical research involving human subjects: a perspective from developing world muhammad waseem khan 1 , sanam zeib khan 2 , afrasiab khan tareen 3 , imrana niaz sultan 4 1,2,3,4, department of biotechnology & informatics, faculty of life sciences & informatics, balochistan university of information technology engineering & management sciences (buitems) quetta balochistan, pakistan. email: muhammad.waseem@buitms.edu.pk, mwaseem.tareen@yahoo.com abstract: standard of care is an ordinary, reasonable formal treatment and diagnostic process that a physician should follow for his/her patient with specific disease. standard of care followed in one country may not suit to other country; the reason may involve economic conditions, certain norms, beliefs, tradition and culture of that society. it may be considered ethical if it does not exploit human rights and poor vulnerable population, once it exploits the human rights it creates ethical dilemmas that need to be sort out to protect vulnerable population and to make the research more ethical. patients attending medicine department of bolan medical complex (bmc) quetta, balochistan, pakistan were selected randomly interviewed and requested to fill the questionnaire. the ethical issues in clinical research conducted on human population have been perplexing and remains to be the same in clinical research settings. exploitive use of research participants in resource poor developing countries has intensified the debate on the ethics of international research and led to increasing attention to exploitation of vulnerable study subjects. the issues of conducting research in developing countries will remain and need to be focused and debated where and whenever require. one has to try sincerely to sort out the ethical problems while conducting a research study, he might fail to solve all the issues but the situation may improve by the time if tried sincerely. keywords: global standard, placebo, resource allocation, clinical research, post-trial benefits introduction: standard of care is defined as an ordinary, reasonable formal treatment and diagnostic process that a physician should follow for a patient with certain and specific symptoms or disease. standard of care is the attention and prudence that a reasonable researcher and physician in the circumstances would try to administer in practice. if a person's actions do not meet this standard of care, then his/her acts fail to meet the duty of care which all people (supposedly) have toward others. failure to meet the standard of care is termed as negligence, and any damages resulting there from may be claimed in a lawsuit by the injured party. a standard of care may differ from one community to the other. standard of care followed in one country may not suit to other country; the reason may involve economic conditions, certain norms, beliefs, tradition and culture of that society. it may be considered ethical if it mailto:muhammad.waseem@buitms.edu.pk mailto:mwaseem.tareen@yahoo.com bangladesh journal of bioethics 2014; 5(2):68-72 69 does not exploit human rights and poor vulnerable population, once it exploits the human rights it creates ethical dilemmas that need to be sort out to protect vulnerable population and to make the research more ethical. in developing countries ethics play a major role in health care and in health research, as better health of any community is the main focus of any government whether in development or developed country for its benefit and development. the recent debate in developing countries is mainly focused on the issue of standard of care that is used for the research participants in research studies that are conducted by multinational companies from developed countries. there are other issues such as voluntary inform consent, community participation, risk benefit ratio, fair subject selection, post trial benefits and many more to be taken care of. the important of all is the issue of autonomy, beneficence and justice that need to be focused and should be considered as primary responsibility of any researcher conducting any research study, it almost covers all other issues that may be labeled as the secondary issues 1 . the ethics of research on human population has been a challenging and remains to be the issue of great debate. exploitive use of research participants in resource poor developing countries has intensified the debate on the ethics of international research and led to increasing attention to exploitation of vulnerable study subjects. as only less than 10% of the world research resources are allocated for the 90% of health problems that causes the debate of standard of care which should be provided to the study participants in research studies that are conducted in developing countries 1 . declaration of helsinki 1996 version answers it, that worldwide best possible available proven standard of care should be provided, but it has been widely rejected by national as well as multinational committees worldwide. interestingly it is interpreted as the best available treatment available in the country where the research is conducted and due to this interpretation, that research study is considered ethically permissible which provide less than possible available standard of care in some circumstances, if not in all situations 2 . there is more than one possibility when standard of care is set which have not been clearly distinguished from one and other. in the presence of these possibilities it becomes difficult to assess the implications of opposing or accepting certain type of standard of care in any research study. the declaration of helsinki which states “best proven therapeutic method” it is interpreted as the best therapy available anywhere in the world it is given the name as “global reference point” (global defacto) or the therapy or the standard of care available and used in the country where the research study is conducted, it is named as “local reference point” (local defacto). bangladesh journal of bioethics 2014; 5(2):68-72 70 following global reference point may be deemed as most suitable for the people of developing countries where the study is conducted, but it is considered as burden by the trial conducting companies or the sponsoring countries. the local reference point make life easy for the researcher to use placebo or no treatment where there is no treatment at all in that country therefore, the use of a placebo in control group is not considered as unethical on the ground that it fails to provide the established standard of care as the standard of care is considered of that country. the use of a placebo in the subjects of control group in these countries does not fall below the established standard of care of that country. while considering the global reference point will not allow the use of placebo or low standard drug in control arm as the researcher has to follow the global standard point that does not take care of the standard of care that is prevailing in the research conducted country 3 . it is argued that if the researchers are obtaining some useful data for the developing countries, some might get less than best standard of care which balances the weight, but all in all it is unethical to do so and it also violates the mutual relationship of trust that research participant has on the researcher. the declaration of helsinki rejects the use of placebo in trials which causes irreversible harm to the research participant and the use of placebo might be considered ethical and less harmful in the trials of less severe diseases, which do not cause irreversible harm. 2 secondly, the use of placebo is considered in trials where no proven diagnostic or therapeutic treatment is available, where no treatment might also be considered. in these settings it is deemed as unethical to conduct a clinical trial in which some subjects receive a level of care that falls below the established standard of care 2, 4 . to avoid the exploitation of host communities where research is conducted, subjects must receive the best methods available worldwide on the other hand this strict requirement may block important research intended to improve health care, especially in developing countries that are already conducted for the benefit of the poor communities or at least they are getting some sorts of benefits from that 5 . standards of care that are applied for the research conducted in the developing countries should be the same as those applied in developed countries. a single moral standard should govern all research on human subjects, regardless of where and when the research is carried out rather than applying different for developing countries than developed countries. it may be argued that sticking strictly for global standard principle might stop a significant amount of important research which is taken out in developing countries. in such cases, after satisfying the issues of autonomy, justice and beneficence the standard of care might be considered as what is usually available in a developing country i.e. in country where the research study is conducted. in cases where research is conducted in that country where there is total absence of care or health services or there is no treatment for the disease about which the research study is conducted, the use of placebo or no treatment in control arm should not be considered as a suitable control standard, and in these situations the use of placebo in control arm should not be allowed bangladesh journal of bioethics 2014; 5(2):68-72 71 but instead, in these cases best available treatment i.e. global standard of care should be used for the subjects in control arm. after all the research conducting companies are taking benefits out of the research study that is being conducted in developing countries 4 . it may dissatisfied with a standard of care to define it only in relation to the treatment or drug that is being provided to the control arm of any research clinical trial, but it should be considered in a broader sense keeping in mind the most important issue that is the ethics of research in developing countries. problems dealing with ethical issues in research if given proper importance would solve all other issues regarding standard of care in developing countries or anywhere in the globe. collaborative and mutual partnership between the researchers and the study participants that starts from proper informed consent following the principles of autonomy, justice and self respect, determining health problems, respecting community’s values, norms, traditions and culture helps to sort out ethical dilemmas. properly assessing the value of research being conducted that specifies the beneficiaries play a major role in avoiding the subject exploitation. in any research study the vulnerable population should be protected at all costs and the study participants should be fairly selected without any biasness. favorable risk-benefit ratio that determines the risks associated with conducting the trial should be clearly mentioned and the study participants should be given more benefit than the associated risks 6 . another important issue is the post trial benefits that should be focused and given importance especially once the research is over, pointing out that the new intervention proves to be effective and functioning then it should be offered to those in the control arm of the study subjects once the research is over 4 . bangladesh journal of bioethics 2014; 5(2):68-72 72 conclusion: following four basic ethical principles of autonomy, justice, beneficence and nonmaleficence might help to reduce the ethical issues while conducting any clinical trial in resource poor settings, but the issues of conducting research in developing countries will remain a worry and need to be focused and debated where and whenever required. one has to try sincerely to sort out the ethical problems while conducting a research study. researchers following ethical rules might fail to solve all the issues but the situation may improve by the time if tried sincerely. references 1. bhutta, zulfiqar ahmed (2002). ethics in international health research: a perspective from the developing world. bulletin of the world health organization; 80:114-120. 2. r k lie, e emanuel, c grady, et al (2004). the standard of care debate: the declaration of helsinki versus the international consensus opinion. j med ethics 30: 190-193. 3. london, alex john (2000). the ambiguity and the exigency: clarifying 'standard of care' arguments in international research', jm&p, 25: 4, 379 -397. 4. j r mcmillan and c conlon (2002). the ethics of research related to health care in developing countries. j med ethics, 30, 204-206. 5. wendler et al (2004). the standard of care debate: can research in developing countries be both ethical and responsive to those countries’ health needs? health policy and ethics forum, american journal of public health, 94:6. 6. emanuel et al (2004). what makes clinical research in developing countries ethical? the benchmarks of ethical research, 20040: 189. competing interests: the authors declare that they have no competing interests. acknowledgements: the authors would like to acknowledge the generous support and guidance of dr. arshi farooqui, dr. maria zawyar and dr. arsalan khan. authors’ contributions: all authors have contributed substantially to the conception and design of the manuscript. muhammad waseem khan is the 1 st and corresponding author. sanam zeib khan, afrasiab khan tareen, and imrana niaz sultan are 2 nd authors and they have contributed equally. muhammad waseem khan has critically revised the manuscript. all authors have read and approved the final manuscript. funding: the authors declare that the current study was not funded. references bangladesh journal of bioethics 2014; 5(3):23-25 23 commentary strikes and doctorspsychosocial and ethical dilemmas avinash de sousa 1, shivanshu shrivastava 2 sushma sonavane 3 nilesh shah 4 1. research associate, 2. research assistant, 3. professor and 4. professor and head, department of psychiatry, lokmanya tilak municipal medical college, mumbai. email: avinashdes888@gmail.com abstract: this paper is a commentary on whether doctors have the right to strike work or not while keeping in mind, psychosocial and ethical implications of the same. certain guidelines and criteria that may be applicable when examining doctors on strike are elucidated and discussed. key words: doctors, strike, ethical, psychosocial. introduction: strikes involving medical doctors have been around since time immemorial. strikes in india and asia differ from the west often in the factors that lead to the strike. the following paper is a commentary on whether strikes by doctors are needed, if yes then are they ethical? and finally are there some criteria or guidelines that can be laid down regarding doctors that strike work? these views are generalized to doctors across various nations, though in individual cases, the nature and reasons as well as the need to strike work may differ. critical points when examining strikes involving doctors:  strikes among doctors differ immensely when the strike involves senior versus junior doctors. the senior doctors would often go on strike when new laws that restrict their freedom and work come into place, in some cases a need for increased salaries and at times protesting against violence towards a senior colleague. junior doctors often go on strike when they demand increase in stipends or violence by patients relatives towards them or if there is some government bond fulfillment or course fee issues that worry them 1 .  doctors are often regarded as selfless people working in the honourable profession. with the advent of private hospitals and public private collaborations, doctors are often made to sign work contracts and forced into bonded labour. does this mean that we equate doctors with industrial labourers and other workforce or should we have separate category that we assign to them. it is a debate that will need considerable thought and deliberation2.  doctors often are asked to adhere to a professional code of conduct as per the ethical guidelines of various medical associations and councils. worldwide doctors adhere to the same. the same ethical guidelines do not specify what the doctor must do when similar moralities are not mailto:avinashdes888@gmail.com bangladesh journal of bioethics 2014; 5(3):23-25 24 adhered to patient’s relatives and kin when talking, dealing and interacting with doctors. many times, doctors are manhandled, faces blackened and beaten up by relatives. angry mobs destroy their clinics and nursing homes causing damage to property and life beyond reasonable doubt 3 .  another thought provoking area is the question whether there could be criteria that may be fulfilled regarding doctors going on strike and whether a strike by doctors is justified after those criteria are fulfilled. interestingly it is very difficult to draft out such criteria in black and white and it is further interesting to note whether fulfillment of such criteria would make doctors striking as legal and legitimate 4 . when can a doctor go on strike the following sections draws on literature related to doctor’s strikes and takes a peek into whether criteria can be drawn with regarding to calling a strike by doctors just and needed.  people believe that when the cause is just and backed by the right intentions, any form of agitation is reasonable. the same way a doctor’s strike when just and with the right intention of greater good of most doctors is considered fine. the strike must not be political or aimed at political ambitions, it should not be because of one man’s ire against the government or an act meant for the aggrandizement of one’s ego or a means to show one’s power 4 .  wage or salary disputes come under just causes as doctor’s that cannot provide for one’s self and their family may often demonstrate a decline in medical skills and this may affect the public health of a nation in general. the wages of a doctor who puts in hours of work often neglecting personal and family time must at least compensate partially for these sacrifices. the issue of wages is of public health importance as the poor wages of doctors force them to work excessively long hours, compromising the quality of the medical care they offer and their ability to act in the best interest of their patients5. poor wages and salaries will also affect the medical teaching in a country as young people may not take up medicine fearing poor salaries and seeks other sources of vocation and employment while senior medical teachers may go abroad or to arenas where the salary justifies their talent and expertise 6 .  the criterion of just cause often demands a utilitarian philosophy determinant which demonstrates that ultimately, the beneficial repercussions of the strike on the health system that must outweigh the temporary disruption and suffering caused by it. during the strike it is pivotal that doctors must demonstrate the right intention and they should remain benevolent to their cause while avoiding gall spewing acts that may compromise their just cause7.  while striking it is of paramount importance that medical emergency services remain unaffected thereby adhering to medical oath and ethical guidelines while yet continuing the fight for one’s rights. just like in a war between two nations, in a doctor’s strike unnecessary civilian bangladesh journal of bioethics 2014; 5(3):23-25 25 casualties must be avoided and doctors on strike should continue to provide at least such critical services as emergency care and intensive care 8 .  it is very essential that doctor’s that strike be assured of success in some way as very often many strikes in the long run prove futile and catastrophic. for example the strike by junior doctors citing an increase in stipends led to the government increasing the stipend by 20% while medical course fees were hiked within a month of this ruling by 60%. thus the loss financially was for the doctors who ended up paying more than they did prior to the strike.  strike must often be the last resort measure and not the first. doctors being a part of essential services must not strike unless all other means and negotiations and talking cures fail. a formal announcement of the strike, adequate warning, candle marches, silent protests and press briefings followed by a one day token strike must lead up to the final strike. this provides a mechanism to help patients prepare in advance for the unsettling effects of the strike i.e. by relocating, stocking medication, and booking appointments with alternative providers 8 . conclusions: the authors of this paper wish to state that they believe that strikes are unnecessary and uncalled for especially when in a profession like medicine. the aim of this paper is to provide an unbiased view regarding some considerations to be made when doctors have no resort but go on strike. as doctors, our duties towards our patients is one of the highest importance, but people must not forget that doctors are human beings, they have a life, a family, responsibilities and bills to pay like all of us. we must remember that human dignity and respect must be preserved from doctor towards a patient and the converse also holds true. doctors are usually very patient and bear a lot silently with courage, but the old adage comes into play once in a while when things cannot be taken lying down….‘when the going gets tough, then the tough get going’ ! references: 1. ekbal b. ima strike: need for public debate. indian j med ethics 2012; 9 (4):226–8. 2. frizelle f. is it ethical for doctors to strike? n z med j 2006;119(1236): 2037 3. sachdev ps. doctors’ strike—an ethical justification. n z med j 1986; 99(803): 412–14. 4. ogunbanjo ga, van bogaert dk. doctors and strike action: can this be morally justifiable? sa fam pract 2009; 51(4): 306–8. 5. grosskopf i, buckman g, garty m. ethical dilemmas of the doctors’ strike in israel. j med ethics 1985; 11: 70–71. 6. selemego m. criteria for just strike action by medical doctors. indian j med ethics 2014; 11(1): 35-8. 7. dunn hp. resident hospital doctors’ strike. n z med j 1992; 105: 20-1. 8. chima sc. global medicine: is it ethical or morally justifiable for doctors and other healthcare workers to go on strike? bmc medical ethics 2013; 14(suppl 1): s5-15. conflict of interest: author declared no conflict of interest and no financial disclosures. bangladesh journal of bioethics 2014; 5(2):61-67 61 shortcomings and inadequacies of autonomy argument for euthanasia mohammad manzoor malik assistant professor department of general studies kulliyyah of islamic revealed knowledge and human sciences international islamic university, malaysia e-mail: philomalik@iium.edu.my / philomalik@gmail.com abstract: patient autonomy has a critical role in making decisions in medical practice and it is accepted by international conventions on health care and various national medical codes. however, pertaining to terminally ill patients, this right becomes very problematic in regards to end of life decisions. utilitarian ethicists motivated by materialistic worldview and individualism have made patient autonomy based arguments for the permissibility of active euthanasia. an appraisal of pro-euthanasia arguments that include the best interest, golden rule, and autonomy is made in this paper. the best interest and golden rule arguments are based on subjective moral judgment thus failing the universalization test. the argument from autonomy is unconvincing because of the confounded autonomy of the terminally ill patients. key words: patient autonomy, golden rule, euthanasia, end of life decisions introduction: patient autonomy has a critical role in making decisions in clinical practice. universal declaration on bioethics and human rights adopted by acclamation on 19 october 2005 by the 33rd session of the general conference of unesco in its article 3 states: “human dignity, human rights and fundamental freedoms are to be fully respected”; it further states in article 5 “the autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. for persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests” 1 . these articles are well thought to affirm autonomy with precautions. nevertheless, utilitarian ethicists take this right too far in defending right to active euthanasia on the grounds of autonomy. this study is made to demonstrate shortcomings of such arguments. the contemporary intellectual discourse in support of euthanasia has potential consequences of leading to dehumanization which ought to be rejected. euthanasia, by definition, is supposed to be for terminally ill persons; therefore, children, adults, and elderly people are subjects to it, however, elderly people are the most vulnerable. the harshness of euthanasia supporters could be understood from what colorado governor richard d. lamm said in an address, which was reported in the new york times, march 29, 1984, to the colorado health lawyers association : “elderly people who are terminally ill have a duty to mailto:philomalik@gmail.com bangladesh journal of bioethics 2014; 5(2):61-67 62 die and get out of the way” 2 . similarly, richard fenigsen, who conducted research on dutch elderly people, argues that a society which promotes euthanasia sends a message to the vulnerable that their lives are not valued. instead, such a society tells them, “we wouldn’t mind getting rid of you” 3 . apart from every sort of disciplinary perspective on the issue of euthanasia, the issue in its essential relation is practically connected with medicine. the issue of euthanasia has brought the medical profession in question. the traditional and common sense understanding of the profession is of life saving. however, the defenders of active euthanasia suggest redefining the profession not only as life saving, but also as life taking. majority of the countries do not allow euthanasia as apparent from their national codes on health care, a position in line with the world medical association’s declaration on euthanasia, adopted by the 38th world medical assembly, madrid, spain, in october 1987, as it states: “euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. this does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness” 4 . however, due to growing individualism in contemporary societies with modern economical modalities there is a need of making a criticism of arguments for euthanasia by developing a philosophical and rationalistic critique of the arguments that argue by using the very cardinal concepts in which legal and ethical discourses are necessarily held such as autonomy, the best interest, public good, human rights, liberties, and duties. best interests, golden rule and autonomy arguments: utilitarian ethicists such as peter singer and marvin kohl have made arguments in favor of active euthanasia on the grounds of autonomy. a very elaborated and inclusive version of these arguments is developed by james rachels from best interests and golden rule. briefly, these arguments affirm that dying people should be free to choose euthanasia as a matter of personal liberty and autonomy. rachels starts from the utilitarian argument in favor of active euthanasia, however, he states that if an argument is based on the mercy alone on the utilitarian grounds, the argument will be faulty due to the principle of utility as a premise of the argument. therefore, rachels tries to avoid such a problem and comes up with an alternative argument, which is inspired, according to rachels, by utilitarianism, but which avoids the difficulties of the pure utilitarian version of the argument, by not making the principle of utility a premise of the argument. therefore, rachels provides the following argument based on doing what is in everyone’s best interests, and he claims that the argument is sound and proves that active euthanasia can be justified: bangladesh journal of bioethics 2014; 5(2):61-67 63 1. if an action promotes the best interests of everyone concerned, and violates no one’s rights, then that action is morally acceptable. 2. in at least some cases, active euthanasia promotes the best interests of everyone concerned and violates no one’s rights. 3 therefore, in at least some cases active euthanasia is morally acceptable 5 . rachels after presenting the above argument complements the argument by other arguments inspired by the golden rule. rachels’s golden rule argument is actually the reinforcement of his best interest argument. he states that immanuel kant incorporated the basic idea of the golden rule into his system of ethics. rachels discusses the categorical imperative of kant which says: act only according to that maxim by which you can at the same time will that it should become a universal law. rachels elaborates on the principle: “that we should act only on rules that we are willing to have applied universally; that is, we should behave as we would be willing to have everyone behave” 6 . rachels while taking the careful analysis of the principle states that the basic idea behind the golden rule is a good one. he points out the following principle: the basic idea is that moral rules apply impartially to everyone alike; therefore, you cannot say that you are justified in treating someone else in a certain way unless you are willing to admit that that person would also be justified in treating you in that way if your positions were reversed 7 . rachels after going into explanatory details about the maxim ultimately tries to explain the meaning of the maxim and its relation to the case of euthanasia. rachels relates the golden rule to active euthanasia by saying that if there are two choices to die: (1) to die quietly without pain by a fatal injection; and (2) to die of an affliction so painful that for several days before death “you would be reduced to howling like a dog, with your family standing by helplessly, trying to comfort you, but going through its own psychological hell”. rachels states that it is hard to believe that any sane person, when confronted by these possibilities, would choose to have a rule applied that would force upon him or her second option. and if we would not want such a rule, which excludes euthanasia, applied to us, then we should not apply such a rule to others 8 . rachels’s main arguments in favor of active euthanasia are basically and essentially based on the consent of the terminally ill patient, that the justification of such practice is based on the free will and autonomy of the patient. therefore, if a person autonomously chooses to end his or her life or have someone else assist him or her in doing so, then it is morally permissible. one should be free to do as one chooses as long as no harm is done to others. in supporting the position, rachels develops a further argument for the legalization of active euthanasia based on the right to liberty. briefly, this argument is that dying people should be free to choose euthanasia as a matter of personal liberty. the supporting argument frequently advanced in support of legalization of active voluntary euthanasia proceeds by way bangladesh journal of bioethics 2014; 5(2):61-67 64 of analogy to the law of suicide. rachels also supports his position by the same argument. the argument begins with the proposition that since it is not unlawful for a person to commit or attempt to commit suicide, the law, implicitly at least, recognizes the right of an individual to take his or her life. from this premise it is argued that if an individual does have the right to take his or her life, he or she should be able to seek the assistance of others in achieving this end 9 . furthermore, rachels’s arguments such as the golden rule and the best interest argument are based on the same notion of autonomy that if a terminally ill patient chooses euthanasia as his best interest such a patient should be granted his wish. problems with best interests and golden rule argument: there are three ways to argue against the best interests and golden rule arguments and therefore rendering them unconvincing. they are: (1) the arguments are based on subjective moral judgment, failing the universalization test; (2) it may not be in my own best interests or in the best interests of others for me to die; and (3) the arguments are based on indefensible autonomy. firstly, the best interest and golden rule arguments are based on subjective moral judgment, therefore they fail the morally universalization test and become subject of partiality. the universalization test is crucial because rachels himself accepts categorical imperative and so he is supposed to be having no objection if his moral position is subjected to such a test. if a person takes anything in his own interest, it does not guarantee that such an act would be desirable to other people. put differently, people can dehumanize themselves and actually do so in active euthanasia by intentionally killing themselves or by others intentionally killing them. the golden rule argument fails due to its partiality and it fails the test of generality. first of all if active euthanasia is accepted because of its acceptance by some patients that does not make it generally acceptable. m. cathleen kaveny has suggestion also supports the above position as follows: the most pressing challenge facing opponents of assisted suicide or voluntary euthanasia can be found in the faces of those who request such practices in order to put an end to their suffering. they are pointing to their own pain as a justification for carving out an exception to the general legal and moral rule against intentionally killing the innocent 10 . the justification which some terminally ill patients give for euthanasia is in need of further scrutiny. the researches suggest that such approval of euthanasia is based mostly on the opinions of patients their decision power is clouded either by medication or depression. hendin, foley, & white (1998) have referred to theses researches which scientifically describe the psychological conditions of terminally ill patients. the diagnosis of depression is particularly important since like other suicidal individuals, patients who desire an early death during a serious or terminal illness are usually suffering from a treatable depressive condition. although pain and other factors, such as a lack of family support, may contribute to a patient’s wish for death, depression is the most important factor. in fact, researchers have found bangladesh journal of bioethics 2014; 5(2):61-67 65 depression to be the only factor that significantly predicts the wish for death. two-thirds of patients requesting assisted suicide are depressed about the same percentage as those who attempt or commit suicide unaided. hopelessness, the aspect of depression that helps distinguish depressed patients who are suicidal from those who are not, has been shown to play a similar role in predicting suicidal ideation in patients who are terminally ill 11 . in face of all these evidences, rachels’s case again fails the test of universalization which includes that the decision should be autonomous, but the researches show that the euthanasia willing patients are not rationally autonomous, they are either depressed or they are driven by other factors than reason. furthermore, it is important to elaborate on kant’s categorical imperative, which negates the conclusions of rachels; “for kant, our rational wills are the source of our moral duty, and it is therefore a kind of practical contradiction to suppose that the same will can permissibly destroy itself. given the distinctive worth of an autonomous rational will, suicide is an attack on the very source of moral authority” 12 . kant argued that taking one’s own life was inconsistent with the notion of autonomy properly understood. secondly, it may not be in my own best interests or in the best interests of others for me to die. if i am willing to allow others to perform active euthanasia on me by the golden rule argument then i am willing to do so to them in return. this line of thought is mistaken. rachels’s point that once we are old what should be done to us could be objected by the similar questions. “as i lie dying, will i be offered humane care, will i be done in too soon by some expediency, or will i be subjected to terminal torture?” 13 . the researches show that the terminally ill patients do not ask for euthanasia in a way that could support any conception of golden rule for the permissibility of euthanasia. those terminally ill patients who wish for euthanasia were found “affected by depression, feel unappreciated, and have significant need for help with the basics of living”; the report concludes: a new study published in the november 15 journal of the american medical association has found that most terminally ill patients would not choose physician-assisted suicide or euthanasia to end their lives. interviews with 988 terminally ill adults and their primary caregivers revealed that around one in ten people seriously considered using physician-assisted suicide or euthanasia and that less than 6 percent had seriously discussed the possibility or taken steps to commit suicide. the researchers, led by ezekiel j. emanuel of the department of bioethics at the national institutes of health, also found that those who considered either option are affected by depression, feel unappreciated, and have significant need for help with the basics of living. the study's authors warn that doctors who receive requests for physicianassisted suicide or euthanasia should not consider patients to be definite about their decisions 14 . the further objection to the argument based on autonomy is about autonomy itself and that is the consent of the patient on termination of life actively. the concerns involved are various such as how can it be sure that the person in condition which requires active euthanasia could have a free will; “there could be bangladesh journal of bioethics 2014; 5(2):61-67 66 concern that the use of a pain killer in a dying individual could so cloud his conscious response that he might not in his dying moments be in a position to make decisions” 15 . the consent therefore received could not be accepted as reasonable and sound to substantiate such a decision. paul r. mchugh argues, but when it comes to terminally ill patients, “outside forces” are likely to “overwhelm the self, rendering it vulnerable to unreflective impulses” 16 . due to these factors, realization of patient’s true autonomy becomes unattainable. conclusion: the best interest and golden rule arguments are based on subjective moral judgment, therefore they fail the morally universalization test and do not make a strong argument for the permissibility of euthanasia. even approval of some terminally ill patients for active euthanasia is due to treatable depression and other factors rendering the approval to be a matter of compulsion instead of free autonomous wish. regarding the relevance of kant’s categorical imperative to the arguments, rachels’s understanding of kant turns out to be a misinterpretation because kant argued that taking one’s own life was inconsistent with the notion of autonomy properly understood. finally, the argument from autonomy fails to claim the sufficient support to substantiate a pro-position for the approval of active euthanasia because autonomy of terminally ill patients is problematic in a way that it seems such patients are not autonomous but influenced by various factors rendering their discretion unreliable. references: 1. universal declaration on bioethics and human rights (oct 19, 2005). 2. kearl mc. endings: a sociology of death and dying: oxford university press 1989. 3. fenigsen r. a case against dutch euthanasia. the hastings center report. 1989;19(1). 4.world medical association, resolution on euthanasia. 2005; available from: www.wma.net/e/policy/e13b.htm. 5. rachels j. more impertinent distinctions and a defense of active euthanasia. in: norcross a, steinbock b, editors. killing and letting die 2nd ed. new york, usa: fordham university press. 6. ibid. 7. ibid. 8. ibid. 9. rachels j. barney clark's key. the hastings center report. 1983;13(2):17-9. 10. kaveny mc. assisted suicide, euthanasia and the law. theological studies. 1997;58(1). 11. hendin h, foley k, white m. physician-assisted suicide: reflections on oregon's first case. issues in law & medicine. 1998;14(3):243-70. and hendin h, foley k, white m. oregon death with dignity act. issues in law & medicine. 1998;14(3):243-70. 12. cholbi m. suicide. 2004; available from: http://plato.stanford.edu/entries/suicide/. 13. vaux kl. debbie's dying mercy killing and the good death. in: baird rm, rosenbaum se, editors. euthanasia: the moral issues buffalo, new york. http://www.wma.net/e/policy/e13b.htm http://plato.stanford.edu/entries/suicide/ bangladesh journal of bioethics 2014; 5(2):61-67 67 14. emanuel e. assisted suicide largely shunned. the christian century. 2000;117:34. 15. koop ce. the right to die: the moral dilemmas. in: baird rm, rosenbaum se, editors. euthanasia: the moral issues buffalo, new york: prometheus books. 16. mchugh pr. on death and dying [review of the article dying made easy] commentary. 1999; 107(5). conflict of interest: this research article is solely written and researched by the author, mohammad manzoor malik. no research grant or funding was obtained from any institution that may deserve any acknowledgement. editorial bangladesh journal of bioethics 2013; 4(2) editorial according to socrates, knowledge is virtue. but mere knowledge of ethical principle is not sufficient to bring people in the road to virtue. training on practical ethics is more effective in producing good conduct. casuistry or the applied ethics is a discipline to apply valid standards to particular concrete cases. keeping this idea in mind bangladesh bioethics society organized a workshop on road safety to raise awareness of the truck and bus drivers. because, everyday reckless driving take a heavy tolls of life in bangladesh. most of the bus and truck drivers do not follows the trafic rules. it is also necessary to handle drug addiction problem. it has been posing a serious threat to our youths and their families as well as the whole society. bbs can organize awareness programme for the youth to combat the menace of drug addiction. it is one of the major cause of social disorganization. five articles have been published in this issue. article on bioethics and patient law u.s.a., u.k. and india raises discussion on the ethical questions of bioethics which include relationship among life science, biotechnology, medicines, politics, law and philosophy. in order to conduct research on bioethics we need a searchable consolidated database. the article under the title ‘pease, conflict and resolution (good vs evil) rightly identifies the colossal structural injustice and inequalities rooted in the global , social and political economy. the philosophy of confucianism and taoism is highlighted based on two basic propositions that man’s original nature is good. secondly the evil nature of the man in the by-product of external environment. ensuring justice, dignity and human rights and philosophical leadership and eradication of poverty and corruptions establish peace in the world. article on islamic perception medication with special reference to ordinary and extra ordinary means of medical treatment. it deals with medication, bioethics, extraordinary medical treatment and medical ethics. article under the title “research involving human subjects – ethical perspective is discuss that research involving human subject should be justifiable and minimal risky for the participant. ethical perspective should be emphasized. “the epistemological import of informed consent in clinical research” is an attempt to establish the epistemological import and limits of informed consent in clinical research. one quest for a moral life in the society will continue. we shall evaluate human achievement in the light of eternal value of truth, beauty and goodness. bioethics will be all pervasive. rowshan ara professor department of philosophy university of dhaka the end of times, armageddon, apocalypse or the last age of mankind: bangladesh journal of bioethics 2013; 4(2):9-21 9 peace, conflict and resolution (good vs. evil) arif hossain vice-president & founding chairman bangladesh bioethics society email: ahossainbbs@gmail.com abstract: the immense structural inequalities of the global social /political economy can no longer be contained through consensual mechanisms of state control. the ruling classes have lost legitimacy; we are witnessing a breakdown of ruling-class hegemony on a world scale. there is good and evil among mankind; thus it necessitates the conflict between the good and evil on earth. we are in for a period of major conflicts and great upheavals. it's generally regarded that mencius (c.371-c.289 b.c) a student of confucianism developed his entire philosophy from two basic propositions: the first, that man's original nature is good; and the second, that man's original nature becomes evil when his wishes are not fulfilled. what is good and what is evil? philosophers of all ages have thought over this question. each reckoned that he had solved the question once and for all, yet within a few years the problem would re-emerge with new dimensions. repeated acts of corruption and evil action makes a man corrupt and takes away a man from his original nature. still now majority of the people of the world give compliance to corruption because of social pressures, economic pressures, cultural pressures and political pressures. the conflict between good and evil is ancient on earth and is prevalent to this day. may be the final confrontation between the descendants of cain and abel is at our doorsteps. during the 2 nd world war america with its european allies went into world wide military campaign to defeat germany, italy and japan. when the second world war ended in 1945 the united states of america came out as victorious. america was the first country to detonate atomic bomb in another country. during that period russia fell into competition with america in politically colonizing countries after countries. with the fall of communism russia terminated its desire wanting to be the champion of the oppressed of the world. the situation in russia continues to deteriorate, a country which until only a few years ago was a superpower. russians are deeply disillusioned today with the new politicians in russia, who they says "promise everything and give nothing." the russians still strongly oppose a world order dominated by the united states. if anyone looks at or investigates the situations in other countries it can be seen that at present almost all countries of the world are similar or same in the forms of structures of corruption and evil. the worldwide control of humanity‘s economic, social and political activities is under the helm of us corporate and military power. the us has established its control over 191 governments which are members of the united nations. the last head of state of the former soviet union, mikhail gorbachev on december 2012, at a conference on the future of the middle east and the black sea region in the turkish city of istanbul, has warned the us of an imminent soviet-like collapse if washington persists with its hegemonic policies. mass public protest occurred against us hegemony are mainly from muslim countries of south east asia, south asia, central asia, west asia, north africa and africa. the latest mass protests erupted in september 2012 when the divine prophet muhammad (pbuh) was insulted by america and israel. there were strong mass protests by people from indonesia to morocco and in the european countries by mostly immigrants and australia were there are muslim populations. this worldwide protest had occurred while the rise of the masses is ongoing against corrupt rulers in west asia and north africa. the masses of the people are thirsty and desperate for justice, dignity, economic welfare and human rights. most major religions have their own sources of information on the last age of mankind or the end of times, which often include fateful battles between the forces of good and evil and cataclysmic natural disasters. humans are evolving to a final stage of their evolution towards a ‗new age‘ that is to come which the corrupt does not understand. at present times a final battle of good versus evil on earth will ensue. the world powers (leaders) and their entourages who are really detached from the masses have organized to keep aloft the present world order that degenerates the masses in corruption, keeps the people in unhappiness, mailto:ahossainbbs@gmail.com bangladesh journal of bioethics 2013; 4(2):9-21 10 and deprives the masses from economic well being, education and keeps promoting wars and conflicts to support corruption and evil. we are at the ―end of times‖. the promised messiah will come to set right what is wrong, no doubt. introduction: at the beginning of the second half decade of this century states and ruling classes are unable to hold back the tide of worldwide popular rebellion and resorting to ever more generalized repression. as the crisis of global capitalism spirals out of control, the powers in the global system appear to be unable to propose viable solutions. the immense structural inequalities of the global social /political economy can no longer be contained through consensual mechanisms of state control. the ruling classes have lost legitimacy; we are witnessing a breakdown of ruling-class hegemony on a world scale. there is the concentration of wealth in fewer and fewer hands. corruption has penetrated every spectrum of society and in governments of all countries. humans are being choked by their rulers everywhere. people are losing security and are being threatened everyday by the corrupt systems of their own countries. today with a global population of 7 billion conflicts and upheaval are showing at unprecedented levels. there is a global battle raging between the corrupt and those who want to break free from corruption (good vs. evil). the world is sinking deeper into chaos. global elites cannot manage the explosive contradictions in societies. global elites are confused, reactive, and sinking into the quagmire of their own making. there is unprecedented concentration of control over the mass media and thought control. the global elites are unable to come up with solutions. they appear to be politically bankrupt and impotent to steer the course of events unfolding before them. humans are evolving to a final stage of their evolution towards a ‗new age‘ that is to come which the corrupt does not understand. there is good and evil among mankind; thus it necessitates the conflict between the good and evil on earth. we are in for a period of major conflicts and great upheavals. global rebellion of the masses is a doorstep away and is already taking place in major parts of the world. the "empire of global capital" is definitely not sitting idle. as global elites regroup and assess the threat of mass global revolution, they will and have already begun to organize coordinated mass repression, new wars and interventions to restore global hegemony. the subtle battle of good versus evil has been waged since the earliest times. at present times a final battle of good versus evil on earth will ensue part 2 the end of times, armageddon, apocalypse or the last age of mankind: do all of us have a mechanical clock in our homes that would tell us the age we are in at present with the affairs of the world? what stage (time) of human evolution or the time of the world we are at present? god‘s messengers, god‘s prophets, wise men of the ancient and philosophers have spoken about the stages of human affairs. they have spoken and brought written scrolls about the ‗end of times‘ or ‗the last age of mankind‘. the final confrontation between the descendants of cain and abel may be near approaching, nearer then how we may perceive it. most major religions have their own sources of information on the last age of mankind or the end of times, which often include fateful battles between the forces of good and evil and cataclysmic natural disasters. according to sources of religions there will be a judgment day on the earth where upon the evil forces on earth will be vanquished, the wicked on the earth will be punished by the hands of a savior from god and the forces of good will be triumphant and delivered. before that the forces of good of the world will be imposed upon with severe and harsh punishments and they will be cornered by the forces of evil on earth. corruption and evil have permeated every niche and corner of society and has put the planet in peril. the present world rulers know that the rise of the promised messiah (savior) is imminent to save the oppressed of the world. thus they are preparing to wage war (armageddon) on him, at present times known as the ‗third world war‘. what does the ancient mayan civilization say? the ancient mayan civilization lived in the mesoamerica's since 2,600 bc. the mayans were known for their advanced grasp on astronomy. mysteriously, they predicted in what year their civilization would be overrun by bangladesh journal of bioethics 2013; 4(2):9-21 11 foreigners coming from over the seas. legend has it they even predicted the world wars. mayans believe cataclysmic or transformative events will occur beginning on 21 december 2012. this date is regarded as the end-date of a 5125-year-long cycle in the mayan calendar. a new age interpretation of this transition is that the date marks the start of time in which earth and its inhabitants may undergo a positive physical or spiritual transformation, and that 21 december 2012 may mark the beginning of a new era. both the hopis and mayans recognize that we are approaching the end of a world age... in both cases, however, the hopi and mayan elders do not prophesy that everything will come to an end. rather, this is a time of transition from one world age into another. the same theme can be found reflected in the prophecies of many other native american visionaries from black elk to sun bear. the mayans spoke of the return of ‗kukulkan‘, a man of god, who will punish the wicked on earth (a snake deity) and the start of a new age of spiritual enlightenment will begin on 21 st december 2012. the mayans says, kukulkan shines in the infinite. kukulkan is the sacred energy beating in every atom. they have predicted thousands of years ago through calculations of astronomy that on 21 st december 2012, the end of the mayan calendar that there will be a planetary alignment in the galaxy and sun would be almost in the middle of the galaxy. on 21-12-2012 an extraordinary and incredibly rare event will take place. the sun will move to a unique spot in the sky -and hold still for a while, since it is solstice day. the sun will sit precisely on the heavenly crossroads between the milky way and the galactic equinox, forming a perfect alignment with the center of the galaxy. the ancient egyptians, aztecs, cherokees, tibetans all have calendars that reset in 2012, and all see a global catastrophe as the start of the next age, whilst others predict the coming of a world teacher. what do the hindu scriptures say? the ancient hindus mainly used lunar calendars but also used solar calendars. if an average lunar year equals 354.36 days, then this would be about 5270 lunar years from the time when the age of kali (corruption and evil) started until 21 dec 2012. this is the same year that the mayans predict rebirth of our planet. it is also about 5113 solar years of 365.24 days per year. by either solar or lunar years, we are over 5,000 years into the age of kali and it is time for krishna's prophecy to happen according to the ancient hindu scriptures. in hindu scriptures the last of the four ages is the age of kali, our current time, during which will be characterized by impiety, violence, decay and chaos. at this time of chaos, the final avatar, kalki, will appear on a white horse. ‗kalki‘ will amass an army to "establish righteousness upon the earth" and leave "the minds of the people as pure as crystal." in hinduism, vishnu coming back in the last cycle of time as a figure called kalki, who rides a white horse, carries a sword that looks like a comet and destroys the forces of evil. mayan prophecy matches hindu prophecy: it is amazing that both calendars began at about the same time over 5,000 years ago and both calendars predict a totally new world and/or golden age after about 5,000 years into their calendars! we are definitely on to something with these mayan and hindu 2012 predictions. historically, this is an amazing fact since these two ancient cultures did not have any contact. what do the buddhists say? buddha described his teachings would disappear thousands of years from when he preached them. at this time, knowledge of dharma will be lost as well. there will be a new era in which the next buddha maitreya will appear, but it will be preceded by the degeneration of human society. this will be a period of greed, lust, poverty, ill will, violence, murder, impiety, physical weakness, sexual depravity and societal collapse, and even the buddha himself will be forgotten. then at the last age buddhist prophecies says, there will be the ‗shambhala‘ equivalent of armageddon, in which good triumphs over evil; however then, the planet is restored rather than destroyed so people can pursue enlightenment. bangladesh journal of bioethics 2013; 4(2):9-21 12 the bible and christian beliefs on the end of times: as 2012 is coming to an end more and more people in america, europe and other parts of the world are programming to prophecies of doom and the signs and wonders that are thought to be harbingers of the coming end time. heavenly forces and a corrupted earth — are the twin engines of apocalyptic movements. for christians awaiting rapture or shiites counting the days until the twelfth imam appears, the trials and injustices of the known world are a prelude for the next age to arrive. polls indicate that up to 50 percent of americans believe that the book of revelation is a true, prophetic document, meaning they fully expect the predictions of ―rapture,‖ ―tribulation‖ and ―armageddon‖ to be fulfilled. but the wicked have to be destroyed and evil has to be overcome for the era of righteousness to dawn. according to one pre millennial christian interpretation, the messiah will return to earth and defeat the antichrist (the "beast") and satan the devil in the battle of armageddon. then satan will be put into the "bottomless pit" or abyss for 1,000 years. armageddon will be, according to the book of revelation the last chapter of the bible, the final battle between good and evil during the end times. the new testament reveals, "they (will gather) the kings together to .... armageddon. the purpose of this gathering of kings in the "armageddon" is "for the war of the great day of god, the almighty". armageddon is the battle of the end of times in which god deals with "the kings of the earth and of the whole world" (rev. 16:14). the christians believe the battle of armageddon will commence just before the second coming of jesus christ. in christianity today there are numerous sects and groups. there are the catholics, protestants, baptists, methodists, mormons, jehovah's witnesses and others. each of the group is strongly confused about the end of times issues. each of the group gives a deferent interpretation of the second coming of jesus and what his position would be in the end of times, what forces he will support and the forces he will oppose in the world today. they are confused about and will remain confused about who is anti-christ in the world. they are confused with what armageddon is meant for that is about to occur in the present world. in the bible at some instances there is mention of the ‗babylon‘ the city that is located in mesopotamia (iraq) and at other times there is mention of the ―mystery babylon the great‖ the ‗country of power‘ at the end of times in the bible. here we are elaborating ―mystery babylon the great‖ of the end of times. christians are confused about what is meant by the country of the ―mystery babylon the great‖ in the bible. to most of the americans and europeans today the world doesn‘t exist beyond america and europe. if ―america and europe or the western allied powers‖ are not the ―anti-christ‖ then why would they wage war on jesus christ when he arrives in the world for the second time? despite having deferent forms of wrong interpretations, in recent times many americans believe ―mystery babylon the great‖ that have been mentioned in the biblical verses is the present day united states of america. at present many americans believes in the destruction of america (mystery babylon) and thus left for other countries to live there anticipating the end of times. as in the bible the mystery babylon is a wicked harlot and she sits upon 7 bodies of water, riding on a beast. upon her forehead was a name written, mystery, babylon the great, the mother of harlots, and abominations of the earth this inscription being written upon her forehead is intended to show that she is not ashamed of her doctrines, but publicly professes and glories in them before the nations of the earth. according to the bible ‗she‘ (mystery babylon the great) will rule over the kings of the earth and the most powerful and influential nation of the end of times. mystery babylon in some way dominates the peoples, multitudes, nations and languages of the world in the end of times. america sits upon 7 bodies of water -more then any other country. america has used its power in an oppressive and relentlessly aggressive manner that is described of the ‗mystery babylon‘ in the biblical scriptures? america's dominant military and financial power gives her a global hegemony or rule through influence and threat of force. the kings of the world have committed fornication with america by chasing the greed, corruption, murder and injustice to the world america offers. america rules over the kings of the earth and that is why the dollar is the world bangladesh journal of bioethics 2013; 4(2):9-21 13 reserve currency. other countries must bow to their demands simply because of america‘s economic and military forces. america is the most dominant and influential nation of the end of times. the nations that dare defy or threaten america get unilaterally invaded or have their funding or resources cut off. some of the verses of the bible mentioned below that reveals the identity and end of time destruction of ‗mystery babylon the great‘. revelation 18:1-24 after this i saw another angel coming down from heaven, having great authority, and the earth was made bright with his glory. and he called out with a mighty voice, ―fallen, fallen is babylon the great! she has become a dwelling place for demons, a haunt for every unclean spirit, a haunt for every unclean bird, a haunt for every unclean and detestable beast. for all nations have drunk the wine of the passion of her sexual immorality, and the kings of the earth have committed immorality with her, and the merchants of the earth have grown rich from the power of her luxurious living.‖ then i heard another voice from heaven saying, ―come out of her, my people, lest you take part in her sins, lest you share in her plagues; for her sins are heaped high as heaven, and god has remembered her iniquities. ... revelation 17:1-6 then one of the seven angels who had the seven bowls came and said to me, ―come, i will show you the judgment of the great prostitute who is seated on many waters, with whom the kings of the earth have committed sexual immorality, and with the wine of whose sexual immorality the dwellers on earth have become drunk.‖ and he carried me away in the spirit into a wilderness, and i saw a woman sitting on a scarlet beast that was full of blasphemous names, and it had seven heads and ten horns. the woman was arrayed in purple and scarlet, and adorned with gold and jewels and pearls, holding in her hand a golden cup full of abominations and the impurities of her sexual immorality. and on her forehead was written a name of mystery: ―babylon the great, mother of prostitutes and of earth's abominations.‖ isaiah 14:4-6, "...how the oppressor has come to an end! how his fury has ended! the lord has broken the rod of the wicked; the scepter of the rulers, which in anger struck down peoples with unceasing blows, and in fury subdued nations with relentless aggression." revelation 17:15 -then the angel said to me, "the waters you saw, where the prostitute sits, are peoples, multitudes, nations and languages. revelation 18:3, 7 ―for all the nations have drunk the maddening wine of her adulteries. the kings of the earth committed adultery with her, and the merchants of the earth grew rich from her excessive luxuries." … revelation 18:9-10, "when the kings of the earth... see the smoke of her burning... they will stand far off and cry: 'woe! woe, o great city, o babylon, city of power! in one hour your doom has come!" revelation 18:4, "come out of her my people, so that you will not share in her sins, so that you will not receive any of her plagues," jeremiah 50:31-32, "behold, i am against you, o most haughty one!" says the lord god of hosts; "for your day has come, the time that i will punish you. the most proud shall stumble and fall..." jeremiah 51:7-8, "babylon was a golden cup in the lord's hand, that made all the earth drunk. the nations drank her wine; therefore the nations are deranged. babylon has suddenly fallen and been destroyed. wail for her! take balm for her pain..." bangladesh journal of bioethics 2013; 4(2):9-21 14 revelation 18:23-24 — 23 the light of a lamp will never shine in you again; and the voice of a groom and bride will never be heard in you again. ⌊all this will happen⌋ because your merchants were the nobility of the earth, because all the nations were deceived by your sorcery, 24 and the blood of prophets and saints, and of all those slaughtered on earth, was found in you. revelation 18:8, 10 and 18--therefore in one day her plagues will overtake her: death, mourning and famine. she will be consumed by fire, for mighty is the lord god who judges her. ... in one hour your doom has come! … when they see the smoke of her burning, they will exclaim, 'was there ever a city like this great city? revelation 14:8 ―and there followed another angel, saying, babylon is fallen, is fallen, that great city, because she made all nations drink of the wine of the wrath of her fornication.‖ the destruction of ―mystery babylon the great‖ will take place at the time of the battle of armageddon. at the time of armageddon america and europe(the end of the times anti-christ )will wage war on jesus and mahdi . the last age, the end of times in the scripts of the muslims: the scriptures of the muslims on the last age or end of times are more particular and detailed with information. the end times figures according to islam, are very detailed and gives names of people and locations and events. it is gathered from muslim ‗hadiths‘ (prophetic source of information) from the prophet muhammed (pbuh) and his family(a.s). according to the scripts of the muslims the descendant of abel, abraham, muhammad, imam ali, the descendant of imam hussein, the descendant of the prophet (s.a.) and the last savior of mankind ―mahdi‖ to the sunnis , the 12 th descendant of the holy prophet, the 12 th holy imam of the ahlal bayit (family of prophet muhammad) to the shias. ―the prince of the south‖ will rise with the sword at the end of times to protect humanity from the corrupt and the evil doers of the earth. end of times savior ―mahdi‖ has been mentioned in the scripts of all muslim sects. the messiah ‗imam mahdi‘ will be joined by jesus son of mary who will descend from the heavens in the world in his second coming; mahdi and his army will wage epic battles against the evil and corrupt of the world which is known in the bible as ‗armageddon‘ the final battle between good and evil on earth. according to the scripts of the muslims at the end of times, all governments of the world will be aligned with major powers of the current world order except for one government. at the time of the advent of the messiah the world will be in turmoil, wars will rage and show its teeth. corruption and chaos will permeate almost all affairs of humanity; the good among mankind will be defeated before the rise of the messiah. at this troublesome juncture of humanity the messiah will rise with the sword to punish the wicked who have taken the reigns of all human affairs. when the foretold events occur and god‘s command comes the mahdi will come to the scene of the world like a shooting star. he will move through the people with a burning lamp. according to prophetic narrations (hadiths) before the coming of the messiah ‗an apocalyptic war‘ will erupt in west asia; during these moments imam mahdi will rise with the sword from the kaa‘ba and then soon after a ready massive army from the ‗nation of the east‘ (iran) will join imam mahdi. before the advent of the mahdi there will be series of vicious storms, earthquakes and volcanoes over the years all over the world. with the advent of imam mahdi the equations of the world will change permanently. immediately after his rise imam mahdi with his massive army shall march towards palestine to face off the army of the corrupt and the evil. at this time mahdi will be joined by jesus son of mary who will descend from the heavens to help imam mahdi. according to the scripts of the muslims the first great war with the commandeering of the mahdi will be in palestine, the next great war after the war of palestine will occur in turkey. then the army of the mahdi will move towards europe. mahdi and his army will move to the east and the west; punish the forces of evil and corruption in the earth and within a short span of time will raise the flags of justice and equity at the four corners of the world. at the end of times god will give judgment to the world with the sword of the mahdi. the messiah mahdi will give science and knowledge to the masses. all the wealth of the world will come under the domain of the messiah and he will distribute the wealth justly to the people. religion will be renovated. false percepts and wrong infiltrations in religion will be removed. bangladesh journal of bioethics 2013; 4(2):9-21 15 according to hadith (prophetic information) the imam will bring a new ‗amr’. this refers to a new command, or a command that may seem new to what the people were familiar with. the narrations say that the mahdi will bring the islam of the prophet, but present day islam will be so corrupted by the people and misinterpreted, that it will seem like the mahdi is bringing a totally new religion. the amr may also refer to a rule or caliphate that is different from the ones we are familiar with at present. the mahdi will bring a rule or world government that is different from the ones we are familiar with. before the advent of the messiah the black flags of khorasan (iran) and the standard of qays in egypt will be raised this is an event leading to the appearance of the qa'im (the mahdi). imam mahdi will rearrange the wealth and power structures in the world. he will bring justice and peace to the nations; the wolf and the sheep will drink from the same pond and the wolf will not harm the sheep. according to the narrations from the prophet {s.a.) arrows shall not touch the mahdi, he shall live up to the very last of the world (kiyamah). most of the followers of the mahdi will be the young generations. there are more then hundreds of information agendas (hadiths) given in the religious texts of all muslim sects about the coming of the savior and about his worldwide military campaigns. mahdi is the true hope of the world. muslim religious texts have numerous information sources about his punishing the corrupt and evil of the world and defeating them and his global rule of justice and peace until the dooms day (kiyamah) arrives. from the source of ali (a.s.) the mahdi will peel off the present world order of corruption and evil like the peeling of the skin from the body (shall cause rebirth of the world). it has been related from the messenger of god (pbuh) that before the rise of the mahdi a caller from the heavens will call out the name of the mahdi that would reverberate in all regions (every home) of the world. the hours for wars and worldwide conflicts are surging upwards. the masses are demanding justice everywhere. regions of west asia and other region of the world have been surrounded by the armies of the world powers. only a spark will ignite vicious wars (third world war). the hour will come of a sudden. we are living at the brink of the apocalypse, but the world is asleep about the coming events. some of the excerpts from muslim religious texts have been given below: the messenger of god muhammad (pbuh) had stated: the prophet (pbuh) said: "allah will bring out from concealment mahdi from my family and progeny before the day of judgment, even if only one day were to remain in the life of the world, and he will spread on this earth justice, and equity and eradicate tyranny and oppression." after me, soon my ahlulbait will face calamity, hardship and misery till people having black flags(army battalions) will rise from the east(iran) and seek justice, which will be denied them. they will wage war, they will be supported and will be given what they were demanding. they will not accept until it is handed over to one from our ahlulbait (i.e. mahdi) .he will fill the earth with justice as it was filled with injustice. whoever amongst you is alive at that period, should try to reach them even if he has to tread on ice in that pursuit." "(armies carrying) black flags will come from khorasan . no power will be able to stop them and they will finally reach eelya (jerusalem) where they will erect their flags". (tirmizi) ali bin abi taleb (a.s) said: "if sufyani's cavalry march to kufa, the people of khorasan(iran) will be requested to come to their aid. the people of khorasan will come out seeking the mahdi. so, the hashimi with an army carrying black banners, at its front end is shuayb bin salih, will meet the followers of the sufyani at istakhar gate and a great battle will occur between them. the black banners will be victorious. sufyani's cavalry will run away. at that time, people will wish for the mahdi (to appear) and ask for him." (nuaim bin hammad's kitab al-fitan) bangladesh journal of bioethics 2013; 4(2):9-21 16 jabir has quoted from imam muhammad baqir (a.s) that he said, “the flags that arrive from khorasan shall reach kufa. and when his eminence, imam mahdi (a.s) reappears from mecca, these flags shall go towards him and pledge allegiance to him.” others traditions that prove that black flags would appear from the east or from khorasan, imply that it is the preface to the reappearance of his eminence, imam mahdi (a.s). a call from the heavens/ a scream from the skies/ a sound (blast) in ramadan before the rise of the mahdi: ali bin abi taleb (a.s.) said: “wait for the end of misery once three things occur." we said: what are they, o' prince of believers? he said: "the dispute among the people of ashsham (greater syria), the black banners (battalions carrying black banners), and the qaz'a in the month of ramadan. it was asked: "what is the qaz'a ? he said: "haven't you heard what allah said in the quran (26:4): 'if we wish, we can send down to them from heaven a sign, such that their necks remain surrendered to it (mesmerized in amazement).' this aya (sign) that makes a girl come out of her bedroom, wakes up the person who is asleep, and frightens the one who is awake." (ibn al-shajari's al-amali al-shajaria) the messenger of allah said: " in, ramadan, there will be a sound (or voice). they said: o messenger of allah, is it in its beginning, in its middle, or in its end ? he said: no, in the middle of ramadan. if the night of the middle is friday, there will be a sound from the sky that causes death to 70 thousand and causes deafness to 70 thousand. they asked: 'o messenger of allah, who will survive from your umma (nation)? ' he said: 'whoever stays at home, seeks refuge (to allah) through sujud (prostration), and openly declares takbir of allah ('allah akbar'). then, another sound will follow it. the first sound is the voice of (angel) gabriel and the second sound is the voice of satan. the sound is in ramadan, the disturbance is in shawwal, the tribes (or nations) form into warring groups in zul-qi'da, and it is feared for the pilgrim in zul-hijja. in almuharram, what is prohibited in muharram? its beginning is calamity on my umma (nation) and its end is a relief to my umma. a rahila (an animal or mode of transportation) that may save him is better than a fortress (castle) that shelters one thousand. " (tabarani, abu amru ad-dani, alhaithami's mujama al-zawa'id) the prophet (pbuh) said: "when there is a sayha (scream) in ramadan, then there will be turmoil in shawwal, and the tribes will form groups in zul-qi'da, and blood will be spilled in zulhijja, and in al-muharram! what is prohibited?" saying it three times, "oh, oh! the people will be killed in a great massacres." he said: "we said: "what is the sayha (scream), o messenger of allah?" he said: "this will be in the middle of ramadan, on a friday morning. that will be when the month of ramadan begins on a friday night. there will be a hadda (powerful, hammering sound) that will awaken one who is asleep, and bring the young women out of their rooms, on a friday night during a year of many earthquakes (and very cold). so when ramadan begins on a friday night in that year, then when you have prayed fajr on friday in the middle of ramadan, then enter your houses, close your doors, block your windows, cover yourselves, and block your ears. when you sense the scream, fall down in prostration to allah and say: "subhanal-quddus, subhanal-quddus, rabbunal-quddus (glory be to the most holy, glory be to the most holy, our lord is the most holy)." for whoever does that will survive, and whoever does not will perish." (nuaim bin hammad's kitab al-fitan, hadith ) prophet muhammad (pbuh) said, “on the 15th of ramadan, friday night there will be a voice (blast) that will awaken the asleep, that will alarm the awake, the noble ladies will come out of their seclusion. that day there will be too many earthquakes. therefore, there will be three major landslides like never seen before. one in the east, one in the west & one in the arabian peninsula. the earth will swallow everything above it & as a result, many people will die”. bangladesh journal of bioethics 2013; 4(2):9-21 17 rising of the sun from the west before the advent of the mahdi: abdullah bin abu-owfa reported: i heard the messenger of allah (pbuh) say, "verily a night equivalent to three of your nights will come upon people. when it comes, those who engage themselves in worship during the night will recognize it. a person will stand in prayer, read a section of the quran and then go to sleep. thereafter, he will wake up, stand in prayer and read a section of the quran, then go to sleep. while this condition remains, the people will begin to shout, scream and call one another. they will say, "what is this?" with fear, they will run to the mosque. to their surprise, they will see that the sun has risen from the west. when it reaches the middle of the sky, it will return and set in the west." he said , "that is when becoming a believer (in islam after witnessing this sign) will no longer be of benefit (because after the sun rises from the west, allah will no longer accept declarations of faith )." (ibn kathir's book al-bidaya wa an-nihaya) the rise of the comet from the east before the advent of the mahdi: "a comet appears when kings go on the pilgrimage to mecca for travel, the wealthy for commerce, the poor for rest, and the hafiz [reciters] to show off. (muhammad ibn `abd al-rasulbarzanji, alisha`ah li ashrat as-sa`ah, p.123) " "a star with a luminous tail will rise from the east before the mahdi emerges‖. (muhammad ibn `abd al-rasulbarzanji, al-isha`ah li ashrat as-sa`ah, p.123) "when this comet first appeared, the people of prophet noah (pbuh) perished, prophet abraham (pbuh) was cast into fire, pharaoh and his people who fought against prophet moses (pbuh) perished, and john [yahya] (pbuh) passed away. when you see that comet, take refuge in god from the evil of fitna (upheaval and chaos). (al-muttaqi al-hindi, al-burhan fi `alamat al-mahdi akhir az-zaman, p. 32) " the star (comet) is a sign of wars and chaos. according to another hadith (prophetic information) "the star will appear after an unexpected double eclipse in the month of ramadan" [al-fadl b. shadhan (reported) on the authority of ahmad b.muhammad b. abi nasr , abu jafar (al-baqir), peace be on him, said: "two signs will come before the one who will arise (al-qa'im/imam mahdi), peace be on him: there will be an eclipse of the sun in the middle of the month of ramadan and an eclipse of the moon at the end of it." "son of the apostle of god," i said, "usually the eclipse of the sun occurs at the end of the month and the eclipse of the moon occurs in the middle of it?" "i know what i have said," replied abu jafar (al-baqir), peace be on him. "they are signs which have not occurred since adam came down." according to hadiths, three banners will fight in syria for government before the rise of the mahdi (a.s.). one will be the red and white striped banner. the messenger of god (pbuh) said: "there will be a fitna (upheaval and chaos) in ashsham (syria). its beginning will be like a play of boys. then, the affairs of people will not settle on anything and unity will not be achieved until a caller calls from heaven: 'follow this person'(the mahdi),................ (nuaim ibn hammad's kitab al-fitan) the end of time dajjal (antichrist): dajjal (anti-christ) will claim to be a social reformer. the advent of dajjal is one of the indisputable signs of the re-emergence of the mahdi to which all previous religions have also alluded. dajjal literally means one who covers truth with falsehood and deceit. dajjal is not a proper name of a single person rather it is a general title for all devious and deceitful individuals and regimes who deceive the masses and bar the path of truth. bangladesh journal of bioethics 2013; 4(2):9-21 18 the end of this dangerous criminal and sinner shall be at the hands of the awaited imam (a.s), the great reformer of humanity. his eminence, imam sadiq (a.s) narrates from his father and he from his great grandfather, the messenger of allah (a.s) that he mentioned about the advent of dajjal, the place of his appearance and some of his characteristics and said that the dajjal would claim divinity and on the first day of his appearance, seventy thousand jews of illegitimate birth, habitual drinkers, singers, musician, bedouins and women shall follow him. he said, “then dajjal would make fornication, sodomy and all sinful activities lawful. so that people may have illicit relationships with women and children openly on the roads. his followers shall be prolific in consuming pork, wine and all types of sinful acts. they would obtain control over various areas of the earth except mecca, medina and shrines of the holy imams (a.s). at the time when his transgression would exceed all limits and the earth full of his oppression and his followers, one behind whom isa bin maryam (a.s) shall pray would slay him. and that person is imam mahdi (a.s).”[1] muntakhabul athar, pg. 480 imam ali(a.s.) narrated from the prophet(s.a.) about signs at the end of time about conditions prevailing on the appearing of dajjal. imam ali(a.s.) said, "there are a few signs which will become noticeable prior to his appearance, those signs are: people would stop offering prayers, people will be robbed of their deposits; twisting facts would be considered an appreciable quality; society will accept interest and use bribe as a means of subsistence; religion will be sold for the worldly gains; idiots will take over the intelligent; innocent will be slaughtered; those with humble and courteous ways will be called weak and naïve; those with harsh and cruel customs will be envied and praised; wealthy will be traitors; government officials will be malicious; prosperous would be evasive; clerics will be devious; adultery and illegitimate relationships will become societal norm; woman will participate in trade with men; falsehood and speculation will be admired; women will ride on saddle and prefer manly styles whereas men would like to dress like women;................. the messenger of god muhammad said, .............the sun will rise from the west; when it rises and the people see it, they will believe, but, 'no good will it do to a soul to believe then, if it will not have already believed or earned righteousness through its faith ...' (quran, al-anam 6:158) the hour will come suddenly: when a man has milked his she-camel and taken away the milk, but he will not have time to drink it; before a man repairing a tank for his livestock will be able to put water in it for his animals; and before a man who has raised a morsel of food to his mouth will be able to eat it." (bukhari) there is an islamic prophecy which states that a ―black man‖ ( barack hussein obama) will take power in the west prior to the emergence of the mahdi. the tradition comes from bihar al-anwar (meaning oceans of light) by mullah majlisi a shiite text of the 17th century, a magnum opus in 132 volumes and the basis of modern shiite islam. according to the tradition, imam ali ibn abi-talib (a.s.) from the prophet had said that at the end of times and just before the return of the mahdi, the ultimate saviour, a “tall black man will assume the reins of government in the west.” commanding “the strongest army on earth,” the new ruler in the west will carry “a clear sign” from the third imam, whose name was hussein ibn ali................ here are the verses from the bible that tells about the mahdi at the end of times (now). when the mahdi rises many armies of the world (different standard bearers) would assemble to wage war on the mahdi and this is what has been said in the bible in the last chapter of ―the book of revelation‖.(in these verses the mahdi is mentioned as the ‗lamb‘) bangladesh journal of bioethics 2013; 4(2):9-21 19 king james version (kjv), revelation chapter 6 rev 6:1 ¶ and i saw when the lamb opened one of the seals, and i heard, as it were the noise of thunder, one of the four beasts saying, come and see. rev 6:2 and i saw, and behold a white horse: and he that sat on him had a bow; and a crown was given unto him: and he went forth conquering, and to conquer. rev 6:3 ¶ and when he had opened the second seal, i heard the second beast say, come and see. rev 6:4 and there went out another horse [that was] red: and [power] was given to him that sat thereon to take peace from the earth, and that they should kill one another: and there was given unto him a great sword. rev 6:5 ¶ and when he had opened the third seal, i heard the third beast say, come and see. and i beheld, and lo a black horse; and he that sat on him had a pair of balances in his hand. rev 6:6 and i heard a voice in the midst of the four beasts say, a measure of wheat for a penny, and three measures of barley for a penny; and [see] thou hurt not the oil and the wine. rev 6:7 ¶ and when he had opened the fourth seal, i heard the voice of the fourth beast say, come and see. rev 6:8 and i looked, and behold a pale horse: and his name that sat on him was death, and hell followed with him. and power was given unto them over the fourth part of the earth, to kill with sword, and with hunger, and with death, and with the beasts of the earth. rev 6:9 ¶ and when he had opened the fifth seal, i saw under the altar the souls of them that were slain for the word of god, and for the testimony which they held: rev 6:10 and they cried with a loud voice, saying, how long, o lord, holy and true, dost thou not judge and avenge our blood on them that dwell on the earth? rev 6:11 and white robes were given unto every one of them; and it was said unto them, that they should rest yet for a little season, until their fellow servants also and their brethren, that should be killed as they [were], should be fulfilled. rev 6:12 ¶ and i beheld when he had opened the sixth seal, and, lo, there was a great earthquake; and the sun became black as sackcloth of hair, and the moon became as blood; rev 6:13 and the stars of heaven fell unto the earth, even as a fig tree casteth her untimely figs, when she is shaken of a mighty wind. rev 6:14 and the heaven departed as a scroll when it is rolled together; and every mountain and island were moved out of their places. rev 6:15 and the kings of the earth, and the great men, and the rich men, and the chief captains, and the mighty men, and every bondman, and every free man, hid themselves in the dens and in the rocks of the mountains; rev 6:16 and said to the mountains and rocks, fall on us, and hide us from the face of him that sitteth on the throne, and from the wrath of the ‘lamb’: rev 6:17 for the great day of his wrath is come; and who shall be able to stand? we the people of the world are now living the end of times. the final battle of good and evil of the world is imminent. the emergence of the messiah mahdi is very near and who will be joined http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/1 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/2 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/3 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/4 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/5 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/6 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/7 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/8 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/9 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/10 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/11 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/12 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/13 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/14 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/15 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/16 http://www.blueletterbible.org/bible.cfm?b=rev&c=6&v=1&t=kjv#comm/17 bangladesh journal of bioethics 2013; 4(2):9-21 20 by jesus son of mary to wage war against the corrupt and the evil of the world. the mahdi will establish the global rule of justice and equity and rule for ages until doomsday of the worlds. the mahdi will prepare mankind for the day of resurrection and through him god will give mankind their last chance to correct themselves. the present world powers are well aware that the mahdi will be rising and they are keeping a secret of it. the world powers study every religion and they take it very seriously. jesus son of mary gave us great spiritual teachings; did not jesus want to give his consciousness of the world and god to the people? the elites knew where this would lead so they censored him and tried to kill him! a few years later they bring out a book of his teachings!! do you really think they would put anything in that book that would empower the masses?? the world powers are getting set to wage war (third world war) on the mahdi when he rises; but information from the prophetic sources says arrows shall not touch the mahdi. we are at the threshold of a new age. cataclysmic and tumultuous changes and events are going to occur most likely by the end of this year 2013 or the next year 2014! apocalypse (armageddon) is ahead of us. conclusion: corruption, evil, social injustice and economic depravity has taken deep root in all countries of the world. the world today with a population of more then 7 billion are more divided and more in chaos then ever before in the history of the mankind. at present we are witnessing more upheavals and mass uprisings throughout the world then ever before and people everywhere are chaotic, violent, restless and unhappy. the people of the world are gathering momentum for a cataclysmic change that is to come our way. the world powers (leaders) have started mass repression, new wars and interventions to restore global hegemony. the world leaders have no solution for the masses. they appear to be politically bankrupt and impotent to steer the course of events unfolding before them. the world leaders and their entourages who are really detached from the masses have organized to keep aloft the present world order that degenerates the masses in corruption, keeps the people in unhappiness, and deprives the masses from economic well being, education and keeps promoting wars and conflicts to support corruption and evil. the world is moving towards collapse of economies, social upheavals, vicious wars and chaos. the world is moving towards a total global conflict (third world war). there will be a judgment day on the earth. the final battle between the good and evil on the earth is to our close proximity. we are at the ―end of times‖. we are living in the ‗messianic era‘. the promised messiah will come to set right what is wrong, no doubt. references: 1) the philosopher, volume lxxxiv, 1996. 2) the russian mafia, may 1996 issue of the tokyo journal, and in manager magazine [thailand]. bangladesh journal of bioethics 2013; 4(2):9-21 21 3) the worldwide network of us military bases (http://www.globalresearch.ca/the-worldwide-network-of-us-military-bases/5564). 4) http://www.isreview.org/issues/64/feat-moseley.shtml. 5) america’s dominance of global wealth is slipping http://economix.blogs.nytimes.com/2010/09/14/americas-dominance-of-global-wealth-isslipping/. 6) conservatism versus race relations in america: volume i . 7) recent trends in military expenditure (http://www.sipri.org/research/armaments/milex/resultoutput/trends). 8) the arab spring, the west and political islam— hisham h. ahmed. 9) major religions on the end of the world (http://www.history.com/topics/the-end-of-the world). 10) mystery babylon by peter goodgame (http://www.apocalypsesoon.org/xfile-6.html). 11) signs & events preceding the mahdi (http://www.discoveringislam.org/signs_before_mahdi.htm). 12) http://www.shiachat.com/forum/index.php?/topic/234997492-the-black-flags-fromkhorasan/. 13) nahjal balagha (peak of eloquence) – imam ali ibn abu taleb(a.s) 14) ummah forum (http://www.ummah.com/forum/showthread.php?120449-black-flags-ofkhorasan). 15) rt news (web based). 16) global rebellion: the coming chaos? – william i robinson ( aljazeera web based). 17) press tv ( web based). 18)the bible, chapter of revelation. http://www.globalresearch.ca/the-worldwide-network-of-us-military-bases/5564 http://www.isreview.org/issues/64/feat-moseley.shtml http://economix.blogs.nytimes.com/2010/09/14/americas-dominance-of-global-wealth-is-slipping/ http://economix.blogs.nytimes.com/2010/09/14/americas-dominance-of-global-wealth-is-slipping/ http://www.sipri.org/research/armaments/milex/resultoutput/trends http://www.history.com/topics/the-end-of-the%20%20world http://www.history.com/topics/the-end-of-the%20%20world http://www.apocalypsesoon.org/xfile-6.html http://www.discoveringislam.org/signs_before_mahdi.htm http://www.shiachat.com/forum/index.php?/topic/234997492-the-black-flags-from-khorasan/ http://www.shiachat.com/forum/index.php?/topic/234997492-the-black-flags-from-khorasan/ http://www.ummah.com/forum/showthread.php?120449-black-flags-of-khorasan http://www.ummah.com/forum/showthread.php?120449-black-flags-of-khorasan bangladesh journal of bioethics 2015; 6(2):8-14 8 child marriage: a discussion paper tahera ahmed former acting chief, srhr, unfpa& editor, bangladesh journal of bioethics email: tahera50@yahoo.com abstract:child marriage is still a massive problem in many developing countries. the issue is more concentrated in countries of sub saharan africa and south asia. this paper, through literature review attempts to assess the situation, the consequences, various programmes and recommendations on the reduction of child marriage. in this article it is reinforced that, consequences of child marriage put the girls at risk of early pregnancies with life-threatening conditions. this paper suggests that each country should set up its own midterm and long-term goals to bring about significant reduction in child marriages. key words: child marriage, consequences, traditions, education, security, poverty background: child marriage defined as marriage before the age of 18 applies to both boys and girls, but it ismore common among young girls 1 .the issue of child marriage is such a reality in many countries that it was not questioned for years together and was accepted as the norm. with the advent of development the adverse effects of child marriage was recognized and comparisons were made with advanced countries were age of marriage below 18 was a thing of the past and men and women have equal access to education, employment and their own personal growth and advancement. the convention of the rights of the child (crc) also set the minimum age of reaching adulthood. according to article 1 of the crc “any human being below the age of 18 is a child,” the crc has been ratified by 194 countries 2 . those countries still having early marriage i.e. below 18 years also exhibit poor indicators relating to the mdgs. they usually have high maternal mortality and morbidity rates, low education levels for girls, especially secondary education, and overall high poverty levels. present situation:though 158 countries have set the legal age for marriage at 18 years, laws are not enforced. the practice of marrying young children is upheld by tradition and social norms. many countries of asia and sub saharan africa still have a high percentage of child marriages (table 1) thereby making their struggle for development particularly difficult.one third of girls in the developing world are married before the age of 18 and 1 in 9 are married before the age of fifteen (15). in 2012, 70 million women 20-24 around the world had been married before the age of 18 3 . south asia has the largest number of child brides with almost half of girls married by 18 while in sub-saharan africa it is more than one third. consequences of child marriage:from the above table it is evident that even in this era, child marriages are quite prevalent in many countries. often new brides are expected to demonstrate their fertility after marriage specially by producing a male heir. according to un 16 million adolescent girls give birth every year and the major cause of death for girls aged 15-19 years in these countries is due to complications during pregnancy and childbirth 3 .according to unicef around 50,000 girls die during pregnancy, mostly in low and middle-income countries. the prevalence of stillbirths and new born deaths are 50 per cent higher in mothers who are below 20 years of age 3 .“these children, because that‟s what they are, are discouraged from using contraceptives or might have to ask their husbands‟ permission, or they have no knowledge of or access to what they need,” says carole presern, phd, executive director of the partnership for maternal, newborn & child health 4 . “even though some parents believe early marriage will protect their daughters from sexual violence, the reverse is often true,” according to a joint press release by unfpa, unicef, who, un women, the united nations foundation, world vision, girls not brides, every woman every child, world ywca and the partnership for maternal, new born and child health, dated 07 march 2013 3 .the press release states that “young girls who marry before the age of 18 have a greater risk of becoming victims of violence. this is especially true when the age gap between the child bride and spouse is large” a study conducted by icrw 5 in two states in india (bihar and jharkand) found that girls who were married before 18 were twice as likely to report domestic violence.these child brides also showed signs of severe depression. child marriage often leads to deterioration of the health of girls. due to complications during pregnancy and childbirth many girls in developing countries die or mailto:tahera50@yahoo.com bangladesh journal of bioethics 2015; 6(2):8-14 9 the table 1 depicts the situation globally: rank country name % girls married before 18 1 niger 75 2 chad 68 3 central african republic 68 4 bangladesh 66 5 guinea 63 6 mozambique 56 7 mali 55 8 burkina faso 52 9 south sudan 52 10 malawi 50 11 madagascar 48 12 eritrea 47 13 india 47 14 somalia 45 15 sierra leone 44 16 zambia 42 17 dominican republic 41 18 ethiopia 41 19 nepal 41 20 nicaragua 41 * source: unicef state of the world's children, 2013 data from unicef multiple indicator cluster surveys (mics), demographic and health surveys (dhs) and other national surveys, and refers to the most recent year available during the period 2002-2011. source: united nations carry the scars of a difficult pregnancy and labour. pregnant girls aged 15 to 19 are twice as likely to die in childbirth as women in their 20s, and girls under the age of 15 are five to seven times more likely to die during childbirth 6 .these are due to physical immaturity where the pelvis and birth canal are not fully developed. due to prolonged/obstructed labour many girls become victims of morbidities like obstetric fistula 7 . girls who give birth before the age of 15 have an 88% risk of developing fistula. fistula patients are usually young girls who come from a socially disadvantaged group with little access to emergency obstetric care. they suffer from incontinence orfaecaldischarge emitting foul odour making the girls social outcasts. challenge to the ethical rights of girls:"child marriage is a huge problem in poor communities,” says nyaradzayi gumbonzvanda, general secretary of the world ywca. "early marriage and child marriage robs their future. girls lose the opportunity for education. they lose the opportunity to choose their partner and must live with that pain for the rest of their lives" 8 . michelle bachelet, executive director of un women 3 states “no girl should be robbed of her childhood, her education and health, and her aspirations. yet today millions of girls are denied their rights each year when they are married as child brides” 3. once a girl is married at an early age she is deprived of her education and the opportunity to equip herself with life skills. she becomes a child mother before her body and mind are ready for this experience.the ill effects child marriage is reflected in the statements of anthony lake, executive director of unicef: “child marriage is not only wrong, it is dangerous. it exposes a young girl to profound health risks from early pregnancy and difficult childbirth and it exposes her baby to complications of premature birth” 3. underlying causes:child marriage has existed for centuries, mainly because of tradition but also due to poverty. in early days parents used to arrange the betrothal of their infant children as a means of uniting two families. in present days the practice of early marriage is common in rural areas or where prospects for girls are few. the would -be brides have no say in the matter as guardians or other family members agree on the marriages and girls have no decision making options. bangladesh journal of bioethics 2015; 6(2):8-14 10 often girls are married early to provide protection, security and the support of a male guardian. the question of „honour‟ is considered by parents and relatives, who may want to make certain the girls are married early to grooms approved by the families. according to a report by girls not brides, “poverty is one of the most powerful drivers of the harmful practice in the country. girls are thought of as an economic burden by parents who believe they will be more financially secure once their daughters are married off and out of their responsibil ity. poor families want to reduce the number of children to feed, clothe and educate” 9 . families may agree to child marriage because of community pressures and norms. sometimes children who refuse to marry or choose a marriage partner against the wishes of their family may be punished or even killed 10,11 . in recognition of the dreadful consequences of child marriage, many organizations are taking up global and country level programmes 12 .some of these organizations are: 1. the elders: the elders are a group of independent global leaders launched by nelson mandela in johannesburg in july 2007. the group offer their collective influence and experience to support peace building, help address major causes of human suffering and promote the shared interests of humanity. the principle is based on traditional village practices where communities take guidance ondifferent issues from elders. similarly if the earth is thought of as a „global village‟ then a group of experienced and dedicated elders could use their valuable experience and influence to focus on serious problems facing the world today. the elders brought together local, national and international organisations in a global partnership to end the harmful practice of child marriage. this alliance is called girls not brides: the global partnership to end child marriage. 2. girls not brides:as mentioned in the earlier paragraph, girls not brides is an alliance of more than 500 civil society organisations from over 70 countries. these organizations have the aim to end child marriage to help girls to fulfil their potential. member organizations are from africa, asia, the middle east, europe and the americas. the common vision is that every girl has the right to lead her life according to her choice. if the girl is not married early she can lead a safer, healthier life leading to a more prosperous future for herself, her family and her community. girls not brides members bring child marriage to the forefront and advocate for the laws, policies and programmes that will make a difference in the life of millions of girls. 3. plan international: plan works with children in communities in 51 developing countries to advance the achievement of gender equality and girls' rights. through the „because i am a girl „campaign, plan„s projects address the barriers to girls completing a quality education of at least 9 years, as well as equip them with the assets they need to safe guard their future, promote gender equality and improve their lives. 4. care – global: care is an international humanitarian organisation, which focuses on working for impoverished women. their mandate includes directly addressing child marriage through targeting education for girls. care works with families, communities and local organisations to reduce the prevalence and mitigate the harmful impacts of child marriage through educational and behaviouralchange programmes. 5. girls up – usa: girls up has dedicated advocacy and organisational efforts to ensure child marriage legislation is a priority in the us foreign policy engagements. in march of 2013, their efforts were rewarded as the us house of representatives passed the child marriage legislation as part of a broader violence against women act. 6. icrw – usa: international center for research on women (icrw) is advocating for the united states to become more involved in curbing child marriage. icrw works with the united states congress and the administration to bring more national and international support to end this harmful practice. 7. save the children – global: save the children works around the world to develop programmes to protect children and prevent child marriage along with other forms of child abuse, trafficking, and exploitation. 8. world vision – marriage later/studies first programme – bangladesh: world vision works towards the provision of global education for children who are at risk for exploitation, early marriage, and lower incomeearning potential. in bangladesh, they address barriers to education and work with communities and local governments to improve the quality of education children receive. the marriage later/studies first programme works with families to educate them on the impact of child marriage. http://www.icrw.org/media/press-releases/press-release-education-critical-%e2%80%93-not-silver-bullet-%e2%80%93-ending-child-marriage bangladesh journal of bioethics 2015; 6(2):8-14 11 9. the united nations: the un resolution on child, early and forced marriage, was supported by 116 member states at the 69th session of the general assembly 13 .every year, an estimated 15 million girls aged under 18 are married worldwide. in the developing world, one in nine girls is married before her 15th birthday .these children are robbed of their childhood, denied their rights to health education and security.the resolution calls on states, with the participation of relevant stakeholders, to develop and implement holistic, comprehensive and coordinated responses and strategies to eliminate child, early and forced marriage and to support already married girls, adolescents, and women through strengthening of child protection systems, protection mechanisms such as safe shelters, access to justice and the sharing of best practices across borders. child marriage is a global problem, but it is particularly widespread in african and indo-pacific countries. in bangladesh, the percentage of women married before they turn 18 is 65%, followed by 47% in india and 40% in pakistan and afghanistan. unfpa is committed to ending child marriage and reducing adolescent pregnancy by promoting legislation and programmes designed to end child marriage. unfpa also supports investments that empower girls with the information, skills and services they need to be healthy, educated and safe. unfpa also works to support the needs of married girls particularly in family planning and maternal health 14 . unicef is working with partners in joint efforts to end child marriage. together with governments, civil society and other agencies unicef is working to end child marriage globally. in 2011, 34 country offices addressed child marriage through social and economic change efforts and legal reform. in india unicef supported the passage of the child marriage prohibition act of 2006, and the development and implementation of a national strategy on child marriage. unicef participated in the development of state action plans and supported work with the community on ending child marriage so girls will develop in a safe and productive environment.unicef estimates globally, almost 400 million women aged 20-49, (more than 40 per cent), were married in their childhood. child marriage puts girls at risk of early and unwanted pregnancies. maternal deaths related to pregnancy and childbirth for girls aged 15-19 worldwide, account for some 50,000 deaths each year. girls between 10 and 14 years of age are five times more likely than women aged 20 to 24 die in pregnancy and childbirth 15 . policies and programmes: though many countries have legislation on age at marriage yet implementation becomes difficult. in bangladesh, the child marriage restraint act of 1929 16 passed during british rule is still applicable in bangladesh, where the legal age for a girl to marry is 18.unfortunately, enforcement efforts are weak, as is indicated by the high rates of child marriage in the country. a national law passed in 2004 requires that all births are registered, which would help determine a girl‟s age when she marries 17 . according to unfpa ,"in 2010, 158 countries reported that 18 years was the minimum legal age for marriage for women without parental consent or approval by a pertinent authority. however, in 146 countries, state or customary law allows girls younger than 18 to marry with the consent of parents or other authorities; in 52 countries, girls under age 15 can marry with parental consent. in contrast, 18 is the legal age for marriage without consent among males in 180 countries. additionally, in 105 countries, boys can marry with the consent of a parent or a pertinent authority, and in 23 countries, boys under age 15 can marry with parental consent" 14 .some countries position has been shown in table 2. way forward: a policy brief by icrw highlights five evidence-based strategies identified to delay or prevent child marriage 18 . 1. empower girls with information, skills and support networks: if young girls know better their options this will strengthen them to act and advocate for themselves. these girls will gain the confidence to look for jobs and alternatives to marriage and guardians will re-consider marrying them off early, which will ultimately impact on changing of traditions and values on child marriage. essential training on life skills, vocational and livelihoods skills as well as reproductive health information will help to teach girls about health, nutrition, money, finance, legal awareness, communication, negotiation, decisionmaking and other relevant topics bangladesh journal of bioethics 2015; 6(2):8-14 12 2. educate and rally parents and community members: with parental and community support and involvement a more enabling environment will be created. as it is the parents and guardians who take the decision regarding when or whom the girls will marry, with parental education and community mobilization a more supportive environment for girls can be attained. this will lead to families willing to change the custom of early marriage. 3. economic support and incentives to girls and their families: poverty is a strong reason for early marriage. the value and contribution of the daughter would increase if the families would perceive her accessibility to table 2 shows the wikipedia on marriageable age which providesthe following information 19 . country male consent female consent notes bangladesh 21 18 bangladeshi law provides penal sanctions for the contraction of under-age marriages, although such unions are not considered invalid despite the law, child marriage rates in bangladesh are among the highest in the world. every 2 out of 3 marriages involve child marriages. india 21 18 if any partner(s) engages in marriage at a younger age, (s)he can ask for the marriage to be declared void. a recent recommendation by the law commission aims to equalize the marriage age for males and females to 18.official policy automatically declares marriages under 16 as "null and void", while marriages at the age of 16 or 17 are "voidable". in 2012, the high court declared that muslim women can marry at 15. additionally, the report declares that "in spite of these legal provisions, child marriage is still widely practiced and a marriage solemnized in contravention of these provisions is not void even under the new pcma, 1929, the hindu marriage act, 1955 and also under the muslim law. afghanistan 18 16 in some cases, even younger girls are forced to marry at the age of 8. pakistan 18 16 (18 in sindh) despite the law against child marriage, the practice is widespread. according to two 2013 reports, over 50% of all marriages in pakistan involve girls less than 18 years old.another unicef report claims 70 per cent of girls in pakistan are married before the age of 16.another custom in pakistan, called swara or vani, involves village elders solving family disputes or settling unpaid debts by marrying off girls. the average marriage age of swara girls is between 5 and 9. zimbabwe 18 16 with parental consent. niger 18 15 under with parental consent. tanzania 18 14 with parental consent bhutan 18 kenya 18 16 with parental consent males. maldives 18 according to custom, the minimum age for marriage is 15. the law on the protection of the rights of the child discourages marriage before the age of 16. nepal 20 18 with parental consent. sri lanka 18 however, the parties must have a quazi's permission to marry before contracting into marriage if they are muslims. other economic opportunities as an alternative to marriage. thus if scholarships and stipends are tied to the condition that girls cannot marry until 18, parents will try to keep their daughters in school. 4. enhance girls' access to a quality education: when girls are in a formal school they are usually looked upon as a child. again the school provides a safe haven for the girls and it also improves their quality of life. if this is tied with stipend then parents will try to keep their daughter in school. bangladesh journal of bioethics 2015; 6(2):8-14 13 5. encourage supportive laws and policies: though many countries have laws and policies prohibiting child marriage yet enforcement has been difficult. in order to bring about acceptance and implementation of these laws icrw suggests a multi-strategy approach, combining legal advocacy with other community or girl-focused approaches. raising awareness among the community on the consequences of child marriage together with information on the existence of the law would help in bringing about a reduction in child marriage. the icrw researchers recommend that “in order for the next generation of development programs to make ending child marriage a priority, policymakers must pay attention to these strategies while continuing to test innovative approaches and evaluation techniques.” conclusion:though there is substantive work initiated to reduce the incidence of child marriages, yet a lot remains to be done to attain zero child marriage. each country has to set up its own mid-term and long term goals to bring about significant reduction in child marriages. the issue is not an isolated one rather it is intertwined with social norms, cultural taboos and traditions and economic conditionsof the families. partnerships with related government agencies, ngos, media, women‟s groups and the private sector will lead to a faster attainment of goals. the problem when addressed through a holistic approach with clearly defined indicators,milestones and responsibilities will help families, communities, nations and regions achieve zero child marriages in a defined time period. conflict of interest: none to declare. references: 1 unicef. child protection from violence, exploitation and abuse. updated: 2014 october 22 2 united nations treaty collection. convention on the rights of the child. retrieved 2015 october 2 3 unfpa, unicef, who, un women, the united nations foundation, world vision, girls not brides, every woman every child, world ywca and the partnership for maternal, new born and child health. joint press release [internet]. 2013 march 7 [cited 2015 july 10]. available from: http://www.unwomen.org/en/news/stories/2013/3/child-marriages 4 pmnch knowledge summary #22 reaching child brides. the partnership for maternal, new born and child health. 2012 5 child marriage and domestic violence. international center for research on women icrw. 2006 6 nour nawal m. health consequences of child marriage in africa. emerging infectious diseases. 2006; 12(11): 1644–1649 7 cook, rebecca j., bernard m. dickens, and s. syed. obstetric fistula: the challenge to human rights. international journal of gynecology and obstetrics. 2004; 87:72-77 8 gumbonzvanda n. ending child, early and forced marriage. presentation in un panel discussion campaign to end child marriage. 2015 9 girls not brides. news on impact of child marriage [internet].2015. [cited 2015 august]. available from http://www.girlsnotbrides.org/what-is-the-impact/ 10 bbc. ethics guide, honor crimes [internet]. 2012 [cited 2015 july 10]. available from: http://www.honordiaries.com/wp-content/uploads/2013/06/hd-factsheet-honorviolenceeast.pdf 11 bbc. ethics honour crimes [internet]. bbc.co.uk 12 olson c. the pixel project's "16 for 16" campaign.16 organizations working to stop child marriage. 2013 december 6 13 united nations general assembly. child, early and forced marriage. sixty-ninth session agenda item 65(a) resolution adopted by the general assembly 69/xx 14 unfpa. news on child marriage [internet]. 2015[cited 2015 july 10]. available from: http://www.unfpa.org/child-marriage 15 unicef. child protection from violence, exploitation and abuse. 2011 http://www.honordiaries.com/wp-content/uploads/2013/06/hd-factsheet-honorviolenceeast.pdf http://16days.thepixelproject.net/author/carololson/ http://16days.thepixelproject.net/author/carololson/ http://16days.thepixelproject.net/16-organisations-working-to-stop-child-marriage/ http://www.unfpa.org/child-marriage bangladesh journal of bioethics 2015; 6(2):8-14 14 16 ministry of law, justice and parliamentary affairs, bangladesh .the child marriage restraint act, 1929. (act no. xix of 1929) 17 bangladesh gazette additional publication. the births and deaths registration act, 2004. 2004 december 7 18 malhotra a. solutions to end child marriage: what the evidence shows. icrw publication. 2011 19 wikipedia [internet]. [cited 2015 july 10]. available from https://en.wikipedia.org/wiki/marriageable_age history of clinical research and ethics bangladesh journal of bioethics 2013; 4(1):20-29 20 history of clinical research and ethics shamima parvin lasker professor & head of anatomy, city dental college, dhaka general secretary, bangladesh bioethics society email: splasker04@yahoo.com abstract: the aim of clinical research is to congregate useful knowledge about the human biology. benefits to the participants are not the purpose of research, although it does secondarily. therefore, exploitation of human subjects occurred in clinical research. many people were harmed and basic human rights were violated as a result of their unwillingness participation in research. there have been many tragedies throughout the history of research involving human subjects. every period of research scandals have been followed by attempt to initiate some ethical codes to protect the human from clinical research. first of such codes is the nuremberg code. thereafter, helsinky declaration, belmont report and lastly obama commission on guatemala syphilis study. to remember history is essential so that it‟s not repeated again. knowledge of the history will provide a better understanding to handle the research fairly. researchers and the healthcare providers have no awareness of the history of ethical requirements for clinical research. therefore, repetition of scandal is being seen. in addition, there are few sporadic studies on this issue. formulation of universal rules and regulations is required which will not be limited to a specific tragedy or scandal or the practice of researcher in one country. it will provide common understanding and unique values of the research all over the world, although their application will require adaptation to particular culture, health condition and economic setting. key words: history, clinical research, ethics, universal rules introduction: biomedical research has made impressive steps during past century to save the human life with new drugs, vaccines and medical devices. but there were many tragedies throughout the history of research involving human subjects as the medical research had undergone on utilitarian consideration only. key objective of clinical research was to generate useful knowledge about the prophylactic, diagnostic, therapeutic, procedure, etiology and pathogenesis of disease and to increase understanding of human biology. many physicians had been pursued research as it was found interesting. consequently, exploitation of human subjects occurred in clinical research by placing some people at risk for the good of others. how the human subjects can be protected from the research and how its fruit would be distributed was a concern. therefore, ethical requirements for clinical research is aim at to minimize the possibility of exploitation by ensuring research subjects are not merely used but are treated with respect while they contribute to social good. in examining and using ethical theories several rules and regulation have been justified. these regulations of clinical research are based on a combination of ethical thought and history. this article presents the historical basis of these regulations and what should be the further step to make research sound and fair in the globe. mailto:splasker04@yahoo.com bangladesh journal of bioethics 2013; 4(1):20-29 21 history of early clinical research: the 1st recorded clinical research may have begun on eighteen century. scurvy was a threatened disease at that time and tolled the life of british sailors abroad. in 1740 james lind, a surgeon in the royal navy of salisbury was influenced by a report of admiral lord anson‟s that his crews were appalling losses to scurvy, including one ship which lost almost half of its crew to the disease. a number of common treatments, including cider, elixir of vitrol, vinegar, leaf past and sea water were in use to treat scurvy at that time. lind was septic of these treatments. he designed a study and chose 12 sailors and divided into six groups. five groups received exiting treatments and sixth group who received two orange and a lemon each day. within a week, sailors of group sixth were nearly healthy again, while the health of the other subjects had declined significantly. although lind noted a dramatic treatment effect from citrus, his findings were largely ignored for decade leading to unaccounted and unnecessary death. after 50 years (1795), royal navy adopted rationing of citrus fruit to their sailors at which point scurvy disappeared from royal navy. scurvy study tragically highlights as an important challenge of disseminating research result. scandals and tragedies in nineteenth century’s clinical research: this early experiment with humans resulted in prevention of serious disease in sailors. medical research with humans is then justifiable because of benefits of many people and society. but there are many examples of research that violate the right and dignity of human subject and in some cases cost their health or even their lives. some of such experiments are mention below. case 1: coley (1892) injected patients with cancer cell to induce artificial erysipelas. he described how he begun treatment with a patient who had a sarcoma and only that some consideration patient “consented” and cancer cell injection began. what interesting about this statement? “consented” this is not the word that people used in those days. case 2: in 1896-1897, a control clinical trail was conducted by johannes fibiger from denmark to see the effectiveness of his invented anti-diptherial serum. all hospitalized patients received standard treatment or diphtheria serum with standard treatment. after 1 year, 8 died of 239 patients in the serum group versus 30 died of 245 patients in the diphtheria serum with standard treatment group. who is the responsible for this death and peril of diseased family is a concern. case 3: guiseppe sanarelli (1897), an italian bacteriologist announced that he isolated bacillus of yellow fever. to prove his claim he injected 5 persons with his isolate and produced yellow fever in them. many were quick to criticized sanareli for yellow fever induction experiment and harm the subjects. in 1898, william osler, professor of john hopkins and oxford university condemns sanareli for deliberately injecting poison of known high degree of virulence into a human being without his consent, it is not ridiculous , it is criminal. human experimentation was running heighten at that time and yellow fever was in epidemic in cuba. walter reed was commissioned by us surgeon general to identify the cause of yellow fever. yellow fever board was establish and proposed yellow fever research includes: self experimentation written consent restriction to adult (older then 24 years) bangladesh journal of bioethics 2013; 4(1):20-29 22 expulsion of children as research participants clearly using the phrase with full „consent‟ in all journal article. payment in gold ($100). reeds established several safeguard. reeds designed the written consent form for local workers that clearly explain the peril of the undertaking research. he mentioned of offer a payment of $100 (payment in gold) to those who were willing to expose and another $ 100 to those who become ill with yellow fever. a written consent was established and our moral responsibility was lessened to a certain extent. scandals and tragedies in clinical research in twentieth century: in the 20th century, the most barbaric experiments were done by nazi doctors. some are as follow: experiment 1: prisoners were put in to low pressure tank to see how long they could survive with little oxygen. many of them died. experiment 2: high altitude experiments: prisoners were hanging to see how long they could survive in high altitude. many of them died and then autopsied. those who did not die immediately were put under water until they died and autopsy followed. experiment 3: cold experiment: prisoners were forced to remain outdoor during winter of -20 0 temperature without cloth for 9 to 14 hours or force to remain in a bath of freezing water till death to see how long a man can bear cold or what are the consequences of cold till death. experiment 6: malaria experimentation: dr klaus karl schilling, an eminent malaria expert, infected more than 1000 prisoners with malaria at dachau and treated with his experimental anti-malarial drug. more than 400 died from complications of treatment with experimental malaria drugs. experiment 7: twins experiment: where, one baby was exposed to a pathogen and killed and then autopsied to determine the natural progression of disease. the other control twin was then sacrificed to see what the differences were. it may constitute a very interesting comparison for a scientific perspective but such an experiment was not only unethical but inhuman. experiment 9: hundred of prisoners were killed for accumulation of skeleton for anthropological investigation. those killed were considered prototype of what the nazi called characteristic sub human. experiment 10: to create a genetically pure population (eugenics) the “law for the prevention of genetically diseased descendants” was passed and sterilization was enforced. within four years, 300 000 people had been sterilized. the modern history of human subject protections begins with the discovery of nuremberg code. in december 1946, following world war ii, america military tribunal opened criminal proceedings against 23 german physician and administrator for their willing participation of cruelty against humanity in the name of research. nuremberg code has 10 basic principal of moral, ethical and legal concept. 1. voluntary consent is essential. german physicians conducted medical experiments on thousands of prisoners of concentration camp without their consent. most of the subjects of these experiments died or were crippled permanently. bangladesh journal of bioethics 2013; 4(1):20-29 23 2. research must benefit to the society. it is unethical to needless endanger the well being of human volunteers if other methods of investigation exist. 3. research must be based on preclinical study on animal. 4. avoidance of all unnecessary physical and mental suffering and injury. 5. avoidance of the death and disability. 6. subjects must have the right to end their participation in research. 7. preparedness and adequate facilities should ensure to protect the subjects against even remote possibility of injury, disability and death. 8. preparedness for termination of experiment at any stage of research if continuation of experiment is likely to result in injury, disability or death of subjects. 9. experiment should be conducted only by scientific qualified persons. 10. research risk must be minimized and relative to the anticipated benefit of research. however, nuremberg code is not the first set of research guidelines. the german themselves had developed systematic guidelines in 1931. these guidelines were in force at the time and clearly prohibited a great deal of what the nazi doctors did. before mid ninetieth, us government had no control over manufacturing and dispensing of drug. in the late 50s, thalidomide was sold as a sedative to control sleep and nausea through out pregnancy in europe. but it was found that taking this drug during pregnancy caused sever deformities in the baby. many patients did not know that they are taking a drug that was not approved by fda nor they give informed consent. some 12,000 babies were born with sever deformities. in 1962, food, drug and cosmetic acts were passed into law to ensure drug efficacy and greater drug safety called kefauver amendments. under this law, for 1st time drug manufacturers were required of fda endorsement for the effectiveness of their products before marketing. in july1963, the legitimacy of the human experimentation was again questioned when research performed by chester m southam and emanual e mandal at the brooklyn jewish chronic hospital where life cancer cells were deliberately injected into elderly patients without their consent to see if cancer cell would cause an immune reaction and that would lead to their expulsion from body. the researcher argue not informing patient about the experiment that might have caused them needlessly psychological distress. finally, the hospital was sued and had license cancelled. research became coercive when the physician himself turned out to be a researcher. children and adolescents with disabilities were exposed deliberately to hepatitis at new york state hospital in willobrook to find preventive measure for hepatitis that was epidemic at that time. the ward was closed to any admission in excuse of over crowdedness but patients were said that the children could be admitted if they were placed in research ward. some children were mentally retarded. due to high critics, the head of research team saul krugman argued that the consent was obtain from their parents. in 1964, the world medical association established & recommended the guidelines for medical doctors in biomedical research involving human is known as helsinki declaration. the declaration bangladesh journal of bioethics 2013; 4(1):20-29 24 delaminate the therapeutic research from non-therapeutic research. issues addressed in the declaration are includes: 1. delaminate practices from research 2. research protocol should be reviewed by an independent committee (irb, erb etc) prior to initiation. 3. informed consent is necessary 4. risk should not exceed from benefit. 5. allow subject representative to consent who cannot consent but willing to take part in research. 6. research with human should be based on the results from laboratory and animal experimentation. 7. well being of subjects should be take precedence over the interest of science and society. helsinki declaration was revised in 1975, 1983, 1996, 2000 and it is the basis for good clinical practices used today. scandal seemed to break out everywhere. in 1966 henry beecher, professor of anesthesiology at harvard medical school published an article with 22 cases of violation of ethical research with human in new england journal of medicine. originally example was 50, due to shortage of space, examples were reduced to 22. all the cases were published in reputed medical journal from respected researcher of leading medical institute. beecher aim was not to condemn the researchers but to raise awareness to serious ethical problem in conduct of research with human. he wanted to point out that unethical activates in united state were very similar to what happened in nazi doctors. his article had a major impact on the development of the regulation. the most unethical research in history was tuskegee syphilis study (1932-1972). a research was conducted in tuskegee, alabama, usa in 1932 on 600 low income african american male. on 400 of who were infected with syphilis and 200 were as control and monitored for 40 years to asses the natural history of syphilis. subjects were not told about the disease and denied any treatment even though a proven cure (penicillin) was publicly available in the 1940s. in some cases when subject were diagnosed by other physician but researchers intervened the treatment. there was no scientific rationale for this study because the natural history of syphilis had already been elicited. many subjects died of syphilis during the study. the study was stopped in 1972 by the us department of health education and welfare only after existence of this research was publicized in media. it became a political embarrassment. but by the time 74 of the subjects were still alive, of 40 wives had contracted syphilis, 19 babies were born with congenital syphilis. in 1970, compensations were given for the survival and for the families of those who died from this study .1997, under mounting pressures; president clinton apologized to the study subjects and their families and granted $ 200,000 for creation of tuskegee university national center for bioethics in research and health. due to publicity from the tuskegee syphilis study, national research act (1974) created the national commission for protection of human subjects of biomedical and behavioral research. in 1979, commission drafted the belmont report. it summarized the basic ethical principles as below: 1. respect for person 2. beneficence and 3. justice bangladesh journal of bioethics 2013; 4(1):20-29 25 these are the corner stone for regulations of research involving human subjects and protection for certain vulnerable research subjects e.g. pregnant women, prisoners and children. in 1981, department of health and human service (dhhs) issue regulations based on belmont report. dhhs issued code of federal regulation (cfr), part 45 (public welfare) and part 46 (protection of human subject). in 1991, the core dhhs regulations (45 cfr subpart a ) were formally adopted by more than 17 departments and agencies. now most of the departments of universities and agencies including fda adopted this rule. this rule is called common rule. common rule includes: 1. documenting inform consent. 2. requirement for ensuring compliance by research institute 3. requirements for institutional review board (irb) membership, function , operations, review of research and record keeping. 4. additional protections for certain vulnerable research subjects (prisons, pregnant women, children, retarded patients etc). fda is responsible for approval and license the drug and device for sale in usa. they are largely in agreement with common rule about the prior irb review and informed consent. the fda issued cfr title 21 (food and drugs) of parts 50 (protection of human subjects) and 46 (institutional review board). in addition certain federally sponsored and much privacy sponsored research is subject to the regulations of the food and drug administration (fda) at 21 cfr parts 50 and 56. after the creation of national commission and implementation of common rules it seemed the biomedical research in us was finally on a more secure ethical footing. but in 1990s controversy regarding research with human erupted once again. news paper and magazine features many examples. time magazine picture s a human in a case with caption “medical testing had turn million people in to guinea pig”. several prominent medical research facilities shut down for non compliance with us regulation for the protection of human in biomedical research. research begins to undertaken in collaboration with developing country, where the research rules and regulations are not stringent. council for international organization of medical science in collaboration (cioms, 1993) with who developed international ethical guidelines for biomedical research with special attention to developing country in response to common research as hiv/aids. to protect participants as well as research enterprise, cioms took 20 years to develop guidelines involving participants from developing and developed country. the first version relapsed in 1993 including 15 guidelines. 2 nd version released in 2002. important guidelines of cioms are: 1. any intervention or product or knowledge generated will be made available for the benefit of the population or community (guideline10) 2. justify the placebo control (guideline 11) when a. there is no established intervention. b. withholding established intervention would exposes subject with temporary discomfort. bangladesh journal of bioethics 2013; 4(1):20-29 26 c. when use of established intervention would not yield scientific reliable result. d. placebo would not any risk of serious irreversible harm to subject. 3. compensation of research injury it also includes a section on compensation for research for injuries not found in other documents. international conference for harmonization good clinical practice (ich-gcp) (1996) was promulgated in 1996 by international conference for harmonization of technical requirements for registration of pharmaceuticals for human use. it depicts the standard for review committee, investigators, and sponsors. it is specific for research on drugs or devices seeking regulatory approval. it opposes the active control trial. ich-gcp is agreed by europe, usa and japan. scandals and tragedies in clinical research in twenty first century: the office for human research protections (ohrp, 2000-2001) provides protection of the rights, welfare and wellbeing of subjects involved in research conducted or supported by the u.s. ohrp works to ensure that human subjects outside of the united states who participate in research projects conducted or funded by dhhs receive the same level of protections as research participants inside the united states. this regulation attempted to ensure that future research with human subject would be ethical and legal. however, susan rever, a medical historian, discovered another syphilis study scandal in 2010. story says, female commercial sex workers known to be infected with syphilis sent to guatemala prisons to infect inmates to establish whether penicillin could be used for prophylaxis against stis. the study was begun in 1946-1948 funded by usa government. more than 1,600 people were infected, of them 696 with syphilis, 772 with gonorrhea and 142 with chancres. none of the participants consented. in 2010, obama apologized on behalf of us. as the research in developed country has become strict day by day, the prevalence of pharmaceutical drug trials is drastically increasing in developing countries. a clinical trail for a new meningitis drug “trovan” had been conducted by pfizer in nigeria in1996. the disease left thousands dead and thousands more permanently disabled. pfizer said it did not get written permission from the parents because they were illiterate but said the trail was sanctioned by the nigerian medical authorities. pfizer came under fire in 2001 for allegedly testing meningitis drugs on nigerian children. in 2008, another trail was conducted by glaxosmithkline in the argentine province of santiago del estero to prevent pneumonia and related diseases. seven babies died while taking part in trials. no informed consent has been taken in this trail. after several scandals, indian government was repealed the law in 2005 that for the drugs safety approval is required from their home countries before being tested in india. astrazeneca has opened a drug-testing facility in bangalore and pfizer has done the same in bombay. discussion and conclusion: the nuremberg code was the part of the judicial decision condemning the atrocities of the nazi doctors and so focused on the need for consent and a favorable risk benefit ratio but makes no mention of fair subject selection and independent review. helsinki declaration was related to research conducted by physician with patients. it differentiates between bangladesh journal of bioethics 2013; 4(1):20-29 27 therapeutic and non therapeutic research. the belmont report provides broad principals that could be used to generate specific rules and regulations to protect vulnerable populations from research in response to us research scandals e.g. tuskegee, wilobrook etc. cioms intends to apply the declaration of helsinki in developing countries and included the compensation for research injury. research funded by us is regulated by dhhs and fda. ohrp provides protection of the rights, welfare, and wellbeing of subjects in research conducted or supported by the u.s.a. both inside and outside of the united states. as the research in developed country has become strict day by day, the prevalence of pharmaceutical drug trials is drastically increased in developing countries. repetition of scandals is being seen. researchers and the healthcare providers seem are not taking lesson from history of ethical research to handle the research fairly and restore the human dignity. formulation of universal rules and regulation (guidelines) is needed which will not be limited to a specific tragedy or scandal or to the practice of researchers in one country, although their application will require adaptation to particular culture, health condition and economic setting. research on this line is needed. references: 1. brandt am. racism and research. the case of the tuskegee syphilis study. . in ezekiel je. crouch ra, arras ja, mereno jd and grady c (editors) 2003, the john hopkins university press. baltimore. 2. brody bs. the ethics of biomedical research. new york, ny: oxford university press; 1998: chapter 9. 3. beecher h. ethics and clinical research. in ezekiel je. crouch ra, arras ja, mereno jd and grady c (editors) 2003, the john hopkins university press. baltimore. 4. bbc news. nigerians angered by drugs trial delay. july 30, 2001. http://news.bbc.co.uk/1/hi/world/africa/1465532.stm. (access may 4, 2011). 5. council for international organizations of medical sciences. international ethical guidelines for biomedical research involving human subjects. geneva, switzerland: cioms; 1993. 6. chan jkl. taking moral diversity seriously a discussion of the foundations of global bioethics. in bioethics and moral content: national traditions of health care morality, h. engelhardt th (ed.). kluwer academic publishers, 2002, pp.235-249. 7. decastro ld. exploitation in the use of human subjects for medical experimentation. bioethics.1995;9:259-268. 8. department of health and human service. code of federal regulations. title 45(public welfare). part 46 (protection of human subjects (45 cfr 46). us government printing office. 2005. 9. ezekiel je, wendler d and grady c. what makes clinical research ethical? jama. 2000;283(20):2701-2711. 10. fakruddin m, chowdhury a, hossain mn, mannan ksb . ethics in clinical research. bangladesh journal of bioethics 2012; 3(3):16-20. http://news.bbc.co.uk/1/hi/world/africa/1465532.stm http://news.bbc.co.uk/1/hi/world/africa/1465532.stm bangladesh journal of bioethics 2013; 4(1):20-29 28 11. ghooi rb. the nuremberg code-a critique. perspect clin res. 2011 apr;2(2):72-6. 12. history of research ethics. http://research.unlv.edu/ori-hsr/history-ethics.html (access october 5, 2011). 13. hearn k. the rise of unregulated drug trials in south america. october 10, 2011 edition of the nation. http://www.thenation.com/article/163547/rise-unregulated-drug-trials-south-america (access on 20 january 2012). 14. human subject research. http://en.wikipedia.org/wiki/human_subject_research (access on january 2012). 15. katz j. experimentation with human beings. new york, ny: russell sage foundation; 1972. 16. katz j, capron am, glass es. jewish chronic hospital case. in ezekiel je. crouch ra, arras ja, mereno jd and grady c (editors) 2003, the john hopkins university press. baltimore. 17. kim y. a common framework for the ethics of the 21sf century. division of philosophy and ethics, unesco, 1999, paris. http://unesdoc.unesco.org/images/0012/001246/124626eo.pdf (access on december 2011). 18. levine rj. ethics and regulation of clinical research. 2nd ed. new haven, conn: yale university press; 1988. 19. ali ma. what makes multinational clinical research ethical & how to minimize possible exploitation in host country? bangladesh j bioethics 2011;2(2):20-23. 20. office for human research studies ohrs: http://www.hhs.gov/ohrp/humansubjects/index.html (access on march 2012). 21. perlman d. ethics in clinical research. a history of human subject protections and practical implementation of ethical standards. socra source may 2004; 37. 22. ruth rdf, ledere se and merono jd. us medical research, the nuremberg doctors trail and the nuremberg case. a review of finding of advisory committee on human medical experiment. in ethical and regulatory aspect of clinical research. ezekiel je. crouch ra, arras ja, mereno jd and grady c (editors) 2003, the john hopkins university press. baltimore. 23. the president's commission for the study of ethical problems in medicine and biomedical and behavioral research. summing up. washington, dc: us government printing office; 1983. 24. the national commission for the protection of human subjects of biomedical and behavioral research. the belmont report: appendix. vol 1. washington, dc: us government printing office; 1978:chap 9. 25. the nuremberg code. jama. 1996; 276:1691. 26. vollman j and winau r. informed consent in human experimentation before the nuremberg code. bmj 1996;313;1445-7. 27. weinstein n. optimistic biases about personal risks. science 1989;246:1232-3. http://research.unlv.edu/ori-hsr/history-ethics.html http://www.thenation.com/article/163547/rise-unregulated-drug-trials-south-america http://en.wikipedia.org/wiki/human_subject_research http://unesdoc.unesco.org/images/0012/001246/124626eo.pdf http://www.hhs.gov/ohrp/humansubjects/index.html bangladesh journal of bioethics 2013; 4(1):20-29 29 28. world medical association. declaration of helsinki. jama. 1997;277:925-926. 29. wertheimer a. exploitation. princeton, nj: princeton university press; 1996: chap 1. 30. wendler d. the ethics of clinical research. the stanford encyclopedia of philosophy in edward n. zalta (ed.). jan 30, 2009. http://plato.stanford.edu/entries (access on november 2010). (*** this article has been published in the proceeding of 13 th asian bioethics conference 2013 concurrent with sixth unesco asia pacific school of ethics roundtable.) http://plato.stanford.edu/entries an overall view of bio ethics practices in our day to day life and it`s remedies bangladesh journal of bioethics 2010;1(3);52-57 an overall view of bio ethics practices in our day to day life and it`s remedies z. u. ahmed director , makan group, dhaka .email: payesz@yahoo.com abstract: historically, ethics has been considered the province of religion i.e moral theology and large, still remains so. in most cases religion provides an important answer to the question, why one should act ethically. the ancient greeks were the first to examine ethics philosophically and thus independently to religion . the major proponents of it were socrates, plato and aristotle in the 5th & 4th centuries b.c. now a days we can see lack of ethics everywhere of our life. this article try to find out –where & what are the ethics we are lacking behind in our day to days life and it`s probable remidies. morality should be practiced and should start from the –“dinning table”. beside this government should pass down policies, which will facilitate this practice to get good citizens. the main thrust of modern ethics or moral philosophy is to attempt to lay the foundations of ethical conduct, which should be bear in mind with good faith. introduction: ethics is related to morality . in the past the subject of ethics was known as –“moral philosophy”-while knowledge of the physical world was referred to as-“natural philosophy”. historically, ethics has been considered the province of religion i.e moral theology and large, still remains so. in most cases religion provides an important answer to the question,why one should act ethically. the ancient greeks were the first to examine ethics philosophically and thus independently to religion . the major proponents of it were socrates, plato and aristotle in the 5th & 4th centuries b.c . now a days we can see lack of ethics everywhere of our life. it include our personal life, family life, social life and official life. this article tries to find out –where & what are the ethics we are lacking behind in our day to days life and it`s probable remidies . historical back ground of implementing ethics: the belief that rational thinking and knowledge can lead to ethical behavior was very appealing. plato believed that philosopher kings can be trusted with unchecked power because their education will have given them knowledge of the forms, inparticular the form of the good, being eternal, extra-mental realities. socrates, unlike religion did not provide instruction how people should conduct their lives. instead, he examined human conduct with the aim of leading a virtuous life. he believed in 52 mailto:payesz@yahoo.com bangladesh journal of bioethics 2010;1(3);52-57 goodness but did not suggest how to achieve it ?. his continuous questioning of things got him in trouble by being accused of corrupting the youth of athens and he was put to death for it . we are at this moment not in that barbarian`s era but at mordarn era where – openion of personal expression is honoured and logically discused with good faith. ethical principles: the following principles (thiroux, 1986) are guidelines for regulating ethical behavior.  value of life – human life has inviolable sanctity. “. . . it is always wrong to act in a way which directly intends to harm or to kill an innocent human person” (goodwin, 1985, p. 7).  goodness or rightness – ethical decisions should involve the principle of the greatest good for the greatest number. doing good, in addition to refraining from doing evil, is required so that the consequences are good for the individual and for society.  justice or fairness – this principle relates to equality of treatment and fair distribution of benefits and burdens among members of society.  truth-telling or honesty – although ethical action should be based on the truth, this principle is complicated by issues related to who has a right to the truth and whether or not it is appropriate to withhold it. when do you know you have all of the facts and can determine what is true? confidentiality (contact-keeping), related to honesty and individual freedom, poses its own set of complications: what do you do when human welfare conflicts with confidentiality? when do you break a promise?  individual freedom – ethical decisions should consider the principle of selfdetermination. “. . . treat human beings as ends in themselves, never as means only” (kant in goodwin, 1985, p.7). related to this standard are the following complexities: whose right is uppermost when one person’s autonomy impinges on another? who should speak for those who cannot speak for themselves? ethical reasoning steps*  clarify the facts.  identify the moral dilemma. what is the ethical question?  identify and interpret the relevant ethical principles: value of life, goodness, justice, truth-telling, individual freedom.  resolve the conflicts among principles. if more than one principle is involved, which one has precedence?  state the moral decision.  formulate a course of action—action steps: what and how, who, when. * adapted from the theory of thiroux (1985). 53 bangladesh journal of bioethics 2010;1(3);52-57 sectors where ethical improvement is immediately needed:  personal life  family life  social life  official life  national life  international life personal life “today’s personality holder is tomorrow’s person’s leader.” so it has got utmost importance to get a well groomed personal among the citizens of a country .this well groomed personality will provide a good person who will lead a good personal life along with other. family life these well groomed persons together will make a happy family life. social life these well reputed family members together will form a civilized society-where ethics will be highlighted in its right spirit. official life at the same time these well reputed family member will be the part of the office. as such they will be more disciplined, efficient and capable enough to achieve the organizational goal as well as the country goal. national life once the personal, family, social and official life is disciplined and organized – the national life will be more prosperous, which will lead the country to the international arena with good reputation. international life once all the nations are good, disciplined and have honor towards ethics in every aspect, then good faith & relation will be developed & maintained properly. as a result less war , less unrest will prevail in the worldwhich is our goal. 54 bangladesh journal of bioethics 2010;1(3);52-57 so, we can say grooming up of a kid in the right direction with ethics in every family is utmost important, which will ultimately lead a happy world. there could be –“two way traffic” (figure 1):  (1) one way (down ward) is government of that individual country by making policies regarding ethics in the parliament.  (2) another way (upward) is “the family dinning table”where family members will introduce the kid with quality ethics. here family member’s need to give quality time to their kids and can provide knowledge on.  religious faith ( good for person & society )  other sensible faith (good for person & society. may be an alternative of religious faith.)  righteous duties towards all.  others (these teachings may be changed with the passage of time basing on the ground requirement to do good to others. for this a committee may be formed to introduce ethical handbook like un-where all ethical subject matter will be written down with guide lines as per the ground requirement). an ethical social example: it is common to refer to the desire for material wealth, mostly expressed in terms of money, as "greed". webster's dictionary defines greed as "acquisitive desire beyond reason". on the other hand, the pursuit of success in the scientific and engineering professions is referred to as "ambition". webster's dictionary defines ambition as "eager or inordinate desire for preferment, honor, superiority, power, or attainment". the connotation of these terms is so different that sometimes we tend to refer to an honest businessman as "greedy", and to a dishonest scientist or engineer as "over ambitious". yet, the consequences of an unethical behavior of an “over ambitious" scientist or engineer can often be more harmful then the unethical actions of a "greedy" businessman. in the scandal surrounding the company enron, no one died or suffered physical injury. on the other hand, the developer of a drug or medical device that results in a faulty product can cause innumerable damage to life and health of many. of course, in the latter case, the marketing of the product also involves a profit consideration that is often vested with the same individuals, as it has been so widely demonstrated in the recent high tech euphoria. 55 bangladesh journal of bioethics 2010;1(3);52-57 both the ways should work together – “upward & downward”. this is more opined below: (2) upward family teaching regarding ethics (dinning table) (1)downwardgovernment pass policies regarding ethics at parliament figure 1: twoway ethical theory for implementation in our day to day life. 56 personal life international life personal life family life personal life social life personal life official life personal life national life bangladesh journal of bioethics 2010;1(3);52-57 conclusion: the subject of ethics was of interest to human kind since before recorded history. historically, ethics has been considered the province of religion, i.e., moral theology, and, by and large, still remains so. in most cases religion provides an important answer to the question why one should act ethically. bioethics is a subset of the larger subject of ethics that is concerned with biological themes. ethics is related to morality. this morality should be practiced and should start from the –“dinning table”. beside this government should pass down policies, which will facilitate these practices to get good citizens. the main thrust of modern ethics or moral philosophy is to attempt to lay the foundations of ethical conduct, which should be bear in mind with good faith. bibliography: 1. www.tutor2u.com 2. www.wikipedia.com 3. www.cbhd.org 4. darryl r.j.macer moral games for teaching bioethics. unesco chair, 2008. haifa, israel. 5. arif hossain & shamima p lasker. importance of bioethics and bangladesh prospective. asian bioethics review 2009;1(2):165-167. 6. goodwin. 1985, p. 7. www.bioethics.com 57 http://www.bioethics.com/ male circumcision in india: some considerations from the west bangladesh journal of bioethics 2013; 4(1):2-8 2 male circumcision in india: some considerations from the west mirko daniel garasic centre for human bioethics, monash university, melbourne, australia and center for ethics and global politics, luiss university, rome, italy email: mirko.garasic@monash.edu; mgarasic@luiss.it abstract: in this work, i will analyse why indian authorities find it so difficult to publicly acknowledge the medical benefits of male circumcision (mc). in doing so, the medical evidence in favour of the practice, as well as the moral duties that governing authorities have towards their citizens shall be taken to the fore. in addition to this argument, a brief explanation of the cultural dimension that refuses to evaluate the medical dimension of mc a priori shall be taken into account and, in relation to that, a parallel with the past and present western tradition will be drawn, putting forward the conclusion that both contexts do not provide satisfactory justification for banning mc nor more relevantly for the indian scenario can any cultural background represent a convincing argument against the public acknowledgement of the medical advantages provided by mc. key words: anti-semitism, hiv, india, informed consent, islamophobia, male circumcision, public policies, stds introduction: the intention of this work is to point out how -in india as well as in a growing number of western countries the hostility against the implementation of male circumcision (mc henceforth) is not based on medical evidence but rather on religious and cultural grounds. despite the fact that in recent years plenty has been written on the therapeutic value of mc to contrast, among others sexually transmittable diseases (stds), hiv/aids 1 an increasingly worrying shadow in indian society, the practice still finds very little support from the indian medical community. however, as rightly pointed out by chandhiok and gangakhedkar in their article “the new evidence on male circumcision: an indian perspective”, 2 at the moment the number of indian citizens affected by the hiv virus is relatively low, but, it is reasonable to believe that, if not properly contrasted at this early stage, the number will multiply exponentially in the coming decades, resulting in a damaging impact not only for the sufferers of the illness and their families but also for indian society as a whole, as this will increase the costs for the health care system dealing with hiv/aids. there is reasonable ground to believe that implementing mc would help reducing the risk of a future epidemic in india and, as a recent study underlined, 3 the disclosure of the beneficial feature of mc could indeed increase the level of awareness among people and their willingness to adopt such a practice also on nonreligious grounds. in this work, i will analyse why indian authorities find it so difficult to publicly acknowledge the medical benefits of mc. 4 in doing so, the medical evidence in favour of the practice, as well as the moral duties that governing authorities have towards their citizens shall be taken to the fore. in addition to this argument, a brief explanation of the cultural dimension that refuses to evaluate the medical dimension of mc a priori shall be taken into account and, in relation to that, a parallel with the past and present western tradition will be drawn, putting forward the conclusion that both contexts do not provide satisfactory justification for banning mc nor -more relevantly for the indian scenariocan any cultural background represent a convincing argument against the public acknowledgement of the medical advantages provided by mc. political uncertainties regarding mc in india: is it justifiable? in the past decade, particularly in sub-saharan africa, mc has been implemented by the local governments as an additional measure to prevent the ever-growing number of cases of hiv/aids. policies have been used to raise awareness among adult males to undergo the surgical operation for the love of their dear ones and their community and the results of these campaigns have been fairly encouraging. 5 despite this global trend to affirm the medical legitimacy for the establishment, once mailto:mirko.garasic@monash.edu mailto:mgarasic@luiss.it bangladesh journal of bioethics 2013; 4(1):2-8 3 and for all, of mc as an indisputable form of prevention for one of the most affecting illness in nonwestern countries, india remains contrary to a public acknowledgement of the constantly increasing data that supports the carrying out of mc as a valid form of prevention against hiv/aids. in fact, as pointed out by madhivanan and krupp, “the government of india has been reluctant to approach an issue that promises to be controversial among conservative hindus. 6 it has been suggested that at times, circumcision status may even have been used to identify people’s religious affiliation during communal riots. 7 popular wisdom holds that even the mention of mc in some communities will trigger sectarian violence. predictably, some opponents have argued that the greater good of society must be protected by withholding information about mc from the population.” 8 it seems that the hindus -be it for their political presence (hinduism is the most prominent religion in india) or for their strong historical clash with islamare the one group that has raised more problems against the adoption of mc as a preventive tool against hiv 9, 9a . for example kounteya sinha writes: “sometime back, when executive director of geneva-based global fund to fight aids, richard feachem, made a statement in paris that he expected the epidemic to grow faster among hindus because they didn't practise circumcision, he received thousands of hate mails from the hindu community”. 10 this attitude towards the possible implementation of a procedure that could benefit indian citizens‟ health remains deeply controversial and raises many points that need attention. due to a lack of space, in this work i will not be able to cover all of them, but i shall instead focus only on three of them. the first point underlines the moral duty of authorities. they must do anything in their power to avoid the suffering of people and the spreading of the disease. after all, as rightly pointed out by prabhakara in his book professional medical ethics, it should never be forgotten that: “no groups of individuals should be discriminated in the context of hiv/aids.” and also: “all individuals and all communities should have availability of information necessary to make good and necessary decisions about their health including how to avoid hiv infection.” 11 in this light, it would be reasonable to affirm that it is the duty of the authorities (in the specific case indian authorities) to at least acknowledge publicly the preventive value of mc against the spreading of hiv. only once ensured a satisfactory level of awareness among the population, it would be possible to consider the decision of the parents or the single individual to undergo -or notthe mc procedure as a proper informed choice. the second point would focus on the traditional indian non-individualistic perspective in medical ethics. in his article “medical ethics in india: ancient and modern”, francis highlights how according to the vedas (4000 bc to 1000 bc), the call to love your neighbour as yourself is “because thy neighbour is in truth thy very self and what separates you from him is mere illusion.” 12 this acknowledgement should perhaps push us to put aside the centrality of autonomy as used in western context by some authors 13 to justify their prejudice against mc. on the contrary, we might be inclined to give relevance to the common outcome of the implementation of mc: allowing individuals to undergo the surgery would benefit any member of the indian society despite his religious background (be it hindu, muslim, sikh, and buddhist, jewish or of any other faith and belief), significantly cutting down costs and -most importantlyrisks. thus, once accepted the medical value of mc, it could be argued that, in some sense, this precautionary intervention is implicitly encouraged in indian tradition. the third and final point would focus on the contrasting attitude that mothers have towards mc bangladesh journal of bioethics 2013; 4(1):2-8 4 after having been isolated from that very political indoctrination that deprives them from the exposure to the medical benefits of the practice. it is interesting to note that, in a recent study conducted in india, 14 it was shown that, even in a low educated, prevalent non-muslim community, once having received a proper explanation of the practice -including the advantages produced by mc and its correlated stds risk avoidancethe vast majority of mothers (81%) were inclined to make their children undergo the operation. only 1% of the interviewed women were still against mc in a convinced way. these are, quite clearly, neat numbers over the importance of informing the population on the medical impact of mc but, unfortunately, a more in-depth examination of these data goes beyond the scope of this paper. however, i would like to put forward, for what it counts, a parallel interpretation of those numbers through an analysis of why the male community might be more reluctant to accept the practice. there is little doubt that -from a strictly physical point of viewfathers share with their sons the very part of the body subject to the potential operation, and, as a result, it is understandable to see why a father could perceive mc as a way of spacing out himself from his child. after all, the same logic (with the reversed argument) is used by the defenders of mc. in addition to the subjective perception though, males also do not want to feel the social pressure to be the direct cause for change to take place within the community at large. in other words, they do not want to be labeled the weak link of the tradition by allowing their own son to undergo an operation that will make the child somehow more detached from his ancestors -at least in pure physical terms. females on the contrary, do not undergo this psychological challenge, and thus mothers have a more detached and objective view on the medical factors that should indeed be considered for the benefit of the individual child as well as the community as a whole. cultural impediments for mc in india: despite the considerations highlighted above, in the indian context the main critique moved against the implementation of mc as a therapeutic tool capable to avoid the spreading of hiv especially in poorer and less educated contextswould affirm that the problem with this solution is related to its “cultural” threat. 15 the defenders of this position would argue that by applying mc to all the new borns in india, this will end up undermining the cultural identity of the non-muslims (or non-jews) indians. this assertion gives rise to two points worthy of consideration: the first point concerns the fact that -differently from the acknowledgements reported in this workthe focus of mc is strictly related only to the muslim identity. however, this is a strongly distorted (and scientifically inaccurate) way of categorising and defining the practice. i believe that it is so for political reasons that want to prevent the introduction of the practice by focusing on the “prevail of the muslim cause”, initiating in this way a fear in the hindu majority in the country. what could perhaps function as a good viaticum against this fear, could be the parallel acknowledgement of the practice as part of the judaic tradition as well as even if in a very limited wayof christianity. the second point would make us question to what extent is it possible to assert that the implementation of certain features not implicitly prescribed by one culture, can be considered to be a way of affirming a loss of one‟s culture instead of a restructure in accordance to more recent changes. today‟s india represents -with its increasingly important visibility and impact at global levelan example for many. in this age of confusion and tendency to close up against „the others‟ in europe as anywhere else in the worldindia's status of the biggest democracy in the world could well function as a way forward for the hopes of humanity. having the courage to live its multiculturalism to the fullest, india‟s politicians should have the strength to implement a policy on mc that will pass on the message that india is capable of acting in the best interest of all its citizens despite their religious, cultural or ethnical backgrounds. some parallelism with the west: in relation to the “cultural” aspect behind the refusal of a mass-implementation of mc in india, it would probably be interesting to note the different treatment that the practice has had in a culturally different setting. in the specific, i shall briefly describe the historical attitude towards mc in europe, and the contemporary stand that the western world has in relation to it; especially in the framework of rising intolerance towards “the different” that currently governs europe. this parallelism of course shall not function as a form of enlightenment for the indian situation, but rather, it should help us putting this delicate debate in a wider and more global context. bangladesh journal of bioethics 2013; 4(1):2-8 5 in hardcore fortresses of roman catholicism such as italy or spain -places where the persecution of jews (and in a more limited way that of muslims) has had a long history based on religious grounds mc has never been encouraged and, only recently, it became tolerated. with the awareness that ostracism against the different, the other has been a sad but true constant in human history in different times and places, it is reasonable to think that, as in the case of muslims in india, ensuring that the procedure was performed “only” by jewish individuals was a very practical way to quickly recognise the jew from the christian when some discriminatory practice be it expulsion or mockeryhad to take place. the stigmatisation of the jewish traditional mc (brit milah) has -among its numerous representativesjustin of caesarea, a deeply influential figure as a martyr and one of the fathers of the church. in line with a gradual and often intentionaldetachment from judaism that christianity has increasingly undergone after the death of all its [at least] jewish born founding forefathers, in his dialogue with triphone, 16 he attacks the jewish mc by contra posing the physically circumcised people (the jews) with the spiritually circumcised ones (the christians). 17 in a way thus, it could be argued that mc was indeed needed in europe, but only in order to remind christians to be -in the eyes of some of themthe evolution of an updated creed. in line with the intention of not wanting mc to become a popular practice among christians, since the middle ages it gained ground in europe the belief -thanks to the well-fed anti-judaic paranoia supported, fed and spread by the churchthat the jews needed to sacrifice christians regularly in order to (besides other nonsensical arguments still recycled in nowadays‟ versions of anti-semitism) stop haemorrhages caused by the brit milah. 18 this intolerant approach to mc reached its peak when the roman catholic church decided to ban it and make it a mortal sin that would result in “loss of eternal salvation”. 19 however, within western countries where the influence of roman catholicism was not as strong (particularly in the usa and australia), towards the end of the 19th century the practice of mc became increasingly common reaching its peak in the 60‟s. 20 this was due to a number of pseudoscientific beliefs concerning mc that ranged from the imaginative claim that it helped prevent masturbation (a huge taboo in the victorian era) 21 , 21a to the more accurate belief that mc had hygienic value. of course not everyone within the christian-directed western societies was ready to give in to the idea that „dirty‟ people such as the jews or the muslims could be systematically and convincinglybe practising an hygienic ritual. 22 since the 70‟s however, the percentage of mc in australia has dropped significantly, 23 while the drastic increase of the number of circumcised males in europe -due to the wave of muslims immigrantshas opened the door to new forms of discrimination inexplicitly claiming to preserve the “purity” of the european value through a misuse of the notion of rights and autonomy. as a result, in more recent years, mc has gradually come under attack as a mere mythological feature that, in truth, does not rely on any medical evidence to justify its implementation. 24 most notably, the attempted ballot in san francisco aimed at fully outlawing infant mc as well as the temporary dis-allowance for the practice in germany last june, 25 showed how vivid is this trend. despite the lack of credibility of such an accusation, this “pseudo-cultural” battle has managed somehow to undermine the medical evidence of the efficacy of mc as a preventive measure against hiv, contributing most probably to the drastic drop of toleration and practice of mc in western countries. conclusion: to conclude, this paper has drawn a parallel between the east and the west in relation to a millenary procedure such as mc. it did so, with the intention of underlining that, what is common between all those positions intolerant to mc in both india and the west is their need to deal only approximately with the medical evidence that the practice carries with it. on the one hand, indian authorities are sceptical over officially affirming that mc can function as a reliable, medically proven preventive against the spreading of deadly illnesses stds more in general and hiv/aids more specifically for their fear of the cultural impact that such a claim could produce. on the other hand, some of the most fervent attackers of the legitimacy of mc in the western world also (but not as explicitly of course) use a bias “cultural-meter” to affirm that mc is against the rights of children for example although forgetting to apply the same principle of uncompromisingly preserve the physical integrity of the child in widely accepted comparable practices such as earpiercing or vaccination. it seems obvious thus, that these attacks have as their ultimate aim that to de-legitimise the non-christian traditions by redefining “western values” as only and purely bangladesh journal of bioethics 2013; 4(1):2-8 6 ascribable to the christian rituals. this commonality between the two situations, with all their unconvincing justifications for not accepting mc, should lead us to affirm with no hesitation that given the continuously growing medical evidence that shows the direct and indirect advantages produced by having a circumcised male population mc should at least be tolerated if not encouraged. cultural differences cannot be considered as a sufficient justification when the health of the population is at stake, and for this reason it seems sensible to affirm that (even if the spreading of such news could produce some tension) indian authorities should not delay any further the communication of the mc‟s proven benefits to the public. after all, this very delicate issue is related to the health of the whole population and therefore, the resulting discussion over its legitimacy should put forward the medico-ethical point of view of a nation. in order for such an opinion to be democratically expressed, however, the population needs to be given the scientific data. only in this scenario we would be talking about a truly informed choice on the matter. surely the topic is sensitive and some politically related problems might arise from the disclosure of the medical evidence related to mc. however, if some protests might occur as a result of this political decision, the competent political authorities will have to face it and deal with it only as a political problem, because the potential political impact of the revelation of the medical evidence highlighted in this work cannot represent a sufficient reason to refrain from communicating vital information to the indian people, who deserves to know all the available data to then be able to truly make a free and competent choice with their lives. thus, the indian government may inform the public of benefits of mc and give the public an option for it. references: 1. who and joint un program on hiv/aids. male circumcision: global trends and determinants of prevalence, safety and responsibility. (december 2007) report. available at: http://whqlibdoc.who.int/publications/2007/978924156169 eng.pdf 2. chandhiok n and gangakhedkarb r. the new evidence on male circumcision: an indian perspective, reproductive health matters 2007, 15& 29: 53. 3. dandona l, dandona r, kumar ga, brahmananda gr, abdul am, mushtaq ga, ramgopal sp, akbar m, sudha t and lakshmi v. risk factors associated with hiv in a population-based study in andhra pradesh state of india. international journal of epidemiology 2008, 1-13. 4. circumcision: it suits hindus also, available at: http://articles.timesofindia.indiatimes.com/2005-08-04/india/27843351_1_circumcised-men-hivrates-richard-feachem 5. gray rh, kigozi g, serwadda d, et al. male circumcision for hiv prevention in men in rakai, uganda: a randomized trial. the lancet 2007, 369: 657-666. 6. it is important to point out that, even if in a less harsh and direct way until now, sikhism has an even higher potential of resistance towards mc on religious ground. in fact, while hindu’s sacred tests do not explicitly ban the practice of mc, in the guru granth sahib, an explicit restriction against it is written. available at: http://www.srigranth.org/servlet/gurbani.gurbaniaction=page&param=477&english=t&id=21608# l21608. in particular p.140 and p.477. 7. chandhiok n and gangakhedkarb r, op. cit. http://whqlibdoc.who.int/publications/2007/978924156169%20eng.pdf http://articles.timesofindia.indiatimes.com/2005-08-04/india/27843351_1_circumcised-men-hiv-rates-richard-feachem http://articles.timesofindia.indiatimes.com/2005-08-04/india/27843351_1_circumcised-men-hiv-rates-richard-feachem http://www.srigranth.org/servlet/gurbani.gurbaniaction=page&param=477&english=t&id=21608#l21608 http://www.srigranth.org/servlet/gurbani.gurbaniaction=page&param=477&english=t&id=21608#l21608 bangladesh journal of bioethics 2013; 4(1):2-8 7 8. madhivanan p and krupp k. doesn’t the public have the right to know that male circumcision protects against hiv? indian journal of medical ethics 2009, 6(1):5. 9. moses s, bailey rc and ronald ar. male circumcision: assessment of health benefits and risks. sex transm infect 1998, 74: 368-373. 9a. castellsagué x, xavier bosch f, muñoz n, meijer cjlm, shah ks, silvia de sanjosé s, elufneto j, ngelangel ca, chichareon s, smith js, herrero r, moreno v and franceschi s. male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. n engl j med, 346(15): 1105-1112. 10. see for example: circumcision can control aids, but is india ready?, available at: http://timesofindia.indiatimes.com/news/india/circumcision_can_control_aids_but_is_india_re ady/articleshow/msid-1670374,curpg-1.cms 11. prabhakara gn. professional medical ethics. paras medical publications 2006, 195. 12. francis cm. medical ethics in india: ancient and modern. indian journal of medical ethics, selected readings 1993-2003, november 2005, p.17. 13. hellsten sk. rationalising circumcision: from tradition to fashion, from public health to individual freedom. j med ethics 2004, 30:248-253. 14. madhivanana p, krupp k, chandrasekaranb v, karatc sc, reingolda al and klausner jd. acceptability of male circumcision among mothers with male children in mysore, india. aids 2008, 22: 983-988. 15. see note 2 above. 16. justin martyr, dialogue with trypho. in particular, chapters 16 and 19. available at: http://www.ccel.org/ccel/schaff/anf01.toc.html 17. i will not be able to analyse this aspect further here, but it is interesting to note the escamotage that justin found in order to preserve a continuity with the past of christianity -judaismand yet be able to detach itself from it in the most productive way in terms of guaranteeing a neat separation: by accusing the rest of not being following god’s will anymore. for more information on the subject see among others: livesey ne, theological identity making: justin’s use of circumcision to create jews and christians, journal of early christian studies 2010, 18(1):51-79. 18. böner k (ed.) ausserlesene bedenken der theologischen facultät zu leipzig, leipzig, 1751. i have used the italian version: parere della facoltà teologica di lipsia dell’8 maggio 1714, l’eco dei tribunali: xiii supplemento al rovigo, 1856, n. 461, p.53. 19. ecumenical council of florence (1438-1445) available at: http://www.ewtn.com/library/councils/florence.htm#5. “therefore it strictly orders all who glory in the name of christian, not to practise circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation.” 20. king pa, caddy gm, cohen sh, et al. circumcision-maternal attributes. pediatr surg int1989, 4:222-226. 21. hodges fm. the history of phimosis from antiquity to the present. in: denniston gc, hodges fm, milo mf, eds. male and female circumcision: medical, legal and ethical considerations in pediatric practice. new york: kluwer academic, 1999, p.37-49. http://timesofindia.indiatimes.com/news/india/circumcision_can_control_aids_but_is_india_ready/articleshow/msid-1670374,curpg-1.cms http://timesofindia.indiatimes.com/news/india/circumcision_can_control_aids_but_is_india_ready/articleshow/msid-1670374,curpg-1.cms http://www.ccel.org/ccel/schaff/anf01.toc.html bangladesh journal of bioethics 2013; 4(1):2-8 8 21a. miller gp. circumcision: cultural-legal analysis, virginia journal of social policy and the law, 9, 2002, p.497-585. 22. among the supporters of such a view there was herbert spencer who, in relation to the hygiene argument wrote that: “while the usage does not prevail among the most cleanly races in the world, it is common among the most uncleanly races.” principles of sociology, 1, westport, connecticut, greenwood press, 1975, p.67. 23. hutson jm. circumcision: a surgeon’s perspective. j med ethics 2004, 30: 238. 24. delaet dl. framing male circumcision as a human rights issue? contributions to the debate over the universality of human rights. journal of human rights 2009, 8: 405-426. 25. germany to introduce circumcision law, http://www.guardian.co.uk/world/2012/oct/05/germany-introduce-circumcison-law http://www.guardian.co.uk/world/2012/oct/05/germany-introduce-circumcison-law microsoft word knowledge attitude bangladesh journal of bioethics 2015; 6(3):1-9 1 original article knowledge, attitude and practice of medical ethics among medical intern students in a medical college in kathmandu ramesh p aacharya1, yagya l shakya2 department of emergency and general practice tribhuvan university teaching hospital institute of medicine, maharajgunj kathmandu, nepal email: raacharya@yahoo.com abstract: this baseline study was conducted to find out the knowledge, attitudes and practices of medical ethics among the undergraduate medical interns who did not have structured ethics curriculum in their course. a descriptive, cross-sectional study was carried out using a selfadministered structured questionnaire among the medical undergraduate interns of maharajgunj medical campus, the pioneer medical college of nepal which enrols 60 students in a year. a total of 46 interns participated in the study. the most common source of knowledge on ethics was lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own reading (17.3%). the main contents of hippocratic oath were known to 98.8% while 60.9% knew the main contents of nepal medical council (nmc) code of ethics. great majority (91.3%) regard ethics as very important in medical profession. “doctors know the best irrespective of patients’ opinion” was disagreed by only 39.1% indicating the paternalistic attitude. however, 78.3% were in favour of adhering to the patient’s wish. none of the participant agreed to abandon confidentiality. only about one-fourth (26.1%) claim to encounter ethical dilemma every day while the highest number (43.5%) had once in a month. to deal with the situation of ethical dilemma, majority approached to immediate supervisor followed by head of the department and colleagues. eighty-seven percent of participating interns were involved in research activities involving human subjects. only one of the participants had encountered the ethical issue on endof-life and it was do-not-resuscitate consent in a terminally ill patient. on implementation of the curriculum on medical ethics focus should be principles of biomedical ethics, sensitive ethical dilemmas like end-of-life care and practical experiences with participation in deliberations of the ethics committee. keywords: biomedical ethics, ethical dilemma, medical education, interns doctors. bangladesh journal of bioethics 2015; 6(3):1-9 2 background: medical council regulations on undergraduate medical courses include practice the principles of medical ethics as one of the core competencies1 and is an important component of medical education. regional meetings of medical councils coordinated by world health organization (who) south east asia regional office (searo) has realised the need to incorporate medical ethics in undergraduate medical education2. students need to develop a rational approach to solve ethical dilemmas that they will face in daily responsibilities of caring the patients. tribhuvan university (tu), institute of medicine has incorporated the medical ethics in the latest version of undergraduate medical curriculum3 and its implementation is in the process. however, the medical interns enrolled in this study were from the previous curriculum and did not undergo structured curriculum on ethics. there have been many reports stressing the importance of incorporating ethical and legal issues in medical curricula4 .medical students are taught various subjects to tackle medical problems; they also need ethics to solve the moral quandaries that they are likely to face in their practice in the future.5 medical ethics are integral to all clinical encounters and public health interventions, and a foundation in medical ethics is essential for students to become virtuous doctors6. studies in other south asian countries have realised the need of medical ethics to be part of the undergraduate medical curriculum7-8. doctors are expected to have ingrained attitude and practice of ethics. a study in neighbouring indian state of manipur revealed the need to sensitise the doctors on medical ethics9. in the developed world, ethical discussions centre on 'micro ethics' like cloning and euthanasia but underdeveloped countries are lagging to deal with the basic questions of ethical professional practice10. however, the ethical issues of all nature do exist in our society as well. science and technology has to be used to protect rather than endanger human dignity, health, wellbeing and diversity. incorporating bioethics in medical curriculum contributes to ensure the appropriate use of science and technology in this direction11. studies have revealed that most of the knowledge of biomedical ethics is acquired during the undergraduate training12. ethics teaching has been shown to have a profound influence on medical professionals' attitudes10,13. it should be a part of ongoing medical education including residency1214. effective medical ethics education enhances the goals of medicine in tangible ways15. it is important to identify deficiencies of students and/or professionals on ethical issues and arrange sensitization and at times, appropriate training16-17. however, implementation of medical ethics curriculum remains ambiguous18. methods: a cross sectional study was carried out using a self-administered structured questionnaire about knowledge, attitude and practice of healthcare ethics among the medical undergraduate interns of maharajgunj medical campus (mmc) – the first medical college of nepal enrolling 60 students per year. recently, the number of enrolment has been increased to 75 students per year. the knowledge was assessed on training in medical ethics, existing professional code of conduct and ethical guidelines. attitude of medical intern students was compiled in terms of informed consent, confidentiality and paternalism. the statements to assess the attitude were optioned in 5 point likert scale – strongly disagree, disagree, not sure, strongly agree and agree. similarly, the practice was evaluated with their involvement in informed consent process and encountering ethical dilemmas in medical practice. the questionnaire was pilot tested in 5 interns and necessary revisions were made. bangladesh journal of bioethics 2015; 6(3):1-9 3 before the commencement of the study, ethical approval was taken from the institutional review board (irb) of tu, institute of medicine. results: questionnaires were distributed to 55 medical undergraduate interns and out of them 46 (84.6% response rate) returned the filled questionnaires. among the total participants of this study, almost three-fourth (73.9%) had completed 11 months of their internship. i. knowledge a. regarding the source of knowledge of medical ethics, naturally there were more than one sources for three-fourth (73.9%) of the participants. the most common source was lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own reading (17.3%). one participant mentioned youtube video as a source of knowledge of medical ethics. only one participant had attended formal training on ethics. b. codes and guidelines: the ‘yes’ answer to a question – would you say ‘you know the main contents of’ was as follows: i. hippocratic oath 98.8% ii. nepal medical council (nmc) code of ethics 60.9% iii. nepal health research council (nhrc) ethical guidelines 4.3% none of the participants knew the main contents of nuremberg code and helsinki declarations. ii. attitude : a. importance of ethics – regarding the importance of ethics in their work, great majority (91.3%) mentioned as very important. the statement that ‘ethical conduct is only important to avoid legal action’ was disagreed by 87% while 8.7% were ‘not sure’. b. autonomy i. a statement on autonomy ‘consent required only in case of operations and not for tests and medications’ was strongly disagreed by 26.1% and disagreed by 52.2% (fig-i). similarly, when asked about the stand on dealing with patients who refuse blood transfusion or operation or treatment; 82.6% were in favour of respecting patient decision while the remaining 17.4% mentioned to find another doctor with their belief. none of the participants were in favour of attempting the procedure forcefully. ii. paternalism – three different statements were used to assess the paternalistic attitude (table-1). c. justice – regarding resource mobilization, the statement ‘certain medical practitioners charge more from financially sound patients in order to raise money for treating poor patients’, was agreed by about one-fourth (26.1%). a substantial number of participants (30.4%) were in dilemma and answered as ‘not sure’, while 43.4% disagreed with this statement. d. confidentiality–‘confidentiality cannot be kept in modern era and should be abandoned’ was strongly disagreed by 34.8% and disagreed by 60.9%. the remaining 4.3% were ‘not sure’. none of the participant agreed with this statement. bangladesh journal of bioethics 2015; 6(3):1-9 4 table 1 – paternalism (n = 46) statement strongly disagree disagree not sure agree strongly agree ‘doctors know the best irrespective of patients’ opinion 2 (4.3%) 16 (34.8%) 10 (21.7%) 16 (34.8%) 2 (4.3%) ‘patient should always be informed of wrong doing’ 0 (0.0%) 8 (17.4%) 10 (21.7%) 18 (39.1%) 10 (21.7%) ‘patient wishes should be always adhered’ 2 (4.3%) 8 (17.4%) 0 (0.0%) 32 (69.6%) 4 (8.7%) iii. practice : a. frequency of ethical dilemma – coming across ethical dilemma once in a month was the highest (43.5%), followed by 26.1% claimed to encounter every day (fig-ii). 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% strongly disagree diaagree not sure agree strongly agree p e rc e n ta g e attitude on consent in healthcare services figure iconsent is required only in case of operations and not for tests and medications daily 26% weekly 19.6 monthly 43.5 yearly 9% never 2% figure ii frequency (in %) of encountering with ethical dilemma bangladesh journal of bioethics 2015; 6(3):1-9 5 to deal with the situation, majority claimed to approach immediate supervisor followed by head of the department and colleagues (fig-iii). b. research ethics – big majority (87.0%) of participating interns claimed to be involved in research activities involving human subjects. in this process, 82.6% were involved in taking informed consent – written 47.8% and verbal 34.8%. a small number (6.5%) did not realise the participant’s right to withdraw from the study as a part of informed consent. c. ethical issue on end-of-life – only one of the participants had encountered the ethical issue on end-of-life and it was do-not-resuscitate consent in a terminally ill patient. discussions: regarding the source of knowledge of medical ethics, the most common source was lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own reading (17.3%). b shiraz et al reported similar findings in a study among surgical residents and interns in pakistan7. another study among medical students in india revealed lecture to be the most common (54.7%) source19. ethical codes and guidelines are the basis for acquiring knowledge on the subject. in this study, almost all (98.8%) claimed to know the main contents of’ hippocratic oath. however, only 60.9% were acquainted with the code of ethics for medical practitioners published by the nepal medical council (nmc). in karachi, about half of the surgical residents and interns had heard about the code of ethics formulated by the pakistan medical and dental council7. regarding the importance of ethics in their work, great majority (91.3%) mentioned as very important. in a study from barbados, all physicians and 90% of nursing staff responded that knowledge of ethics is important to their work16. the statement that ‘ethical conduct is only important to avoid legal action’ was disagreed by 87% while 8.7% were ‘not sure’. this was different than the study done on medical students done in india where 37.8% had rather agreed and 18.3% were uncertain19. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% colleague supervisor head of department hospital administrator ethics committee professional association internet find solution by yourself percentage a p p ro a ch f o r e th ic a l p ro b le m figure iii whom do you approach for ethical problem? bangladesh journal of bioethics 2015; 6(3):1-9 6 a statement on autonomy ‘consent required only in case of operations and not for tests and medications’ was disagreed by 78.3% (strongly disagreed by 26.1% and disagreed by 52.2%). thus, about one-fifth (21.7%) of the interns either do not feel the need of consent for tests and medications or not sure about the issue. in studies from barbados, 91% of medical students and 72% of physicians disagreed16-17. sensitivity to cultural diversity need to be reinforced continually starting from the medical student life and continue throughout the professional careers.20 in this study, when asked about the stand on dealing with patients who refuse blood transfusion or operation or treatment; 82.6% were in favour of respecting patient decision while the remaining 17.4% mentioned to find another doctor with their belief. none of the participants were in favour of attempting the procedure forcefully. the ethical and medicolegal reasoning regarding consent to and/or refusal of treatment is based on the principle of autonomy.21 autonomy can be ensured only when the individual comprehends the procedure and the consequences and thus, it is informed consent or informed refusal. the hippocratic physician respected a principle of professional responsibility and by tradition, the duty of the patient was to accept the physician's decisions and intervention22. beauchamp and childress define paternalism as “the intentional overriding of one person’s known preferences or actions by another, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden” 23. paternalistic attitude prevailed in the participants as majority (60.8%) of them either disagreed (39.1%) or were not sure (21.7%) about the statement “doctors know the best irrespective of patients’ opinion”. this may be due to the focus on learning abundant clinical information rather than the ethics. on the other hand, the statement that ‘patient wishes should be always adhered’ was agreed by 78.3% revealing the important understanding of autonomy. such contradiction was observed in indian study as well19. anyone not adhering to the patient's wishes indicate the lack of knowledge of the basic principles of medical ethics16. ‘patient should always be informed of wrong doing’ was agreed by 60.8% in this study. studies have shown up to 74.5% of medical students and 79% nurses agree with this statement16-17. in relation to mistakes and/or negligence, the explanation for the excessive deference towards health care professionals was the presumption of beneficence to their patients but the medical fraternity should be more open to scrutiny with regards to their decision making24. regarding resource mobilization, the statement ‘certain medical practitioners charge more from financially sound patients in order to raise money for treating poor patients’, was agreed by about one-fourth (26.1%). a substantial number of participants (30.4%) were in dilemma and answered as ‘not sure’, while 43.4% disagreed with this statement. of course, the issue of justice is not straight forward and probably, because of this, the opinion is fairly distributed throughout the scale. it is important to elucidate the moral dimension of distribution choices through balanced argumentation to come to a decision of healthcare package25. none of the participant agreed with this statement ‘confidentiality cannot be kept in modern era and should be abandoned’. it was disagreed by 95.7% strongly disagreed by 34.8% and disagreed by 60.9%. the remaining 4.3% were ‘not sure’ about the issue. similar studies have revealed the disagreement ranging from 82% to 89%16-17. though electronic medical records pose new bangladesh journal of bioethics 2015; 6(3):1-9 7 obstacles to maintain confidentiality, physicians have a professional ethical obligation to protect patients’ health information and it cannot be abdicated26. at times the perception of physician may be inconsistent with the patient’s perceptions of how his/her medical information should be treated27. coming across ethical dilemma once in a month was the highest (43.5%), followed by 26.1% claimed to encounter every day. to deal with the situation, majority claimed to approach immediate supervisor followed by head of the department and colleagues. similar findings have been reported in other studies majority of physicians and medical students reporting to the immediate supervisor16-17 .regarding ethical issue on end-of-life, only one of the participants had encountered the ethical issue on end-of-life and it was do-not-resuscitate consent in a terminally ill patient. big majority (87.0%) of participating interns claimed to be involved in research activities involving human subjects but only 4.3% knew the main contents of nepal health research council (nhrc) ethical guidelines. in the research activities, 82.6% were involved in taking informed consent – written 47.8% and verbal 34.8%. a small number (6.5%) did not realise the participant’s right to withdraw from the study as a part of informed consent. a signed consent document does not necessarily mean an informed consent and rather it is a process of giving the participant understandable information about the study, providing ample opportunity for the participant to consider all options and alternatives to taking part in the study, ensuring that the participant comprehends the information he or she is given, obtaining the participant’s voluntary agreement to take part, and continuing to provide additional pertinent information during and after study completion28. none of the participants of this study knew the main contents of nuremberg code and helsinki declarations. this is one of the important areas in biomedical ethics which needs priority in medical education. limitations: the sample size of this study was limited due to the number of students in the college. it may not represent the national scenario. all the principles of biomedical ethics have not been explored to the same extent. as the sample size was small, no comparisons were planned between the groups and statistical tests were not used. conclusions: this baseline study among the medical graduates of the institute serves a basis to identify the areas requiring focus on implementation of the curriculum on medical ethics. paternalism was evident in the attitude that doctors know the best irrespective of patients’ opinion. however, it was better regarding the informing wrong doing and adhering to patient wishes. the principles of biomedical ethics and sensitive ethical dilemmas like end-of-life care deserve attention including deliberation activities of the ethics committees. the results of the study are expected to assist the faculties for upgrading the quality of teaching medical ethics and guiding them for professional conduct. conflict of interests: none. authors' contributions: rpa conceptualized, designed the study and drafted the manuscript. yls coordinated data collection and revised the manuscript. both authors reviewed and approved the final manuscript. bangladesh journal of bioethics 2015; 6(3):1-9 8 acknowledgements: the authors are grateful to dr. shankar raj lamichhane of 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feb;80(2):106-13. 13. sulmasy dp, geller g, levine dm, faden rr. a randomized trial of ethics education for medical house officers. j med ethics. 1993; 19:157-63. 14. mckneally mf, singer pa. bioethics for clinicians: 25. teaching bioethics in the clinical setting. cmaj: 2001; 164(8): 1163-7. 15. eckles re, meslin em, gaffney m, helft pr. medical ethics education: where are we? where should we be going? a review. acad med. 2005 dec; 80(12):1143-52. 16. hariharan s, jonnalagadda r, walrond e, moseley h. knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in barbados. bmc med ethics. 2006 jun 9; 7:e7. 17. walrond er, jonnalagadda r, hariharan s, moseley hs. knowledge, attitudes and practice of medical students at the cave hill campus in relation to ethics and law in healthcare. west indian med j. 2006 jan; 55(1):42-7. bangladesh journal of bioethics 2015; 6(3):1-9 9 18. rhodes r, cohen ds. understanding, being, and doing: medical ethics in medical education. camb q healthc ethics. 2003 winter; 12(1):39-53. 19. chatterjee b, sarkar j. awareness of medical ethics among undergraduates in a west bengal medical college. indian j med ethics. 2012 apr-jun; 9(2):93-100. 20. ramesh k. start sensitising medical students. indian j med ethics 2007; 4(2):64. 21. migden dr, braen gr. the jehovah's witness blood refusal card: ethical and medicolegal considerations for emergency physicians. acad emerg med. 1998 aug;5(8):815-24. 22. mallardi v. the origin of informed consent. acta otorhinolaryngol ital. 2005 oct; 25(5):31227. 23. beauchamp tl, childress jf. principles of biomedical ethics. 6th edition, new york: oxford university press. 2009. 24. hartwell m. medical negligence: can doctors and nurses still rely on the doctrine that they know best? leg med. 2005 oct;7(5):293-8. 25. leget c, hoedemaekers r. teaching medical students about fair distribution of healthcare resources. j med ethics. 2007 dec; 33(12):737-41. 26. black l, anderson ee. physicians, patients and confidentiality: the role of physicians in electronic health records. am j bioeth. 2007 mar; 7(3):50-1. 27. petronio s, dicorcia mj, duggan a. navigating ethics of physician-patient confidentiality: a communication privacy management analysis. perm j. 2012 fall; 16(4):41-5. 28. raich pc, plomer kd, coyne ca. literacy, comprehension, and informed consent in clinical research. cancer invest. 2001; 19(4):437-45. microsoft word pdf 5 20 bangladesh journal of bioethics 2010; 1(2):20-23 animal research in diabetes and ethical consideration shamima parvin lasker1 rishad raihan 2 1. professor & head, department of anatomy, city dental college, dhaka, 2. business information technology, kuala lampur, malaysia abstract: research must have a clear statement that is the hypothesis. this hypothesis may involve a clinical question or pathophysiologic mechanism that cannot be tested ethically or appropriately using human subjects or alternative methods. therefore, numerous animal models have been developed that mimic to human diabetes. they provide additional knowledge about and insight into disease processes and hopefully better methods for treatment or prevention of diabetes in humans. all scientific research involving the use of animals should begin with an ethical focus by examining the risk-benefit ratio (i.e., morbidity or mortality to the animal versus the potential importance of the knowledge acquired). the aim of this paper is to discuss these ethical aspects within the context of research on diabetes and form a framework for the decision-making process. key words: animal research, diabetes and ethics introduction: diabetes researches have a hypothesis. this hypothesis may involve a clinical question or pathophysiological mechanism that cannot be tested ethically or appropriately using human subjects or alternative methods 1. therefore, animals have been routinely used in the field of diabetic research 2. numerous animal models have been developed that mimic to human disease states. one must assess an animal model on the basis of species appropriateness. the risk to the animal must then be minimized to obtain the best model to test the hypothesis 1. it is legal and moral obligation of investigator who uses animals to ensure the minimization of pain and suffering of experimental subjects. different type of diabetic model: diabetes can be induced by surgical, pharmacological or genetic engineering means 1. the surgical model of type i diabetes is done by total pancreatectomy, and the large animals (dog, canine, horse etc) usually is the choice of this model. this model was used by banting and best in 1920 in their studies for understanding the mechanism of diabetes leading to the discovery of insulin 3, 4. total pancreatectomy is technically easiest in this species for its large size ( 5 ). but now a day this model for diabetes research is avoided because of 1) it requires major surgery, adequate postoperative analgesia, and good postoperative care with administration of antibiotics 2) the animal has little counter regulatory response to hypoglycemia and 3) chronic insulin supplementation is required 1. in pharmacological means diabetes may be induced via a number of drugs eg streptozotocin and alloxan that selectively destroy pancreatic β cells only 6. this type of diabetes has been performed usually in small animal (e.g. cats, rabbits, guinipig and mice). the advantages of this model are 1) the use of these chemical agents leaves the remainder of pancreatic function intact; 2) smaller animal models that have high rates of reproduction might be helpful in studies on genetics and the environment effect of diabetes and 3) smaller animal models are more economic. but the disadvantages of this model is that the drugs used can be toxic to other organ systems and the response to the drugs can be variable 1. spontaneous models of diabetes, e.g. the bb (bio breeding) rat and the nod (non obese diabetes) mouse. destruction of β cells is done in the 1sr month of age of animal and inbred in laboratories for many generations by selective mating for diabetes 7. major distinguishing features of this type of diabetic prone animals are good for genetically transmitted diseases study. the diabetic syndrome in this type of animals is highly reproducible (>50 percent incidence) and closely resembles insulin-dependent, ketosis-prone type i diabetes mellitus in humans. this model has been useful for studying immunologic mechanisms of diabetes and developing cyclosporin therapy for use in type i diabetes in humans 8. in addition, this type of model are prone to long-term complications of diabetes eg the nephropathy , retinopathy cardiovascular complications bangladesh journal of bioethics 2010; 1(2):20-23 21 and neuropathy, and that are very similar to complications in human diabetics 9. in generic engineering technique, a single gene that is responsible for insulin production is disrupted in embryonic stem cell and then transmitted along the germ cell line and develop to grow. selective breeding will allow producing knockout animals 2. transgenic diabetic animal refer to incorporation of modify gene (insulin gene) in to the pronucleus of zygote and offspring will therefore over express the modify gene that play a key role to develop diabetes 2. advantage of these models are 1) a large number of diabetic animals can be produced to gain insight into the pathogenesis of diabetes, 2) it is the best choice for the follow up study to see the complications to other organs. use of appropriate animal model: several animal models of diabetes are currently available. it must be determined what particular animal model will provide new insight into the problem studied. therefore, one must assess an animal model on the basis of species appropriateness 10. the risk to the animal must then be minimized to obtain the best model to test the hypothesis. one must evaluate the appropriate use of these models to answer the hypothesis based on original contention that are clinically relevance. against animal research: some people regard animal experiment as an unjustified means of pursuing knowledge about human diabetes 2. it is morally unjustifiable for mankind to make animals as subject for experiment that cause them discomfort as animal is enable to provide inform consent 11,12. moreover, no model of diabetes can accurately and completely reproducible the human syndrome 9. some argue that animals should not be used in experiments for provision of a substantial contribution to human welfare as most of cases researchers do not get expected result. it is obvious that biomedical research in which animals are used does not always provide an immediate benefit to humans 13. this is often impossible to predict when animal models will develop the human disease 14. in uk, as a result of public concern (regarding vivisection on unanaesthatic animal, research by entrain investigator), animal research is controlled by animal scientific procedure act 1986, passed by parliament. according to this regulation any experiment or other scientific procedure causing animal pain, distress, suffering or lasting harm are illegal unless covered by appropriate licences. therefore, individual researcher must hold a personal licence (pilis granted after appropriate training of specific procedure on animal). pil can only be used in conjunction with project licence ( pplit authorized specific work for specific purpose must indicate in details in protocol for each regulated procedure)15. furthermore, some diabetes charities that rely heavily on public donations may come under pressure not to fund animal research. some donors seek reassurance that their money will not be used for animal research 16. animal welfare committee (awc) has already been introduced in many nations in europe 17. india adopted cpcsea (committee for the purpose of control and supervision of experiment on animal) by parliament in 2004 18. bangladesh perspective: recently, an animal experimental ethical review committee (aeerc) is established by the dhaka university in bangladesh. guidelines for animal study have been formulated in 2005. but it is not functioning in full swing. international centre for diarrhoeal disease and rehabilitation bangladesh (icddrb) has institutional animal care committee. bangladesh medical research council (bmrc) over see the ethical issue on human as well as animal. researchers seek the ethical clearance for the protocol funded by foreign or large fund by government only from these regulatory in bangladesh 19. rs for protection of animal to reduce cruelty to animal research, 3-rs (reduction, refinement and replacement) are widely accepted, proposed by russell and burch in 1959 20. india adopted 4-rs (reduction, refinement replacement and rehabilitation) (18).hans martin sass, a german philosopher, proposed 7-rs (reduction, refinement, replacement, rehabilitation, respect, review and relate)21 to protection animals from researchers. bangladesh journal of bioethics 2010; 1(2):20-23 22 the investigator who uses animals has both a legal and moral obligation to ensure the minimization of pain and suffering of experimental subjects. care should be taken to avoid duplicate research on animal. strenuous efforts should be made to reduce the number of animals required for any particular study 2. previously pyrogen testing on animal is now replaced by computer simulation. like the pyrogen testing computer model of diabetes should be invented 2, 22. researcher should rehabilitate the survival animal from diabetes experiment. chronic animal studies should be designed for maximum efficiency to obtain the highest possible rate of success and the maximum amount of information from each experimental subject. the effects of stress on the animal causes increase heart rate that causes the animal discomfort. the animal must be little or fully unconscious at any time during the surgical/medical procedure to reduce stress. if the animal is allowed to remain diabetic for a protracted period, the end-organ disease may occur; how far it is necessary to allow the disease to progress is the concern. in no way, the animal should keep on starvation more than 48 hours for examining fasting glucose or induction of drug. dose of anesthesia should be calculated according to body weight of animal before injection. euthanasia should be done by over dose of anesthesia rather then decapitate or hit on the head of the animal. investigators must closely monitor the animals and treat their metabolic disease as is appropriate to the research goals of the protocol. new investigators in this field should seek advice and counsel from experienced researchers. the experimental methods are continually refined and improved. there is no doubt that the development of animal models of diabetes conclusion: has improved treatment and provided a better understanding of this disease. hypothesis should be tested according to appropriate use of model for the animal walefare. ethical issues must be addressed before the project begins and adhered to throughout the project to ensure the values of rs for protection of animal in diabetes experiment. reference: 1. frederick es and richard j t 1993. ethical issues involved in the development of animal models for type i diabetes. ilar journal; 35 (1): http://delsold.nas.edu/ilar_n/ilarjournal/35_1/35_1ethical.shtml 2. rees da and alcolado cj 2004. animal models of diabetes mellitus. diabet med;22: 359-370. 3. s.p. lasker, c.s. mclachlan, l. wang, s.m.k. ali, h.f. jelinek. 2010 journal of diabetolog; 1(1):1-8 4. bliss m. the discovery of insulin. chicago: university of chicago press, 2000. 5. sarr, m. 1988. pancreas. in experimental surgery and physiology: induced animal models of human disease. m.m. swindle and r. j. adams, eds. baltimore, md.: williams & wilkins. pp. 204-21 6. lenzen s, patter u. alloxan ; history and mechanism odf acrion.diabetologia1988;31:337-342. 7. artkinson m , leiter eh1999. the nof mouse model of insuline dependent diabetes: as good as it ge5ts? nat med; 5:601-604. 8. stiller, c. r., j. dupre, m. gent, m. r. jenner, p. a. keown, a. laupacis, r. martell, n. w. rodger, b. von graffenried, and b. m. j. wolfe. 1984. effects of cyclosporine immunosuppression in insulin-dependent diabetes mellitus of recent onset. science 223:1362-1367. 9. marliss, e. b., a. f. nakhooda, p. poussier, and a. a. sima. 1982. the diabetic syndrome of the "bb" wistar rat: possible relevance to type i (insulin-dependent) diabetes in man. diabetologia 22:225-232. 10. held, j. r.. 1983. appropriate animal models. ann. n.y. acad. sci. 406:13-19. 11. british union for the abolition of vivisention. http://www.buav.org 12. petterson c, eternal treblinka. out treatment of animals and the holocaust, new york: lantern books, 2002. 13. hoff, c. 1980. immoral and moral uses of animals. n. engl. j. med. 302:115-118. bangladesh journal of bioethics 2010; 1(2):20-23 23 14. drs. ray and jean greek 2009. animals in scientific research: medical research diabetes http://www.navs.org/site/pageserver?pagename=ain_sci_medicalresearch_diabetes, seen in june 2009 15. guidance of operation of the animals (scientific procedures) act 1986: the stationary office 2000. 16. diabetes uk animal research.position staterment from diabetes uk.2002. http;//www.diabetes.org.uk.infocentre/state/animals.html 17. european federation of pharmaceutical industries and association 1999. policy statement on the use of aniumal in research and development. efpia, 1999. 18. pereira s, tettamanti m 2005. ahisma and alternatives – the concepts of the 4th r; the cpcsea in india. altex 22:3-6 19. lasker sp , hossain a 2009. review of bioethics education in bangladesh. proceedings of 1st unesco ethics workshop, dhaka. 20. russell wms, burch rl 1959. the principal of humane experimentation technique. london 21. hans-martin sass 2008 animal in research: 7-r principals and corporate responsibility .ejaib vol 18(3):74-75 22. petea (people for the ethical treatment of animals) 2010. http://www.freshnews.in/why-peta-isagainst-more-usual-diabetes-research-18285 bangladesh journal of bioethics 2015; 6(2):1-7 1 medical ethics and medical professionalism in low and middle income (lamic) countries: challenges and implications. albert m. e. coleman, md, mph, msc. centre of bioethics, medical law and patient advocacy. sekondi, ghana (w. africa) email: albert.coleman@gmail.com. abstract: this article examines the (bio) ethical and professionalism issues that may arise in the context of medical practice in low and middle income countries (lamic), and the challenges this poses for medical regulatory bodies in the regions, in upholding ethics in professional practice. a quadrangle of source of the problems given rise to the breach of ethics in medical practice is identified, and suggested steps, based on ethical principles and concept, is proposed towards the resolution of the problems presented. as lamic progress to improve the health of its population, this endeavour should occur hand in hand with contemporary medical ethics theories, taking in context the region’s ethnographic and cultural beliefs and practices. key words. physicians, low and middle income countries, medical (bio) ethics, professionalism. introduction: the core of medical practice is the doctor-patient interaction and relationship. this can take the form of a clinic one to one encounter, or between the doctor/medical team, and the community. for the individual patient or the population that relationship plays a big part in the management of his/ her or their illness, as well as when issues of patient satisfaction is explored. the issue of doctor-patient relationship is not that straight forward, as several factors influence the balance of forces at play in that relationship. in this complex inter-play of doctor-patient relationship, the factors that influence the relationship, and the issue of the balance of force, or otherwise put the power balance at any point in the relationship; brings up the vital role of (bio) ethics and professionalism in medical practice. several breaches immediately crop up when one then considers the quadrangle of factors [doctors, patients, (bio) ethics and professionalism], especially in lamic. these breaches reported on in the public domain include doctors using the professional encounters to strike up inappropriate liaisons with their patients 1 , doctors coercing patients to cough up extra sums of monies to access or obtain treatment, in otherwise non-fee public hospitals 2,,3 , in some instances doctor’s with-holding treatment as their asking price could not be met by public sector patients. doctors given out sick certificates to otherwise well persons in exchange for money 4 , doctors accepting bribes from patients in exchange for rendering care to patients 5 . doctors engaging in clandestine organ trade and organ harvesting 6 or doctors conniving with pharmaceutical companies to cheat state health systems, or encourage trading in counterfeit medications 2 . the list and prevalence of breaches is long, and covers acts of commission or omission among doctors from lamic, (as well as in a few countries with developed economies) 2 . several factors come to mind as contributing to such a situation, among which is lack of stringent professional governance, reluctance of professionals to blow the whistle on those brazenly bringing the profession into disrepute, and probably institutional denial. none the less, real life tells us that all over the world it is not the attributes of the majority who play by the rules that matter, --(after all medical professionals are expected to play by the rules)! it is the mischief of the minority who do not work or play by the rules that make the notorious headlines, and hence bring the profession into disrepute. in the case of sub-saharan countries, an article describes these unethical professional behaviour in the specific country as “live hood strategies”, in response to the effects of economic mismanagement, poverty and bad governance 7 ; or in other countries, survival related emergent strategies, mentioned elsewhere by other authors 8-10 . in most countries classified socioeconomically as “developed”, the doctor patient relationship and ethical behaviour of doctors in their day to day practice, (and even outside the work place) are considered serious. this is so vital that the various professional governing bodies have taking strong stands on this, with medical ethics and professionalism, patient rights and protecting the patient/public being the centre of focus. prototypes of such regulatory activity in the english speaking countries, especially on patient –doctor relationship is that of the general medical council (gmc), of england and wales 11 and the american medical association (ama) principles of medical ethics 12 . granted, in principle professional governing bodies in lamic have most of the core tenants of ethical medical practice enshrined in their code of practice, the evidence indicates enforcement is relatively weak, in comparison with the situation in developed mailto:albert.coleman@gmail.com bangladesh journal of bioethics 2015; 6(2):1-7 2 or non-lamic countries 8 . some of the cited reasons for this non-ethical behaviours among some lamic physicians being that a lot of these countries are considered “low resource” countries in terms of professional manpower, finances, oversight, governance, and the problem of level of population literacy etc. the snowball effect of these factors impacts on the local regulatory agencies to effectively do their work; these factors are even more pronounced in sub-saharan africa 8-10 . in the area of clinical research in most lamic settings, the problem of patient rights and medical (bio) ethics has been relatively pursued in recent years, in part due to collaboration with (bio) ethicists from the developed countries 13-14 . on the other hand the issues of patient’s rights, (bio) ethics and medical (mal) practice or patient related fitness to practice issues involving offending doctors in most developing countries; do not generally get the publicity and press to inform patients, the public or serve as warning to other doctors. the literature on this in the public domain is sparse, this being a situation in other countries outside western europe, hence an effort being initiated to develop a worldwide regulatory and information exchange agency 15 . brief overview of principles of medical ethics and professionalism: the word ethics in general usage preoccupies with issues to do with moral existence and the norms that determine what is morally acceptable or not, in society at large (and in particular). ethics as applied to medicine otherwise known as medical ethics, falls under the general umbrella of bioethics (recognised as applied ethics), and preoccupies with the application of moral philosophy principles to resolving moral problems in the field of medicine 16 . the principal theories underlying contemporary medical ethics stems from the various moral philosophical/ethical theories viz consequential ethical theory, utilitarianism,, deontological or duty based ethical theory and some combination of the two 16,17 ; recognising though, the existence of other theories of ethics. for healthcare professional bodies of the like of medicine though, prescriptive “professional obligations” are primary, but not necessarily enough. hence supererogation (beyond obligation), which relies on the moral ideal or excellence, becomes important 17 , therein lies the importance of virtue ethics. clearly, the times when physician behaviour was tied to the ancient hippocratic oath or even any of its modified forms, as oaths or dictates informing physician behaviour, cannot necessarily be described as contemporary medical ethics. consequential ethical theory is a consequence-based theory, with utilitarianism being a usual example of consequentialism. utilitarianism centres primarily on maximising happiness (and for that matter minimising suffering). this is best described by bentham as the greatest happiness for the greatest number 16. deontological theory on the other hand is a duty based theory where call of duty is the core principle, the name kant is very much associated with duty based moral theory, in ethics and philosophy texts. beyond these theories several others, for example personalist, human rights based, communitarian, libertarian etc, and other moral theories exists to be looked at and applied where appropriate. frameworks in navigating ethical issues in medical settings: in navigating issues of medical ethics, several moral theories can be utilised, as mentioned above. on the other hand, time limited real life clinical settings, may not immediately lend itself as a theatre of moral philosophical discourse. however some moral philosophy based ethical frameworks do exist for immediate application and use in clinical settings, that can withstand the pressure of time limited clinical encounters. one such framework well known among healthcare professional (hcp), especially physicians and medical students, is “the four principles” 19-20 . the four principles are autonomy, beneficence, non-malfeascence and justice. patient autonomy is at the core of ethical medical practice in most developed countries (especially anglo-american). this recognises the rights of the patient, and bestows upon the patient certain undeniable privileges a patient is due, in his or her capacity as a person and patient. autonomy recognises the individual and his/her attributes of personhood, and as a rational being. beneficence is the duty only to do good in the interest of the person/patient. non-malfeascence, or the duty not to cause harm to the person/patient, otherwise the duty of the doctor not to abuse his/her professional role in the patient doctor relationship 16 . finally justice primarily focuses on adjudication of competing interest between people; or for communities, distributive justice in allocation of scarce resources. bangladesh journal of bioethics 2015; 6(2):1-7 3 another framework utilised increasingly in clinical settings is the four boxes approach. in this case ethical dilemmas arising are looked at from the point of view of the patient, medical necessity, quality of life and contextual or other factors 21 . a third frame work emphasizes the healthcare professional (hcp) and patient dyadic relationship under the guise of care ethics, which combines elements of feminine ethics, levinasian ethics and virtue ethics. care ethics seeks to ensure the patient “does not fall through the web of vulnerability” 22 . in this case the importance of a “virtuous” character, in combination with a caring nature, and an ability to perceive the patient’s suffering in the light of the “thou and l” levinisian concept 23 , is key to ensuring the suffering patient does not slip through the web of vulnerability, and get lost. these mentioned frameworks are meant to quickly prime and orientate physicians, and act as ethical road maps, to guide their day to day doctor – patient interaction, in an otherwise hectic and time limited clinical setting. discussion: medical practice worldwide over and above the hippocratic oath is governed by normative or moral philosophical theories as enshrined in (contemporary) medical ethics 16 . contemporary medical ethics is considered a sub-field of bioethics (informed in a large part by normative based scholarship from the field of philosophy). in developed countries, just as with governance, there are checks and balances which ensures good state governance, and in that sense good professional codes of practice. unfortunately one cannot say that with confidence about similar attitudes to governance in most lamic settings 2 . notwithstanding even in developed countries, there is the occasional slip in the execution of the mechanism of governance and equally of the code of practice of professionals 2 . a case in point in england was the harold shipman saga, which eventually changed the internal composition and some operational procedures of the oversight role of the professional governing body of medicine, and part of the code of practice of medicine (18). unfortunately in lamic settings, as mentioned earlier there appears to be an array of factors that may contribute to systematic abuse of the patient-doctor relationship by physicians, relative to the situation in developed countries 8-10 . the issue of relatively high illiteracy rates in developing countries, could be contributory too. there have been case studies indicating that doctors in some lamic settings may use the issue of illiteracy to exert paternalistic pressure in the patient-doctor relationship, with doctors adopting the “know best" attitude 19 . in some lamic regions, relatively high poverty levels coupled with poor governance has contributed to an increasing pool of vulnerable groups in the population. as one author writes “vulnerable individuals and groups are subjected to exploitation, and exploitation is morally wrong” 20 , hence a need for vulnerability to be a pre-occupation of bioethics. of note and of some relevance is that a fair number of lamic, are plagued with issues of corruption and human rights abuses; these problematic factors, may probably filter down and impact on the doctor-patient interaction/setting (although admittedly not necessarily). i raise this issue as corruption and human rights abuse, do not occur in a vacuum, and are especially relevant negative forces, in a setting of power imbalance (as the like of the doctor-patient-relationships). admittedly if these two problematic factors rear its head in the doctor-patient interaction, medical ethics and professionalism stands to lose. issues of ethics, governance and regulation of medical practice, among others has been the focus of all regulatory organisations that oversees the practice of medicine in almost all countries. however when one compares regulatory practices in the developed nations to that in most lamic settings, the standard and thresh-hold of how those that breach these ethical guides of good medical practice are held accountable may differ 24 . a case in point to illustrate the intersection of poverty, vulnerability, corruption in medicine and medical practice, corruption in medical education, medical regulation and medical ethics/bioethics in a lamic setting is the example in india, considered one of the largest (if not the largest) democracies; which prompted an article in the indian journal of medical ethics 25 . i am sure what the author was writing about is not a situation of concern only for india, but occurs in many lamic settings, except that in this case the article zoomed in on the situation in india. of importance in medical practice is to re-enforce the notion of respect for the patient/community, not respect in the semantic sense but the special sense relevant to the doctor-patient relationship 26 . this in a way is akin to kant’s notion of rational person or agent, being an end in him/herself, and not a means to an end 27 . as to the poverty and governance issues in some developing countries that tend to contribute to questionable ethical behaviour; governments in those countries have to seriously tackle the factors and machinery of perpetual poverty. this can be achieved by way of tackling social injustice, sound economic policies and promoting appropriate socio-political development 28 .this eventually will free its citizenry (including doctors and other health staff), from the attribute or bangladesh journal of bioethics 2015; 6(2):1-7 4 survival factors that impact on good ethical practices. this last point is somehow in line with the ethics of liberation theology 29-30 , which attempts to debate problems of this sort. considering the ethics of doctor-patient interaction models, (paternalistic, independent, autonomy and passive) (31), medical practitioners in some lamic settings tend to be paternalistic, this most times tends to down play patient autonomy in the interaction 32 . this brings me to the other important thing in patient-doctor interactions in developed countries (especially anglo-american settings), that is pronouncements on “medical professionalism” 33 . this new professionalism among other things recognise and embody some of the moral and ethics based issues previously mentioned autonomy 17 , personhood/rational agent 27 and respect 26 . obviously for a meaningful change for physicians from lamic settings to meet ethical expectations demanded by the profession, there need to be a shift to discard the current style of doctor –patient interaction that potentially could set the stage for unethical practices. instead they and their national regulatory bodies should embrace seriously the tenets of medical ethics and revamped concept of medical professionalism, as mentioned earlier 33 . whilst on the subject of professionalism, one cannot ignore an important attribute of a professional as applied to physicians mentioned earlier, that of going beyond the obligation imposed by the profession, otherwise referred to as supererogation 17 . this denotes not only competence as a member of a professional body, but the use of this competence in the best interest of the patient and where the situation demands, going over and above the usual obligations demanded by the profession; all this against a background of trust. this all encompassing professional attribute is a virtue based ethics, or specifically virtue in the ethics of the medical profession. it is this that confers the “special status to those of the medical profession in society at large” 34 . here again, the task is to effect such a paradigm shift in the profession in developing countries. one can realise that a fundamental or basic starting threshold for tackling the problems of moral and ethical importance in the practice of medicine in these regions, is a strong and energetic drive to train medical practitioners in the region in the principles and practice of contemporary medical ethics. in medical schools in the region, the curriculum of medical schools should have a compulsory biomedical ethics component 24, 34 , as increasingly pertains in the curriculum in most (if not all) developed countries, rather than being offered as an elective 35 . this should extend also to post-graduate medical education 36, 37, with accelerated training of medical ethicist as with other medical specialties. eventually (and hopefully) a critical mass of medical ethicist can come into being in lamic settings to teach, form institutional ethics board, research ethics committees, think tanks etc. this is not a developed or western country ideal, but rather an inescapable relevance 38 for the maintenance and continued improvement of the professional level of practitioners of the medical profession. additionally this ensures accountability of the profession and eventually empowers our patients to participate equally in the promotion and maintenance of their health. one would argue some restraint about medical regulatory bodies adopting what may be seen as culturally unsuitable moral principles or ethical guidelines 39-40 . an approximation of such a worry was expressed by an academic in north america, commenting on ethical practice by black physicians based on the phenomenon of “belonging” and “negriscence building”, in their professional interaction with fellow black patients 41. this as opposed to what he considered a white culture based ethical theory/practice. i am afraid any analogous reasoning along those lines in the case of the medical profession and regulatory bodies in lamic settings in raising their level of ethical practice, to levels as practised and maintained in developing countries is nothing short of “ethical relativism” 40 . on the other hand considering the world –wide variety of cultures, some attention to specific cultural norms in ethical decision making against a background of contemporary ethical principles may prove good practice in the long term. another school of ethical thinking however argues that there are core ethical principles that are universal and nonnegotiable, across cultural lines 42 . conclusion: all said there is relatively an obvious gap in medical ethics practices and adherence in lamic settings in comparison to what pertains in most developed economy settings (even for some lamic settings otherwise classified as “higher middle developed countries”) 43 . these gaps may be attributed to various cultural, social and finance driving factors as elaborated in previous chapters, as well as a relative dearth of medical ethics teaching in medical education in lamic settings. medical (bio) ethics education is considered essential in the formative stages of undergraduate medical education, and the life span of the practising physician. it is not expensive to acquire as the likes of some of the out of reach diagnostic equipment and medical procedures, even for those in developed economy settings. on the other hand what is required for its strong incorporation in lamic settings is a commitment by medical regulatory bodies, professional associations, medical schools and governments to put in bangladesh journal of bioethics 2015; 6(2):1-7 5 place the directives and mechanisms to ensure that medical (bio) ethics is whole heartedly incorporated in medical education and practice, as done in “developed “regions 14-15 . hopefully such an education driven measure incorporating some elements of social marketing initiatives may eventually lead to a change in attitude of most medical practitioners in lamic settings, towards an (bio) ethics driven professional attitude coupled with their technical expertise; leading to improved doctor patient relations, increased patient satisfaction, increased patient outcome measures as well as upholding of patient dignity in lamic settings. competing interest: none to declare. references: 1. simms g. hawks and vultures coming home to roost. jamaica gleaner. published: sunday/march 1, 2009. www.mobilejamaicagleaner.com20090301/focus/focus3php. accessed: 30/09/2014. 2. savedoff w and hussman k, ‘why are health systems prone to corruption?’ in transparency international’s global corruption report 2006 (london: pluto press, 2006). 3. myjoyonline.com. doctors to face probe. www.myjoyonline.com/tools/print/printnews.asp?contentid=775. source: daily graphic: 17/01/2007. accessed: 30/09/2014. 4. azure jp. unseemly medical practice. jamaica gleaner, letter. friday/february 25, 2005. www.jamaica-gleaner.com/gleaner/20050225/letters/letters2.html. accessed: 30/09/2014 5. fan r. corrupt practices in chinese medical care: the 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r, gastmans c. towards a levinasian care ethics: a dialogue between the thoughts of joan tronto and emmanuel levinas. ethical perspectives. journal of the european ethics network. 13, no. 1 (2003): 33-61. 24. ogundiran t o. enhancing the african bioethics initiative. bmc medical education. 2004, 4:21 doi: 10.1186/1472-6920-4-21. published 15 october 2004. www.biomedcentral.com/1472-6920/472-6920/4/21 accessed: 30/09/2014. 25. chattopadhyay s. black money in white coats: wither medical ethics. indian journal of medical ethics januarymarch 2008; 5(1):20-21. accessed 07/09/15 26. beach m c, duggan ps, geller ckc. what does respect mean. exploring the moral of health professionals to respect patients. j. gen. intern med 2007 may; 22(5): 692-695 27. kant i. critique of pure reason. in: kemp smith, n. ed. immanuel kant’s critique of pure reason. london; macmillan, 1993. 28. sen a. development as freedom. oxford university press. 1999. 29. boff l, boff c. a concise history of liberation 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perspective on medical ethics. j am acad psychiatry law 2005; 33(3):371-81. 42. baker r. a theory of international bioethics: the negotiable and the non-negotiable. kennedy inst. ethics j. 1998 sep; 8(3):233-73 43. holt e. slovak bribery case sparks wider debate in eastern europe. the lancet 2015; 385 (june 6): 2242. www.thelancet.com. accessed june 5 th , 2015. http://www.thelancet.com/ competing interest: none to declare. bangladesh journal of bioethics 2015; 6(2):23-25 23 accountability for reasonableness, for priority setting and resource allocation: a case scenario zoheb rafique lecturer department of biochemistry liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: dr_zohaib@hotmail.com abstract: the purpose of this paper is to discuss the accountability for reasonableness and its four conditions. this explains the priority setting and resource allocation for scarce resources. in this article it is discussed that how the scarce resources in a developing country like pakistan be allocated in health care. this is explained with the help of case scenario. key words: accountability, reasonableness, priority setting, resource allocation introduction: pakistan as a developing country has very limited health care resources when considering a huge population of over 180 million. we have very few tertiary care hospitals and they are providing services to the whole country. majority of people in our country are poor and they are unable to afford the expenses of private hospitals, though private hospitals are also very few. thousands of doctors are unemployed and still we have shortage of doctors in public sector. majority of bhu (basic health units) are closed as majority of doctors belong to urban areas and they don’t want to work in remote village areas. in all these situations, it is very difficult to maintain health care throughout country. in this paper, i will take into account four conditions of accountability for reasonableness for priority setting and resource allocation. i will consider a tertiary care hospital scenario where i did my house job in medicine ward a few years ago. there were majority of patients suffering from chronic liver diseases (cld). discussion: before discussing the four conditions of accountability for reasonableness, i will briefly discuss the case scenario. in my medicine ward as i earlier said majority of patients were of chronic liver diseases (cld) and it includes hepatitis b, hepatitis c and cirrhosis of liver. cirrhosis is the end result of hepatocellular injury that leads to both fibrosis and nodular regeneration throughout the liver. the clinical features result from hepatic cell dysfunction, porto-systemic shunting, and portal hypertension. cirrhosis may cause no symptoms for long periods. one of the major complications is upper gastrointestinal tract bleeding which may occur from varices, portal hypertensive gastropathy, or gastroduodenal ulcer. hemorrhage may be massive, resulting in fatal exsanguinations. esophageal varices are found in 50 % of patients with cirrhosis. there are several treatment and management options available for esophageal varices including acute resuscitation as initial management, pharmacologic therapy, balloon tube tamponade, portal decompressive procedures and emergent endoscopy. endoscopic techniques are also used for prevention of rebleeding 1. now, i will discuss my case scenario. in our hospital there was one professor of medicine who was trained in doing endoscopy and wednesday was fixed for performing endoscopies. emergent endoscopy is performed after the patient’s hemodynamic status has been appropriately stabilized (usually within 2-12 hours). majority of poor patients come to hospital in end stage liver diseases. i have taken this case scenario as it is a perfect example of scarce resources. many patients faced problems as their endoscopies were not performed on time as there was only one day fixed in a week and the reason was the professor was busy and though he was training others in the meantime (every wednesday). now i will apply the four conditions of accountability for reasonableness for priority setting and resource allocation. these four conditions are publicity condition, relevance condition, revisions and appeals condition and regulative condition. accountability for reasonableness makes it possible to educate all stakeholders about the substance of deliberation about fair decisions under resource constraints. it facilitates social learning about limits. it connects decision making in healthcare institutions to broader, more fundamental democratic deliberative processes 2. in my case scenario i will apply the four conditions as follows. the first one is publicity condition. it states that decisions regarding limits to care and their rationales must be publicly accessible to clinicians, patients, and citizens in a publicly administered system. when the patients suffer the complication of esophageal varices, they are informed about the limited capacity of the ward to arrange endoscopy as it is done on only wednesdays and surgical ward have their own burden of patients to be done endoscopies, due to this reason we were unable to send patients to surgical wards and the patients and their relatives mostly agrees on this setup and if mailto:dr_zohaib@hotmail.com bangladesh journal of bioethics 2015; 6(2):23-25 24 any emergency happens, only then we take help from surgical ward or send the patients to any other hospital, so the first condition is fulfilled. in above scenario second condition is also fulfilled which is relevance condition. it states that the reasons for limit-setting decisions will be reasonable if it appeals to evidence, reason, and principles that are accepted as relevant by fair-minded people who are disposed to finding mutually justifiable terms of cooperation. in my case scenario the decision making is according to the framework. the rationales were reasonable as it is evident that we had limited facility of endoscopy and it was fairly accepted by patients and their relatives and also by doctors and other hospital staff. in our setup priority was given to those patients who needed emergency endoscopy rather than those who requires endoscopy for diagnostic procedures. the third condition is revisions and appeals condition. this condition is a very common problem in government hospitals and in our scenario we request consultants from surgical ward to do emergency endoscopy if we think patient is serious and he or she may die if the endoscopy is not performed on time or in other case the other hospital is very far so that it will be late if we send the patient to other setup and here comes the function of on call consultants also, the on call consultants plays huge role in these emergency situations. this third condition is a mechanism for challenge and dispute resolution regarding limit setting decisions, including the opportunity for revising decisions in light of further evidence or arguments 3. thus we fulfill the third condition also by revising our decisions as i explained above. the fourth and last condition is regulative condition or enforcement. there is either voluntary or public regulation of the process to ensure that conditions 1-3 are met. this condition is also fulfilled in our setup as we communicate with the patient and their relatives about our limited resources. we are able to convince patients in our case scenario. the hospital leadership is constantly making efforts to meet the conditions of ‘accountability for reasonableness’ 4. conclusion: in this paper i have discussed all four conditions of accountability for reasonableness, for priority setting and resource allocation. ‘accountability for reasonableness’ is a framework that can be used to guide legitimate and fair priority setting in health care organizations, such as hospitals. in our beloved country pakistan we have few government civil hospitals bearing the burden of millions of population. we try our best to serve the humanity. i am not claiming this system a perfect one, it needs a lot of improvement and the example is my case scenario in which we have very limited resources. government should establish civil hospitals in small cities also and should increase their budget; they should recruit more doctors and nurses as we have shortage. they should train doctors with latest equipment and provide hospitals appropriate medicines. in addition to this all the hospitals should be provided with computers and also be made online so that a data system can be established and it can help the patients and also hospitals for future reference. the case scenario i took was from 2008 when i did my house job, but now i have been informed that the condition is further improving at our hospital because other physicians are also trained in doing endoscopies and they are sharing the burden of cases. it must also be noted that our teaching hospital was upgraded as our college transformed into university in the previous decade and now we have more budget and more slots for the senior physicians who are working hard to make things better. we also have now increased capacity of postgraduate students. in mean while one private center is also working towards hepatic patients in our city and they are doing fine job and so sharing the burden and they have qualified gastroenterologists. i will conclude by saying that in such scarce resources our hospital (public sector) is doing fine job as it has to share the burden of millions of people because we have very few public sector hospitals in our country with the population of over 180 million. confict of interest: no conflict of interest. references: 1. current medical diagnosis and treatment. 2004; 43rd edition. 2. norman daniels. accountability for reasonableness. bmj. 2000; 321:13001301. 3. d k martin et al. access to intensive care unit beds for neurosurgery patients: a qualitative case study. j. neurol. neurosurg. psychiatry. 2003; 74: 1299-1303. bangladesh journal of bioethics 2015; 6(2):23-25 25 4. jennifer ah bell et al. sars and hospital priority setting: a qualitative case study and evaluation. bmc health services research. 2004; 4:36. microsoft word bbs news bangladesh journal of bioethics 2017; 8(2):38 bbs news: shamima parvin lasker bangladesh bioethics society (bbs) in collaboration with directorate general of health service (dghs), ministry of health bangladesh and american university of sovereign nation (ausn), usa, had organized a “graduation ceremony and intensive bioethics training programme” on 15-16 july, 2017 at iedcr auditorium, dgsh, mohakhali, dhaka. prof dr syed modasser ali, chairman, bmrc & former health advisor of prime minister, people’s republic of bangladesh was the chief guest in this programme. special guests were prof dr. mohammad abul klam azad, director general (dg), dghs, dr ferdousi haque, director, planing & research, dghs prof. dr. meerjady sabrina flora, director, institute of epidemiology, disease control and research (iedcr) respectively. two members of bbs have graduated from ausn, usa in july 2017 and honored by bbs through this programme. following are ausn, usa graduates. dr mahmood-uz-jahan director, bangladesh medical research council (bmrc) master of bioethics prof. dr. md. anower hussain mian bds (du), dds (bsmmu), phd (japan), post doc. fellow (usa), professor and head, dept. of community dentistry, faculty of public health, bangladesh university of health sciences (buhs) mph two ausn, usa graduates with chief guest and special guests, 16 july, 2017 bangladesh journal of bioethics 2014; 5(2):73-79 73 case study the nijmegen method of case deliberation and clinical decision in a multicultural society fayemi ademola kazeem phd lecturer, department of philosophy, lagos state university, nigeria & fellow, scientific institute for quality of healthcare, radboud university, nijmegen. email: kcaristotle@yahoo.com abstract: the nijmegen method of ethical case deliberation is one of the ways of reflecting, clarifying, evaluating and making decisions about moral problems, conflicts and dilemmas in the clinical settings. it is a hybrid concentration of relevant ideas from different normative ethical traditions applied to the clinical practices. as a team multidisciplinary based deliberation, the method involves a professional ethicist serving as both a critical tutor and a facilitator in the process of deliberating and arriving at most ethical decision in clinical dilemmas. in such process, the nijmegen method is not a democratic replacement of the decision and responsibility of the healthcare team. rather it helps to motivate rational decision and reasoned responsibility in healthcare through consensus building which does not attenuate moral uprightness. the nijmegen method is part of the healthcare process and aims at improving communication among patient, family and the healthcare team as well as enriching the decision making process. it is a promising method in resolving moral dilemmas in healthcare especially in multicultural societies. besides enhancing the quality and transparency of the decision making process, ethical case deliberation on the ward using the nijmegen method has prospect of serving as a baseline in guiding through similar dilemmas in the future. key words: case deliberation, nijmegen method, clinical decision, multicultural society introduction: one of the key elements of the nijmegen method of case deliberations is that it is a structured process involving consideration of all the basic factors, dimensions and inventory of facts relevant to a clinical case. as a multidisciplinary deliberative process, the method is differentiated into four steps 1 : (i) the moral problem, which consists of actual moral problem implicit in the case; (ii) the inventory of the facts in the case: diagnosis, therapy, and prognosis of the patient; nursing care, selfcare, patient’s activities of daily living, patient’s values (social, religious, cultural and psychosocial dimensions), the institutional and legal dimensions relevant to the case; (iii) weighing of moral values and norms, which include the patient’s well-being, respect for autonomy, informed consent, respect for life, representation by proxy, question of justice, responsibility of the health care professionals and the team; and (iv) decision making with justifiable reasons and putting such decision into action. mailto:kcaristotle@yahoo.com bangladesh journal of bioethics 2014; 5(2):73-79 74 in this piece, an attempt is made in providing a post-reflection on a clinical case using the nijmegen method of ethical case deliberation on the ward. the aim is to: (i) explore how the case would have been deliberated upon peradventure there was clinical ethics committee in the hospital where the case happened; (ii) proffer prospective baseline in guiding through similar dilemmas in future clinical decisions anywhere it may occur. ethical considerations: informed consent procedure was followed in the collection and reportage of the data. in line with the terms of consent agreement reached with the family, the identities and locations of family members, the traditional physician, and the clinical laboratory were veiled in order to ensure confidentiality. only the researcher listened to the audio recording. case: mrs. x, a yoruba woman in her early forties who was fourteen weeks pregnant, developed a severe headache on her return from the market. her husband, mr. x, massaged her head with the traditional herbal balm, which did not relieve her. the intensity of her condition till the following day made mr. x to call on the herbalist who promised to make some spiritual healing ritual the subsequent day if the herbal medication he brought did not relieve mrs. x from the headache. some hours later that night mrs. x suddenly lost vision in one eye; on the intervention of their neighbours, she was taken to the hospital in the city rather than the herbalist. a ct scan of mrs. x’s head revealed an intracerebral hemorrhage with massive swelling which put pressure on the brainstem. the option of surgical operation has 50% chance of survival, so revealed the physician. upon hearing this, mr. x reached out to family members who consented to the surgery and rallied round for financial support. the operation was done without complications. but the neurosurgeons found no explanation for the etiology of her hemorrhage; neither was there evidence of an aneurysm, a tumor, a vascular malformation, nor hypertension or clotting disorder. the neurosurgeons sent necrotic brain tissue to the pathology for analysis. in the icu mrs. x did not regain consciousness as she was put under mechanical ventilation. on the next day, a repeat ct scan showed a stroke in the opposite hemisphere from the hemorrhage. in explaining these new findings to mr. x and some family members in presence through the help of an interpreter, the doctor reported her poor prognosis. she became hypertensive that night and required medication to maintain her blood pressure. while not contesting any of the clinical actions, the family members pulled further resources to allow the ‘city technologists’ save mrs. x. in the two-day hospitalization of mrs. x, there was a steady-stream of about 20-30 family members, and friends in the visitors’ lounge wanting to see her. this situation did not go down well with the nurses who repeatedly disclose the icu policy of no more than two visitors at the bedside at a time. on the third day, an obstetrician did a fetal ultrasound that showed evidence of a pregnancy but no fetus. this led him to the conclusion that either mrs. x had had a miscarriage or was less than seven weeks pregnant. mr. x was mystified by the ultrasound result as he openly disclosed that his wife had bangladesh journal of bioethics 2014; 5(2):73-79 75 been pregnant for more than three months and there was no sign of miscarriage. there, in the presence of the family, nurses and the physicians, mr. x disclosed that the pregnancy was as a consequence of a traditional herbal contraceptive failure as they never wanted to have another child in addition to their sixth children. however, they have both contemplated on abortion, which they never did after all. on this confession, some family members speculated that the couple’s thoughts about abortion of the fetus might have spiritually caused the illness of mrs. x. the family therefore agreed to perform some traditional rituals and oral medicinal treatments that could keep her soul, dissolve clot and release brain swelling. to burn incense as part of the ritual, they needed the doctor’s permission to turn off the supplementary oxygen in her room in the icu. the doctor did not agree to the request of performing ritual in the icu let alone discontinuing the oxygen. upon return to the hospital the following day to further persuade the doctor, the doctor through the assistance of a trained interpreter told the family that mrs. x was brain-dead. the nurses made request about organ donation, which one of the family members said this could not be tabled before the family because of their cultural beliefs about it. mr. x complained that had the physician agreed with the family’s request on complementary traditional healing, his wife would not have died with her pregnancy. while leaving in grief, the family members asked the doctor to remove the fetus because it is not culturally allowed to bury two persons in the same grave. when they were shown the ultrasound picture of an empty uterus again, the family members were confused; however, many of them recourse to spiritual etiology in understanding the absence of the fetus: the fetus’s soul had caused the deceased illness and then had left her without any vaginal bleeding. however, the pathologist’s later report indicated the presence of placental tissue in mrs. x’s brain. the physician’s explanations for her hemorrhage was that she had a cancer of the placenta that had spread from the uterus and undeveloped fetal tissue to the brain, causing the intracerebral hemorrhage. the nijmegen method of ethical analysis of case deliberation following the nijmegen protocol of case deliberation in the clinical setting, the case of mrs. x is analyzed as follows: a. what is the moral problem? does the doctor have a moral duty to concede to the family’s request of turning off the patient’s mechanical ventilator in order to allow traditional healing ritual in the icu? b. inventory and interpretation of facts: 1. medical dimension (diagnosis, therapy and prognosis): the patient was pregnant, lost vision in one eye and had severe headache, which the husband thought initially that massaging with herbal balm in-line with traditional self-medication practices would cure. but first clinical diagnosis showed bangladesh journal of bioethics 2014; 5(2):73-79 76 that the patient’s severe headache was as a result of bleeding in the brain. emergency intracranial surgery was performed and the patient later became hypertensive with a stroke in the opposite hemisphere of the hemorrhage. she developed apnea and was sustained by mechanical ventilator. though with a pregnancy of more than three months, the ultrasound conducted and interpreted by the obstetrician showed pregnancy without fetus. while there was delayed understanding of the etiology of the patient’s condition, which caused serious crisis of confidence in the whole clinical care process among the patient’s family despite their believe in the potency of ‘the city technology’, the later report of the pathologist cleared the air as it showed that the patient had placental cancer. the patient’s prognosis was poor as she was in coma being sustained with ventilator in the icu. given the late pathological diagnosis of mrs. x condition, her chance of neurological recovery was slim as her comorbidity assessment showed that not only did she have undeveloped fetal tissue because of the cancer of the placental, her medical condition is also not within curative limits as the cancer had spread from the uterus to the brain, causing severe intracerebral hemorrhage, which eventually resulted in her brain-death. her brain cells and reflexes are dead. 2. nursing dimension: the nursing team did not have a smooth and companion relationship with the patient’s family as they challenged many of the yoruba traditional practices throughout mrs. x’s brief and painful stay in the hospital: long waiting at the emergency department; sticking strictly to the hospital policy of restricted number of visitors at the bedside at a time; dismissing the family’s explanations of other possible etiology of the patient’s condition; inviting organ donation even under the emotional tormenting and grief moment without anticipation of cultural and personal outrage. the family’s experience of the nursing team was one of hopelessness and professional routine controlled. the nursing team prevented the overcrowding of the patient’s bed in order to ensure control, avoid distraction and allow bed-rest, which they thought was in the best interest and care of the patient. 3. patient’s view (values, religious, psychological and cultural dimensions): the patient was an illiterate and not immersed in orthodox medicine. giving the rural setting of the patient’s environment, she had more access to traditional herbal medical care than orthodox medicine in clinical setting. this is evident in the kind of contraceptive patronized and the consequent failure in preventing unwanted pregnancy after six children. she had no clinical diagnosis of her pregnancy nor was there prenatal treatment in a hospital setting. the patient had preference for traditional medicine and there are strong indications that she believed in the efficacy of religious rituals. however, the possible lack of state-ofthe-art diagnosis and medical check-ups in the traditional medical practices, which she is culturally accustomed to may have accounted for why the cancer of the placenta was not early diagnosed. 4. social dimension: the social context of the case is very important because the medical dilemma and tensions happened in a multicultural context of different understanding of care, death, organ donation practices, privacy, and informed consent, which altogether played out, negatively, in the patient, family, healthcare team relationships. the patient and her family are from a culture that honors communal solidarity together with the complementariness of the ancient medicinal wisdom with bangladesh journal of bioethics 2014; 5(2):73-79 77 western orthodox medicine. this accounted for why the family agreed taking mrs. x to the hospital with the hope that the ‘city medical technology’ would save her. but the healthcare professions did not share that sense of mutual complementarily as they conceived clinical practices as a necessary antithesis of traditional medical practices. this conflict played out in the case. the financial aspect also comes in as evident in the family social cooperation in pooling resources in order to pay the bills of their wife, sister, cousin and friend. in addition, the patient’s family belief about the spiritual repercussion of mere contemplation of abortion even without actually carrying it out showed the strong value the yoruba attach to sanctity of human life from conception. while such taboo was discountenanced by the scientifically-minded physician, the patient’s family believed it was the cause of her condition. though the physician with the assistance of the professional translator in the hospital tried to convince mrs. x family that she was dead, the family had some difficulties initially in believing that she was dead not until the mechanical ventilator was removed. 5. organizational dimension: the clinical setting is a private hospital in a multicultural society with diverse languages and ethnic groups. the hospital has team of professional translators who facilitate communication between the healthcare team in the hospital and patients, who cannot communicate in the official english language. this notwithstanding, there is little evidence that the hospital management recognized that non-western-values immersed patients often experience the orthodox healthcare system as invasive, frightening and antithetical to their aged-long practice of traditional indigenous medical care. for instance in the case, the hospital policy did not reckon with the solidarity culture of many well-wishers being around a patient. 6. the legal aspect: currently, while there are laws regulating each healthcare system separately, there is no legislation in nigeria on integrative healthcare such that compels the clinical physician to allow the application of rituals, herbs and other healing processes by the traditional herbal practitioners in a clinical setting. clinical guidelines in government owned hospitals prohibit ritual performance in the hospital; however, it is accepted in few private hospitals depending on the perception of the owner. therefore, in this case, the doctor’s decision and refusal of the request to turn off the oxygen on the patient in order to allow traditional healing ritual in the icu is not illegal. c. moral values and norms: 1. well-being of patient: while the healthcare team wanted to promote the well-being of the patient by means of the best healthcare, which the physician interpreted as keeping the patient on ventilator, the family also wanted to promote the patient’s well-being by requesting to be allowed to complement the western clinical healthcare with the traditional healing process. but there was a conflict between the physician and the family in this process of promoting the patient’s well-being. on the one hand, the physician’s actions and decisions were based on the duties of beneficence (e.g. the prompt the surgical intervention) and maleficence (e.g. protection of the patient from harm that may result by bangladesh journal of bioethics 2014; 5(2):73-79 78 keeping her off-oxygen). on the other hand, the family’s decision was taken on the basis of care hinged on solidarity. there were differences in the family’s and physician’s perceptions of the etiology of mrs. x’s condition and that influenced different ideas about the needed care for her well-being. these differences in perspectives caused misunderstanding and mistrust which at the end, did not promote the patient’s well-being. giving the awareness that there was little left to offer mrs. x, a perspective may suggest that the physician should have agreed to the family request of complementary traditional healing in the icu. another view may in fact counter-argue that the patient’s relatives ought not in the first instance to have taken the patient to the hospital with its own different clinical guidelines which are not fully in tandem with the family’s understanding of etiology, diagnosis and prognosis. after being declared brain-dead, the family believed that even at death, the patient’s well-being must be taken into consideration by respecting the dignity of her body. the expectation in this regard is that keepng her on the ventilator is an abuse of the body; burying her with the fetus, which they believed was still in the patient constitute a taboo; and organ donation of any of her bodily part was understood not only a terrible humiliation but also a bodily loss. 2. autonomy of the patient and informed consent: up to the pre-surgery moment, mrs. x was conscious but was not as concerned about her autonomy as getting relieved from her severe headache and sight loss condition. given the communal nature of the yoruba, proxy and extended consent play greater role than patient’s autonomy and informed consent. the husband together with the family consensually took decision in the patient’s best interest. 3. responsibility within the team of health care professionals: there seem to be a good team working relationship among the health care professionals: doctor, nurses, obstetrician, pathologist, and the interpreter. however, none of them responded well to pertinent aspects of patient’s cultural practices, values and beliefs in traditional medicine in the clinical setting. the traditional medicinal practitioner was seen as a non-collaborative agent that they owe no responsibility in the caring process of the patient. d. conclusion and decision making on the case: in view of the facts of this case, it is evident that “cultural differences may create barriers to the delivery of care.” 2 when such differences are not prudently handled, they result into moral dilemmas and distress not only for the healthcare team, but also for the patient and the family caregivers. it is therefore important that “healthcare providers identify and address possible cultural barriers at the levels of organizational management and clinical practices.” 2 in multicultural and ethnic societies, healthcare providers need to be open to combined therapeutic approaches to patient well-being. the western engrossed healthcare team in the case of mrs. x was intolerant of possible complementary indigenous medical practices, which mrs. x’s family believed could have saved her life. the imprecision and late clinical understanding of the actual bangladesh journal of bioethics 2014; 5(2):73-79 79 etiology of mrs. x’s condition underestimated the much trust and confidence the patient and her family had in western clinical practices. while it is arguable that the doctor has a moral duty to promote the patient’s best interest in the face of poor prognosis by allowing the traditional healing process to be conducted alongside the clinical treatment (even when there is no guarantee of the outcome of the traditional healing intervention), such duty was beclouded by the absence of dialogue and lack of respect for alternative medicinal model. though there was communication as transmitted by the translator, there was no substantive dialogue and trusting relationship between the family caregivers, patient and the healthcare team. a genuine dialogue between the doctor and the family may have given rise to rational compromise, which may have saved the patient’s brain death. the paternalistic posture of the doctor was not beneficent for the well-being of the patient. fundamental to good patient care and family’s satisfaction with the health services is sensitivity to patient’s healthcare beliefs, practices and shared preferences with the physician. references 1. steinkamp n, gordijn b. ethical case deliberation on the ward: a comparison of four methods. med health care philosophy, 2003; 6(3): 235-46. 2 . culhane-pera, k. et. al. (eds.) healing by heart. nashville: vanderbilt university press, 2003. conflict of interest: the author has no conflict of interest. acknowledgments: my profound gratitude goes to professor norbert steinkamp and mrs. anifowose seun for their valuable suggestions. i thank the erasmus mundus master of bioethics programme for the opportunity of my participation in the 2013/2014 edition of the programme bangladesh journal of bioethics 2015 vol.6 (1):1-5 1 ethical relation between physicians and pharmaceutical industries in the perspectives of bangladesh shahinul alam 1 , nahiduzzaman 2 , monsur hallaj 3 , jahangir ul alam 4 , shoaib momen majumder 5 1. dr. md. shahinul alam, associate professor of hepatology, bangabandhu sheikh mujib medical university, dhaka, bangladesh. email: shahinul67@yahoo.com, 2. resident, department of rheumatology, bangabandhu sheikh mujib medical university, dhaka, bangladesh. 3. assistant professor, department of surgery and urology. northern international medical college, bangladesh. 4. resident, department of rheumatology, bangabandhu sheikh mujib medical university, dhaka, bangladesh. 5. resident, department of rheumatology, bangabandhu sheikh mujib medical university, dhaka, bangladesh. abstract: relation between physicians and pharmaceutical industry is required for the benefit of the patient. but it may turn into business and overthrow the patients’ benefit. the relation might be in question at present and in future. several questions are flowing in bangladesh. to solve these queries we have explored the situation in developed and developing countries. the physicians and associations of pharmaceutical industries developed several ethical guidelines in those countries. they have addressed the long lasting issues on gift provided to physician, cash back, sample, industry sponsored scientific meetings, research and hospitality. there are huge restrictions to ensure the right of the patient’s e.g. limitation of inexpensive gift by the pharmaceuticals, avoiding expensive medicine instead of equally effective low priced medicine. we are lacking behind to protect the patient right properly: regulation, adherence to existing guide line, lack of guidance from statutory bodies. the current scenario is far behind the right of patient. in bangladesh it is not yet addressed either by professionals or by pharmaceutical associations. it is the immediate need to construct a guide line for physicians and pharmaceutical industry of bangladesh. key words: ethics; physician; pharmaceutical industry; gifts; hospitality; sponsorship introduction: our patients have to bear the expenses of medicine and other costs of treatment. very small amount is served by public fund. two third of expenditure is bored by out of pocket. the drug and its price are regulated by drug administration authority under the ministry of health and family welfare. clinical trial is at infantile stage. apprehension over conflicts of interest in medicine is rooted in a concern that professional judgments about the welfare of patients may be inappropriately influenced by a secondary interest — in this case; the personal gain derived from relationships with pharmaceutical companies 1 . a drug company’s primary interest is to maximize sales of its product. physicians do not (or should not) share this goal, but they are the chief conduit for sales. consequently, physicians have been the central target of marketing strategies 2 . the pharmaceutical industry and professional organizations should anticipate some elements of the gathering storm. their voluntary initiatives in this heretofore largely unregulated area could be interpreted as an attempt to forestall sterner measures by addressing the kinds of activities. mailto:shahinul67@yahoo.com bangladesh journal of bioethics 2015 vol.6 (1):1-5 2 the promotion of medicines is very influential and needs to be carefully controlled. the pharmaceutical industry differs from other industries in that its products directly affect the health of patients. the sale of these medicines is strictly controlled through market authorization (registration), prescribing and dispensing regulations. ethical promotion of medicines is important in order to ensure that medicines are prescribed and used in a rational way. promotional activities that do not comply with ethical criteria for medicinal pharmaceutical promotion are an important factor contributing to inappropriate overuse and unnecessary costs 3 . in the world, the rise of the pharmaceutical industry’s importance as a funder of mainstream research and education is increasing. approximately 60 percent of biomedical research and development today is funded by industries 4, 5 . pharmaceutical companies’ share of funding for clinical trials is more than 70 percent 6, 7 . the industry also shoulders more than half of the costs of continuing medical education 8, 9 . financial entanglement has bred close ties between the industry and physicians. there is hardly a physician practicing today who has not been the beneficiary of small “educational” gifts such as pens and memo pads or lunch for the office staff 10 . many physicians attend dinners to hear a hired expert talk about a product, take educational trips to resorts, or receive funds in the form of research grants, trainee support, or lucrative consulting fees 11, 12 . these benefits are defended as a way to provide useful information for physicians as they address difficult problems in treating their patients. but at what point does the influence become corrosive to the good of the patient 13 ? methods: for the purpose of this review we have gone through the web site of world health organization, american medical association, world medical association, general medical council, bangladesh medical and dental council, indian medical council, irish medical council. necessity to follow these organizations was as because these organizations have already established the guidelines for their country and for the world as a whole. exclusive summary was written with the followings: ethical criteria for medicinal drug promotion, world health organization, geneva 1988, self-regulation of drug promotion a cross-sectional analysis of pharmaceutical marketing codes and the who ethical criteria for medicinal drug promotion 2007, code of practice for the pharmaceutical industry, the association of the british pharmaceutical industry; 2 nd edition 2012, oppi code for pharmaceutical practices, organization of pharmaceutical producer of india; 2012, guide to professional conduct and ethics for registered medical practitioners. relationships between doctors and industry: frequently asked questions, irish medical council october 2012, code of interaction with health care professionals of the pharmaceutical research and manufacturers of america (phrma) 2012 and code of practice 2012 of the r&d-based pharmaceutical association committee (rdpac) of china.rarmaceutical association committee 3. current status in bangladesh: the pharmaceutical industries and their business are progressively increasing in the country. country is earning foreign currencies by exporting drugs .there are huge assumption and speculation about the relationship between physician and pharmaceutical industries in the country. several stories has been published and broadcasted in the print and electronic medias 14 . though the existing bangladesh medical & dental council act 15 prohibit any unethical relation between physician and pharmaceutical industry; there are evidences that pharmaceutical industries are providing cash, hospitality, pleasure trips, medical equipments, books, sponsorship for conferences, workshop, decoration for chamber, professional and non professional gifts for doctors. clinical trials are very few in the country and pharmaceuticals are not much interested to support this. clinical trials are regulated by institutional review board/ bangladesh medical research council. at this stage profession is losing its image and respect, though a very bangladesh journal of bioethics 2015 vol.6 (1):1-5 3 small number of physicians are involve with these misconduct. if it is not addressed by professionals it could be dealt by state prosecution as like usa where a third party, a body of federal law dealing with “fraud and abuse” 16 has evolved to the point where it was being used by prosecutors to punish pharmaceutical companies and physicians. in 2002, three leading professional organizations — the american medical association 17 , the american college of physicians, 18 the accreditation council for continuing medical education 19 —and pharmaceutical association 20 published guidelines regarding physicians’ interactions with drug companies. several other guide lines have been published in last 10 years from europe and asia on the abovementioned subject except from bangladesh. it is the time demand to build up a standard guide line on “ethical relation between physician and pharmaceutical industries” for bangladesh from professionals and from pharmaceuticals. leading issues to be addresses in the country a. cash/kickback/ commission: according to the world medical association 21 . "the code provides that payment by or to a physician solely for the referral of a patient is unethical as is the acceptance by a physician of payment of any kind, and in any form, from any source such as a pharmaceutical company or pharmacist”. indian medical council act strictly prohibit this 22 . in usa it is considered as criminal activity and prosecuted by fraud and abuse law 23 . b. gifts provided by pharmaceutical company: gifts are frequently supplied by medical representatives or at events to health-care professionals. ethical criteria for medicinal drug promotion (who-ecpm) mentioned “gifts offered to members of the medical and allied professions should be secondary to the purpose of the meeting and should be kept to a modest level” 24 .the code analysis demonstrates that some gifts are permitted under strict circumstances. the benefit for the profession or the opportunity for education of the health-care professional plays a key role in the permission of gifts. apart from the permission of the supply of medical utilities or small gifts for the benefit of the health profession by the various codes, some offers with regard to hospitality are permitted. in the various national codes, requirements should be included to ensure that nothing be offered that would interfere with the independence of the health-care professional’s prescribing or dispensing practices. the association of the british pharmaceutical industry (abpi) permits the supply of promotional aids to health professionals as long as these are inexpensive and relevant to the practice of the recipient’s work. the abpi also mentions a maximum cost of a utility, being six pounds 25 . utilities for use by patients are also permitted. the abpi requires that non professional gifts or other material or financial benefits should not be offered to healthcare professionals or administrative staff in order to induce them to prescribe, supply, administer, recommend, buy or sell any medicine 26 . c. sample of drug: according to organization of pharmaceutical producer of india (oppi) free samples of a pharmaceutical product may be supplied to healthcare professionals or to persons duly authorised by them who are qualified to prescribe such products in order to enhance patient care. drug samples should not be resold or otherwise misused. 26 irish medical council further clarifies that the number of such samples of each product that may be supplied to any one recipient in any one year shall be limited; the supply of any such sample is made only in response to a written request, signed and dated, by the recipient; each such sample is marked “free medical sample — not for sale” or words to the like effect 27 . d. sponsoring and hospitality of scientific meetings, conferences, seminars and symposium: american medical association recommended conference subsidies should meet the following conditions: they should be accepted by conference sponsor, not physician attendees. they do not cover travel, lodging, time, or other personal http://en.wikipedia.org/wiki/world_medical_association bangladesh journal of bioethics 2015 vol.6 (1):1-5 4 expense of physician attendees who are not faculty. hospitality subsidies should be limited to modest meals or social events held as part of meeting .faculty honoraria and reimbursement must be reasonable. organizers should retain responsibility for and control over selection of content, faculty, educational methods, and materials. scholarships and special funds for trainees to attend “carefully selected education conferences” are permitted if selection of recipients is controlled by training institution. “legitimate” conferences or meetings are defined as having the following characteristics: they are primarily dedicated (in time and effort) to objective scientific and educational activities. they are convened to further knowledge on topic presented. they ensure appropriate disclosure of financial support or conflict of interest. payments for consulting services must be limited to reasonable compensation and reimbursement for travel, lodging, and meal expenses; must be “genuine” services, not “token”. physicians may accept gifts at the conference from pharmaceutical companies under the following conditions: the gift must be primarily for the benefit of patients and be primarily related to the physician’s work. the gift must be of insubstantial value and must not be cash. drug samples permitted for physicians; personal and family use of the samples also permitted, provided that it does not interfere with patient access to the samples. 13 these criteria are also supported in uk and ireland 25, 27 . implementation: further background research is required for present situation and on feasibility and usefulness of a guideline. motivational work, awareness through training, conference and workshop by bangladesh medical association and other professional organization will break the ground of darkness. directorate of health services and drug administration may collaborate with pharmaceutical industry and physician to construct a guide line for the nation and further implementation of it. conclusion: the relationship between physician and pharmaceutical industry requires excellent ethical value. it might be in question at present and in future. in developed countries and our neighbor country had establish and published their status. a practice guideline is essential for bangladesh regarding this issue. professional organization and pharmaceutical association could take the initiative to reflect the transparency of relationship. acknowledgement: we thankfully acknowledge the contribution of center for medical ethics education and research (cmer) for inspiring us to write this article references: 6. thompson df. understanding financial conflicts of interest. n engl j med 1993; 329:573-6. 7. rosenthal mb, berndt er, donohue jm, frank rg, epstein am. promotion of prescription drugs to consumers. n engl j med 2002; 346:498-505. 8. who. rational use of medicines: progress in implementing the who medicines strategy. who executive board 2006; 118th session 11 provisional agenda item 5.3 eb118/6. 9. bekelman je, li y, gross cp. scope and impact of financial conflicts of interest in biomedical research: a systematic review. jama 2003; 289:454-65. 10. dimasi ja, hansen rw, grabowski hg. the price of innovation: new estimates of drug development costs. j health econ 2003; 22:151-85. 11. bodenheimer t. uneasy alliance: clinical investigators and the pharmaceutical industry. n engl j med 2000; 342:1539-44. 12. morin k, rakatansky h, riddick fa jr, et al. managing conflicts of interest in the conduct of clinical trials. jama 2002; 287:78-84. bangladesh journal of bioethics 2015 vol.6 (1):1-5 5 13. greider k. the big fix: how the pharmaceutical industry rips off american consumers. new york: public affairs, 2003. 14. relman as. defending professional independence: accme’s proposed new guidelines for commercial support of cme. jama 2003; 289:2418-20. 15. wazana a. physicians and the pharmaceutical industry: is a gift ever just a gift? jama 2000; 283:373-80. 16. moses h iii, braunwald e, martin jb, thier so. collaborating with industry — choices for the academic medical center. n engl j med 2002; 347:1371-5. 17. chren mm, landefeld cs. physicians’ behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary. jama 1994; 271: 684-9. 18. david m, michel m, troyen a. financial conflicts of interest in physicians’ relationships with the pharmaceutical industry — self-regulation in the shadow of federal prosecution. n engl j med 2004; 351, 1891 – 1900. 19. https://video.search.yahoo.com/video/play;_ylt=a2kio9yws79ucaqaqw77w8qf;_ylu=x3odmtbyctlydwi1bh nlywnzcgrzbgsddmlkbhz0awqdbgdwb3mdoa--?p=jamuna+television+prescription+360+degree 20. medical and dental council act. xvi of 1980 and approved by the council in its meeting held on 24.3.1983 21. havighurst cc, blumstein jf, brennan ta. health care law and policy: readings, notes, and questions. 2nd ed. new york: foundation press, 1998. 22. american medical association. opinion of the council on ethical and judicial affairs, e-8.061. (accessed october 7, 2004, at http://www.amassn.org/ama/pub/category/4001.html.) 23. coyle sl. physician-industry relations. 1. individual physicians. ann intern med 2002; 136:396-402. 24. accreditation council for continuing medical education. standards for commercial support of continuing medical education. http://www.accme.org/incoming/17_system98_essential_areas.pdf.) 25. pharmaceutical research and manufacturers of america. code on interactions with healthcare professionals. http://www.phrma.org/publications/policy/2004-01-19. 26. http://www.wma.net/e/meetings/leaders1.htm 27. the indian medical council (professional conduct, etiquette and ethics) regulations, 2002. 28. department of health and human services, office of inspector general. oig compliance program guidance for pharmaceutical manufacturers. fed regist 2003; 68(86):23731-43. 29. ethical criteria for medicinal drug promotion. world health organization, geneva 1988. 30. code of practice for the pharmaceutical industry. the association of the british pharmaceutical industry; 2 nd edition 2012 31. oppi code for pharmaceutical practices. organization of pharmaceutical producer of india; 2012. 32. guide to professional conduct and ethics for registered medical practitioners. relationships between doctors and industry: frequently asked questions. irish medical council october 2012. conflict of interest: there is no conflict of interest between the authors and no financial relation with any person or organization regarding this review. https://video.search.yahoo.com/video/play;_ylt=a2kio9yws79ucaqaqw77w8qf;_ylu=x3odmtbyctlydwi1bhnlywnzcgrzbgsddmlkbhz0awqdbgdwb3mdoa--?p=jamuna+television+prescription+360+degree https://video.search.yahoo.com/video/play;_ylt=a2kio9yws79ucaqaqw77w8qf;_ylu=x3odmtbyctlydwi1bhnlywnzcgrzbgsddmlkbhz0awqdbgdwb3mdoa--?p=jamuna+television+prescription+360+degree research involving human subjectsethical perspective bangladesh journal of bioethics 2013; 4(2):41-48 41 research involving human subjectsethical perspective md. fakruddin 1* , khanjada shahnewaj bin mannan 2 , abhijit chowdhury 1 , reaz mohammad mazumdar 3 , md. nur hossain 1 , hafsa afroz 4 1 industrial microbiology laboratory, institute of food science and technology (ifst), bangladesh council of scientific and industrial research (bcsir), dhaka, bangladesh 2 center for food & waterborne diseases, icddr,b, dhaka, bangladesh 3 bcsir laboratories chittagong, chittagong, bangladesh 4 department of microbiology, primeasia university, dhaka, bangladesh abstract: research involving human subjects are important to develop new therapeutics for the betterment of the human race. to take part in such research as volunteers is moral duty of any human. but such experiments should be justifiable and minimal risky for the participants. history of unethical research involving humans led to the development of many guidelines to make such research ethical as well as to gain maximum possible output. several guidelines have been formulated to ensure research with human participants ethical. all the guidelines emphasize on one thing in particularinformed consent of the human subjects. other considerations include rational benefit-harm ration, beneficence, justice, adequate research design and approval from proper authorities. all these guidelines aim to prevent any unethical research involving humans against their will. key words: research, human, ethics, consent introduction: research refers to a class of scientific activities designed to develop or contribute to generalizable knowledge. the term “human research”, then, refers to research that involves human subjects. research is a public trust that must be ethically conducted, trustworthy, and socially responsible if the results are to be valuable 1 . all parts of a research project – from the project design to submission of the results for peer review – have to be upstanding in order to be considered ethical 2 . when even one part of a research project is questionable or conducted unethically, the integrity of the entire project is called into question 3 . types of research involving human: two subtypes of human research can be identified. (1) therapeutic research is closely akin to therapy. therapeutic research has dual purpose: it is performed primarily for the benefit of the patient subjects; at the same time, the treatments are administered in a systematic and controlled way, so that treatment results can be applied to other contexts or to future subjects and patients. an example of therapeutic research is a study that compares the relative effectiveness of two similarly promising anti-cancer drugs administered to cancer patients. (2) nontherapeutic research, on the other hand is performed primarily for the purpose of gaining new knowledge, not for the benefit of the subjects involved in the study. for example, healthy human bangladesh journal of bioethics 2013; 4(2):41-48 42 volunteers who need no drugs for therapeutic purposes frequently participate in the early phases of drug testing, when the safety of new drugs for human use is being evaluated 4 . the moral justification of research involving human subjects: the primary argument in favor of human research appeals to the principle of beneficence. it asserts that the social benefits to be gained from such research are substantial and that the harms resulting from the cessation of such investigations would be exceedingly grave 3 . a second approach to the justification of human research is based on a joint appeal u the principles of beneficence and justice. according to this view, beneficence requires that each of us make at least a modest positive contribution to the good of our fellow-citizen or the society as a whole. if our participation in research promises significant benefit for others, at little or no risk to ourselves, then such participation may become a duty of beneficence. in addition, if we fail to fulfill this modest duty, while most of our contemporaries perform it, we may be acting unjustly, since we are not performing our fair share of a communal task 5 . every person currently alive is the beneficiary of earlier subjects' involvement in research. to be specific, the willingness of past human volunteers to take part in studies of antibiotics (like penicillin) and vaccines (like the polio vaccine) contributes to the health of us all. accordingly, it seems unfair for us to reap the benefits of already-performed research without making a reciprocal contribution to the alleviation of disability and disease 4 . investigators should be free to decide what kinds of research they will perform and how they wish to conduct that research. according to this view, the freedom of scientific inquiry should be protected from outside interference, unless there are strong reasons for overriding the presumption of freedom. thus, if an investigator can find human subjects who are willing to take part in some proposed research, he or she should generally be allowed to proceed with the research 6 . research design and benefitharm ratio: the requirement of adequate research design is end-oriented or utilitarian in character. the central aim of this requirement is to ensure that human research will be conducted efficientlythat is, in a way that maximizes the amount of information gained from exposing human subjects to the minimum amount of risk. the codes of research ethics add a second stipulation, that research involving humans should be based upon prior laboratory and animal studies 7 . a third stipulation is that all studies involving human subjects should be carefully controlled, so that the biases of the investigator do not invalidate research results. fourthly, careful methods of statistical analysis should be employed in interpreting the data derived from human research, so that the greatest possible informational benefit is derived from each study 8 . even if the optimal research is selected for a particular study, questions about the probability and magnitude of anticipated harms and benefits resulting from the study may remain. a maximum level of anticipated harm is suggested in the nuremberg code: “no experiment should be conducted where there is a priori reason to believe that death or disabling injury will occur” 9 . bangladesh journal of bioethics 2013; 4(2):41-48 43 informed consent: since the nuremberg trials, no aspect of human research has received greater attention than the issue of consent. in parallel fashion, several codifications of research ethics, including the helsinki declaration, have gradually developed the concept of informed consent in the context of research 10 . informed consent is designed to protect individuals participating in clinical research trials. an individual interested in participating in a medical research trial will receive a document that contains information about the benefits and risk of the trial, the research procedures and the reasons for the research. the participant should be able to review the document with doctors and ask questions about things they do not understand. official consent to participate in the trial is given when this document is signed, with the researcher and the participant retaining a copy. the researchers are obligated to keep the participant updated and answer any questions the participant has. informed consent does not obligate the participant to finish the trial. a participant has the right to leave the trial at any time during the study 11 . the principle of informed consent is the cardinal canon of loyalty joining men together in medical practice and investigation. the law of battery protects patients and subjects against unauthorized interventions while the law of negligence holds investigations liable for falling short of the customary standard in informing patients or subjects about the potential risks of a particular intervention. it is the duty of the investigators to provide full information to subjects concerning both the fact of randomization and the progress of the trial 12 . the requirement of adequate research design, favorable benefit-harm ratio and reasonably free and sufficiently informed consent are generally regarded as necessary conditions of ethically acceptable human research. some also add that all subjects who accept the risks of research for the sake of the society should also receive equitable compensation for injuries sustained in the course if their participation in that research 13 . privacy and confidentiality: privacy and confidentiality are very important components for research involving human subjects. people have a right to protect themselves, and information gathered during research participation could harm a person by violating their right to keep information about themselves private. the information gathered from people in biomedical studies has a unique potential to be particularly embarrassing, harmful, or damaging 14 . recently, a number of research projects have focused on unlocking genetic information. genetic information may violate a person’s right to privacy if not adequately protected. the very fact that genetic information contains information about identity provides a unique challenge to researchers. many genetic experiments may seem harmless, but during the process of collecting genetic information on, for example, breast cancer, a researcher will inevitably collect a wealth of other identifiable information that could potentially be linked to research participants as well 15 . beneficence: beneficence is a principle used frequently in research ethics. it means, “doing good.”48 biomedical research strives to do good by studying diseases and health data to uncover information that may be used to help others– through the discovery of therapies that improve the lives of people with bangladesh journal of bioethics 2013; 4(2):41-48 44 spinal cord injuries or new ways to prevent jaundice in infants. the crux of this issue lies in the fact that uncovering information that may one day help people must be gathered from people who are living and suffering today 16 . while research findings may one day help do good, they may also cause harm to today’s research participants. for example, research participants in an aids study could be asked to take an experimental drug to see if it alleviates their symptoms. the participants with aids take on a risk (ingesting the experimental drug) in order to benefit others (information on how well the drug works) at some time in the future. researchers must never subject research participants to more risk than necessary, be prepared to cease research if it is causing harm, and never put participants at a level of risk disproportionate to the anticipated benefits 17 . justice: the principle of justice demands that individual research subjects be selected fairly and that appropriate populations are selected as research subjects. because historical abuses of research subjects tended to occur among those who were in some way disadvantaged or vulnerable, justice in the selection of subject populations was typically considered as the need to protect such populations from inclusion in research 18 . however, justice has come to be understood in some situations as fairness in access to the benefits of participating in research, for individuals and for groups. aids and other diseasebased activism in the 1980s offered powerful arguments for access to potentially life-saving but experimental drugs as well as an appreciation that a protective stance towards research participants could lead to serious inequities in the availability of medical treatments (e.g., if drugs are not tested with children, there may not be good drugs available for use with children). as a consequence, there are now multiple policies of government and professional groups requiring the inclusion of various population subgroups in research 19 . the principle of justice means giving people what is due to them. this means that the risks and benefits of research should be shared in a fair way, between all parties involved, e.g. sponsors, trial participants and communities. so it is fair to:  invite people and communities to take part in the research because it helps researchers achieve their scientific goals. but they should not be invited for reasons that have nothing to do with the research, e.g., because it is convenient for the researchers to ask them. for example, in phase iii hiv vaccine trials, people at high-risk of hiv infection will be recruited 5 .  select participants in a way that lowers the risks involved. for example, researchers should choose those who are less vulnerable. so, adults should be involved in hiv vaccine trials first, then older adolescents, then younger adolescents and so on 20 .  ask a person to take on the risks of research, as long as they or the population or community they represent, have a chance to benefit from it. anyone who stands to benefit should also take on some of the risks. for example, it would not be fair to ask poor participants living in africa to take on the risks of hiv vaccine research if only persons in the west will benefit. similarly, if sponsors stand to benefit from a successful vaccine, they must take on some of the risks like the cost of making the vaccine 21 . research involving children: ethical guidelines for human research generally presuppose that the subjects who take part in research are adults who have normal mental capacities and who are not pregnant, seriously ill, institutionalized, or in desperate need of money. special subjects groups who differ bangladesh journal of bioethics 2013; 4(2):41-48 45 in one or more respects from this model of the normal adult human subject include the mentally retarded, the dying, the comatose, fetuses and children 6 . the general justification for including children in biomedical research is that physiologically children are not merely “little adults”. for example, many drugs produce totally different effects in adults and children, or even in newborn infants and two-year-olds. unless carefully controlled studies of pediatric reactions to such drugs are performed, children are likely to receive either ineffective or highly toxic doses of drugs 22 . in general, parents are legally empowered to give permission-often termed proxy consent. no nontherapeutic research should be performed without the informed consent of the research subject. young children are incapable of giving informed consent. therefore, no nontherapeutic research involving young children should be performed. in some cases the risks of nontherapeutic pediatric research may be minimal, while the potential benefits of the research to children as a class may be substantial 23 . all members of society are mutually interdependent and therefore owe to each other the performance of certain minimal moral duties. among these duties is the obligation to take part in minimally risky nontherapeutic research that promises great promises to the society as a whole. since, children, too, are members of the society; they stand under a similar obligation, although they may be too immature to recognize the fact. according to this argument, it is permissible for parents to provide proxy consent for their children’s participation in minimally risky non-therapeutic research 24 . does incentives ethical? there is considerable confusion regarding the ethical appropriateness of using incentives in research with human subjects. previous work on determining whether incentives are unethical considers them as a form of undue influence or coercive offer. incentives become problematic when conjoined with the following factors, singly or in combination with one another: where the subject is in a dependency relationship with the researcher, where the risks are particularly high, where the research is degrading, where the participant will only consent if the incentive is relatively large because the participant’s aversion to the study is strong 25 . incentives in medical research induce people to do something inherently good (assuming of course that the research is necessary, sound in design, and conducted with integrity), not to violate their duties. so they are not bribery. neither is they blackmail, since incentives are offers and not threats; one can refuse them and remain no worse off than before. the problem centers around the claim that incentives, particularly relatively large incentives, are a form of undue influence or undue inducement 26 . an offer can be irresistibly attractive so that a destitute person may be induced to do something against his or her better judgment, and even almost against his or her will, by the offer of a large amount of money. thus, the debate in this form is unresolvable because the positions arise out of irreconcilable paradigms. the argument that incentives maximize choice and therefore maximize freedom arises from the economic paradigm according to which an incentive is simply one form of trade. the alternative argument that incentives can constitute undue influence evaluates incentives as one form of power 27 . grant and sugarman 28 suggested that the use of incentives in medical research will not pose ethical problems. according to them, most of the time for most research studies, the use of incentives to recruit bangladesh journal of bioethics 2013; 4(2):41-48 46 and retain research subjects is entirely innocuous. the ethical responsibility to improve medical care must be balanced against the ethical responsibility to treat research subjects as autonomous individuals deserving of respect. incentives used in an ethically appropriate manner can play an important role in striking that balance. ethical approval for research involving human participants: in carrying out their work researchers inevitably face ethical dilemmas which arise out of competing obligations and conflicts of interest. all research proposals involving data collection involving human participants normally requires prior ethical approval to ensure the safety, rights, dignity and well-being of the participant and those of the researcher. ethical approval should not be considered as a bureaucratic obstacle; it is a mechanism for ensuring and demonstrating that the design of your research respects the rights of those who are the participants of the research 29 . ethical guidelines: guidelines for the use of human subjects in research are relatively recent, with the first modern and formal efforts to protect human subjects coming after world war ii. the birth of modern research ethics began with a desire to protect human subjects involved in research projects. the first ever ethical guideline was that of nuremberg code formulated in 1946 which was resulted due to abhorrent and torturous “experiments” with concentration camp inmates by the nazi doctors 18 . the nuremberg guidelines paved the way for the next major initiative designed to promote responsible research with human subjects, the helsinki declaration. the helsinki declaration was developed by the world medical association and has been revised and updated periodically since 1964 30 . following the helsinki declaration, the next set of research ethics guidelines came out in the belmont report of 1979 from the national commission for the protection of human subjects of biomedical and behavioral research. council for international organization of medical science in collaboration with who developed international ethical guidelines for biomedical research in 1993 with special attention to developing country in response to common research as hiv/aids 20 . each set of regulations and internationally adopted principles concerning research with human subjects consider the following issues to be of tantamount concern:  human subjects must voluntarily consent to research and be allowed to discontinue participation at any time.  research involving human subjects must be valuable to society and provide a reasonably expected benefit proportionate to the burden requested of the research participant.  research participants must be protected and safe. no research is more valuable than human well being and human life.  researchers must avoid harm, injury, and death of research subjects and discontinue research that might cause harm, injury, or death.  research must be conducted by responsible and qualified researchers.  no population of people can be excluded from research or unfairly burdened unless there is an overwhelming reason to do so. bangladesh journal of bioethics 2013; 4(2):41-48 47 conclusion: participation of human subjects is a must to make any clinical research successful while the guidelines direct the researchers to perform such project ethically. under-developed and developing countries are more vulnerable in terms of unethical clinical research due to loose monitoring and underimplementation or lack of appropriate law. scientists and regulatory authorities should be aware of the basic principles of bioethics regarding human participation in research. this article will provide readers basic understanding on ethical principles regarding inclusion of human participants in clinical research. references 1. harris j. scientific research is a moral duty. journal of medical ethics 2005; 31: 242–248. 2. fakruddin m. ethics in stem cell research. bangladesh journal of bioethics 2012; 3(1):13-18. 3. beecher hk. ethics and clinical research. the new england journal of medicine 1966; 274(24): 1354-1360. 4. kapp mb. ethical and legal issues in research involving human subjects: do you want a piece of me? journal of clinical pathology 2006; 59:335–339. 5. memon iu. justification of participation of human subjects in phase 1 clinical trials: an ethical analysis. bangladesh journal of bioethics 2011; 2(2): 26-29. 6. macklin r. bioethics, vulnerability, and protection. bioethics 2003; 17(5-6): 472-486. 7. verweij m, dawson a. public health research ethics: a research agenda. public health ethics 2009; 2(1): 1–6 8. rid a, wendler d. a framework for risk-benefit evaluations in biomedical research. kennedy institute of ethics journal 2011; 21(2): 141–179. 9. ghooi rb. the nuremberg codea critique. perspectives in clinical research 2011; 2(2):72-76. 10. joseph ks. ethics in clinical research: searching for absolutes. canadian medical association journal 1998; 158:1303-1305. 11. ali ma. what makes multinational clinical research ethical & how to minimize possible exploitation in host country? bangladesh journal of bioethics 2011; 2(2): 20-23. 12. emanuel ej, wendler d, grady c. what makes clinical research ethical? journal of the american medical association 2000; 283: 27012711. 13. fakruddin m, chowdhury a, hossain mn, mannan ksb. ethics in clinical research: bangladesh journal of bioethics 2012; 3(3): 16-20. 14. fakruddin m, chowdhury a, hossain mn, mannan ksb. scientific freedom & limitsclinical research perspective. bangladesh journal of bioethics 2013; 4(1): 30-34. 15. brody ba, mccullough lb, sharp rr. consensus and controversy in clinical research ethics. journal of the american medical association 2005; 294(11): 1411-1414. bangladesh journal of bioethics 2013; 4(2):41-48 48 16. coughlin ss. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology 2006; 3:16. 17. bhutta za. why regulate? ethical regulation of health research. journal of college of physicians & surgeons 2001; 11: 537-540. 18. grodin ma, annas gj. legacies of nuremberg: medical ethics and human rights. journal of the american medical association 1996; 276: 1682–1683. 19. kahn jp, mastroianni am, sugarman j. (eds.) beyond consent: seeking justice in research. new york: oxford university press. 1998. 20. pandey a, aggarwal a, seth sd, maulik m, juneja a. strengthening ethics in clinical research. indian journal of medical research 2011; 133: 339-340. 21. hyder aa, wali sa, khan an, teoh nb, kass ne and dawson l. ethical review of health research: a perspective from developing country researchers. journal medical ethics 2004; 30(1): 68-72. 22. caldwell phy, murphy sb, butow ph, craig jc. clinical trials in children. lancet 2004; 364:803– 811. 23. rothman dj. the shame of medical research. the new york review of books 2000; 47 (19): 60– 64. 24. rivera r, borasky d, rice r, carayon f. many worlds, one ethic: design and development of a global research ethics training curriculum. developing world bioethics 2005; 5(2): 169-175. 25. faden r, beauchamp t, king n. a history and theory of informed consent. newyork: oxford university press. 1986. 26. wilkinson m, moore a. inducement in research. bioethics 1997; 11: 373–389. 27. tishler cl, bartholomae s. the recruitment of normal healthy volunteers: a review of the literature on the use of financial incentives. journal of clinical pharmacology 2002; 42: 363–373. 28. grant rw, sugarman j. ethics in human subjects research: do incentives matter? journal of medicine and philosophy2004; 29(6): 717–738. 29. kalantri sp. ethics in clinical research. indian journal of anaesthesia 2003; 47 (1): 30-32. 30. lasker sp. history of clinical research and ethics. bangladesh journal of bioethics 2013; 4(1):2029. bangladesh journal of bioethics 2014; 5(1):1-4 1 ethical issues of randomized controlled trials jyotirmoy sarker lecturer, department of pharmacy, south-east university, dhaka, bangladesh. email: jy.sarker@gmail.com abstract: clinical trials involve the application of different medical interventions on human participants. randomized controlled trials involve different groups of human subjects undergoing different clinical interventions. this process ensures bias free subject allocation which leads to a way to statistically establish the research result. strict ethical guidance is necessary from selection of participants to the analysis of trial results. without proper guidance the trial participants would be subjected to unethical experiments. before starting the randomized controlled trials the investigators must meet all ethics issues. the institutional review board (irb) must check whether all ethical demands are met or not before permitting the research. key words: randomized clinical trials, ethics, clinical research introduction: a randomized controlled trial is an experiment that is designed to check the effectiveness of a medical intervention by comparing it with another medical intervention in a control condition. intervention is not restricted to treatment only, it includes all sorts of clinical manipulations offered to the trial participants that may affect their health 1 . during a randomized controlled trial the participants are assigned to separate groups to compare different treatments. the trial participants are assigned randomly, i.e. they are not given any chance to choose a group. the groups should be similar in some extent so that the different interventions can be compared easily. before starting the trial the researcher should establish the necessity of the comparison. some researchers considered randomized controlled trials as the most powerful tool in modern clinical research 2 while some others consider randomized controlled trials to be the best of all research designs 3 . the probable reason behind this is to equalize other possible causes that may affect the result of a research. this helps to attribute the difference in result between the two groups to the applied clinical interventions. thus it ensures the validity of the research outcome. methods: this is a review article done during research ethics course of bangladesh bioethics society in collaboration with national institutes of health, bethesda, maryland, usa through video conferencing on september 25 through november 11 of 2013. the search was confined to google search and pubmed published articles. key words was ‘rcts, ethical issue and clinical research’. important features of rcts: rcts are very useful in determining the causal relationship between different interventions and their results. this is due to some salient features of rct that differentiates it from other clinical trials. the participants are randomly allocated to various treatment groups. both the participants and the researchers are sometimes uninformed about which treatment is given to which patient. even both the groups are treated in the same manner. this method of keeping both the trial and control group uninformed about their treatment is called ‘double-blind’ test. the aim of the randomized control study is to measure the difference of a targeted outcome mailto:jy.sarker@gmail.com bangladesh journal of bioethics 2014; 5(1):1-4 2 between the trial and controlled group 4 . sometimes large population is needed for conducting rcts to establish statistical significance of the result. advantages of randomization: randomized controlled trials are advantageous in various ways. proper randomization is very important to make a clinical research outcome authentic. randomized clinical trials can cancel any chance of bias during selection of participants. in case of blind test both the investigators and patients are unaware about the type of treatment. rcts establish that the significant differences in research outcomes are due to the difference in interventions only 5 . process of randomization: randomization of patients to different control treatment groups can be done by following two different steps. appropriate implementation of these interrelated steps is necessary for authentic randomization. at first we have to generate a random allocation sequence. this sequence should use arbitrary numbers. random number list can be used. computer programs that can generate arbitrary numbers are available now. the next step is the implementation of concealed allocation sequence. for achieving this goal, a central trial coordination centre should be established. the drugs should be coded before dispensing. there should be a way of monitoring the drugs that are being used for trial purpose 6 . ethical issues regarding rcts: one of the biggest drawbacks regarding rct is that it needs to follow a lot of ethical guidelines. this is time consuming and sometimes may affect the validity of the trial significantly. though a lot of enthusiasts advocate for rcts many important aspects of health care cannot be subjected to a rct for ethical issues. before conducting a rct we must ensure that there is equipoise i.e. there should be a doubt about whether one course of action is better than another 7 . when there is a chance that one group of the study patients is going to get the better treatment than the other a question arises about the ethical basis of that trial. rcts are designed when there is enough uncertainty about whether the new treatment is better than the existing one or not. this balance is known as equipoise. without establishing this equipoise we should not go for any randomized clinical trials. both of the groups should have the equal possibility of getting the better treatment before starting the treatment. thus for meeting the ethical demands a randomized controlled trial must ensure:  free and independent choice of the participant without coercion  provision of informed consent of the participants  maximum benefit with minimum risk  equal opportunity for all to participate in the trial  there is no therapeutic misconception in the mind of the participants  bias free trial in case of industry funded research free and independent choice of the participant: there should be no coercion or any sort of undue influence for taking part in the research. those who are willing to participate should know that they can withdraw from the program anytime in the future if they wish. they should also be informed that they can refuse the offer to participate in the bangladesh journal of bioethics 2014; 5(1):1-4 3 program if they want. the total process should be free from any sorts of undue influence that may motivate the patient to participate in the program 8 . provision of informed consent of the participants: informed consent means the free consent of the participant about taking part in the trial. the investigators must provide sufficient information enough information about the possible risks and benefits. the objective of informed consent is to protect both the investigator and the participant. this ensures that the investigator has not deceived the participant. the researcher should ensure that the subject of the research has given the informed consent in written format. they should be given sufficient time to consider the proposal. the participant should sign at the end of the form 8 . maximum benefit with minimum risk: in case of studies where the risk of harm exceeds the ‘minimal’ level it is necessary to establish that the expected benefit outweighs that risk distinctively. a study will be ethical only when the benefit clearly offsets the possible risk factors. the helsinki declaration 9 and the consort statement 10 stress a favorable risk benefit ratio. the declaration of helsinki states that, “all medical research involving human subjects must be preceded by careful assessment of predictable risks and burdens to the individuals and groups involved in the research in comparison with foreseeable benefits to them and to other individuals or groups affected by the condition under investigation. measures to minimize the risks must be implemented. the risks must be continuously monitored, assessed and documented by the researcher.” physicians may not be involved in a research study involving human subjects unless they are confident that the risks have been adequately assessed and can be satisfactorily managed 9 . therapeutic misconception in the mind of the participants: therapeutic misconception refers to the misunderstanding in the participants mind about the difference between clinical trial and treatment. some participants believe that the trial is a part of their treatment and if they do not agree with the trial they will not receive their treatment properly. this was first discussed by paul appelbaum et al. in 1982 11,12,13 . bias free trial in case of industry funded research: clinical trials are frequently conducted under the collaboration of pharmaceutical industry with researchers. in those cases there is a possible chance of biased result. one of the most well-known examples of bias involves the selective serotonin reuptake inhibitor (ssri) paroxetine (paxil), an anti-anxiety medicine. the pharmaceutical company funding this research suppressed results from four trials that not only failed to show treatment effectiveness for off-label use of its ssri among children and teens, but also showed possible increased risk of suicidal tendencies in this age group. in case of funding of drug studies by the pharmaceutical industry the research team must ensure that the industry will not affect the trial result to be biased for their benefit. the investigators who are involved in various steps of the research should clarify whether they have any industry ties or not. the irbs must check for conflict of interest among the researchers. conclusion: clinical trials are the primary means to evaluate the efficacy and safety of new drugs and other medical technologies. rct is the ‘gold-standard’ for clinical trials. rct allows to check the efficacy of different interventions in groups with varying risk factors. randomization eliminates the chance of investigator bias while selecting the participants for different groups. this method also checks whether the research outcomes are statistically significant or not. however, before designing a rct the ethical issues should be clarified properly. the irbs must check whether the research proposal meets all the regulatory and ethical demands or not. http://en.wikipedia.org/wiki/consolidated_standards_of_reporting_trials bangladesh journal of bioethics 2014; 5(1):1-4 4 references : 1. jadad ar. randomised controlled trials: a user's guide. london, england: bmj books; 1998. 2. nystrom l, rutqvist le, wall s, et al. breast cancer screening with mammography: overview of swedish randomised trials. lancet 1993; 341:973-8. 3. okeh um, ugwu ac. randomized controlled trials: the most powerful tool in modern clinical research. east afr j public health. 2009; 6(suppl 1):8-10. 4. understanding controlled trials: why are randomized controlled trials important? bmj 1998; 316:201 5. schulz kf, grimes da. generation of allocation sequences in randomized trials: chance, not choice. lancet 2002; 359(9305):515-9. 6. university of bern website. available from : http://www.ispm.ch/index.php?id=1646 (retrieved on 29 nov. 2013) 7. duffy sw. interpretation of the breast screening trials: a commentary on the recent paper by gotzsche and olsen. breast 2001; 10:209-12 8. http://designingwithpeople.rca.ac.uk/ethics/consent (retrieved on 11 nov 2013) 9. wma. declaration of helsinki – ethical principles for medical research involving human subjects. 10. http://www.consort-statement.org/ (retrieved on 12 dec 2013) 11. appelbaum ps, roth lh, lidz c. the therapeutic misconception: informed consent in psychiatric research. int j law psych 1982; 5(3-4):319-29. 12. appelbaum ps, roth lh, lidz cw, et al. false hopes and best data: consent to research and the therapeutic misconception. the hastings center report 1987; 17(2):20-4. 13. henderson ge, et al. clinical trials and medical care: defining the therapeutic misconception. public library of science medicine. 2007; 4(11):e324. http://www.who.int/entity/rhl/lancet_515-519.pdf http://www.ispm.ch/index.php?id=1646 http://designingwithpeople.rca.ac.uk/ethics/consent http://www.consort-statement.org/ 3. okeh um, ugwu ac. randomized controlled trials: the most powerful tool in modern clinical research. east afr j public health. 2009; 6(suppl 1):8-10. 4. understanding controlled trials: why are randomized controlled trials important? bmj 1998; 316:201 13. henderson ge, et al. clinical trials and medical care: defining the therapeutic misconception. public library of science medicine. 2007; 4(11):e324. the epistemological import of informed consent in clinical research bangladesh journal of bioethics 2013; 4(2):34-40 34 the epistemological import of informed consent in clinical research adenugba, oluwaseun adeola dept. of philosophy, olabisi onabanjo university, ago-iwoye, ogun state, nigeria. email: seunfunmiade@yahoo.com abstract: this paper attempts to establish the epistemological import and limits of informed consent in clinical research. it points out that informed consent is a necessary requirement in clinical research because it ensures adequate participation of care receivers in issues relating to their health. besides ensuring that care receivers have knowledge of whatever medical intervention they are consenting to, informed consent, as an ideal, provides assurance that care receivers and others are neither coerced nor deceived. while the question of the value of informed consent in health care delivery is not so much controverted, in contest is the question of whether or not complete and wholly specifically informed consent can indeed be realized in medical intervention. two orientations are identified in this debate. one insists that an individual will be able to make an informed decision and make reasonable choices amongst alternatives when fully informed. the other orientation sees as an epistemic illusion, achieving full informed consent, and rather opts for informed request. this paper examines this debate by clarifying the notion of informed consent, its components and its nexus with knowledge. the position of the paper is that informed consent is not only an ethical ideal in clinical research and health care; it is also an epistemic virtue that must be continuously strived towards. this paper establishes that health care receivers can only have an epistemic claim of their medical situation if all requirements of informed consent in health care delivery such as provision of adequate information, the risk and benefits of treatment, avoidance of vague/ambiguous statements, voluntariness, etc. are met. keywords: informed consent, epistemology, autonomy, health care, clinical research introduction: epistemology and ethics are interrelated areas of philosophy. in the area of philosophy of medicine, this nexus plays out as well, though unusually recognized. in this paper, our intent is to critically discuss the epistemological import of informed consent in health care delivery. in doing this, the paper shall delve into the meaning and features of informed consent in relation to health care. in exploring the epistemological implications and limits of informed consent, conceptual analysis of knowledge and its conditions is provided. consequently, the paper examines the connection between informed consent and knowing with some concluding critical notes. informed consent: some clarifications: aderogba, a 58 year barrister had received treatment for prostate cancer. at the time of diagnosis, investigations revealed local spread of the disease but there was then no evidence of systemic spread. following initial treatment, he remained well for one bangladesh journal of bioethics 2013; 4(2):34-40 35 year when the picture changed radically. the cancer had spread to several bones and, in particular, his spine. he was told of his diagnosis which he accepted in due faith. because of his situation, he viewed life has a great mystery. few months after, his physician told him about some researchers who visited the hospice where he was. the intent of the research team was to conduct certain research on prostate cancer. his physician wanted him to participate in the research but he failed to fully inform him of the risk of participating. the only picture he had of the research was a positive one. aderogba ignorantly consented and signed the informed consent form given him by the physician. the above clearly shows the case of a research participant who consented to research procedure without information and knowledge. what then is informed consent? informed consent is very much prominent in modern bioethical discussions. it is a concept that recognizes the importance of the patient in health care system. ideally, a patient who visits a physician is meant to divulge certain medical history about himself to the physician and the physician is equally meant to carefully digest the information given to him by the patient. this information is meant to assist the physician in the process of diagnosis. this is also applicable to research in health care delivery where prior information given to the patient is important in decision making. as an ethically acceptable medical practice especially when taking actions that concern others, informed consent can either be on medical treatment or on research on human subject. for the purpose of this paper, informed consent is used and understood in the latter sense. voluntary request and informed consent of human subjects have been the central focus of nontherapeutic research on human experimentation. there is a serious concern in research as a whole especially in relation to the involvement of research participants who are unable to consent to intervention. research on human subject is a worrisome practice and this accounts for why there remains no satisfactory ethical justification for the inclusion of incompetent adults and children without any immediate intended benefits in the clinical research outcome. these set of individuals are seen as belonging to a vulnerable group. the inclusion of children has been extensively discussed in bioethics debates, and to this effect, it has been addressed in legislation and recommendation 1. we cannot dispute the fact that research on humans are vital because of the obvious and challenging problems faced in health care system on daily basis. these problems require urgent attention especially in the wake of high number of avoidable death recorded on a daily basis on health deficiency ground. some of these problems are not new while some are recent medical problems. medical research have led to proffering cure to all sort of diseases such as cancer, leukemia, dementia, hiv etc. this has no doubt promoted the public good hence the need for research. on the above premise, informed consent is important and necessary in medical practices specifically in clinical research; though there are some basic difficulties confronting it. we cannot give informed consent when we are very young or very ill, mentally impaired, demented or unconscious, or merely frail or confused. often people cannot give informed consent to emergency treatment 2 . besides these problems, even in cases of adult with maturity of minds, we must also note that the way in which persons comprehend information differs. one may probe further the cogency of informed consent by asking whether or not a competent care receiver whose consent has been sought with full information disclosed and discussed is disposable to responding more positively to care and treatment than a care receiver without informed consent. this is a very important question to be considered. there are two sides to addressing this vital question. on one hand, a patient who has adequate information of his health in general and who is well informed of bangladesh journal of bioethics 2013; 4(2):34-40 36 the research procedure he wants to engage in may respond positively to treatment. some patients respond better when they are informed and know of the intended intervention. such patients consciously decide to care less about the painful medical procedure in such research with the sole intention of achieving a positive end. for such patients, knowing is a contributing factor to their health. on the other hand, some patients may have a different outlook of life after knowing. in fact, they make a very radical decision by not even wanting it to work. such patients may consciously decide not to cooperate in any way with the care giver considering the fact that the cooperation of the care receiver matter a lot in care delivery. dealing with difficult patient in the process of care can be quiet frustrating and the objective of intervention may be a mirage. however, whether knowing yield a positive result for some and yield otherwise for the other does not make knowing and information giving not worth pursuing. informed consent in research is a medical necessity that must be pursued giving all due recognition. components of informed consent: having understood what informed consent is there is a need to point out the vital features of informed consent. informed consent consists of two major components. one is the physician’s disclosure of all necessary information to the patient. this information must include diagnosis, prognosis, available and alternative treatment, and the risk, benefits, and consequences of having or refusing treatment 3 . the second component is the consent of the patient who decides whether to accept or refuse treatment on the basis of the information provided. informed consent in clinical research has highlighted in ad protocol, 2005 art.13 should include the purpose of study, study design, risk and benefits, alternative to participation, duration of study, voluntariness and confidentiality of personal data 4 . we may therefore ask if all these requirements are met before enrollment of research participants and if yes, can we be sure that participant fully get the information right. nuremberg code is a response to notorious abuses in researches in the past. this code establishes voluntary and informed consent of the human subject as the grounding principle for the ethical conduct of research. voluntary consent according to the nuremberg code is defined in terms of the following: this means that the person involved must have legal capacity to give consent should be so situated as to be able to exercise power of choice without the intervention of any element of force, fraud, deceit, duress, over reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and should have sufficient knowledge and comprehension of the elements of the subject matter involved to enable him to make an understanding and enlightened decision (nuremberg code) 5. despite the cogency of this code, we cannot pretend as if it does not have its limitations. deducing from the above quotation, this code says that person involved must have legal capacity to consent. but what about a situation where the concerned person is not legally competent to consent? the inadequacies in nuremberg code was addressed and recognized by the world medical association’s declaration of helsinki. the declaration states that in case of legal incompetence, informed consent should be obtained from the legal guardian in accordance with national legislation 6 . informed consent goes beyond informing and consenting. there are situations where consent is given as a result of coercion or manipulation. this cannot be considered as a genuine consent even if the patient is fully informed and fully understands 7 . coercion sounds very cruel and is something to be discouraged bangladesh journal of bioethics 2013; 4(2):34-40 37 in health care delivery. this is the same to paternalism in doctor patient relationship where the physician believes s/he always knows better than the patient. however, it is not all unlikely that information might be provided to the patient in a way which will lead to the patient choosing as the practitioner would wish 8. the above mentioned requirements of informed consent need to be further explained. in research, it is expected that the participant be given adequate information in comprehensible form. this is necessary in order to avoid participation in the absence of knowing. this is what is referred to as informed consent form. the informed consent form states very clearly all that the research is all about. these requirements are highlighted and briefly explained thus: the purpose of research: the informed consent form should state the purpose of the research. why the research? what objective does it hope to attain? what are the contributions of the research to human life and existence? how can the research help develop the area of medicine and knowledge acquisition. all these need to be fully explained in the informed consent form the protocol purpose: research protocol is also given to research ethics committee before the approval of the research. research ethics committee and research review board can either approve or deny the protocol as long as they are not satisfied with the content of the research protocol. this is done in order to ensure the protected of individual right and dignity. the study design: the study design is included in the informed consent form so that patient can know and understand the pattern the research is going to take. risk and benefits: there is no research without its risk and benefit; therefore, the researchers should endeavor to provide the participant the likely risk in participating and also with the things to be benefited in participation. we cannot dispute the fact that there can be unexpected risk but information on the expected one should be made available in order to help in decision making in either to participate or not. alternative to participation: this like any other requirement of informed consent is also very important. the patient needs to know the alternative to participation. as a patient, if i am not participating, what do i lose? what other treatment is available for those who have chosen not to participate? this must be told with all sense of sincerity. the researcher does not need to present terrible situation to the patient so that he feels the best decision is to participate. duration of study: the patient need to know how long the research is taking. when the research is starting and when is ending. this will ensure proper planning and enable patient to have an already made mind set. voluntariness. in an ideal situation, it is expected or assumed that a person have the right to voluntarily accept or reject any offer. acceptance of any proposal should be strictly voluntary and not through coercion. equally, the patient should be allowed to exercise his or her right to refuse or to withdraw from intervention when he feels uncomfortable at any stage or phase. confidentiality of personal data: certain information is needed before a person can be enrolled in research. ideally, some research has age range. this is a convenient way of searching for those that truly qualify to participate in research. this information is meant to be kept strictly confidential and not be made available for public consumption. it is worth noting that if any of the components is missing then, informed consent has not been met. it takes only a patient who has an in-depth understanding to either refuse or accept any intervention. bangladesh journal of bioethics 2013; 4(2):34-40 38 however, a combination of these components is necessary but may be difficult to attain. these components can only be attained when we spell out the necessary requirements needed for a patient to be capable of consenting. here comes in the issue of competency. competency in decision making is a major problem with informed consent. how can we define competency and when is a person said to be capable of consenting? who determines a competent patient? what happens in case of incompetency? having discussed the meaning and components of informed consent, there is a need to do a conceptual clarification of epistemology i.e. knowledge in a bit to bring out the epistemological imports of informed consent. what is knowledge? the concept of knowledge is the central concern of the field of epistemology. in philosophy, there is no way we can possibly discuss knowledge without situating it in epistemology. in the literary sense, there are two usages of knowing. the two senses are ‘knowing that’ and ‘knowing how’. to ‘know that’ could mean to have a fact and information about something while ‘knowing how’ means the ability, proficiency and skill to do something. with this explanation, it is clear that there is a difference between ‘knowing that’ and ‘knowing how’. it is possible to know that something is the case and may not be able to know how. for example, if i can swim, i can as well make a categorical statement that i can swim and may not be able to explain how i do it. this is not the case in philosophy; when you claim to have a knowledge claim of something you should be able to justify further that the claim is true. epistemology is a branch of philosophy that is concerned with the nature and scope of knowledge (9). the latin word episteme means knowledge or knowing. thus epistemology is knowledge or the study of knowing. epistemology addresses questions such as what is knowledge? how is knowledge acquired? what do we know? how do we know that we know what we claim to know? how certain is our knowledge claim? while these questions can be slightly confusing for common man, philosophers ponder on these questions in an attempt at coming up with plausible answers. like philosophy, there is no universal acceptable definition of knowledge because there are divergent definitions provided. not until 1960 when edmund gettier wrote a provocative essay to debunk these existing criteria of knowledge, for a very long time, the traditional definition of knowledge as justified, truth, belief was greatly embraced by scholars and considered a sufficient definition of knowledge. the traditional definition of knowledge as justified, truth and belief states that ‘s’ knows that ‘p’ if and only if ‘p’ is true, ‘s’ believes that ‘p’ and ‘s’ is justified in believing that ‘p’. this definition of knowledge goes in line with ayer and chilsom’s definition of knowledge. gettier argument is that the traditionally held notion of knowledge cannot be considered an adequate definition of knowledge because it is possible for a person to be justified in believing a proposition that is in fact false. knowledge is more than mere belief. when you claim to know something; you must also understand what you claim to know. epistemology also states the difference between believing something and knowing something. you can believe something but that does not need to be right or wrong. in other words, you can believe in something and it could be right or wrong. on the other hand, if you know something, it cannot be wrong, as knowledge is absolute while belief is not. you continue to believe in things only when you are not sure of them. the moment you are sure of something, in other words, the moment you are certain about something, you stop believing it, as you know it. it is important at this juncture to establish the connection between informed consent and knowing this would assist a great deal to bring out the epistemological import of informed consent in clinical research. bangladesh journal of bioethics 2013; 4(2):34-40 39 the nexus between informed consent and knowing: informed consent is closely linked to knowing. information gives the opportunity to know and knowing guarantees and secures consent. the patient needs to know or have knowledge of what h/she is consenting to. knowledge opens up a wide range of understanding without which one cannot make an informed choice or decision. some lessons can be deduced from the citation of isaiah berlin. he writes: i wish my life and decisions to depend on myself, not on external force of whatever kind. i wish to be the instrument of my own, not of other men's acts of will. i wish to be a subject, not an object to be moved by reason, by conscious purposes, which are my own, not by cause which affects me, as it were, from outside. i wish to be somebody, not nobody; a doerdeciding, not being decided for, self-directed and not acted upon by external nature or by other men as if i were a thing, or an animal or a slave...i wish, above all to be conscious of myself as a thinking, willing, active being, bearing responsibility for my choices and able to explain them by references to my own ideas and purposes 10. the above quotation points to important thing that cannot be undermined. it shows very clearly the importance of autonomy, individual decision making capacity, and rejection of paternalism whether in clinical research or health care. in clinical research, if all the stipulated guidelines and conditions are fully explored, the potential participant cannot in any way claim ignorant during the research process because he would have been made to understand the risk/benefit of participating. besides this, the avenue for exercising competence and autonomy would have been guaranteed. in all these, informed consent is intrinsically linked to knowledge because information produces knowledge and having the knowledge of something shows one has been informed. let us briefly examine the case of mr. aderogba. from the analysis of his case, it is clear that he consented without having the information that will enable him makes an informed decision. this can simply be termed consent void of information. the researcher in his case had failed to respect his autonomy, respect him as a person and respect his desires. this point can further be strengthened when will look closely at the components of informed consent earlier explained in this paper. we may need to ask if the purpose of research was adequately explained in the inform consent form. does the participant understand the risk and benefit of the research? did he give a voluntary consent? can we say that mr. aderogba was duly informed prior to the carrying out of the research on him? how can we assess the competency of mr. aderogba in his decision? these and many more are the envisaged problems of informed consent and research in human subject. the issue here is not limited to whether the research exposes a subject to harm, but the moral wrong of using a person as a means to an end and only a means to an end 11. it is crystal clear from the case given above that mr. aderogba did not give an informed consent in the research he was made to participate in. he consented without information. this is because to give an inform consent to something, you must have a detailed and elaborate knowledge of that very thing and you must truly know the danger and likely benefit of what you are consenting to. in knowing, you must also understand what you claim to know. if understanding is lacking then it cannot be referred to as an informed consent. conclusion: having thoroughly discussed the content, meaning and requirements of informed consent in research, it is deducible that informed consent is a key requirement for the ethical conduct of human subjects’ research. informed consent no doubt guarantees participants actual participation in decision bangladesh journal of bioethics 2013; 4(2):34-40 40 making of their health without any form of coercion medical paternalism. it is quiet unfortunate today that in many ways, care receivers are vulnerable to many medical interventions specifically in research. they are vulnerable because they do not know and cannot claim to have an epistemic claim of what they have consented to. we cannot at the same time claim ignorant that many researchers may want to use this avenue to exploit participant because research is highly important and vital to human continuous existence. on the whole, clinical research is often the most efficient and valid method to generate valuable knowledge that improves patient care. without it, medical knowledge becomes static and health care delivery becomes handicap. this statement poses a very serious worry. there is problem with contradictory interest; should we sacrifice the interest of the majority at the expense of protecting and ensuring the individual's interest or vice versa? if this holds, then utilitarianism as an ethical theory should be embraced. this goes to show that informed consent is not only an ethical ideal in clinical research and health care; it is also an epistemic virtue that must be continuously strived towards. it is the position of this paper that informed consent is necessary only that all requirements of informed consent should be worked towards being met in order to protect the integrity of the research and ensure the dignified interest of the research participants. references: 1. us department of health and human services. protection of human subjects 45cfr 46; civil code of quebec, l.q. 1991, c.64, article 20-2. 2. o’neil, some limits of informed consent in j. med ethics, 2003: p 4. 3. walter glannon, biomedical ethics, oxford university press, 2005. p. 24. 4.ad protocol, 2005 art.13 5. the nuremberg code as found in united states v carl brandt, trials of war criminal before the nuremberg military tribunal.vol. 11. the medical case: washington, dc: us government printing office 1948). 6. kathleen cranley and marc speyer-openberg, incompetent persons as research subjects and the ethics of minimal risk in cambridge quarterly healthcare ethics (1996)5,362-372. 7. robert young, informed consent and patient autonomy in helga kuhse and peter singer, a companion to bioethics (usa: blackwell publishing ltd., 2001). 8.d. brook., informed consent in t. regan and d. van de veer, health care ethics (philadelphia: temple university press, 1987. 9. enclopedia of philosophy, vol. 3, 1967. 10. i. berlin, four essays on liberty, oxford, clarendon press. 1969. p. 131. 11. h.t., jason and m. d, karlawish., conducting research that involves subjects at the end of life who are unable to give consent in journal of pain and symptoms management 25,no 4.april 2003. bangladesh journal of bioethics 2015; 6(1):27-39 27 commentary pay walled retraction notices jaime a. teixeira da silva p. o. box 7, miki-cho post office, ikenobe 3011-2, kagawa-ken, 761-0799, japan email: jaimetex@yahoo.com abstract: a retraction of a scientific paper is made, most often due to errors or lack of publishing ethics on the part of authors, or, on occasion, duplicate publication by a publisher in error. the retraction notice that accompanies the retraction is an extremely important document, because it is the only information that provides a background to the public regarding the reason why the manuscript was retracted. in most cases, if the retraction notice is truly transparent, it will contain a few sentences that indicate the reason, and possibly also the authors’ responsible, among other facts. according to the committee on publication ethics (cope), retraction notices should be free to view, i.e. open access. this opinion piece exposes how several publishers are selling access to retraction notices, including cope members, despite, in some cases, being paying cope members. the business and academic ethics of such an action is thus called into question. key words: accountability, cope, errors, ethics, free, literature correction, open access retraction notices: the window on retractions when scientists commit misconduct, fabricate or duplicate data, plagiarize the work of others, or their own (selfplagiarism), due to malice or to honest error, or on occasion when a publisher accidentally publishes a paper in duplicate, the most likely outcome, if such an error is detected, is a retraction1. greater awareness and tools to detect such cases have most likely been the reason for a spike in the number of journals issuing retractions 2 . retraction notices thus serve not only to correct the literature, they also serve as important historical documents that inform, and alert, peers and the wider scientific public, that errors exist in that scientific paper, most likely as a result of the permeability and imperfection of the traditional peer review system3,4. retractions (and also errata, corrigenda and expressions of concern) need to be issued quickly, openly and transparently, and should be informative. in most cases, the correct way to represent a retraction is with a prominent red, water-marked “retraction” stamped across each page of the original retracted pdf file or html content online. in most cases, publishers tend to publish a pdf file as the retraction notice and this may or may not have an equivalent html text. the retraction notice is thus an important document that bridges the divide between what other scientists or peers can see, and what the propents of the retraction (i.e., the authors, the editors, and the publisher) know. the document is important, and is in fact an essential complement to the public academic record. the importance of the public nature of the notice becomes greater when we are dealing with scentists who have either received public funding, or whose paid salaries are based on tax-payers’ (i.e., public) funds. the same principle applies to corrections or corrigenda, or to errata, which point out other errors in the manuscript, but which do not necessarily result in a retraction. retraction notices should be open to the public mailto:jaimetex@yahoo.com bangladesh journal of bioethics 2015; 6(1):27-39 28 one of the salient points regarding retraction notices specified in the cope (committee on publication ethics) retraction guidelines (cope 2015)5 is that “ notices of retraction should …be freely available to all readers (i.e. not behind access barriers or available only to subscribers).” cope consists of, on the 13th july 2015, 10,124 members (http://publicationethics.org/members). one would thus expect that paying cope member journals and publishers would follow the rules and guidelines set out for them by cope. thus, should any cope member be charging money for access to retraction notices, would this not be a direct violation of cope’s code of conduct? should non-cope members adhere to the same principle? despite this, several journals and publishers, some of which are cope members, are selling the retraction (or expression of concern, errata, or corrigenda) notices (10 cases shown in appendix 1). questioning pay walled retraction notices the morality of the business model in which information should be freely available to other scientists and the public, but is not, but is instead sold for a profit, is thus highly questionable. in most cases, the retraction notice is a pdf file, sometimes only a single page long, with information that is vital to public understanding, yet is sold for a few dozen us$. the ethics of the business model employed by cope members then becomes questioned when we are dealing explicitly with cope members that are issuing retraction notices behind a pay wall, even though cope has explicitly indicated that the best practice is not to do so. one of the academic and corporate responsibilities of publishers is to be consistent with the ethics and the rules of engagement that they impose upon the authorship6. if, however, a publisher is unable to respect the principles by which it claims to abide by, then what does this say about the business model, or the ethics, of that publisher? conclusions retractions are becoming increasingly part and parcel of the publishing platform. retraction notices serve as the only information available to the public informing them of the background. thus, they should be both open, and free to view. this issue needs wider and more serious debate and greater enforcement by cope of cope members. those publishers that are not cope members need to reflect on the ethics of selling information that is vital to other scientists and the public. post-publication peer review is one tool that allows scientists to identify such discrepancies between publisher’s stated norms, guidelines and ethics, and their actual practice, and bring them to the attention of the wider scientific community 7 . the porous nature of cope’s clause 3.1 of its code of conduct for editors is another issue of concern related to cope and cope member journals and publishers 8 . conflicts of interest: the author declares no conflicts of interest. copyrighted images in screen-shots used under the fair use agreement: http://en.wikipedia.org/wiki/fair_use. the author declares that information related to cope members and the status of free vs paid in the screen-shots of the retraction notices remains valid, at least until the date of acceptance of this paper. references: 1. fang fc, steen rg, casadevall a. misconduct accounts for the majority of retracted scientific publications. proc natl acad sci usa 2012; 109: 17028-17033. doi: 10.1073/pnas.1212247109 2. fanelli d. why growing retractions are (mostly) a good sign. plos med 2013; 10(12): e1001563. doi:10.1371/journal.pmed.1001563 3. teixeira da silva ja. the importance of retractions and the need to correct the downstream literature. j scientific exploration 2015; 29(2): 353-356. 4. teixeira da silva ja, dobránszki j. problems with traditional science publishing and finding a wider niche for post-publication peer review. accountability res: policies quality assurance 2015; 22(1): 22-40. doi: 10.1080/08989621.2014.899909 http://publicationethics.org/members http://en.wikipedia.org/wiki/fair_use bangladesh journal of bioethics 2015; 6(1):27-39 29 5. cope (committee on publication ethics) (2015) http://publicationethics.org/files/retraction%20guidelines.pdf (last accessed 18 may, 2015) 6. teixeira da silva ja. responsibilities and rights of authors, peer reviewers, editors and publishers: a status quo inquiry and assessment. asian australasian j plant sci biotech 2013; 7(special issue 1): 6-15. 7. teixeira da silva ja. debunking post-publication peer review: what it is and what it’s not. int j edu infor technol (public sci framework) 2015; 1(2): 34-37. 8. teixeira da silva ja. cope code of conduct clause 3.1. under the microscope: a prelude to unfair rejections. curr sci 2015; 109(1): 16-17. http://publicationethics.org/files/retraction%20guidelines.pdf bangladesh journal of bioethics 2015; 6(1):27-39 30 appendix 1 examples of publishers selling retraction notices (i.e., behind a pay wall), rather than making the files open access. the original reference, the link to the retraction notice url, the charge as well as whether the publisher is a cope member, are indicated. prices and facts valid until july 13, 2015. case 1 (informa health) publisher is cope member? no journal is cope member? yes lee db, suh hs, choi ys. a comparative study of low-fluence 1,064nm q-switched nd:yag laser with or without chemical peeling using jessner’s solution in melasma patients. j cosmetic laser ther 2014; 16(6): 264-270. doi: 10.3109/14764172.2013.864201 retraction: http://informahealthcare.com/doi/full/10.3109/14764172.2014.998978 the charge to access the retraction notice: us $52.00 http://informahealthcare.com/doi/full/10.3109/14764172.2014.998978 bangladesh journal of bioethics 2015; 6(1):27-39 31 case 2 (american physical society) publisher is cope member? no journal is cope member? no puentes g, gerhardt i, katzschmann f, silberhorn c, wrachtrup j, lewenstein m. observation of topological structures in photonic quantum walks. phys rev lett 2014; 112, 120502. doi: 10.1103/physrevlett.112.120502 http://journals.aps.org/prl/abstract/10.1103/physrevlett.112.120502 retraction: http://journals.aps.org/prl/abstract/10.1103/physrevlett.113.019901 the charge to access the retraction notice: us $25.00 click, then… pay http://journals.aps.org/prl/abstract/10.1103/physrevlett.112.120502 http://journals.aps.org/prl/abstract/10.1103/physrevlett.113.019901 bangladesh journal of bioethics 2015; 6(1):27-39 32 case 3 (elsevier) (expression of concern) publisher is cope member? yes journal is cope member? yes firoz bf, henning js, zarzabal la, pollock bh. toxic epidermal necrolysis: five years of treatment experience from a burn unit. j ame acad dermatol 2012; 67(4): 630-635. doi: 10.1016/j.jaad.2011.12.014 http://www.sciencedirect.com/science/article/pii/s0190962211022808 expression of concern: doi: 10.1016/j.jaad.2014.06.027 http://www.sciencedirect.com/science/article/pii/s0190962214015886 the charge to access the notice: us $39.95 http://www.sciencedirect.com/science/article/pii/s0190962211022808 http://www.sciencedirect.com/science/article/pii/s0190962214015886 bangladesh journal of bioethics 2015; 6(1):27-39 33 case 4 (wiley) publisher is cope member? yes journal is cope member? no fan x, yang z, parker dj. flow structure and particle motions in a gas-polyethylene fluidized bed. aiche j 2007; 67(4): 630-635. doi: 10.1002/aic.11232 retraction: http://onlinelibrary.wiley.com/doi/10.1002/aic.11232/full the charge to access the notice: us $38 http://onlinelibrary.wiley.com/doi/10.1002/aic.11232/full bangladesh journal of bioethics 2015; 6(1):27-39 34 case 5 (the royal college of psychiatrists) publisher is cope member? unclear journal is cope member? yes perroud n, dayer a, piguet c, nallet a, favre s, malafosse a, aubry j-m. childhood maltreatment and methylation of the glucocorticoid receptor gene nr3c1 in bipolar disorder. br j psychiatry 2014; 204(1): 30-35. doi: 10.1192/bjp.bp.112.120055 http://bjp.rcpsych.org/content/204/1/30#fn-2 retraction: doi: 10.1192/bjp.205.2.164a http://bjp.rcpsych.org/content/205/2/164.2 the charge to access the notice: us $30 (for one day) click, then… pay http://bjp.rcpsych.org/content/204/1/30 http://bjp.rcpsych.org/content/205/2/164.2 bangladesh journal of bioethics 2015; 6(1):27-39 35 case 6 (wiley) publisher is cope member? yes journal is cope member? yes liu z, wang y, deng z, liu t. high-level production of 3-hydroxypropionatein escherichia coli and saccharomyces cerevisiae by introducing part of the 3-hydroxypropionate/4-hydroxybutyrate cycle from metallosphaera sedula. biotech bioeng 2014; 111: 1906. doi: 10.1002/bit.25275 retraction: http://onlinelibrary.wiley.com/doi/10.1002/bit.25275/abstract the charge to access the notice: us $38 http://onlinelibrary.wiley.com/doi/10.1002/bit.25275/abstract bangladesh journal of bioethics 2015; 6(1):27-39 36 case 7 (springer) publisher is cope member? yes journal is cope member? yes hu j, qiu x-j, li r-x. nematic ordering pattern formation in the process of self-organization of microtubules in a gravitational field. j biol phys 2007; 33(1): 97. doi: 10.1007/s10867-007-9044-1 retraction: http://link.springer.com/article/10.1007%2fs10867-007-9044-1 the charge to access the notice: us $39.95 http://link.springer.com/article/10.1007%2fs10867-007-9044-1 bangladesh journal of bioethics 2015; 6(1):27-39 37 case 8 (wiley) publisher is cope member? yes journal is cope member? yes iorio l. a new type of misconduct in the field of the physical sciences: the case of the pseudonyms used by i. ciufolini to anonymously criticize other people's works on arxiv. j assoc inf sci technol 2014; 65(11): 2375. doi: 10.1002/asi.23238 retraction (labelled as a withdrawal): http://onlinelibrary.wiley.com/doi/10.1002/asi.23238/abstract the charge to access the notice: us $38 click, then… pay http://onlinelibrary.wiley.com/doi/10.1002/asi.23238/abstract bangladesh journal of bioethics 2015; 6(1):27-39 38 case 9 (mary ann liebert, inc. publishers) publisher is cope member? no journal is cope member? no trapasso f, aqeilan ri, iuliano r, visone r, gaudio e, ciuffini l, alder h, paduano f, pierantoni gm, soddu s, croce cm, fusco a. targeted disruption of the murine homeodomain-interacting protein kinase-2 causes growth deficiency in vivo and cell cycle arrest in vitro. dna cell biol 2009; 28(4): 161-167. doi: 10.1089/dna.2008.0778 http://online.liebertpub.com/doi/abs/10.1089/dna.2008.0778 retraction: dna and cell biology. march 2014, 33(3), 189-189 http://online.liebertpub.com/doi/full/10.1089/dna.2008.0778.retract the charge to access the notice: us $51 (24 h access) http://online.liebertpub.com/doi/abs/10.1089/dna.2008.0778 http://online.liebertpub.com/doi/full/10.1089/dna.2008.0778.retract bangladesh journal of bioethics 2015; 6(1):27-39 39 case 10 (sage) publisher is cope member? yes journal is cope member? yes guo k, jiang y-b, zhou z-w, li y-g. nut consumption with risk of hypertension and type 2 diabetes mellitus: a meta-analysis of prospective cohort studies. eur j prev cardiol 2013; august 8: 2047487313501120. doi: 10.1177/2047487313501120 http://cpr.sagepub.com/content/early/2013/08/08/2047487313501120.abstract retraction: http://cpr.sagepub.com/content/early/2013/08/08/2047487313501120/suppl/dc1 the charge to access the notice: us $36 (24 h access) http://cpr.sagepub.com/content/early/2013/08/08/2047487313501120.abstract http://cpr.sagepub.com/content/early/2013/08/08/2047487313501120/suppl/dc1 microsoft word ethics in telemedicine bangladesh journal of bioethics 2015; 6(3):30-36 30 original article: ethical aspects of dhaka university tele-medicine system ahmed raihan abir 1, shamima parvin lasker 2 1. department of biomedical physics & technology,university of dhaka, bangladesh email: raihan.abir@bmpt.du.ac.bd 2. professor & head, department of anatomy, mh samorita medical college, dhaka abstract: to provide basic health care services in rural areas is one of the major challenges for developing countries like bangladesh because of lack of infrastructures and unavailability of qualified medical doctors in the villages. telemedicine viewed as a new way of offering health care services that has the potential to overcome this problem. author is a member of extended group at dhaka university (du) which has been developing telemedicine equipment and data acquisition software to promote telemedicine practice in bangladesh. pc based ecg equipment, digital stethoscope, digital microscope, digital x-ray view box and some other essential medical equipment was developed for telemedicine services. the data acquisition software establishes an easy and appropriate patients to doctor interaction through a trained operator in a remote center that involve management and arrangement of consultation of a chosen and agreeing doctor by a patient. upon establishing audio-visual connection between patient and doctor relevant physiological data from different diagnostic instruments will be uploaded securely in a dedicated web server which can be viewed real time using unique patient/doctor id and password. recently the telemedicine group of du and a local ngo named samama with support from service innovation fund (sif) of prime minister office (pmo) of bangladesh took the initiative to establish eight rural telemedicine centers and one expert center for the field trial of telemedicine in bangladesh. the aim of this paper is to examine the ethical challenges of such health care system and our effort to overcome those problem before starting the field trial. keywords: telemedicine, bioethics introduction: almost 70% of total population live in rural areas of bangladesh. there are only 3.6 doctors for 10,000 people. for this reason many people tend to take religious medication from various religious institutions or consult village doctors who has little or no formal training for curative purpose 1. the who has identified the necessity for further medical resources in the developing countries and has suggested telemedicine as a promising solution 2. telemedicine can be defined as a practice of medicine over a distance, in which interventions, diagnostic and treatment assessments and recommendations are based on data, documents and other information transmitted through telecommunication systems. bangladesh government has recently established internet links with video capability to almost all the rural health complexes (called upazilla health bangladesh journal of bioethics 2015; 6(3):30-36 31 complex), together with pc and necessary accessories. recently thousands of rural community clinics have also been provided with laptop and internet connections. therefore it is an appropriate field for the incorporation of telemedicine. in bangladesh, several groups are working in telemedicine. however most of these depend on video conferencing only having no diagnostic equipment at the rural end. although some of these are using some diagnostic equipment from abroad, but the cost are prohibitively high. besides, most of foreign equipment are not designed to work in the hot and humid climate under an uninterrupted electricity supply. keeping these problem in view, the department of biomedical physics and technology (bmpt) at dhaka university started developing a telemedicine system based on a pc with some integrated diagnostic equipments using information such as documents, laboratory results, ecgs, heart sound, digital photograph, real-time ultrasonography or video, video recordings and physiological data such as blood pressure, hemoglobin saturation, heart rate and spirometry can be transferred from rural center by secure web based application3-8. hardware developed for telemedicine purpose has been tested, compared with existing technology and had been certified by an expert board formed by the directorate general of health services to implement health programs and services for the ministry of health of bangladesh. figure 1: basic concept of telemedicine system telemedicine is rapidly becoming popular in many countries in the world. it has several advantages such as being cost effective and ability to provide better access to health care in remote areas in many parts of the world including developed countries. like telemedicine, as with anything new, there is often resistance. gainsayers have been quick to cite possible ethical and regulatory complications associated with telemedicine. one of the major challenges is that of patients’ rights and confidentiality in the use of telemedicine. there are still no standard guidelines and procedures in the practice of telemedicine which make both patient and physician uncertainity about the standard of practice and how to maintain confidentiality. medical liabilities of such system are also very crucial. in cases where damages occur a clear identification of the medical liabilities involved has to be ensured 9. there are several guidelines for telemedicine has bangladesh journal of bioethics 2015; 6(3):30-36 32 been found to overcome such ethical challenges mostly developed by the usa, uk, india and australia which focus, to different extends, on clinical, operational or technical aspects of various types of telemedicine and tend to be specific or a sub-specialty with the medical field. only three countries and one association have published ethical guidelines. after the publication of clinical guideline developed by the general assembly of the world medical association in 1999 and finland in 1997 and internet ehealth code of ethics was drafted in 2000 to ensure that the people can use the internet to manage health with knowledge of the risks and benefits. the world medical association (wma) started four principles of telemedicine practice in ethical guideline 10. the aim of this paper is to examine the ethical challenges of such health care system in bangladesh and how to uphold the ethical principles. figure 2: bmpt du proposed telemedicine web application procedure of telemedicine in bangladesh: du developed telemedicine offers a direct consultation between patient and a registered doctor, by creating a ‘virtual consultation’ environment through communication links as provided by existing technology. since the invention of telephone, telemedicine started through telephonic conversation between a patient and a doctor at a distance. however, one can easily understand its limitations, so telemedicine did not go a long way in the past. in the present age, computers with their astonishing capacity and power with fast internet links can facilitate almost real time video & audio communication and other data transfer from electro-medical diagnostic equipment, creating an environment which is very close to direct consultation by a doctor. in general, doctor-patient relationship has been characterized by the clinician’s duties relating to confidentiality, risk disclosure and patients right to privacy and autonomy. in the present form of our telemedicine system, a patient comes to a rural center manned by one or more trained technician and equipped with internet connected computers and appropriate diagnostic instruments. this rural center is connected to an expert center situated at bangladesh journal of bioethics 2015; 6(3):30-36 33 another place, possibly in a city or a district town, through internet. the expert center is manned by qualified doctors. the patient consults the doctor through internet communication and the doctor tries to acquire as much diagnostic information as possible during the session including a direct video conversation. the doctor then gives a prescription to the patient giving advice on medication, diet, physical movement or exercise, and may ask for carrying out some other specialized investigation and to come back with the report at a later session for update. a few doctors taking turns in one expert center can serve many remote rural centers, and distance is of no problem. generally speaking, the medico-legal position of doctors involved in our telemedicine consultation is similar to that when telephone, fax, email or letter is used instead. all amount to the delivery of advice from remoteness and the standard of care and skill will apply. the patient – physician relationship will be based on a personal encounter and sufficient knowledge of the patient’s personal history. it will be based on mutual trust and respect and will be assisted primarily by expert technician deployed in the rural centers. historically, doctor-patient connection has been characterized by the clinical right to confidentiality and sovereignty. with the introduction of electronic mediation and the possibility for extended facilities, the physician’s duties also increased. in our system, obligations, appropriately, are placed on both the rural and expert center. the service will be provided in a private setting with digital line. the consumer will be educated about the nature and purpose of the system, equipment and any potential breaches of confidentiality inherent in the technologies installed and will be question regarding the level of satisfactory action. data confidentiality and security: du developed telemedicine web application has the capability to produce digital patient file, digital physician’s consultation, digital prescription and patient registration card. these will facilitate and improve the treating of sensitive medical data as well as the promises for using medical resources in an unusual degree and can thereby considerably contribute to the well-being of the patient. a research conducted by kenyon reveals that security is not merely a technological challenge, but represents potentially significant human factor barrier 11, 12. by improving the quality of health care, our system has no intention to degrade patients’ rights, in particular their self-determination. but as it will be a field trial certain evaluation of patient data is required to ensure better service and to gain better understanding about certain disease and demography. therefore, the technician will let patient know about the future research possibilities with the data and will give a consent form. each patient will have the right to share their medical data for research purposes. if any person doesn’t want to share his/her data it will be remain secured and will then only be accessed by the patient and physician involved. our system follows the legal basic conditions for medical data processing and data security i.e. the discretion, the integrity, the accessibility of the data at any time and the verifiability of the data processing will be guaranteed as well. web server containing all the medical information will be secured efficiently against any dangers resulting from open networks, particularly the internet. electronic patient’s files can only be opened by the treating physician and the medical assistants up to necessary magnitude, safeguarding the likelihood of an emergency access. any access beyond will bangladesh journal of bioethics 2015; 6(3):30-36 34 require the approval of the patient. the medical secrecy will be ensured. the digital prescription with a documentation of the patient's medication will require the consent of the patient and will protect the rights of the physicians. in particular, physician's prescribing behavior can only be seen by the physician and won’t be available for a third party. furthermore it will protect the pharmacists' right to hide their revenue from other pharmacies. patient registration cards will require the consent of the patient. the right of the patient to keep his information secret will be ensured with access options to the information stored on the registration card. responsibilities of doctor and rural technician: to understand responsibilities of doctor and rural technician let us first review how a direct consultation between physician and patient works with the help of rural technician in our telemedicine system. a patient comes to a doctor, and the doctor gets information in various waysa) listening to physical complains from the patient directly through mobile phone either by audio or video call. b) visual observation of the overall look of the patient. c) special focused look at certain organs like eye, tongue, or skin, etc. d) touching and pressing different points of the body of the patient to feel for any abnormality. d) using different diagnostic devices to probe further into the body that which is not apparent externally. some of these are used by the doctor on the patient directly (as a stethoscope), and for some s/he asks for data and reports of diagnostic tests carried out by others, to be produced during a later visit by the patient. e) sometimes an assistant takes some prior information on the patient like height, weight, temperature, blood pressure, etc., and hands over the records to the doctor. based on all information received, the doctor makes an assessment of the medical problem and may prescribe medicines, diets and give necessary advice. a physician whose consultation is sought through the use of telemedicine will store a detailed record of the advice s/he conveys as well as the medical data s/he received was conveyed. both the physician and technician will ensure that the patient or family members caring for the patient are able to use telecommunication system and necessary instruments accordingly. they both will also ensure that the patient has understood the advice and treatment recommendations given and that the continuity of care is assured. there will be an emergency transportation service available and will be used when direct consultation between physician and patient is required. implications of telemedicine in bangladesh: rural people are often deprived of proper medical treatment in bangladesh as it is difficult to retain qualified doctors there. telemedicine offers a solution but most of the current telemedicine systems in use in bangladesh are based on videoconferencing only which may lead to incorrect diagnosis and wrong treatment. pc based diagnostic equipment, if added, could allow a doctor to assess and diagnose a patient better. such equipment based telemedicine systems are available from foreign manufacturers, but the cost is very high. since such pc based diagnostic equipment will be needed at each of the hundreds or thousands of rural health centers eventually, the final bill will be prohibitively high. furthermore, if something goes wrong in any equipment, it will be very difficult to fix, if not impossible, to get it repaired locally that may interrupt the service to the people. bangladesh journal of bioethics 2015; 6(3):30-36 35 du telemedicine project will essentially bring the services of qualified medical experts to the doorsteps of the common people throughout the country, even in the remote rural areas. although a telemedicine cannot match a face to face consultation, it is much better than no consultation at all. rural poor, particularly the marginalized people, women and the physically disabled are deprived of the consultation of a qualified doctor for most of their ailments, as it is difficult to go to a hospital or a clinic in the town, physically and financially too. telemedicine can at least give them an opportunity of consulting a qualified doctor at a reasonably low cost at a center very close to their place of residence. even in remote areas of industrially developed countries telemedicine has rooms to play. the use of indigenously developed diagnostic equipment and software for telemedicine has opened up the possibility of spreading this service out to a much larger population. conceptually the whole of bangladesh can be brought under a network with affordable costs. since the equipment and the software are locally developed, local maintenance and repair, and that at low cost, is ensured, in turn ensuring sustained service. conclusion: du telemedicine system can lead to a big change with respect to improved healthcare within a few years for people living in rural areas through providing consultation of qualified doctors, and particularly, through providing vital diagnostic information using the diagnostic equipment that go with it. indeed there are several ethical challenges of such system but is possible to overcome. once this technology and the model of delivery are successful in bangladesh, it may be possible to export the concept as well as hardware and software to other countries of the third world, bringing a big positive change globally. references: 1. bhuiya a. 2009. health for the rural masses:insight from chakaria monograph no. 8. icddr,b cahpter 8. 2. who committee a. 2005. world health assembly ehealth resolution (wha 58/28). a58. :4–6. 3. rabbani k s, amin abdullah-al, bodiuzzaman a k m, khan ahamad imtiaz, abir ahmed raihan & tarafder zihad. an indigenously developed affordable and sustainable telemedicine system. appropriate healthcare technologies for low resource settings aht2012, 2014 london, uk. 4. rabbani k s, amin abdullah-al, bodiuzzaman a k m, khan ahamad imtiaz, abir ahmed 5. abir ahmed raihan & rabbani k s. indigenous development of a computerised 12 lead diagnostic ecg equipment. international conference on physics of today, 2012a buet, dhaka. bangladesh physical society. 6. abir ahmed raihan & rabbani k s. low cost computerised stethoscope for phonocardiography and real time telemedicine. international conference on physics of today, 2012b buet, dhaka. bangladesh physical society. bangladesh journal of bioethics 2015; 6(3):30-36 36 7. rabbani k s, abir ahmed raihan & bodiuzzaman a k m. 2011a. design and development of a low cost personal computer based ecg monitor. bangladesh journal of medical physics, 4. 149. http://dx.doi.org/10.3329/bjmp.v4i1.14701. 8. rabbani k s, al-amin abdullah, abir ahmed raihan, bodiuzzaman a k m, khan ahamad imtiaz & tarafdar m zihad. 2011b. a rural health monitor with telemedicine. biomedical engineering. 9. gulick pg. 2002. e-health and the future of medicine: the economic, legal, regulatory, cultural, and organizational obstacles facing telemedicine and cybermedicine programs. . albany law journal of science and technology, 12. 351-408. 10. wma. 2007. wma statement on the ethics of telemedicine [online]. 58th wma general assembly, copenhagen, denmark. 11. kenyon ji sessions gr. security and confidentiality issues. telemedicine journal and ehealth, 2003. 12. tachakra s mullett st, freij r, sivakumar a. 1996. confidentiality and ethics in telemedicine. ournal of telemedicine & telecare, 2 suppl 1. 68-71. conflict of interest: no authors' contributions: 1st author conceptualize and written the article whereas 2nd author scrutinized and meticulously contribute in correction of manuscript. microsoft word organizational justice bangladesh journal of bioethics 2015; 6(3):10-24 10 original article organizational justice and employee’s service behavior in the healthcare organizations in bangladesh: an agenda for research md. nuruzzaman 1 md. humayun kabir talukder 2, 1. hrm freelance consultant and mphil researcher, bangladesh university of professionals, dhaka; email: zaman.sph@gmail.com, phone: 01721786945 (corresponding author) 2. professor (curriculum development), centre for medical education, dhaka abstract: bangladesh is aspiring to achieve universal health coverage by 2030. in this regard, quality and efficient healthcare delivery have been regarded as a major challenge. proper management of employees is crucial for service organizations like healthcare because in healthcare employees provide life saving services which make them unique from other non-health professionals. they directly interface with the patients or service seekers who make evaluative judgment of the quality of service delivered by the employees. therefore, it is important that healthcare organizations (both public and private) comprehend specific organizational factors and issues that influence employee’s attitudes and behaviors, which ultimately affect their service behaviour at work. drawing from the organizational justice principles and other management theories, this article presents a conceptual framework and a set of hypotheses regarding the relationships among distributive justice, procedural justice, interactional justice, employee’s citizenship behaviour, role prescribed behaviour and counterproductive behaviour for the healthcare organizations in bangladesh. the purpose is to assist the policy makers and service providers in identifying desirable human resource management practices that healthcare organizations in bangladesh should seek and engage in and at the same time, avoid undesirable practices in order to maintain optimum level of employee commitment, and citizenship behavior essential for ensuring quality and efficient service delivery to the communities. this article is ‘theoretical’ but it has practical implications for the policy makers and service providers who are directly involved with service delivery system. it is also expected that the paper enriches the health service delivery literature and also advocates focusing on justice perspectives particularly in bangladesh. key words: organizational justice, distributive justice, procedural justice, interactional justice, employee service behavior, citizenship behavior, role prescribed behavior, counterproductive behavior, healthcare organization, and bangladesh bangladesh journal of bioethics 2015; 6(3):10-24 11 introduction: the issue of justice is a key concern to virtually all individuals across the society or organization1. the concept “organizational justice” has emerged and widely discussed in various disciplines such as organizational behavior, human resources management (hrm), social psychology, industrial relations and others. contemporary studies2 3 4 5 6 indicate that employee’s perception of organizational justice immensely influences his or her service behavior at work and hence organizational performance is affected. with this conception, this study has been planned. primary aim of this study is to investigate the relationship between organizational justice (oj) and employee service behavior (esb) in the healthcare organizations of bangladesh. to do so, hrm practices of the relevant organizations will be explored. this will be done through conducting extensive literature review. it is expected that this literature review will assist to gather in-depth knowledge and information to explore the mediating factors contributing to build the relationship between oj and esb and also to develop the conceptual framework of the study followed by development of related hypotheses. background rationale: employee’s perception of justice or the state of being just in the organization has been discussed for long time. all most everybody has an aversion to injustice7 8. this is also true for the human resource working for health or involved in delivering health services. human resources for health (hrh) are the most valuable assets of any health service organization. in fact, health care cannot be thought without a human resource9. the unique feature of this resource is – they save lives, lesson sufferings of the patients and promote well being of the people. according to the world health report10, human resource is the central of every health system. it also suggests that “health care providers are the personification of a system’s core values – they heal and care for people, ease pain and suffering, prevent diseases and mitigate risk”10. therefore, proper management of this resource is crucial for achieving organizational success. but little is known about the state of feeling “just” among the human resources attached with the health service organizations. justice literature indicates that organizational justice has significant influence on organizational performance as well as individual performance. since healthcare is highly a labor intensive service, ensuring organizational justice is, therefore, critical to any healthcare organizations, in fact, any organization related with service delivery e.g. hospitality, banking, education and others. in bangladesh not many studies have been conducted to investigate the relationship between organizational justice and employee service behaviour particularly in the public sector. however, empirical experiences, study reports, evaluations, policy documents11, 12 indicate that management of human resources has been a challenge and a priority area of intervention of the ministry of health & family welfare (mohfw). employee retention especially in rural areas, absenteeism, recruitment and selection, performance appraisal, training and career development and compensation and benefit are the major management concerns of mohfw and other organizations bangladesh journal of bioethics 2015; 6(3):10-24 12 in the private sector. therefore, it is important to assess and explore the state of justice as perceived by the employees through scientific assessment hence the study is planned. purpose/aim of the study: the study primarily aims to develop a conceptual framework and a set of hypotheses based on organizational justice principles while analyzing the relationship between employee’s perception of organizational justice and their behaviour at work at healthcare organizations in bangladesh. while going to do so, key determining factors of the concepts ‘organizational justice’ and ‘employee’s service behaviour’ are to be identified. later how those determinants affect each other will be assessed in order to establish mutual relationship. methods: it is important to mention that the paper is mostly theoretical as opposed to applied research. a research can be defined as theoretical when: “it aims to increase understanding of phenomena and the relationships among key components of phenomena; and to accomplish these goals, researchers develop and test models reflecting the properties of the phenomena, the relationships among various aspects of the phenomena, and the relevant external factors”13. an extensive literature search was conducted during the period october – november 2015 for development of an academic research proposal for the study master of philosophy (mphil) of the lead author. ‘google scholar’, ‘google web’, ‘biomedcentral human resources for health’ and ‘ebscohost’ search engines were used to collect peer reviewed journal articles and other academic publications related to the concepts ‘organizational justice’ and ‘employee service behabiour’. in this study, we have developed a model and a set of hypotheses depicting the relationship between the concept organizational justice and employee service behaviour. key components of those concepts are identified and then effect is tried to be explored. hence, although the paper is said to be theoretical it, however, has practical applications for practitioners, researchers, and policy makers because testing the model could lead to identification of hrm best-practices that can be used in solving the real organizational problem of health service delivery in bangladesh. in developing the model, we started with an extensive literature review aimed at among others identifying relevant variables and comprehending their interconnectedness. in this respect, we used sekaran’s method14 (figure 3) that involves identifying the dimensions (key variables) relating to a problem under investigation and the dimensions (variables) into measurable elements3. through the review of the related literature we identified employee justice perceptions at the workplace which include distributive justice, procedural justice and interactional justice; employee’s citizenship behaviour, role-prescribed behavour and counterproductive behaviour as the key variables related to the problem effective and quality service delivery in the healthcare organizations in bangladesh. following on this, we decomposed each of these dimension (variables) into measurable elements. we then linked the variables together to form an integrated model. based on the model, we developed a set of hypotheses regarding the relationships among those variables. the figure 3 is bangladesh journal of bioethics 2015; 6(3):10-24 13 summary of key concepts and relationships among variables that represents the overarching framework of this paper. literature review: organizational justiceorganizational justice (oj) got significant attention when homans15 introduced the concept of distributive justice and later social scientists including management experts began to pay attention to this fundamental aspect of human behavior. the concept started getting focus in organizational behavior research with the work of the scholars like blau16 and adams17. definition of organizational justice varies significantly as most of the definitions come from individual perceptions while looking into this as it refers to anyone's subjective perceptions of the fairness of allocations18. cropanzano, bowen and gilliland19 define organizational justice as it is a subjective and descriptive concept that captures what individuals believe to be right, rather than an objective reality or a prescriptive moral code. it is further mentioned that it is a personal evaluation about the ethical and moral standing of managerial conduct. this denotes that management needs to take an employee’s perspective while defining justice. the authors like bowen, gilliland and folger20 and moorman et. al.21 have correlated a set of "justice principles" associated with fairness in hrm practices. three types of principles are proposed such as: distributive, procedural, interactional justice. distributive justice: distributive justice is called the first component of justice principles. it is concerned with the reality that all employees are not treated in the same way as allocation of outcomes is differentiated in the workplace22. employees are concerned whether they receive the just share or not17. sometimes things are distributively just when the most qualified person gets promoted. but sometimes it goes in an unusual way as someone is promoted due to the political relations with the higher management. adam’s equity theory17 has a significant contribution on distributive justice. according to the equity theory, people are interested in how much they get table 1: component of organizational justice source: cropanzano, bowen and gilliland19 bangladesh journal of bioethics 2015; 6(3):10-24 14 relative to how much they contribute. one must work harder in order to be equitable. cropanzano19 et al. identified three allocation rules that can lead to distribute justice if they are applied appropriately: equality (to each the same), equity (to each in accordance with contribution), and like no other person (need) 19. equity tends to provide individual rewards for high performance, whereas equality tends to build esprit de corps among teammates. these rules embark on aristotle’s famous dictum that all men wish to be treated like all other people (equality), like some other people (equity), and like no other person (need)19. procedural justice: procedural justice is the process by which outcomes are allocated but not specifically the outcomes themselves 19. the key message of this principle is that everybody is equal in front of law or rules and its process. a justified process is one that is applied consistently to all, free of bias, accurate, representative of relevant stakeholders, correctable, and consistent with ethical norms and values. further, just decisions are those that result from fair procedures. the most influential of early procedural justice researchers were thibault and walker who examined perceptions of justice in dispute resolution23. procedural justice research has resulted in vast evidence that decision control (authority to make a decision) is an important contributor to perceptions of justice. people are more likely to perceive that a decision is fair if they feel they have had a voice or a sense of process control (opportunity to influence the decision maker) and people are more likely to accept unfavourable outcomes when they perceive that the process of arriving at the decision was fair24 25 26 27. these findings suggest that employees are not simply looking for favorable outcomes in decisions; they expect fair procedures in decision making. interactional justice: according to cropanzano et al. and folger and cropanzano, interactional justice refers to how one person treats another19, 25. interactional justice is associated with communication and interpersonal treatment. informational justice is the result of open and honest clarifications and explanations as well as adequate justification of actions18. pursuing perceptions of informational justice could prove to be difficult in the context of talent management, as the majority of organizations do not inform their employees about talent management practices18, 28, 29. this is related with organization’s recruitment and selection strategies including succession planning. there is another kind of interactional justice which is about interpersonal justice. it refers to the respect and dignity with which one treats another19. in healthcare organization it has an immense implication. in healthcare, not a single category of health professionals provide or responsible for providing care to the patients. there are more than one such as physician, senior physician, nurse, technologist, pharmacist, cleaning staff and other support staff. for workplace productivity and smooth functioning of the organization there is a need to respect each and acknowledgement to each other contribution. understanding the concept ‘employee service behaviour’: several authors have taken the effort to define employee service behaviour (esb)30 31 32. zerbe, dobni & harel have conceptualised bangladesh journal of bioethics 2015; 6(3):10-24 15 service behaviour as ‘the nature and content of the interpersonal interaction between the service providers and the customers’31. simply we can say that the behaviour that is showed by the employee towards the customer during interaction in job can be stated as employee service behaviour (esb). behaviour could be either positive or negative, both have consequences on organizational performance. obviously, there is no doubt, in any service organisation esb refers to the positive behaviour towards service seeker or customers. in a study conducted by zerbe dobni & harel it is found that the degree of positive behaviour employees showed towards passengers (happy, pleased) was strongly related to airline passenger satisfaction with customer service provided both by the airline and individual employee31. moreover, browning has stated that service oriented behaviour focuses on people’s needs and taking action, often beyond the call of duty, to meet those needs, which refers to extra role service behaviour32. considerably tsaur and lin have defined esb into two categories; “extra-role” service behaviour, which is also known as citizenship behaviour (czb) and “role-prescribed” behaviour (rpb)33. this definition is consistent with that pro-social service behaviour in the organisational behaviour literatures34. behavioural scientists and management experts identified another type of behaviour which is called “counterproductive bevaiour (cpb)”. cpb goes against the goals and objectives of organizations36. the authors rotundo and spector describe the individual and environmental factors that increase the likelihood of 'cpb', which include interpersonal conflict amongst employees; job insecurity; and perceptions of organizational injustice35. figure 1: describing employee service behaviour citizenship behaviour: citizenship behaviour (czb) refers to the discretionary behaviour of contact employees in serving the recipients that extends beyond formal role requirements34. to perform czb, employees always need to take extra responsibilities on behalf of the organisation. these responsibilities usually cannot be classified in the job description. this is particularly true for healthcare organizations. they seem to be the stakeholders of the organisation as they hold the ownership of their jobs. it is the organisation who will provide ownership to the employees. the most popular definition of citizenship behaviour is given by organ37; “… discretionary behaviours that are not directly or explicitly recognised by the formal reward system and that, in the aggregate, employee service behaviour citizenship behaviour counterproductive behaviour role-prescribed service behaviour bangladesh journal of bioethics 2015; 6(3):10-24 16 promote the effective functioning of the organisation.” he identified five major types of organizational citizenship behviours (ocbs): altruism (discretionary behaviours related to help a specific other person with an organization); conscientiousness (discretionary behaviours that go well beyond the minimum role requirements of the organization); sportsmanship (willingness to avoid complaining, petty grievances, railing against real or imagined slights or alike)37; courtesy (i.e. willingness to prevent work-related problems with others from occurring); civic virtue (willingness to participate in, is involved in, or is concerned about the organization). role-prescribed service behaviour: ‘‘role-prescribed’’ service behaviour refers to expected employees behaviour that may derive from implicit norms in the workplace or from explicit obligations as specified in organizational documents such as job descriptions (cited in tsaur and lin33). for example, hotels like holiday inn monitor role-prescribed service behaviour such as greeting the customer by name, answering the phone within three rings, and making a personal pledge to a customer that a request will be handled33. marketing studies reinforce the importance of similar behaviours for customer service quality perceptions38. counterproductive behaviour: there are three types of work behaviour identified (figure 2) and counter-productive behaviour (cpb) is one of them. cpb upholds the various acts which include: rumours among co-workers, absenteeism, stealing, sabotage of co-workers, theft, refusing to cooperate, withholding of efforts of the coworkers, physical assault, withdrawal, and lying against your co-workers39. however, spector et al.36 identified five primary categories of counterproductive work behaviors: sabotage (i.e., wasting materials/supplies, damaging equipment/property, destroying the atmosphere of the office); withdrawal (i.e., absenteeism, tardiness, leaving work early, taking excessive or long breaks); production deviance (i.e., doing work incorrectly or slowly, failing to follow instructions); abuse (i.e., making offensive comments, starting arguments or making rude gestures, threatening or harming others, disrespecting privacy); and theft (i.e., taking items from office or employees, incorrectly reporting hours worked). we will consider spector’s classification of cpb in this study. why employees care about justice: a good number of studies has been conducted to investigate why employee look for justice at workplace. however, justice or fairness is a common concern to all including employee. the extent employees perceive their work environment as unfair, they may develop negative attitudes and emotions such as job dissatisfaction, anger, frustration, and mistrust, leading to deviant behaviour against the organization and other employees40 . cropanzano and his colleagues19 discussed this issue in their article published in the peer reviewed journal “academy of management”. they mentioned about three reasons for which people matter justice. long-range benefit: people are usually contracted in the organization for quite a long period of time. consequently, they assess the present work climate how they are likely to be treated over bangladesh journal of bioethics 2015; 6(3):10-24 17 time19. a just organization helps to make this prediction easy. appropriate personnel policies signal that things are likely to work out eventually. cropanzano and his colleagues suggest that justice provides us with more certainty regarding our future benefits. people want fairness because fairness provides things they like. social considerations: people wish to be accepted and valued by important others while not being exploited or harmed by the powerful decision makers19. the justified treatment tells us that we are respected and esteemed by the larger group. this sense of belongingness is important to us even apart from the economic benefits it can bring. ethical considerations: people also care about justice because they believe it is the morally appropriate way others should be treated26. ethical practice creates tension upon the employees as soon as they observe within the organization and they are more likely to take considerable risks in the hopes of extracting retribution40. in the follow through, injustice may spread ill consequences19. the need to promote employee service behaviour in healthcare organizations: health human resources are engaged in providing life saving services and also reducing ailment of the patients10. patient’s satisfactions and continuous improvement of service quality as well as timely service delivery are the key focuses of healthcare organizations41. since employees are the key service providers they are the key concerns of the organization. world health report10 identified four dimensions of health workforce/employee’s performance which are such as: availability, productivity, competency, and responsiveness. availability encompasses distribution of the employees and their timely attendance at the workplaces. competency denotes the combination of knowledge, skills and behaviours. responsiveness encompasses that people are treated decently, regardless of whether or not their health improves or who they are. finally productivity indicates maximum utilization of existing resources and reduction of time wasting 10. all of those dimensions urge for promotion of employee service behaviour at the workplace. moreover, organisations are continuously focusing on improving service quality for several reasons: (a) there are pressures from outsider competitors and stakeholders; (b) customers are increasingly willing to take services elsewhere if they are dissatisfied with service quality30; finally (c) organisations all over the world normally keep trying to improve service quality to keep up with the changing pattern of taste and demands of service recipients30. for many manufactured goods, quality can be evaluated against objective internally defined criteria. this is not the case for healthcare services, because of its intangibility, inseparability, heterogeneity and perishability natures of quality. the literature on services management has not addressed in any systematic framework the specific types of behaviours that are required for service excellence30. moreover, organisations may not want to specify fully all of the service-oriented behaviours, which employees should display at bangladesh journal of bioethics 2015; 6(3):10-24 18 work. as doing so may reduce employees' intrinsic motivation42 and may limit flexibility in the face of unforeseen contingencies. as katz43 in 1964 argued, “an organisation which depends solely upon its blue-prints of prescribed behaviour is a very fragile social system”. he argued that organisations must leave some things unspecified so that employees can appropriately deal with unexpected contingencies30. if they can perform their functions properly it is an advantage, but if they perform poorly, it is not favourable to the organisation. so employees need to have some rights or capabilities to show extra care or to react positively to the customers/service recipients to satisfy their needs. research gaps: in the secondary literature the concept organizational justice is well discussed and it is not a new concept and its determining components are also referred by many authors in several journals. in the review of literature, importance of oj is discussed and described and its determining factors are identified and explained how oj contributes to organizational performance and also its sustainability. it is also described why employees are concerned about justice and how oj impact on their work behaviour which ultimately affect on achieving organizational outcomes. theoretically the concept oj is supported by various literature17 44. but a gap has been observed how oj principles affect the work behaviour of the employees in healthcare organizations particularly in bangladesh. in fact no study has been found available in the public domain on the issue of oj and employee’s work behaviour realizing that healthcare organizations in bangladesh are suffering from various work-related challenges such as absenteeism, lack of productivity, inefficiency in resource utilization, high turnover in the private sector and others, which is a priority concern of this study. conceptual framework: based on the literature review the key words or concepts can be identified such as organizational justice (oj), employee service behaviour (esb) and healthcare organization. each of the concepts can be broken down into its determining factors. oj has its three forms i.e. distributive justice (dj), procedural justice (pj), interactional justice (ij). esb is described by three determining factors which are such as citizenship behaviour (czb), roleprescribed behaviour (rpb), and counterproductive behaviour (cpb). if all key concepts and variables are put together and relationship is established in order to assess associated impact the conceptual framework can be drawn like this (figure 2). bangladesh journal of bioethics 2015; 6(3):10-24 19 developing hypothesis: considering the context of bangladesh and literature review following hypotheses can be framed: h1: there is a relationship between organizational justice and employee’s service behaviour in the healthcare organizations in bangladesh distributive justice and employee’s service behaviour h2: perception of distributive justice is positively related with employee’s citizenship behaviour in the healthcare organizations in bangladesh. h3: perception of distributive justice is positively related with employee’s role-prescribed behaviour in the healthcare organizations in bangladesh h4: perception of distributive justice is negatively related with employee’s counterproductive behaviour in the healthcare organizations in bangladesh. procedural justice and employee’s service behaviour h5: perception of procedural justice is positively related with employee’s citizenship behaviour in the healthcare organizations in bangladesh. h6: perception of procedural justice is positively related with employee’s role-prescribed behaviour in the healthcare organizations in bangladesh. h7: perception of procedural justice is negatively related with employee’s counterproductive behaviour in the healthcare organizations in bangladesh. interactional justice and employee’s service behavior h8: perception of interactional justice is positively related with employee’s citizenship behavior in the healthcare organizations in bangladesh bangladesh journal of bioethics 2015; 6(3):10-24 20 h9: perception of interactional justice is positively related with employee’s role-prescribed behavior in the healthcare organizations in bangladesh h10: perception of interactional justice is negatively related with employee’s counterproductive behavior in the healthcare organizations in bangladesh. figure 3: conceptual framework of the study figure 3 denotes the relationship between the determining factors of two concepts oj and esb. dj is described by three factors i.e. equity, equality and need. pj is described by six factors i.e. consistency, unbiased, accuracy, representativeness, correction and ethics. ij is described by two factors i.e. informational and interpersonal. on the other hand, rpb is prescribed by one factor i.e. behavior according to job description; czb is symbolized by helping attitudes and cpb is prescribed by five factors i.e. sabotage, withdrawal, production deviance, abuse and theft. now the study aims to explore how justice-determining factors correlate with the esb determining factors, more specifically whether the relationship between oj and esb is positively or negatively correlated with an example of healthcare organizations in bangladesh. conclusion: the literature review suggests that perception of organizational justice (oj) has an impact on employee service behaviour (esb), which ultimately affects organizational performance. since healthcare is a specialized field and multiple categories of staff work together, application of justice theories and principles are not significantly tested in the healthcare organizations particularly in bangladesh. this study has been guided by an extensive literature review and proposed to apply as well as verify the justice principles in the healthcare context in bangladesh as healthcare organizations are suffering from various employee’s performance related problems and challenges both at public and private sectors and affecting healthcare delivery system of the country resulting inefficiencies, poor customer/patient satisfaction and low level of service quality. going to do so this study has proposed a conceptual framework, which establishes the relationship between the bangladesh journal of bioethics 2015; 6(3):10-24 21 components of oj and the components of esb to show how they affect each other positively or negatively. this relation leaves policy implications in order to strengthening justice framework at organization level. recommendations: the study is important for a number of reasons but the most important reason is that it promotes organizational performance and provides the organizations the strengths to maintain sustainability/competitive advantage. it is expected that the study will introduce the concept oj to the policy makers, health managers, researchers and academicians who are concerned about the performance of healthcare organizations where performance of the health personnel is an issue of attention. there are some recommendations, which can be proposed. firstly, oj should be taken into account while making employee decisions. to support this, justice culture can be advocated to be created at organizational level; secondly, organizations should take into account counterproductive behaviours of the employees and to do so regular monitoring and supervisory systems should be strengthened; thirdly, both equity and equality principles should be taken into consideration while distributing organizational outcomes and benefits; fourthly, interactional justice principles should be strengthened and put into place to promote trust and confidence at organization. fifth and finally but not the least, justice audit should be introduced on regular basis at organization level. limitations: the major limitation of this study is that it is still in development phase. validity test of the conceptual model is yet to be conducted. sample design and data collection are the key activities, which are also considered as challenges`. finance and manpower allocation is also an issue for consideration given that it is an academic study. a vital component of the framework is not taken into account in the study, which is “human resource management practice” (hrm). hrm is the mediating factor by which organization and employee interacts each other. conflict of interest: the authors declare no conflict of interests. references: 1. tsai mc. 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(1964), “the motivational basis of organizational behavior”, behavioral science. vol.9, pp.131-146; 44. dzansi, d. y. and dzansi, l. w.(2010), “understanding the impact of human resource management practices on municipal service delivery in south africa: an organizational justice approach”, african journal of business management, vol. 4 (6), pp. 995-1005 bangladesh journal of bioethics 2014; vol 5 issue 3 editorial this is the last of the 2014 issue of the bangladesh journal of bioethics and we look forward to newer and stronger issues in 2015 with a theme based approach bringing aspects and concerns on bioethics to the fore front. as the name suggests bioethics deals with the ethical standards and practices relating to all living being –humans, flora and fauna. research articles from different organizations, experts and institutions are welcomed for peer review and selection. the current issue presents the following articles: zoheb rafique and urooj bhatti discuss the practice of informed consent, confidentiality and privacy by physicians at a tertiary care teaching hospital . the paper assesses the practice of medical ethics by the physicians at a public sector hospital in sindh through a survey of four medical units of tertiary care hospital at jamshoro . the majority of patients reported that informed consent was taken from them and that privacy and confidentiality maintained during their treatment. however, many patients stated that they were not properly informed about the laboratory findings, role of proposed drugs and also side effects of drugs. the authors recommend awareness workshops to be conducted to update and improve the knowledge of medical ethics among physicians alma linkeviciute, et al discusses the challenges of setting up ethical oncofertility practice in developing countries. the authors bring up issues related to fertility preservation for cancer patients which offers possible solution but also raises ethical questions. the authors provide a summary of ethical principles with options and restrictions to access fertility preservation in developing countries. their proposed model is patient centered and focuses on patient values, needs and wishes. they also provide a list of organizations working in oncofertility field. norman k. swazo discusses the case of jahi mcmath and the ethics of the brain death standard. the author questions the definition of brain dead in the classical sense versus the current evidence of recovered brain function. the author focuses on the case of 13-year old jahi mcmath, certified dead on the basis of neurological criteria but maintained in mechanical ventilation and care at the insistence of the parents who claim she is alive. in this brief discussion, the medical and legal issues are reviewed. avinash de sousa et al provide an insight on psychosocial and ethical dilemmas arising when doctors are on strikes. this paper is a commentary on whether doctors have the right to strike work or not while keeping in mind, psychosocial and ethical implications of the same. tahera ahmed discusses the role of the recently formed midwifery cadre in ensuring safe motherhood and decreasing maternal deaths. she provides the background and an overview of the midwifery strategic directions for the policy, education, research and deployment for the midwifery profession. she stresses on the need for such a dedicated cadre to bring about a rapid decrease in maternal deaths and bangladesh journal of bioethics 2014; vol 5 issue 3 morbidities in bangladesh where currently 5000 women die every year due to complications of pregnancy, most of which are preventable. shamima parvin lasker general secretary, bangladesh bioethics society; provides an update on recent activities of bbs. she highlights important events such as the establishment of an academic scholarly exchange and collaborative agreement with american university of sovereign nation (ausn), arizona, usa and bbs. ausn is offering a one year master of bioethics and global public health hybrid online and onsite master’s degree program with free tuition fees. collaboration has also been established with college of medicine, national taiwan university & hospital for research and professional training workshop for cancer treatment, hospice/palliative care and bioethics in southeast asian countries. bbs is organizing an intensive training workshop on bioethics and research in dhaka, bangladesh, 2-4 january 2015 in collaboration with eubios ethics institute and ausn. professor darryl macer, director of the institute of indigenous peoples and global studies, and dean, masters program in bioethics and global public health (mbgph), ausn, usa will conduct the training. two members attended the 15th asian bioethics conference, november 2014 in japan. they contributed with their scholarly research papers in the conference and enhance the prestige of bbs. please continue to bring up issues and concerns in the realm of bioethics which will contribute to the improvement of the quality of life on our planet. season’s greetings and happy new year to all our readers and authors! tahera ahmed chief, sexual and reproductive health, unfpa, faculty, north south university, and editor, bangladesh journal of bioethics microsoft word bbs news bangladesh journal of bioethics 2016; 7(1):37 37 bbs news: bbs signed a mou in january 2015 with ausn, arizona, usa for sending its members with scholarships for one year master of bioethics & global public health (mbgph) and master of public health (mph). out of 15 students, eleven students have graduated for the session of 2014-2015. bbs handed over the certificates to awardees at a ceremony of joint ausn-bbs intensive bioethics training course on 13 february 2016 at auditorium of press institute bangladesh, dhaka, bangladesh. following experts were the thesis supervisors. 1. prof darryl macer,phd dean & provost, america university of sovereign nation (ausn), usa. 2. siti nurani mohd noor phd . associate professor of philosophy and bioethics. university malaya, malaysia 3. prof shamima parvin lasker, professor & head of anatomy, mh samorita medical college, dhaka, bangladesh. 4. professor m. selvanayagam, phd., dean research, loyola icam college of engineering and technology (licet), india. 5. duujian tsai, ricd, professor at taipei medical university, twain. 6. chutatip umavijani, associate prof at thammasat university, thailand. master certificate awardees with some of their mentors reflections on the right to palliative care in bangladesh: legal regime revisited bangladesh journal of bioethics 2013; 4(3):25-33 25 reflections on the right to palliative care in bangladesh: legal regime revisited md. jobair alam lecturer , department of law, university of dhaka, bangladesh email: jobairalam@ymail.com abstract: patients with life-limiting illness and their families face many problems and complexities. the gravity of such problem is often escalated with the fact of the patients‘ deprivation of the proper care as a corollary to their fundamental health rights. the legal aspects of the palliative care thus concern the issues of concentrating more on the rights of the patients in getting relief from sufferings of all kinds, physical, psychological and spiritual. as such, it may include the opportunity of getting legal interventions not only in the way of claiming the protection of palliative care (such as securing access to health and social benefits) but also in the face of dealing with other life-transactions of the patients and their families (such as protecting and disposing of property; planning for children and other dependents). this paper is an attempt to articulate these legal dimensions of the right to palliative care in the context of bangladesh. the major focus of this paper will be founded on the wide-ranging constitutional obligation on the right to health, which offers a meaningful space for the right to palliative care by way of implications. more importantly, this paper will clarify the point that taking the right to palliative care seriously will at least result in sensitizing the health right of the people of bangladesh, especially for the poor communities, having limited awareness of their human rights and limited access to and little experience of legal services. key words: palliative care, constitutional obligation, fundamental right, right to life introduction: palliative care is an approach that meliorates the quality of life of patients facing the problems associated with life-limiting illness. in essence, it relates to the prevention of and relief from suffering (and other problems for instance, physical, psychosocial and spiritual) by means of pain management 1 . within the scheme of palliative care, some of the most perplexing and troubling ethical issues are nursing ethics and bioethics. the legal aspects of palliative care thus speak so much for the shift of the rights of the patients to have a holistic and humane treatment from ethical to legal domain. by implications, the right of the palliative care is recognized in some major international and regional human rights instruments 2 , encompassing the issue of health rights 3 . however, in 2006, the world health organization (who) invited the international association for hospice and palliative care (iahpc) 4 to develop an essential medicines list for palliative care in recognition of the centrality of pain management medication to basic health care. apart from this, the who and the international narcotics control board (incb) 5 have called on governments to ensure availability of essential pain medication for all. in the national level, the constitutional provisions guaranteeing ‗right to life’ 6 envisage the similar background of offering the commitment to palliative care. to fulfill this commitment, some countries 7 have established statutory legal regimes for directly regulating the right of the palliative care. this trend of treating the patients‘ right to palliative care as a legal right is getting growing relevancy. but in the context of bangladesh, the issue of the right to palliative care is still negligible. the main reason of this fact relates to the lack of sensitivity and respect to the constitutional obligation to protect and promote public health. for the context mailto:jobairalam@ymail.com bangladesh journal of bioethics 2013; 4(3):25-33 26 of bangladesh, it is thus ironically true that while the rights of the people to the essential health or medical care is yet to cast a serious concern 8 , the issues of palliative care is supposed to be a mere intellectual sophistication. the metaphor of palliative care: ‘the meaning of life in the face of death’ : the legal dimensions of the palliative care can generally be determined with reference to the metaphor of palliative care. the logical link between the reduction of suffering from pain and the enhancement of the pleasure or quality of life is central to the metaphor of palliative care. palliative care provides relief from pain and other distressing symptoms by affirming life and regarding dying as a normal process 9 . by integrating the physical, psychological and spiritual aspects of patients‘ care 10 , it positively influences the course of illness and offers a support system to help the patients live as actively as possible until death. the right to palliative care is thus founded upon the rationale that the patients are entitled to a ‗meaningful life‘ even in the face of death. seen in this light, the legal dimensions of palliative care encompass the idea of patients‘ care by offering a range of facilities including a support system for the family of the patients. this mainly includes the mechanism of overcoming the legal barriers to palliative care such as analyzing of policies and laws that limit access to opioids for pain management, developing the arguments necessary to take a complaint of denial of pain medication to a national, regional or international human rights body or court, providing provision of legal aid to palliative care patients, human rights body, etc. however, life-limiting illness can mean pain and difficulty in a time of bewilderment. it can also bring practical problems, some with legal overtones. these can increase stress for patients and families, and make coping harder. thus, the statutory regime regulating the rights of palliative care should also encompass the system of overcoming other complicated legal challenges such as: protecting and disposing of property, planning for children and other dependents, and securing access to health and social benefits, empowering others to make medical decisions; and writing of wills and so forth. it appears that the legal dimensions of palliative care should offer a support system 11 to help the family cope during the patient‘s illness and in their bereavement, and should use a team approach 12 to address the needs of patients and their families, including bereavement counseling. in this way, the scheme of palliative care is thus intended to ensure that every patient deserving palliative care is coupled with the right of getting a holistic and humane treatment so that the meaning of life of the patients remains unaffected even in the face of death. constitutional obligation to the right to life: searching the space for palliative care: the constitution of the people‘s republic of bangladesh does not specifically provide for the right to the palliative care. under article 15(a), the constitution however, makes it a fundamental responsibility of the state to secure the provision of the medical care for its citizens 13 . again, it is mentioned in article 16 that the state shall adopt effective measures for the improvement of public health 14 . apart from this, article 18 of the constitution speaks for the protection and promotion of public health as among its primary duties 15 . as a matter of law, the obligations of the state relating to medical care or public health do not offer any enforceable rights for the people, because of the fact that these articles fall within the domain of the fundamental principles of state policy 16 . thus, the most important provision relating to the health right of the people can be found under article 32 of the constitution 17 , which guarantees the right to life as fundamental rights. compared to the provisions of article 15(a) and article 18, this article is more sanctified and effective 18 in the sense that it offers a precise space for the right to health care as a corollary to the right to life. thus, the combined reading of bangladesh journal of bioethics 2013; 4(3):25-33 27 these articles seems to cast an obligation on the state as well as on the individual to be sensitive to the rights of the patients suffering from life-limiting diseases. this proposition can be substantiated with reference to the trends of judicial interpretation touching the issues of right to life in bangladesh. the case of dr. mohiuddin farooque v bangladesh is the most striking example of the illuminating interpretation of right to life. in this case, the court gives an extended and more liberalized interpretation by observing that the term ‗right to life‘ means a meaningful life—a life where men can live with dream and dignity. here, the court showed its adherence to exclude anything which might affect the enjoyment of life. the court observed that: ―...articles 31 and 32 of our constitution protect right to life as fundamental right. it encompasses within its ambit, the protection and preservation of environment, ecological balance free from pollution of air and water, sanitation without which life can hardly be enjoyed. any act or omission contrary thereto will be violative of the said right to life‖ 19 . the court in this case further opined that the word ‗life‘ can not be given any restrictive interpretation when it is used particularly with human being and a human life must be distinguished from animal life. the court said: ―…..word life is very significant and broad as it covers all facets of human existence. the word life has not been defined in the constitution but it does not mean nor can it be restricted only to animal life or mere existence form conception of death. life includes such amenities and facilities that a person born in a free country it entitled to enjoy with dignitylegally and constitutionally‖ 20 . in another case the supreme court (sc) of bangladesh extended the term ‗right to life‘ specifically in two cases. firstly, to the protection of health; and secondly, to the normal longevity of an ordinary human being. so, the protections of health and to ensure normal longevity are the constitutional obligation to the persons concerned and a right to the citizen. the sc observed: ―…if right to life under articles 31 and 32 of the constitution means right to protection of health and normal longevity of an ordinary human being endangered by the use of or possibility of any contaminated foods, deeds, etc then it can be said that fundamental right of right to life of a person has been threatened or endangered‖ 21 . it thus appears from this interpretation that the provision guaranteeing right to life is suggestive of at least among others, a) providing the protection of health; b) stabilizing the normal longevity of an ordinary human being; and c) ensuring a dignified life where the persons are entitled to ‗the interest in dying with dignity.‘ in general, the trend of judicial activism in bangladesh does also reflect that our constitution offers space for grounding the rights to palliative care as a constitutional right. in the case of advocate zulhasuddin v bangladesh (2009), the court‘s 22 invalidation of imposition of vat 23 on the medicine and medical care exemplifies that the issue of medication is of prime consideration. again, the recent decision of the court to the point that the treatment of the patient should not be postponed on the requirement of police certification signifies the same respect to medication and pain management 24 . seen as such, it can thus be argued that the right of the patient to the palliative care undoubtedly has constitutional overtones. bangladesh journal of bioethics 2013; 4(3):25-33 28 health related laws and right to palliative care in bangladesh: in bangladesh, there are nearly 90 laws that are found to be related with health or health related subjects 25 . these 90 enactments fall under the seven broad subject-areas of health legislation: vital registration and welfare legislation, public health, communicable disease control, food and drugs control, health education and health practice, environmental health, and protection of children and women 26 . of all these enactments, none has precisely addressed the issue of palliative care. as such, there is still a serious legal vacuum relating to the right of the patients deserving palliative care. however, a patient‘s rights may occur at different levels even under the existing legal regimes. in recent times, there has been a tendency of elevating the position of the patient‘s right, containing a significant bearing upon the rights to palliative care. for example, in 2003 the ministry of health and family welfare published a lift let that recognizes some important rights of the patients, such asright to receive information from the physician about the service; right to safe and continuity of health care; right to confidentiality; right to get respect and dignity; right to share idea; right to get redress; right to inform the highest authority when the rights are violated; right to choice treatment and the method of family planning; right to get all documents relating to treatment; and right to receive all information about the treatment. so, owing to the absence of this legal vacuum in the legal fields relating to palliative care, a kind of indifference to the patients who need palliative care is noticeable. the care which is provided in this arena in different hospitals and clinics is scattered and not made following a holistic approach. so, in order to bring this matter as a fact of significance, specific substantive legal mechanism and compliance are necessary both in terms of content and quantity of law addressing various matters of palliative care. 1. criminal law, negligence and pain management: as a matter of fact, the right to palliative care can well be derived from the law of negligence. the standard of care in palliative medicine may, in addition to the above areas of pain management, also include taking an adequate history, examining the patient, addressing symptoms and, where reasonable, referring on to other experts. the unreasonable failure to do any of the above may constitute a breach of the doctor‘s duty of care to a patient with a life-limiting illness. it is important to note that the law of negligence consistently requires of doctors only what is reasonable in the circumstances of the case. in many jurisdictions the courts will be guided by current accepted professional standards shown by, amongst other things, authoritative guidelines in palliative care practice 27 . in many common law countries, the issues of medical negligence are governed under the purview of tortuous liability 28 . but in bangladesh, the concept of tortuous liability has been accommodated within the fabric of criminal liability. thus, the redress to the medical negligence can be found under the criminal laws of the country. for example, section 284 of the penal code, 1860 29 deals with negligent conduct with respect to poisonous substance which states that whoever does, with any poisonous substance, any act in a manner so rush or negligent as to endanger human life, or to be likely to cause hart or injury to any person, or knowingly, or negligently omits to take such order with any poisonous substance in his possession as is sufficient to guard against probable danger to human life from such poisonous substance shall be punished with imprisonment of either description for a term which may extend to six month, or with fine, which may extend to five thousand taka or both. again, section 304a of the penal code deals with causing of death by negligence. thus, a doctor may be liable under this section, if he gives by his busyness to the patient a toxic medicine in replace of the appropriate one. it appears that the right of the patient to get relief from bangladesh journal of bioethics 2013; 4(3):25-33 29 suffering may be protected under these sections. apart from these provisions of general law governing the issues of negligence, the code of medical ethics, 1991 touches the matter in a triviality. moreover, the bangladesh medical and dental council‘s power is very confined, because they lack power to address the ‗negligence‘ issue. 2. constitutional obligation and public interest litigation: as discussed earlier, the constitution of bangladesh offers a space for grounding the right to palliative care. thus, a patient deserving palliative care can seek constitutional remedy by invoking article 32 of the constitution guaranteeing the right to life. in so doing, the patient deprived of the rights can rely on the interpretive value 30 of the fundamental principles of the state policy which relate to the commitment of protecting and promoting the health rights. more importantly, all the doctors and all other public employee of the hospitals can be held liable on the ground of negligence in the duty by invoking article 21(2) of the constitution 31 . thus, the constitution of bangladesh offers the plausibility of the ‗public interest litigation‘ 32 in respect of the right to palliative care 33 . for example, in a case filled by the ain o salish kendra, the high court division of the supreme court has promulgated a rule nisi 34 directing to the concerned authorities to provide the citizens proper and sufficient health service by abiding the provisions of law 35 . all such remedies are provided under the writ jurisdiction of the high court division of the supreme court of bangladesh. under article 44, the constitution of bangladesh recognizes the right to go to the court for the enforcement of such right itself as fundamental right. conclusion: palliative care is about achieving the highest quality of life (qol) and promoting comfort and dignity for patients with incurable and life limiting diseases. palliative care advocacy has been strengthened by pronouncing that ‗the provision of palliative care is a human right.‘ international covenants have agreed upon this. there are huge unmet needs of patients with life-limiting illnesses in bangladesh as well as in the world 36 . hence, formal palliative care policies and an integrated palliative care services to meet basic standard guidelines in the provision of palliative care is a sine qua non for addressing the issue. the nature of the right entails strong legal dimensions which essentially require a legal web i.e., enactment, statutory framework covering both substantive and procedural provisions. but bangladesh is still in the need of statutory regime directly addressing the rights to palliative care 37 . at this point, it is thus indispensable for bangladesh to develop a home-grown approach of protecting the right to palliative care, based on the general constitutional obligation to the right to life. towards this end, it may follow the different models for a statutory framework which have already been started to be used globally to address this issue. the first is an explicit statutory statement of the right to pain relief. the second model is a statutory protection for doctors. an example is contained in the south australian consent to medical treatment and palliative care act (1995) that protects medical practitioners, in their care of terminally ill patients, from any criminal or civil liability if they administer treatment “with the intention of relieving pain and distress” providing such treatment is given with consent, in good faith, without negligence, and in accordance with “proper professional standards of palliative care.” the third model is a wider package of statutory requirements for pain management and education. many analysts may however disagree about the establishment of a distinct statutory regime protecting the right to palliative care in bangladesh. the major argument leading to such disagreement can be found from the fact that the government of bangladesh has been tremendously failing to satisfy the standard of primary health care to the larger portion of its citizen. in such a context, the concern for the right to palliative care may thus seem to be a mere bangladesh journal of bioethics 2013; 4(3):25-33 30 intellectual sophistication. however, the viable response to this argument is that any initiatives to uphold the right to palliative care will result at least in sensitizing the state as well as the individual to the fundamental health rights of the people. references: 1. the world health organization http://www.who.int/cancer/palliative/definition/en/, (accessed on 14 november 2013). 2. the right to health is the economic, social and cultural right to a universal minimum standard of health to which all individuals are entitled. the concept of a right to health has been enumerated in international agreements which include the universal declaration of human rights, 1948 international covenant on economic, social and cultural rights, 1966 and the convention on the rights of persons with disabilities, 2006. 3. the human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment. on the other hand, the human right to health care means that hospitals, clinics, medicines, and doctors‘ services must be accessible, available, acceptable, and of good quality for everyone, on an equitable basis, where and when needed. the design of a health care system must be guided by certain human rights standards and principles like, universal access, availability, acceptability and dignity, quality, non-discrimination, participation and accountability. see more at: http://www.nesri.org/programs/what-isthe-human-right-to-health-and-health-care, last accessed on 15 november 2013. 4. iahpc is a global non-profit, charity organization dedicated to the promotion and development of palliative care. the mission of this organization is to collaborate and work to improve the quality of life of patients with advanced life-threatening conditions and their families, by advancing hospice and palliative care programs, education, research, and favorable policies around the world. 5. the incb is the ―independent and quasi-judicial‖ body for monitoring member states‘ implementation of the un drug control treaties. its primary functions consist of a) ensuring that there is adequate supply of licit drugs for scientific and medical purposes ; b)helping to prevent the diversion of licit drugs and precursor chemicals into illicit supply channels ; c) identifying weaknesses in international and national drug control systems, and recommending measures to address those weaknesses ; and d) maintaining a permanent dialogue with governments to assist them in complying with their obligations. 6. the united nations charter, 1945 does not define the term ‗right to life‘. however, the term can be interpreted through the concept of ‗well-being‘. later on, the udhr, 1948 affirms the right to life (article-3) and a right to a standard of living adequate for health and well-being (article25). the iccpr and the icescr affirm that every human being has the ‗inherent right to life‘ and the right of everyone ‗to the enjoyment of the highest attainable standard of physical and mental health. in environmental terms the ‗right to life‘ may include a positive obligation on the state to take steps to prevent a reduction of or an extension of life expectancy. for example, by providing better drinking water or less polluted air. article 8 of the european convention on human rights incorporates the right to be free from interference with one's home and property. the limited case law in this area usually deals with noise pollution, for example, in alleged nuisance complaints about excessive aircraft noise at heathrow airport the european court on human rights found that the benefits to the community out-weighed the individual's right to bring a claim. however, in the case of lopez ostra v. spain (20 ehrr 277 of 9 december, 1994), the court ruled that the applicant suffered health problems from the fumes of a tannery waste treatment plant operating a few meters away from her home. again, economic, social and cultural rights include the right to a healthy environment, a decent working environment, decent living conditions and to health. these rights are covered by various treaties which establish the close relationship between socio-economic development, environmental and human rights concerns. the 1981 african charter on human and peoples’ rights was the first human rights treaty to expressly recognize the right of ‗[a]ll peoples‘ to a ‗satisfactory environment favorable to human health and development‘. within europe, the organization of economic and development (oecd) stated that a ‗decent‘ environment should be recognized as one of the fundamental human rights. 7. for example, south australia has already enacted an act namely, consent to medical treatment and palliative care act, 1995. http://www.who.int/cancer/palliative/definition/en/ http://en.wikipedia.org/wiki/economic,_social_and_cultural_right http://en.wikipedia.org/wiki/universal_declaration_of_human_rights http://en.wikipedia.org/wiki/international_covenant_on_economic,_social_and_cultural_rights http://en.wikipedia.org/wiki/international_covenant_on_economic,_social_and_cultural_rights http://en.wikipedia.org/wiki/international_covenant_on_economic,_social_and_cultural_rights http://en.wikipedia.org/wiki/convention_on_the_rights_of_persons_with_disabilities http://www.nesri.org/programs/what-is-the-human-right-to-health-and-health-care http://www.nesri.org/programs/what-is-the-human-right-to-health-and-health-care http://incb.org/incb/en/about/mandate-functions.html http://incb.org/incb/en/about/mandate-functions.html bangladesh journal of bioethics 2013; 4(3):25-33 31 8. bangladesh has made great strides in improving the health of its population. although, problems still remain in reducing child malnutrition and maternal mortality in particular, the aggregative results achieved in the last three decades are quite impressive. these achievements have certainly have gone a long way although overall progress of the health sector of bangladesh suffers from a number of inadequacies that militate against the rights-based approach to health. these include persistent inequities in access to healthcare (including gender inequity, and inequity along the poor versus non-poor divide), lack of meaningful participation of citizens in the running of the health system, and the absence of effective accountability mechanisms through which the providers of healthcare can be held responsible for their actions. see, chowdhury, omar haider and s.r. osmani, towards achieving the right to health, vol. xxxiii, march-june 2010, nos. 1 & 2, the bangladesh development studies. 9. cancer control, knowledge into action: palliative care, the world health organization, 2007, geneva. 10. palliative care includes all aspects of care, medical and nonmedical, and as such is described as total care. this aligns with the who definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity the requirement for a multidisciplinary team is necessary in order to be able to provide this comprehensive care. many health care professionals have viewed palliative care as a ‗soft option‘ and equate it with withdrawal of care. however, palliative care is active therapy, assessing and managing difficult symptoms and psychosocial and spiritual issues. appropriate assessment of patient problems enables the care team to develop an individualized care plan for each patient in consultation with the patient. available at: http://hospicecare.com/uploads/2013/7/legal%20aspects%20of%20palliative%20care%20-%20entire%20book.pdf. last accessed on 15 november 2013. 11. ibid. 12. ibid. 13. article 15 (a) of the constitution of the people‘s republic of bangladesh states that it shall be a fundamental responsibility of the state to attain, through planned economic growth, a constant increase of productive forces and a steady improvement in the material and cultural standard of living of the people, with a view to securing to its citizens – the provision of the basic necessities of life, including food, clothing, shelter, education and medical care. 14. article 16 of the constitution of the people‘s republic of bangladesh states that the state shall adopt effective measures to bring about a radical transformation in the rural areas through the promotion of an agricultural revolution, the provision of rural electrification, the development of cottage and other industries, and the improvement of education, communications and public health, in those areas, so as progressively to remove the disparity in the standards of living between the urban and the rural areas. 15. article 18 of the constitution of the people‘s republic of bangladesh states that the state shall regard the raising of the level of nutrition and the improvement of public health as among its primary duties, and in particular shall adopt effective measures to prevent the consumption, except for medical purposes or for such other purposes as may be prescribed by law, of alcoholic and other intoxicating drinks and of drugs which are injurious to health. 16. part-ii of the constitution of the people‘s republic of bangladesh contains the provisions relating to the fundamental principles of state policy which are not judicially enforceable. this is because article 8 (2) of the said constitution states that the principles set out in this part shall be fundamental to the governance of bangladesh, shall be applied by the state in the making of laws, shall be a guide to the interpretation of the constitution and of the other laws of bangladesh, and shall form the basis of the work of the state and of its citizens, but shall not be judicially enforceable. 17. article 32 of the constitution of the people‘s republic of bangladesh states that no person shall be deprived of life or personal liberty save in accordance with law. 18. article 32 of the constitution of the people’s republic of bangladesh is judicially enforceable as it is placed within part-iii of the said constitution (fundamental rights). the provisions of this part can be enforced by the higher judiciary through writ petition as article 44 (1) states that he right to move the high court division in accordance with clause (1) of article 102, for the enforcement of the rights conferred by partiii is guaranteed. 19. 49 dlr 1997 ad 1, para-102. 20. ibid., the same view was expressed in a pakistani case namely, ms. shehla zia vs. wapda pld 1994 sc 693. http://hospicecare.com/uploads/2013/7/legal%20aspects%20of%20palliative%20care%20-%20entire%20book.pdf bangladesh journal of bioethics 2013; 4(3):25-33 32 21. dr. mohiuddin farooque v. bangladesh 48 dlr 1996 hcd 438, paras 18-21. 22. the high court division of the supreme court of bangladesh. 23. value added tax. 24. the direction of the hcd in this regard has been given to the ministry of health and family welfare in 2013. 25. barkat, abul, muhd. azizul karim, md. motiur rahman saha, md. ibrahim ali, health legislation in bangladesh: a content analysis and scope for improvement, who, 2001. 26. health laws by broad groups (categories, segments): out of the total of 90 health related laws, 23.3 percent are related to food and drugs control; 18.9 percent related to environmental health; 16.7 percent each related to vital registration and welfare legislation, and health education and health practice; 11.1 percent are related to public health, 8.9 percent are related to protection of children and women; and only 4.4 percent are related to communicable disease control. 27. margaret somerville has long argued that the unreasonable failure to provide adequate pain relief constitutes negligence. there is a solid foundation for this assertion. the emphasis in law regarding medical negligence is the taking of reasonable care in all aspects of patient management. there are several aspects of pain relief where doctors may potentially breach their standard of care: an unreasonable failure to take an adequate history of pain from the patient (giurelli v girgis)123; an unreasonable failure to adequately treat pain (estate of henry james v. hillhaven corporation)72; and in the context of uncontrolled pain, an unreasonable failure to consult an expert in pain management (a general principle of referral is stated in dillon v leroux124 and o’shea v o’sullivan)125. somerville also points to what she refers to as ―systems negligence‖ when health care institutions fail to take reasonable steps to establish systems that offer patients ready access to pain management.101,126. 28. legal obligation of one party to a victim as a results of a civil wrong or injury. this action requires some form of remedy from a court system. a tort liability arises because of a combination of directly violating a person's rights and the transgression of a public obligation causing damage or a private wrongdoing. available at: http://www.businessdictionary.com/definition/tort-liability.html#ixzz2kmh4geoi., last accessed on 16 november 2013. 29. act no. 45 of 1860. 30. within the meaning of the constitution of the people’s republic of bangladesh, the fundamental principles of state policy are not judicially enforceable whereas the fundamental rights are enforceable in the courts. it seems to give higher legal status to the latter in comparison to the former. but, by virtue of article 47(1) it can reasonably be stated that the constitution has maintained a balanced relationship between these two. it provides that no law shall be deemed to be void on the ground that it is inconsistent with, or takes away or abridges, any of the fundamental rights, if parliament in such law (including, in the case of existing law, by amendment) expressly declares that such provision is made to give effect to any of the fundamental principles of state policy set out in part ii of this constitution. 31. article21 of the constitution of the people’s republic of bangladesh states that it is the duty of every citizen to observe the constitution and the laws, to maintain discipline, to perform public duties and to protect public property and every person in the service of the republic has a duty to strive at all times to serve the people. 32. lexically the expression 'public interest litigation' (hereinafter referred to as pil) means litigation filed in a court of law for the protection of ‗public interest‘, such as pollution, terrorism, public safety, constructional hazards, livelihood and so forth. pil is not defined in any statute. it has been interpreted by judges to consider the interest of public at large. although, the main and only focus of such litigation is on ‗public interest‘ there are various areas where a pil can be filed. it is not necessary, for the exercise of the court‘s jurisdiction, that the person who is the victim of the violation of his or her right should personally approach the court. the court can itself take cognizance of the matter and proceed suo motu or cases can be commenced upon the petition of any public-spirited individual in that situation. see, wadehra, basant lal. public interest litigation: a handbook. universal publishing limited, 2009, at p. 47. 33. an example of litigation based on the public interest in better pain management occurred in india in 1998. on behalf of the nation‘s cancer patients and drs. sr and rb ghooi, the all india lawyers forum for civil liberties fi led a public interest suit in the delhi high court. they requested a court order to state governments to simplify the procedures for the supply of morphine for cancer patients. the applicants were successful. the court ordered that every application for licenses or supplies of morphine must be attended to expeditiously. state governments were asked to allot morphine without delay and aggrieved persons were granted the freedom to approach the court if http://www.businessdictionary.com/definition/legal.html http://www.businessdictionary.com/definition/obligation.html http://www.businessdictionary.com/definition/party.html http://www.businessdictionary.com/definition/victim.html http://www.businessdictionary.com/definition/result.html http://www.businessdictionary.com/definition/civil-wrong.html http://www.businessdictionary.com/definition/injury.html http://www.businessdictionary.com/definition/action.html http://www.businessdictionary.com/definition/form.html http://www.businessdictionary.com/definition/remedy.html http://www.businessdictionary.com/definition/court.html http://www.businessdictionary.com/definition/system.html http://www.businessdictionary.com/definition/combination.html http://www.businessdictionary.com/definition/person.html http://www.businessdictionary.com/definition/right.html http://www.businessdictionary.com/definition/damage.html http://www.businessdictionary.com/definition/tort-liability.html#ixzz2kmh4geoi bangladesh journal of bioethics 2013; 4(3):25-33 33 dissatisfied. again, a rights-based discourse entered the final judgment: “it is a right of patients to receive any medication they need, particularly morphine. any official standing in the way will be viewed very seriously by the court.” 34. a rule or order upon condition that is to become absolute unless cause is shown to the contrary. 35. writ petition no 1783/1994. 36. khan, farzana, nezumuddin ahmad, mostak anwar, palliative care as a human right, journal of the bangladesh society of anesthesiologists, vol 21, no 2 (2008). 37. the law commission of bangladesh recommended for enacting a separate medical negligence law. http://www.banglajol.info/index.php/jbsa http://www.banglajol.info/index.php/jbsa http://www.banglajol.info/index.php/jbsa http://www.banglajol.info/index.php/jbsa/issue/view/221 bangladesh journal of bioethics 2013; 4(3):25-33 34 bangladesh journal of bioethics 2014; 5(2):49-60 48 intellectual property right of transgenic crops and right to work: bioethical challenges in rural communities bahareh heydari 1 , najmeh razmkhah 2 1 assistant professor, department of law, payame noor university, tehran, i.r. of iran. 2 lecturer, department of law, payame noor university, tehran, i.r. of iran. email: baharheydari@yahoo.com; najmehrazmkhah@yahoo.com abstract: increasing importance of intellectual property rights (ipr) over the area of seed production, is radically transforming agricultural production relations. one major effect of this transformation is the exclusive control of biotech companies on process of transaction of gm crops. this new status, that is the part of a trend that was set in national and international documents to protect inventors, may have adverse impact on the right to work of poor and vulnerable farmers in developing countries. in the framework of international human rights, the right to work is the fundamental right of every one to have sustainable access to decent work that meets the needs and welfare of his livelihood. rural communities enjoy this right similar to the urban communities. but, the main question, which is our major concern, is the relationship between ipr and the right to work with attention to articles of international covenant on economic, social and cultural right and international treaty on plant genetic resources for food and agriculture. keywords: biotechnology, genetically modified seeds, intellectual property right (ipr), rural communities, right to work, international covenant on economic, social and cultural right, international treaty on plant genetic resources for food and agriculture introduction: labor is one of the basic necessities for survival of mankind. human being is social and attempts to work, despite the variety of collections, ecology, and diversity in the pace of technical progress and the evolution of social and economic construction. the work is a necessary condition of human life in society. work fundamentally changes the nature. human beings use technology to create an effect on other human beings and nature. marx wrote in his classic book entitled capital: "at first glance, work is the interaction that occurs between man and nature." international labor organization (ilo), as one of the specialized agencies of the united nations has consistently emphasized that labor is not a commodity. unemployment causes poverty, and poverty anywhere is a threat to public welfare. therefore, the fight against poverty at the national and international level is necessary. secretary-general of the ilo considers decent work as a mailto:baharheydari@yahoo.com mailto:najmehrazmkhah@yahoo.com bangladesh journal of bioethics 2014; 5(2):49-60 49 concept in creating equal opportunities for women and men to achieve appropriate and productive work in conditions of freedom and security, with dignity. in the framework of international law, the right to work has been recognized as a fundamental right of every person to benefit from the opportunity to earn a living by work which must be chosen or accepted freely. the legal basis for the right to work is article 6 of the international covenant on economic, social and cultural rights (hereafter covenant), which says:" the states parties to the present covenant recognize the right to work, which includes the right of everyone to the opportunity to gain his living by work which he freely chooses or accepts, and will take appropriate steps to safeguard this right." in the second paragraph of this article it is emphasized that "the steps to be taken by a state party to the present covenant to achieve the full realization of this right shall include technical and vocational guidance and training programmes, policies and techniques to achieve steady economic, social and cultural development and full and productive employment under conditions safeguarding fundamental political and economic freedoms to the individual". in addition to the covenant, the right to work as a concept of international human rights, has been emphasized in international instruments on human rights, such as universal declaration of human rights, the convention on the elimination of all forms of discrimination against women. committee on economic, social and cultural rights (hereafter committee) in general comment no. 18 considers that: "the right to work is essential for realizing other human rights and forms an inseparable and inherent part of human dignity. every individual has the right to be able to work, allowing him/her to live in dignity. the right to work contributes at the same time to the survival of the individual and to that of his/her family, and insofar as work is freely chosen or accepted, to his/her development and recognition within the community." however, human rights activists often have expressed concern about the ignorance of the rights of communities, especially rural communities. with the adventure of new technologies and introduction of transgenic seeds to farmers, various questions on risk factors have been raised by many authors, e.g. problems related consequences of ip on right to work of villagers. because rural work primarily is based on agriculture, and biotech patents by large companies lead farmers to depend on these companies, to bear the high costs to buy the crops which they need, therefore poor villagers because of high expenditure are removed from the work market and this means the violation of the farmer's right to work. consequently, this article will attempt to review the terms and provisions contained in the instruments of international law, the obligations of states in relation to the right to work and describe the impact of patent of transgenic seeds on this right. bangladesh journal of bioethics 2014; 5(2):49-60 50 to this end, at first the situation of right to work in international instrument of human rights has been described , second , the obligation of governments about this right and then negative effects of ip of gm crops on the right to work in rural communities have been discussed . finally, at the end of the article conclusions and recommendations from the study will be presented. transgenic crops: transgenic organisms, also called genetically modified organisms (gmo), are generally produced by applying the techniques of genetic engineering or modification of genetic materials of crops1. the modification can most simply be defined as the transfer of genetic material from a different species or from a chemically synthesized gene in to a target plant. the first successful genetic engineering of a plant was reported in 1983. biotechnologization of agriculture represent the ongoing attempts to transform agriculture through the commercial deployment of biotechnological innovations, as a result of newly acquired insights in molecular biology and genetic, and, in turn, development of technological products and processes based on living organisms for collectively described as biotechnology 2 . geneticallymodified (gm) seeds are a significant step forward in the production of agricultural crops. gm seeds are seeds that have been modified to contain specific characteristics such as resistance to herbicides (in the case of "roundup ready" products) or resistance to pests (in the case of bt corn) 3 . right to work: work is essential for every body in the organization of contemporary society. it not only contributes to the formation of the individual , but it is also necessary if one is to be able to support oneself and his family, make and keep social contacts and fulfill his or her duties toward society 4 . the importance of work and productive employment in any society is not only because of the resources which they create for the community, but also because of the income which they bring to workers, the social role which they confer and the feeling of self-esteem which workers derive from them. the right to work is an individual right that belongs to each person and is at the sometime a collective right. it encompasses all forms of work, whether independent work or dependent wage-paid work and is essential for realizing other human rights and forms an inseparable and inherent part of human dignity. every individual has the right to be able to work, allowing him/her to live in dignity. the right to work contributes at the same time to the survival of the individual and to that of his/her family, and insofar as work is freely chosen or accepted, to his/her development and recognition within the community. covenant as laid down in article 6, deals more comprehensively than any other instrument with this right: " the states parties to the present covenant recognize the right to work, which includes the right of everyone to the opportunity to gain his living by work which he freely chooses or accepts, and will take bangladesh journal of bioethics 2014; 5(2):49-60 51 appropriate steps to safeguard this right. " the exercise of work in all its forms and at all levels requires the existence of the following interdependent and essential elements, implementation of which will depend on the conditions present in each state party: (a) availability. states parties must have specialized services to assist and support individuals in order to enable them to identify and find available employment. (b) accessibility. the labor market must be open to everyone under the jurisdiction of states parties. international obligations of governments in field of right to work 1. the status of right to work in international instruments on human rights: unlike negligence about right to work in practice, much attention has been focused in theory on this right. ilo constitution and declaration of philadelphia , which demonstrates the organization’s goal, without mentioning the term '' right to work '', relying on the principle that human labor should not be regarded as a commodity , on the endorse the fact that working does not itself , this is the man who works, work is part of his personality. for the first time right to work were cited in article 55 of un charter: '' with a view to the creation of conditions of stability and well-being which are necessary for peaceful and friendly relations among nations based on respect for the principle of equal rights and self – determination of peoples, the united nations shall promote: ''a higher standards of living, full employment, and conditions of economic and social progress and development''. under paragraph 1 of article 23 of the universal declaration of human right:'' everyone has the right to work, to free choice of employment, to just and favorable conditions of work and to protection against unemployment ''. universal declaration of human right has been accepted such an extent that many lawyers believe that at least a certain portion of its contents have arrived into customary international law. even if you reject this theory, this matter could not be denied the higher position of declaration on any other legal soft law 5 . apart from the basic documents on human rights in the context of many other international human rights instruments, the right to work is mentioned including, the first paragraph of article 11 of the convention on elimination of all forms of discrimination against women, article 18 of the convention relating to the status of refugees, which deals with the issue of employment in non-government, article 15 of african charter on human and peoples, right ( banjul charter), first and second paragraphs of article ii of section 2 of europe social charter and the article 7 of additional protocol to the american convention on human rights , the law on economic , social and cultural (protocol of san salvador). bangladesh journal of bioethics 2014; 5(2):49-60 52 2. states and actors other than states parties' obligations to right to work: the principal obligation of states parties is to ensure the progressive realization of the exercise of the right to work. states parties must therefore adopt, as quickly as possible, measures aiming at achieving full employment. while the covenant provides for progressive realization and acknowledges the constraints due to the limits of available resources, it also imposes on states parties various obligations which are of immediate effect.11 states parties have immediate obligations in relation to the right to work, such as the obligation to guarantee that it will be exercised “without discrimination of any kind and the obligation “to take steps” towards the full realization of article 6.12 such steps must be deliberate, concrete and targeted towards the full realization of the right to work. like all human rights, the right to work imposes three types or levels of obligations on states parties: the obligations to respect protect and fulfill. the obligation to respect the right to work requires states parties to refrain from interfering directly or indirectly with the enjoyment of that right. the obligation to protect requires states parties to take measures that prevent third parties from interfering with the enjoyment of the right to work. the obligation to fulfill includes the obligations to provide, facilitate and promote that right. it implies that states parties should adopt appropriate legislative, administrative, budgetary, judicial and other measures to ensure its full realization. in its general comment no. 3 (1990), the committee draws attention to the obligation of all states parties to take steps individually and through international assistance and cooperation, especially economic and technical, towards the full realization of the rights recognized in the covenant. in the spirit of article 56 of the charter of the united nations and specific provisions of the covenant (arts. 2.1, 6, 22 and 23), states parties should recognize the essential role of international cooperation and comply with their commitment to take joint and separate action to achieve the full realization of the right to work. states parties should, through international agreements where appropriate, ensure that the right to work as set forth in articles 6, 7 and 8 of the covenant is given due attention. to comply with their international obligations in relation to article 6, states parties should endeavor to promote the right to work in other countries as well as in bilateral and multilateral negotiations. in negotiations with international financial institutions, states parties should ensure protection of the right to work of their population. states parties that are members of international financial institutions, in particular the international monetary fund, the world bank and regional development banks, should pay greater attention to the protection of the right to work in influencing the lending policies, credit agreements, structural adjustment programmes and bangladesh journal of bioethics 2014; 5(2):49-60 53 international measures of these institutions. the strategies, programmes and policies adopted by states parties under structural adjustment programmes should not interfere with their core obligations in relation to the right to work and impact negatively on the right to work of women, young persons and the disadvantaged and marginalized individuals and groups. while only states are parties to the covenant and are thus ultimately accountable for compliance with it, all members of society, individuals, local communities, trade unions, civil society and private sector organizations have responsibilities regarding the realization of the right to work. states parties should provide an environment facilitating the discharge of these obligations. private enterprises national and multinational while not bound by the covenant, have a particular role to play in job creation, hiring policies and non-discriminatory access to work. they should conduct their activities on the basis of legislation, administrative measures, codes of conduct and other appropriate measures promoting respect for the right to work, agreed between the governments and civil society. such measures should recognize the labor standards elaborated by ilo and aim at increasing the awareness and responsibility of enterprises in the realization of the right to work. according to the committee interpretation, governments and nongovernmental commercial organizations are obliged to respect this right. governments at the national and international levels have a duty to take all necessary measures in order to provide people with the opportunity to enjoy the right to work and remove obstacles in the implementation of this right and of course, apply necessary regulations on commercial activities, to prevent violation of the right of people to work. another significant point is that neither the covenant nor the committee’s interpretation has been addressed special resolution based on the nature of the work. therefore farmers and the agricultural sector have been subject to the rights which provided by international documents, so governments are committed towards them to provide and ensure the right to work on all three levels. but in practice the situation is not quite as good and nowadays, the poor condition of the employment in rural communities has become one of the human rights activists concerns. an issue that has not attracted much attention at the international level, so at any time speak of the right to work, employment in urban communities comes to mind. thus it has been neglected by governments and non governmental organizations such as biotech companies. evidence for this claim is a condition in which the transgenic seeds have been sold to farmers in less developed countries which has become a serious challenge in communities, especially in less developed countries, where most farmers are poor and vulnerable part of society. the next section according to the provisions of the international instruments describes these problems and legal issues arising from the conflict between the ip of biotech companies and farmers right to work. bangladesh journal of bioethics 2014; 5(2):49-60 54 ipr of gm crops and right to work of farmers 1. negative effects arising from the ipr on the labor market in rural communities: perhaps the most contentious issue related to biotechnology today is that of intellectual property rights (iprs). iprs in general terms, allow developers of gmos to patent a new transgenic variety and claim exclusive rights to that product, making it illegal for use in the countries where a patent is awarded without the user’s agreement to meet conditions imposed by company. in many cases, these conditions include payment of a ‘technology fee’ (to help cover the research and development investment) and signing a contract pledging not to save, replant, or sell the seeds from crops grown with the patented seed 6. patenting living organisms is a recent legal development that causes concern for a number of reasons. one potential result of patenting transgenic plant varieties is the effective criminalization of centuries old agricultural practices such as seed selection, saving, and sharing. historically, farmers themselves have been the major innovators in agriculture, developing superior crops through their own selection processes. in the 1990s, 80 percent of crops planted in developing countries were sown from farm-saved seeds. with patented seeds, farmers’ ability to save seeds for future planting is constricted and dependence on large multi-national companies increases because farmers must buy new seeds every season 7 . in many communities, seeds also serve as a type of social capital, and sharing seeds provides a basis for interdependence among farmers within a community. if patented gm seeds become commonplace, the possibility exists for behaviors that form the backbone of traditional agriculture, such as seed-sharing, to become illegal, thereby eroding farming communities themselves 8. the contracts of seed companies require that buyers of their gm seeds sign when obtaining those seeds may disadvantage farmers. seed companies have invested significant funds in the research and development of gm seeds, and they protect this investment through their contracts with agricultural growers. these contracts aggressively protect the biotechnology company's rights to the seeds, frame the context within which disputes may be settled, and limit the liability of the company. under a private contract between a grower and a biotech company, the g rower's rights to the purchased seed are significantly limited. such contracts generally contain a "no saved seed" provision. this provision prohibits growers from saving seed and/or reusing seed from gm crops. in effect, the provision requires growers of gm crops to make an annual purchase of gm seeds 9 . contracts between seed companies and farmers sometimes contain a clause that limits the "liability of [the seed company] to or any seller for any and all losses, injury or damages resulting bangladesh journal of bioethics 2014; 5(2):49-60 55 from the use or handling of a product containing [the seed company's] gene technology shall be the price paid by the grower for the quantity of such product involved, or at the election of [the seed company] or any seller, the replacement of such quantity. in no event shall [the seed company] or any seller be liable for any incidental, consequential, special or punitive damages. under such a clause, if the use of gm seed has a negative impact on another aspect of the farmer's operations, this clause precludes the farmer from recovering any damages from the company in the event the use of the product causes harm 10 . with this process, farmers have to pay for the use of seeds which are used and protected over the centuries, so the rural communities will expose to the risk of dependence of farmers with commercial suppliers of critical materials like seeds. on the other hand, most of these farmers could not compete with large farmers, so they forced to sell or lease their farms to rich farmers or biotech companies. these issues often lead to deprive poor and vulnerable farmers of their basic right to work. so farmers will be unemployed and their family well-being will be in trouble. this situation is not limited to violations of the right to work, because of interdependence between the fundamental principles of human rights: violation of one right can lead to dangerous consequences for rural communities. 2. analysis the conflict between ipr of seeds and the right to work: as was discussed in the previous section, biotechnology companies as breeders of genetic manipulated and improved seeds on the base of legal sources, including the covenant and other supporting documents of intellectual property claim that they have exclusive right on these seeds. problems in this regard and violation of farmers, right have been attracted the international community considerations. in this regard, the united nation food and agriculture organization (fao) for the first time presented concept of '' farmer's right''. in this sense, the right of farmers and rural communities for the control, management, development and exploitation of plant genetic resources belong to them has been recognized and then international treaty on plant genetic resources for food and agriculture ( here after treaty), in order to afford greater attention to this right in the thirty-first fao conference in 2001, was approved. in the preamble of the treaty, farmers, right and plant breeders, rights have been identified as complement. so governments must accordance to their needs and priorities identify and reorganize these rights. each member should take measures to protect and promote farmers, rights at national and international level to adopt the following measures: protection of traditional knowledge relevant to plant genetic resources for food and agriculture, the right to equitable participation in sharing benefits from the use of plant genetic resources. bangladesh journal of bioethics 2014; 5(2):49-60 56 in fact, this treaty was formulated to establish an independent legal system for protection of farmers, right and create balance between the rights of inventors and creation of new varieties of plants by ipr system and rights of farmers to reuse, sale and exchange of plant genetic resources. article 9 of the treaty, was developed with the title of farmers, right. accordance to paragraph b of this article: '' the contracting parties agree that the responsibility for realizing farmers, right, as they relate to plant genetic resources for food and agriculture, rests with national governments. in accordance with their needs and priorities, each contracting party should, as appropriate and subject to its national legislation, take measures to protect and promote farmers, right, including: (a) protection of traditional knowledge relevant to plant genetic resources for food and agriculture; (b) the right to equitably participate in sharing benefits arising from the utilization of plant genetic resources for food and agriculture; and (c) the right to participate in making decisions, at the national level, on matters related to the conservation and sustainable use of plant genetic resources for food and agriculture. according to the third paragraph of article 9:'' nothing in this article shall be interpreted to limit any rights that farmers have to save, use, exchange and sell farm-saved seed/propagating material, subject to national law and as appropriate''. another strong point of this treaty is a multilateral system of access and benefit sharing, which was included in part iv. under the provisions of this section, the genetic material derived from 64 kinds of food and feed crops listed in annex i to the treaty, is freely available to researchers, which in turn should share due benefits with other beneficiaries to these species. the rights of farmers, without mentioning the name of the right to work, is shown of the provisions of this treaty, of course the content of article 9 can be useful in providing job security for farmers. despite the points were raised, weaknesses can be seen in the treaty. in general, treaty is vague on the way of sharing benefits and how to determine the beneficiaries. in addition the content of treaty have been enacted in a way, which the biotech corporations, interests have priority over the interests of farmers. for example, in the seventh paragraph of the preamble clearly states that: ''affirming that nothing in this treaty shall be interpreted as implying in any way a change in the rights and obligations of the contracting parties under other international agreements''. also in the sixth section of the third paragraph of article 12 states that:''access to plant genetic resources for food and agriculture protected by intellectual and other property rights shall be consistent with relevant international agreements and with relevant national laws''. so in case of a conflict between the rights of farmers which has defined by article 9 and ipr which are supported by another agreements and national regulations, ipr will be preferred. on the other hand, in bangladesh journal of bioethics 2014; 5(2):49-60 57 article 9 only farmers, right have been enumerated without anticipated specific enforcement of these rights. because of disagreement between member states on how to implement this regulation exists, in practice it has been dropped. so the biotech companies relying on the other international agreements, including the covenant, exercise their ipr, and the rights of farmers have been ignored. among the principles that have been invoked by biotech companies to apply their ipr is the article 15 of the covenant, therefore the analysis of this article and it’s relationship with other articles such as article 6 of the covenant is necessary. the first paragraph of article 15 of the covenant declares that: ''1. the states parties to the present covenant recognize the right of everyone: (a) to take part in cultural life; (b) to enjoy the benefits of scientific progress and its applications; (c) to benefit from the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author.'' as it could be seen, this paragraph contains three human rights and according to the statement it seems that the right to participate in cultural life, included the other two rights and in fact, is prerequisite for two other rights. thus simultaneously confirms people,s right to benefit from scientific progress and ipr of scientists. the next important point is that, human rights principles are joined together, so articles of human rights instruments, including the covenant should not be without considering the other principles. for this reason, the committee has brought out in paragraph 4 of interpretation no. 17. ''the right to benefit from the protection of the moral and material interests resulting from one’s scientific, literary and artistic productions seeks to encourage the active contribution of creators to the arts and sciences and to the progress of society as a whole. as such, it is intrinsically linked to the other rights recognized in article 15 of the covenant, i.e. the right to take part in cultural life (art. 15, para. 1, a), the right to enjoy the benefits of scientific progress and its applications (art. 15, para. 1, b), and the freedom indispensable for scientific research and creative activity (art. 15, para. 3). the relationship between these rights and article 15, paragraph 1 (c), is at the same time mutually reinforcing and reciprocally limitative. the limitations imposed on the right of authors to benefit from the protection of the moral and material interests resulting from their scientific, literary and artistic productions by virtue of these rights will partly be explored in this general comment, partly in separate general comments on article 15, paragraphs 1 (a) and (b) and 3, of the covenant. as a material safeguard for the freedom of scientific research and creative activity, guaranteed under article 15, paragraph 3 and article 15, paragraph 1 (c), also has an economic dimension and is, therefore, closely linked to the rights to the opportunity to gain one’s living by work which one freely chooses (art. 6, para. 1) and to adequate remuneration (art. 7, a), and to the human right to an adequate standard of living (art. 11, para. 1). bangladesh journal of bioethics 2014; 5(2):49-60 58 so to interpret obligations arising from the article 15, other articles of covenant such as article 6 and two following points must be considered. first, it is a mistake to believe that always and in all circumstances, similar forms of support must be applied to individual or collective rights of people to enjoy the benefits of science and new technologies, because depending on different conditions and circumstances, this type of support may be desirable or not. second, to interpret human right principles, more attention must be taken to poor and vulnerable communities. thus while respect to ipr is necessary but because of expression of this right, the right to benefit of scientific progress and its applications, in one article, it can be said that ipr can be a tool to support the right of farmers to benefit from scientific progress. it is also noteworthy to refer to the second paragraph of article 15 of the covenant, which states that:'' the steps to be taken by the states parties to the present covenant to achieve the full realization of this right shall include those necessary for the conservation, the development and the diffusion of science and culture.'' conclusion: every human being has the right to have a job. right to work as a fundamental concept is supported in international human rights. as was stressed, under the covenant, governments are obliged to ensure benefit from the rights, including the right to work, by using maximum resources and all appropriate measures. this obligation is closely related to article 11 of the covenant as the right of everyone to adequate standard of living for himself and his family. without a job and money, allowing the enjoyment of other human rights, including live on welfare, is impossible. offering exclusive and patented transgenic seeds by biotech seed companies and selling them to farmers with extensive control over the whole process is a matter that means affiliation of the farmers to these companies. in addition, the high cost of seeds, without the right to save seeds for planting next year, will exacerbate problems. as such, farmers have no choice but to sell their farms to large farmers and biotech companies. to solve the conflict between the right to intellectual property and right to work in rural communities, governments must uphold, farmers, rights and civil needs within the framework of national and international law, and due to the legal limitations for neutral and unstable to access native plant species, they must develop a system to foster the breeding species. for example, by facilitating access to traditional agriculture seed varieties which are bred for food and agriculture, for commercial markets and sell their products, so that farmers encouraged continuing their activities. in addition, local exchange of traditional seeds have great importance in supporting local seed breeding, especially in areas that local seed are not available in market. one method of achieving this goal is the establishment of community seed banks, like india and the philippines, these association indigenous farmers share their seeds and other farmers, would find and buy their bangladesh journal of bioethics 2014; 5(2):49-60 59 requirements. in fact farmers are the base of these associations. public arrangements must guarantee appropriate availability of planting material at the right time and also sufficient diversity of seed and plant species. these efforts help to increase the income of a large section of the population of vulnerable small farmers. the patent laws of many countries, including east asian countries are also taken into account ethical considerations. for example, japanese patent law considers that:'' government must refrain to record inventions which seem to be contrary to public order, morality or public health.'' under patent law of the people, s republic of china '' an invention which is against the law of the state or social morality or public interest, patent license would not be granted.'' but in practice, these provisions are rarely invoked and legal literature in this area is very poor. because of the absence of fair legal procedure, there is a risk that farmers would be marginalized. thus the following suggestions are noteworthy to solve the problems: 1. the leaders of the rich nations must not ignore the implicit restrictions in the intellectual property in the way that development and technological achievement for the south makes difficult or even impossible: the need to adopt a policy of real practical benefit to the south. 2. world intellectual property organization (wipo), must begin a survey on social and legal impacts which causes from ipr of transgenic crops. 3. the food and agriculture organization (fao) and the un conference on trade and development ( unctad), must begin to organize a cooperation with social movements, including trade unions, representatives of indigenous and traditional communities in the evaluation of ipr effects on the other fundamental human rights including the right to work and implications of technology transfer and the needs and interests of developing countries to provide practical solutions to the existing problems in rural communities and overcome the crisis. references: 1. kowalski s. transgenic crops, biotechnology, ownership rights: what scientists need to know. the plant journal 2002; 31(4):407-421. 2. abaidoo s. globalization, biotechnologization of agriculture and farmers. international journal of manpower 2000; 21(6): 481-491. 3. kruft d. impacts of genetically modified crops and seeds on farmers. legal research 2010; (100)97: 2-15. 4. lam h. a new approach to resolve the right to work, ethical dilemma. journal of business ethics2006 ; ( 2007) 73:231-243. bangladesh journal of bioethics 2014; 5(2):49-60 60 5. hannum h. the status of the universal declaration of human rights in national and international law. georgia journal of international and comparative law1998; (70)25: 270-293. 6. warner k d. are life patents ethical? conflict between catholic social teaching and agricultural biotechnology’s patent regime. journal of agricultural and environmental ethics2001; 14(3): 301–319. 7. ymmin r. iprs, biotechnology and food security paper prepared for the “globalization and the international governance of modern biotechnology” project. 2004 http://www.gapresearch.org/governance/ fyiprsfinal.pdf. 8. fransen l. integrating socio-economic consideration in to biosafety decision. world research institute2005; 1-53. 9. enriquez j. genomics and the world's economy. science2008;(290) 281: 925-940. 10.tisdell c. safety and social economic issues raised by modern biotechnology. international journal of social economics2009; (30)24: 670 699. conflict of interest: ●i declare no conflict of interest. bahareh heydari phd in human rights, aix-marseille university, france prof, payame nour university, iran, 4/7/2014. title: scientific freedom & limitsclinical research perspective bangladesh journal of bioethics 2013; 4(1):30-34 30 scientific freedom & limitsclinical research perspective md. fakruddin 1* , abhijit chowdhury 1 , md. nur hossain 1 , khanjada shahnewaj bin mannan 2 1 institute of food science and technology (ifst), bangladesh council of scientific and industrial research (bcsir), dhaka, bangladesh. 2 center for food & waterborne diseases, icddr,b, dhaka, bangladesh. email: fakruddinmurad@gmail.com abstract: being a scientist, especially a clinical research one, is a noble but tough job. scientific job is different from other jobs in terms of working hour and pressure; they need more freedom in their job & research that also put lots of responsibility on them. research is funded by public money and it is the responsibility of scientists to gain maximum output from it. clinical research is very complex and involves the use of animal, microbial as well as human samples and volunteers which make it more prone to ethical scrutiny. minority of researchers who commit fraudulent use of public money & unethical clinical practice threaten public support for science. now a day, there is growing concern of public and politicians on the freedom of scientists and unethical scientific practice in clinical trials. the most efficient measures to prevent scientific misconduct are awareness—notably, self-awareness— education and transparency. most of the developed countries have formulated their own guidelines to ensure proper utilization and ethical clinical research and trials. bangladesh is still lagging behind in terms of regulation and monitoring of clinical research and trials. this review aims to make related peoples to be aware of the necessity of its own guidelines for clinical research and trials. key words: scientific, freedom, limitation, clinical research introduction: scientific research is the only means of elucidating what is unexplored to human knowledge 1 . scientists need freedom of thinking and research to gain maximum output of the money spent. the universal declaration on the human genome and human rights, which was adopted in 1997 by the general conference of the united nations educational, scientific and cultural organization (unesco), states that ―freedom of research, which is necessary for the progress of knowledge, is part of freedom of thought‖ 2 . but, this freedom also raises the debate of implementation of some regulations to seal off any possible scientific misconduct 3 . most of the more controversial issues in relation to freedom of scientific enquiry and research arise in the fields of medicine, biology and genetics where specific research potentially conflicts with the right to life or with the dignity of living beings including human 4 . some argues that bioethics and limitation in scientific freedom is suffocating the creativity of researchers in the biomedical field, and is seriously limiting the productivity of clinical research 5 . other argues that as research is conducted by public money, there should be transparency, regulation and limitation in conducting clinical research so that ay research against morality should not be repeated again 6 . abuses of scientific research: there have been many occasions in the past when shocking abuses of human rights were carried out in the name of scientific or medical research. the worst mailto:fakruddinmurad@gmail.com bangladesh journal of bioethics 2013; 4(1):30-34 31 examples are well known and include the atrocities carried out by dr. mengele and others in the concentration camps in nazi germany under the guise of medical experimentation 7 and the ―experiments‖ carried out in the ussr in stalin‘s time by prof. ilya ivanovich with the intention of interbreeding humans and chimpanzees 8 . such abuses of human rights were by no means confined to totalitarian states, as the infamous example of the ―tuskegee study of untreated syphilis in the negro male‖ demonstrates. this study concerned 616 african american males, who were given blood tests in 1932. four hundred and twelve of those were diagnosed with syphilis. the test subjects were not told they had syphilis and were not treated for it despite the fact that after 1943 penicillin was available as a cure. the purpose of the research was to study the long term effects of untreated syphilis. the research was discontinued only in 1972 after a journalist reported on it. meanwhile many medical experts had been aware of the study and had raised no objection 9 . what all these examples of human rights abuses have in common is that they were carried out on the subjects of the experimentation without their consent 10 . scientific freedom in research involving human: research involving human genome and stem cells pose great threat to human race if conducted unethically. introducing a sudden major discontinuity in the human gene pool might well create a major mismatch between our social order and individual capabilities 11 . even a minor perturbation such as a marked change in the sex ratio from its present near equality could shake our social structures 12 . debates on ethical practice and scientific freedom are thus mostly raises on research involving human subjects. past unethical clinical research practice involving human subjects warns everyone about the necessity of regulations and scientific limits of clinical researchers 13 . nuremberg code and the declaration of helsinski reserve the right of any individual to choose himself/ herself to be included in any sort of clinical trial. to perform any clinical trial involving children, adult, elderly, handicapped or even prisoners, scientist must abide by some strict regulations and supervised by ethical review committees and the subjects could be included in these trials only by informed consent. no one is allowed to misuse scientific freedom for the sake of exploring new knowledge if it showed to be against human morality 14 . scientific freedom in research involving animals: perhaps the first question to be clarified in any discussion of animal research is: which animals are to be included within the scope of consideration? 15 two primary issues can be identified in the animal research debate: (1) the consequences of the research and (2) the moral status of animals. proponents of animal research usually advance arguments that appeal rather straightforwardly to the principle of beneficence. the weak form of the argument can be formulated as follows: good consequences are achieved through the use of animals in research. a somewhat stronger claim is that at least some of these good consequences can be achieved only by means of animal research; that is, no alternative (nonhuman) means to the desired end exists 16 . the empirical background for the strong claim by proponents of animal research is that intact, live animals respond to research interventions in complex ways that cannot be simulated through any other research technique involving non-animal systems. for example, administering a drug to a dog or presenting a learning stimulus to a rat may produce a complex reaction that affects multiple physiological systems 17 . at present such a response simply cannot be duplicated through the manipulation of cells in tissue culture or even through the use of sophisticated computer simulations. in theory at least, human subjects could be-substituted for animal subjects and would be capable of producing the same kinds of complex response. however, given the painful, invasive, and even lethal character of much animal research, the use of humans in such research would itself pose serious ethical problems 18 . critics of animal research can also appeal to the principle of beneficence. in response to the weak form of the proponents' argument, the critics urge that alternatives to animal research be more bangladesh journal of bioethics 2013; 4(1):30-34 32 vigorously explored and more actively employed. however, if animal research is the only means for achieving a desirable consequence, then the critic can respond by insisting on a conscientious weighing of research benefits against harms to animals 19 . the second major issue in the animal research debate is the moral status of animals. this issue closely parallels the problem of personhood and the question of fetal status. some argued that animals can have rights because they have, or can have, interests. among the rights ascribed to animals is the right to be treated humanely. again some regarded animals as mere machines 20 . to explain the moral status of animal, let us consider whether humans with extremely limited intellectual capacitiesfor example, severely retarded individuals-should be involved in painful or fatal research, as animals often are. negative answer is based on the premise that we cannot ―safely permit anyone to decide which human beings fall short of worthiness‖. some will argue that ―our respect for the interests of [infants and mentally retarded humans], and our neglect of the members of other species with equal or superior capacities, is mere ‗speciesism‘-a prejudice in favor of ‗our own kind‘ that is analogous to, and no more justifiable than, racism‖ 21 . scientific freedom in research at the molecular level: when we move from the world of vertebrate animals to that of bacteria, viruses and dna, our ethical problems concerning the research subjects are immediately simplified. here there is unlikely to be a problem of sentience, and little philosophical ink has been spilled on the moral status of e. coli bacteria 22 . recombinant dna research involves the joining of segments of dnathe basic genetic material in all living things. this technique is important for many kinds of laboratory research, but in addition it has potential technological applications in such diverse fields as medicine, agriculture, and industry. indeed, recombinant dna methods are already being employed to produce medically important hormones, such as insulin and human growth hormone 23 . recombinant dna research is of philosophical interest primarily as another instance in which riskbenefit analysis seems appropriate. numerous reports depicts the potential benefits of recombinant dna research and technology but cautions that the enthusiastic use of new technological capabilities in large-scale programs of genetic engineering could introduce ―a sudden major discontinuity in the human gene pool‖ and thus could destroy the delicate balance between biological evolution and human culture 24 . a reasonable public policy on recombinant dna research in effect should combine the principles of autonomy and beneficence: the freedom of scientific inquiry should be protected unless the negative consequences of research significantly outweigh its positive consequences 17 . conclusion: it is the nature of scientists to shake every tree possible to explore ay field unknown to them. to do so, sometime they may perform some experiments that may stand against human ethics. for this reason, many countries formulates and imposed regulations on scientists performing research involving humans, animals or even recombinant dna. to impose any limit upon freedom of inquiry is especially bitter for the scientists whose life is one of inquiry; but science has become too potent. it is no longer enough to wave the flag of galileo. such type of regulations may protect the human race against greater threats in future. references: 1. breithaupt h. freedom and responsibility. embo reports 2011; 12:744. bangladesh journal of bioethics 2013; 4(1):30-34 33 2. corbellini g. scientists, bioethics and democracy: the italian case and its meanings. j med ethics 2007; 33: 349–352. doi: 10.1136/jme.2007.020586 3. emanuel ej, wendler d, grady c. what makes clinical research ethical? journal of the american medical association 2000; 283: 2701-2711 4. beecher hk. ethics and clinical research. the new england journal of medicine 1966; 274(24): 1354-1360 5. bhutta za. why regulate? ethical regulation of health research. journal of college of physicians & surgeons 2001; 11: 537-540. 6. appelbaum ps, lidz cw, grisso t. therapeutic misconception in clinical research: frequency and risk factors. irb: ethics and human research 2004; 26: 1–8. 7. grodin ma, annas gj. legacies of nuremberg: medical ethics and human rights. journal of the american medical association 1996; 276: 1682–1683. 8. harris j. scientific research is a moral duty. journal of medical ethics 2005; 31: 242–248. 9. rothman dj. the shame of medical research. the new york review of books 2000; 47 (19): 60– 64. 10. fakruddin m, chowdhury a, hossain mn, mannan ksb. ethics in clinical research: bangladesh journal of bioethics 2012; 3(3): 16-20 11. fakruddin m. ethics in stem cell research. bangladesh journal of bioethics 2012; 3(1):13-18 12. brody ba, mccullough lb, sharp rr. consensus and controversy in clinical research ethics. jama 2005; 294(11): 1411-1414 13. caldwell phy, murphy sb, butow ph, craig jc. clinical trials in children. lancet 2004; 364: 803– 811. 14. sullivan r. the good, the bad and the ugly: effect of regulation on cancer research. lancet oncology 2008; 9: 2–3 15. ali ma. what makes multinational clinical research ethical & how to minimize possible exploitation in host country? bangladesh journal of bioethics 2011; 2(2): 20-23 16. coughlin ss. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology 2006; 3:16. doi:10.1186/1742-7622-3-16 17. gilman rh, anderton c, kosek m, garcia hh and evans ca. how many committees does it take to make a project ethical? lancet 2002; 60: 1025-1026 18. gilman rh, gracia hh. ethics review procedures for research in developing countries: a basic presumption of guilt. canadian medical association journal 2004; 171(3): 248-249. 19. joseph ks. ethics in clinical research: searching for absolutes. cmaj 1998; 158:1303-1305 20. hyder aa, wali sa, khan an, teoh nb, kass ne and dawson l. ethical review of health research: a perspective from developing country researchers. journal medical ethics 2004; 30(1): bangladesh journal of bioethics 2013; 4(1):30-34 34 68-72 21. macpherson cc. ethics committees. research ethics: beyond the guidelines. developing world bioethics 2001; 1(1): 57-68. 22. pandey a, aggarwal a, seth sd, maulik m & juneja a. strengthening ethics in clinical research. indian j med res 2011; 133: 339-340 23. rid a, wendler d. a framework for risk-benefit evaluations in biomedical research. kennedy institute of ethics journal 2011; 21(2): 141–179. 24. stewart pm, stears a, tomlinson jw, brown mj. regulation—the real threat to clinical research. british medical journal 2008; 337: 1085–1087. microsoft word svetoslav mars bangladesh journal of bioethics 2016; 7(2):31-34 31 short communication planetary protection for mars: time for reconsideration svetoslav alexandrov department of experimental algology, institute of plant physiology and genetics, bulgarian academy of sciences email: saturn@gbg.bg abstract: in this manuscript i discuss the ethics of the protection of hypothetical organisms on mars in terms of upcoming manned space missions and subsequent colonization. keywords: space, bioethics, mars introduction: back in 2013 it looked very rational to hold the following neutral, neither strictly anthropocentric nor biocentric position: “the assumption about the existence of life on mars should not be the reason to stop the red planet colonization, but precautions should be taken to minimize risks of introducing the earth life on mars, and to prevent mars contamination” 1. after all, prospects of the existence of mars life were generally not thought to be very high – it was either considered to be entirely in past tense, or currently existing underground. three important things, however, have happened during the last two and a half years. first, it was the discovery of hydrated salts and possibly liquid water in present times on the recurring slope lineae on mars 2. this increased the chance of mars being inhabited even today, only in shallow depths, close to the surface. second, people have started speaking openly against near-term manned missions to mars on the basis of planetary protection. in 2015 the planetary society (an organization publicly involved in space advocacy) suggested a roadmap for mars called “orbit first” 3. the roadmap envisions sending astronauts near the moon throughout 2020s, to mars orbit and phobos in 2033 and to the surface of mars in 2039. thus the last step (a human mission to the surface of mars) would happen after more bangladesh journal of bioethics 2016; 7(2):31-34 32 than two decades. the planetary geologist and space blogger for the planetary society emily lakdawalla stated 4 that she supports this “orbit first” strategy, and that human beings should stay away from the mars surface for a while, until robots conduct experiments concerning mars water and life. lakdawalla says that humans would contaminate mars and after that it will be harder to answer the question whether we are alone in the universe or not. keith cowing, an astrobiologist and a space journalist, has sharply criticized lakdawalla’s position. he has stated that the planetary society does not want humans on mars, that the society wants to stretch a human program to the surface of mars further in time due to the belief that human bodies do not belong there 5. third, the time of interplanetary manned spaceflight is approaching, and the colonization of mars is next. private entrepreneur elon musk would like to send humans to mars as soon as 2024 6. this is in a stark contrast with what both nasa and the planetary society envision (midto late 30s). although 2024 is a date that yet remains to be seen if it will be met, the private space industry has developed very fast in the last few years. because of these events in the past two years and a half, it is time to quickly rethink the ethics and policies of planetary protection in terms of human space exploration and subsequent colonization. discussion: solar system planets and their satellites, with the exception of earth, are harsh places and inhospitable for humans. even mars is more extreme than the most extreme places on earth. earth’s biological organisms cannot just be emplaced and expected to thrive on the present martian surface 7. but could hypothetical life on mars, which may be different from earth life, exist there and be able not only to survive, but also grow and reproduce? we do not know yet. in terms of the planetary protection of such hypothetical life, we could still create artificial habitats on mars and these are not necessary to be physically close to the places considered with a potential for life, such as the already mentioned recurring slope lineae 2, the features on mars that have been connected with the action of liquid water. if these features host hypothetical local martian microorganisms, we could keep human habitats far from these places with the intention to protect them. bangladesh journal of bioethics 2016; 7(2):31-34 33 a task colonists on mars could do in the more distant future is not just living there in protected habitats, but actually converting the planet and making it suitable for earth’s life. this is a process called terraformation. but if the idea of terraformation ever comes to fruition, we will be changing the whole conditions of the planet. plus, we will introduce the martian surface to earth organisms, especially photosynthetic species (like cyanobacteria and algae) which will be able to convert the already present carbon dioxide into oxygen. do we have the right to do so, even at the cost of endangering hypothetical local organisms? here we must remind the opinion of the prominent visionary carl sagan, one of the co-founders of the planetary society: “if there is life, then i believe we should do nothing to disturb that life. mars then, belongs to the martians, even if they are microbes” 8. the opinion of carl sagan, however, is one of several. as mckay has explained, except for the opinion that mars should be left alone to the martians, there are also opinions to alter mars to a point its own biota could become a global biological system that controls the biogeochemical cycles of the planet, or to take samples of the whole hypothetical biodiversity on mars and store them in biobanks, before spreading earth life forms to the planet 9. as an author of this manuscript, in the light of recent opposition to human spaceflight to mars, i have recently adopted more anthropocentric rather than biocentric position 10 for the following reasons: firstly, anthropocentrism poses no fundamental moral objection to terraforming mars. secondly, space colonization activities would benefit humanity. and thirdly, even if the argument is raised that mars life should be studied first before the planet is exploited, on anthropocentric grounds such objection doesn’t assign intrinsic worth to the extraterrestrial environment, because for the anthropocentrist it’s the humanity that counts 11. thus my opinion differs from the biocentric opinions of sagan and mckay (the later thinks terraforming is not fair concerning indigenous martian life). i still think we should try to protect foreign life whenever possible, however the value of the human life is supreme. i firmly believe that we should first do everything to ensure survival of the humans, as they are currently the only known intelligent species in the universe. colonization of space and later terraformation will ensure our survival in long terms and should have higher priority. preservation, while still very important in order to study the foreign life, should come second. thus, some associated risks with colonization and terraformation of mars concerning its hypothetical organisms are acceptable. bangladesh journal of bioethics 2016; 7(2):31-34 34 conclusions: due to the fact the time of manned interplanetary travel is approaching because of the fast private space industry's development, i state that scientists should reignite the debate about planetary protection and possible lessening of the requirements as soon as possible. i worry that current overprotection trends could stall the human exploration of mars and subsequent colonization for years to come. references: 1. alexandrov s. a new rationale for space colonization. space col journ 2013; 8:1-4. 2. ojha l, wilhelm mb, murchie sl, mcewen as, wray jj, hanley j, massé m et al. spectral evidence for hydrated salts in recurring slope lineae on mars. nature geoscience 2015; 8(11): 829-832. 3. the planetary society. humans to mars – affordable and possible. 2015 http://hom.planetary.org/ (seen on oct 2016) 4. lakdawalla e. nasa's mars announcement: present-day transient flows of briny water on steep slopes. 2015 http://www.planetary.org/blogs/emily-lakdawalla/2015/09281219-nasasmars-announcement.html (seen on oct 2016) 5. cowing k. planetary society's mars mission takes longer to do less. 2015 http://nasawatch.com/archives/2015/09/planetary-socie-4.html (seen on oct 2016) 6. gough e. elon musk is sending humans to mars in 2024. 2016 http://www.universetoday.com/129313/elon-musk-sending-humans-mars-2024/ (seen on oct 2016) 7. fogg m. terraforming mars: a review of current research. adv space res 1998; 22(3): 415-420. 8. sagan c. blues for a red planet. carl sagan’s cosmos episode 5. 1980 http://www.imdb.com/title/tt0759805/ (seen on oct 2016) 9. mckay cp. let's put martian life first. the planetary report 2001; 21: 4-5. 10. alexandrov sd. algal research in space: history, current status and future prospects. innovare journal of life sciences 2016; 1:1-4. 11. fogg mj. the ethical dimensions of space settlement. space policy 2000; 16(3): 205-211. conflict of interest: declared none. author’s contribution: author developed the conceptual idea and wrote the manuscript. microsoft word sheikh arslan reseasrch ethics bangladesh journal of bioethics 2016; 7(2):35-38 35 short communication we still need to improve our research writing ethics sheikh arslan sehgal department of bioscience, comsats institute of information technology sahiwal pakistan state key laboratory of biomembrane and membrane biotechnology; institute of zoology; chinese academy of sciences; beijing, china university of chinese academy of sciences; beijing, china email: arslansehgal@yahoo.com abstract: the aim of current effort is too sentient that the people should have to know what is happening and to explore the reasons behind the veil of reasons so they can generate and amend their opinions and deduce their own conclusions. the most worthy asset of a researcher is to publish valuable research and must first be earned the scientific professional integrity and then maintained it. the scientific community must obey the scientific ethical norms and rules if they want to play its due role. still, we are bearing ethical quandaries in our research and we have to solve them for advancement of research in scientific community including pakistan. keywords: plagiarism, ethical issues, authorship issues, data fabrication introduction: breaches of publication ethics such as redundant publication, authorship issues, plagiarisms and data fabrication are recognized forms of research misconduct that can undermine the scientific literature 1. still, we are facing the ethical dilemmas in our academic and research work. the research misconducts where data is manipulated for never or fallaciously performed experiment, has been traced from many sides of world 2. we must change such an environment and teach our students the international, institutional and professional standards regarding research and research methodologies. an overlooked research misconduct; freakishly least or nearly become untraceable; is the authorship issues 3. such construing effect of research misconduct with bangladesh journal of bioethics 2016; 7(2):35-38 36 respect to authorship is a big problem where the credit of real researcher is being haunted by research feudal. a gap has been produced to fill which tangible need to define basic ethics has emerged. to cope such issues, some basic ethics needs to be aware and followed for betterment of research work in scientific community including pakistan. observed issues: faculty/supervisor should discuss the research work and publication credits with students throughout the research work and publication process. such understanding between supervisor and student will become a helpful tool for research progress. the authorship should reflect the contribution of the authors 4. usually, the faculty members overvalue their contributions to the projects and mostly in authorship situation. genuinely, both the parties believe that they are right. the supervisor should take the credit only for the work to which they have substantially contributed and they have actually performed. the write-up of the publication or minor contributions to the research should be acknowledged appropriately in appropriate sections 5. if student substantively contributes to the conceptualization, design, execution, analysis or interpretation of the research reported, they should be listed as authors 6. usually, senior lab-members, supervisor’s good friends, department chairperson, supervisor’s relatives and favorite students share the authorship without any contributions 5. the same rule applies to the students not to share the authorship with their best friends without contributions. in contrast, as result of supervisor’s unnatural feudalistic dictatorialness, students are infusing themselves with the trend to take over supervisor by dismantling his authorship. such trend produces bad effect in scientific community which in turn aggressively taken by supervisors as offence. there are many other least observed issues that are genuinely not research misconducts, but disturb research enhancement, like some supervisors even do not start the project of the students at appropriate time. suggestions to scientific community: the supervisor and student should keep the research theme, idea, results and interpretations confidential. researchers should have to be honest in all scientific communications. report the data, results, methods and procedures honestly. misrepresenting, falsification, and fabrication of data should be discouraged at every stage. it is not ideal to deceive public, science, sponsors, research and colleagues. bangladesh journal of bioethics 2016; 7(2):35-38 37 student should always try to be unbiased in write-up, decisions, peer review, data interpretation, data analyses, experimental design and other aspects of research work. students should always keep their agreements, words and promises and act with sincerity. avoid careless negligence, errors and erratum. if nessecerily important, be confidential with the findings till it’s published but conversely and needfully share the resources, tools, equipment and basic useful data. students should always show patience for criticism. scientific community should always show honor and respect to the intellectual properties including patents and copyrights. do not cite unpublished results and methods without author permission. properly mention the credits and acknowledgments to the contributors. researchers should publish the data for the advancement of research and science rather than to enhance and/or advance their own career and funds. also they should avoid publishing duplicative and wasteful data. discrimination should always be avoided, discouraged, and bumped off among students and colleagues on the basis of favoritism, ethnicity, race, religion, sex or any other factors that could destroy one’s scientific integrity and competence. if you are the journal manuscript reviewer, then it’s your duty to make that idea and work confidential. if you receive the manuscript of your friend, you should have to review it with unbiased decision. conclusion: research should be pure from data fabrication and misconducts for the advancement of science. supervisors and students have to perform their duties, experiments and contributions honesty. both the parties should not cheat and ditch each other for the betterment of research work. acknowledgements: sheikh arslan sehgal acknowledges mirza ahmad hammad and rana adnan tahir, bioinformatics research laboratory, department of biosciences comsats institute of information technology sahiwal, for their guidance and suggestions. bangladesh journal of bioethics 2016; 7(2):35-38 38 references: 1. wager, e., fiack, s., graf, c., robinson, a. and rowlands, i., 2009. science journal editors’ views on publication ethics: results of an international survey. journal of medical ethics, 35(6), pp.348-353. 2. https://grants.nih.gov/grants/research_integrity/research_misconduct.htm 3. al-adawi, s., ali, b.h. and al-zakwani, i., 2016. research misconduct: the peril of publish or perish. oman medical journal, 31(1), p.5. 4. https://www.councilscienceeditors.org/resource-library/editorial-policies/white-paper-onpublication-ethics/2-2-authorship-and-authorship-responsibilities/ 5. shamima p lasker. preceding s of bioethics and humanity (pernas 8 jbhki & abc17). indonesia. nov 2016. 6. http://www.apa.org/monitor/jan03/principles.aspx conflict of interest: declared none. author’s contribution: author developed the idea and wrote the manuscript. microsoft word fair subject selection final bangladesh journal of bioethics 2015; 6(3):37-40 37 review article ethical issues of fair subject selection in the research sifat rahman b.d.s (du), mph (aiub) email: rahmansifat@yahoo.com abstract: ethics and ethical principles extend to all spheres of human activity. they apply to our dealings with each other, with animals and the environment. they should govern our interactions not only in conducting research but also in commerce, employment and politics. ethics serve to identify good, desirable or acceptable conduct and provide reasons for those conclusions. fair subject selection is the first and foremost concern which must be ensured before initiating a research project. which subjects may enroll in the research is determined by the study’s inclusion or exclusion criteria. one of the important aspects of fair subject selection is to have an oversight system through international review board (irb) to review to conduct the research and to have approval whether subject selection is fair or not. key words: fair subject selection, research introduction: to maintain ethical regulation in clinical research involving human subjects is very much important. medical research is subject to ethical standards that promote respect for all human beings and protect their health and rights. some research populations are vulnerable and need special protection. the particular needs of the economically and medically disadvantaged must be recognized. special attention is also required for those who cannot give or refuse consent for themselves, for those who may be subject to giving consent under duress, for those who will not benefit personally from the research and for those for whom the research is combined with care. according to who (2008), fair subject selection can be expressed as; subjects should be selected on the basis of scientific importance, not based on convenience, vulnerability or bias1. method: this is a brief article prepared as a part of the assignment in the educational activity and training on research ethics titled “ethical and regulatory aspects of clinical research” arranged by the bangladesh bioethics society (bbs), dhaka, bangladesh, in collaboration with the department of bioethics of national institutes of health (nih), bethesda, maryland, usa, through video conferencing between october 1, 2014 and november 12 of 2014. the information gathering conducted through search was confined to ‘google’, ‘hinari’ and ‘pubmed’ search. besides, some guidelines on roles and responsibilities of institutional review board (irb) were taken into consideration. ethical aspects of fair subject selection: there are three aspects of subject selection2. these aspects are: bangladesh journal of bioethics 2015; 6(3):37-40 38 1. selection: determining eligibility of individual group 2. recruitment: approaching individuals in selected group 3. retention: retaining enrolled subject methods of recruitment: vulnerable groups should not be recruited.2 incentives may be offered to physicians to refer their patient to trials. incentives may encourage investigators to enroll inappropriate subjects. international review board should monitor advertising and evaluate relative size of type used and other visual effects.3 selection, recruitment & retention should distribute burdens and benefits properly, ensure social value of research, enhance scientific validity, minimize risks to subjects and protect the vulnerable. though there may be conflicts between these goals in some cases. excluding very sick person from the research may give rise to chance of decreasing of social value of research. by balancing the competing goals investigators, review committees and sponsors can minimize conflict. circumstances should be judged for understanding so that importance of factors in that case, can be determined.2 criteria of subject selection: subject selection should be based on two criteria2: 1. inclusion criteria 2. exclusion criteria inclusion and exclusion criteria may include factors such as age, sex, race, ethnicity, type and stage of disease, the subject’s previous treatment history, and the presence or absence (as in the case of the “healthy” or “control” subject) of other medical, psychosocial, or emotional conditions. inclusion criteria are used to determine whether a person can participate in a research study or whether an individual study can be included in a systematic review. exclusion criteria are those who cannot participate in a research study or whether an individual study can be excluded with good reason2. exclusion without a good reason may be unfair or discriminatory2. research should be begum with considering that everyone is eligible to ensure fairness. in determining who can enroll, the scientific goals of study should be the primary consideration. individuals with physical and mental disability who cannot respond to scientific questions and who cannot satisfy the protocol requirements or who cannot make the required visit should be eliminated. exclusion criteria are important in minimizing risks of research study. subject selection should focus on enhancing benefit of study2. vulnerable groups unless their participation is mandatory for scientific reason should be excluded for their protection.2 according to belmont report, adults should be selected prior to children.3 those who are less able to protect their own interest and being unable to give bangladesh journal of bioethics 2015; 6(3):37-40 39 voluntary informed consent, defined as vulnerable subjects. those who are unable to consent should be excluded unless there is a compelling reason to enroll them.2 according to declaration of helsinki-2008, medical research involving a disadvantaged or vulnerable population or community is only justified if the research is responsive to the health needs and priorities of this population or community and if there is a reasonable likelihood that this population or community stands to benefit from the results of the research4. protections for vulnerable populations: current federal regulations provide additional protections and special requirements for research involving children and prisoners and instruct irbs to be cognizant of the special problems of research involving vulnerable populations. groups considered to be vulnerable are: children, prisoners, pregnant women, mentally disabled persons, and economically or educationally disadvantaged persons. studies seeking to enroll vulnerable subjects must provide additional safeguards to protect the rights and welfare of these subjects.5 informed consent: when seeking informed consent for participation in a research study the physician should be particularly cautious if the potential subject is in a dependent relationship with the physician or may consent under duress. in such situations the informed consent should be sought by an appropriately qualified individual who is completely independent of this relationship2. for a potential research subject who is incompetent, the physician must seek informed consent from the legally authorized representative.2 these individuals must not be included in a research study that has no likelihood of benefit for them unless it is intended to promote the health of the population represented by the potential subject, the research cannot instead be performed with competent persons, and the research entails only minimal risk and minimal burden.2 review by an institutional review board: human subject research is reviewed and approved by an irb using the following criteria: 1) risks to subjects must be minimized and reasonable in relation to anticipated benefits; 2) the selection of subjects must be equitable, with attention to the special problems of research involving vulnerable populations ; 3) additional safeguards must be included if the research involves vulnerable populations; 4) informed consent must be sought and appropriately documented if the risk is greater than minimal; 5) researchers must continually monitor the data collected to ensure safety of subjects ; and 6) the privacy of subjects must be maintained.5 three fundamental ethical principles3 1. respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent. researchers must be truthful and conduct no deception; bangladesh journal of bioethics 2015; 6(3):37-40 40 2. beneficence: the philosophy of "do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; 3. justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly — the fair distribution of costs and benefits to potential research participants and equally. conclusion: loss of enrolled subjects undermines scientific validity and wastes resources. future research is needed to identify ways to encourage subjects to continue to participate, and retain them, without undermining their right to withdraw. subject selection, recruitment and retention are central to the ethics of clinical research.2 yet, these issues have not received the attention they deserve in practice, or in the literature. subject selection should be fair for ethical regulation of research involving human subjects. often, subject selection is not given much thought. however, one of the principles of ethical clinical research is just that subjects should be selected for participation principally based on the scientific question. due consideration should be given to risk, benefit and vulnerability of the subjects. references: 1. jon c tilburt, ted j kaptchuk, bulletin of the world health organization, volume 86, number 8, august 2008, 594-599. 2. david wendler, department of bioethics, nih clinical center, fair subject selection, http://bioethics.nih.gov/courses/pdf/2012/wendler.pdf 3. national commission for the protection of human subjects of biomedical and behavioral research, department of health, education and welfare (dhew) (30 september 1978). the belmont report (dhew pub. no.(os) 78-0012). washington, dc: united states government printing office. 4. world medical association declaration of helsinki, ethical principles for medical research involving human subjects 5. u.s. department of health & human services 200 independence avenue, s.w. washington, d.c. 20201 conflict of interest: there is no conflict of interest islamic perceptions of medication with special reference to ordinary and extraordinary means of medical treatment bangladesh journal of bioethics 2013; 4(2):22-33 22 islamic perceptions of medication with special reference to ordinary and extraordinary means of medical treatment mohammad manzoor malik assistant professor department of general studies, kulliyyah of islamic revealed knowledge and human sciences international islamic university malaysia e-mail: philomalik@iium.edu.my / philomalik@gmail.com abstract: this study attempts an exposition of different perceptions of obligation to medical treatment that have emerged from the islamic theological understanding and how they contribute to diversity of options and flexibility in clinical practice. particularly, an attempt is made to formulate an islamic perspective on ordinary and extraordinary means of medical treatment. this distinction is of practical significance in clinical practice, and its right understanding is also important to public funded healthcare authorities, guardians of the patients, health and life insurance institutions, and employers who provide health care coverage to their employees. not only these parties, but also lawyers and justice administration functionaries such as public prosecutors and judges are in need of understanding this distinction to deal with relevant litigations. the distinction could be made regarding terminally ill patients and non-terminally ill patients separately. the essential factors that matter in making the distinction between ordinary and extraordinary means of treatment are: (1) patient capacity (2) expert advice, and (3) nature of medication. regarding terminally ill patients, medical treatment can become extraordinary because of (1) patient capacity and (2) nature of medication. in both these case the deciding condition applies: the expert advice taken from a group of physicians. in regards to nonterminally ill patients, extraordinary medical treatment includes three cases: (1) treatment that is known to be useless and futile, (2) treatment that endangers the life or cause more harm than what it removes, and (3) useful treatment, but the patient is unable to bear the cost. key words: medication, bioethics, extraordinary medical treatment, medical ethics introduction: deciding on medical treatment becomes sometimes complicated because of the quality of available medical treatment; multifaceted considerations related to the patients, their financial strength, and the nature of the diseases they suffer. making an adequate distinction between ordinary and extraordinary means of medical treatment is one of such difficult times. the distinction is of high significance in clinical practice and its right understanding is also important to public funded healthcare authorities, guardians of the patients, health and life insurance institutions, and employers who provide health care coverage to their employees. not only these parties, but also lawyers and justice administration functionaries such as public prosecutors and judges are in need of understanding this distinction in dealing with relevant litigations. therefore, an islamic stance on the issue is attempted in this paper. the underpinnings of this discourse are necessarily rooted in the ways muslims perceive importance of medical treatment from the basic theological sources: the quran and the sunnah. the multiple perceptions of obligation to medical treatment allow flexibility in the clinical practice and, at the same time, help formulating an executable, applicable distinction of ordinary and extraordinary means of medical treatment. in the subsequent sections, the researcher will attempt to explore the position of the quran and the sunnah on the subject of medication; different perceptions of medication that have emerged from these sources from the early times to the present; and, finally, how by deriving on the aforesaid sources and perceptions, formulating the distinction between ordinary and extraordinary means of medical treatment is possible. mailto:philomalik@iium.edu.my mailto:philomalik@gmail.com bangladesh journal of bioethics 2013; 4(2):22-33 23 sources and applied methods in islamic ethico-juristic studies: in face of changing circumstances and advances in medical science, muslims seek guidance (hidayah) from the quran, which is foremost a book of guidance: “… guidance unto those who ward off (evil)”. 1 along with the quran, the sunnah is the second source: “… obey allah and obey the messenger and those charged with authority among you. if you differ in anything among yourselves, refer it to allah and his messenger…” 2 beside the quran and the sunnah, there are other additional sources such as ijma (consensus), qiyas (analogical deduction), istihsan (juristic preference), al-maslaha al-mursalah (public interest), istidlal (textual indication), urf (common practice), etc. however, different schools of islamic jurisprudence do disagree on inclusion and exclusion of some of these sources or understand them differently in terms of their scope and referents; yet, without any disagreement, they are unanimous on accepting the first two sources. the common agreeable authorities among all sects and schools of islam in their theologies and jurisprudences are the quran and the sunnah alone. moreover, ijma (consensus) depends itself on the quran and sunnah and it includes certain unanimous resolutions whereas qiyas (analogical deduction) is not the source of islamic law; it is rather the method. therefore, the door of taking decisions by making intellectual effort (ijtihad) is always open for competent muslim scholars by rethinking the quran and the sunnah, especially when new issues (nawazil) emerge that require resolution from islamic perspective. the ethical, juristic, and doctrinal guidance from these two sources has manifested in a bulk of classics of islamic studies known to muslims as turath. islamic turath is itself sometimes diversified with dimensions diverging in conclusions and converging in one or other way to the primary sources of islam i.e. the quran and the sunnah. the rest of the sources are based on ijtihad of different sects and schools of muslims. regarding the first source, the quran, the important matter is understanding it by using sound approach and valid methods; whereas, the sunnah requires both verification of the authenticity of the reports and comprehension of their contents. there is a meaningful difference between hadith and the sunnah, though they are very often used interchangeably. the sunnah is an established path or practice; whereas, hadith is everything that is reported on any subject from the prophet muhammad, including his sayings, deeds, approvals, and descriptions of his personality. some of the narrations are abrogated or specific to particular persons or contexts. the various hadith (prophetic narrations) on any subject have led to difference of opinion on various subjects. however, the main ideal pursuit is to find what could be called as the sunnah, for the practical purposes; and the most important categories of the sunnah are those which either proves obligation (wujub), or prohibition (hurmah). very closely connected to this methodological discourse is the consideration that scholars give to the higher intentions of shariah or maqasid al-shariah. the higher intentions of shariah are in fact conceptual parameters that present the very essence of the spirit of islam regarding laws and ethics. there are specific objectives and aims which islamic shariah wants to safeguard. imam alghazali (d. 505/1111), al-izz bin abdul salam (d. 660/1262) in, al-syatib (d. 790/1388), to mention a few leading scholars, have raised the question: what is the end, or the objective of shariah? the essential maqasid are five: life, intellect, faith, lineage, and property. 3 quranic approach to health care and medication: the quranic approach to health care and medical treatment is based on its clear statements or verses. a comprehensive study would show that the quran touches the subject in five ways. firstly, the actual healer, according to the quran, is allah himself, though means (asbab) of medication are not prohibited. the quran states: “whatever of good reaches you is from allah…” 4 and “if god touches thee with affliction, none can remove it, but he: …” 5 the quran tells the story of ibrahim, the prophet, in which he says, “… and when i was sick, he (allah) was the one who healed me”. 6 the story of ayyub, (job), the prophet, provides evidence for both divine favor in healing and resorting to appropriate means in pursuing cure. 7 bangladesh journal of bioethics 2013; 4(2):22-33 24 secondly, the quran, as the word of allah, has power of healing. the quran states “o mankind: there has come to you a direction from your lord and a healing for the (disease) in your hearts …” 8 this verse would mean that diseases are not just physical ones, but they can be spiritual, mental, and psychological. the quranic worldview and its teachings on ethics, self purification and behavior provide guidance that could be used in healing patients who suffer from many diseases that are non-physical; for example, anxiety, despair, hopelessness, rage, excessive anger, jealousy, negative thinking, and some forms of minor depression, etc. however, the quran proclaims its healing power in general sense that includes both physical and non-physical disease as it states: “and we send down of the quran that which is a healing and a mercy to those who believe” 9 and “… say unto them (o muhammad): for those who believe it is a guidance and a healing...” 10 this could be well illustrated by the prophetic traditions (hadith) that speak of the healing power of the quran in curing the physical ailments. for example, one of the companions of the prophet mohammad healed a chief of a tribe, who was bitten by a snake or stung by a scorpion, by reciting surat al-fatihah, the first chapter of the quran. 11 thirdly, the quran considers substances of having healing power. the quran clearly mentions honey: “…there comes forth from their bellies, a drink of varying colour wherein is healing for men…” 12 this verse shows that healing could be done by using proper substances. fourthly, the quran sets forth guidance on maintaining health. according to imam ibn al-qayyim, the basic principles of medicine are three: prevention, maintaining good health, and removing harmful substances from a person‟s body. and these principles are mentioned in the quran. regarding prevention, allah allows a sick person to perform tayammum (the islamic act of dry ablution using sand or dust, which may be performed in place of ritual washing ), so preventing the sick person from using water, which may harm him 13 ; regarding maintaining good health, a traveler and ill are allowed to break their fast during ramadan, for protection of their health, otherwise fasting along with the difficulties of travel can weaken them and affect their health adversely 14 ; and regarding removing harmful substances from a person‟s body, allah allowed shaving a person‟s head in ihram (for hajj or umrah) for the removal of harmful things, an exception to the general prohibition of doing so 15 . 16 lastly, the quran gives very high importance to sanctity of life and provides clear injunctions that are relevant to contemporary issues in bioethics such as euthanasia, abortion, persistent vegetative state (pvs), and physician-assisted suicide. these guidelines include: prohibition of killing, consenting to self-destruction, suicide, and collaborating on accomplishing prohibited acts. regarding the prohibition of killing, the quran prohibits unjustified killing: “and do not kill anyone whose killing allah has forbidden, except for a just cause….” 17 in addition, intentional killing of a human being is highly prohibited: “and whoever kills a believer intentionally, his recompense is hell to abide therein, and the wrath and the curse of allah are upon him, and a great punishment is prepared for him”. 18 similarly, self-killing is prohibited: “... and do not kill yourselves (nor kill one another). surely, allah is most merciful to you.” 19 equally, the quran prohibits helping and collaborating on conducting sinful acts: “and do not help each other in sin and aggression”. 20 prophetic traditions (the sunnah) on health care and medication: the sunnah or hadith deal with medication in three ways. the first type of the prophetic traditions encourages and in a recommendable fashion suggests opting for medical treatment. for example, the prophet muhammad said, “…seek medicine, for allah has not created a disease except that he has created its cure…” 21 ; “there is no disease that allah has created, except that he also has created its treatment” 22 ; “… so you seek medical treatment and do not seek it unlawful” 23 ; “it is not god sent down a disease but also sent down the cure” 24 ; and “verily, allah does not send down a disease but also the medicine. the drug was known to the person who can know it and not known by those who could not tell.” 25 in addition, there is, in many chapters in the canons of hadith that are related to the prophetic traditions on the subject of medicine, mention of many substances, fruits, and items praised for their medicinal bangladesh journal of bioethics 2013; 4(2):22-33 25 effects and therefore recommended for healing. among these various stuffs are indian incense 26 ; black cumin 27 ; and talbina (a meal made from barley flour, formed by adding milk and honey), 28 etc. regarding quarantine, when epidemics outbreak, the prophetic tradition states: “if you hear of an outbreak of plague in a land, do not enter it; but if the plague breaks out in a place while you are in it, do not leave that place.” 29 the second type of traditions speaks about the tawakkul (reliance upon god). for example, “whoever seeks treatment by cauterization, or with ruqyah (incantation) then he has absolved himself of tawakkul (reliance upon allah).” 30 the prophet also said that seventy thousand men of his ummah (muslims), who neither practice charm, not take omens, nor do they cauterize, but they repose their trust in their lord, would enter paradise without rendering account. 31 however, as mentioned earlier, medication is allowed and encouraged and so is ruqyah (incantation) allowed and proven as stated in the prophetic traditions. to suffice, “the prophet used to treat some of his wives by passing his right hand over the place of ailment and used to say, “o allah, the lord of the people! remove the trouble and heal the patient, for you are the healer. no healing is of any avail but yours; healing that will leave behind no ailment”. 32 furthermore, medication is part of the destiny one will come across as abu khuzamah narrated: “i said, „o messenger of allah, the ruqyah (divine remedies islamic supplication formula) that we use, the medicine we take and the prevention we seek, does all this change allah‟s appointed destiny? he said, „they are in fact a part of allah‟s appointed destiny”. 33 the third type of traditions, on the other hand, allow abstaining from medication, as aishah (may allah be pleased with her) narrates about an incident before the demise of the prophet (peace and blessings of allah be upon him). she states: “we put medicine in one side of his mouth, but he started waving us not to insert the medicine into his mouth. we said: he dislikes the medicine as a patient usually does. but when he came to his senses he said: did i not forbid you to put medicine (by force) in the side of my mouth….” 34 ata bin abi rabih narrates: ibn abbas said to me: “may i show you a woman of paradise? i said: yes. he said: here is this dark-complexioned woman. she came to allah‟s apostle (may peace be upon him) and said: i am suffering from falling sickness and i become naked; supplicate allah for me, whereupon he (the holy prophet) said: show endurance as you can do and there would be paradise for you and, if you desire, i supplicate allah that he may cure you. she said: i am prepared to show endurance (but the unbearable trouble is) that i become naked, so supplicate allah that he should not let me become naked, so he supplicated for her”. 35 the trends and approaches to medication in the first two sources of islam provide a rich matrix to rethink and resolve the emerging issues in bioethics. likewise, the potentiality of these trends in deriving less strict and more flexible orientations can lead to formulation of flexible juristic and ethical normative guidelines and codes in clinical practice, counseling, and provide space for the autonomy of patients to exercise discretion in respect to patient‟s own capacities and capabilities. comprehending the guidance on medical treatment from the basic sources of islam has throughout history culminated into different perceptions as present in classics of islamic jurisprudence. these perceptions furthermore substantiate the trend on the subject which evades rigidity and encourages flexibility. the following section of the paper will explore the opinions of the jurists and contemporary juristic thought on the subject. islamic medical jurisprudence: different perceptions from ijtihad: the opinions on obligation to medical treatment in the works of islamic jurisprudence are varied, held by their opponents due to their methodological preferences while making ijtihad. muslim jurists are unanimous in upholding permissibility (ibaha) of medical treatment. some jurists, while deliberating on the theological evidences, have formulated positions on medical treatment, relying considerably on the nature of diseases and medical conditions of patients; hence, different opinions are made on the issue, culminating in formulation of normative positions. however, a single normative position has tendency of reducing the whole issue of obligation to medication to a single guiding principle that may not fit in the holistic view based on various evidences from the bangladesh journal of bioethics 2013; 4(2):22-33 26 quran and the sunnah on the subject. ibn taymiyyah (1263–1328 ce) has rightly appropriated it, as he states that the scholars have disputed on medication whether it is mubah (permissible), mustahab (recommended) or wajib (obligatory), when in fact, the correct view is that medication is of types, some of the types are muharram (prohibited) and makruh (disapproved) and some are mustahab, and wajib. 36 the jurists including some mystics have divided in two groups on the subject of medical treatment: opponents and proponents. opponents comprise of two groups. the first group is outrightly against medical treatment; some extremist sufi (mystics) belong to this group. 37 their justification follows from the popular concept of tawakkul (reliance upon allah), believing that god ultimately holds power to heal and harm, and they drive on some prophetic traditions which are understood, in an unholistic manner any literally, discouraging any obligation to medical treatment. however, the more reliable account that could be attributed to sufis is that permissibility of medication is not contrary to tawakkul and reliance upon allah. 38 on the other hand, there are juristic opinions that although treat medical treatment permissible, yet they prefer avoiding it. in hanbili school of jurisprudence, avoiding medication is treated as the best option (afdal) to practice. 39 al-muruzi also states that medication is permitted (ruksah) and avoiding it is the best option 40 ; imam nawawi prefers the similar view. 41 as a matter of fact, there are reports that some of the disciples of the prophet (sahabah) and the generation after the sahabah (tabieen) abstained from medication such as abu bakar, abu darda, ubay ibn kaab and abu dhar; 42 and their abstention was not disputed or “criticized by their contemporaries”. 43 the second group is of jurists who oppose medication in case the patient believes that it is medication alone –without allah‟s permission-that will heal him. some hanafi scholars hold this position. 44 proponents hold four positions: (1) mubah (permissible) (2) mustahab and mandub (recommended) (3) makruh (disapproved) and (4) wajib (obligatory). permissibility (ibaha) of medication is held by the majority of scholars of hanafiyah, malikiyah, and hanbaliah schools of islamic jurisprudence. the overriding opinion (rajah) regarding medication is permission (jawaz) and consensus (ijma) of sahabah and tabeen is reported in favor of it. 45 among hanafi scholars, imam kasani and syafi'iyah school of jurisprudence treat medication mustahab and mandub. 46 some of the scholars of the first three centuries of islam (salf) 47 and malikiyah school of jurisprudence treat medication makruh if the medication is yet to be discovered. those who consider medication wajib (obligatory) comprise of two groups. the first group considers medication absolutely obligatory; they are some of the scholars of hanbaliah school of jurisprudence. this view is supported by one of the opinions of imam ahmad 48 .the second group believes that medication is obligatory if a person knows that he will not live without it. this view is held by some scholars of syafi'iyah and hanbaliah schools of jurisprudence; ibn taymiyyah holds the similar position. 49 the traditional scholarship of islamic jurisprudence as briefed above presents many perceptions of obligation to medical treatment, emerging basically from the original sources of islam. the contemporary scholarship on the issue is clearer than the traditional discourse, especially in delineating classification of levels of obligation and their corresponding types of diseases with helpful conceptual content in understanding the nature of diseases under consideration. contemporary islamic approach to medication: the contemporary approaches to bioethics in islamic writings are based on the aforementioned discourse in islamic jurisprudence and reconsideration of the first two sources of islam. the topics included in the traditional works of islamic jurisprudence do not have separate chapters on bioethical matters. however, the sub branch of islamic jurisprudence to which scholars contribute independently or institutions in an organized form called as fatwa has been meeting the challenges. in addition, independent bangladesh journal of bioethics 2013; 4(2):22-33 27 scholars have written exclusive works on the subject. juristic organizations and bodies have produced unanimous resolutions on the matters pertaining to bioethical issues. the professional organizations have also drafted codes. in terms of methods, a comprehensive study of these writings demonstrates that the contemporary writings on islamic bioethics rely on five sources: (1) principles of islamic jurisprudence (usool alfiqh) (2) higher intentions of islamic law (maqasid alshariah) (3) maxims of islamic law (al -qawaid alfiqhiyah)). in addition, different from the traditional way of developing legal and moral positions, the writings on islamic bioethics lay a great emphasis on (4) expert advice (clinicians) and (5) intentionality and capacities (of clinicians, patients, and guardians), allowing space for what has come to be known as “patient autonomy”. the jurisprudential discourse on medical treatment has culminated into some decisiveness in the contemporary time. though different perceptions of medical treatment still matter to help in solving some issues that clinicians and patients face at times; however, the important issue is to decide when medical treatment becomes obligatory (wajib). knowing this is important to many concerned people such as public policy experts, physicians, patients, guardians of the patients, insurance companies, employers, lawyers, etc. a very comprehensive statement worthy of consideration is the resolution of islamic fiqh academy, al-majma al-fiqh al-islami, on the medication that was made in its seventh session in jeddah on 7-12, 11, 1412 h. as follows: the medication is permissible because of its justification from the quran, both statements and acts of the prophet (sunnah), and for the reason that it guards the self of a person, which is one of the basic objectives of the shariah. the injunctions regarding medication differ according to patients. the medication becomes obligatory (wajib) in cases where not giving medication could cause death, disability or the loss of a limb, or where the sickness is bound to spread if not treated, as in contagious diseases. medication becomes encouraged (mandub) in cases where not giving medication may weaken a person physically, and it is not as bad as the cases that are under preceding obligatory (wajib) type. it becomes optional or permissible (mubah) in cases which are not covered in the two preceding categories: wajib and mandub. it is discouraged or disliked (makruh) in cases where the treatment could lead to complications that are worse than the original disease that is considered to be cured. 50 in these categories, it seems that decision making on medical treatment is solely based on the patient autonomy. however, in certain cases patient autonomy and consent is disregarded against greater good of public. authorities have right to force medication in certain situations such as in case of contagious disease, or in case of giving of vaccines or inoculations. in an emergency, where lives are at stake, treatment does not depend on obtaining permission of patients. 51 furthermore, the medication of terminally ill patients should be in accordance to the expert advice of the doctors, the availability of medication in time and place and the circumstances of the patient. 52 the abovementioned discourse on medication, which follows from the quran and the sunnah, shapes into guidelines and norms in the jurisprudential heritage of islam and into resolutions of jurisprudential bodies in our contemporary time is still in need of further development to address the modern-day bioethical concepts, distinctions, and issues. one of such important issues is the distinction between ordinary and extraordinary means of medical treatment. ordinary and extraordinary medical treatment: classification: ordinary and extraordinary means of medical treatment distinction is important because of its usefulness in many medical issues. if, in some cases, medical treatment is obligatory in islamic sense, as described above, then it needs to be demonstrated whether such obligation is absolute or conditional. patients as individuals need to know it to make choices on medication. in addition, countries where access to medical treatment is right of a citizen, the public policy needs to be clear on what treatment is ordinary and what is extraordinary. in the corporate sector, the insurance companies also need to know which treatments they need to cover as ordinary and which they are not obliged to cover as extraordinary. in the similar manner, in a paternalistic model when right to refuse treatment may apply and when a surrogate‟s interest in approving or refusing medical treatment could be justified and considered in good faith, having a definite understanding of the issue becomes indispensable. therefore, the question arises: is it possible to bangladesh journal of bioethics 2013; 4(2):22-33 28 make a distinction between ordinary and extraordinary means of medical treatment on islamic lines; and if so, what should be the basis for the distinction? in order to understand the issue, the below classification is followed: 1. ordinary and extraordinary distinction in regards to terminally ill patients 2. ordinary and extraordinary distinction in regards to non-terminally ill patients islamic concept of obligation (takleef): islamic concept of obligation (takleef) is always qualified by some conditions and capacities that vary in respect to various duties and responsibilities. it is a concept which applies to all obligations. the central to the obligations (takleef) which comes with duty (ada) is that the person who is addressed with any obligation should be mukallaf: a mukallaf is a person who should have the capacity (ahliyyah) to carry out the duty. the concept of capacity (ahliyyah) is also understood as capability (istitaah). the classics of islamic jurisprudence are clear on the subject of capacity (ahliyyah) with details regarding performing rituals, transactions, contracts and other various matters. however, on many ethical matters this concept has received insignificant treatment; obligation to medical treatment is one of such issues. therefore, construction of right concept of obligation (takleef) regarding medical treatment is in need of adequate formulations. the aforementioned classification of obligation to medical treatment as stated in the resolution of al-majma al-fiqh al-islami is made in relevance to the nature of diseases. how a patient‟s own capacities and relevant circumstances and conditions affect the general rules brings the whole subject under a new scrutiny where general principles are subject to change on case by case basis by giving a patient due consideration as the subject who has influence on decision making. this line of thinking gives considerable weight to both the means of medical treatment and the patient in the process of deciding the obligation to medical treatment, generally, and, particularly, in determining extraordinary means of medical treatment. methodologically, the abovementioned concepts are to be understood adequately for the purpose of formulating the distinction between ordinary and extraordinary means of medical treatment, and to do so in a sophisticated manner, it requires comprehensive study of the writings on the relevant issues including fatwas (edicts), codes, independent researches, organized resolutions on various medical issues that touch obligation to medication, patient consent and autonomy, nature of medication, and overall understanding of the issue from the evidences in the quran and the sunnah. the study of relevant fatwas, cases, and statements that are available to me show that there are two factors which can lead to the formulation of the distinction between ordinary and extraordinary means of medical treatment. they are (1) patient capacity and (2) nature of medication. along with these two factor, the determining factor is (3) expert advice. it is the experts who are right authority to judge patient capacity and nature of medication. terminally ill patients and the distinction: regarding terminally ill patients, medical treatment can become extraordinary in certain instances; therefore, the patient would not be obliged to opt for medical treatment. the cases which come under this category, as the study of statements and fatwas on the relevant cases show, can be classified into two classifications: medication can be extraordinary, thus non-obligatory, because of (1) patient capacity and (2) nature of medication. in both these case expert advice taken from a group of physicians applies as the condition that would decide on the presence or absence of the capacity of the patient and the nature of the medication that may be under consideration. patient capacity: medication can become extraordinary, thus non-obligatory, if patients lack in certain capacities. various statements of muslim scholars on withholding, withdrawing, and suspending medical treatment from terminally ill patients include mention of certain capacities, and judging their absence or presence is determined by “expert advice”. to illustrate this, for example, mufti ali gomma‟s fatwa regarding euthanasia is helpful in discerning nature of extraordinary bangladesh journal of bioethics 2013; 4(2):22-33 29 means of medical treatment. in light of his statement, using life sustaining medical equipment with patients with no hope to recover and without any progress made on restoring their health becomes extraordinary, precisely when the patients are “clinically dead”; however, he qualifies such a decision with expert advice taken from physicians. 53 muzammil siddiqi of the fiqh council of north america supports stopping medication when a patient is in terminal condition with no hope of recovery and switching off the life support machine with due consultation and care when expert advice from medical experts determine so. 54 islamic medical association of north america (imana) supports discontinuing life support except nutrition and hydration when a patient is in a “vegetative state”. 55 council of islamic jurisprudence (al-majma al-fiqh al-islami) issued a resolution on discontinuing, on advice of specialist and experienced doctors, life support system when patient‟s brain functions cease completely even if some of the patient‟s organs like the heart are kept functional by artificial means. 56 on the issue of resuscitation, standing committee for academic research and issuing fatwas (fatwa al-lajnah al-daimah) endorsed “do not resuscitate” (dnr) in several cases including when the patient‟s condition is not fit for resuscitation; when patient‟s sickness is chronic and untreatable, and death is inevitable; if the patient is incapacitated, or is in a persistent vegetative state and chronically ill, or in the case of cancer in its advanced stages, or chronic heart and lung disease, with repeated stoppages of the heart and lungs; if there is any indication in the patient of brain injury that cannot be treated; and if reviving the heart and lungs is of no benefit and not appropriate because of a certain situation. most of these cases are conditioned with “expert advice”, three trustworthy specialist doctors. 57 nature of medication: some means of medical treatment can become extraordinary because of the nature of medical treatment itself: by examining the quality, usefulness, and effectiveness of the means of medical treatment. in this case, categorizing medical treatment as extraordinary depends primarily on the expert advice taken from a group of physicians or medical committees. for example, the islamic code of medical ethics, in its article sixty-two allows “the termination of a treatment when its continuation is confirmed, by the medical committee concerned, to be useless, and this includes artificial respirators, in as much as allowed by existing laws and regulations” and “declining to begin a treatment that is confirmed to be useless”. 58 sheikh yusuf al-qaradawi holds that a physician can suspend useless medical treatment for the sake of the patient‟s comfort and the relief of his family. 59 sheikh muhammed salih al-munajjid holds the view that if there is no certainty that treatment will be of benefit, and indeed it is likely to cause suffering to the patient, then there is nothing at all wrong with not giving the treatment. 60 furthermore, islamic code of medical ethics states that “if it is scientifically certain that life cannot be restored then it is futile to diligently keep the patient in a vegetative state by heroic measures or to preserve the patient by deep freezing or other artificial methods”. 61 non-terminally ill patients and the distinction: in regards to nonterminally ill patients, the concept of ordinary and extraordinary means of medical treatment has not been given any adequate treatment in the current bioethics; however, it is possible to formulate the concept of extraordinary means of medical treatment on islamic lines. medical treatments which are known useless, their harm is more than the diseases in question , or are deceptive in their effects, and which while being free from these defects are not possible because of the financial incapacity of the patients are extraordinary. some of these types of treatment are even treated not only extraordinary but also prohibited by statements made by some islamic scholars in fatwa literature. there are three types of means of medical treatment, as they seem to me, which deserve to be categorized as extraordinary in respect to non-terminally ill patients. they are: (1) treatment that is known to be useless and futile; (2) treatment that may endanger the life or cause more harm than what it removes; and (3) treatment is useful, but the patient is unable to bear the cost. useless and futile treatment: the means of medical treatment that are known to be useless and futile are extraordinary. therefore, because of the nature of the medication, such medication would not be obligatory for a muslim patient in case the obligation to medical treatment falls within the obligatory (wajib) category; this decision has to be based on the advice of expert bangladesh journal of bioethics 2013; 4(2):22-33 30 physicians, as the research shows that expert advice has decisive importance in almost all cases in which treatment is withheld or discontinued. this position is further supported by the legal maxim: al yaqin la yuzal bil shakk, certainty is not dispelled by doubt. if there is certainty that the medical treatment will not cure the patient, doubting otherwise will not turn that medical treatment into ordinary. life endangering and harmful treatment: those means of medication are extraordinary if they cause danger to life or cause more harm than they could possibly remove. the legal maxims state: no injury or countering injury (la darar wa-la dirar); “harm must be eliminated but not by means of another harm” (ad-dararu yuzalu wa lakin la bi-darar); “harm is not eliminated by another harm” (ad-dararu la yuzalu bid-darar); and “harm is not eliminated by the similar harm” (ad-dararu la yuzal bi mithlihi). however, “a greater harm is eliminated by means of a lesser harm” (ad-dararu alashadd yuzal bid-darar al-akhaff). unbearable, overcostly medication: the very important component of any obligation in islam is the capacity or takleef of a patient. this capacity could be broken down into many subcomponents relevant to various religious obligations. regarding sickness and disease, if a patient is not in position to pay the expenses of medication, in that case the patient does not have any obligation to medication. the prophetic tradition states that “…if i forbid you to do something, then keep away from it. and if i order you to do something, then do of it as much as you can.” 62 to help such patients in paying the expenses for medication, governments, charity organizations, society, and individuals do play some role. and it would be encouraged on islamic lines. shariah compliant insurance system called takaful can also be a solution. in islam, all these ways are permissible besides islam encourages donating (sadqah) to those who are needy. even obligatory form of charity or alms-tax (zakah) could be spent on such cases. for example, shaykh ibn uthymin in majmu al -fataawa while answering the question, “is it permissible to give zakah to those who are suffering from kidney failure?” responds, “…a person‟s need for medical treatment is a real need, so if we find someone who needs medical treatment but does not have enough money to pay for treatment, there is nothing wrong with giving zakah to him, because the aim of zakah is to meet people‟s needs.” 63 conclusion: the researcher attempted to show the importance of medical treatment from the primary sources of islam: the quran and the sunnah, and, furthermore, how this issue is debated by muslim jurists in the classics of islamic jurisprudence. connecting the traditional discourse to the latest development in islamic jurisprudence, the researcher showed that medical treatment becomes obligatory (wajib) if its abandonment leads to the fatality of the life or an organ or its inability or the disease transmits to others such as communicable diseases. deriving on this concept of obligation, the researcher discussed the distinction of ordinary and extraordinary means of medical treatment. the researcher showed that the distinction can be made in two ways regarding terminally ill patients and non-terminally ill patients. the factors that lead to the distinction between ordinary and extraordinary treatment are: (1) patient capacity (2) expert advice, and (3) nature of medication. regarding terminally ill patients, medical treatment can become extraordinary if it is (1) extraordinary because of patient capacity and (2) extraordinary because of nature of medication. in both these case the condition applies and that is expert advice taken from a group of physicians. in regards to nonterminally ill patients, the three types of extraordinary means of medical treatment are very prominent: (1) treatment that is known to be useless and futile, (2) treatment that may endanger the life or cause more harm than what it removes, and (3) treatment is useful, but the patient is unable to bear the cost. bangladesh journal of bioethics 2013; 4(2):22-33 31 references: 1. the quran, 2:2. 2. the quran, 4:59. 3. kamali mh. maqasid al-shariah made simple herndon: the international institute of islamic thought; 2009. 4. the quran, 4:79. 5. the quran, 6: 17. 6. the quran, 26:80. 7. see the quran, 38: 41-44. 8. the quran, 10: 57. 9. the quran, 17:82. 10. the quran, 41:44. 11. al-bukhari. sahih al-bukhari. beirut: dar ibn kathir; 2002/1423h. hadith no:5737. 12. the quran, 16: 69. 13. see the quran, 4: 42 and 5:6. 14. see the quran, 2:185. 15. see the quran, 2:196. 16. ibn-qayyim. zad al-maad fi hadyi khair al-ibad. beirut: dar al-kotob al-ilmiyah. 17. the quran, 17: 33. 18. the quran, 4: 93. 19. the quran, 4:29. 20. the quran, 5:2. 21. at-tirmidhi. sunan at-tirmidhi. beirut: dar ihya al-turath al-arabi. hadith no: 2038. 22. al-bukhari. sahih al-bukhari. beirut: dar ibn kathir; 2002/1423h. hadith no: 5678 . 23. abu dawud. sunan abi daawud mohideen m, editor: darul fikir. hadith no: 3874. 24. ibn hambal. musnad imam ahmad ibn hambal. cairo: muasasah qurtubah. hadith no: 3578 . 25. ibn-majah. sunan ibn majah. al-qazuwaini mbyaa, editor. beirut: darul fikir. . hadith no: 3436. bangladesh journal of bioethics 2013; 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4(2):22-33 33 49. ibn-taymiyyah ta. majmu fatawa ibn taymiyyah al-kubra. cairo: dar ar-rahmah. 50. resolution of the islamic fiqh academy on medicine. organization of islamic conference; [cited 2013 20 april 2013]; available from: http://www.saaid.net/tabeeb/69.htm. 51. resolution of the islamic fiqh academy on medicine. organization of islamic conference; [cited 2013 20 april 2013]; available from: http://www.saaid.net/tabeeb/69.htm. 52. organization of islamic conference. majallat majma al-fiqh al-islami, vol. 6, 3/1791. 53. goma a. ethics of euthanasia. 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[fatwa] [updated 12 march 2011]; available from: http://www.islamqa.com/en/ref/2438. 61.islamic code for medical and health ethics. the islamic organization for medical sciences; 1981 [cited 2013 20 april]. available from: www.emro.who.int/docs/em_rc52_7_en.pdf. 62. al-bukhari. sahih al-bukhari. beirut: dar ibn kathir; 2002/1423h. hadith no: 7288 . 63. can zakaah be given to one who suffers from kidney failure? : islamqa; [cited 2013 20 april]; available from: http://islamqa.info/en/ref/105328. ethical debate on animal research bangladesh journal of bioethics 2013; 4(3):11-18 11 ethical debate on animal research abu sadat mohammad nurunnabi 1 , rokhsana dil afroz 2 , salman nur alam 3 1. dr. abu sadat mohammad nurunnabi, erasmus mundus master of bioethics student, centre for biomedical ethics and law, katholieke universiteit leuven, belgium. email: shekhor19@yahoo.com (corresponding author) 2. dr. rokhsana dil afroz, assistant professor, department of pharmacology & therapeutics, shaheed suhrawardy medical college, dhaka, bangladesh. 3. salman nur alam, graduate student, department of pharmacy, university of dhaka, bangladesh. abstract: animal research or animal testing is done worldwide, where vertebrate animals, from zebrafish to non-human primates, millions in number are used annually. the practice is regulated to various degrees in different countries. scientists and science authorities still have their arguments to justify animal testing. however, dialogues and protests are also evident against it. awareness and campaign in recent years has made scientists and governments make statement that animal testing should cause as little suffering to animals as possible and that animal tests should only be performed where necessary. we should also look into the matter deeply and compassionately. key words: animal research, animal testing, vivisection, ethical debate, care, use of animals introduction: animal research or animal testing is the use of non-human animals in experiments. however, animal experimentation, in vivo testing, and vivisection have similar denotations but different connotations. literally, ‘vivisection’ means the “cutting up” of a living animal, and historically referred only to experiments that involved the dissection of live animals 1 . the term is occasionally used to refer pejoratively to any experiment using living animals; for example, the encyclopædia britannica defines ‘vivisection’ as “operation on a living animal for experimental rather than healing purposes; more broadly, all experimentation on live animals” 2 . the word has a negative connotation, implying torture, suffering and death 3 . the word ‘vivisection’ is preferred by those opposed to this research, whereas scientists typically use the term ‘animal experimentation’ 4,5 . supporters of the use of animals in experiments, such as the british royal society, argue that virtually every medical achievement in the 20 th century relied on the use of animals in some way 6 , with the institute for laboratory animal research of the u.s. national academy of sciences arguing that even sophisticated computers are unable to model interactions between molecules, cells, tissues, organs, organisms, and the environment, making animal research necessary in many areas 7 . however, animal rights organizations and some animal welfare groups, such as people for the ethical treatment of animals (peta) and british union for the abolition of vivisection (buav) raised questions on the legitimacy of it, arguing that it is cruel, poor scientific practice, poorly regulated, that medical progress is being held back by misleading animal models, that some of the tests are outdated, that it cannot reliably predict effects in humans, that the costs outweigh the benefits, or that animals have an intrinsic right not to be used for experimentation 3,8 . hence, there exists a strong debate on animal research till date. http://en.wikipedia.org/wiki/vertebrate http://en.wikipedia.org/wiki/zebrafish http://en.wikipedia.org/wiki/primates http://en.wikipedia.org/wiki/dissection http://en.wikipedia.org/wiki/british_union_for_the_abolition_of_vivisection bangladesh journal of bioethics 2013; 4(3):11-18 12 history of animal experimentation: the earliest references to animal testing are found in the writings of the greeks in the 2 nd and 4 th centuries bc. aristotle (384-322 bc) and erasistratus (304-258 bc) were among the first to perform experiments on living animals 9 . galen, a physician in 2 nd century rome, dissected pigs and goats, and is known as the ‘father of vivisection’ 10 . avenzoar, an arabic physician in 12 th century moorish spain, who also practiced dissection, introduced animal testing as an experimental method of testing surgical procedures before applying them to human patients 11,12 . animals have been used repeatedly through the history of biomedical research. the founders, in 1831, of the dublin zoo — the fourth oldest zoo in europe, after vienna, paris, and london — were members of the medical profession, interested in studying the animals both while they were alive and when they were dead 13 . in the 1880s, louis pasteur convincingly demonstrated the germ theory of medicine by inducing anthrax in sheep 14 . in the 1890s, ivan pavlov famously used dogs to describe classical conditioning 15 . insulin was first isolated from dogs in 1922, and revolutionized the treatment of diabetes 16 . on november 3, 1957, a russian dog, laika, became the first of many animals to orbit the earth. in the 1970s, antibiotic treatments and vaccines for leprosy were developed using armadillos 17 , then given to humans 18 . the ability of humans to change the genetics of animals took a giant step forwards in 1974 when rudolf jaenisch was able to produce the first transgenic mammal, by integrating dna from the sv40 virus into the genome of mice 19 . this genetic research progressed rapidly and, in 1996, dolly the sheep was born, the first mammal to be cloned from an adult cell 20 . toxicology testing became important in the 20 th century. in the 19 th century, laws regulating drugs were more relaxed. for example, in the u.s., the government could only ban a drug after a company had been prosecuted for selling products that harmed customers. however, in response to the elixir sulfanilamide disaster of 1937 in which the eponymous drug killed more than 100 users, the u.s. congress passed laws that required safety testing of drugs on animals before they could be marketed. other countries enacted similar legislation 21 . in the 1960s, in reaction to the thalidomide tragedy, further laws were passed requiring safety testing on pregnant animals before a drug can be sold 22 . historical debate: as the experimentation on animals increased, especially the practice of vivisection, so did criticism and controversy. in 1655, the advocate of galenic physiology edmund o'meara said that “the miserable torture of vivisection places the body in an unnatural state” 23, 24 . o'meara and others argued that animal physiology could be affected by pain during vivisection, rendering results unreliable. there were also objections on an ethical basis, contending that the benefit to humans did not justify the harm to animals 24 . early objections to animal testing also came from another angle — many people believed that animals were inferior to humans and so different that results from animals could not be applied to humans 24 . on the other side of the debate, those in favor of animal testing held that experiments on animals were necessary to advance medical and biological knowledge. claude bernard, known as the ‘prince of vivisectors’ 8 and the father of physiology whose wife, marie françoise martin, founded the first anti-vivisection society in france in 1883 25 , wrote that “the science of life is a superb and dazzlingly lighted hall which may be reached only by passing through a long and ghastly kitchen” 26 . arguing that “experiments on animals ... are entirely conclusive for the toxicology and hygiene of man ... the effects of these substances are the same on man as on animals, save for differences in degree” 27 , bernard established animal experimentation as part of the standard scientific method. http://en.wikipedia.org/wiki/ancient_greece http://en.wikipedia.org/wiki/aristotle http://en.wikipedia.org/wiki/erasistratus http://en.wikipedia.org/wiki/ancient_rome http://en.wikipedia.org/wiki/ibn_zuhr http://en.wikipedia.org/wiki/louis_pasteur http://en.wikipedia.org/wiki/louis_pasteur http://en.wikipedia.org/wiki/germ_theory_of_disease http://en.wikipedia.org/wiki/anthrax http://en.wikipedia.org/wiki/classical_conditioning http://en.wikipedia.org/wiki/insulin http://en.wikipedia.org/wiki/diabetes http://en.wikipedia.org/wiki/laika http://en.wikipedia.org/wiki/leprosy http://en.wikipedia.org/wiki/genetics http://en.wikipedia.org/wiki/rudolf_jaenisch http://en.wikipedia.org/wiki/sv40 http://en.wikipedia.org/wiki/genome http://en.wikipedia.org/wiki/dolly_the_sheep http://en.wikipedia.org/wiki/clone_(genetics) http://en.wikipedia.org/wiki/toxicology http://en.wikipedia.org/wiki/elixir_sulfanilamide_disaster http://en.wikipedia.org/wiki/galen http://en.wikipedia.org/wiki/ethics_%28philosophy%29 http://en.wikipedia.org/wiki/animal_testing#cite_note-croce11-27 http://en.wikipedia.org/wiki/animal_testing#cite_note-31 http://en.wikipedia.org/wiki/scientific_method bangladesh journal of bioethics 2013; 4(3):11-18 13 in 1896, the physiologist and physician walter b. cannon remarked the antivivisectionists as the second of the two types, as described by theodore roosevelt when he said, “common sense without conscience may lead to cr ime, but conscience without common sense may lead to folly, which is the handmaiden of crime.” 28 these divisions between proand antianimal testing groups first came to public attention during the brown dog affair in the early 1900s, when hundreds of medical students clashed with anti-vivisectionists and police over a memorial to a vivisected dog 29 . in 1822, the british parliament passed the first animal protection law, followed by the cruelty to animals act (1876), the first law specifically aimed at regulating animal testing, and in the united states, when henry bergh founded the american society for the prevention of cruelty to animals (aspca) in 1860s, with the american antivivisection society (aavs), founded in 1883, are noted as anti-animal testing approach 30 . however, in the usa the antivivisectionists' efforts were defeated in every legislature, as overwhelmed by the superior organization and influence of the medical community. however, their success came when laboratory animal welfare act was passed in 1966 30. some ethical viewpoints: the ethical concerns raised by performing experiments on animals are subject to much debate, and viewpoints have shifted significantly over the 20 th century 25 . disagreements remain about which procedures are useful for which purposes, as well as disagreements over which ethical principles apply to which species. the dominant ethical position worldwide is that achievement of scientific and medical goals using animal testing is desirable, so long as animal suffering and use is minimized 24 . two special considerations are presented here for readers’ understanding. 1. pain and suffering: the extent to which animal testing causes pain and suffering, and the capacity of animals to experience and comprehend them, is the subject of much debate 31,32 . according to the u.s. department of agriculture, in 2006 about 670,000 animals (57%) (not including rats, mice, birds, or invertebrates) were used in procedures that did not include more than momentary pain or distress. about 420,000 (36%) were used in procedures in which pain or distress was relieved by anesthesia, while 84,000 (7%) were used in studies that would cause pain or distress that would not be relieved 33 . in the uk, research projects are classified as mild, moderate, and substantial in terms of the suffering the researchers conducting the study say they may cause; a fourth category of "unclassified" means the animal was anesthetized and killed without recovering consciousness, according to the researchers. in december 2001, 1,296 (39%) of project licenses in force were classified as mild, 1,811 (55%) as moderate, 63 (2%) as substantial, and 139 (4%) as unclassified 34 . there have, however, been suggestions of systemic underestimation of procedure severity 35 . the idea that animals might not feel pain as human beings feel it traces back to the 17 th century french philosopher, rené descartes, who argued that animals do not experience pain and suffering because they lack consciousness 1,36 . bernard rollin, the principal author of two us federal laws regulating pain relief for animals, 37 writes that researchers remained unsure into the 1980s as to whether animals experience pain, and that veterinarians trained in the usa before 1989 were simply taught to ignore animal pain 38 . in his interactions with scientists and other veterinarians, he was regularly asked to "prove" that animals are conscious, and to provide "scientifically acceptable" grounds for claiming that they feel pain 38 . carbone writes that the view that animals feel pain differently is now a minority view. academic reviews of the topic are more equivocal, noting that although the argument that animals have at least simple conscious thoughts and feelings has strong support 39 , some critics http://en.wikipedia.org/wiki/cruel_treatment_of_cattle_act_1822 http://en.wikipedia.org/wiki/cruelty_to_animals_act_1876 http://en.wikipedia.org/wiki/henry_bergh http://en.wikipedia.org/wiki/american_society_for_the_prevention_of_cruelty_to_animals http://en.wikipedia.org/wiki/suffering http://en.wikipedia.org/wiki/anesthesia http://en.wikipedia.org/wiki/consciousness http://en.wikipedia.org/wiki/animal_testing#cite_note-rydersinger-89 http://en.wikipedia.org/wiki/ren%c3%a9_descartes http://en.wikipedia.org/wiki/consciousness bangladesh journal of bioethics 2013; 4(3):11-18 14 continue to question how reliably animal mental states can be determined 36,40 . the ability of invertebrate species of animals, such as insects, to feel pain and suffering is also unclear 41,42 . the defining text on animal welfare regulation, "guide for the care and use of laboratory animals" defines the parameters that govern animal testing in the usa, stating that “… the ability to experience and respond to pain is widespread in the animal kingdom...pain is a stressor and, if not relieved, can lead to unacceptable levels of stress and distress in animals” 43 . the guide also states that the ability to recognize the symptoms of pain in different species is vital in efficiently applying pain relief and that it is essential for the people caring for and using animals to be entirely familiar with these symptoms. on the subject of analgesics used to relieve pain, the guide states “… the selection of the most appropriate analgesic or anesthetic should reflect professional judgment as to which best meets clinical and humane requirements without compromising the scientific aspects of the research protocol” 43 . accordingly, all issues of animal pain and distress, and their potential treatment with analgesia and anesthesia, are required regulatory issues in receiving animal protocol approval. 2. animal euthanasia: there is general agreement that animal life should not be taken wantonly, and regulations require that scientists use as few animals as possible 44 . however, while policy makers consider suffering to be the central issue and see animal euthanasia as a way to reduce suffering, others, such as the rspca, argue that the lives of laboratory animals have intrinsic value 45 . regulations focus on whether particular methods cause pain and suffering, not whether their death is undesirable in itself 46 . the animals are euthanized at the end of studies for sample collection or post-mortem examination; during studies if their pain or suffering falls into certain categories regarded as unacceptable, such as depression, infection that is unresponsive to treatment, or the failure of large animals to eat for five days; 47 or when they are unsuitable for breeding or unwanted for some other reason 48 . the following methods of euthanizing laboratory animals are chosen to induce rapid unconsciousness and death without pain or distress 43 . the animal can be made to inhale a gas, such as carbon monoxide and carbon dioxide, by being placed in a chamber, or by use of a face mask, with or without prior sedation or anesthesia. sedatives or anesthetics such as barbiturates can be given intravenously, or inhalant anesthetics may be used. amphibians and fish may be immersed in water containing an anesthetic such as tricaine. physical methods are also used, with or without sedation or anesthesia depending on the method. recommended methods include decapitation (beheading) for small rodents or rabbits. cervical dislocation (breaking the neck or spine) may be used for birds, mice, and immature rats and rabbits. maceration (grinding into small pieces) is used on 1 day old chicks. high-intensity microwave irradiation of the brain can preserve brain tissue and induce death in less than 1 second, but this is currently only used on rodents. captive bolts may be used, typically on dogs, ruminants, horses, pigs and rabbits. it causes death by a concussion to the brain. gunshot may be used, but only in cases where a penetrating captive bolt may not be used. some physical methods are only acceptable after the animal is unconscious. electrocution may be used for cattle, sheep, swine, foxes, and mink after the animals are unconscious, often by a prior electrical stun. pithing (inserting a tool into the base of the brain) is usable on animals already unconscious. slow or rapid freezing, or inducing air embolism are acceptable only with prior anesthesia to induce unconsciousness 49 . besides, a wide range of minority viewpoints exist. the view that animals have moral rights (animal rights) is a philosophical position proposed by tom regan, who argues that animals are beings with beliefs and desires, and as such are the “subjects of a life” with moral value and therefore moral rights 50 . regan still sees ethical differences between killing human and non-human animals, and argues that to save the former it is permissible to kill the latter 50,51 . likewise, a ‘moral dilemma’ view suggests that avoiding potential benefit to humans is unacceptable on http://en.wikipedia.org/wiki/animal_euthanasia http://en.wikipedia.org/wiki/rspca http://en.wikipedia.org/wiki/pain http://en.wikipedia.org/wiki/carbon_dioxide http://en.wikipedia.org/wiki/decapitation http://en.wikipedia.org/wiki/irradiation http://en.wikipedia.org/wiki/electric_shock http://en.wikipedia.org/wiki/pithing http://en.wikipedia.org/wiki/air_embolism http://en.wikipedia.org/wiki/animal_rights bangladesh journal of bioethics 2013; 4(3):11-18 15 similar grounds, and holds the issue to be a dilemma in balancing such harm to humans to the harm done to animals in research 51 . in contrast, an abolitionist view in animal rights holds that there is no moral justification for any harmful research on animals that is not to the benefit of the individual animal 36 . rollin argues that benefits to human beings cannot outweigh animal suffering, and that human beings have no moral right to use an animal in ways that do not benefit that individual 52 . another prominent position is that of philosopher peter singer, who argues that there are no grounds to include a being's species in considerations of whether their suffering is important in utilitarian moral considerations 51 . however, recently the british government has taken the position to observe that the cost to animals in an experiment should be weighed against the gain in knowledge 53 . some alternatives to animal research: scientists and governments state that animal testing should cause as little suffering to animals as possible, and that animal tests should only be performed where necessary. the ‘3 rs’, originally proposed by wms russell and rl burch in 1959 54 , are guiding principles for the use of animals in research in most countries. replacement refers to the preferred use of non-animal methods over animal methods whenever it is possible to achieve the same scientific aim. reduction refers to methods that are facilitating the researchers to obtain comparable levels of information from fewer animals, or to obtain more information from the same number of animals. refinement refers to methods that alleviate or minimize potential pain, suffering or distress, and enhance animal welfare for the animals still used. the 3-r approach has become the golden standard since it has been practiced by the efpia 55 , the council of europe convention ets 123 and most recently successfully been used in a report by an ec community research report ‘animal welfare committees in the european research area’ 56 . as already mentioned, the indian cpcsea (committee for the purpose of control and supervision of experiments on animals) proposed and implemented a 4 r’s set of principles – replacement, reduction, refinement, rehabilitation 57 . rehabilitation is added to ensure proper attention to provide for rehabilitation and retirement centers for primates who have survived medical experiments for the sake of humans. later in 2008, hans-martin sass 58 used this 4 r’s model to propose an extended 7 r’s model for the use in animal research ethics and corporate governance on a global and corporate level. the 7-r approach includes the ‘replace, reduce, refine’ principles and the indian ‘rehabilitation’ concept, but adds three more principles: ‘respect, review, relate’ – either complementing or re-enforcing to the goals and methods already expressed in the use of the first three principles 58 . respect refers to a special emphasis that should be laid on species-specific forms of harm, pain, distress, as they are related to the captivity environment and to the research itself. moreover, animal welfare committees (awcs) are the instrument of choice to review and to improve animal research on the local level and to reconcile different approaches and to set standards on the national or international level, i.e. thinking locally and act globally. besides, to relate issues, solutions, even uncertainties, as transparently and as simple and well reasoned as possible is always beneficial both for animal research and the corporate policy. of course, in order to be effective, the 7-r model must be supported strongly by internal corporate policy, also not been confronted with financial or administrative shortcomings, if the ethically better option is considered to be the option of choice 58 . horst spielmann, german director of the central office for collecting and assessing alternatives to animal experimentation, while describing in the ‘deutsche welle’ about germany's progress in this area said, “using animals in teaching curricula is already superfluous. in many countries, one can become a doctor, vet or biologist without ever having performed an experiment on an animal.” 59 however, there are efforts in many countries to find alternatives to using animals in education 60 . moreover, alternative methods include positron emission tomography (pet), which allows scanning of the human brain in vivo, 61 and comparative epidemiological studies of disease risk factors among human populations 62 . several invertebrate systems are considered acceptable alternatives to animals in very early http://en.wikipedia.org/wiki/bernard_rollin http://en.wikipedia.org/wiki/peter_singer http://en.wikipedia.org/wiki/utilitarianism http://en.wikipedia.org/wiki/human_brain http://en.wikipedia.org/wiki/animal_testing#cite_note-199 http://en.wikipedia.org/wiki/clinical_study_design bangladesh journal of bioethics 2013; 4(3):11-18 16 stage discovery screens 63 . because of similarities between the innate immune system of insects and mammals, insects can replace mammals in certain types of studies. drosophila melanogaster (a fruit fly) and galleria mellonella (waxworm) have been particularly important for analysis of virulence traits of mammalian pathogens 64,65 . waxworms and other insects have also proven valuable for the identification of pharmaceutical compounds with favorable bioavailability 66 . conclusion: progressive changes have been made in recent years in the principles and practice of animal testing. although such principles of care and use of animals and alternative propositions to animal research have been welcomed as a step forwards by some animal welfare groups 67 , they have also been criticized as 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32(5): 525-32. 69. rusche b. the 3rs and animal welfare – conflict or the way forward? altex 2003; 20(suppl 1): 63-76. http://www.dw-world.de/dw/article/0,1564,1687760,00.html http://en.wikipedia.org/wiki/deutsche_welle http://www.pcrm.org/resch/anexp/abstract_teaching.html http://www.medicalnewstoday.com/articles/154877.php http://www.pnas.org/content/105/41/15967.long http://www.pnas.org/content/105/41/15967.long http://www.ncbi.nlm.nih.gov/pubmed/14975532 http://www.plosone.org/article/info%3adoi%2f10.1371%2fjournal.pone.0022674 http://www.plosone.org/article/info%3adoi%2f10.1371%2fjournal.pone.0022674 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1974785/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1974785/?tool=pubmed microsoft word elderly antony bangladesh journal of bioethics 2016; 7(1):27-36 27 the situation of the elderly in bangladesh antoni barikdar 1, tahera ahmed 2, shamima parvin lasker 3 1. project manager-health, world vision bangladesh, 2. former acting chief, srhr, unfpa, 3. professor and head of anatomy, mh somrorita medical hospital & college, dhaka. abstract: in bangladesh due to improved quality of life the number of people over 60 years is increasing rapidly. this should be seen as an emerging challenge as the elderly will have special needs and require different care-giving services. since bangladesh does not have a social welfare system there will be competition for inadequate resources specially health and medical services .it is envisaged that due to more elderly population the demographic structure will undergo a slow change from the present pyramid structure. the growing trend towards nuclear family or where children live abroad will put the elderly parents in a dilemma-the financial and social support that is essential for them has not yet emerged. the nutrition and health status of elderly people depend on adequate food safe water, proper sanitation facilities and maintaining hygienic standards. to provide special medical care for the elderly there is a need to establish who recommended age-friendly primary health care centers and separate wards /units are to be set up in the hospitals. to reduce vulnerability of older women there is a need to distribute assets and properties according to the law. . our new generations have to be responsive, informed and attentive about their duties and responsibilities towards the elderly people. taking proper care of the elderly is our ethical duty and responsibility. key words: situation; elderly; ageing; bangladesh introduction: a person mainly passes five stages in his lifespan. the stages are infancy, childhood, adolescence, adulthood and old age. old age starts after sixty years of age and ends in death. old age is one of the vulnerable situations in a natural process of life. in this stage, people experience decreased physical strength and deteriorating health conditions with age related disease. all over the world proportion of elderly are increasing where numbers of children are decreasing. according to world population ageing report 2013, world‘s population 60+, 65+ and 80+ were 840628, 570459 and 120199 respectively. moreover this number were 468549, 307699 and 57576in asia, 60033, 38513 and 5248in africa, 169874, 125152 and 33239in europe 1 .the statistical data of bangladesh represent the number of aged population has increased from 1.38 million to 7.59 million from the year of 1974-20012. bangladesh is the seventh largest populated (152.51 million) and most densely (1015 person live per square kilometers) country3. furthermore, the nuclear family is increasing in bangladesh day by day and older people left alone living separately from their family and becoming vulnerable. this condition demands more health and welfare services and more provision to the elderly support system4, 5. bangladesh journal of bioethics 2016; 7(1):27-36 28 there is not enough data about the situation of elderly people in bangladesh. therefore, this retrospective study was done on elderly population of bangladesh to identify emerging issues and challenges of the elderly and to explore different type of vulnerabilities of elderly people in bangladesh. methodology: this study focuses on vulnerability about elderly people of bangladesh. for this, we have chosen different types of paper work and networking as well as some qualitative tools as research methodology. the major sources of information of this study were literature review. literature review was done using different search engine e.g. google scholar, online library pubmed between 1974 and2015. key words were elderly, old people, aging, elderly, condition, bangladesh, world. this study prepared as internship report for the fulfillment of the requirements of the master of public health (mph) degree of north south university, dhaka, bangladesh. definition: elderly people: most people above 60 years of age are considered as ‘old’. those who are 60 years and above makeup the elderly section of any population6. though this age limit also applies to bangladesh,7, in reality people in this country become older earlier because of poverty, and the conditions related like hard labor, malnutrition, illness and their geographical condition7. population ageing: defined as an increase proportion of population, which is elderly7. social safety net: this is a network of services usually provided by the state which includes social services like old age benefits, healthcare, shelters, and subsidized services such as public transport, which prevent individuals from falling into poverty8. elderly people: context bangladesh: previously the society of bangladesh took care of the elderly but now the situation is becoming changed due to change of social, psychological and economic standpoint. social, economic and political viewpoint elderly population is now growing rapidly and it’s a big concern for bangladesh. according to the national census between 1974 and 2011 the growth of elderly people is gradually increasing. in 1974, the populations between 60-64 years were 1682629 and in 2011 the numbers were 3218974. at the same way aged between 65-69 years population were 735255 and 1998760in 1974 and 2011 respectively. in the same period of time populations of elderly over 70 years were 1639056 to 1998760. report shows that percentage of elderly people age between 60-64, 65-69, 70-75 and over 70 years were 37%, 21% 20% and 22% respectively. according the report of bangladesh bureau of statistics the trends of elderly population increase gradually. figure 1 shows the gradual increased percentage of elderly in bangladesh. bangladesh journal of bioethics 2016; 7(1):27-36 29 figure 1: trend in percentage of elderly population in bangladesh 9 a study report shows that in bangladesh, majority of the people over 60 live in the rural areas where there is a lack of proper health care services, economic services and job opportunities are very limited. the situation of the elderly is dismal where more than 50% of the elderly are widowed or single9.63% are jobless and 14-15% engaged in agricultural works and daily labor. this compares badly with that of tehran where 85% elderly are unofficially employed10. elder person encountered non-communicable diseases such as cardiovascular diseases including heart attacks and stroke, chronic respiratory diseases including chronic obstructed pulmonary disease and asthma, renal disease cancers, and diabetes as well as other chronic diseases11, 12. moreover, research shows that children of older parents in bangladesh live in cities for education, employment or living. again, the older people fill comfortable to live in the rural settings and sometimes children are leaving their older parents to live in the city.13 44.3% people live in poverty and in order to maintain their living expenses as well as family needs; the elderly people get involved in beggary14 however, older women especially widows and those who are without sons are facing economic vulnerability and consequence of health problem15, 16. modern society has failed to keep the dignity and honor of the elders. this may be attributed to various reasons like individualistic attitudes, instability of family structures, devaluation of dignity, differences in incomes, and other social problems17. the same scenario is happening in bangladesh. constitution of the bangladesh mentioned the rights of elderly people. in the constitution part ii section 15 entitled “provision of basic necessities” described social security of the elderly people as the “ provision of the basic necessities of life, including food, clothing, shelter, education and medical care; the right to reasonable rest, recreation and leisure; and the right to social security, that is to say, to public assistance in cases of undeserved want arising from unemployment, illness or disablement, or suffered by widows or orphans or in old age, or in other such cases mentioned in the 15 (a) (c) and (d) clause respectively18.” 5.7 5.6 5.42 6.38 7.48 0 1 2 3 4 5 6 7 8 1974 1981 1991 2001 2011 % of elderly bangladesh journal of bioethics 2016; 7(1):27-36 30 old age allowance introduce in bangladesh in the fiscal year (fy)’1997-1998 and the main objectives of this allowance is ensuring socio-economic development and social security for the elderly; increase dignity of elderly within family and community. aim of the allowance is to strengthening of mental health through grant for medicare and increase of nutritional support for elderly people of bangladesh. the age of 65 years for male and 62 years for female whose yearly average income not exceeding 10,000 bdt are considered eligible for the old age allowance. the total budget in fy’1997-1998 was 125.00 million bdt and monthly allocation for 100 taka per person and total beneficiary were 40,311. that amount of grant per head has been increased in the present fy’ 2015-2016.bangladesh government allocated bdt 14,400 million and the total beneficiary is 3 million, each beneficiary getting 400 bdt per head per month19. however, bangladesh has pension policies to ensure social security on old age for retired government employees only. according to public service retirement act 1974b now the retirement age of government employee of bangladesh is 59 years20. bangladesh introduced program implementation plan for protecting old age health and ensures health care. this program aims to provide efficient and sustainable health service delivery and management system with skilled and special emphasis on the development of a sustained health system and improved and responsive efficient human resources21. recently the parent care act 2013 of bangladesh tried to ensure that the children have to take necessary steps to look after their parents for three years and provide them with maintenance. but it is not in fully functioning yet. 22. many elderly welfare organizations work for elderly people and elderly people to get involved with the elderly welfare organization. such as, probin hitoishi kendra, probin hitoishi sangha bangladesh association for the aged and institute of geriatric medicine (baaigm), retired officers welfare association (dhaka), retired police officers welfare association (dhaka), service center for elderly people (rajshahi), elderly development initiative (manikganj), senakalyan sangstha, etc. there are initiatives taken by government and ngos and social organizations for elderly but it is not enough to cover the whole elderly population of bangladesh. elderly in traditional situation: traditionally, the son is to take responsibility to provide food and shelter to their parents as well as take care of the other elderly members of their family. due to their economic condition they are not able to meet the basic needs. sometimes older people get involved in begging to meet their needs as well family needs14. bangladesh journal of bioethics 2016; 7(1):27-36 31 in bangladesh customarily gender roles are clearly defined and accepted. it is usually the men who are the main source of income while women maintain the household. in this male dominated society it is often the older men are still involved in economic activities23. still in bangladesh older persons are respected and valued in the society. they have a special position in the family, often asked for advice especially during major events, like marriage, name giving ceremonies etc. in many joint families and households, they not only continue receiving care and support from the family members but also provide care to the family members such as financial help and love and care to grandchildren. no in this day in rural and urban area especially urban area both male and female are employed. in those families where parents are employed, grandparents are taking care of the family. in bangladesh older people are treated as an important advisor in the family as well as community. the older people resolve the family as well as community level problems. but this situation is changing for family setup and social change23. findings: root causes of vulnerability of elderly in bangladesh: available literature shows that in our society, elderly person are facing many kinds of social, mental, medical and economic problem. because of their age, the elderly in bangladesh is facing following challenges. figure 2 shows the cause of vulnerability of elderly. due to the social context of bangladesh, most of women in rural and slum area do not own land and other property and they are on worse situation in the old age, though the country has law to distribute assets and land to the women. moreover, according to the muslim personal law (shariat) application act, 1937 (act no. xxvi of 1937) the wife inherits one-eight if there is child and if there be no child gets one-fourth24. in bangladesh traditional family patterns are breaking down which change norms and values such as respect to elderly people in the family and the community. as a result vulnerability of the elderly people is increasing. the vulnerability is in terms of food consumption, shelter, community and social attitude. in bangladesh, the elderly suffer from multiple health problems. such as, weakness, tooth problem, hearing problem, vision problem, body ache, back pain, rheumatic pain and stiffness in joint, dementia, prolonged cough, breathing difficulty, asthma, palpitation, high blood pressure and micturition incompetence, which may demand long term psychosocial treatment, nursing care and hospitalization. bangladesh journal of bioethics 2016; 7(1):27-36 32 root causes of vulnerability elderly people are sometimes abused by community and also by the family members. due to increasing small sized family elderly people are living a corner of the house. elderly people now are often living in isolation as other family members are busy with their own business and do not have enough time to spend with them .in this modern life children are living in cities for earning, or for education. their parents live in separately in the rural setup, and in this busy life children are not able to visit their parents regularly. as a result parents feel lonely and isolated. economic intermediate cause illness emotional vulnerable elderly people family burden immediate cause -retirement -no income source -no fixed income -age -decrease body resistance -chronic disease -no attachment with family members -feel lonely -unemployment -unfit for work -no income source underlying cause basic cause -physically unfit for work -less education -don‘t get support from descendants -no son -have to pay loan -absence of strong social security system -less employment opportunity -treatment cost is high -economic insolvency –lack of income source -lack of proper care -died of spouse -family members away from them -absence of adequate health facilities for elderly -lack of laws for elderly people. -lack of elder friendly environments in the society -don’t get support from family members -lack and less implementation of the laws. main problem figure 2: root causes of vulnerability bangladesh journal of bioethics 2016; 7(1):27-36 33 loneliness and anxiety are grave emotional problems encountering the older population, especially for the elderly women. life expectancy of bangladeshi people is 65 for male and 68 for female (ref). in this study revealed that that the situation of older women is much worse than older men because of their longer life expectancy and extreme vulnerability due to social and economic marginalization. emerging issues and challenges of elderly: taking adequate care of the elderly will be a major challenge for bangladesh. this is mainly due to inadequate resources being allocated for the services to the elderly and no proper planning or strategic interventions for providing holistic care to them. the emerging issues of the elderly are mentioned as a ‘current and upcoming challenges’ in the draft national health policy, 200825. the challenges are: unemployment and burden: elder persons are being considered “unemployable” because of their age and forced to stop working because of mandatory retirement ages. the ratio of work force to dependent population will show too many dependent people which will lead to a burden for the working group. more treatment cost: elder person facing non-communicable diseases which may need long term treatment and its cause burden more treatment cost and nursing care. the economic vulnerable people cannot afford the treatment cost to treat the older people considerable resources need: as the increasing size of the elderly population in bangladesh will become a major social challenge, well planned programmes have to be undertaken and adequate resources allocated for the support, of the elderly population. pressure in pension scheme: with people enjoying longer lives pension schemes will have more beneficiaries who will be eligible for pensions for a longer period. social security scheme system will come under increasing pressure: social security schemes will have to accommodate more people and therefore will be under pressure. conclusion: the root causes of vulnerably of elderly are medical, economical, emotional and social issues which are concerns not only for the individual or family, but s also a concern for the community. increase in medical costs, pressure on social security and unemployment are main challenges of elderly facing in bangladesh. elderly have knowledge, experience, and wisdom. society can use these resources of elderly in the national reconstruction. they are the asset of the nation. it is the responsibility of everyone to take care of them and utilize this asset. the elderly is the last stage of our life cycle and a reality. everybody has to pass through this stage. so it is the responsibility of all citizens of bangladesh to come forward for the wellbeing of our elderly. bangladesh journal of bioethics 2016; 7(1):27-36 34 recommendations: to ensure wellbeing of elderly persons following measures should be taken. 1. dialogue with the family members of the elderly persons to ensure their wellbeing and proper care. 2. family members, students, practitioners should be trained in elderly care. 3. the elderly themselves should be educated in self-care. 4. aware and motivate the elderly people to involve with the elderly welfare organizations. 5. for elderly care and responsibilities should be including in text book to teach new generation to teach theirs roles and responsibility. 6. establishment of recreation facilities for the old people, 7. to ensure good health and refresh mind of elderly people need to ensure home-based and institute-based health care centers where they receive proper nursing and care. to ensure refresh mind need to established recreation centers for them. 8. increase ngo services such as outdoor and indoor health care. 9. retirement age should increase to 65 years to create opportunities and they can utilize their productive years for the benefit of the society and can establish their positive image in the country. 10. increase large scale social security programs, like, pension, old age allowance and health insurance. government should increase outdoor service units in government hospitals and special free transport services for the elderly. 11. implement recommendation of vienna international plan of action on aging and political declaration and madrid international plan of action on ageing. 12. need to have a detailed survey providing current data on the number and conditions of the aged. limitations of the study: we used qualitative tools for data collection but only qualitative findings are not sufficient for entire data analysis. for this it was needed to use quantitative data collection tools in this research. further scope of study: though we have some limitations in our study this study will also open opportunities for further research regarding elderly people such as study on indigenous people elderly people in bangladesh. conflict of interest: all authors declared no conflict of interest. bangladesh journal of bioethics 2016; 7(1):27-36 35 references: 1.world population ageing 2013, department of economic and social affairs population division, united nations • new york, 2013 available from: available from: http://www.un.org/en/development/desa/population/publications/pdf/ageing/worldpopulationageingrep ort2013.pdf 2.bangladesh bureau of statistics (bbs) 2003 3. population & housing census report 2011, bangladesh 4. m. nazrul islam, dilip c. natha future journey to the elderly support in bangladesh, journal of anthropology, volume 2012 (2012), article id 752521 5.k.m. mustafizur rahman , muntasir ibn mohsin and ismail tareque, trends of population ageing from 1950-2050: a comparative study between bangladesh and world, pakistan journal of social sciences, year: 2009, volume: 6, issue: 1, page no.: 6-10 6. definition of an older or elderly person, health statistics and information systems, who. available from: http://www.who.int/healthinfo/survey/ageingdefnolder/en/ 7. unnayan onneshan policy brief on present social context and elderly population in bangladesh. author k. m. mustafizur rahman. http://www.unnayan.org/reports/policy%20brief%20on%20elderly%20population.pdf 8. social safety net wikipedia, the free encyclopedia 9. abedin, s., population aging in bangladesh. issues and perspectives, summary of the country paper, escp, asian popultion studies series, 1996, no. 145. 10. m. taj uddin, md. nazrul islam, md. johurul alam and gias uddin baher, socio-eonomic status of elderly of bangladesh: a statistical analysis, research article, 11. j shaheed suhrawardy med coll, 2012;4(1):1-2, ageing and health : how far bangladesh is prepared 12.russell kabir, hafiz t. a. khan, mohammad kabir, m. twyeafur rahman, population ageing in bangladesh and its implication on health care, european journal of scientific research 9(33):3447 · november 2013. 13. rahman, h., 1999. international year of the older persons and the cases of bangladesh. bangladesh j. geriatrics, 36: 144-144. 14. rahman, a., beggary on aging: an analysis (bangoli). dhaka university patrica, dhaka, 2000. vol. 66, pp: 89. 15.kabir m, haque m, and chaklader h. mainstreaming ageing in health: will it be possible. paper presented in the international conference on mainstreaming ageing in health system and rural development, dhaka, november, 2005. 16. abedin s., living and care arrangements of the elderly in bangladesh. the elderly contemporary issues: bangladesh association of gerontology. 2003. 17. roy, s. (2002) “psychological problems of older people and some aspects of alighting from these problems”, social science journal, rajshahi university, vol. 7, pp. 73-83. 18 .bangladesh parliament, quick link, constitution, the constitution of the people’s republic of bangladesh, available from: http://www.parliament.gov.bd/index.php/en/view-all http://bdlaws.minlaw.gov.bd/pdf_part.php?id=367 19. ministry of social welfare, government of the people’s republic of bangladesh, bangladesh journal of bioethics 2016; 7(1):27-36 36 available from: http://www.msw.gov.bd/site/page/18350636-86ea-46fc8ecfdf73ed933a96/%e0%a6%ac%e0%a7%9f%e0%a6%b8%e0%a7%8d%e0%a6%95%e0%a6%ad%e0%a6%be%e0%a6%a4%e0%a6%be 20.the public servants (retirement) act, 1974, government of the people’s republic of bangladesh, legislative and parliamentary affairs division, 21. health, population and nutrition sector development program (hpnsdp), planning wing ministry of health and family welfare, government of the people’s republic of bangladesh 22.parent care act 2013of bangladesh. laws of bangladesh, legislative and parliamentary affairs division, bangladesh. available from: http://www.ilo.org/dyn/natlex/natlex4.detail?p_lang=en&p_isn=95797 23. professor samad abedin, social and health status of the aged in bangladesh, cpd, unfpa, paper 4, available from: http://www.cpd.org.bd/pub_attach/unfpa4.pdf 24.muslim personal law (shariat) application act, 1937 (act no. xxvi of 1937), laws of bangladesh, legislative and parliamentary affairs division, bangladesh. available from: http://bdlaws.minlaw.gov.bd/index.php?page=html&language=english 25. national health policy, final draft 2008, ministry of health and family welfare government of the people’s republic of bangladesh available from: https://extranet.who.int/nutrition/gina/sites/default/files/bgd%202008%20national%20health%20policy .pdf bangladesh journal of bioethics 2014; 5(3):1-5 1 practice of informed consent, confidentiality and privacy by physicians at a tertiary care teaching hospital zoheb rafique 1 , urooj bhatti 2 1 lecturer, department of biochemistry, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan 2 lecturer, department of physiology, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: dr_zohaib@hotmail.com abstract: objective: the aim of this paper was to assess the practice of medical ethics by the physicians at a public sector hospital in jamshoro sindh. material and methods: this survey was conducted at four medical units of tertiary care hospital at jamshoro in the month of august 2014. participants were randomly selected from patients aged over 18 years. a structured questionnaire was designed and the participants were asked about their demographic profile and their physician’s practice regarding informed consent, maintaining confidentiality, privacy and other treatment formalities. written consent was taken from all the participants before interview. results: a total of 100 patients were randomly selected for this study. the majority of patients reported that informed consent was taken from them. the patients also responded that privacy and confidentiality is maintained during their treatment. however, many patients agreed that they were not properly informed about the laboratory findings, role of proposed drugs and also side effects of drugs. conclusion: there is marked improvement in the practice of medical ethics by physicians of this tertiary care hospital. however, awareness workshops should be conducted to update and improve the knowledge of medical ethics among physicians. this will surely help them translate the knowledge into practice. key words: informed consent, confidentiality, privacy introduction: in the rapidly changing system of health care, many different factors have affected and changed the perception about how health care is practiced today. the rights of patient are also affected. patient rights have now become the center of attention in practice of medicine. today, concerns about patients’ choice and the respect for their preferences, values and the access to medical care are getting more complex. the patients’ expectations are becoming higher and now they always want every thing best. they want active participation in decision making and proposed treatments or procedures and the other alternatives available 1 . information regarding designed surgical or medical intervention should be presented to patients before starting any procedure or treatment. in addition to this, the risks of treatment mailto:dr_zohaib@hotmail.com bangladesh journal of bioethics 2014; 5(3):1-5 2 as well as benefits should also be explained to the patient, so that patient can make a decision regarding what he/she demands. it is recognized as an essential measure, to ensure the preservation of patient rights. the requirement for obtaining informed consent is established in every decision making situation in clinical practice. fully informed patient is able to participate in decisions regarding his/her health care 2 . along with informed consent, respect for confidentiality and privacy is also included in responsibility of doctors/physicians throughout history. very recently though attention has been centered on these principles with the formal introduction in modern codes of medical ethics. the concepts of confidentiality and privacy are closely related. confidentiality is a narrow term referring to informational privacy and also to the responsibility not to disclose any information about patients without prior permission from the patient. privacy is a broad term including informational privacy, physical privacy, protection of the personal identity and ability to make informed choices without interference. confidentiality and privacy are basic rights of patients and they also serve to nurture a frank, trustful and open relationship with doctor/physician, thus improving patient care 3 . numerous studies have shown that doctors in routine medical practice don’t consider it necessary to take proper consent after providing the patients with thorough information. similarly despite the fact that respect for confidentiality and privacy has been a responsibility of physicians/doctors throughout history, it is noted that doctors often neglect the aspect of medical ethics. however, despite the fact that regulatory body for medicine in our country, the pakistan medical and dental council commonly known as (pmdc), has formulated code of ethics for doctors, no major steps have been taken in order to ensure its implementation. recently, there has been a significant change in the thinking of the patients, mainly because of greater influence of ict (information communication technology, primarily of electronic media and the internet). thus, due to the increasing awareness, now patients demand full information about treatment options, treatment plans and also possible complications and these aspects were not practiced in the past 4 . in this paper the patient’s perceptions regarding practice of physicians in a tertiary care teaching hospital was discussed. material and methods: to assess the perception of patients in the medicine wards regarding practice of medical ethics by the physicians, a survey was conducted at liaquat university of medical and health sciences (lumhs) hospital jamshoro in the month of august 2014. a structured questionnaire was designed and the patients were then interviewed. a total of 100 patients were randomly selected in four medical units. the patients were taken above the age of 18 years, so that they can understand and give consent themselves. written consent was taken at the time of interview. the questionnaire consisted of eight (08) questions and it took 15 minutes to complete the interview and fill the questionnaire. results: a total number of 100 patients participated in this study. our study population included 59 male patients and 41 female patients. the demographic data of patients is shown in table 1 and table 2 shows the patient’s responses to the questionnaire. bangladesh journal of bioethics 2014; 5(3):1-5 3 table: 1 demographic profile sex no of patients male 59 female 41 table: 2 shows the perception of patients regarding physicians practices statement responses (1) yes (2) no (3) don’t know 1. informed consent taken (1) 85 (2) 15 (3) 0 2. confidentiality of the patients assured (1) 94 (2) 05 (3) 01 3. privacy of the patient maintained (1) 92 (2) 08 (3) 0 4. patients are informed about the diagnosis (1) 90 (2 ) 10 (3) 0 5. patients are informed about the reason for investigations (1) 79 (2) 21 (3) 0 6. physicians have discussed with the patient the relevant laboratory findings (1) 66 (2) 34 (3) 0 7. physicians have explained the role of the proposed drugs (1) 28 (2) 72 (3) 0 8. physicians have explained the side effects of the proposed drugs (1)10 (2) 90 (3) 0 discussion: this study was designed to assess the practice of informed consent, confidentiality, privacy and other treatment modalities by physicians at a tertiary care hospital. in our study 85 % of the patients were of the view that informed consent was taken from them. we asked about taking informed consent during general physical examination, history taking and routine procedures. this percentage is very good because of the reason that we have teaching hospital and now bioethics is being taught at undergraduate as well as postgraduate level, so physicians are familiar with informed consent, its components and requirements. we also looked at physician’s practice of maintaining and assuring privacy and confidentiality. in our study we found that 94 % of the patient agreed that confidentiality was assured and maintained during their treatment and only 6 % of the patient either disagreed or not sure about their confidentiality. when we asked about the maintenance of privacy, 92 % of the patients were of the view that privacy was maintained during their examination, treatment and routine procedures and only 8 % of the patients negated this statement. our study data is better then other studies conducted in pakistan indicting that physicians are aware of the actual practice of medical ethics. in one question we asked the patients about the information regarding the diagnosis, 90 percent of the patient agreed that they were informed about the diagnosis or the disease they are suffering, while 10 % patients disagreed and were not told about their diagnosis. 79 % of the patients were of the view that they were informed about the bangladesh journal of bioethics 2014; 5(3):1-5 4 reason for investigation/laboratory reports and 21 % disagreed and were having view that they were not informed about the reason for having different laboratory reports, blood tests, urine tests and other investigations etc. when asked about the discussion of relevant laboratory findings, only 66 % of the patient agreed and 34 % of the patients disagreed with the statement. in our last two questions we asked the patients about the role of the drugs given to them by the physicians and also the side effects of those drugs. we found that only 28% of the patients agreed that they were explained in detail the role of the drugs given to them, means why that particular drug is given and for how much time and at what time the patents have to take those drugs and 72 percent of the patient disagreed. only 10 % of the patient agreed that they were explained the side effects of the drugs which they were taking and 90 percent disagreed and told us that they were not briefed about the side effects of the treatment they took. when we discussed these issues in detail with some patients and also with some residents/physicians working in medicine wards, we found some interesting answers. doctors say that majority of patients are illiterate, so it is of no use to tell them about the laboratory findings and drug side effects in detail. some physicians were of the view that patients and their relatives are only interested to see patient get well soon and they are not interested how and why. patients were having view that doctors are over burdened. some patients say doctors are less interested and some physician’s say that patients are not educated much and they don’t understand even the basic things some time, so therefore they don’t discuss things in detail. residents say they have less house officers and senior doctors and consultants don’t give much time and some patients say that doctors are sincere with their duty. informed consent enjoys unassailable position in both research and clinical situations as safeguard of patients’ rights. the involvement of the patient in decision making process is much easier when there is direct link/communication with the individual. the pakistani milieu carries challenges to this process because important decision making is very often done by the family members or in some cases it is left entirely to the attending physician. this also raises some ethical dilemmas for the physicians who may not feel comfortable with the communication which excludes the patient or in accepting the paternalistic decision making role 5 . this study has one potential limitation that this study was conducted in one single hospital and its results cannot be generalized for all government/public sector units/hospitals in pakistan. conclusion: the results of our study suggest that physicians at teaching hospitals may have improved their practice of medical ethics. however, due to the fact that data was collected only at one tertiary care/teaching hospital, we can’t comment on ethical practices of the physicians from private healthcare sector and other public sector hospitals. nonetheless, to encourage the ethical practice, steps should be taken in highlighting the importance of basic principles of medical ethics: informed consent, confidentiality and privacy. furthermore, awareness campaign should be conducted for the physicians to improve their knowledge of the ethical principles. bangladesh journal of bioethics 2014; 5(3):1-5 5 references: 1. farida m, habib and hind sulaiman al siber. assessment of awareness and source of information of patients’ rights: a cross sectional survey in riyadh saudi arabia. american journal of research communication. 2013; 1(2):1-9. 2. faisal ghani siddiqui, jan mohammad shaikh, mohammad munir memon. an audit of informed consent in surgical patients at a university hospital. j ayub med coll abbottabad. 2010; 22(1). 3. ayesha humayun et al. patients' perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of lahore. bmc medical ethics. 2008; 9:14. 4. waris qidwai et al. informed consent, privacy and confidentiality practiced by doctors of a tertiary care hospital in a developing country. indian journal of medical ethics. 2013; 9(1). 5. a m jafarey, a farooqui. informed consent in the pakistani milieu: the physician’s perspective. j med ethics. 2005; 31:93–96. conflict of interest: there is no conflict of interest. microsoft word chapter peer revew (1) bangladesh journal of bioethics 2018; 9(1):13-23 13 peer review system: a golden standard for publications process shamima parvin lasker phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd) professor & head of anatomy, mh samorita medical college, dhaka, bangladesh visiting professor, clinical anatomy, dentistry, and bioethics, ausn, usa. sectary general, bangladesh bioethics society. treasurer, world association of medical editors (wame) chairperson, ethics & publication, asian pacific association of medical editors (apame) senior vice president, bangladesh society for scholarly journal editors (base) executive editor, bangladesh journal of bioethics abstract: peer review process helps in evaluating and validating of research that is published in the journals. u.s. office of research integrity reported that data fraudulence was found to be involved in 94% cases of misconduct from 228 identified articles between 1994–2012. if fraud in published article are significantly as high as reported, the question arise in mind, were these articles peer reviewed? another report said that the reviewers failed to detect 16 cases of fabricated article of jan hendrick schon. superficial peer reviewing process does not reveals suspicion of misconduct. lack of knowledge of systemic review process not only demolish the academic integrity in publication but also loss the trust of the people of the institution, the nation, and the world. the aim of this review article is to aware stakeholders specially novice reviewers about the peer review system. beginners will understand how to review an article and they can justify better action choices in dealing with reviewing an article. key words: peer review, review system, bioethics, publication ethics introduction: “peer reviewers are the ‘gatekeepers’ of science” that helps in evaluation and validation of research 1. editors, academics and readers have full trust of peer-review system 2. but sometimes their peer reviewing system raise question 3. according to report of u.s. office of research integrity, fraud articles were found in 94% cases from 228 published article of misconduct over 15 years period 4. jan hendrick schon, 31 year-old physicist, while working at bell laboratory in murray hill, new jersey, published duplicated, fabricated and falsified article in reputed journal including science and nature. careless review process failed to detect misconduct of 16 articles of schon 3. however, a survey on 590 editorial board members of chemistry journals revealed that 97% of the journals were not double-blinded 3. a research analyzed the effectiveness of peer review process of three journals, namely british medical journal, annals of internal medicine and the lancet. they found that 946 submitted article were rejected among the dataset of 1,008 submitted manuscripts. among the rejected article 757 manuscripts were resubmitted to another journals for publication. these articles bangladesh journal of bioethics 2018; 9(1):13-23 14 were cited extensively over time 5. peer-reviewed journals were not doing their jobs. the poor quality of peer review significantly reduces the confidence of researchers and clinicians. some said peer reviewers take excessive time and delay the publication 3. in spite of criticisms, peer review is the most conventional technique for quality and validity of individual articles 1. a survey of ware and monkman proposed that of 93% believe the peer review is important and necessary; 85% believed scientific community has been benefited from peer reviewer and 83% thought peer review is the only system to control of misconduct 6 . editors belief on peer reviewers for fair assessments of article. peer reviewers has responsibilities and obligations to review the article and identify all the ethical issues raised by the research 2 . academic integrity is essential not only for progress within the academy, but also for maintaining the trust of the people as a whole. utmost awareness is necessary in peer reviewing process especially to the apprentice reviewers. therefore, this review article has been undertaken so that novice learner can comprehend the whole peer reviewing system and they can able to consider the issues need to be think off during peer reviewing process. historical background: the first identified peer review process was found in 854–931 b.c. in the book of ishāq ibn ʻalī al-ruhāwī entitled “ethics of the physician”. according to him, physician kept notes on patient's condition for every visit. when patient “cured or died”, the local medical council scrutinized the records of the physician if the treatment was consistent with the standards of medical care 7,8. the first documented journal peer-review was seen in 1665 at philosophical transactions journal where an editor requests independently experts from his field for his private use 1. in 1731, peer review was introduced to scholarly publication of medical articles by the royal society of edinburgh. all these type of peer review were like conference now a day 3. till mideighteen editor use to act as peer reviewer. in 1750s, denis diderot said “a journal embraces such a large variety of matters that it is impossible for a single editor to oversee every issue specially in mediocre journal” 7. until world war ii, editorial process is not shape what we call peer review process today 3 . science, nature and the journal of the american medical association started peer reviewing in mid-20th century 8 . the lancet did not implement peer-reviewers outside the journal until 1976 9 . definition: peer review is a process of evolution in order to publish for scholarly community. peer reviewer is also called referee and articles are called "refereed articles". according to wame “a peer-reviewed biomedical journal is one that regularly obtains advice on individual manuscripts from reviewers who are not part of the journal’s editorial staff to intend to improve the accuracy, clarity, and completeness of published manuscripts and to help editors to decide to publish 10. peer review is the “golden standard” for evaluating the publications 11. editors request at least two reviewers to evaluate a manuscript. sometimes journals call an additional reviews. additional peer reviewer is needed for cross bangladesh journal of bioethics 2018; 9(1):13-23 15 disciplines, statistical analyses, complex, controversy or strong disagreement work for thorough evaluation of a paper 12 . types of peer review: many types of peer reviewing system has been recognized. each model has pros and cons 12 . but it is not clear which system is the best 12 . different disciplines use different model of peer review system according their benefits and feasibility 2 . different types of peer review system has been shown in table 1. table 1. different types of peer review system type definition prons cons reference single blind peer review only reviewers aware of the identities of authors. reviewers are not influenced by the authors, protecting against possible reprisals by author. highly subjective, possibility to bias review in favor of or against the author. delay the review. in case of competitor may take advantage of ideas of article yet unpublished. cse, 201212 double-blind peer review both the reviewers and authors are not aware of each other identities. reduce biasness, prevent unreasonably critical in case of the competitors work. e.g. most of the journals delay the review. sometimes superficial review of an article. cse, 201212 open peer review both the reviewers authors are aware each other identities more transparent, rapid and better quality of reviews. reviewers comments are openly available with reviewers name in published article. reviewers may be less willing to review, less critical and impartial, if their identity is revealed, particularly when judging their colleagues’ work cse, 201212 bangladesh journal of bioethics 2018; 9(1):13-23 16 transparent peer review similar to open peer review. similar advantage similar disadvantage. however, the reviewer’s names are not available in the article. cope, 201713 interactive or collaborative peer review peer review usually takes place on a platform, reviewers can interact with authors or each other facilitate the review process. review process occur through over phone, skype etc. can make reprisals or reviewers may be less critical and impartial. cse, 201212 multi-stage open peer review reviewers plus other members of the scientific community can openly discuss for a designated period of time and openly comments. the manuscript is then revised, edited (re-reviewed if needed) and finally published. very rapid publication. e.g. atmospheric chemistry and physics identity of reviewers’ names can make hostility or reviewers may be less critical and impartial. pöschl, 201214 cascading or shared peer review when manuscripts rejected after review, article can transfer among sister journals in the same publisher. no need to reformat and further peer review. e.g. sage journals: otolaryngology head and neck surgery and oto open; jama family of journals; elsavier etc. rejected article is accepted anyhow bangladesh journal of bioethics 2018; 9(1):13-23 17 postpublication peer review usually anonymous, blogs, and social media comments e.g. letters to the editor, journal online comments, editorial comments, third party website commenting such as pubmed commons and pubpeer. take long time to publish. traditional print-based journals generally batch letters to the editor and request a response from the authors, publishing them together in a single issue a few months after the original article. only letters to the editor are indexed. cope, 201713 process of peer review: peer review is a wellknown professional practice in scholarly publication 15. after completion of research, article is submitted to a journal. editors send the article to the reviewers in the same field. reviewers provide feedback on the article. authors address the article according to reviewer’s comments and submit it for publication. editor take the final decision whether article is accepted or rejected for publication. only the articles based on objectives, wellstructured methodology, logical reasoning and argument with evidence etc are accepted for publication 16. what do reviewers do with manuscript? each reviewer assesses the article by asking questions. based on the answers to these questions, the reviewers decide whether the article is worthy to publication. they then make a recommendation to the editor whether article can be approved or rejected. questions are like: 1. what is this research about? 2. is it interesting? 3. is it important in existing knowledge? 4. does the paper fit the scope of the journal? 5. is the research question clear? 6. is the approach appropriate? 7. does it develop novel concepts? 8. are the study design, methods and analysis appropriate to the research question? 9. are the methods of statistical analysis and level of significance appropriate? 10. are the findings original? bangladesh journal of bioethics 2018; 9(1):13-23 18 11. is the methodology sound? 12. are the conclusions logical? 13. in case of research with human or animals, was ethics approval gained? 14. is the article duplication publication? 15. it is plagiarized? role and responsibility of peer reviewer: peer should follow some norms and values to be a reviewers. following are some universally accepted responsibilities of reviewers for sound peer review outcome 12. 1. timeliness and responsiveness: provide scholarly and unbiased feedback in a timely manner. reviewers should promptly decline when they cannot meet the deadline. 2. competency: reviewers should be the expertise in the field of article. without expertise reviewer may recommend an article with considerable insufficiencies or reject the worthy paper. in such cases, the reviewer should decline to review. 3. financial conflict: reviewer should disclose the conflict of interest if any. in this case reviewer should decline to review. 4. impartiality: reviewer comments and recommendation should be based on article objectives and scientific merits in regard to nation, creed, race, color, ethnic origin, sex and religion. 5. comply with: comply with the editor’s instructions. identify if the writing is clear, abridged, scientifically accurate, original and appropriate to the journal. determining scientific merit, and indicating ways to improve it. 6. constructive critique: reviewer should assess the manuscript in sympathetic and positive way, providing unbiased and enlightening critique to the submitted work, identifying negative aspects constructively and avoiding personal comments or criticism. 7. ethical approval: noting any ethical violation during research with animal or human. 8. duplicate publication: alert editor in case of any knowledge of similar article to prevent duplicate publication 9. confidentiality: reviewer should not share or disclose information with third parties, from the reviewed paper. 10. material handing: reviewers should not keep copies of submitted manuscripts and should not use the knowledge of their content for any purpose other than the peer review and destroy the manuscripts after reviewing finish. 11. contact to author: reviewers should refraining from direct communication to author. reviewer’s misconduct: peer review does not guarantee manuscript quality and does not reliably detect scientific misconduct” 10. reviewer misconduct may include 1. falsifying the facts in a review 12. 2. unnecessary delaying the review process; most journals request reviews within one to three weeks12. bangladesh journal of bioethics 2018; 9(1):13-23 19 3. unfairly criticizing on a competitor’s work 12. 4. proposing changes according to and support the reviewer’s own work or hypotheses 12. 5. use of manuscript content for one’s own benefit, plagiarism of manuscript content, intellectual property theft during peer review 2. 6. sharing manuscript content without permission, 7. not disclose one’s conflict(s) of interest. 8. the reviewer does not destroy the manuscript in paper or electronic form after review process. keep it for later use. use the manuscript or information obtained from it for personal gain (be it professional, personal, or financial) 17. reviewer selection: editor should invite reviewers who expertise in the same field of article 12. editors should avoid rude, defamatory peer reviewer. editors should avoid using reviewers who provide poor quality reviews and/or are very tardy in submitting their reviews 17. editors should screen out reviewers for potential conflicts of interest. editors should not make reviewers from the same institution, least not in the same department of the authors. editors generally should avoid asking reviewers to review more than a couple of times per year, unless the reviewer has agreed to review more often (e.g., as an editorial board member) or there are unique circumstances the editor discusses with the reviewer 10. editors may select peer reviewers according to author’s suggestion but not accept the blinding system 2. if editor is requested by the author not be used certain reviewer, editors should consider the requests if justified 10. time requires for peer review: “peer review and publication system are time-consuming process, frequently involving more than a year between submission and publication”2. reviewers should be reminded as the deadline draws near and when it is reached or overdue, if reviewers do not return reviews in a timely fashion and do not respond to reminders, the editor should contact another reviewer. the author should be informed of the reason for the delay. if the manuscript already has two peer reviews, the editor should assess the manuscript (or ask another editor with the journal who specializes in the area to assess it) to determine if the existing peer reviews are sufficient to make a decision 17. review quality: peer review process should be fair and minimize bias 2. when the editor receives the peer reviews, the editor should consider whether the reviewers’ comments are constructive and whether the reviewer provides specific examples from the manuscript to support the comments. for example, “this study was poorly designed and executed, and such shoddy work should not be published,” the reviewer should provide specific examples of why the study design is not well suited to answer the study question and the problems that may result. several types of comments are not appropriate for a review. first, the reviewer should not address the manuscript’s suitability for publication in comments for the author; if the journal permits comments for the editor, the bangladesh journal of bioethics 2018; 9(1):13-23 20 reviewer can make recommendations there. the decision to publish is the editor’s; the reviewer’s role is to evaluate and explain the study’s strengths and weaknesses. second, reviewers should not ask authors to preferentially cite their work unless the citation is truly justified. third, reviews that are insulting or demeaning with no useful comments should not be sent to the author. if a review is useful but includes comments that are not constructive, the editor should modify those comments before sending to the author, and share the modified comments with the reviewer. editors should thank reviewers when they complete their review and, in due course, inform reviewers of the manuscript decision and provide them with the other reviewers’ comments 17. rewarding reviewers: some journals published list of reviewers in order to recognize the reviewer’s generous volunteer efforts with thanks publicly 18. editors may include them in publons, a free review reporting services18. some journals reward reviewers who have provided several high quality reviews by publishing their names as distinguished reviewers; star reviewers and awarding them a certificate and/or letter signed by the editor and journal owner (head of the academic institution or professional organization 17. journals may include reviews in the continuing medical education credits 12. other incentives include free journal subscriptions, complementary access to databases (or for a limited time during the review period) and waived submission or article processing fees for reviewers who submit future research as authors 17 discussion: biasness: value of the journal is depend on the peer review process. some cases, especially in quantitative research, biasness is discernable as the direct violation of impartiality underdetermining the criteria of peer review system during evaluation process 15. reviewers should not assess the article on the basis of “sense of self and relative position” but its rational content 19. sometimes, biasness may be occur due to social characteristics of the author/reviewer e.g. prestige bias, nationality bias and language bias 15. limitation: sometimes, peer review takes too much time and delay publishing substantially. “it’s one of the bottle necks of scholarly publishing” 2. sometimes, number of experts in same arena are limited to review. reviewer is not paid as job. they are occupied by other academic tasks that delay the peer reviewing process 2 . payment: timothy mctighe, executive director of jisrf and editor-in-chief of reconstructive review, in his personal letter in the wame blog think that reviewer should not be paid. reviewer cannot pay at the same rate that his job pays him. it comes very close to a conflict of interest. if the payment is made to expedite the review process the reviewer might be tempted to accept the submission believing he will get more paid request for review. it also clouds the overall merit of the quality of content 20. he also argue that if there is merit in the journal content there should be enough quality experts willing to review manuscripts as part of their overall professional goals of keeping their standards high in their chosen profession 20. payment may bring about bangladesh journal of bioethics 2018; 9(1):13-23 21 suspicion and doubt about the peer review process 20. some cases, statistician may be paid for their services to review the article, but most peer reviewers are not paid because they will receive the same service when their manuscripts are under review 17. review process: it is believed that the doubleblind review system is better than single-blind as it is less biased but there is also doubt whether true blinding is really possible 15. as for example, israel is a small country, double blinding process is really useless as everyone of scholar society knows each other and knows what research is going on in which institute 3. sometimes authors can be easily identifiable by the reviewers through their writing style, subject matter and selfcitation 1. a research shown that after masking the authors’ identity, of 30% of the authors were identified by the reviewer due to self-citation 3. in small research fields this number is higher. double blinding is pointless because the content and references could not be truly masked 3. however, a report says, most of the people prefer still double blinding (56%) than single blinding (25%) 6. some consider open review system is the best way to prevent plagiarism, malevolent comments and stop reviewers from implement their own agenda. others realize it is a less effective process, reviewer may withhold or tone down criticism in fear of retribution 1 . in case of transparent peer review, comments are posted on the journal website may appear at any time and generally are not indexed. authors should be encouraged to respond to them as appropriate. authors of letters to the editor and authors of online comments both should be required to disclose their conflicts of interest in adherence with the journal's policies and the conflicts should be published alongside their comments. the journal article should link to the journal's related post-publication peer review, and vice versa. journals may wish to link out to non-journal post-publication peer review 17. in case of cascading, same manuscript need not to review again for different journals of parent journal. if articles are rejected authors can transfer article to another journal of same family without reformatting. it save time to author as well as editors 1. whatever the mode of peer review process, it does not guarantee manuscript quality and does not reliably detect scientific misconduct” 10. editorial support to peer reviewers: peer reviewers should be protected from authors when peer reviewer’s identity are revealed. editor should write authors explicitly discouraging to contact peer reviewers directly, especially if misconduct is suspected 2 . authors appeals: “authors have the right to appeal editorial decisions”. journals should have a policy and clearly mention in the journal’s instructions that authors can appeal of peer reviewer’s decisions. this may be benefitted for both authors and editors but editor should careful and discourage repeated or groundless appeals 12. publisher: to increase the standard of peer review system, publishers can audit the bangladesh journal of bioethics 2018; 9(1):13-23 22 percentage of accepting and rejecting peer reviewed papers annually and asses how journal’s reporting standards can be increased. publishers can collaborate with software company to create a meta-researchers /peer reviewer that may help editors to compare the peer and review processes 21. like the plagiarism checker, technology may develop a software to identify illegitimate declaration of peer review journals can be detected 21. publishers should undertake to develop review metrics (e.g., number, role of reviewers and review commentary) along with journal metadata to increase the quality and legitimacy review system of article 21. conclusion: peer review system was deployed date back 7th century, in medical profession to scrutinize treatment was consistent with the standards of medical care. until world war ii, peer review process is not shape like today. the peer review is the key process to evaluate and validate the research that increase the overall quality of the journal.. superficial and poor quality peer reviewing process does not identify the misconduct and ethical issues raised by the research. peer review system is the gold standard to review an article. there is no system develop above peer review process for academic integrity. lack of systemic knowledge of review process abolish the academic integrity in publication and trust of the academics and readers. i belief this document will make aware the stakeholders about the peer review process. reference: 1. elsevier 2016. what is peer review? https://www.elsevier.com/reviewers/what-is-peerreview (accessed on feb 2017). 2. chris, g., elizabeth, w., alyson, b., suzan, f., diane, andrew, r. best practice guidelines on publication ethics: a publisher’s perspective journal compilation. j clin pract. 2007; 61(suppl.152): 1-26. 3. hadas s. the birth of modern peer review. retrieved from: https://blogs.scientificamerican.com/informationculture/the-birth-of-modern-peer-review/ (accessed on feb 2017). 4. steen rg, casadevall a, fang fc. why has the number of scientific retractions increased? plos one 2013; 8 (7): 1-9. 5. silera k, leeb k. & beroc l. measuring the effectiveness of scientific gatekeeping. pnas. 112(2): 360–365. 6. ware, m. & monkman, m. peer review in scholarly journals: perspective of the scholarly community — an international study. publishing research consortium. 2008. retrieved from http:// www.publishingresearch.net/documents/prcsummar y4warefinal.pdf 7. wikipedia. peer review retrieved from: https://en.wikipedia.org/wiki/peer_review (accessed on feb 2017) 8. spier, r. the history of the peer-review process. trends in biotechnology. 2002; 20(8): 357-358. 9. benos dj, bashari e, chaves jm, et al. the ups and downs of peer review. advances in physiology education. 2007; 31(2): 145-152. 10. wame. definition of a peer-reviewed journal. retrieved from: http://www.wame.org/policystatements#definition%20pr (accessed on june 12, 2017). 11. kelley dm. 2012. peer review: publication’s gold standard. j adv pract oncol, 3 ( 2) :117-121. 12. council science editors. cse’s white paper on promoting integrity in scientific journal publications, 2012 update. editorial policy committee (2011-2012). retrieved from: www.councilscienceeditors.org (accessed on january 20, 2017). 13. cope. cope discussion document: who “owns” bangladesh journal of bioethics 2018; 9(1):13-23 23 peer reviews? cope council, 2017. retrieved from: https://publicationethics.org/files/who_owns_peer_rev iews_discussion_document.pdf?platform=hootsuite (accessed on feb 2017). 14. pöschl, u. multi-stage open peer review: scientific evaluation integrating the strengths of traditional peer review with the virtues of transparency and self-regulation. frontiers in computational neuroscience. 2012; 6:33. 15. lee cj, sugimoto cr, guo z, and blaise c. bias in peer review. advances in information science journal. 2013; 64(1):2–17, 16. underrstanding science. 2017. scrutinizing science: peer review. http://undsci.berkeley.edu/article/0_0_0/sciencetoolkit _01(access feb 2017) 17. lapeña jr jf and winker m. 2017 peer review, manuscript decisions, and author correspondence. wame elearning program. (in press). 18. van noorden, r. the scientists who get credit for peer review. nature. 2014. q &a. https://www.nature.com/news/the-scientists-who-getcredit-for-peer-review-1.16102 (access feb 2017). 19. beatriz b, ricardo c, konrad, martin t. bias in peer review: a case study. f1000research 2015, 4:21. 10.12688/f1000research.6012.1 (access feb 2017) 20. mctighe t. jisrf and editor-in-chief. reconstructive review. retrieved from: www.jisrf.org (accessed on feb 2017). 21. lee cj and moher d. 2017 promote scientific integrity via journal peer review data: publishers must invest, and manage risk. science. 2017; 357(6348): 256-257. author’s contribution: author conceived the idea, perceived the knowledge, and drafted the manuscript. conflict of interest: none editorial bangladesh journal of bioethics 2013; 4(1):1 1 editorial debate on pediatric research in the 18th century, children were viewed as property of adults. children were also considered as cheap (not-valued) for rsearch. early experiments on infectious diseases, new vaccines and medical procedures were often performed on children of servants, orphanages, mentally ill or physically disabled children. in the late 19 century, objections to the use of children in research were presented by the usa antivivisection society (1896). prussian minister for religious, educational and medical affairs issued a directive in 1900 that medical interventions other than for diagnosis, healing and immunisations children were excluded. for many years after nuremberg, it was felt that research with children was unethical, if not illegal. helsinki declaration (1964 2008) says children can participate in research by parental informed consent. research involving children is only justified if it the medical interests of that child and are necessary to improve the health and well being of children. this is the most important stages of the evolution of necessity on pediatric research. in 1974, the pediatric research act established the national commission for the protection of subjects of biomedical and behavioural research for broad justification of research involving children under protection. convention of human rights and biomedicine council of europe, oviedo 1997 express research with children can be undertaken if research questions that cannot be answered by similar research carried out in adults. g. koren in 2003 said children are not small adults in the way their bodies function and develop. hence, unless a new device or pharmaceutical preparation is tested in them, one cannot assume their safe and effective use in the pediatric age group. in the europe and us, a number of legislative actions has been taken to encourage pediatric research. pediatric research is needed bcause some diseases are typical of children and there is metabolic differences between children and adults. shamima parvin lasker (professor & head of anatomy, city dental college, dhaka) associate editorial bangladesh journal of bioethics microsoft word editorial for march issue 2018-1 bangladesh journal of bioethics 2018; 9(1): editorial for special issue on publication ethics, march 2018 dear readers, happy summer holidays for all of us up in the northern hemisphere. while we are basking in the warmth of sunny days our friends in australia are buying winter clothes. how strange is this world! and stranger are the creations who are supposed to look after all other organic and inorganic objects in this planet and maybe beyond. the simple virtues of ethical and value based behavior is often forgotten when we are focus on getting the best for ourselves without thinking or respecting the rights of others. the case of ethics in publication is not any different. we have few papers this issue but they are of extreme value and relevance: the paper by jaime a. teixeira da silva titled ‘macchiarini gate: the fall from grace of stem cell healer, paolo macchiarini, and clues and concerns from the early literature that cast ethical doubts ‘ is a real eye opener into the misconduct and ethical behavior of doctors to patients. this article indeed takes an important realistic look into what is happening in the medical innovation field and how authorities and patients are being fooled to believe in magical cures without and real scientific evidence, which are being manipulated to produce results for the financial benefit of a particular physician. the dream of being cured, without any pain is a very understandable emotion and belief which has been long existing from the very ancient times. even now people believe in crystals and, remote places where the fountain of youth is believed to have existed. so dr. paolo macchiarini , a tracheal surgeon in 2008 became famous with the transplantation of a trachea from a dead body and the patient’s stem cells to ‘regenerate’ new trachea. among the nine patients operated by macchiarini, six had died. allegations of misconduct against macchiarini was filed in 2014 by the karolinska institutet (ki) fellows and an independent investigation was launched. the institute claimed that not only was the procedure of high risk, patients information was incomplete and none or incomplete ethical approval were taken. this constitutes gross malpractice and misconduct. in 2016, the results of the investigation came out and most of these allegations have been proven to be true, macchiarini was found guilty and actions taken accordingly. this paper will be a real help to many modern day patients who are being lured into medical interventions with the promise of being cured. yet none of them has been scientifically proved or received formal approval from any country’s medical regulatory boards like usfda and others. the ethical norms and values of many physicians particularly the new fad of prp and stem cells have been overcome by the greed for money, fame without caring about the patients’ real needs and taking advantage of their pain and dependence, when all reasons are ignored. are these 1st world doctors better than the quacks in the bazaars of bangladesh and india where a single powder of taka 50 will cure you of all maladies from diabetes, infertility to cancer? another interesting paper titled ‘peer review system: a golden standard for publications process’ by shamima parvin lasker looks deeply into the peer review process. how peer review can help to improve an article, kinds peer review and also remuneration of reviewers. the bangladesh journal of bioethics 2018; 9(1): hon’ble author is excellent in pointing out not only the need for in depth, unbiased peer reviews but also how paying to the reviewers could often lead to conflict of interest. the paper on ‘basic concept of intellectual property rights (iprs)’ by arif hossain explores the gamut of intellectual rights. the author states that different classifications of iprs have been formulated to protect the original work and the credit of the author and researchers. these are patent, copy rights, license, trade mark, trade dress and trade secret. the author concludes that the basic knowledge about copyright and ownership of a publication is needed to avoid embarrassment and harassment. it seems actions in this is needed in terms of knowledge and information specially for the students and researchers. this paper concludes our publication for this issue and we are really proud to state that quality has clearly outpaced quantity in our cherished bangladesh journal of bio ethics. have a great summer/ winter and enjoy this lovely time with all. see you next issue with more interesting and insightful papers. best wishes professor tahera ahmed editor bangladesh journal of bioethics 2014;5 (1):43 bbs news bbs organized a day long training workshop on human rights education for youth leadership on 31 st january 2014 at city dental college, 1085/1 malibagh chowdhury para, dhaka to promote strong ethical values and morality among the young generation in their leadership and social life to lead the nation for upholding human rights for long term sustainability of the country. of 35 students of various disciplines of medical, dental, science, law, philosophy, social science were take part in this workshop. the programme was co-coordinated by prof rowshan ara, honorary professor of philosophy, dhaka university and assisted by prof dr noor e parvin, professor of zoology, dhaka college, jobair alam, lecturer, department of law, dhaka university and nd luna sharmin, lecturer of zoology, dhaka college. certificates were distributed among the participants by the general secretary of bbs, prof shamima parvin lasker. introduction bangladesh journal of bioethics 2013; 4(2):1-8 1 bioethics and patent law: usa, uk and india. a bibliometric analysis mona gupta 1 , divya srivastava 2 arvind singh kushwah 3 1,2,3 research scientist, scientometric unit, division of publication and information, indian council of medical research (hq.), ansari nagar, new delhi, india, email: gmona7@gmail.com, drdivta.srivastava@gmail.com, welcomein.arvind@gmail.com abstract: this article discusses the view of bioethics in terms of “need of ressearch” and gives more weight to various cultural traditions and their respective moral beliefs. it is argued that this view is implausible for the following three reasons: it renders the disciplinary boundaries of bioethics too flexible and inconsistent with metaphysical commitments of biomedical sciences, it is normatively useless because it approaches cultural phenomena in a predominantly descriptive and selective way, and it tends to justify certain types of discrimination. compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. when a hotly-contested phenomenon like assisted dying is debated, all-or-nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. in order to qualify as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. the product that will result from such a process will also need to split the difference between the warring parties. in assisted dying, i argue that a reduced offence of 'compassionate killing' can achieve this. clinical research is revolutionizing the practice of medicine in an unprecedented way. some current legal and ethical concerns evolving from this revolution are addressed, pointing to the emerging concepts in jurisprudence, which regards medical research as an important contribution to patient empowerment, to medical risk management and in managing the resources of a national health system. while bioethics as a field has concerned itself with methodological issues since the early years, there has been no systematic examination of how ethics is incorporated into research on the ethical, legal and social implications. we aim of better understanding the methods, aims, and approaches to ethics that its researchers employ. we found that the aims of ethics are largely prescriptive and address multiple groups. this is a life concern issue. it is an important issue for researchers, teachers as well as for student. this articles main aim is to provide systematic outline of the complex relationship between bioethics and patent between india, usa and uk. this study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor-patient discussions of health care costs. better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter. it will give an overview of the bioethics and patent. the literature survey has indicated that there is no comprehensive work has been done by any researcher on this topic. therefore the present study would concentrate on the work being carried out by indian, usa and uk r & d scientists vis-a-vis global researchers. studies aims to map basic human needs such as human health, food and a safe environment, touches on fundamental values, such as human dignity and the genetic integrity of humanity, can raise human rights issues such as access to health and benefits from scientific progress, raises concerns over equitable access to the fruits of new technologies, the consent of those involved in research, and protection of the environment and compare these among india, usa and uk. the research map out many issues and policy communities, but main aspect is the ethical implications of protecting biotechnological inventions through the intellectual property (ip) system. a bioethicist assists the health care and research community in examining moral issues involved in our understanding of life and death, and resolving ethical dilemmas in medicine and science. this research provides a systematic outline of the complex relationship between bioethics and ip. it will give an overview of bioethics. it sketches core principles in the interaction of ip and bioethics among these three countries. mailto:gmona7@gmail.com mailto:drdivta.srivastava@gmail.com mailto:welcomein.arvind@gmail.com bangladesh journal of bioethics 2013; 4(2):1-8 2 the basic data for the bibliometric analysis has been collected from sci and for mapping different parameters suitable analytical software eg. spss, bibtech mon is used. the analysis arises questions such as: does india do enough work in this field. which country is fastest growth among these? introduction: bioethics is the study of controversial ethics brought about by advances in biology and medicine. bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, and philosophy. bioethics is the process of the matters which occur biologically. bioethics is the compound word with "bios" which represent life or something concerning life with "ethikos" which represent ethics or mores. both words are traced from greece. bioethical studies have developed significantly in the united states. bioethics purports to deal with the value and ethical issues that have been brought about by the rapid developments of science, technology, and biomedicine during the past fifteen years. bioethical issues are a serious concern for all of us living in an era of "life-manipulation". this is the reason why the new "supra-interdisciplinary" study of "bioethics" deals with issues relating to all integrated aspects of life's beginning, ending and quality, compared to the too narrow segmentation and ramification trends of traditional academic disciplines dealing with human and life issues separately. the term bioethics was coined in 1927 by fritz jahr, who "anticipated many of the arguments and discussions now current in biological research involving animals" in an article about the "bioethical imperative," as he called it, regarding the scientific use of animals and plants. bioethics and animal research: a personal perspective and a note on the contribution of fritz jahr. fritz jahr's 1927 concept of bioethics. in 1970, the american biochemist van rensselaer potter also used the term with a broader meaning including solidarity towards the biosphere, thus generating a "global ethics," a discipline representing a link between biology, ecology, medicine and human values in order to attain the survival of both human beings and other animal species. life science innovations may significantly influence our future. developments in molecular biology and their applications in health technologies and agriculture have provided new perspectives and created hope for new solutions. the rapid advances in this area accompanied by grant of patent rights on inventions related to, for example dna sequences, protein sequences, stem cells, and other similar technologies, has prompted examination in international flora of the implications of intellectual property rights and their ethical underpinnings. bioethical issues are a serious concern for all of us living in an era of "life-manipulation". "bioethics" is a result of the various human rights movements responding to the de-humanizing phenomena caused by political, economical, technological, and biomedical problems emerging since the end of 1950s mainly in the u.s., europe and some other places in the world. for example, these various human rights movements are civil liberty movement, woman's rights movement, student movement, and so on. it is sure that our future direction should be formed in the framework of public participation by having input from the lay-public and the experts in anticipating our "future image" of the world. in this sense, the supra-interdisciplinary study of bioethics and its public policy should be based upon the notion of "anticipatory democracy" as well as an action in "participatory democracy". the main objective of the study is to provide a systematic outline of the complex relationship between bioethics and patent. it will give an overview of the bioethics and patent. it sketches core principles in the interaction of patent and bioethics. it looks at the main sets of issues that are emerging, that are challenging and complex issues. it does not offer any readymade or preferred solutions to today's difficult questions concerning bioethics and patent. but presents a way of clarifying the actual position of patent laws role in issues related to bioethics. these issues are http://en.wikipedia.org/wiki/ethics http://en.wikipedia.org/wiki/biology http://en.wikipedia.org/wiki/medicine http://en.wikipedia.org/wiki/life_sciences http://en.wikipedia.org/wiki/biotechnology http://en.wikipedia.org/wiki/medicine http://en.wikipedia.org/wiki/politics http://en.wikipedia.org/wiki/law http://en.wikipedia.org/wiki/van_rensselaer_potter bangladesh journal of bioethics 2013; 4(2):1-8 3 discussed more fully in a background study, which discusses some of the leading cases mentioned briefly in this study bioethics within the law of patents: the scope for judgments about morality in assessments on patentability. the field of bioethics has addressed a broad swath of human inquiry, ranging from debates over the boundaries of life (e.g. abortion, euthanasia), surrogacy to the allocation of scarce health care resources (e.g. organ donation, health care rationing) to the right to turn down medical care for religious or cultural reasons. bioethicists often disagree among themselves over the precise limits of their discipline, debating whether the field should concern itself with the ethical evaluation of all questions involving biology and medicine, or only a subset of these questions. some bioethicists would narrow ethical evaluation only to the morality of medical treatments or technological innovations, and the timing of medical treatment of humans. the literature survey has indicated that there is no comprehensive work has been done by any researcher on this topic. therefore the present study would concentrate on the work being carried out by indian r & d scientists vis-a-vis global researchers. about the database : in view of the importance of bioethics research in the field of human health and well being it becomes important to map out the research activities being carried out by researchers around the world and in india by indian scientist. for this purpose we need a searchable consolidated database, but there is no exclusive comprehensive global database on bioethics publications and for indian efforts also in the field of bioethics. a comprehensive database have been developed for bibliographical details of all the research papers published in usa, uk and india. methodology: to carry out the research, efforts were made to collect global information on research publications in the field of bioethics and indian research papers published during last 5 years .the data sources have been searched using the search string. medline and isa were used to access the trend individually and in comparison to each other. global publications analysis: the total numbers of papers published during 2005-09 is 2982. during 2009 the number of papers in the field of bioethics was at its maximum with 51.06% as shown by the graph. the cumulative publication share in world research output indicated an exponential growth of papers from 8.12 (2005) to 51.06(2009). commitment of countries towards bioethics research: india with its global publications share of 21.66% computed on the basis of cumulative publications output during the period of 2005-2009. the united states tops the list with global publications share of 63.21%. the united kingdom global publication share was 15.12%. http://en.wikipedia.org/wiki/abortion http://en.wikipedia.org/wiki/euthanasia http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/technology bangladesh journal of bioethics 2013; 4(2):1-8 4 . global share of usa, uk and india: the average growth rate of countries is from -4.29 to 64.27 during successive years. india‟s annual growth rate increased from -12.07 to 35.17. united kingdom also came up with increased share but its average growth rate decreased from 18.62 to 18.40. in 2006 its growth rate was maximum 23.05%. united state‟s average growth increased, from 4.29 to 64.27 during the period of 5 years. united state is on the top as in the united states more than 25 universities offer degrees in medical ethics. in many instances, the subject also is part of the curriculum in the education of physicians and other health care professionals. many medical schools include ethics courses that examine topics such as theories of moral decisionmaking and the responsible conduct of medical research. so there is much awareness in bioethical field compression to other country. bangladesh journal of bioethics 2013; 4(2):1-8 5 analysis of papers on the basis of subject area (1981-2005): 75 subject areas within bioethics research were identified, as shown in the list of „key words‟. areas of health sciences that are the subject of published, peer-reviewed bioethical analysis include: 1. abortion 2. animal rights 3. artificial insemination 4. artificial life 5. artificial womb 6. assisted suicide 7. biocentrism 8. biopiracy 9. biorisk 10. blood transfusion 11. body modification 12. brain-computer interface 13. chimeras 14. circumcision 15. cloning 16. confidentiality (medical records) 17. consent 18. contraception (birth control) 19. cryonics 20. disability 21. eugenics 22. euthanasia (human, non-human animal) 23. exorcism 24. faith healing 25. feeding tube 26. gene theftgene therapy 27. genetically modified food 28. genetically modified organism 29. genomics 30. great ape project 31. human cloning 32. human enhancement 33. human experimentation in the united states 34. human genetic engineering 35. iatrogenesis 36. infertility treatments 37. life extension 38. life support 39. lobotomy 40. medical malpractice 41. medical research 42. medical torture 43. mediation 44. moral obligation 45. moral status of animals 46. nanomedicine 47. organ donation 48. organ transplant 49. pain management 50. parthenogenesis 51. patients' bill of rights 52. placebo 53. political abuse of psychiatry 54. population control 55. prescription drugs (prices in the us) 56. procreative beneficence 57. professional ethics 58. psychosurgery 59. quality of life (healthcare) 60. quaternary prevention 61. recreational drug use 62. reproductive rights 63. reprogenetics 64. sex reassignment therapy 65. sperm and eggs (donation) 66. stem cell research 67. suicide 68. surrogacy 69. three parent babies 70. transhumanism 71. transplant trade 72. vaccination controversy 73. xenotransfusion 74. xenotransplantation 75. yoga http://en.wikipedia.org/wiki/abortion http://en.wikipedia.org/wiki/animal_rights http://en.wikipedia.org/wiki/artificial_insemination http://en.wikipedia.org/wiki/artificial_life http://en.wikipedia.org/wiki/artificial_womb http://en.wikipedia.org/wiki/assisted_suicide http://en.wikipedia.org/wiki/biocentrism http://en.wikipedia.org/wiki/biopiracy http://en.wikipedia.org/wiki/biorisk http://en.wikipedia.org/wiki/blood_transfusion http://en.wikipedia.org/wiki/body_modification http://en.wikipedia.org/wiki/brain-computer_interface http://en.wikipedia.org/wiki/chimera_(genetics) http://en.wikipedia.org/wiki/circumcision http://en.wikipedia.org/wiki/cloning http://en.wikipedia.org/wiki/confidentiality http://en.wikipedia.org/wiki/medical_records http://en.wikipedia.org/wiki/consent http://en.wikipedia.org/wiki/contraception http://en.wikipedia.org/wiki/birth_control http://en.wikipedia.org/wiki/cryonics http://en.wikipedia.org/wiki/disability http://en.wikipedia.org/wiki/eugenics http://en.wikipedia.org/wiki/euthanasia http://en.wikipedia.org/wiki/exorcism http://en.wikipedia.org/wiki/faith_healing http://en.wikipedia.org/wiki/feeding_tube http://en.wikipedia.org/wiki/gene_theft http://en.wikipedia.org/wiki/gene_theft http://en.wikipedia.org/wiki/genetically_modified_food http://en.wikipedia.org/wiki/genetically_modified_organism http://en.wikipedia.org/wiki/genomics http://en.wikipedia.org/wiki/great_ape_project http://en.wikipedia.org/wiki/human_cloning http://en.wikipedia.org/wiki/human_enhancement http://en.wikipedia.org/wiki/human_experimentation_in_the_united_states http://en.wikipedia.org/wiki/human_experimentation_in_the_united_states http://en.wikipedia.org/wiki/human_genetic_engineering http://en.wikipedia.org/wiki/iatrogenesis http://en.wikipedia.org/wiki/infertility http://en.wikipedia.org/wiki/life_extension http://en.wikipedia.org/wiki/life_support http://en.wikipedia.org/wiki/lobotomy http://en.wikipedia.org/wiki/medical_malpractice http://en.wikipedia.org/wiki/medical_research http://en.wikipedia.org/wiki/medical_torture http://en.wikipedia.org/wiki/mediation http://en.wikipedia.org/wiki/moral_obligation http://en.wikipedia.org/wiki/moral_status_of_animals http://en.wikipedia.org/wiki/nanomedicine http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/organ_transplant http://en.wikipedia.org/wiki/pain_management http://en.wikipedia.org/wiki/parthenogenesis http://en.wikipedia.org/wiki/patients%27_bill_of_rights http://en.wikipedia.org/wiki/placebo http://en.wikipedia.org/wiki/political_abuse_of_psychiatry http://en.wikipedia.org/wiki/population_control http://en.wikipedia.org/wiki/prescription_drugs http://en.wikipedia.org/wiki/prescription_drug_prices_in_the_united_states http://en.wikipedia.org/wiki/procreative_beneficence http://en.wikipedia.org/wiki/professional_ethics http://en.wikipedia.org/wiki/psychosurgery http://en.wikipedia.org/wiki/quality_of_life_(healthcare) http://en.wikipedia.org/wiki/quaternary_prevention http://en.wikipedia.org/wiki/recreational_drug_use http://en.wikipedia.org/wiki/reproductive_rights http://en.wikipedia.org/wiki/reprogenetics http://en.wikipedia.org/wiki/sex_reassignment_therapy http://en.wikipedia.org/wiki/sperm_donation http://en.wikipedia.org/wiki/egg_donation http://en.wikipedia.org/wiki/stem_cell bangladesh journal of bioethics 2013; 4(2):1-8 most productive journals: there were total 1503 journals publishing a total of 2982 papers during the whole study period (2005-09). there were 593 journals having one article each. 50% papers (1490) appeared in a total of 88 journals with an average of approximately 17 papers per journal. the rest of the papers were distributed among a total of 1415 with an average of 1 papers per journal. the top most journal was blood with 321 papers followed by american journal of bioethics (81). growth of journals and articles: table below gives the number of journals and articles in the area of bioethics research. it suggests that both the journals and articles increase exponentially. the number of articles has increased from 243 to1522. also the number of journals has increased from 156 to 566 (2005-09). the figures clearly show that the exponential model fit the empirical data. number of articles and journals in bioethics research year no. of journals articles average growth of articles in journals 2005 156 243 64.19753086 2006 222 368 60.32608696 2007 245 373 65.68364611 2008 314 476 65.96638655 2009 566 1522 37.18791064 6 bangladesh journal of bioethics 2013; 4(2):1-8 multiple authorship: an attempt had been made to study the co-authorship. table below, gives the data on single and multiple authorship in the area of bioethics research for the period 2005-09. above figures clearly indicate that the percentage of papers with multiple authors significantly increased, indicating that the research was towards interdisciplinary in nature. distribution of single and >2 author papers year # of one author # of ≥ 2 authors 2005 93 150 2006 186 182 2007 206 167 2008 249 227 2009 1230 292 conclusion: while the roots of bioethics lay in philosophy, today‟s bioethics requires collaboration among many additional areas of research, including law, medicine, biology, genetics, environmental toxicology, public health, pharmaceuticals, stem cell research, biotechnology, politics, sociology and business. bioethical dilemmas, once rare, now are commonplace, in part because new medical bangladesh journal of bioethics 2013; 4(2):1-8 technologies have outpaced our ability to understand their implications. the field of bioethics has addressed a broad swath of human inquiry, ranging from debates over the boundaries of life (e.g. abortion, euthanasia), surrogacy to the allocation of scarce health care resources (e.g. organ donation, health care rationing) to the right to turn down medical care for religious or cultural reasons. bioethicists often disagree among themselves over the precise limits of their discipline, debating whether the field should concern itself with the ethical evaluation of all questions involving biology and medicine, or only a subset of these some bioethicists would narrow ethical evaluation only to the morality of medical treatments or technological innovations, and the timing of medical treatment of humans. the literature survey has indicated that there is no comprehensive work has been done by any researcher on this topic. therefore the present study would concentrate on the work being carried out by indian r & d scientists vis-a-vis global researchers. references: 1. de alba ulloa. difficulties of the negotiation process of the convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine (and a call for its adhesion)]. j.gac med mex 2012 may-jun;148(3):307-20. 2. devaiah vh. impact of bioethics on patentability of inventions. indian j med ethics 2010 jan-mar. 7(1):14-7. 3. byk c. patenting human stem cells: an urgent need for a clarification. j int bioethique 2008 sep.19(3):105-19.125-6. 8 http://en.wikipedia.org/wiki/abortion http://en.wikipedia.org/wiki/euthanasia http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/organ_donation http://en.wikipedia.org/wiki/technology http://www.ncbi.nlm.nih.gov/pubmed/22820368 http://www.ncbi.nlm.nih.gov/pubmed/22820368 http://www.ncbi.nlm.nih.gov/pubmed/22820368 http://www.ncbi.nlm.nih.gov/pubmed/22820368 http://www.ncbi.nlm.nih.gov/pubmed/20166289 http://www.ncbi.nlm.nih.gov/pubmed/19244945 microsoft word chapter itellectual property rights bangladesh journal of bioethics 2018; 9(1):24-28 24 basic concept of intellectual property rights (iprs) arif hossain mbgph (usa), phd (usa) professor & course co-ordinator, etrat university, iran. founding chairman & vice president, bangladesh bioethics society, email: ahossainbbs@yahoo.com abstract: intellectual property rights (iprs) is protected by different systems of laws. journals must choose a definitive form of systems. some blackwell journals use copyright system and some blackwell use license from authors. now a days online journals are using creative common licenses. under creative common license journals are open access, allowed to download, copy, distribute, and display derivative works with proper attribution to author or owner for noncommercial purpose at a free cost. education on iprs will support to comprehend ones rights, professional code of conduct and the doctrine of "fair use" in publication. one cannot do anything with once writing. researchers, academic, editors and readers must have the basic knowledge on who owns the rights in a publication and what users can do with the publication by law. key words: iprs, publication ethics, copy rights introduction: journals are protected by intellectual property rights (iprs). therefore, journals are required to implement a system of law of iprs that is best ensembles their philosophy and purpose 1. some blackwell journals use copyright system where authors need to surrender their rights to publishers to reproduce and distribute for commercial purpose for a period of time 2. other blackwell journals use creative common license from authors, where authors permit to publishers to reproduce and distribution of their work at a free of cost if their work is properly cited. most of the online openaccess journals are under creative commons licenses 1. according to bethesda statement, in open access publishing system, all published works in open access journal are freely available to anyone; anyone can copy, distribute, and display the work at a free of cost for noncommercial purpose provided proper attribution to authors. violate of copyright / license is illegal and subjected to imprisonment 2. education on iprs will assist anyone to understand professional code of conduct and their rights and prevent everybody from embarrassment. definition: “intellectual property rights (iprs) are legal and institutional devices to protect creations of the mind” e.g. inventions or innovations 3. any artistic works (music, art, video and literature), discoveries or inventions of symbols, designs, monogragraph, words, axioms, and expression bangladesh journal of bioethics 2018; 9(1):24-28 25 are protected by iprs4. researchers or the inventors can get incentive in return of their investment of knowledge by iprs through patents, copyrights, trademarks etc. 5 copyrights is denoted as ©. copy rights sign is followed by year and the name of the owner. example: © 2011 john doe. creative commons attribution is denoted as cc by. e,g, cc by 2011 john doe 2. “iprs have been justified on basis of both consequentialist approach and rights-based grounds in order to appreciate their importance intellectual works in return of monetary benefit for sustainable economic growth and development of the global economy” 3. classification of iprs: iprs can be classified in to patent, copy rights, license, trade mark, trade dress and trade secret. non-material objective e.g. ideas, inventions and procedures are protected by patent law whereas material objects e.g. publications, literature, music, arts, film are protected by copyrights. the words, names or symbols are protected by trademark law and business information e.g. customer lists is protected by trade secret law 6. patent: “a patent is a form of rights to an inventor granted by the government to gain material benefits from an invention for a limited period of time” 3. it provide protection to owner of invention not to exploit by other to copied, sale, use, offer for sale, or import without authorization of the owner of the patent for 20 years of time 7. although patent rights was evident in sybaris, an ancient city of greece but the first came in statutory as venetian patent statute in vanice in 1450 to protect industrial innovation 4. first, an inventor need to apply provisional or short term patent giving the outline of the tentative invention at the concept stage to restrict other to use the innovation. then they need to apply again to complete application within one year period from the date of the provisional application after completion of the work to claim the rights to the innovation. work is scrutinized and approved upon final application8. patent are three type e.g. utility patents, design patents and plant patents 9. utility patent or rights: it is granted the rights of material benefits to the inventor for novel procedure or functionality of a product. utility patent protects working of a machine even in improvement than previously designed product9. design patent or rights: it is the rights to inventors of material benefits who discover a new industrial design or product (e.g. shape, configuration or color, or twoor three-dimensional pattern, composition of pattern) 9. plant patent: it is the rights of material benefits of an inventors to discover some new variety of plant 9. copyright: copyright law protects the intellectual creation of original author of mass communication e.g. publication, literature, music, bangladesh journal of bioethics 2018; 9(1):24-28 26 arts, film to prevent from other to reproduce/ distribute/ sale/ rental/ leasing/ lending in the form of copies, phonorecords to the public without authorization of original author 7. in case of journals, materials are copyrighted and have exclusive right to publisher to publish, modify, reproduce, distribute, or sell of those products. traditionally publisher have the exclusive right on the material works. now a day, an authors are allowed ownership of their work. however, both cases authors need to transfer copyright to the publisher to publish and re-use the work 2. in “open access” journals, author approves distribution of his/her works without prior permission at a free of cost provided cited properly the name of original author(s). unauthorized use of copyrighted work is infringement the copyright law. doctrine of fair use: it is the exceptions to copyright infringement in case of nonprofit educational and research purposes2. as for example, a students may make a photocopy an article or book chapter for their own personal use without asking permission from original author or the results of an author may be described or some sentences from an article are inscribed in students writing with citation will be considered as “fair use” 10. wide-range of text sentences with quotation from a copyrighted source can constitute copyright infringement. according to american psychological association (apa), authors need prior permission to borrow more than 500 words of text from any apa journals article. so plagiarism is qualify as copyright infringement 10. work for hire: when a work has been done within the opportunity of employment or commissioned for a specific project, the constructed work is belonged to the employer not for the writer 9. therefore, in “works for hire”, employee is the author 2, e.g. “comedy writer of the david letterman show writes many jokes for the monologue. the jokes are the property of the employer, not for the comedy writer because they were written within the scope of the writer's employment. the writer does not own the copyright to those jokes” 9. in entertainment industries and ghostwriting arrangements in pharmaceutical companies the “work for hire” are very common. in a freelance situation work for hire" are also seen when the authors are commissioned for a specific work, e.g. presidential speech, news of a newspaper etc6. time: date of the copyrights automatically start when the intellectual work is first fixed in a copy or phonorecord and ends till author’s death plus an additional 70 years after the author’s death. copies are material objects e.g. books, articles, music, photograph, film, videotape, or microfilm. “phonorecords” are cassette tapes, cds, or vinyl disks 6. duration of copyrights for "works for hire" last for 75 years from the date of first publication or 100 years from the date of creation6. license: copyright says who "owns" the rights in a publication but the license says what users can do with the publication. license are two types e.g. a restricted or open license, open access (oa) license says that the article can be reused for any bangladesh journal of bioethics 2018; 9(1):24-28 27 purpose without asking permission. publisher can choose what license they want to publish. trademarks: trademark is a sign, which indicates the products of a specific trader and distinguishes from parallel products of other traders7.trademarks was existed date back 3,000 years ago, when indian craftsmen exported their artistic product to iran engraving with their signatures. it had only had the identity of the originator of the product but did not have economic importance in that time 7. however, with the growing of trade, the paris convention denotes a trademark by registration to distinguish the goods from their competitor’s goods. over one hundred and fifty states are the signatory of the paris convention 7. trade dress: trade dress are the physical appearance, ‘packaging, trade policy, marketing techniques, advertisement themes” of a products to distinguish from other similar product that prevent the consumers from buying similar products4. for example, chocolate packet, magazine cover, chain of mexican/ chinese style restaurants. similar appearance may cause the confusion to public and it is subject to infringement of trade dress4. trade secrets: for economic growth of the business over competitors and customers sometimes formula or practice or information is kept secret from public is considered as trade secret. trade secret is not protected by law, business shall have own methods to guard its own trade secrets e.g., formula of coca-cola, kfc recipe etc 4. difference between copyrights and patent: 7 patent copyrights paten protects new and useful inventions copyright protects authorship of literary, musical and dramatic work. patent are science-based protections copyrights are arts based new, useful and non-obvious. authorship must be original and real medium. rights is not confer unless apply copyright begins when work is created patent provides protection for 10-20 years from the date of application. copyright is issued to the author until his/her life plus 50-70 years. patent is much difficult as the checking process of invention is lengthy and costly. a copyright is easy and less complicated. conclusion: intellectual property rights (iprs) are protected by different systems of law. journal should choose one form of licensing system that are the greatest benefit for their purpose and ethos. journals should have policy of iprs to protect from plagiarism. this ethics education on iprs will help to understand ones rights, codes of conduct in profession writing and the doctrine of fair use in publication. one cannot do anything with once writing. research, academic, editors bangladesh journal of bioethics 2018; 9(1):24-28 28 and readers must have the basic knowledge who owns the rights in a publication and what users can do with the publication by law to prevent embarrassment and harassment. reference: 1. graf c, wager e, bowman a, fiack s, scott-lichter d, robinson a.. best practice guidelines on publication ethics: a publisher’s perspective. int j clin pract 2007, 61 (suppl. 152): 1–26. 2. u.s. copyright office · (2012). copyright basics. library of congress washington, dc · www.copyright.gov (access on oct.2017) 3. unctad/icts. 2002. intellectual property rights and development – policy discussion paper unctad/ictsd capacity building project on intellectual property rights and sustainable development. 4. wikipedia 2017 https://en.wikipedia.org/wiki/intellectual_property (access on nov..2017) 5. european commission. 2017. intellectual property rights enforcement. http://www.pressreleasepoint.com/intellectualproperty-rights-enforcement . 6. white ce.1997 basic copyright concepts for writers http://www.writerswrite.com/journal/sep97/basiccopyright-concepts-for-writers-9973 (access on oct.2017) 7. wipo . 2008. wipo intellectual property handbook: policy, law and use. chapter 2 fields of intellectual property protection. http://www.wipo.int/export/sites/www/aboutip/en/iprm/pdf/ch2.pdf (access on oct.2017) 8. dutta r. 2017. patent rights in india. https://www.hg.org/article.asp?id=4995 (access on oct.2017) 9. diferencebetween.com. 2010. difference between copyright and patent. http://www.differencebetween.com/differencebetween-copyright-and-patent/ (access on nov. 2017) 10. roig m 2003 avoiding plagiarism, self-plagiarism, and other questionable writing practices: a guide to ethical writing, ori, pp 1-63 http://ori.hhs.gov/education/products/roig_st_johns/on %20ethical%20writing.html (access on oct.2017). author contribution: the 1st author develop the idea and meticulously review the article and the 2nd author execute the idea, drafting the article, precisely review the article. conflict of interest: authors declare no conflict of interest between them. research is done by self-finance. bangladesh journal of bioethics 2014; 5(1):11-19 11 a review of ethics in developing country in perspective of dental research dr. md. haider ali khan 1 shamima parvin lasker 2 1. assistant professor, department of dental public health, dhaka dental college, dhaka, bangladesh email: haiderkhan3@hotmail.com 2. professor and head of anatomy, city dental college, dhaka, bangladesh email: splasker04@yahoo.com abstract: the objectives of this review were to examine the ethical issues in research in developing country and perspective of dental research. in this review, we performed the systematic literature search, screening process through the web in existing published and unpublished articles and reports that related to our topics between1990 to 2013. in the past few decades, the research and discoveries in the discipline of dentistry have increased dramatically. recently many dental institutes in developing country is constantly looking for opportunities to borrow, enhance, and integrate knowledge from biomedical and technological research by using modern technology. the retrieved information in this review reflect that to make any research involving human subjects ethically acceptable, a number of key features have to be considered by the researchers. those who conduct oral health research are compelled by regulations and convention to follow established ethical standards to protect human rights. bioethics and in ethical review of research in developing countries reveals many major gaps and have seen that there are indeed many ethical issues to be considered to clinical trials taking place in developing countries. professional societies have a major influence in shaping the moral tone and ethical climate for research through the adoption of standards, the development of educational programs designed to reinforce those standards. research ethics committees or institutional ethical review committees is to ensure that studies involving human research participants are designed to conform the relevant ethical standards and that the rights and welfare of participants are protected. research ethics committees should not function under the influence of others and should ensures the favorable balance of potential benefits and risks. in developing country it is necessary to strengthen local capacity and manpower by developing innovative training models for ethics that are cost-effective and sustainable. the actions required to move ahead in this field include strengthening bioethics capacity, linking health research to community needs in a transparent and participatory process and increasing communication between scientists and ethicists in industrialized and developing countries. key words: ethical issues, dental research, biomedical research, developing countries. introduction: debates on the ethical requirements for conducting medical and dental research in developing countries have reached in a considerable prominence in recent years. in developing countries, where cultural, linguistic, economic and other barriers may prevail between researchers and subjects 1 . health research plays a pivotal role in addressing inequities in health and human development, but to achieve these objectives the research must be based on sound scientific and ethical principles. although it is accepted that ethics play a central role in health research in developing countries, much of the recent debate has focused on controversies surrounding internationally sponsored research and has taken place largely without adequate participation of the developing countries. the relationship between ethical guidelines and regulations, and indigenously sponsored and public health research has not been adequately explored. in order to support health research in developing countries that is both mailto:haiderkhan3@hotmail.com mailto:splasker04@yahoo.com bangladesh journal of bioethics 2014; 5(1):11-19 12 relevant and meaningful, the focus must be on developing health research that promotes equity and on developing local capacity in bioethics. only through such proactive measures can we address the emerging ethical dilemmas and challenges that globalization and the genomics revolution will bring in their wake 2 . good oral health is fundamental to good general health. oral health research is therefore essential for improving health and wellbeing, and the dental research has been developed to accommodate all strands of clinical dental research, including quantitative and qualitative research, clinical trials and translational research. in the past few decades, the research and discoveries in the discipline of dentistry have been led to dramatic changes and paradigm shifts in terms of professional practice. new and enhanced research areas in dentistry include genomics, bone biology, forensics, implantology, community health, and applied clinical materials. for a number of years, bioengineers have been miniaturizing labs on a chip and discovering many modern dental equipments. individuals or communities in developing countries assume the risks of research, but most of the benefits may accrue to people in developed countries 3 . although poverty, limited health-care services, illiteracy, cultural differences, and limited understanding of the nature of scientific research neither cause nor are necessary for exploitation, they increase the possibility of such exploitation 4 . thus, a growing commercialization of research and its effects on the ethical conduct of researchers and the advancement of scientific knowledge are of concern today and need serious thought. the misconduct in research and publication affects authors, reviewers and editors. recently, there has been considerable debate raised about the ethical conduct and reviewing of health research, but this debate has largely taken place among ethicists and researchers in industrialized countries. the views of public health practitioners and researchers from developing countries have been underrepresented. 5 research investigators have an ethical obligation to conduct their research honestly through the judicious use of grant and contract funds for the purposes intended; accuracy in fully disclosing all research strategies, methods, results and analyses; and generous and accurate citation of other investigators’ preceding or competing work 6 . in developing country maximum researches are participatory that allows to the community and researcher to collaborate on research process and the development of knowledge that is beneficial to the community. this is due in part to the three main principles of participatory research that include collaboration, mutual education, and acting on results from research questions. the results of this type of research are adaptable and thus applicable to other communities 7 . advancement of dental research and implication of research ethics: a good deal of pioneering research has been carried out in gene therapy, stem cell research and regenerative medicine applied to oral health problems. indeed, a recent editorial in the focused on the contentious issue of the potential research applications of human embryonic stem cells in tissue engineering and regenerative medicine. in future scientists will discover the method for growing teeth from stem cells obtained in urine and stem cells sourced from dental pulp, ligament, and gum have previously been examined for tooth regeneration approaches. although having particular advantages that human dental stem cells and may raise ethical issues. bangladesh journal of bioethics 2014; 5(1):11-19 13 dentistry of tomorrow will embrace the ability to restore form and function to parts of the oral cavity and craniofacial complex that have been damaged by either pathology or trauma using the regeneration techniques and reversal of the disease process being studied right now. dentistry will have a whole new arsenal of opportunities and abilities to tackle devastating diseases and conditions that require restoration, as well as diagnostic and preventive measures. between stem cells and tissue engineering, as well as gene therapy, dentists will be able to achieve what was previously impossible. in the future, emerging materials and techniques will allow the researcher to detect early signs of a carious lesion in a tooth and then, instead of actually drilling and filling, researcher will think about how to regrow enamel and dentin on that broken, researcher will able to use therapeutic medications to reverse the disease and stop it. the saliva research could lead to the salivary gland being used as a general bioreactor to replace proteins that are missing from an individual. for example, in the case of diabetes, gene therapy could be used to “trick” the salivary gland into producing insulin, if an individual lacked sufficient growth hormones, the salivary gland could be manipulated into producing what’s needed. in the last few decade many development by research dramatically changed the dentistry such as invention of general and local anesthesia, adhesive bonding, high-speed rotary instrumentation, digital radiography, computer aided design and computer aided manufacturing and implant dentistry have created a revolution in the practice of dentistry. with fluoridated water and fluoride toothpastes in the 1950s and 1960s, the era of preventive dentistry began, leading subsequently to topical fluoride solutions, gels, and varnishes. the focus on the prevention of dental disease—not just the treatment of it—also led to increased interest in oral health education in hopes that preventive measures would have a positive impact on children’s oral health. this is very significant and became important to the profession as well as for the public also. the introduction and later widespread use of toothpastes containing fluoride demonstrated that teeth could be retained caries-free for years. in the past few decades, the research and discoveries within the discipline of dentistry have led to dramatic changes and paradigm shifts in terms of professional practice. dentistry can credit such initiatives for its ahead role in health promotion, risk assessment, disease prevention, treatment planning, treatment therapeutics, restorative materials, and predictable clinical outcomes, among other achievements. recently many dental institutes is constantly looking for opportunities to borrow, enhance, and integrate knowledge from biomedical and technological research by using modern technology. to make any research involving human subjects or samples ethically acceptable, a number of key features have to be considered by the scientists. those who conduct oral health research are compelled by regulations and convention to follow established ethical standards to protect human rights, regardless of where their research is conducted. as for most areas of research that come under ethical scrutiny, therefore, this research was done to observe the current ethical status in developing country giving special attention to dental research. research questions: we addressed the following questions: 1) what are ethical issues arises in conducting research in developing country? 2) how we can minimize the conflict that raise during conducting dental research? 3) what are the things should be consider during conducting dental research in collaboration with others? we systematically reported the relevant scientific information for each question. bangladesh journal of bioethics 2014; 5(1):11-19 14 objectives: 1. to examine the various ethical issues in research in developing country. 2. to gather information that will helpful for overcoming the ethical dilemma in research in developing country 3. to identify success factors for conducting the ethical dental research 4. to develop an ethical framework for research in developing country. materials and methods: in this review was done during the educational activity of national institutes of health bethesda, maryland held by bangladesh bioethics society through video conferencing on september 25, 2013 through november 11, 2013. we performed the systematic literature search, screening process, rating of the evidence, assessment of the evidence and presentation of the contents of the evidence to the reader through the literature searched existing published and unpublished articles and reports that related to our topics of interest. in addition, web searches were conducted to get a general understanding of trends in these areas and to seek out further documents and potential key informants. along with google and yahoo search we also used database including medline, pubmed, hinari etc .a total of 40 articles were retrieved and 17 of them were selected for review. . all protocols between1990 to 2013 were cited by applying the key words; ethical issues, dental research, biomedical research, developing countries. papers only published in english were included in this review. multiple reports from the same study only contributed once to the review. inclusion and exclusion criteria of article: studies reported any ethical issues in relation with dental research in developing country were eligible for inclusion, additionally due to unavailability of related article, study with research ethics in developing country also were included. however, abstracts in conference programs with lack of essential information are excluded from this study. retrieved information and discussion: in recent years, controversies have arrived concerning the ethics of biomedical research sponsored by wealthy nations and conducted in resource poor countries. individuals or communities in developing countries assume the risks of research, but most of the benefits may accrue to people in developed countries in order to support health research in developing countries that is both relevant and meaningful, the focus must be on developing health research that promotes equity and on developing local capacity in bioethics a a hyder et al 8 conducted a study on ethical review of health research; a perspective from developing country. in their study forty four percent of the survey respondents reported that their studies did not undergo any review (technical, scientific, or ethical) by a ministry of health in the developing country where the research was conducted. twenty five percent of the respondents also reported that their studies did not undergo an ethics review by an irb, ethics board, or ministry of health in the country. further analyses showed that 15% of the studies being described in the survey were neither reviewed by the ministry of health nor by any ethics board in the developing country, of which one third were us funded. of those studies funded by us sources, 12% were not reviewed by the country’s own ministry or department of health or an ethics board, while 17% of the non-us funded studies did not get any such review. bangladesh journal of bioethics 2014; 5(1):11-19 15 the researchers were also asked to indicate which issues were raised by their irbs. developing country irbs were most concerned about cultural appropriateness of the studies (59%), need for local language consent form (58%), relevance of research question to country where research was conducted (54%), and the availability of intervention to host country after study was over (54%). researchers were also asked to report on their experiences with us irb reviews. us irbs were more likely to raise issues regarding, need for local language consent forms (84%), need for letters of approval from developing country representatives (79%), and complexity of the consent form (64%). they concluded that researchers in the developing world have valuable experience with international and local ethical reviews, which contribute to global thinking on these. the researchers have reported that the review process generally happens and the proportion for us funded studies is not significantly different from non-us funded studies; however, there are gaps in the review process, which can result in a number of research projects not being reviewed. therefore, the capacity to conduct ethical review in developing countries needs to be developed or enhanced. zulfiqar ahmed bhutta 9 in his study on ethics in international health research; a perspective from the developing world concluded that in developing country strength in ethical review is insufficient and should be developed by strengthening models for reviewing the ethics of research, ethics in international health research undertaking research must include the capacity to undertake ethical review of the planned research and its conduct. local capacity could also be strengthened by developing partnerships, although international and regional networks or partnerships in bioethics are no substitute for local action. a review of the existing capacity in bioethics and in ethical review of research in developing countries reveals major gaps. bioethics training must be strengthened in undergraduate medical education, and in postgraduate and public health training programmes. this will require a major investment in manpower and a new approach to the teaching of bioethics. the immediate need, however, is to strengthen local capacity and manpower by developing innovative training models for ethics that are cost-effective and sustainable. the opportunities afforded by the internet for learning and education in ethics should also be utilized. michael et al 10 have seen that there are indeed many ethical issues to be considered with reference to clinical trials taking place in developing countries. the difficulty of applying western ideals on poor societies with different cultural and educational status is evident. and, sometimes, motivations of profit can make the sponsors behave in a rather unethical, or even unlawful and violent way. however, it needs to be kept in mind that these negative practices do not take place very often, and that clinical trials are usually conducted on the basis of the widely accepted international principles of ethical research. developing countries have much to gain from western sponsors, and international bodies recommend the development of more research programs for these areas. priority should be given to training local health care professionals in ethical principles, and to organizing effective research ethics committees in order to supervise the procedures. progress may be slow, but, in the long run, clinical trials have the potential to contribute significantly to the improving of health status in developing parts of the world. in an article benjamin caballero 11 recommended to give efforts to strengthen the application of ethical principles in research should focus on the underlying conditions that make it difficult to achieve a sustainable ethical climate in less-developed countries. some of the tasks that should be considered as priorities include training in research ethics as part of the science curriculum at the undergraduate and graduate levels, support for capacity building in research ethics, and community involvement. bangladesh journal of bioethics 2014; 5(1):11-19 16 g.r. gillett 12 stated in his article, in all contemporary medical research, there is an inherent conflict between the ethical requirement that we share information which will help those who are suffering and the need to preserve rights to competitively sensitive information related to product development and academic funding. these various pressures on research emphasize the need for an active and lively appreciation of ethical issues in contemporary biomedical sciences. the relevant information required for informed consent varies from situation to situation but should take into account the need for participants to make a reasoned decision about their involvement. where community research is involved, there should be consultation with appropriate representatives benatar et al 13 described that when those in privileged positions and in wealthier countries consider undertaking collaborative research with colleagues in developing countries it is necessary to understand both their own framework of thinking, and the implications of very different mind-sets and environments in which research projects may be carried out in developing countries. the mind set of researchers from industrialized countries, and in which the debates on research ethics are taking place, is characterized by a biomedical approach to disease, and by a neoliberal approach to economics and trade. these powerful forces shape the world and a dominant worldview. there is a need to be sensitive to the fact that not all, and especially not those who are disadvantaged or who have been exploited, will see the world through the same lenses. md. fakruddin et al 14 in their study described the perspective in research ethics in bangladesh. in any clinical research it is essential to maintain an ethical guideline but unfortunately no such guideline is still formulated in bangladesh. every research organization should have an ethical review committee comprised of qualified ethical reviewer, but unfortunately except icddr,b, no organization have ethical review committee. bangladesh medical research council is mandated by govt. to monitor and maintain the quality and ethical status of clinical research, its activity is not satisfactory till now. again, most of the clinical researcher and other researchers are not aware of the importance of ethical clearance of their research. as a result, they face difficulty in publishing scientific article is reputed and international journals. again, due to lack of ethical guidelines, participants or volunteers do not get back the feedback of the research. it is high time that the country formulate a national guideline on ethics for biomedical and clinical research involving human participants or involving samples from human such as blood. involved scientists and workers as well as common peoples should be aware of the applicability of the guideline a study conducted in brazil by dalton et al 15 and have shown that many advances in ethical issues have been made in the developing country. the dental community has adhered to and complied with the parameters of the ethical regulations. an effort has been made by dental researchers to obtain free and informed consent by research subjects, and greater care has been taken. dental research in brazil has been conducted in teaching and research institutions, often in the form of activities connected with graduate programs supported by funds from these institutions or from funding agencies, all from the public sector. the interests of sponsors should also be harmonized with those of society in connection with the use of public equipment, particularly when the research entails using research facilities or personnel trained and/or funded by public institutions. this same consideration should be borne in mind when the research involves both public health care institutions and those assisted by them, causing the study to ultimately make use of already limited public healthcare resources. additionally, one must consider the issues relating to the transfer of technology. in this sense, two major fronts should be considered. one refers to a set of bangladesh journal of bioethics 2014; 5(1):11-19 17 actions aiming at strengthening the ethical appreciation system; another important front is to guarantee the transparency of the whole research development process. frankel, m. s 16 in his article ethics in research; current issues for dental researchers and their professional society showed that the values associated with scientific investigations affect the conduct, evaluation, and reporting of research and lead to ethical issues for scientists engaged in dental research. this essay examines the relationship between scientists and the larger society in which they work, and how that relationship defines the boundaries of scientific freedom and autonomy, on the one hand, and scientific responsibility and accountability, on the other. values underlie disputes over data sharing, perceptions of conflict of interest, and scientists' commitment to research integrity. mj et al 17 conducted a survey of ethical issues in dental research. they showed that the overall, respondents rated practices that undermine the trustworthiness of science (falsifying or fabrication of research data, retaliation, failure to present negative results, failure to disclose involvement with commercial enterprises, failure to maintain research records, etc.) as more serious, but less prevalent, than practices considered disrespectful of the work of others (gift authorship, citing sources without reading them, dividing a project into many small units, etc.). all respondents said that they had observed each of the less serious problematic practices one or more times, whereas 10% reported having observed retaliation, 30% reported having observed falsification, and 54% reported having observed plagiarism one or more times. they concluded that status and years of experience are associated with more frequent observations of misconduct. conclusion: the actions required to move ahead in this field include strengthening bioethics capacity in developing countries; linking health research to community needs in a transparent and participatory process; and increasing communication between scientists and ethicists in industrialized and developing countries. the clear goal in all these activities must be the reduction of global inequities in health. this may take time, but it is the only way to bring about true change in the ethics of international health research, instead of having a superficial debate on the language of regulations. all guidelines are provided by the experts are internationally accepted and without following these guidelines, no clinical research is acceptable in the world. though, there are many countries in the world which don’t have any ethical guidelines of their own and thus scientists in those countries do not adhere the any ethical guideline while conducting their research. each country should have their own ethical guidelines and each clinical research institutes should have own ethical review committee to ensure ethical clinical research. recommendation: research ethics committees or institutional ethical review committees (ercs) is to ensure that studies involving human research participants are designed to conform the relevant ethical standards and that the rights and welfare of participants are protected. ethics committees must be an independent research organization and should not function under the influence of others. methodical review should ensures that studies have a favorable balance of potential benefits and risks, and that the participants are selected equitably, and that procedures for obtaining informed consent are adequate bangladesh journal of bioethics 2014; 5(1):11-19 18 the research plan must receive prior review by an independent ethics review committee. the research must involve a reasonable risk-benefit ratio and efforts must be made to minimize the risk to research participants. adequate plans for the care and compensation of participants for injuries directly related to the research must be presented. all participants must receive equal consideration and care. individual informed consent must be obtained from all participants. bangladesh medical research council (bmrc), the focal point for health research in the country has to play pioneer role to review the ethical aspects of a research project by ‘national research ethics committee’. the national institute of preventive and social medicine (nipsom), all the government medical colleges and different specialized government & private health institutes have to patronize their own ethical review committees (ercs). references: 1. marshall p.a. the relevance of culture for informed consent in us funded international health research. consultation report for the president’s national bioethics advisory commission. 2001; vol 11. 2. zulfiqar ahmed bhutta, ethics in international health research: a perspective from the developing world, department of paediatrics, the aga khan university, karachi, pakistan. bulletin of the world health organisation (impact factor: 5.25). 02/2002; 80(2):114-20. source: pubmed 3. benatar sr. avoiding exploitation in clinical research. camb q healthc ethics 2000; 9:562–5. 4. glantz lh, annas gj, grodin ma, mariner wk. research in developing countries: taking “benefit” seriously. hastings cent rep 1998; 28:38–42. 5. zulfiqar ahmed bhutta,ethics in international health research: a perspective from the developing world, bulletin of the world health organization 2002;80:114-120 6. richard p. ellen, dds; richard singleton, human rights and ethical considerations in oral health research, jcda • www.cda-adc.ca/jcda • june 2008, vol. 74, no. 5 7. macauley, a. c., commanda, l. e., freeman, w. l., gibson, n., mccabe m. l., robbins, c. m., et al. participatory research maximizes community and lay involvement. british medical journal 1999; 319, 774778 8. a a hyder, s a wali, a n khan, et al. ethical review of health research: a perspective from developing country researchers, j med ethics 2004 30: 68-72 9. zulfiqar ahmed bhutta. ethics in international health research: a perspective from the developing world. bulletin of the world health organization (impact factor: 5.25). 02/2002; 80(2):114-20 10. michael igoumenidis1, sophia zyga healthcare research in developing countries: ethical issues health science journal. 2011;vol 5, issue 4. 11. benjamin caballero, ethical issues for collaborative research in developing countries, am j clin nutr october 2002, vol. 76 no. 4 717-720. 12. g. r. gillett , informed consent and moral integrity, journal of medical ethics.1989; 15 (3):117-123. 13. s r benatar lee & zwi, reflections and recommendations on research ethics in developing countries, social science & medicine 54 (2002) 1131–1141 bangladesh journal of bioethics 2014; 5(1):11-19 19 14. md. fakruddin, abhijit chowdhury, md. nur hossain, khanjada shahnewaj bin mannan, ethics in clinical research, bangladesh journal of bioethics 2012; 3(3):16-20 15. dalton luiz de paula ramos development of dental clinical research in brazil a few (new) ethical challenges, braz. oral res. vol.25 no.5 são paulo sept./oct. 2011 16. frankel, m. s. ethics in research: current issues for dental researchers and their professional society journal of dental research . nov1994, vol. 73 issue 11, p1759-1765. 7p. 17. bebeau mj, davis el, survey of ethical issues in dental research. j dent res. 1996 feb; 75(2):845-55. frankel, m. s16 in his article ethics in research; current issues for dental researchers and their professional society showed that the values associated with scientific investigations affect the conduct, evaluation, and reporting of research and lead to ethical issues for scientists engaged in dental research. this essay examines the relationship between scientists and the larger society in which they work, and how that relationship defines the boundaries of scientific freedom and autonomy, on the one hand, and scientific responsibility and accountability, on the other. values underlie disputes over data sharing, perceptions of conflict of interest, and scientists' commitment to research integrity. bangladesh journal of bioethics 2014; 5(3):6-17 6 setting up an ethical oncofertility practice in developing countries alma linkeviciute 1 , giovanni boniolo 2 , fedro a. peccatori 3 1, 2, dipartimento di scienze della salute, university of milano, italy & department of experimental oncology, european institute of oncology (ieo), milan, italy. email:1. alma.linkeviciute@ieo.eu 2. giovanni.boniolo@ieo.eu 3. fertility and procreation unit, gynaecologic oncology department, european institute of oncology, milano, italy. email:fedro.peccatori@ieo.it abstract: fertility preservation for cancer patients is a relatively new field in medicine which requires interdisciplinary approach. improving therapies and rising survival rates require to consider patient’s quality of life after cancer is cured which is relevant personal issue regardless of the individual income and the level of development of the country of origin. fertility preservation offers possible solution but also raises ethical questions. we provide a summary of ethical principles embodied in professional guidelines together with options and restrictions to access fertility preservation in developing countries. we also make a suggestion that oncofertility counselling could be a pillar to address fertility preservation issues in cancer patients. our proposed decisional support model is patient centred and focuses on patient values, personal philosophy and view of life emphasizing sensitivity to individual patient’s needs and wishes. some fertility preservation concerns in oncology might be addressed mirroring already available expertise while some others will call for innovative and region specific solutions. therefore, in addition to our proposal we also provide a list of organisations working in oncofertility field. key words: fertility preservation, cancer, decisional support, ethical counselling, personal philosophy introduction: oncofertility stands for “an interdisciplinary field that bridges biomedical and social sciences and examines issues regarding an individual’s fertility concerns, options, and choices in light of cancer diagnosis, treatment, and survivorship” 1 . however, scientific literature does not always use this term and ‘oncofertility’ is referred to as ‘fertility preservation for cancer (oncology) patients’. patrizio and caplan simply call it: “fertility preservation is a newly developed branch of reproductive medicine aimed at preserving the potential for genetic parenthood in adults of reproductive age or children, who are at risk of sterility, before undergoing anticancer treatment” 2 . being a sensitive and complex issue, fertility preservation in cancer cannot be self standing but an interdisciplinary approach is necessary. cancer patients do not usually suffer infertility as a direct cause of cancer. more often it is cancer treatment such as radiotherapy, chemotherapy or surgery, which results in reduced fertility or even sterility in cancer survivors. infertility in cancer survivors and general population is commonly agreed to be the inability to conceive after one year of intercourse without contraception 3 . ability to conceive and have children is an important aspect concerning life and its quality for people worldwide. western countries have been working towards fertility preservation methods and establishing principles for mailto:alma.linkeviciute@ieo.eu mailto:giovanni.boniolo@ieo.eu mailto:fedro.peccatori@ieo.it bangladesh journal of bioethics 2014; 5(3):6-17 7 ethical practices for a few years, while the situation in developing countries is less clear. some of already existing expertise could be applied globally acknowledging that there might be new region and culture specific concerns which will require innovation and creative approach in order to reach a solution. this article aims to show that fertility preservation for cancer patients is globally relevant, because cancer incidence is increasing even in developing countries. the quality of life after cancer treatment is a relevant personal issue regardless the individual income and the level of development of the country of origin. existing fertility preservation options allow cancer patients to have a possibility to enjoy parenthood in the future. however, it also raises a number of ethical concerns. professional guidelines from around the globe reflect on a number of ethical principles which we present in a light of opportunities and restrictions patients in the developing countries might face. considering global obstacles to access fertility preservation services, we suggest that a thorough oncofertility counselling for all cancer patients could be the first pillar to address fertility issues in cancer patients. we also provide a decisional support model which focuses on patient values and provide a short overview of resources available online to establish an effective oncofertility counselling service in oncology hospitals. cancer survival worldwide: cancer survival rates are increasing and life after cancer is a real possibility for many patients worldwide. this is why it is also important to speak about life after cancer and take steps to ensure a good quality of life for cancer survivors even before cancer treatment begins. in europe about one third of adult cancers have a relative 5-year survival rate greater that 80% 4 , combined 5-year survival rates for all childhood cancers is ranging from 70% to 82% 5 . similar 5-year survival rates for adult and childhood cancers are available from the united states, canada and australia 6,7,8,9 . china, south korea, singapore and turkey have slightly lower relative 5-year cancer survival rates ranging between 44-82% 10 and brazil below 60% 7 . there is no much data from african countries where survival does not exceed13-22%. in the gambia and uganda with exception of breast cancer survival reaching 43% 10 , reports on childhood cancer survival rates vary widely 11 . however, it is estimated that the number of cancer cases in african countries will increase significantly by 203012. lower survival rates in developing countries are most likely due to late diagnosis and limited availability of standard treatments 13 , the same problem is reported in eastern european countries 4,7 . cancer is predominantly associated with older age, even though it also affects children, adolescents and young adults. survival rates are known to be the highest for patients aged between 15 and 44 years old 4 . childhood cancers represent 1% of all recorded malignancies 14 . moreover, epidemiological data from the usa and europe also suggests that there has been an increase in childhood cancer incidence by 1% each year15,16 and the most frequent single diagnoses in children are acute lymphoblastic leukaemia, astrocytoma, neuroblastoma, non-hodgkin lymphoma, and nephroblastoma 17 . fertility preservation solutions and practices in western countries: well established fertility preservation methods for women are embryo and oocytes cryopreservation and sperm bangladesh journal of bioethics 2014; 5(3):6-17 8 cryopreservation for men. these methods are widely described in the literature 18,19,20 and recognised by professional guidelines such as american society of clinical oncology (asco) 21 , american society of reproductive medicine (asrm) 22 and european society of medical oncology (esmo) 23 . other fertility preservation methods are less well established and still considered experimental. ovarian and testicular tissue cryopreservation is the sole fertility preservation method available for prepubertal children 21 . it is still highly experimental and there is no proven benefit that patients who had their fertility preserved using these methods will be able to benefit from them in the future. ovarian tissue cryopreservation has been used as fertility preservation methods in adult women and nearly 30 live births have been reported using this method 24 . however, there is still no certainty if it can successfully be used when ovarian tissue was obtained from prepubertal ovaries. following the guidelines, all cancer patients and /or their parents or guardians should be informed about cancer treatment effects on future fertility and physicians should discuss available options to preserve fertility. usually there are time constrains to consider all available options because in many cases cancer treatment has to be initiated as soon as possible to achieve good health outcomes. however, despite available guidelines and established methods, recent review of oncologists’ attitudes and practices revealed that not all physicians are prepared to discuss fertility related issues with their patients indicating that concerns about patient’s prognosis, lack of knowledge and sometimes personal biases prevent them from addressing fertility preservation needs adequately 25 . meanwhile, patients are interested to receive fertility preservation consultation and appreciate such information as part of shared decision making even if they choose not to preserve their fertility before cancer treatment commences26. a number of recent studies suggest that nearly half of cancer patients do not receive appropriate fertility preservation counselling 25,27 . moreover, in many instances female patients are informed and proceed with fertility preservation less often than men 28, 29 . however, despite of fertility importance for female patients it has been reported that globally only less than 10 % would accept lower chances to survival in order to preserve fertility30. ethical implications of currently followed practices: as it has been shown above, current fertility preservation practices for cancer patients are still far from perfection. oncofertility field is still new and being multi-disciplinary requires innovative solutions and close cooperation among different healthcare providers. it brings up some new ethical issues but a good number of ethical concerns relating to fertility preservation in oncology are not new, they just have to be addressed in a different light 31 . the following questions are still lacking comprehensive answers in the literature but they could help to initiate a self reflection on developing a personal stand on fertility preservation issue in general. medicine: how do we set treatment priorities? is it appropriate to delay cancer treatment to preserve the chance to have biological child if patient survives? could doctor’s suggestion to preserve fertility give false hopes about survival? emotional wellbeing: what feelings, expectations, and wishes are held by patients and physicians? how do frustration, anxiety and fear affect quality of care? bangladesh journal of bioethics 2014; 5(3):6-17 9 sociology: what roles does fertility preservation play for patients’ identity during and after cancer treatment? is there societal pressure to be a parent? is infertility stigmatised? law: how should storage of cryopreserved biomaterial be regulated? can cryopreserved gametes be used posthumously? who decides and under what circumstances? who decides for the best interest of the child? can law interfere with parental choices of children fertility preservation? research ethics: what is the actual status of fertility preservation technologies? is there a difference between experimental and innovative treatment? should they be developed further? how should they be introduced for patients? communication: why some physicians feel uncomfortable about discussing fertility preservation? decision making: when is child mature enough to make his/her own decision? when is patient too ill for fertility preservation? can fertility preservation be denied on the grounds of low prospects to survive? are there age limits for candidates to preserve fertility? should there be such limits? economics: should preserving fertility for cancer patients be paid by society? who should bear the costs: healthcare system, private insurance, individual, charity funds? commercialisation of reproductive technologies: could the interests of fertility clinics overweight patients’ best interest? are fertility clinics selling fertility preservation services and future hope which is sometimes false hope? human rights: does having cancer create a right for fertility preservation? does european convention on human rights (art.12) ‘right to found a family’ have exceptions in case of cancer? interests of potential future children: does cancer patient’s/survivor’s right to have a child comes at the expense of the rights of a child to be born? answers to the questions above could be different and could be influenced by one’s culture, religion, personal values and beliefs. medical professionals are still lacking knowledge and skills on how to approach personal biases in order to be able to address cancer patients’ needs. strengthening communication skills and developing counselling services are the possible solutions 3,25,27,32 . guiding principles in fertility preservation for cancer patients: a number of guidelines appeared in the last couple of years proposing that informing cancer patients about cancer treatment effects on fertility should be a standard 21,22,23,33 . in europe, the european society of human reproduction and embryology (eshre) has been publishing ethical considerations on human reproduction related issues since 2001. their task force on ethics and law does not seem to look at oncofertility related issues and takes a broader view when releasing considerations on posthumous reproduction, cryopreservation, pre-implantation genetic diagnosis. overall consensus of currently available guidelines is that clinicians should: bangladesh journal of bioethics 2014; 5(3):6-17 10 inform patients about fertility preservation options and future reproduction before treatment starts 21,22,23,33,34 ; parents may act to preserve fertility for minors 22 ; pre-implantation genetic diagnosis (pgd) to avoid offspring inheriting high risk of cancer is acceptable 22 ; concerns about welfare of resulting offspring are not sufficient reasons to deny assistance in reproduction 22 ; patients should be referred to mental health, genetic and financial counsellors if needed 21,22,34 ; fertility preservation discussion should allow time for reflection and involve partner, if present 33 . in bioethics literature fertility treatment is not always seen as a positive right where every individual is enabled to procreate 35 . however, right to reproduce is often defended as ability to bear autonomy, personal identity, self-determination and possession of dignity where infertility can be addressed as disability 36 . concerns can be raised that the hype of fertility preservation options give patients the false hope of survival and future fertility even if the goal of cancer treatment is to cure with the least amount of damage and side effects. moreover, when physician feels that risks of doing so outweighs the benefits, fertility preservation procedures could be denied or patient referred to another physician 37 . the currently established clinical pathway is based on informing the patients about cancer treatment effects on fertility, illustrating how fertility can be preserved and referring patients to fertility specialists and support services as soon as possible. support services include decision coaching 32 , psychosocial support 21 or ethical counselling 25 . options and restrictions for fertility preservation in developing countries: technologies and skills can travel easily around the globe but sometimes restrictions including cultural and religious acceptability, financial constraints and lack of local expertise or regulation are met. unfortunately, there is very little data on available services and how often cancer patients in developing countries use them. as resources in developing countries are usually scarce, it could be argued that fertility preservation is not a primary health concern, because it is not a medically necessary procedure. however, people without children, especially women, can often be seen as having lower social status and experience ostracism by other members of their society38. this implies that fertility preservation is an important and relevant issue globally and should not be ignored. nonetheless, the following obstacles are found in the developing world. cultural and religious obstacles: difficulties with particular aspects of fertility preservation and its acceptance can be detected in most religious traditions. oncofertility field is new and views on procreation in different religions may vary. embryo’s right to life, duty to procreate, attitudes towards bangladesh journal of bioethics 2014; 5(3):6-17 11 adoption, meaning of sexual intercourse and acceptable ways on how a new human life can be conceived may assume different values in different cultural context 39 . financial obstacles: fertility preservation procedures are expensive and financial constraints might be the major cause why some patients do not pursue them. while in western countries there are a variety of funding sources available, in developing countries these procedures might be available only for wealthy individuals. however, it is argued that expensive drugs could be replaced with cheaper ones. low cost ivf foundation is currently running clinics in tanzania, south africa and sudan and this is a good example on how ivf costs can be reduced below €200 euro per cycle 38 . geographic obstacles and lack of trained specialists: medical centres providing fertility preservation services have scarce geographical distribution in developed countries and there are even fewer of them in developing countries. long travelling distance, and the related expenses, could be one of main restrictions for patients in developing countries to use fertility preservation services. it might also be difficult to find fertility specialist and even be referred to one. very few studies from non western countries report that more than half oncologists do not have enough knowledge about fertility preservation to feel comfortable in discussing it with their patients 40,41,42 . lack of regulation or legal restrictions on fertility preservation methods: not all countries have legal base which allows fertility preservation methods to be used by everyone. for instance some countries in latin america only allow artificial reproduction technologies to be used by married couples or only homologous insemination to be used for ivf 38 . such practices deny reproductive autonomy for individuals who do not qualify for procreation assistance under restrictive laws. patient centred counselling: providing high quality decisional support services for patients require trained counsellors who master a number of skills. these include helping patient to understand his or her medical condition and reflecting on personal philosophy and view of life which usually shape patient’s goals, wishes and expectations 25 . involving patient’s partner is sometimes also encouraged 33 as well as some cultures might see acceptable to have other family members participating in fertility counselling, especially where patients are children. training of counsellors will take time and require resources but this should be in the agenda of every oncology hospital. counsellors should primarily inform patients both on medical conditions and their implications on future life, and also provide information about fertility preservation options. moreover, they should be able to identify patient’s wishes and expectations. counsellors should also be knowledgeable of local legislation, be prepared to handle patient’s emotions, have sensitivity to patients spiritual or religious needs, and be ready to evaluate which fertility preservation options can be affordable, when resources are limited. resources for ethical practice: these are offered by a number of organisations worldwide. the oncofertility consortium based at northwestern university in chicago (usa) pioneered fertility preservation in oncology and provides online tools for oncofertility communication. they developed oncofertility consortium web site (http://oncofertility.northwestern.edu) for communication among http://oncofertility.northwestern.edu/ bangladesh journal of bioethics 2014; 5(3):6-17 12 professional including biomedical humanities and the web site for general public myoncofertility (http://myoncofertility.org). the american society for bioethics and humanities (http://www.asbh.org) have numerous publications on core competences and skills required to qualify as health care ethics consultant and also code of ethics and professional responsibilities for ethics consultants. the european school of oncology (eso) and the european school of molecular medicine (semm) at european institute of oncology (ieo) in milan, italy are also developing conceptual tools and providing training for oncologists in ethical counselling (http://www.semm.it/master.php). conclusions: cancer survival rates are improving and treatment outcomes are promising that there could also be life after cancer. this brings up a new challenge for healthcare professionals who have to address patient’s quality of life issues after cancer is cured. assuring the best quality of life to cancer survivors some issues like fertility preservation have to addressed before starting the treatment. professional guidelines from the usa and europe suggest that all cancer patients should be informed about treatment effect on their future fertility and available fertility preservation options should also be discussed. however, there are still communication problems induced by lack of time and expertise followed by personal biases held by physicians when initiating discussion on fertility preservation with a patient. next to the information provided to all cancer patients about treatment effect on fertility and fertility preservation options other core principles allow parents to act in order to preserve fertility for their children, accept the use of pdg to avoid serious inherited conditions in the offspring, do not justify the denial of reproductive services based on the concerns about the welfare of the future child. moreover, patients should be referred to other relevant specialists and support services when needed and given time to reflect on fertility preservation discussion and possible choices before making decisions. there is very little data on fertility preservation services and how often cancer patients use them in developing countries. cultural and religious constraints, financial restrains, long distance to the facilities and lack of trained specialists as well as lack of regulation and legal restrictions on fertility preservation methods are often met in developed countries and can be relevant globally. our proposal is that despite of limited resources fertility preservation issues in cancer patients should be addressed regardless the individual income and the level of development of the country of origin. a set up of ethical oncofertility practice can be started though oncofertility counselling where providing quality decision support services for all cancer patients. such service would help patient to understand his or her medical condition and possible solutions while reflecting on personal philosophy and view of life which usually shape patient’s goals, wishes and expectations. counsellors will play an important role and in addition to medical knowledge and communication skills will need to be knowledgeable of local legislation, have sensitivity to patient’s religious and spiritual needs, be ready http://myoncofertility.org/ http://www.asbh.org/ http://www.semm.it/master.php bangladesh journal of bioethics 2014; 5(3):6-17 13 to handle patient’s emotions and also help patient to evaluate which fertility preservation options could be affordable when resources are limited. references: 1. snyder ka. oncofertility and the social sciences. in: woodruff tk, snyder ka, editors. oncofertility: fertility preservation for cancer survivors. boston, ma: springer us; 2007: p. 137– 48. available from: http://link.springer.com/10.1007/978-0-387-72293-1 2. patrizio p, caplan al. ethical issues surrounding fertility preservation in cancer patients. clin obstet gynecol. 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available from: http://www.ncbi.nlm.nih.gov/pubmed/21767834 36. backhus le, zoloth l. today’s research, tomorrows cures: the ethical implications of oncofertility. in: woodruff tk, snyder ka, editors. oncofertility: fertility preservation for cancer survivors. boston, ma: springer us; 2007. p. 163–79. available from: http://link.springer.com/10.1007/978-0-387-72293-1 bangladesh journal of bioethics 2014; 5(3):6-17 17 37. gracia cr, gracia jje, chen s. ethical dilemmas in oncofertility: an exploration of three clinical scenarios. in: woodruff tk, zoloth l, campo-engelstein l, rodriguez s, editors. oncofertility: ethical, legal, social, and medical perspectives. boston, ma: springer us; 2010. p. 195–208. available from: http://link.springer.com/10.1007/978-1-4419-6518-9 38. fleetwood a, campo-engelstein l. the impact of infertility: why art should be a higher priority for women in the global south. in: woodruff tk, zoloth l, campo-engelstein l, rodriguez s, editors. oncofertility: ethical, legal, social, and medical perspectives. boston, ma: springer us; 2010. p. 237–48. available from: http://link.springer.com/10.1007/978-1-4419-6518-9 39. zoloth l, henning aa. bioethics and oncofertility: arguments and insights from religious traditions. in: woodruff tk, zoloth l, campo-engelstein l, rodriguez s, editors. oncofertility: ethical, legal, social, and medical perspectives. boston, ma: springer us; 2010. p. 261–78. available from: http://link.springer.com/10.1007/978-1-4419-6518-9 40. rabah dm, wahdan ih, merdawy a, abourafe b, arafa ma. oncologists’ knowledge and practice towards sperm cryopreservation in arabic communities. j cancer surviv res pract. 2010;4(3):279–83. available from: http://www.ncbi.nlm.nih.gov/pubmed/20652434 41. küçük m, yavaşoğlu i, bolaman az, kadıköylü g. knowledge, attitudes, and practices of hematologists regarding fertility preservation in turkey. turkish j haematol off j turkish soc haematol. 2013;30(3):269–74. available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3878530&tool=pmcentrez&rendertype= abstract 42. ghorbani b, madahi p, shirazi e, ardekani hs, kamali k. iranian oncologists’ attitude towards fertility preservation in a sample group. j reprod infertil. 2011;12(1):33–6. available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3719279&tool=pmcentrez&rendertype= abstract conflict of interest: the authors have no conflict of interest. 15 bangladesh journal of bioethics 2015; 6(1):15-21 human rights: illusion or reality; theological (shiite) perspective ali jamkarani undergraduate student, department of human rights & theology, etrat university, iran email: ali.agigh@gmail.com, online1journal@gmail.com abstract: the discussion is based around these issues, history of human rights, timeline for human rights history, question asked in this regard and enemy and friend of ‘human rights’. describing the problems and its resolve from logical reasoning perspective; intellectual argumentation based on logical reason of, what is universal human right, democracy and illegal wars in the world by super powers as example america? attempt to describe the inner construction of a human being-perfection-. introduction to the concept of infallibility in different parts in the article, purify yourself and being purified. what is it, is it possible for a creation named human to be not fallible, is the idea or practicing it impossible or there is a great sphere of being able to practicing it and reaching the status if one finds guidance for the right way with peace and human rights prevailed in the world. majority of the thought in the text, based on hadith-traditionfrom the prophet of islam peace upon him and his family ahl al-bait peace upon them. key words: human right; corruptions; infallibility; spirituality; psychology, fitra-core of human being, democracy; intellect; ignorance; senses; illegal wars part 1 introduction: what are human rights universally? is, the theoretical and practical perspective in desired subject established in the world? jack donnelly has done research in this area, but research material remains intact and untouched in areas such as infallibility; one must reflect and not ignore this concept in planting democracy in world scene by establishing human rights universally through a democratic state with core of human as seed and perfection its fruit; human rights its root, infallibility its trunk and democracy its branches, its leaves righteous deeds. a main problem is ‘unity between humanity’ that only can be achieved through putting the concept of infallibility beside the concept of human rights, justice-adl, democracy, unity itself, perfection, education and peace to achieve complete perfection in highest decree for the theoretical perspective of ‘universal human rights’ conceptualization. one of the purposes of this article is to show the theoretical flow in wordings as democracy and human rights that is weaved into the concept of justice-adlone of the pillars of faith in islam. if the practical perspective does not work properly, the problem is the theoretical side that is imperfect and needs to be, worked on, in new ways to open the doors of practical revolution of human rights in human history. these sources 1 are glimpses in knowing the concept purely from those who acknowledged the concept! mailto:ali.agigh@gmail.com mailto:online1journal@gmail.com 16 history of human rights: human rights have roots old but have recently under this century got more attention and been emphasized in the world stage. if one studies human rights history, generally one discovers a pattern that is, that human rights advanced when humans where in difficulty to find a solution for a problem or because of wars done without firm ground for the cause of war; example world wars. human rights can concern an individual, family and society and implemented in universal scale. as part of our inner nature; disposition-fitrahumans are bound to be in contact-socializewith not only their species but all natural creation, everything that allah has created, above all of it human being and said; you be as a leader on my behalf on earth-khalifatal-lah. these said, human rights do not concern only human verses one; human individual or oneself, family or society without it concerns also human verses nature-all allah creation, and obvious human verses the only and only creator. normally if we are alone and go in a jungle, or we feel that we are in the midst of a society but still feeling; one is in jungle with animals, maybe it is difficult to practice and be a leader on earth and follow all the laws that comes with accepting the leadership. many of those laws one cannot practice or discover it from our natural instincts and disposition that allah has given us because we do not get the opportunity or success of simply being a human. we have also it in our nature; that is working as a group, together for an achievement. doing something together has more chance of success and acceptance than being an alone individual without inspiring the masses. human being from all times shared responsibilities, duties and rights to each other and from each other. one can find and read some facts about these old texts divine and non-divine, and understand the content of it; of how advanced these were in giving and announcing human rights; the hindu vedas, the babylonian code of hammurabi, the holy bible, the holy quran and the analects of confucius. from making and following a timeline about the history of human rights one can see that human rights tendencies grow and become more and more. different human rights issues arises in the history of mankind or new human rights issues get accepted and implemented in societies when discovered and not invented. here follows a simple timeline that one can get help and use it in a research ‘hunt’, to know human rights history. these are the names of documents in different societies and later global documents. a few personalities are in the timeline ‘because of developing human rights’ and were active in the field. for documents what can be interested is why; what for were these documents issued and by who? with other words under what circumstance was, it issued. what is the content of the document, how much of human rights exposed itself by the document? how is there evidence of how the documents implements in the society? where was the event taken place? when where it taken place; what time in history and a follow up question, in the time it was implemented what was the situation of other nations or societies at that time? timeline edicts of ashoka early poleis of ancient greece; the twelve tables law cyrus cylinder 6th-539 bccentury bc 17 risalatul huquq imam zainal abideen son of imam al-hossein peace upon them a seventh century islamic document on various legal and moral rights of human beings. the english translation was done from the original arabic from shayakh al-harrani’s book -4th century of hijra. magna carta 1215 ‘great charter’ -habeas corpus-. laws of burgos age of discovery 15th and 16th century petition of right 1628 bill of rights 1689 us revolution 1776; virginia declaration of rights 1776 us constitution 1787 french declaration of the rights of man and of the citizen 1789 us bill of rights 1791 john locke developed the concept of natural law 17th and 18th century native american sources: inca, aztec codes of conduct and justice and iroquois constitution 18th century philosophy of liberalism 18th century age of enlightenment philosophy: thomas paine, john stuart mill and g.w.f. hegel 18th and 19th centuries. world wars of 20th century universal declaration of human rights 1948 21th century moyn: “the human rights movement expanded beyond its original anti-totalitarianism to include numerous causes involving humanitarianism and social and economic development in the developing world.” enemy and friend of human rights: word human indicates of being in a certain way. when called human and not something else, example animal, plant, mountain, cloud, or letters and numbers, rights come that has to do with human standards and nature, that normally should be considered practical by a human being because it is compatible with the being of a human. one important aspect: that the only human right of being a human is oppressed because when we say human rights, nothing can oppress or take it, even allah has the power to do it but since it is an act against being just and against his wisdom, god does not commit the act of taking away rights of human beings 2 . the creations are void of intellect and speak in highest decree, like humans; this said nothing has power to take human rights of the humans except themselves. someone that understands human rights learns it good, memorized it and act upon it with recognition and insight from highest degree of certainty to those rights, maybe that being is a human. how can it be possible without ethical morality both inside out in an individual? when individuals practice the outer layer of any religion without understanding and craving for its depth to change them as example: those muslims that limit religion, to empty ritual acts practically without feeling the delicious taste of worship and tired later, without gaining ‘akhlaq’, that is observing ethically the boundaries of morality as humans after performing ritual acts prescribed by religion. many people may not have belief in the devil and its satanic whispers in the ear that triggers the weak souls, the one sworn enemy of mankind, but they may have belief in the soul “psyche” “nafs of human being” that said, its nature is disobedience if not trained and hold for that training accountable. the humanity in the same way their bodies are 18 different, their souls are different, some are trained and some not in different decrees. these two enemies have two other friends respectively ignorance and corrupt; evil, bad people among the humankind. if one has knowledge of human rights that means one is not ignorant in this regard, but still socialize with corrupt people, will not make the individual to practice it, opposite one learns to use the knowledge against other humans and fight against human rights instead promoting human rights. how can going with corrupt people help one fight and discipline the psyche and being away from whispers of satan, yes one is away from whispers of the devil in regard that one do not need his whispers when one are in the nest it wants people to be. being with corrupt people having diseased souls make even a healthy soul sick and opposite, being with right people, will flourish the soul, as said friends can take you to hell or paradise. reference of these words are the holy quran from religion islam, if we say our heart is locked, dumb, blind and deaf still there is some sense in the holy verse for us. its context is; that some people, in the day of judgment when asked why they are in hell, reply comes, because of our friends, we are in hell; we listened to them. this said a book is a friend, the classic friend! the book can become a movie that is also a friend, the movie has sound and picture, so pictures are also friend not necessary from that movie in the mind, the sound is friend not necessary from the movie in the mind. music industry that sings about alcohol, drugs, daily romance dreaming girls and boys, bad language, bad unofficial behavior, and obviously pictures in movies that show blood, killing, immoralities, weapons, drugs, abuse of humans, bad language, fantasy example ‘the concept of the worlds end’, apocalypse. these are the friends of societies in majority of virtual world on earth and implemented by real corrupt individuals in real world. these virtual friends are corrupt friends and at the same time corruption, right or wrong! can corrupt people spread physical, virtual and spiritual corruption, through misusing life, technology, sociality, and knowledge “intellect”! what is corrupt people enjoying or having in their psyche “nafs” that is so dangerous maybe even more than the devil. if we begin from greatest sins that can occupy the soul is; love of this world-material-[that gets born by one having greed and two not having love of the creator in the heart], self-conceit, arrogance, anger, showing off, hypocrisy, hastiness, and wastefulness and so on more concepts of words that go back to their king ignorance 3 . if one wants to learn knowledge on a specific field firstly act upon systematic phenomena that is in this case, being away from corrupt people so one gets pure from any symptoms of corrupt people and ready to get knowledge from only the right people. this means before getting knowledge on the field, firstly be with people of knowledge and good will, so being only away from corrupt people is not a help of being away from corruption, only way is to completely change friends and socialize with only people that respect human rights and follow it in their daily life. than by being with friends, that do always good one can fight individual ignorance and learn necessary knowledge one desires, with intention that increase the intellects power in the mind and by it human gets ready for practicing the good one learns. the knowledge in turn will help in developing the nafs of the human being and used to train for humanity a human; that in turn being human, one can fight the whispers of the devil and oppose it for the cause of human rights universally, differently said evil, wrong and bad thoughts that come in one mind. so purifying is definitely possible to oppose the whispers of the devil, but sometimes still one listens to him but not always in his grip as in past. what is necessary to completely not obey him but instead obey righteous humans and the creator, only with doing the right thing and practically spreading human rights by action? one purifying method is you purify yourself for the cause of 19 human rights that is in the essence-fitra of a human being, waiting to be discovered and touched by a mature intellectual being. however, at this stage of never listening to the devil, happens only by his grace, the creator of the core of human being and all it contains, that the allah purifies one-the soulfor one -allah. except those of your servants among them who are pure (holy quran verse 40 c. 15) this purity is both sided that said if one loves allah, allah loves back, you can’t say that you love allah until one does not love you back, when the loving back happens than it’s a love complete both sided and everlasting and known for the concept of love, the same with purity. how can this be possible if one do not with intellectual honesty have an intention, an intention with desire for the cause? as we have in the book ‘essence of life’ from allama majlisi may his soul rest in peace a sentence, mentioned as explanation to the words of ahl al-bait-a-, that intention without desire for that intention is useless and desire without intention again not of much use. word ‘mukhlis,’ genitive case in arabic indicates and means people that have the concept of honesty, sincerity engraved and practicing it to purify themselves, but same word with accusative case ‘mukhlas’ means those that are pure, mukhlas is used in the verse above. “this is because satanic temptations have no effect on sincere believers who have put their trust upon god in purifying themselves from the stains of evil” 4 . it’s here that one can understand the necessary importance of a healthy society, always around one, so one is exposed to righteousness than one exposed to corruption. corruption and righteousness can be in an individual, in society or universally. universal scale both righteousness and corruption are in fight and which one wins depends on the minor scale wars that are happening in societies around the world and obviously all humanity individually each one are in fight for or against righteousness. corruption as alcohol, cigarette, chunk food with taste but no nutrition and taking advantage of the creation, environment, nature for making money. using women as ads and products in the name of hiring for jobs of slavery for their body and educational purposes for making money, not to forget modern slavery, money renting, smuggling weapon, smuggling body parts, smuggling drugs, smuggling animals in land and sea for making money, secularity, extremism-radicalismand capitalism ‘obviously’ for money making purposes; affects different societies. doing illegal wars for making money as in afghanistan, iraq, libya, by united states of america! summary, the media is owned in europe and america of few, the banks are owned of few [not to mention the system of usury in banking in the world, which even is an infection in islamic republic of iran banking system, which has infected majority of the population to usury], the knowledge system based on atheist philosophy and of course there can be other corruptive motives involved and helpers maybe. if there is corruption, there is a corruptive person from humanity and non-humanity only example, the devil, the great evil-doer with ever having highest score, the corrupters are worse than the corruption itself that is happening in society. .فاِعُل الشَّرِّ َشرٌّ ِمنُھ): َعَلیِھ اّلَسالُم(اإلماُم عليٌّ imam ali peace upon him said, 'the doer of evil is worse than the evil itself’ 5 . if we take out corruption and not corrupters it may stop corruption from spreading universally; then again the corruption spreads in society of some individuals with those base inspirations and the effort is only that corruptions 20 do not spread universally. the root of corruption can be erased from the surface of the earth by not having corrupters in societies and the seed of corruption can be nullified if all individuals in a society or universally are trained from the best personalities-role modelsavailable, in having human qualities, human training and tame the soul. to spread the righteousness same steps must be taken but opposite direction, that is not stopping righteousness but making it more advanced (see below) charter: every day is ashura, every land is karbala; every day is ashura, every mind/soul is karbala enemies-corruptorsof human rights: friends-righteousof human rights: shaitan the accursed prophets & their vicegerents; specially prophet mohammad & his 12 vicegerents from his linage peace upon them all nafs-soul nafs-soul foolishness; ignorance intellect; knowledge corrupt people-friends righteous people-friends specific corrupt ethical morality specific righteous ethical morality ‘love of this world’ ‘love of allah’ general corrupt qualities ex. wastefulness general righteous qualities ex. frugality corrupt beliefs, laws, actions righteous beliefs, laws, actions agnostic world-view monotheistic world-view ashura, the 10th of muharram, and karbala the place of the event! the great sacrifice by the grandson of the last prophet of islam peace upon him and his family, against the grandson of abu sufyan curse upon him, the enemy and further disbeliever in message of peace. yazid the unjust ruler, curse upon him, wanted to bring forth the era of foolishness and ignorance of the arabian peninsula and eradicate islam from the surface of the earth, sea and sky. the climax of righteousness and corruption! foolishness and ignorance versus intellect and knowledge! despite the fact all knowledgeable and intellectual personalities got martyred, thought us a lesson and give life to passion and revolution against the foolish and ignorant tyrants. that there are lines that cannot be crossed by enemies of the creator mighty; wise! the challenge was not hamans, pharaohs for prophet mosa or nimrods for prophet ibrahim peace upon them and curse upon their enemies; it was greater than all the tyrants of history! yazid curse upon him was worse than pharaoh, nimrod and haman. each year muslims commemorate the occasion and millions travel to the tomb of imam hossain peace upon him. about, more than 20 million muslims travel to the tomb, which is a great lesson for justice and human rights. the same, every day for muslims is like ashura and the battle ground is their mind where the war of foolishness; ignorance against the intellect; knowledge is happening to have control of us, of our soul, of our psyche. this is called the greater jihad in islam; this is how we use word jihad. *** this article has two parts. part 2 nd of this article including conclusion and full bibliography will be published in bjb 2015; vol 6 issue 2. 21 end note: 1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team: infallibility of the prophets part 1 part 2 part 3, leadership and infallibility part 1 part 2, the twelve imams part 1 part 2, the holy qur’an and the pure imams 2 see bibliography for study material, for purpose of adl-justice of god-! 3 “description on the armies of intelligence and ignorance (jonud aqle va jahle) -by imam khomeini peace upon him.-: this is a valuable book by the imam on ethics. the religious (kalami) and ethical opinions and mysticism of the imam are more clearly opened in this book and, like his book "the description on forty narratives", more layers (of people) can benefit by it. currently, the research section of the institute (qum branch) is editing the explanatory footnotes and preparing the related lists and other research works, which it will publish, in two volumes of over 800 pages.” source: http://www.imam-khomeini.com/web1/english/showitem.aspx?cid=1662&h=13&f=14&pid=1794 4 exegesis-tafsir namonah-, aya. makarem, english version, verse 40 chapter 15 5 [nahj al-balagha, saying 32; scales of wisdom chapter corruption] conflict of interest: no conflict of interest. http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-3 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/leadership-and-infallibility-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/leadership-and-infallibility-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/twelve-imams-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/twelve-imams-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/holy-quran-and-pure-imams http://www.imam-khomeini.com/web1/english/showitem.aspx?cid=1662&h=13&f=14&pid=1794 microsoft word editorial bjb vol 8 issue 2 a bangladesh journal of bioethics vol 8; issue 2, 2017 editorial greetings readers and members! it has been a very hectic 2017 for all of us especially in the bangladesh bioethics society. bangladesh bioethics society (bbs) in collaboration with directorate general of health service (dghs), ministry of health bangladesh and american university of sovereign nation (ausn), usa, had organized a “graduation ceremony and intensive bioethics training programme” on 1516 july, 2017 at iedcr auditorium, dgsh, mohakhali, dhaka. prof dr syed modasser ali, chairman, bmrc & former health advisor of prime minister, people’s republic of bangladesh was the chief guest in this programme. special guests were prof dr. mohammad abul klam azad, director general (dg), dghs; dr ferdousi haque, director, planing & research, dghs; prof. dr. meerjady sabrina flora, director, institute of epidemiology, disease control and research (iedcr) respectively. prof. darryl macer, president, ausn, prof. taslima mansoor, president of bbs and prof. shamima lasker, secretary general of bbs put in great efforts to make all events successful and we are really proud of our team. two members of bbs have graduated from ausn, usa in july 2017 and honored by bbs through this programme. many members are enrolling in the masters or ph.d programmes and we foresee a large community of alumni in the near future. bangladesh graduates seem to be leading the graduate programme and we congratulate the member of bbs for their intense work and commitment to moving forward the agenda of bioethics. in this issue, several issues on bioethics has been covered and following is a brief summary of the articles: astronomic bioethics: terraforming x planetary protection by dario palhares and íris almeida dos santos in their paper provide a philosophical viewpoint on astrobiology and the precise definition of life. they argue that since all living beings have a cellular structure, so the basic definition of life is based on this hence the search for extraterrestrial life is restricted to extraterrestrial cells. there are two principles related to astronomic bioethics: planetary protection and terraforming. planetary protection is based on the fear of interplanetary crossinfection and possible ecological damages caused by alien living beings. terraforming is the intention of modifying the environmental conditions of the neighbouring planets in such a way that human colonisation would be possible. these principles lead to the formulation of the concept of ecopoiesis, a concept related to the creation of new ecosystems in other planets. so, by taking portions of the terrestrial permafrost, or ocean or soil, to other planets and if a single species could grow, a new ecosystem would start. the authors conclude that ecopoiesis should be the bioethical principle to guide practices and research in astrobiology. zika virus disease as public health emergency and ethics by rhyddhi chakraborty and edmond fernandes argue that zika virus infection has its ethical implications beyond the reproductive health of women. referring to the recent zika virus infection in brazil the authors recommend highlighting the lapses in the current zika ethics consultations and recommendations, and claim that public health emergencies need to focus on the ethical vision of health capability to act and promote sustainable healthcare during emergency times and normal period. they recommend that during public health emergencies, healthcare systems should focus on the health bangladesh journal of bioethics vol 8; issue 2, 2017 care of women, and the national healthcare systems should be adequately capable to maintain global health equity. in the paper on nutritional status, personal hygiene and health seeking behavior of the workers of british american tobacco company, dhaka, bangladesh by m j haque, a awal, m rahman and j sazzad report on a cross sectional study carried out among the workers of british american tobacco company, dhaka to explore their nutritional status, personal hygiene and health seeking behavior particularly because they are working in a tobacco processing company. the sample size was 179 which were selected purposively. the study showed that out of 179 respondents 89 (49.7%) were in the age groups of 30-39 years and the mean age of the respondents were 31.99 ± 6.01 years. majority (53.6%) respondents informed that they learned about personal hygiene from television, and majority (69.83%) of the respondents used only water as materials for hand washing. this study provided some important information which might help the concerned authority to take appropriate measures to improve the health status of the workers. the authors conclude integrated programs of health promotion in companies should be implemented. the people should be motivated about maintaining personal hygiene and sustain good health habit. occupational health, safety and healthy working environment should be maintained by the authority. in the article on cervical cancer and ethical issues in hpv vaccination, authors fariha haseen and sadia akther sony have focused on the ethical aspects of mass cervical cancer immunization programme. the authors present information on the prevalence of cervical cancer globally which according to world health organization (who) is sexually transmitted by the human papilloma virus hpv, one of the major causes of cervical cancer. cervical cancer is one of the top five cancers that affect women around the world. every year more than 250,000 people die from human papilloma virus (hpv) infection. in june 2006, the food and drug administration (fda) approved a new vaccine for women, gardasil, produced by the pharmaceutical company merck that protects against infection by certain strains of hpv. universal vaccination of girls and young women may bring up ethical challenges which might make it difficult for smooth implementation of the vaccination campaigns. most parents expressed the desire for more information about the vaccine before they agree to vaccinate their children. the authors conclude that it is the basic right of the parents to have access to all information regarding the hpv vaccine and if the parents consider the vaccine inappropriate for their daughters they must have the right to refuse to vaccinate their daughters. the ultimate decision on vaccinate the children should be taken by their parents to ensure parental autonomy. thank you authors! readers, let us all commit ourselves in ensuring ethical standards in all our lives and work. please continue to submit interesting and thought provoking articles. seasons’ greetings to all! tahera ahmed, editor, bjb microsoft word commercial surrogacy_in india final 1 bangladesh journal of bioethics 2017; 8(3):9-17 9 can coercion be justified when it benefits the poor? the case of commercial surrogacy industry in india packiaraj asirvatham an independent researcher, india. email: packiaraj.a@gmail.com abstract: commercial surrogacy in india is a booming industry however the raising number of poor illiterate women's participation as commercial surrogate poses serious question of coercion, on the other hand it economically empowers them. in this context, this article analyses the crucial question, can coercion be justified when it benefits the poor by investigating commercial surrogates’ life stories and looking into the various types of coercion discreetly operates. it concludes with few recommendations which can help in empowering poor commercial surrogates who involved in commercial surrogacy industry in india. key word: commercial surrogacy, coercion, poverty, reproductive tourism, india introduction: commercial surrogacy in india is a crucial bio ethical issue. according to an indian law commission report commercial surrogacy has been viewed as a golden pot for poor surrogate women on the one hand, and on the other hand as a great help for childless couples 1. it is estimated that nearly 200,000 clinics across the india offer artificial insemination, ivf, and surrogacy. the confederation of indian industry analyzed that commercial surrogacy had grown to a $2.3 billion industry in india in 2012 2. in this context, emerging ethical issues of commercial surrogacy are of serious concern as the commercialization of reproduction can lead to exploitation of women, unfair distribution of economic benefits, and legal battles especially in cross-border commercial surrogacy3,4. presently, little research exists about how uneducated, rural women who participate in commercial surrogacy grasp the facts of advanced medical treatments. moreover, how do they correspond with commissioning parents from abroad? do they really understand the surrogacy contracts? are they voluntarily involved in the process or coerced? in this context, an increasing number of surrogate mothers from economically deprived backgrounds pose serious questions about coercion. approach: this paper explores the basis of a commercial surrogate’s coercion and portrays how they are forced to participate in commercial surrogacy by their family, private sector clinics, and the governments. then it focuses on the ethical question: can this coercion be justified since it helps their economic development? this study will be approached in four stages 1. a survey the presence of coercion in the scholarly journals 2. an exploration of the main forces of coercion 3. an ethical analysis of the ethical acceptability of coercion in the context of economic development of poor communities and 4. a series of suggestions to eliminate coercion in the commercial surrogacy industry. limitation: the parties involved in crossborder commercial surrogacy are the commissioning parents, medical doctor, brokers, commercial surrogate, and family and friends of the surrogate mother; however, this study only focuses on the commercial surrogate women. commercial surrogacy is a broad research topic where this study only focuses on cross-border commercial surrogacy. the word “coercion” used in its basic meaning of “compulsion” or “force”. the context: cross-border commercial surrogacy is very unique. it is like an export and import business. it occurs not only between bangladesh journal of bioethics 2017; 8(3):9-17 10 two parties but between citizens of two countries. the issue of cross-border commercial surrogacy in india is a very modern phenomenon. when india opened its markets in 1991 as part of economic liberalisation many industries thrived. for instance, in the state of gujarat, which is the most industrially developed state, they adopted commercial surrogacy as one of their main business, so it has become one of the largest industries. it is claimed that the district of anand, gujarat is the unofficial capital of the commercial surrogacy industry5. as a starting point to understand the issue of coercion from practical contexts, i would like to present a few of testimonies of commercial surrogates from the anand district, the state of gujarat, india. these testimonies are from established studies of pande and sarvanan who spent considerable time on the field and published their results in scholarly journals from 2009-2010. pande has predominantly focused her studies on hope maternity clinic in anand where saravanan researched in akanshka clinic in anand and bavishi clinic in ahemedbad. however, they both undertook their studies in anand which is the core of commercial surrogacy in india. commercial surrogates voices: let us move to the commercial surrogate mothers testimonies, they all express their idea on commercial surrogacy, their motivations and reason to take part in it. salma expresses that commercial surrogacy is a majboori because of family circumstances which means compulsion or force, anjali expressess that she is in desperate need for money to take care of her child, vidyaben notes that she was convinced by her inlaws and persuaded by a nurse, meena was convinced by her husband to become surrogate, sapna is helping her inlaws to build a house, and raveena committed to commercial surrogacy to save the life of her younger child6.regina, a forty-two-year-old surrogate, was persuaded by a nurse when she met this nurse at a hospital where she treated her daughter7. in all these cases, these women are persuaded by someone and submitted themselves to the commercial surrogacy industry. this raises the question of coercion. however, jyotsna agnihotri gupta argues that the impact of art on women shifted them from subject to object and as the controller of their own body. on the contrary, in my perspective the rural women involved in the commercial surrogacy industry would have not even had the right to choose their own life partner for their marriage. if that is the case, then how can we assume that these women are the controller of their own bodies with regard to commercial surrogacy? types of coercion: commercial surrogacy in india is still an unregulated industry which is operating on the basis of the guidelines from the indian council for medical research (icmr). so every maternity clinic operates in their own way to choose commercial surrogates. recruiting the commercial surrogates is the first and foremost step. it is very evident that formal and informal brokers are the surrogacy recruiters. they include: former surrogates, women who could not become surrogates for medical reasons, and midwifes in various hospitals. finding and selecting a surrogate is a crucial issue since the demand is very high; for example, dr. khanderia, head of the clinic explains that “at the moment (in 2008 and 2009) there are more than 300 intended parents on the waiting list”6. so commercial surrogates are recruited aggressively to meet this heavy demand. especially, there are three main ways in which these women are forced to undertake commercial surrogacy as their survival strategy: firstly, circumstances from family and husband, and the patriarchal society and its force; secondly, the economic circumstances in which the need for money forces the surrogates to undertake surrogacy, and thirdly, profit centered policies of governments which view commercial surrogacy as a beneficial industry force the women to undertake commercial surrogacy. these are three main categories in which coercion is systematically executed. bangladesh journal of bioethics 2017; 8(3):9-17 11 family driven coercion: india is still a patriarchal country where women have limited choices especially with reproduction. predominantly the power is vested with men. pande argues that though many women accept the fact of social stigma, they involve in this industry secretly because of the compulsion of their family8. obviously, many of the men from poor background view their wives as a money making machine and look forward to make use of this new fortune. private clinics also capitalize on this idea. for example, the consent of the husband is crucial in becoming a commercial surrogate. every commercial surrogate is obliged to get consent from her husband 8.technically, to a large extent, the husband’s desire to make money through his wife is easily executed by the brokers. more interestingly, there is no space for the surrogate’s informed consent and the surrogacy contract is in english, a language most of the surrogates are unfamiliar with. so systematically the in-laws and the husband force the women to be a surrogate. more interestingly, most of the surrogates sideline the aspect of choice in their involvement. they attribute that it is because of their family, children, or husband and they also express that, “it was not in my hand”9.on the whole, commercial surrogates are the product of patriarchal societies who lack choices and are powerless to make decisions on their own. economic needs based coercion: coercion predominantly takes place in the context of severe economic need. it is a systematic approach to target the people in need of money and coerce them to be a surrogate. nirmala narrates how she came to be a broker by saying, “i came here to donate eggs, but i was refused because of my age. so i started getting women from my hospital. it is easy for me to find the right women because i used to be a midwife. i know which women have very young children, which ones are in desperate need of money”7. bailey recalls a surrogate who accepted $1,500 instead of $2,000 when another woman offered for $1,500 10. sandel claims “coercion is when people buy and sell things under conditions of severe inequality or dire economic necessity. according to this objection, market exchanges are not necessarily as voluntary as market enthusiasts suggest. a peasant may agree to sell his kidney or cornea in order to feed his starving family, but his agreement is not truly voluntary. he is coerced, in effect, by the necessities of his situation”11. as per sandels definition it is very clear that commercial surrogates in india are coerced deliberately. obviously, commercial surrogacy travels in the line of organ trafficking where brokers convince and collect the organ from the vulnerable people for payment. ultimately this systematic coercion puts these surrogates into work. further, pande remarks that the sole strategy is identifying and persuading women in desperate need of money for their children and she claims that half of her interviewees are recruited by brokers12. these coerced women who are in severe economic need are further persuaded by individual counseling session. their counseling session is all about moral justification of commercial surrogacy by differentiating it from sex work. in addition, they describe this idea through convincing parables. for example, by saying “just like renting a house for nine months”, “god’s gift to serve childless couple”, “motherworker” and “act like a vessel”7. on the other hand, a commercial surrogate may earn around $5000 to give birth to a child which is considerably a good earning compare to her normal income per year and it is likely her 2-3 years income altogether. so it is considered as economic empowerment however taking into consideration of 10 months of intensive labor and pre term and post term physical and psychological complications and associated risks in addition to social stigma victimize the commercial surrogate. in this context, being a commercial surrogate is like bonded labor with legal contracts! policy driven coercion: another very important type of coercion is from the government. many scholars like qadeer, unnithan, and jaiswal argue that commercial surrogates are systematically coerced by government policies. bangladesh journal of bioethics 2017; 8(3):9-17 12 they describe how these policies target vulnerable communities. for example, indian government classifies commercial surrogacy under medical tourism, which is one of the potential income generating methods to the country, and it encourages the inflow by giving special medical visas to foreigners13,14,15. unnithan refers to this as “hyper-fertile bodies of poor women subject to state-backed technological intervention”16. qadeer argues that the government is willingly commercializing public resources to favor international and private actors; consequently, it contributes to the economic growth of the country17. meanwhile, governments of developed countries also indirectly encourage their citizens to access this service in india, where it saves a lot of money compared to their own context, and “outsourcing children” is a viable option to make their citizens happy at the cost of third world women. this neo-colonialist approach from the developed countries and the economic growth centered policies of indian government are deliberately pushing commercial surrogates to undertake commercial surrogacy. reproductive choices and coercion: contemporary bio ethical debates are predominantly focused on the choice aspects of participants in commercial surrogacy. commissioning parents always have a high level of freedom and reproductive autonomy, who are predominantly from western countries, and are from wealthy context a large extent 18. whereas the commercial surrogates in india lack choices and it is believed that they do not have autonomous consent but express, as amartya sen coined “adaptive preference”. wilkinson is very critical of consent in a coercive context and he claims that coercion invalidates the consent19. moreover, there is no assistance to protect the decision making authority of surrogates in (developing) countries. according to donchin this is one of the main reasons why poor women lack autonomy20. bailey argues that coercion not just confined to the selection of surrogates but exists throughout the contract. in addition, she rejects the common idea that commercial surrogates are free and involved in autonomous choices. she says it is hype from western media and there is no evidence for the claim10. whereas sama claims, ‘‘[t]he fertility market issues a price tag to reproductive tissues and then appropriates them in order to sell the unfulfilled dream to millions of people, under the rubric of choice and rights’’21. in addition, bryn williams-jones argues that “there is a clear contrast between surrogacy in developed and underdeveloped countries. in developed countries, surrogacy may be a choice for women to improve their financial situation and perform an altruistic act; in underdeveloped countries, surrogacy may be a form of slavery, reminiscent of the black nannies who raised white children in the american south during the slavery era, or in apartheid south africa”22. petersen argues that women should reject assisted reproductive services (art) because they are coerced by a patriarchal society and their choices are not autonomous23. though his argument comes from the perspective of art for childless women it correlates with the commercial surrogate women in general. however, he argues from a developed country context where women have more choices and economic independence which can help them, to some extent, escape from coercion. jaiswal contends the western liberal feminist perspective on surrogacy, which claims that surrogacy is an expression of reproductive choice and economic autonomy. she argues that in india socioeconomic conditions determine their choices (poverty, low education levels, marginalization in labor markets, and patriarchal family and social structures)15. ethical acceptability of coercion in commercial surrogacy: in this context, i argue that the primary objection to coercion is that it eliminates the freedom of a women and infringes upon the autonomy of the surrogate. it is very clear that coercion subordinates the woman’s ability to reproduce freely and infringes upon her autonomy. it uses the woman’s body for material benefit against her wishes which is morally bangladesh journal of bioethics 2017; 8(3):9-17 13 unacceptable. however, humans always tend to gain from using their physical capacities; for example, education, physical labor, and knowledge development, in a way, helps to make money. so why do we oppose the involvement of poor women in commercial surrogacy? here, the pressing issue is coercion which invalidates the reproductive right of poor women and victimizes their reproductive capacity. for example, in india the girls who trapped in sex trafficking are often coerced by brokers by showing economic benefits and false promises, many of the girls don't have any idea what they are going to do however they believe in the promise of the brokers who express that “you can get out of poverty if you come with me”, they just follow their words and trapped in various fields like sex work, bonded labor and so on. commercial surrogate recruitment also priorities economic benefit than the nature of job and its pros and cons. in addition you may ask how their autonomy is violated. it is very simple, in indian context already women don't have any right over their body with regard to reproduction a large extent, it is their husband who decides. if this is the case, being commercial surrogate also should be the wish of her husband than herself. then you may argue reproductive capacities of women are always subject to their husbands wish then whats different with normal pregnancy and commercial surrogacy in both contexts a woman is coerced by her husband. however, within family relationship it is a matter of shared responsibility where they involve in physical relationship and share genetic materials where in commercial surrogacy its mere a commercialization of body which is just used as means to an end. they are subjected by their husbands to be a reproductive slave. in addition to husband, they are subjects of the doctors and the commissioning parents. saravanan interestingly denotes the word “inertness” as one of the prerequisites for being a commercial surrogate. inertness is all about being like an object which is a subject of others than its own. if “inertness” is the prerequisite of a commercial surrogate then the commercial surrogacy industry considers the surrogate as an reproductive object, which does not have any wish and can be influenced and coerced. the commercial surrogacy industry forces the surrogate against her wishes and uses her to fulfill the desire of the commissioning parents on the one hand and their husbands and close family on the other hand. obviously, the whole argument of coercion in the context of economic benefit is of serious consideration. why can’t a woman benefit by using her reproductive capacity though she is coerced? for example, even advertisements influence customers to purchase a product and employ the marketing technique of repeatedly contacting the customer and persuading them to purchase the service. is this coercion? here, the customer has the choice to purchase or reject the product since they possess money, but in the commercial surrogacy context, commercial surrogates have reproductive capacity, which is really valuable, but do not have money. the clinics/brokers who are in need of surrogates swindle the reproductive services of poor women at the cost of their economic vulnerability. it is very important to note that the commercial surrogacy industry does not operate to develop the economic benefit of the rural poor, but it is a commercial industry which is completely profit centered and uses poor women as their profit-making machine. if these industries operate ethically, people automatically enroll and there is no need for force. on the other hand, in terms of business, coercion is never justified as a good business practice. because it is very evident that predominantly most of the impoverished surrogates are persuaded by showing the economic benefits. to prevent coercion, few governments restrict payments for reproductive services; for example, in the uk commercial surrogates are not supposed to be paid, but they can receive compensation. besides, how these women involve in this, is it a well-informed business model in which the commercial surrogate is one of the stakeholders or just an object which is making profit for someone else. the commercial surrogate is bangladesh journal of bioethics 2017; 8(3):9-17 14 exploited and subjected by the family, society, and even the government. remarkably, she benefits the least compared with the others involved in this industry: for example, the clinics and commissioning parents. when we weigh the benefit and the risk of commercial surrogates, the risk is higher than the benefit. they are: economic, physical, and psychological risks; meanwhile, the whole idea of benefit is also questionable in the context of coercion. coercion nullifies the idea of benefit. benefit is about receiving an outcome without any compulsion and bargaining in exchange for ones labor. according to ilo forced labor defined as, “work or service extracted from a person under threat or penalty, which includes penal sanctions and the loss of rights and privileges, where the person has not offered him/herself voluntarily”24. in this context, no coercive activity is ethically justified as beneficial since it is executed by force and considered as forced labor. more interestingly, coercion is culturally defined to an extent in india. for example, people still exercise forced marriages in india. however, it is not morally acceptable, so according to government forced marriage is a crime. if the government considers forced marriage as crime then it should treat forced reproduction the same. moral standards should never be compromised for economic benefit especially by the rulers of a country. in addition, the husband’s consent is never considered in medicine except in family planning in india; however, here, the husband’s consent is used as a tool to moralize and force women into commercial surrogacy. can a man force his wife to have a baby? that is also considered a crime since reproduction is about sharing responsibilities through mutual cooperation. forcing a woman to sell reproductive services for the benefit of her family is never justified or legalized; however, current practices endorse the husband’s consent and completely remove the ownership of the body of the women and subordinate her as a subject of her husband’s consent, which is unethical. on the other hand, the government also forces women to be a surrogate. the government policy on commercial surrogacy operates in two ways: it forces the women from india to undertake commercial surrogacy in order to benefit the economy, and the governments of developed countries promote access to reproductive services in india for cost-cutting reasons, ultimately for economic benefit. however, no one can justify forcing rural women into commercial surrogacy in a country where the maternal mortality rate is very high and 70% of women are affected by anemia during pregnancy25. moreover, encouraging women to become commercial surrogates without firm regulations and laws increase the risk of coercion. many arguments have been made for the development of commercial surrogacy in india, they are; “lower costs, the large number of women willing to engage in surrogacy, top-notch private healthcare, english-speaking providers, a business climate that encourages the outsourcing of indian labor, world-famous tourist destinations, and the total absence of government regulation” (points 2008). meanwhile, points is not clear on how women “willingly” participate in commercial surrogacy; however, he affirms the complete absence of government regulation. in terms of social justice, the government is the guardian of its people and it should never use its citizens to make a profit. it is the government’s moral responsibility to protect these vulnerable communities rather than forcing them to undertake commercial surrogacy through the private sector in the name of economic development. consequently, the government has failed in its duty of protecting its vulnerable citizens from coercion. obviously, most of the commercial surrogates engage in commercial surrogacy secretly which cuts off their social interactions and alienates them from their loved ones. they lack social acceptance for being a commercial surrogate; on the other hand, they experience tremendous force by families which creates “reproductive refugees”. i deliberately call them “reproductive refugees” because of their status in society. it is bangladesh journal of bioethics 2017; 8(3):9-17 15 the government’s duty to help them come out of the crisis and put a stop the coercion. protecting vulnerable groups from coercion and exploitation is always an important thing to be prioritized. universal declaration of bioethics and human rights calls for protecting vulnerable communities in order to sustain their human dignity, promote their human rights and fundamental freedom. article 8 affirms, “in applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected”26. in this context, capitalizing on human vulnerability to increase profits by using reproductive technologies is against human rights, and consequently plunders the human dignity of a person. so it is the government’s responsibility to enhance the choices of commercial surrogates and protect them from the coercive forces of private sector clinics and patriarchal society in addition to rectify the compromising policies. a call for change: response to coercion in commercial surrogacy varies from exploitation to ethics of care. humbyrd calls for a fair trade international surrogacy27 where surrogates are fairly treated. however, comparing reproductive services to coffee trade and coming to a conclusion that fair trade international surrogacy is a solution may be misleading since human beings and human values are involved in the commercial surrogacy industry. shalev remarks that the market is driven by forprofit motivation where there is no moral ideal of personal freedom and she emphasizes that the liberal autonomy based approach alone never solves the problem and it should be supplemented by an ethics of care based on responsibility, cooperation, and dependence. she explains, “an ethic of care and responsible self-restraint requires a shift in consciousness: from calculation of self-interest and benefit to contemplation of our mutual vulnerability and interdependence; from observation of others as external objects and instruments for our own ends, to inner awareness of the seamless web of life and relationship in which we are implicated by our very nature as human beings”28. unnithan also affirms the crisis and calls for contextually-based ethics which moves beyond the biomedical frame and issues of choice, consent and access alone. she is citing kleinmans distinction between ethics and morality and calls for the development of morality which is based on social commitments may be the answer to solve the issue. on the other hand her idea sounds like john harris’ “green paper” and “white paper” concept: however, she emphasizes practical commitment and action over academic discussion16. on the whole, coercion is never justified, though it benefits the economic development of poor communities, since it erases the reproductive freedom of every poor commercial surrogate and prioritizes money over a woman’s reproductive capacities and creates “reproductive refugees”. with regard to economic benefit, it hardly benefits the women who are involved in commercial surrogacy; however, it puts them under tremendous physical and psychological risk. though the government supports the commercial surrogacy industry it is very important to note that people are the priority and it is the duty of everyone to protect the vulnerable communities from coercive forces of economic development. conclusion: the issue of coercion of rural, poor, women in the commercial surrogacy industry in india reveals how vulnerable poor women are! obviously, we can understand the lack of the government and private sector’s commitment on the issue. whatever the case, coercion should be curtailed since it is unethical and commercial surrogacy in india should be regulated in order to ensure a better future for women since it is impossible to ban commercial surrogacy and the successive ban may lead poor women to become more vulnerable position of exploitation. in this context, it is very bangladesh journal of bioethics 2017; 8(3):9-17 16 important to protect the commercial surrogates from coercion in order to ensure their human dignity, reproductive rights, and fundamental freedom. personally i think the following suggestions can help to eradicate coercion since it is unethical. the following suggestions will be helpful to empower the autonomy of rural women which will help to eliminate coercion and ensure justice for the commercial surrogates in india. 1. commercial surrogate’s consent should be mandatory and the consent should be an “informed consent” rather than “coercive consent.” 2. availability of alternative choices should be encouraged. empowering woman's decision making capacity by protecting their reproductive rights can eliminate coercion. 3. promoting the husband’s consent which is the root of coercion, should be made illegal and seeking husband’s consent should be stopped. 4. broker’s involvement in recruiting commercial surrogates should be stopped and we should find a better way to recruit surrogates through a transparent manner without coercion. 5. fixed compensation procedure should be introduced to protect commercial surrogates from cheap bargaining and coercion. 6. awareness and education to the rural women with regard to their choices and rights in commercial surrogacy and to the intending parents about the best, ethical practices in commercial surrogacy. this will empower commercial surrogates 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http://www.ncbi.nlm.nih.gov/pubmed/2069091 6 21. arts and women [internet]. new delhi: sama; 2006. available from: http://www.samawomenshealth.org/pubs/book .pdf 22. bryn williams-jones. commercial surrogacy and the redefinition of motherhood. j philos sci law [internet]. 2002;2. available from: http://www6.miami.edu/ethics/jpsl/archives/pa pers/comsur_williamsjones.html 23. petersen ts. a woman’s choice? – on women, assisted reproduction and social coercion. ethical theory moral pract. 2003;7:81–90. 24. ruwanpura kn, rai p. forced labour : definitions , indicators [internet]. geneva; 2004. (18). available from: http://www.ilo.org/wcmsp5/groups/public/--ed_norm/--declaration/documents/publication/wcms_081 991.pdf 25. mittal s. addressing iron deficiency anemia: 12 x 12 initiative [internet]. new delhi; 2012. available from: http://whoindia.org/en/section6/section324_1 467.htm 26. report of ibc on the principle of respect for human vulnerability and personal integrity. paris; 2011. 27. humbyrd c. fair trade international surrogacy. dev world bioeth [internet]. 2009 dec [cited 2012 mar 5];9(3):111–8. available from: http://www.ncbi.nlm.nih.gov/pubmed/1950829 0 28. shalev c. an ethic of care and responsibility: reflections on third-party reproduction. med stud [internet]. 2012 mar 23 [cited 2012 may 6]; available from: http://www.springerlink.com/index/10.1007/s1 2376-012-0074-z bangladesh journal of bioethics 2014; 5(1):20-35 20 informed consent of human subjects: a review mohammad rashedul islam assistant director bangladesh college of physicians and surgeons (bcps) mohakhali, dhaka. email: mrislam96@gmail.com abstract: informed consent is a vital part of the research process, and as such entails more than obtaining a signature on the consent form. researchers or investigators must educate potential subjects to ensure that they can reach a truly informed decision about whether or not to participate in the research. their consent must be given freely, without coercion, and must be based on a clear understanding of what participation involves. only then it can be regarded as ‘informed consent’. although a relatively recent phenomenon, the role of informed consent in human research is central to its ethical regulation and conduct. however, guidelines often recommend procedures for obtaining informed consent (usually written consent) that are difficult to implement in developing countries. this paper reviews the guidelines for obtaining informed consent and also discusses prevailing views on current controversies, ambiguities and problems with these guidelines and suggests potential solutions. key words: informed consent, human subjects introduction: the world medical association has developed the declaration of helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects. medical research involving human subjects includes research on identifiable human material or identifiable data 1 . medical research is subject to ethical standards that promote respect for all human beings and protect their health and rights. some research populations are vulnerable and need special protection. the particular needs of the economically and medically disadvantaged must be recognized. special attention is also required for those who will not benefit personally from the research and for those for whom the research is combined with care 1 . methods: the article was written in research and training monitoring department of bcps is located in dhaka, bangladesh during research ethics course of bangladesh bioethics society in collaboration with national institutes of health, bethesda, maryland, usa through video conferencing on september 25 through november 11 of 2013. in this study the systematic literature search has performed published during 2000 to 2013, using four database including medline, pubmed, hinari and google scholar. only studies that focused informed consent in human subjects were included in this review process. a total of 30 articles were retrieved and 16 of them were selected for review. mailto:mrislam96@gmail.com bangladesh journal of bioethics 2014; 5(1):20-35 21 all protocols were cited on the world wide web (www) by applying the key words; informed consent of human subjects. inform consent: assent of the child: the willing cooperation of the child should be sought, after the child has been informed to the extent that the child's maturity and intelligence permit. the age at which a child becomes legally competent to give consent differs substantially from one jurisdiction to another; in some countries the "age of consent" established in their different provinces, states or other political subdivisions varies considerably. often children who have not yet reached the legally established age of consent can understand the implications of informed consent and go through the necessary procedures; they can therefore knowingly agree to serve as research subjects. such knowing agreement, sometimes referred to as assent, is insufficient to permit participation in research unless it is supplemented by the permission of a parent, a legal guardian or other duly authorized representative. some children, who are too immature to be able to give knowing agreement, or assent, may be able to register a 'deliberate objection', an expression of disapproval or refusal of a proposed procedure. the deliberate objection of an older child, for example, is to be distinguished from the behaviour of an infant, who is likely to cry or withdraw in response to almost any stimulus. older children, who are more capable of giving assent, should be selected before younger children or infants, unless there are valid scientific reasons related to age for involving younger children first 2 . consent is an important area and one that the reviewer and the committee will focus when reviewing the application. consent must be informed and freely given. there must be no coercion. participants must have the capacity to consent and the right to withdraw without penalty and providing an explanation. it must be ensured that all relevant information is included and it must be explained clearly what the participants will be asked to do on the participant information sheet. participants should be told why they have been selected to take part and how many people have been approached. as part of the information given to the participants, it must be stated that the research study has been approved by the ethical committee of the bmrc. participants must be informed of any risks. there will always be some, is not acceptable to say there are no risks. participants must also be informed of their legal rights, the storage and destruction of data and right to withdraw from participation in research at any time, without giving a reason. participants must also be provided with contact details for further information, which should include a postal address and a telephone number where a person will be available at certain time to answer questions. taking consent must be viewed as a process, not just the person reading the information sheet and signing a consent form. there is evidence that people understand much less than what they are thought to understand. the participant information sheet should therefore be checked for readability. the committee will also want to be assured that the participants are being adequate time to decide whether they wish to take part and have the opportunity to discuss the research with family and friends. if direct quotes from participants is going to be used for dissemination, or recording using audio or video equipment, this must be bangladesh journal of bioethics 2014; 5(1):20-35 22 stated on both the participant information sheet and as one of the statements on the consent form. if personally identifiable information is going to be used for dissemination for example photographs, participants must be given the opportunity to be contacted on each occasion that these will be used, in addition to taking their consent. it is good practice to notify all participants regarding the last approximate date it will be possible to withdraw their data (for example, prior to publication). it will need consideration whether participants’ data will still be useful if they decide to withdraw. if this is the case, they will need to consent for its use, they can therefore be given the option to withdraw and also have their data withdrawn, or to withdraw but state that they will allow their data to be used. if a focus group is being carried out, it will not be possible to withdraw one person’s data following the intervention without removing the data for all the participants, because what one person says will affect the responses from others. it must be made clear on the participant information sheet that it will not be possible to withdraw data in this case. it is also necessary to make it as easy as possible for people to withdraw, bearing in mind that they might not feel comfortable telling the investigator directly that they no longer wish to participate. options, such as posting a slip, will need to be included. one should also guard against unrealistic assurances to participants about data being anonymous. it is essential that every effort is made to remove all identifying information relating to participants prior to dissemination. information that could identify people is not limited to their names. it is sometimes possible with case studies that people may be identified. this needs to be made explicit in the participant information sheet. the words anonymous and confidential are often confused. these must be refereed to correctly on the participant information sheet. it must be ensured that the documentation is inclusive. for example if the research involves people who cannot speak or write english, the documentation needs to be translated (a professional translator needs to be employed unless the investigator is fluent in bengali). consideration for people with special needs, for example, dyslexia, will need to be included and the provision for alternative formats of documentation should be made. if research is related to other people, for example asking questions about family member’s participants, consent or permission from them should also be taken, as applicable. the assumption should not be made that because participants are revealing information about family members (as opposed to others outside their family) that this will be all right. even if research is carried out that does not ask participants about other people. consideration should be given beforehand whether others are likely to be discussed. if so, it should be considered whether consent should be taken from them 3 . informed consent will be obtained: in order to approve research involving adults as study participants, the irb must determine that legally effective informed consent will be sought and obtained from each prospective study participant or the study participant's legally authorized representative, unless informed consent requirements can be waived or altered under federal regulations. any such waiver or alteration must be consistent with applicable federal and state laws and regulations. bangladesh journal of bioethics 2014; 5(1):20-35 23 where consistent with state law, case irb policy recognizes as legally authorized representatives: (1) persons appointed as health care agents under a durable power of attorney for healthcare; (2) court appointed guardians; (3) next of kin in the following order: spouse, adult child, parent and adult sibling. however, case irb policy limits the conditions under which the irb may approve the use of consent from legally authorized representatives. 4 informed consent process: the ethical foundation of informed consent is the principle of respect for persons. competent individuals are entitled to choose freely whether to participate in research, and to make decisions based on an adequate understanding of what the research entails. decisions for children or adults who lack the mental capacity to provide informed consent should be made by an authorized surrogate decision-maker. recs should examine the process through which informed consent will occur, as well as the information that will be provided. recs may waive the requirement of informed consent only when doing so is consistent with international guidelines and national standards. while informed consent to research is important, the fact that a participant or surrogate may be willing to consent to research does not, in itself, mean that the research is ethically acceptable. 5 informed consent is an essential component of a research project. obtaining informed consent enables research and clinical procedures to be conducted both ethically and legally. consent is considered ‘informed’ when given by a person who understands the purpose and the nature of research, and what is required of themselves as participants, in addition to the potential benefits and risks resulting from the study. elements of valid consent include the capacity of participants to provide consent, disclosure of necessary and important information, freedom to choose to participate without coercion (i.e., freedom not to participate), and consent of participants 6 . informed consent is a vital part of the research process, and as such entails more than obtaining a signature on the consent form. researchers or investigators must educate potential subjects to ensure that they can reach a truly informed decision about whether or not to participate in the research. their consent must be given freely, without coercion, and must be based on a clear understanding of what participation involves. only then it can be regarded as ‘informed consent’ 7 . the process of educating subjects about the study begins during initial contact and continues for the duration of their participation. thus, information conveyed through advertisements, recruitment letters, pre-screening phone calls, study description sheets as well as written informed consent documents and discussions must be understandable to the subjects and should contribute to their understanding of the research. technical and medical terminology should be avoided or explained in “lay” language, and materials should be written at an 8th grade reading level or lower. non-english speaking subjects must have information presented in a language they understand. the partners human research committee (phrc) must approve written and oral information (including recruitment materials) provided to subjects before and during the informed consent process 7 . bangladesh journal of bioethics 2014; 5(1):20-35 24 the consent discussion should begin sufficiently in advance of the initiation of study-related procedures to allow potential subjects time to reflect on the potential benefits and risks and possible discomforts of participation. the following method is preferred, though clearly it may need to be tailored to the circumstances of individual studies and may not be appropriate or feasible in all situations. first, potential subjects are given general information about the research and if they are interested in learning more about the study, they contact study staff. the investigator then meets with the potential subject to review and to discuss the details of the research study using the informed consent document as a guide. this discussion should include all of the required elements of informed consent, e.g., the purpose of the research, the procedures to be followed, the risks and discomforts as well as potential benefits associated with participation, alternative procedures or treatments, if any, to the study procedures or treatments, and provision of compensation, if any, due to unwanted damage/disability of the research subjects 7 . preferably, potential subjects are then given a copy of the informed consent document to take home so they can carefully read the document and discuss the research with their family, friends and/or physician and develop questions to ask at their next meeting with the research staff. subjects must always be given the opportunity to ask questions and have them answered by the investigator and, whenever possible, to consult with friends/family and/or their physicians. once they have read the consent document and their questions are answered, if they agree to participate in the research, they sign and date the informed consent document. however, subjects must be asked as well for written authorization for the use and disclosure of their identifiable information for research 7 . special consideration must be given to the timing of the consent process when the subject population includes patients who will be same-day admissions for surgical procedures or who present for diagnostic or other tests, such as cardiac catheterizations or radiological examinations. clearly, the time frame for the consent process will be more limited in these situations. generally, the investigator should allow potential subjects at least 12 hours to consider participation. whenever possible, the patient’s physician should be asked to provide potential subjects with information about the study well in advance, for example, when the surgery, test, or examination is scheduled 7 . with few exceptions, the informed consent of subjects, whether patients or healthy volunteers must be obtained and documented in writing before the start of any study-related procedures that include screening tests and examinations done solely to determine their eligibility for the study. informed consent is to be obtained directly from each subject, with the exception of children (as there are some special regulations for children as research subjects) and adults who have impaired decision-making capacity. once the informed consent document has been signed, subjects are considered enrolled in the study 7 . individuals who can obtain informed consent: for most studies involving more than minimal risk and all studies involving investigational drugs/devices, a licensed physician investigator listed on the protocol must obtain informed consent. study nurses or other study staff may assist in the consent process, but physicians should be actively involved in the consent discussions and should not delegate this vital investigator function. it is the investigator’s responsibility to ensure that proper informed consent is obtained from every subject according to the procedures approved by the phrc. for minimal risk studies and very carefully selected studies involving more than bangladesh journal of bioethics 2014; 5(1):20-35 25 minimal risk (but not investigational drugs/devices), it may be appropriate for study nurses or other study staff to obtain consent, with “back up” provided by licensed physician investigators. the phrc will allow a licensed nurse or non-licensed physician investigator to obtain informed consent if that nurse or non-licensed physician would be permitted, in a clinical setting, to perform the procedures for which consent is required. if the investigator proposes that other than licensed physician investigators obtain informed consent, the rationale and justification for this approach and the qualifications and training of the relevant study staff must be submitted to the review and approval 7 . if subjects are to be enrolled from among the investigator’s own patients, consent procedures must be put in place to ensure that subjects do not feel obligated to participate because the investigator is their treating physician. there is always concern about the possibility of patients feeling obligated to participate because it is their physician who is doing the asking. while the phrc does not have an absolute prohibition about physicians obtaining consent from their own patients, researchers are asked to think about this issue and address it. there are many possible ways to do this. one can contact the patient in writing initially, and allow him/her to make the first contact if interested. one can ask a physician colleague to present the study to a patient to try to make it more impartial. one can have a nurse or colleague re-contact the patient after the investigator has had the consent discussion and offer them an opportunity to ask additional questions, raise concerns, or opt out, with someone who is not their physician 7 . obtaining parental/legal guardian consent for children: federal regulations require that consent to participate in research on behalf of a child be provided by a parent or an individual authorized under applicable state or local law to provide consent on the child’s behalf to general medical care. under massachusetts law, a parent is generally authorized to consent to general medical care on behalf of their child. however, in some circumstances (such as when both parents are deceased), it may be necessary to identify another individual with this authority (for example, a court-appointed guardian). before an investigator allows an individual other than a parent to consent on behalf of a child, the investigator should document the basis for the individual’s authority to consent on behalf of the child to general medical care and place any relevant documentation in the research file. in situations when it is unclear under state law who has the authority to provide consent to general medical care on behalf of a child, and thus who can consent to the child’s participation in research, the phrc will consult with the office of general counsel as needed 7 . under the federal regulations, where consent to the research is to be provided by a child’s parent and the research involves no greater than minimal risk or greater than minimal risk, but with the prospect of direct benefit to the subjects, the phrc may decide that consent of one parent is sufficient. however, when the research involves greater than minimal risk and no prospect of direct benefit to the subjects, permission must be obtained from both parents, unless one parent is deceased, unknown, incompetent, or not reasonably available, or when one parent has legal responsibility for the care and custody of the child. 7 in addition to permission of the parent(s) or guardian, assent to participate in the study must be obtained from each child age 7 years or older who, in the opinion of the investigator, is able to provide assent based on their age, maturity or psychological state. when the phrc determines that the intervention or procedure involved in the research holds out a prospect of direct benefit that is important to the health or well-being of the children involved in the research and the intervention or procedure is only available in the context of the research, the assent of the children is not a necessary condition for proceeding with the research. even when the children are capable of bangladesh journal of bioethics 2014; 5(1):20-35 26 assenting, the phrc may waive the assent requirement as described elsewhere in this document [alteration or waiver of elements of informed consent]. 7 when obtained, assent must be documented in writing using the phrc-approved consent/assent form. when assent is not obtained, the investigator must document his/her rationale in the research records7 minors who can give legally effective informed consent: under massachusetts state law and mgh/bwh clinical policies, some minors (less than 18 years of age) can provide legally effective consent for their own medical care, in certain circumstances, without parental consent or knowledge and therefore may not meet the dhhs and fda definition of “children” and the requirements of subpart d may not apply. “emancipated” minors, i.e., those who are married, widowed or divorced, or have a child or are pregnant (or believe themselves to be), are in the armed forces, or living apart from their parents and managing their own affairs, can provide informed consent for their own medical care. minors in massachusetts may also give consent to research procedures that involve:  psychiatric treatment, if the minor is 16 or over;  treatment of drug dependency, if the minor is 12 or over; and  treatment of certain diseases dangerous to public health (vd and others). because these minors nonetheless may represent a vulnerable population, the irb will review all consent issues involving these minors on a case-by-case basis to ensure that any required additional protections are met. for example, although these minors may be allowed to consent to the research, the irb may decide that permission of a parent or other individual is appropriate either instead of or in addition to the minor’s consent. 7 if the phrc approves the obtaining of informed consent from specified minors, informed consent follows generally the same procedures that are being followed for adults. the investigator must also document the specific circumstances that justify designating a particular subject less than 18 years of age as capable of providing consent to the treatments and procedures involved in the particular research. 7 language and literacy: the language spoken by study participants and literacy levels of study populations are essential factors to consider in developing tailored approaches to informed consent. although it may seem obvious for investigators to develop linguistically appropriate consent documents using clear and simple language, the use of complicated biomedical and scientific language, and lengthy and cumbersome consent forms, continue to be challenging for participants, particularly in low-income settings around the world. comprehension of information provided in consent forms and consent discussions is foundational to voluntary participation. how much information is necessary and in what format for individuals to understand the implications of joining a genomic study? these are important issues to consider in tailoring informed consent processes for genetic and genomic research. for example, in our podoconiosis project, we observed that the majority of participants did not understand that information in the informed consent document and discussion was provided to enable them to make a decision about participating in the study. instead, participants thought the information was provided as a form of health education. 15 use of a subject advocate: in certain situations, the phrc will require the use of a subject advocate in the consent process. the subject advocate is an individual who has no vested interest in the research and who agrees to act as bangladesh journal of bioethics 2014; 5(1):20-35 27 an impartial third party in the consent process. when a subject advocate is appointed, the subject advocate is expected to act in the best interests of the subject by sharing in discussions with the investigator and with those responsible for giving consent. individuals who might fulfill this role include the subject's primary care physician or other health care professional not involved in the research. the subject advocate is responsible for ensuring that the subject understands the research procedures and the risks and potential benefits of participation and that his/her consent is free and voluntary. when a subject advocate is used, the subject advocate must sign and date the consent form. 7 situations in which the use of a subject advocate may be required include: 1. when the risks to subjects are significant and the subject is the patient of the investigator and, as such, may feel obligated to participate; or 2. when consent is to be obtained in the emergency room or in an emergency situation when the time frame to obtain consent prior to start of study-related procedures is limited; or 3. when surrogate consent is to be obtained for research involving more than minimal risk with the potential for direct benefit to the subject. 7 documentation of informed consent: in almost all cases, investigators must document the informed consent process by use of a written consent document (research consent form) signed and dated by the subject or his/her legally authorized representative (or surrogate) and the investigator (or study staff if approved by the phrc) who obtained the subject’s consent. when the research will begin on the same day that informed consent is obtained, the phrc recommends recording time of consent in addition to date of consent to document that informed consent was obtained prior to any study-related procedures. in certain situations, the phrc may approve a waiver or alteration in the consent process (see below) 7 . the research consent form must include the basic elements of informed consent outlined in appendix a. the entire text of all research consent forms must be approved by the phrc as part of the review process. the effective date of the phrc-approved consent form and expiration date of phrc approval (one year or less) are noted in the footer added to the research consent form by the human research office staff. subjects must be given and sign the most recently approved version of the research consent form. out-dated and/or expired research consent forms must not be used in the consenting process and to document informed consent 7 . usually, three copies of the signed and dated research consent form are needed. the original signed and dated research consent form should be retained in the research records. a copy of the signed and dated research consent form must be given to the subject and a copy placed in the subject’s medical record, if relevant to his/her ongoing medical care. if the study involves sensitive research, (e.g., alcohol or drug use, some genetic studies) a copy of the research consent form ordinarily should not be placed in the subject’s medical record. (if the sensitive study involves a drug or otherwise might implicate care decisions, the investigator should discuss with the irb how best to make this information available to a caregiver with a need to know) 7 . http://healthcare.partners.org/phsirb/infcons.htm bangladesh journal of bioethics 2014; 5(1):20-35 28 to further document and facilitate clarification of any future questions regarding the consenting process, the investigator should consider including the following information in a clinic chart/progress note/other source document: that xx study was explained, questions were answered (if any), subject agreed to participate and signed the consent form, and a copy of the signed consent form was given to subject. this note should be signed and dated by the person obtaining consent 7 . waiver of written informed consent: the phrc may waive the requirement to document informed consent with a signed written informed consent document for some or all subjects if it finds either: (1) that the research is not subject to fda regulations and the only record linking the subject and the research would be the consent document and the principal risk would be potential harm resulting from a breach of confidentiality. each subject will be asked whether s/he wants documentation linking him/her with the research, and his/her wishes will govern;if the phrc approves waiver of signed consent based on consideration (1), the full consenting process for these subjects including being given a written informed consent document embodying all the elements of informed consent remains the same except that the subject will have the option to not sign the consent document or have information linking them to the study placed in their medical file. 7 or (2) that the research presents no more than minimal risk of harm to subjects and involves no procedures for which written consent is normally required outside of the research context. if the phrc approves waiver of the requirement to obtain a signed written consent form based upon consideration (2), investigators must fully inform prospective subjects about the study, answer their questions and obtain their verbal informed consent. in lieu of a written consent form, the phrc may require the investigator to provide subjects with a written statement regarding the research. (to obtain oral authorization for use/disclosure of identifiable information under the privacy rule, see obtaining oral authorization for use and disclosure of identifiable information) 7 . when the phrc approves waiver of the requirement to obtain a signed written consent form based upon consideration (2), the investigator should consider including the following information in a clinic chart/progress note/other source document: who was approached, for what study, who explained the study, brief summary of what was explained, subject (or surrogate) expressed an understanding of the research study and willingness to participate, questions (if any) were answered to the subject’s satisfaction, subject agreed to participate, and written information about the study was given to the subject, if appropriate. this note should be signed and dated by the person obtaining consent 7 . alteration or waiver of elements of informed consent: the phrc can approve a consent process that does not include, or that alters, some or all of the elements of informed consent or even waive the requirement to obtain informed consent provided the phrc finds that the research is not subject to fda regulations and documents that all of the following requirements are met: 1. the research involves no more than minimal risk to the subjects; 2. the waiver or alteration will not adversely affect the rights and welfare of the subjects; 3. the research could not practicably be carried out without the waiver or alteration; and http://healthcare.partners.org/phsirb/oralauth.htm http://healthcare.partners.org/phsirb/oralauth.htm bangladesh journal of bioethics 2014; 5(1):20-35 29 4. whenever appropriate, the subjects will be provided with additional pertinent information after participation 7 . requests for alterations in or a waiver of informed consent requirements should be made in writing and justified by addressing each of the 4 points above. (for waiver or alteration of authorization under the privacy rule, see waiver and alteration of informed consent and authorization for research) 7 . obtaining new consent and/or notifying subjects of major changes to any component of the informed consent document. subjects should be asked for new consent i.e. through the investigator’s explanation and request to sign a revised, phrc-approved consent form -when they are actively engaged in the research and there have been major changes to any component of the consent form, e.g. drug dose(s), device, study procedures, risks and discomforts, benefits, and alternatives. this is paramount if knowledge of the new information might affect subjects’ willingness to continue participation. subjects should also be notified of a change of the principal investigator or contact information; however, in most cases this type of change can be adequately communicated in a letter. please note that a change in co-investigators and/or study staff is not considered a major change requiring new consent or notification. 7 it is important to note that as part of the review of amendments to the protocol and/or informed consent document, the phrc will determine whether the change(s) require obtaining new consent from subjects enrolled in the study. examples of when a subject should be asked for new consent in writing:  the procedures section of the consent form has been revised to include a new procedure that the subject will be asked to undergo, e.g., genetic testing, cardiac catheterization, biopsy, colonoscopy, mammogram, ultrasound, etc. an investigator may not perform a procedure on a subject without new consent if the procedure was not mentioned in the original consent process and form. subjects should be given the following information in a timely manner so that they can make a fully informed decision about whether they wish to continue their participation. the greater the import of the new information, the more quickly subjects should be made aware of it.  the risks and discomforts section of the consent form has been revised to include a newly identified serious adverse event  the risks and discomforts section of the consent form has been revised to include a change in the severity or frequency of a serious expected event  the alternatives section has been revised to include newly identified alternative therapies or diagnostic tests  the procedures and alternatives section have been revised to include a change in fda approval status of the drug or device being studied examples of when the phrc may approve a letter being sent to notify the subject of the change include:  the principal investigator has been changed  the study contacts have been changed and/or the contact telephone numbers have been changed  the subject has completed the study interventions and is in the follow-up phase of the study or in some cases has completed the study, and the information is such that learning it would not materially affect the subject’s decision to continue participation in follow-up 7 . bangladesh journal of bioethics 2014; 5(1):20-35 30 appendix a – basic elements of informed consent: 45 cfr 46.116(a) (b) and 21 cfr 50.25(a) (b) the following information about the study must be provided to research subjects when obtaining informed consent: 1. a statement that the study involves research, an explanation of the purposes of the research and the expected duration of the subject’s participation, a description of the procedures to be followed, and identification of any procedures which are experimental; 2. a description of any reasonably foreseeable risks or discomforts to the subject; 3. a description of any benefits to the subject or to others which may reasonably be expected from the research; 4. a disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the subject; 5. a statement describing the extent, if any, to which confidentiality of records identifying the subject will be maintained, and when applicable, that notes the possibility that the food and drug administration may inspect the records; 6. for research involving more than minimal risk, an explanation as to whether any compensation and an explanation as to whether any medical treatments are available if injury occurs and, if so, what they consist of, or where further information may be obtained; 7. an explanation of whom to contact for answers to pertinent questions about the research and research subjects’ rights, and whom to contact in the event of a research-related injury to the subject; and 8. a statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled and the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled. when appropriate, the following information must be provided to each subject: 1. a statement that the particular treatment or procedure may involve risks to the subject (or to the embryo or fetus, if the subject is or may become pregnant) which are currently unforeseeable; 2. anticipated circumstances under which the subject’s participation may be terminated by the nvestigator without regard to the subject’s consent; 3. any additional costs to the subject that may result from participation in the research; 4. the consequences of a subject’s decision to withdraw from the research and procedures for orderly termination of participation by the subject; 5. a statement that significant new findings developed during the course of the research which may relate to the subject’s willingness to continue participation will be provided to the subject; and 6. the approximate number of subjects involved in the study. note: any informed consent, whether written or oral, must not include exculpatory language such that the subject is made to waive, or appear to waive, any of his or her legal rights or to release the institutions or its agents, the investigators, from liability or negligence. examples of exculpatory language: bangladesh journal of bioethics 2014; 5(1):20-35 31  by agreeing to this use, you will give up all claims to personal benefit from commercial or other use of these substances.  i voluntarily and freely donate any and all blood, urine, and tissue samples to the u.s. government and hereby relinquish all right, title, and interest to said items.  by consent to participate in this research, i give up any property rights i may have in bodily fluids or tissue samples obtained in the course of the research.  i waive any possibility of compensation for injuries that i may receive as a result of participation in this research 7 . discussion: informed consent is universally recognized as a central component of ethical conduct in scientific research. investigators working with diverse populations throughout the world face myriad challenges. the application of standards for informed consent can be daunting for researchers when they face the pragmatic constraints of the field and the reality of cultural beliefs about consent that may be in direct conflict with regulatory requirements. this paper explores cultural and social factors underlying informed consent for health research with diverse populations in international settings. sociocultural influences on comprehension of information, perceptions of risk, and beliefs regarding decisional authority are reviewed. the implications of power inequities between study sponsors, researchers and participants are also considered. issues associated with the development and prepara tion of consent forms, including translation and documentation are highlighted. recommendations for good practices are outlined and future directions for research are explored 8 . since the nuremberg trials, informed consent (ic) has been recognized as a basic ethical requirement for research involving human participants. such consent encompasses two distinct elements: (1) researchers communicate detailed information about study procedures, outcomes, risks, and benefits for the participating individual or community, and (2) after understanding and careful consideration, the participants consent to take part under these conditions. however, the suitability of ic for genomic studies has been recently challenged. because the research protocol for such studies may evolve over time, the condition in ic of providing detailed information for a well-defined protocol is not easily satisfied 11 . genetic and genomic research requires access to human dna from biological specimens, which can be stored and used in multiple research studies. access to stored biospecimens for genetic and genomic research is critical because understanding genetic variation and its association with common and complex disorders on a genome-wide scale requires large sample sizes to achieve sufficient power. biospecimens are most useful when linked to clinical and other phenotypic information about the sample source. this has been accomplished in some countries by the creation of national biobanks. in addition to the proliferation of population-based biobanks, many investigators, pharmaceutical companies, and institutions are collecting and storing biological specimens, clinical data, and genetic information in local and regional repositories. often, cell lines are made so that the specimens can be studied indefinitely, and resulting dna data are made broadly available for secondary analysis through publicly accessible or restricted databases. how specimens and data are collected and stored, for how long, by whom, and for what purposes vary tremendously. however, most genetic and genomic research projects share several common features bangladesh journal of bioethics 2014; 5(1):20-35 32 that challenge the established norms of informed consent. in this article, we discuss these challenges, explore specific elements of informed consent for genetic and genomic research, and consider alternative consent models that have been proposed. all of these models attempt to balance the obligation to respect and protect research participants with the larger social interest in advancing beneficial research as quickly as possible 12 . marshall pa et al. highlights the need for more effective approaches and interventions to improve comprehension of consent for genetic research among ethnically and linguistically diverse populations in all settings 13 . linking principles to practices at the ground level is the most powerful way to ensure that valid consent is indeed realized. in this paper we have highlighted a number of key areas of practice and policy relating to the achievement and understanding of valid consent in genomic epidemiology in developing countries. in turn, these have suggested a number of areas of practice in which embedded ethico-social research would be of great value. these include: research into models of community consent and education for genomic epidemiology; the development of models for embedded empirical research on obtaining valid consent; research into the ethical and social factors important in building trust between communities and researchers; and research into the use of broad consent and the secondary research use of data and archived samples 14 . informed consent is essential for research involving human subjects. however, little is known about whether researchers manage to communicate to potential study participants the required information as outlined in the helsinki declaration. the potential participants in a developing country may be illiterate and may have limited experience with medical care and research. the researchers’ communication skills are particularly important in such situations. only a few empirical studies have addressed this issue 16 . professor dame margaret turner-warwick made the suggestion that, for treatments such as surgery where damage could potentially result, the term “informed request” should be used rather than “informed consent”. the patient is, in effect, requesting treatment and this way of putting it might put the relationship between doctor and patient on a more trusting basis. baroness o’neill said this raised the issue of whether different rituals or procedures of consent should be used according to the context that is, according to the level of risk. the risks involved, and therefore information required by the patient, are very different when taking a blood sample, when compared with having surgery, taking part in a clinical trial or having your data used in medical research. her opinion was that it was not a good idea to impose uniform procedures on how to inform the patient such as a mandatory form that needed to be filled in to prove consent was given only after the patient had been given all the relevant facts. it also raised the question of how much information a patient required to be considered “informed”. in her opinion, the amount and level of information given should be dictated by the patient, donor, or research subject, not by the physician. and it would be ethically wrong to require patients to handle a form as complicated as a mortgage application at a difficult time in their lives. not all patients want to be burdened with all the detail, while other require an in depth understanding. she emphasized that there are two parts to the issue of informed consent: the information given and the consent of the patient. the information available at a particular time influences a patient’s decision. in an ideal world, if patients can make a choice, then they should be able to rescind that decision 17 . bangladesh journal of bioethics 2014; 5(1):20-35 33 most of the participants signed informed consent forms and a vast majority felt that they received enough information before deciding to participate. on the contrary, several were not aware that they could voluntarily withdraw their participation. participants in observational studies were more likely than those in clinical trials to perceive that refusal to participate in the parent study would affect their regular medical care 18 . all the factors involved in the decision-making process described may enhance participant’s ability to exercise their autonomy and their right to choose. they may also assure research institutions that they are conducting the trials without exercising any type of coercion over the participants. therefore, it is relevant for every research setting to design strategies to ensure the confluence of volunteers’ and researchers’ interests in a harmonic and equitable way 19 . these conclusions are bound to be resisted or simply dismissed. they do propose a highly regulated, and possibly unrealistic, exchange of information, and will surely be rejected by hard core scientists, paternalistic physicians, and interested third parties. nevertheless subjects and patients must be protected, because it is perverse for biomedical practice to support regressive attitudes toward safeguarding the weak and defending the autonomy of individuals. it is also worrying to observe how bioethics is becoming ever more sympathetic to the interests of the strong and the mighty, offering arguments that favour sponsor countries, research institutions, biomedical big business, and career minded investigators. patients and research subjects must continue to be the main concern of ethics, taking care to eliminate any and all weaknesses and deficiencies from the process of providing complete and pertinent information to ensure protection of the vulnerable and unfailing respect for their autonomy 20 . the quic is a brief, reliable, and valid questionnaire that holds promise as a standardized way to assess the outcome of the informed consent process in cancer clinical trials 21 . conclusion: many accounts of informed consent in medical ethics claim that it is valuable because it supports individual autonomy. unfortunately there are many distinct conceptions of individual autonomy, and their ethical importance varies. a better reason for taking informed consent seriously is that it provides assurance that patients and others are neither deceived nor coerced. present debates about the relative importance of generic and specific consent (particularly in the use of human tissues for research and in secondary studies) do not address this issue squarely. consent is a propositional attitude, so intransitive: complete, wholly specific consent is an illusion. since the point of consent procedures is to limit deception and coercion, they should be designed to give patients and others control over the amount of information they receive and opportunity to rescind consent already given. references 1. world medical association: declaration of helsinki. in: 64th world medical assembly, fortaleza, brazil, october 2013. 2. council for international organizations of medical sciences: international ethical guidelines for biomedical research involving human subjects. 3rd edition. geneva: cioms; 2002. bangladesh journal of bioethics 2014; 5(1):20-35 34 3. bmrc ethical guideline 4. case irb guidebook 5. who (ed): operational guidelines for ethics committees that review biomedical research. 2000. 6. joffe s, cook ef, cloary d, clark n, wuky jc. quality of informed consent: a new measure of understanding among research subjects. j natl cancer inst 2001; 93:130-47. http://healthcare.partners.org/phsirb/infcons.htm (accessed on 20.11.2013 7. marshall pa: informed consent in international health research. j empir res hum res ethics 2006, 1(1):25–42. 8. vargas-parada l, kawa s, salazar a, mazon jj, flisser a: informed consent in clinical research at a general hospital in mexico: opinions of the investigators. dev world bioeth 2006, 6(1):41–51. 9. verastegui el: consenting of the vulnerable: the informed consent procedure in advanced cancer patients in mexico. bmc med ethics 2006, 7:e13. 10. mascalzoni d, hicks a, pramstaller p, wjst m: informed consent in the genomics era. plos med 2008, 5(9):e192. 11. mcguire al, beskow lm: informed consent in genomics and genetic research. annu rev genomics hum genet 2010, 11:361–381. 12. marshall pa, adebamowo ca, adeyemo aa, ogundiran to, vekich m, strenski t, zhou j, prewitt te, cooper rs, rotimi cn: voluntary participation and informed consent to international genetic research. am j public health 2006, 96(11):1989–1995. 14. chokshi da, thera ma, parker m, diakite m, makani j, kwiatkowski dp doumbo ok: valid consent for genomic epidemiology in developing countries. plos med 2007, 4(4):e95. 15. rotimi cn, marshall pa: tailoring the process of informed consent in genetic and genomic research. genome med 2010, 2(3):20. 16. lynoe n, hyder z, chowdhury m, ekstrom l: obtaining informed consent in bangladesh. n engl j med 2001, 344(6):460–461. 17. o’neill o. some limits of informed consent. j med ethics 2003; 29:4–7. 18. kiguba r, kutyabami p, kiwuwa s, katabira e, sewankambo nk. assessing the quality of informed consent in a resourcelimited setting: a cross sectional study. bmc medical ethics 2012, 13:21. 19. sanchez s, salazar g, tijero m, diaz s: informed consent procedures: responsibilities of researchers in developing countries. bioethics 2001, 15(5–6):398–412. 20. upvall m, hashwani s: negotiating the informed-consent process in developing countries: a comparison of swaziland and pakistan. int nurs rev 2001, 48(3):188–192. 21. joffe s, cook ef, cleary pd, clark jw, weeks jc: quality of informed consent: a new measure of understanding among research subjects. journal of the national cancer institute 2001, 93(2):139-47. http://healthcare.partners.org/phsirb/infcons.htm mohammad rashedul islam assistant director bbs news bangladesh journal of bioethics 2013; 4(3):34 34 bbs news course on ethical and regulatory aspects of clinical research, department of bioethics, nih, usa bangladesh bioethics society (bbs) has conducted the three months bioethics course on ethical and regulatory aspects of clinical research in collaboration with department of bioethics, nih, usa. this course was designed to provide an overview of the important issues in the ethics of human subject research for clinical investigators and others who participate in the conduct of research. five members of bbs participated in this course and successfully completed the course with credits. following are the intellectual of nih. dr. abu sadat mohammad nurunnabi, assistant professor and head, mendi dental college, dhaka. dr md. haider ali khan, asstt. professor of dental public health, dhaka dental college jyotirmoy sarker, lecturer of pharmacy, south-east university, dhaka dr. mohammad rashedul islam, assistant director (research & training monitoring department) bangladesh college of physicians and surgeons (bcps), dhaka dr. shahanaz chowdhury, assistant professor of community medicine, bangladesh university of health sciences (buhs), dhaka members of bbs in conferences in india a team of three members from bbs have attended the 14 th asian bioethics conference concurrent with ethics in emerging technologies to make lives better together from 19-23, november 2013 in chennai, india. they contributed with their scholarly written paper presentation in the conference and enhance the prestige of bbs. in addition, shamima parvin lasker, professor & head of anatomy, city dental college, dhaka , bangladesh; general secretary, bangladesh bioethics society; vice president for south asia, asian bioethics association chaired a session. following papers had been read during conference. research scandals and need of universal bioethics. shamima parvin lasker professor & head of anatomy, city dental college, dhaka , bangladesh; general secretary, bangladesh bioethics society; vice president for south asia, asian bioethics association. study of ethical issues practiced with patients in the department of surgery. md borhan uddin, prof of pharmacology, ibn sina medical college, bangladesh; member, bangladesh bioethics society. ethical perspectives on the legal dimensions of palliative care in bangladesh md. jobair alam, lecturer, faculty of law, university of dhaka; member, bangladesh bioethics society. challenges of palliative care, shamima parvin lasker , professor and head of anatomy, city dental college, bangladesh; general secretary, bangladesh bioethics society & vice president (south asia), asian bioethics association. bangladesh journal of bioethics 2015; 6(2):38-39 38 bbs’s news first ausn master of bioethics graduates: bbs signed a mou in january 2015 with american university of the sovereign nations (ausn), arizona, usa for sending its members with scholarships for one year master of bioethics & global public health (mbgph) and master of public health (mph). for the session of 2014-2015, out of 15 students, four are awarded graduation at a ceremony of 16th asian bioethics conference in manila on november 2015 along with one student from thailand. these five are the first master's degree graduates from ausn who have given their thesis defense in front of more than 100 experts from every continent assembled. i, on behalf of bbs, congratulate them for their achievements. our next graduate of mbgph at ausn will be dr arif hossain who will give his public thesis defense in december 2015 in kumamoto, japan. following have been conferred master degree: prof shamima parvin lasker, professor & head of anatomy, mh samorita medical college, dhaka & general secretary, bbs; dr. shahana dastagir, associate professor and head of the department of dental public health, city dental college, dhaka; dr. shahanaz chowdhury, assistant professor, dept. community medicine, bangladesh university of health sciences (buhs); md. jobair alam, lecturer in law, department of law, university of dhaka. photo of the graduates with their thesis examiners members of bbs are international conferences: following members of bbs attended bioethics conference abroad. rishad raihan. assistant project manager, bit mascot (pvt) ltd, dhaka. youth looking disaster (lbd 7), 27-30 october, 2015, kathmandu, nepal. tarana ahmed, system analyst, technochic limited. joint intensive bioethics course, 1 november, 2015, kuala lumpur, malaysia. bangladesh journal of bioethics 2015; 6(2):38-39 39 tamjida ahmad, research assistant, center for civilizational dialogue, university of malaya, kuala lumpur. joint intensive bioethics course, 1 november, 2015, kuala lumpur, malaysia. prof shamima parvin lasker, professor & head of anatomy, mh samorita medical college, dhaka & general secretary, bbs. 16th asian bioethics conference, 4-8 november 2015, manila, philippines. microsoft word bjb editorial 2016 (2) bangladesh journal of bioethics volume 7, issue 2, 2016 editorial hello readers! hope everyone is fine especially in this season where we often are prone to attacks of cold or flu. the holiday season is at our threshold, and we wish everyone to be in the best of health and happiness. this issue of the bjb is very interesting with topics stretching from non communicable diseases to the ethical issues related to the habitation of the planet mars, and proves how forward looking are our readers and authors. mohammad rashedul islam et al discuss the application of the sara method in a district in bangladesh. the method is based on the principle of service availability and readiness assessment of who. the study in a district in bangladesh found that about 62% of all the facilities were ready to provide general services like basic amenities with basic equipment, standard precautions for infection prevention, diagnostic capacity and essential medicines. however in case of non-communicable diseases (ncd), only 40% of the health facilities had chronic respiratory disease and cardiovascular diseases diagnosis/management and only 32% had availability of diabetes diagnosis/management. therefore, service availability and readiness of the health facilities to provide ncd related health services were not satisfactory. the authors emphasize that sara which is a tool to monitor facilities to be ready for provision of services including ncd, should be used by all clinic managers. the very scientific and forward looking article titled “scnt method and the application for patent eligibility on cloned animals” by norman k. swazo reviews us federal court decisions regarding applications for patent in the case of live-born animal clones. a decision issued from the united states court of appeals for the federal circuit established an earlier decision of the patent trial and appeal board that live-born animals cloned by the somatic cell nuclear transfer method (scnt) like cattle, sheep, pigs, and goats are not patentable, so a scientist using the method is not eligible for a patent claim on the animals. the author feels that this decision has ethical implications related to the moral status of cloned animals. the author argues whether the end product of a scnt (somatic cell nuclear transfer) application is same as an invention or only a revelation of nature at the cellular level. the author quotes article 11 of universal declaration on the human genome and human rights undhgr “practices which are contrary to human dignity, such as reproductive cloning of human beings, shall not be permitted.” he concludes that the judicial assessments in the usa deciding on the question of patenting of animal clones provide important barriers to human reproductive cloning research, safeguarding moral and legal commitment to human dignity. bangladesh journal of bioethics volume 7, issue 2, 2016 the article on ethics in public health research and clinical research by muhammad waseem khan et al discusses on the need to continue to focus on ethical values in conducting any research. tha authors stress the importance, either in public health research or clinical research, of the need to recognize an ethical standard that respects individual’s autonomy and community’s wellbeing. this can be achieved through collective collaboration for the protection of individual’s autonomy, dignity and wellbeing. research ethics is a fundamental criterion to be complied with throughout a research study. the very interesting article on planetary protection for mars: time for reconsideration by svetoslav alexandrov looks into the ethical questions beyond mother earth but which could be affected by people from our planet. in this manuscript the author discusses the ethics of the protection of hypothetical organisms on mars in terms of planned manned space missions and subsequent colonization. the author discusses the possible problems related to a process called terraformation where the planet is converted to make it suitable for earth life. he argues that terraformation will change the whole condition of the planet. the author quotes carl sagan, of the planetary society: “if there is life, then i believe we should do nothing to disturb that life. mars then, belongs to the martians, even if they are microbes” .i think we all agree with this brilliant recommendation. the article ‘we still need to improve our research writing ethics’ by sheikh arslan sehgal looks into the value of maintaining professional integrity of research work. particularly with issues like plagiarism, ethics, authorship and data fabrication. he argues that the scientific community must obey the scientific ethical norms and rules. he feels that ethical problems must be resolved for the advancement of research in countries including pakistan. the author recommends teaching students the international, institutional and professional standards regarding research and authorship issue. thus from the beginning researchers will know the key components of ethics in conducting research and the end product will be research work of quality and acceptability. dear readers, we look forward to your articles, commentaries, observations on different issues which touch our lives and will help in broadening our knowledge and understanding of bioethics. season’s greetings! tahera ahmed editor bangladesh journal of bioethics bangladesh journal of bioethics 2015 vol.6 (1):22-26 22 crispr/cas9-mediated editing of human β-globin gene in human cells: a commentary on the research ethics norman k. swazo, ph.d., m.h.s.a. department of history and philosophy north south university bashundhara r/a 1229, dhaka, bangladesh email: norman.swazo@northsouth.edu abstract: recently, chinese researchers published the results of their research using a gene-editing technology on abnormal human zygotes. the research team believes this research has prospective clinical application, viz., for gene therapy for β-thalassemia, a white blood cell disorder, and plan to persist with further studies, despite technical problems in this experiment. the research has elicited international criticism from both scientific and bioethics domains, because it innovates beyond the current global consensus against human germ line modification. this paper comments on some ethical issues presented by the research report and concludes that, under present circumstances, the chinese research team did not meet a standard of scientific responsibility. keywords: crispr/cas9; human germ line modification; ethics; china; gene-editing technology reporting: on 01 april 2015, chinese researchers puping liang et al. (from the guangdong province key laboratory of reproductive medicine, sun yat-sen university), published a research article in the journal protein & cell, reporting the results of an experiment using a gene-editing tool known as crispr/cas9 (clustered regularly interspaced short palindromic repeats/cas9, the “editing” enzyme) 1 . this experiment used polyspermic human zygotes, specifically tripronuclear (3pn) zygotes (i.e., zygotes having one oocyte nucleus and two sperm nuclei) that are not viable for human reproduction and which are, therefore, discarded during in vitro fertilization (ivf). the authors in this case pursued their research opining that, 3pn zygotes provide “an ideal model system to examine the targeting efficiency and off-target effects of [the] crispr/cas-9 [gene editing tool used] during early human embryonic development.” the scientific team here is concerned with eventual therapeutic application of the technology for treatment of β-thalassemia, a disease that involves mutations of the β-globin gene. the therapeutic task is to “repair” the mutation with gene-editing techniques, hence the choice here of crispr/cas9 for that purpose. the results of the experiment showed 28 of 54 embryos cleaved by the cas9 enzyme (~52% efficiency). the genetically edited embryos were “mosaic”—the significance of which is that “it would be impossible to predict gene editing outcomes through pre-implantation genetic diagnosis (pgd).” there were also “notable off-target effects.” the research team estimated an editing efficiency of 25%, then cautioned that the “high rate of repair using endogenous sequences presents obvious obstacles to gene therapy strategies using crispr/cas9,” i.e., “unwanted mutations” being the most obvious. the authors interpret the results to mean that there is need for “further investigation of the molecular mechanisms of crispr/cas9-mediated gene editing in human model.” the most important cautionary note here is that the “off-target effect of crispr/cas9 should be investigated thoroughly before any clinical application.” mailto:norman.swazo@northsouth.edu bangladesh journal of bioethics 2015 vol.6 (1):22-26 23 in a section of the paper entitled, “compliance with ethics guidelines,” the authors declare that the study (1) “conformed to ethical standards of the helsinki declaration, (2) “was approved by the medical ethical committee” of the affiliate hospital, and (3) the 3pn zygotes were donated with “signed informed consent forms.” informed consent and human subjects (irb) review are standard requirements for this kind of research, of course. the helsinki declaration, revised most recently in october 2013, addresses human subjects research and, pertinent to this experiment, “research on identifiable human material” 2. thus, the authors signal their responsibility relative to “applicable international norms and standards,” including “generally accepted scientific principles.” in this sense, then, it would seem the research conducted here is not prohibited either by extant applicable international norms and standards or by any applicable generally accepted scientific principles. discussion: notwithstanding, the foregoing summary of experimental results raises any number of ethical questions. the most important concerns the fact that the research team decided to use human embryos, albeit ivf-discarded abnormal polyspermic zygotes. citing earlier experimental work, the authors recognize there has been “great progress in understanding the utilization of crispr/cas9 in a variety of model organisms,” in which case it is clear that current research designs can investigate the molecular mechanism of crispr/cas9 and progress adequately when undertaken in model organisms other than human embryos 3 . the latter point is significant in view of ethically grounded caution about human germline modification that can occur through genetic manipulation of human zygotes. for example, anticipating this publication from the chinese team, a number of researchers published their perspective in the journal science on 19 march 2015, recommending appropriate caution because “crispr/cas9…can be used to change the dna in the nuclei of reproductive cells that transmit information from one generation to the next (an organism’s ‘germ line’),” thus because of “unknown risks to human health and well-being” that are consequent to germ line modification 4 . the caution pronounced by this group is grounded on known results from in vivo research (using mice and monkeys). the authors of the science paper are correct to point to a fundamental question that requires some answer prior to proceeding with the use of such technology in human models—even if such models are abnormal 3pn zygotes: is the treatment or cure of severe disease in humans (e.g., β-thalassemia, for which the chinese team anticipated prospective application of the crispr/cas9 technology) a responsible use of genome engineering? if so, under what circumstances is the use of this technology responsible (e.g., those circumstances clinically identifiable for a disease such as β-thalassemia)? by proceeding with their research design, the chinese team presumes that use of this technology for a disease like β-thalassemia is a morally responsible use. but it is not clear that one can argue defensibly that once the technique’s efficiency is assured, with the risk of off-target mutations reduced measurably or predictably, one can move to clinical application. that presumption is not morally warranted as long as non-human animal models are available for testing the molecular mechanism of the technology, especially since it is also unclear, as the science authors warn, that there may be “on-target events that have unintended consequences” 5. thus, the recommendation to discourage germ line modification research is indeed morally compelling, thus making any continued research involving abnormal human zygotes as used by the chinese team prohibitive for the time being. another group, publishing in nature on 12 march 2015, argued that, given “unpredictable effects on future generations” that follow from use of “genome editing in human embryos using current technologies,” not to mention that this type of research “could be exploited for non-therapeutic modifications,” therefore this research is “ethically unacceptable” 6 . so long as there are other non-human organisms that can serve as effective models for this kind of research, it is generally thought that there is no scientific or moral warrant for use of such geneediting technology on human embryos. thus, the appeal is to (a) generally accepted scientific principles, (b) the bangladesh journal of bioethics 2015 vol.6 (1):22-26 24 current standard of research in animal models such as mice, rats, monkeys, cattle, sheep, and pigs, as well as to (c) morally relevant assessments of benefit (safety, efficiency) and risk (unintended and unpredictable adverse harm from on-target editing and off-target mutations). the chinese research clearly ventured beyond currently accepted research models, these models providing the responsible-use “paradigm” according to which researchers demonstrate their compliance with internationally sanctioned norms. as the nature authors write, “all techniques currently in various stages of clinical development focus on modifying the genetic material of somatic cells, such as t cells (a type of white blood cell)”—thus, not human reproductive cells (i.e., “germ” cells— sperm and ova) [italics added] . the chinese “innovation” ventures well beyond currently permissible research even for the disease of concern, e.g., intravenous transfusion of modified t cells in patients having βthalassemia. the publication has prompted numerous scientific and ethical commentaries from the public at large. the center for genetics and society (a prominent public interest advocacy organization in the usa) calls for strengthened global policies designed to constrain and restrain germ line modification. the center’s executive director underscores the central concern: “no researcher has the moral warrant to flout the globally widespread policy agreement against altering the human germline” 7. this opinion is supported independently, given the statement on germ line genome modification issued by the international society for stem cell research, dated 15 march 2015, which “calls for a moratorium on attempts at clinical application of nuclear genome editing of the human germ line to enable more extensive scientific analysis of the potential risks of genome editing and broader public discussion of the societal and ethical implications” 8. so long as properly regulated gene-editing research can be done in human somatic tissues, there is no need for basic research on human germ cells, thus allowing appropriate opportunity for public deliberation about the ethical, legal, and social implications of such technology. similarly, the council for responsible genetics has issued its position paper on human germ line manipulation, acknowledging that, “given what has been accomplished in animals and the availability of in vitro fertilization, there appear to be no technical obstacles to initiating germ line modification experiments in humans” 9 . but, the council “strongly opposes the use of germline gene modification in humans,” based on “scientific, ethical, and social concerns”—the “scientific,” including inefficiency of techniques used in mammals, unintended adverse harm observed in mouse models (e.g., mice lacking eyes, lacking “the semicircular canals of their inner ears”), and, yet more problematic, “developmental disruptions in the manipulated embryo itself;” the “ethical,” including the fact that foregoing pregnancy, prenatal genetic diagnosis, abortion, and adoption are morally defensible options; “social,” in the sense of identifying and implementing relevant social measures that are enabling, short of genetic enhancement. at issue in the foregoing discussions is a concern for scientific integrity in such research and thus what a report published by the american association for the advancement of science (aaas) in the year 2000 called “balancing scientific freedom and responsibility”10. it is important to note here that public “policy” is generally regulatory oversight that does not entail “proscription” in the sense of an “explicit ban,” in which case governmental regulatory authorities are free to alter the current global consensus against human germ line modification. in the case of china, the government’s “guidelines on human assisted reproductive technologies” (2003) prohibit using “human egg plasma and nucleus transfer technology for the purpose of reproduction, and manipulation of the gene in human gamete, zygote, or embryo for the purpose of reproduction” 11 . the chinese research team can argue that they have been compliant with national policy. however, as frankel and chapman argue, “to act responsibly…with respect to igm [inheritable genetic modifications] means not engaging in such bangladesh journal of bioethics 2015 vol.6 (1):22-26 25 research until public regulatory mechanisms are in place to review proposals, while also supporting educational efforts to help scientists and the public to consider the broader implications of the research” 12. conclusion: clearly, the question about public regulatory mechanisms is not a matter to be governed only by national guidelines, even if the research is not directed towards human reproduction as such. it is research that must be responsive to global policy concerns about human germ line modification, precisely because this is a transnationally human interest that is not contained by sovereign political right or nationally derived public policy. the chinese researchers have not exercised their scientific freedom according to this concept of responsibility, in which case one can only conclude that this particular research should not have been done at this particular time. references: 1. liang p, xu y, zhang x, ding c, huang r, zhang z, lv j, xie x, chen y, li y, sun y, bai y, songyang z, ma w, zhou c, huang j. crispr/cas9-mediated gene editing in human tripronuclear zygotes. protein & cell, 2015. 18 april. doi: 10.1007/s13238-015-0153-5. 2. world medical association. ethical principles for medical research involving human subjects, 64 th wma general assembly, october 2013. http://www.wma.net/en/30publications/10policies/b3/, accessed 26 april 2015. 3. liang p, xu y, zhang x, ding c, huang r, zhang z, lv j, xie x, chen y, li y, sun y, bai y, songyang z, ma w, zhou c, huang j. crispr/cas9-mediated gene editing in human tripronuclear zygotes. protein & cell, 2015. 18 april. doi: 10.1007/s13238-015-0153-5. 4. baltimore d, berg p, botchan m, carroll d, charo ra, church g, corn je, daley gq, doudna ja, fenner m, greely ht, jinek m, martin gs, penhoet e, puck j, sternberg sh, weismann js, yamamoto kr. a prudent path forward for genomic engineering and germline modification. science, 2015; 348(6230):36-38. http://www.sciencemag.org/content/348/6230/36; accessed 26 april 2015. 5. baltimore d, berg p, botchan m, carroll d, charo ra, church g, corn je, daley gq, doudna ja, fenner m, greely ht, jinek m, martin gs, penhoet e, puck j, sternberg sh, weismann js, yamamoto kr. a prudent path forward for genomic engineering and germline modification. science, 2015; 348(6230):36-38. http://www.sciencemag.org/content/348/6230/36; accessed 26 april 2015. 6. lanphier e, urnov f, haecker se, werner m, smolenski j. don't edit the human germ line, nature, 12 march 2015. http://www.nature.com/news/don’t-edit-the-human-germ-line-1.17111; accessed 26 april 2015. 7. center for genetics and society, public interest group calls for strengthening global policies against human germline modification [press statement], 22 april 2015, http://www.geneticsandsociety.org/article.php?id=8528; accessed 26 april 2015. 8. international society for stem cell research, the isscr statement on human germline genome modification, 19 march 2015, http://www.isscr.org/statement-on-human-germline-genome-modification, accessed 26 april 2015. 9. council for responsible genetics, position paper on human germline modification, 2001, http://www.councilforresponsiblegenetics.org/viewpage.aspx?pageid=101; accessed 26 april 2015. 10. frankel, m.s., chapman, a.r., human inheritable genetic modifications: assessing scientific, ethical, religious, and policy issues, american association for the advancement of science, september 2000; http://www.aaas.org/sites/default/files/migrate/uploads/germline.pdf http://www.wma.net/en/30publications/10policies/b3/ http://www.sciencemag.org/content/348/6230/36 http://www.sciencemag.org/content/348/6230/36 http://www.nature.com/news/don't-edit-the-human-germ-line-1.17111 http://www.geneticsandsociety.org/article.php?id=8528 http://www.isscr.org/statement-on-human-germline-genome-modification http://www.councilforresponsiblegenetics.org/viewpage.aspx?pageid=101 bangladesh journal of bioethics 2015 vol.6 (1):22-26 26 11. ishii, t. potential impact of human mitochondrial replacement on global policy regarding germline gene modification. 2014, reproductive biomedicine online, 2014, 29:150-155; http:dx.doi.org/10.1016/j.rbmo.2014.04.001; accessed 26 april 2015. 12. frankel, m.s., chapman, a.r., human inheritable genetic modifications: assessing scientific, ethical, religious, and policy issues, american association for the advancement of science, september 2000; http://www.aaas.org/sites/default/files/migrate/uploads/germline.pdf conflict of interest: no conflict of interest to report. microsoft word g v quinones singerian vegetarianism and the limits of utilitarianism bangladesh journal of bioethics 2016; 7(3): 46-57 46 original article singerian vegetarianism and the limits of utilitarianism: a path towards a meaning ethics gabriel vidal quiñones pontifical catholic university of chile, chile email: gtvidal@uc.cl abstract: the advent of the technological era put us in a radically different position against nature, because the whole biosphere can now be affected by our actions. therefore, even though non-humans always had moral significance, only recently we start to realize their importance. so, we recognize them as morally significant much more than before. this brings a renewal to, and makes more patent than ever, the discussion over vegetarianism, since it challenges our view on the relation between human beings and other sentient beings. in utilitarianism and vegetarianism, peter singer tries to answer the question through the conceptual resources of utilitarianism. in contrast, we shall try to show that the issue of vegetarianism can start to be solved better in an ethical consideration that transcends the merely prescriptive. key words: vegetarianism, animal ethics, utilitarianism, hans jonas, peter singer, food ethics. introduction: in this paper, i will try to show that singer’s arguments in favour of vegetarianism are insufficient to resolve the controversy over eating meat, as long as they are exclusively supported on a utilitarian basis. this is because the problem, as i shall demonstrate later, exceeds the limits of utilitarianism. overcoming these limits leads us to further ethical considerations that show the necessity of rethinking our relationship with nonhuman animals in a way that is not merely normative, i.e., considerations that solely prescribe rights and wrongs from a merely regulatory perspective. i will try to shed light upon what kind of ethical reflection is necessary to answer the question, namely, if is morally acceptable to eat animals, through the concept of ethical vision, which i shall explain later on. i shall start by recalling singer’s main arguments. next, i will subject them to a plausible objection, proceeding under the conceptual background of utilitarianism as well and showing how this exercise takes us to a dead point. finally, from this impossibility of knock-out arguments, it will be shown what kind of reflection is necessary to shed light on the issue of our food ethics in relation to the ethical vision. singer’s utilitarian arguments for vegetarianism: in utilitarianism and vegetarianism, singer argues that, from a consistent utilitarian position, it follows that, given the contemporary state of factory farming, one should abandon meat-eating and become a vegetarian. so, at the beginning of his essay he says: “i’m a utilitarian. i’m also a vegetarian. bangladesh journal of bioethics 2016; 7(3): 46-57 47 i’m a vegetarian because i am a utilitarian”1. for singer, taking animals into consideration is a simple and obvious corollary of the principle of utility, as he states: when we apply utilitarianism to the issue of how we should treat animals, one vital point stands out immediately. utilitarianism, in its classical form, aims at minimizing pain and maximizing pleasure. many nonhuman animals can experience pain and pleasure. (perhaps some simpler forms of animal life cannot, but i shall leave this qualification aside.) therefore, they are morally significant entities. they have moral standing. in this respect they are like humans and unlike rocks2. nonetheless, as he starts supporting such a position, it becomes clear that the relation between animal suffering and vegetarianism does not seem to result in an obligatory prescription. even though his arguments increase the plausibility of vegetarianism as a more compassionate lifestyle, he cannot prove its mandatory character, because apparently there are no knock-out arguments against meat-eating. now, i shall analyse singer’s arguments and give some counterarguments against them, showing how this procedure leads us to a point where it seems that both positions can equally be sustained under a utilitarian standpoint. one of the pivotal singerian arguments shows that the universal adoption of vegetarianism and the consequent elimination of factory farming would maximize pleasure, and this is because, when considering advantages and disadvantages, the consequentialist calculation results in a positive balance in favour of vegetarianism. nonetheless, it is possible to dissolve each part of the argument providing some alternatives that could equally maximize pleasure: a) the end of factory farming reduces wastes and contamination from industrial production: one can answer to this that vegetarian and carnivorous industries can be equally contaminating if production is irresponsible. a sustainable meat industry is perfectly possible. an adequate management of wastes and resources is something that both kinds of industries can perform, so, contamination is not an intrinsic characteristic of meat production. an exploration of a possibly sustainable meat production can be found in simon fairlie’s meat, a benign extravagancy3. b) the elimination of industrial farms releases a huge amount of high quality vegetable food that could feed the hungry and marginal human populations, instead of feeding animals for meat production: one can say that the problem of hunger is not the scarceness of food, but an inefficient and negligent distribution of it. while some have excess food, others do not have enough. a righteous distribution of food restores a positive balance of pleasure, and one can provide for this end vegetable foods as well as food from animal sources. c) even though the most important factor in this calculation is animal suffering, the utility of people involved must be taken into consideration too, as singer does in his argument. singer points out that working in an industrial factory farm is obnoxious and psychologically harming for workers: this issue is not intrinsically related to all factory farming, in a similar way presented in a), since one can have poor working conditions in a carnivorous industry as well as a vegetarian one. cruelty-free farms bangladesh journal of bioethics 2016; 7(3): 46-57 48 can be created or simply an adequate administration of human resources can be performed. i think this exercise can be applied to most of the arguments in utilitarianism and vegetarianism, so i shall not go further with it to prove the point. nonetheless, this does not reduce their legitimacy at all, because my hypothetical objections operate only through plausibility as well, and not as knockout arguments. through this, one can see that, in the defence or abolishment of vegetarianism, we would arrive at a dead end from the point of view of utilitarianism, since there are a lot of alternatives that equally maximize utility. singer seems, in fact, to concede this point at the end of his essay when he says: finally, becoming a vegetarian is a way of attesting to the depth and sincerity of one’s belief in the wrongness of what we are doing to animals. perhaps in a society of sophisticated philosophers there would be no need to attest to one’s sincerity in this way, because sophisticated philosophers would understand that one can sincerely oppose the exploitation of animals in factory farms while continuing to buy and enjoy the product of these very farms. but to most of the members of our society this would mean, as it seemed to oliver goldsmith’s fictitious chinese traveler, a “strange contrariety of conduct”4. however, one can stretch the sort of alternatives mentioned earlier even further, as evelyn pluhar does in meat and morality, where she explores methods such as in vitro meat production5. this method can unpainfully extract some stem cells from animals, and then produce meat in a laboratory with completely cruelty free conditions; with such a method, animal life is not disturbed at all. an exploration through this kind of alternative, from the point of view of a utilitarian calculation, may be very fruitful, but can also be very unappealing to some sensitivities outside of a utilitarian outline, as she says: granted, the initial reaction of many meat-eaters to the in-vitro meat initiative is repulsion. an unscientific poll conducted by this author elicited comments such as “that’s disgusting!” and “who knows what they would put in that stuff?” they envision meat cells replicating like mold in a laboratory, injected with dubious additives by white-coated frankensteins. currently, production does involve a queasiness factor: cells mature in “fetal bovine serum.” researchers are at work substituting a plant-based nutrient agent, however, well aware that this would be advantageous in marketing the product to erstwhile vegetarians as well as meat-eaters with humane concerns6. however, there could be more reactions that do not exclusively consist in mere disgust, especially if we take into consideration religious and conservative beliefs, conceptions with a stronger underlying anthropology or moral theories whose main criteria is not pain and pleasure. in this sense, such methods can raise even more complicated ethical and anthropological problems than factory farming, concerns the principle of utility does not take into account as long as their consequences maximize pleasure. even more, if our humane bangladesh journal of bioethics 2016; 7(3): 46-57 49 concern for animals is solely based on suffering and rights derived from it, one could perfectly ask: why not produce human meat in vitro? in this manner, there is no risk of somehow violating animal interests in any way, since no pain or invasion on animals is at play at all. this way, humans, who are the ones interested in consuming meat, put themselves unpainfully as resource for meat production without causing any suffering or invasion to other species. if meat can be produced from human stem cells, this would be a really good solution from a point of view concerned with animal suffering. but evidently, such a provocation is not ethically neutral at all, since most people would be really perturbed by such a possibility, even though one cannot articulate significant reasons for this disgust immediately that are related to our intuitions over human nature. is not my intent with this argument to support an ethical view purely based on intuitions, but to show how intuitions give rise to ethical reflections that can eventually be supported by reason or rejected, because, as michael sandel points out, is difficult to find significant reasons for our unease7. in this sense, rejection of animal suffering shows itself, initially, as a pre-moral unease that is not yet clearly articulated. later, the rationally-driven agent tries to articulate significant reasons for this concern, as singer does. therefore, in a similar way as sandel in the case against perfection8, the starting point of our considerations for the limited purposes of this paper will be our intuitions, and in this sense, it has pre-moral components; this does not mean that further development of the concepts proposed here will remain at this stage. so, in the next section, i will try to provide a conceptual resource that can help to articulate our concern which is related to animal suffering and that utilitarianism seems to not take into account. the ethical vision: if one takes a look at aristotle’s ethics of virtue, one can see two distinct aspects come into play. in the first place, a set of principles that prescribe good actions, in this case virtuous actions, are provided. through the middle within two extremes and other principles, action is restricted to a certain frame of legitimacy, and in this sense, this part of the theory is normative or prescriptive. however, one can also see that these principles are related to a prefigured image of the subject’s life as a whole. the means and ends are chosen by the subject in order to fulfil the content of this image under the guidance of virtues. in this sense, the second component of aristotle’s ethics is concerned with meaning, rather than setting prescriptive principles, and as macintyre points out “generally to adopt a stance on the virtues will be to adopt a stance on the narrative character of human life”9. the image described is not a merely abstract outline, but is filled with concrete representative content, for example, a dream of certain career that drives a student’s life. however, one can detach this conceptual background from aristotle’s specific interpretation of virtues and happiness. in this sense, ethics in general can have this prescriptive aspect and another concerned with meaning. the first is concerned with providing a set of a priori principles that determine which actions are good or evil. the second aspect analyzes a posteriori the representative content of our life as a totality of meaning. i shall call this representative content ethical vision, which contains different narratives that guide our actions in an intelligible way. this is because “behavior is only characterized adequately bangladesh journal of bioethics 2016; 7(3): 46-57 50 when we know what the longer and longest-term intentions invoked are and how the shorterterm intentions are related to the longer. once again we are involved in writing a narrative history.”10 this guidance is not only restricted to the personal level, but extends to the interpersonal as well because, as macintyre explains, “[w]e cannot, that is to say, characterize behavior independently of intentions, and we cannot characterize intentions independently of the settings which make those intentions intelligible both to agents themselves and to others.”11 this adds an intersubjective function to the ethical vision. generally, if we find someone whose behavior is not intelligible from the point of view of our shared narratives, we most likely will be unable to recognize this person as a morally significant agent; in this sense they are moral strangers. detached from aristotle’s particular point of view, an ethical vision can vary in length, since it can go from the wishes of self-realization of some subject to the grand narratives that underlies a strong political or religious belief. in this last sense, it can be similar to those grand narratives the postmodern condition rejects12. it is true that an ethical vision could actually consist in a teleological explanation of history but, as described earlier, since they vary in length, not all ethical visions are grand narratives. so, i shall state that a grand narrative is a certain type of ethical vision. therefore, the concept of ethical vision does not commit us to the postmodern condition criticism, since the latter rejects an ultimate meaning behind history, but not every possible way of meaning behind actions. one could say then, more specifically, that the ethical vision has grades that vary from the local and particular point of view of a subject to a universal position, or from biography to eschatology. as explained above, ethical vision has a crucial importance, because it provides meaning and a common ground to actions that, without its guidance, appear just as unconnected events with no moral relevance. in other words, its absence might result in the conclusion of pure nihilism or a human condition of mere automatism. an otherwise unconnected series of events acquire moral significance when an ethical vision underlies them. from the former description one can easily infer that an ethical vision underlies singer’s argumentation as well. to determine its content completely, one should ask the author for it, but i shall tentatively describe it. i think the ethical vision behind singer’s argumentation consists, at least, in a certain spiritual status or humane consideration for animals, and a relationship with humans that follows from this status. from this point of view, it seems that animal liberation is a much clearer testament of singer’s ethical vision. what renzo llorente says could support this, as he explains: what does prove surprising, however, is the frequency with which even professional philosophers have misconstrued or misstated some of animal liberation’s central theses. the most common error among professional philosophers no doubt consists in the belief that the moral argument advanced by animal liberation is based on utilitarianism, or – what in effect amounts to the same thing – the tendency to analyze the book as though its normative basis were utilitarian, when in reality the views defended in animal liberation are derived, at bottom, from the principle of nonbangladesh journal of bioethics 2016; 7(3): 46-57 51 maleficence, i.e. “not causing harm”, and the principle of “equal consideration of interests”13. this further emphasizes that utilitarianism is not the only resource for justifying vegetarianism in singer’s philosophical framework, but neither just a set of principles for a mere logical exercise. i think singer actually envisions a certain world that he considers morally ideal. i shall argue, then, that in utilitarianism and vegetarianism the intuitions of his ethical vision tend to slip in too, even though he clearly states his intention to base vegetarianism exclusively in the principle of utility and equal consideration of interests. in the passage of citizen of the world, quoted at the beginning of utilitarianism and vegetarianism, where humans being are described as tender and compassionate beings, his vision seems to be suggested14. also, when he criticizes the consideration of animals as mere means to an end and gets accused of being a kantian, but he quickly moves back to avoid betraying the exclusivity of the principle of utility: this is a “slippery slope” argument: no matter how humane our original intentions, as long as we continue to eat animals there is a danger of our sliding back into the methods of treating animals in use today. [...] i may have been insufficiently critical of my own use of the argument, but i have not become a kantian15. the limits of utilitarianism: the reason why it seems possible to give good arguments in favour and against vegetarianism lies in the fact that we have reached what seems to be the limits of utilitarianism. it is not my intent to discredit this ethical theory at all, but to reorientate its application context. utilitarianism is supposed to be a regulatory framework for our actions, it tells us when an action is right or wrong, but is not able to provide an ethical vision. for this reason, it is possible to propose very different states of affairs which could result in the same calculation of total pleasure, and this is why all the alternatives proposed in the former sections apparently stood with equal ground against singer’s arguments. the best alternative according to its consequences, at this point, gets out of our grasp, and so it is very difficult to solve the issue from a utilitarian point of view. the principle of utility is applied to an already given situation or to the methods one chooses to carry out a certain goal. it orients us to take the best choice with regard to a certain ethical dilemma, but the same thing that assures the freedom of the subject in utilitarianism is what prevents it from solving the issue of vegetarianism: the fact that it abstains from determining the content of the ethical vision. one can carry out whatever vital plan one chooses, as long as it goes along with principle of utility, and one can be a vegetarian or a meat-eater as long as one proceeds in a way that actually preserves a positive balance in the total amount of pleasure. so, with regard to the singerian question, namely, whether utilitarianism commits its adherents to the obligatory practice of vegetarianism, i think the answer is negative. anyway, this does not mean we should give up completely any attempt to solve the issue and abandon the decision of being a vegetarian to mere personal preference. for similar reasons as those bangladesh journal of bioethics 2016; 7(3): 46-57 52 that i have pointed out, jordan curnutt proposes an argument for vegetarianism which dispenses of pain or utility as a main criteria16. ethics as a normative frame and as meaning ethics: i consider utilitarianism to be a normative frame, in the sense that what it does is prescribing the right action for every choice we make. it enables us to distinguish quickly and exactly the right from the wrong choice. however, is not a meaning ethics, in other words, it does not tell us what our plan for a good life should be, how we should interact with others fruitfully, how we should represent us the world as a utopian place, etc. in this sense, a normative frame could be defined as a set of principles or guidelines that indicates when an action is right or wrong, in the case of utilitarianism being the principle of utility. on the other hand, i shall define a meaning ethics as the reflection which enable us to critically fill with ideal representations a certain ethical vision. it is an anthropological, creative, and critical reflection over the narratives behind our moral representations and actions. i think the controversy over vegetarianism can be greatly clarified under this understanding of ethics, since it concerns a new relationship, still in development, between human and non-human beings. even though we have always eaten animals, now they are subject to production through technology in a global-scale way. also, even if animals always had moral significance, one can argue that only recently we have started to realize it, especially taking into consideration how new the animal liberation movement is. the overwhelming advance of technics that led to the technological era, has transformed the preceding character of action where, according to hans jonas, “action on non-human things did not constitute a sphere of authentic ethical significance”17. so, the field of meaning in which our actions had been taking place was established long ago and we take this field for granted, as a given fact. for example, all of us, in a certain way, presuppose that other human beings have certain dignity or that we, at least, owe them some respect, even if it is for instrumental reasons because, otherwise, we would live in a state of war. the context in which this takes place has an underlying common ground for our ethical visions to coexist, a common narrative of elements and values we mostly agree on. as jonas states: the effective range of action was small, the timespan of foresight, goal setting and accountability was short, control of circumstances limited. proper conduct had its immediate criteria and almost immediate consummation. ethics accordingly was of the here and now, of occasions as they arise between men, of the recurrent, typical situations of private and public life. [...] all enjoinders and maxims of traditional ethics, materially different as they may be, show this confinement to the immediate setting of the action. “love the neighbour as thyself”; “do unto others as you would wish them to do unto you”; “instruct your child in the way of truth”; “strive for excellence by developing and actualizing the best potentialities of your being qua man”; “subordinate your individual good to the common good”; “never treat your fellow man as a means only but always also as an end in himself” and so on18. bangladesh journal of bioethics 2016; 7(3): 46-57 53 when someone has a different narrative as ground for his ethical visions, we usually consider them moral strangers, for example, a person who has no empathy or care for other human beings, and has a dream to be a serial killer. the alluded narrative has been developing, probably, since the birth of civilization, and so it is deeply implanted in our behaviour; please concede this very hasty historical consideration. however, this narrative is no longer adequate for our current situation since, as jonas points out, our relationship with nature has radically changed. the recent advances of technology are gestating a new milestone, maybe as relevant as the agriculture revolution: the technological revolution, whose extent is still on the horizon. but basically, it introduces a new narrative where morally relevant actions are no longer restricted to the interpersonal, but have consequences for the whole biosphere. human action transcends its immanency and starts to affect non-humans. so nature is no longer an infinite, indomitable, and inexhaustible resource. now, it shows a vulnerability that demands that we act as responsible agents19. because of this, we should renovate the ontology behind our ethics, namely, rethink what the elements that constitute our current narrative are. before, the answer was clear: the elements of this ontology were men, groups of men, and immediate consequences. now, the answer is not so clear. we know how humans play their part in this narrative, but we have no idea how to think of or relate to non-humans, and this includes non-human animals. a somehow unreflective history led us to the previous narrative, we did not choose it because it was provided by our circumstances. but now, it is in our hands to critically acquire our new narrative, because we have an increasingly hegemonic position over our environment, so it no longer imposes on us a certain narrative. finally, we need a meaning ethics that displays the new scenario for morally relevant actions. i think under this kind of ethical reflection the discussion over vegetarianism should be placed, because it questions a critical point concerning our new moral narrative, namely, which is our relationship to non-humans that are sentient. this last dimension has a huge existential value, since pain and pleasure are critically significant components of our lives. so, viewing ourselves as large-scale agents of pain through meat production is something that inevitably shocks our sensitivity and lead us to some sort of self-criticism. our previous narrative provided an easy ground to condemn actions such as murder, cannibalism, and others, but is unable to afford any data to judge condemnable actions affecting non-human animals. in this incipient technological era, it is decisive that we put our efforts on comprehending the new extent of human action, so we can provide an adequate narrative for the changes it brings and lead our ethical visions towards the common ground of a desirable future. so, if we were to ask, “which values and principles should guide our interaction with other animals and the whole biosphere”? i would advance that i consider, at least, unappealing a future where we become insensitive and cruel beings, or one where we completely run out of the resources of our planet. the specific normative frame, namely, the specific set of guidelines for our actions, are to be discovered after we deeply meditate through a meaning ethics, but should be in line with the sentiments and self-image of humanity, and the dangers described earlier. bangladesh journal of bioethics 2016; 7(3): 46-57 54 i consider a very remarkable effort in this line the one discussed in a. g. holdier’s the pig’s squeak. he demystifies a connection between ethics and aesthetics as a mere sentimentalism that roughly can be described as “[t]his sentiment that effective arguments must be existentially satisfactory as well as logical if they are to spark genuine change [...]”20. i would add that these kinds of considerations, that may include different sentiments such as compassion, empathy, guilt, disgust, etc., should be taken seriously in any philosophical account, since they provide data for how we could represent animals in our new narratives. in this sense, i think we must put aside the idea that invoking these reasons are mere fallacies or irrelevant personal preferences. a very advanced and developed form of the meaning ethics i propose here is the deep ecology theoretical framework, by arne naess, because it performs an exhaustive and radical revision of the relation between humans and the whole biosphere21. deep ecology insights provide a renewed ontology that takes into account living beings in a way that is adequate for the current situation of the planet. so, it can shed light on the consequences and dangers of the advent of a technological era, and our relationship with other animals. however, extending more about this subject would fairly exceed the pretensions of this essay. finally, if we were to ask, “is there a sound justification for the common view that humans have a higher moral status than other animals, or is this a view we should no longer accept?,” i think that from the point of view of a meaning ethics, one should answer a different question first, namely, how we should treat animals, because this can shed light on the moral status of non-human animals. we have to ask in what way we see ourselves coexisting with other animals and what moral sentiments we can have towards them, and transform our initial unease into a rational conviction. through coexisting, we determine what their moral status is. asserting moral superiority prima facie equals to proceed in the opposite way, namely, determine from a pre-existing theoretical consideration how we should coexist. also, stating a moral superiority implies that we assert some sort of ontological superiority of human beings, a discussion that could be very difficult and may have no sense, at least from the point of view of meaning ethics, since this type of thinking dispenses of – but does not necessarily reject or abolish – a metaphysical outline. conclusion: under the light of all we have previously said, i shall argue that it is a mistake on singer’s part to believe that explicitly aiding himself with his own ethical vision equals betraying utilitarianism. what really happens, in my opinion, is that it was initially wrong evaluating through a normative framework an issue that is supposed to be treated under the considerations of a meaning ethics. the question regarding the moral status of animals cannot be answered completely under the mere consideration of their sentient nature, which only means that they can be added as an element to take into account in the principle of utility and become a factor in a consequentialist calculation. this is because the principle tells us nothing about how they should be taken into consideration, namely, with a certain dignity, or rights, or in some specific interrelations with humans, with a compassionate consideration by humans, a loving relationship with humans, etc., because there are a bunch of possible states bangladesh journal of bioethics 2016; 7(3): 46-57 55 of affairs one can propose that massacre animals and still preserve a positive balance of pleasure. in this sense, if one was in singer’s position, namely, trying to formulate a strong defence of vegetarianism, one should put most of one’s efforts in increasing the plausibility of one’s ethical vision. i think one could proceed, tentatively, in this way: revise and increase the plausibility of one’s ethical vision, propose a way in which we should interact with animals, and explicitly put on the table how we want to think of ourselves, namely, as cruel or compassionate beings; but the exact argumentation should derive from singer’s own ethical vision whose exhaustive content is only available to himself. following this, i think that the places of utilitarianism and vegetarianism where singer seems to retract because he believes he could be exceeding a self-imposed utilitarian outline actually mark the points he should emphasize to proceed in the way of a meaning-producing ethic. i argued that singer proceeds in utilitarianism and vegetarianism under the misunderstanding that one is committing a fallacy if one explicitly points out one’s own ethical vision; in other words, providing reasons that exceed considerations taken into account on the principle of utility imply a betrayal to utilitarianism. this could not be further from the truth, since normative frames and meaning ethics are not mutually exclusive. one can perfectly come up with a plausible ethical vision for our relationship with animals, and then test its legitimacy by the principle of utility. this implies that utilitarianism would reject every ethical vision that may result in a negative balance of pleasure, and this is the only way the principle of utility coerces the ethical vision, in the requirement of providing the best possible world one can imagine, one where pleasure is maximal. finally, i think singer has pointed out a very crucial issue when he puts the discussion over vegetarianism in the forefront, since diet constitutes a dimension of human life of tremendous existential significance that is usually underestimated. eating is one of our most frequent activities, and is a sine qua non for life itself in a biological sense. and not only this. our need for food makes us extract resources and transform the surrounding habitat in a very specific way, so it raises deep environmental concerns as well. it is not an accident that our current practices and eating habits had led to a certain industry, namely, factory farming. so, this dimension has a radical importance for critically understanding the advent and consequences of a technological era. about this, singer himself says in eating ethically: when we eat, or more specifically, when we pay for what we eat, whether at a farmer’s market, a supermarket, or a restaurant, we are taking part in a vast global industry. americans spend more than a trillion dollars on food every year. that's more than double what they spend on motor vehicles and also more than double what the government spends on defense. food production affects every person on this planet and untold billions of animals as well. it is important, for the sake of the environment, animals, and future generations, that we see our food choices as raising serious ethical issues and learn the implications of what we eat22. bangladesh journal of bioethics 2016; 7(3): 46-57 56 author contribution: author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgements: i would like to express my gratitude to luca valera, who provided valuable insight and guidance for the writing of this paper. references: 1 singer p. utilitarianism and vegetarianism. philosophy and public affairs 1980; 9(4): 325. 2 singer p. utilitarianism and vegetarianism. philosophy and public affairs 1980; 9(4): 328. 3 fairlie, s. meat, a benign extravagance. chelsea green publishing company 2010: 35-43 (specifically chapter 4). 4 singer p. utilitarianism and vegetarianism. philosophy and public affairs 1980; 9(4): 337. 5 pluhar e. meat and morality: alternatives to factory farming. journal of agricultural and environmental ethics 2010; 23: 455–468. 6 pluhar e. meat and morality: alternatives to factory farming. journal of agricultural and environmental ethics 2010; 23: 464-465. 7 sandel m. the case against perfection. the belknap press of harvard university press 2007: 5-12. 8 sandel m. the case against perfection. the belknap press of harvard university press 2007. 9 macintyre, a. after virtue, a study on moral theory. university of notre dame press 2007: 144. 10 macintyre, a. after virtue, a study on moral theory. university of notre dame press: 208. 11 macintyre, a. after virtue, a study on moral theory. university of notre dame press: 206. 12 lyotard j. the postmodern condition: a report on knowledge. university of minnesota press 1984. 13 llorente r. the moral framework of peter singer’s animal liberation: an alternative to utilitarianism. ethical perspectives 2009; 16(1): 62. 14 goldsmith o. citizen of the world; taylor & hessey 1809: 44. 15 singer p. utilitarianism and vegetarianism. philosophy and public affairs 1980; 9(4): 332. 16 curnutt j. a new argument for vegetarianism. journal of social philosophy 1997; 28(3): 153-172. 17 jonas h. the imperative of responsibility: in search of an ethics for the technological age. university of chicago press 1985: 4. 18 jonas h. the imperative of responsibility: in search of an ethics for the technological age. university of chicago press 1985: 5. 19 jonas h. the imperative of responsibility: in search of an ethics for the technological age. university of chicago press 1985: 6-8. bangladesh journal of bioethics 2016; 7(3): 46-57 57 20 holdier a. the pig’s squeak: towards a renewed aesthetic argument for veganism. journal of agricultural and environmental ethics 2016; 29: 632. 21 naess a. ecology, community and lifestyle: outline of an ecosophy. cambridge university press 1990. 22 singer p. eating ethically. free inquiry 2005; 25(4): 19. microsoft word 2. research drug article-nurunnabi et al.-bjb bangladesh journal of bioethics 2018; 9(3): 11-15 11 mass vaccination programme: public health success and ethical issues – bangladesh perspective abu sadat mohammad nurunnabi1, miliva mozaffor2, mohammad akram hossain3, sadia akther sony4 1. internationally trained medical doctors (itmd) bridging program, the g. raymond chang school of continuing education, ryerson university, toronto, on, canada. email: abu.nurunnabi@ryerson.ca (corresponding author) 2. clinician researcher, biomedical research foundation (brf), dhaka, & laboratory consultant and lecturer, department of biochemistry, medical college for women & hospital, uttara, dhaka-1230, bangladesh. 3. professor and head, department of microbiology and mycology, national institute of preventive and social medicine (nipsom), dhaka-1212, bangladesh. 4. program manager, department of public health and informatics, bangabandhu sheikh mujib medical university (bsmmu), dhaka-1000, bangladesh. abstract: vaccines are responsible for many global public health successes, such as the eradication of smallpox and significant reductions in other serious infections like diphtheria, pertussis, tetanus, polio and measles. however, mass vaccination has also been the subject of various ethical controversies for decades. several factors need to be considered before any vaccine is deployed at national programme like the potential burden of disease in the country or region, the duration of the protection conferred, herd immunity in addition to individual protection, vaccine-related risks, financing and the logistical feasibility of the large-scale vaccination. moreover, several ethical dilemmas revolve around authority and mandates for vaccination, informed consent, benefits vs. risks, and disparities in access to vaccination. this review paper aims to elaborate the ethical issues involved in mass vaccination programme and present some additional challenges in the context of a resource-poor settings of public health in bangladesh. keywords: ethical issues, vaccine, mass vaccination, immunization, epi, public health, bangladesh. introduction: the invention of the vaccine is unarguably one of the greatest medical achievements in the past century. vaccines have saved millions of lives, prevented significant morbidity and suffering, and even eradicated smallpox and significantly reduced other serious infections like diphtheria, pertussis, tetanus, polio and measles around the globe1. for an example, measles deaths decreased by 60% worldwide between 1999 and 2005, and polio, although missing the goal of eradication by 2005, has decreased significantly as there were fewer than 2,000 cases in 20062. vaccines have become readily available in most parts of the world, yet debates continue as to the appropriateness of requirements for mass vaccinations, including legal mandates of vaccinations in public health practice and public health emergencies and more routinely bangladesh journal of bioethics 2018; 9(3): 11-15 12 for school entry3. vaccine ethics can be conceptualized as a set of issues at the intersection of public health policy, clinical ethics, and professional ethics4,5. several factors need to be considered before any vaccine is deployed at national programme like the potential burden of disease, the duration of the protection conferred, herd immunity in addition to individual protection, vaccine-related risks, cost, and the logistical feasibility of the large-scale vaccination5. moreover, several ethical and value-based debates revolve around authority and mandates for vaccination, informed consent, benefits vs. risks, and disparities in access to vaccination4. this review paper aims to elaborate those ethical issues involved in mass vaccination programme and present some of the additional challenges in the context of a resource-poor settings of public health sector in bangladesh. expanded programme on immunization (epi) in bangladesh: the world health organization (who) initiated the expanded programme on immunization (epi) in may 1974 with the objective to vaccinate children throughout the world. ten years later, in 1984, the who established a standardized vaccination schedule for the original epi vaccines for six serious infectious and fatal diseases: bacillus calmette-guérin (bcg) for tuberculosis, dpt for diphtheria, pertussis and tetanus, oral polio vaccine (opv) for polio myelitis, and measles for measles6. since epi was launched in bangladesh on 7th april of 1979, in 1999, the global alliance for vaccines and immunization (gavi) was created with the sole purpose of improving child health in the poorest countries by extending the reach of the epi. the gavi brought together a grand coalition, including the un agencies and institutions (who, unicef, the world bank), public health institutes, donors and implementing countries, the bill and melinda gates foundation and the rockefeller foundation, the vaccine industry, nongovernmental organizations (ngos) to accomplish the mission7. the creation of the gavi has helped to renew interest and maintain the importance of immunizations in battling the world’s large burden of infectious diseases7. some important update on epi8: i) tt5 dose for wcba started in 1993, ii) hepb vaccine introduced in 2003, iii) ad syringes introduced in 2004, iv) pentavalent vaccine introduced in 2009, v) mr vaccine and measles vaccine second dose introduced in 2012, vi) pcv introduced in 2015, vii) topv to bopv switched on 23 april 2016 and ipv to fipv switched on november 2017, viii) hpv demonstration projects launched on 16 april 2016 in 4 upazillas and 1 zone under gazipur district which is being completed in 2017, ix) tt switched to td on march 2019. as a result of outstanding performance in improving the child immunization status, bangladesh achieved gavi alliance award in 2009 and 2012, which is given as a recognition to achieving the millennium development goals (mdg), particularly in reducing child mortality9. other mass vaccination programmes: there are several special mass vaccination programme launched and done through epi bangladesh journal of bioethics 2018; 9(3): 11-15 13 authority. recently, the human papilloma virus (hpv) vaccine has been introduced for the first time in bangladesh in 2016 by the ministry of health and family welfare (mohfw), with support from the gavi10. this programme has run in a pilot basis for two years in gazipur district and as it has become successful. then the gavi has become interested to provide support for national introduction of hpv vaccine soon10. moreover, several mass vaccination programmes are arranged yearly, e.g. special measles campaign, mass vaccination in disaster and during humanitarian crisis, e.g. in rohingya refugee camps, etc.8, as per decision of the ministry of health and family welfare, government of the people’s republic of bangladesh. ethical issues in mass vaccination: in spite of demonstration of individual and collective benefit and cost effectiveness of vaccination, one of the contemporary challenges in providing medical care for children is the increasing proportion of vaccination refusal, especially in the western world11; however, vaccination rates in developing countries like bangladesh are very impressive9. it is not a surprise that parents’ refusal to vaccinate their children can cause collective harm by raising unprotected, susceptible individuals in the community. besides, with herd immunity compromised, devastating disease outbreaks may occur. in these settings, individuals are morally obligated to accept vaccination to prevent harm to others12. apart from this, in a specific humanitarian crisis or in disaster, failure to provide a vaccine violates the principle of non-maleficence5. moreover, only vaccines having proven effectivity and safety are to be considered for mass administration5. such vaccines confer additional benefit through herd immunity apart from protecting people against specific diseases when administered on a large scale5,11. looking at a long term investment in health care, the statistics illustrate the benefits and economics of vaccines and disease eradication. for an example, smallpox eradication has saved millions of lives over the decades, and millions of dollars in terms of quarantine and treatment13. from a human rights perspective, vaccination equitably promotes and protects public health which satisfy the notion of the article 25 of the universal declaration of human rights as stated: “everyone has the right to a standard of living adequate for the health and well-being of himself and his family … … … by progressive measures, national and international, to secure [its] universal and effective recognition.”5 however, access to vaccination is still not achievable universally. racial or ethnic disparities in immunization programme is an ethical concern4,5,13. for example, in the united states, blacks and hispanics were significantly less likely to report receipt of nearly all preventive services like vaccination12,13. even a few years back, immunization coverage in the hilly regions and some areas of our country (hard to reach areas) was below national average8. however, we could overcome the situation in a very short time. a new round of polarizing debates started up with the steps taken to make the hpv vaccine mandatory. some religious conservatives were worried with the programme and they thought that the bangladesh journal of bioethics 2018; 9(3): 11-15 14 availability of a vaccine against a sexually transmitted disease would threaten abstinence-based prevention messages before the vaccine was licensed, this concern created argument for the vaccine10,14. abstinence is one of the approaches to hiv prevention taken by the physicians’ organizations. preventive measures include abstinencebased prevention massages like counseling adolescents and their families for being more responsible on sexual decision making including abstinence13,15. some religious conservatives thought that the availability of the vaccine could affect the promotion of these messages10,13. some advocacy groups agreed availability of the vaccines in public health systems; however, they did not agree on making the vaccine mandatory4,10,12,13. their perspective was this decision of the state may lead to force a child to undergo an intervention that may be incompatible with her family’s religious values and beliefs15. the huge expense of vaccines starting from research to introduce a successful product in the market along with maintenance of its safety and efficacy is a debatable concern in public health in terms cost – as most of the developing countries have some other priorities like pure water supply or sanitation13. moreover, just as a vaccine that works in one population might not be as effective in another population, so might adverse effects of a vaccine be specific to one population13. this raises another concern about hidden exploitation by the vaccine manufacturers. once again, parental attitudes and concerns, as most parents expressed the desire for more information about the vaccine before they agree to vaccinate their children, is an essential topic to address16. physicians and health authority should discuss openly and transparently about necessity of vaccination with parents – as the ultimate decision should be taken by their parents to ensure parental autonomy17,18. however, where the threat of widespread, serious infectious disease is imminent, individual liberties may be justifiably curtailed5,19. in such situation, national health authorities are morally obligated to do all that they reasonably can to implement evidence-based guidelines to avert preventable harm13,15. conclusion: the benefits of vaccination extend beyond prevention of specific diseases in individuals. vaccination makes good economic sense, as well as meets the need to care for the weakest members of societies. there may be situations where there is an ethically valid public health justification for restricting individual rights – both in circumstances where such actions benefit the community and in situations where the actions only benefit the individual. however, restrictions should only be placed after meeting certain conditions to ensure judicious use of this power. we conclude that a comprehensive vaccination programme is a cornerstone of good public health and will reduce inequities and poverty especially in a developing country like bangladesh. references: 1. andre fe, booy r, bock hl, clemens j, datta sk, john tj, et al. vaccination greatly reduces disease, disability, death and inequity worldwide. bull world health organ. 2008;86(2):140-146. bangladesh journal of bioethics 2018; 9(3): 11-15 15 2. greenwood b. the contribution of vaccination to global health: past, present and future. philos trans r soc lond b biol sci. 2014;369(1645):20130433. 3. amin ane, parra mt, kim-farley r, fielding je. ethical issues concerning vaccination requirements. public health rev. 2012;34:14. 4. isaacs d. an ethical framework for public health immunisation programs. nsw public health bull. 2012;23(5-6):111-115. 5. moodley k, hardie k, selgelid mj, waldman rj, strebel p, rees h, et al. ethical considerations for vaccination programmes in acute humanitarian emergencies. bull world health organ. 2013;91(4):290-297. 6. hadler s, cochi s, bilous j, cutts f. vaccination programs in developing countries. chapter 55: vaccines, 4th ed. philadelphia: elsevier; 2004. 7. global alliance for vaccines and immunizations (gavi). global immunization challenges [internet]. accessed may 15, 2018. retrieved from: http://www.vaccinealliance.org/reference/globali mmchallenges.html 8. world health organization (who). hpv vaccine introduced in bangladesh who south-east asia regional office. 2017. [internet]. accessed may 16, 2018. retrieved from: http://www.searo.who.int/bangladesh/hpvvacci nelaunch/en/ 9. directorate general of health services (dghs). bangladesh epi coverage evaluation survey 2013. dhaka: expanded programme on immunization, dghs; 2013:33. 10. haseen f, sony sa. cervical cancer and ethical issues in hpv vaccination. bangladesh j bioethics. 2017;8(2):31-37. 11. salmon da, omer sb. individual freedoms versus collective responsibility: immunization decision making in the face of occasionally repeating values. emerg themes epidemiol. 2006;3(1):1-3. 12. dawson a. vaccination and the prevention problem. bioethics. 2004;18(6):515-530. 13. ulmer jb, liu ma. ethical issues for vaccines and immunization. nat rev immunol. 2002;2(4):291-296. 14. salmon da, haber m, gangarosa ej, phillips l, smith n, chen rt. health consequences of religious and philosophical exemptions from immunization laws: individual and societal risks of measles. jama. 1999, 282(1):47-53. 15. jacobs aj, arora ks. when may government interfere with religious practices to protect the health and safety of children? ethics med public health. 2018;5:86-93. 16. holman dm, benard v, roland kb, watson m, liddon n, stokley s. barriers to human papillomavirus vaccination among us adolescents: a systematic review of the literature. jama pediatrics. 2014;168(1):76-82. 17. feikin dr, lezotte dc, hamman rf, salmon da, chen rt, hoffman re. individual and community risks of measles and pertussis associated with personal exemptions to immunization. jama. 2000;284(24):3145-3150. 18. leask j, kinnersley p, jackson c, cheater f, bedford h, rowles g. communicating with parents about vaccination: a framework for health professionals. bmc pediatr. 2012;12:154. 19. gostin lo. influenza a(h1n1) and pandemic preparedness under the rule of international law. jama. 2009;301(22):2376-2378. author contributions: asm nurunnabi and m mozaffor were involved in concept and design of the paper; asm nurunnabi, m mozaffor, ma hossain and sa sony were equally involved in the literature search, review, compilation, manuscript writing and revision. conflict of interest: there is no conflict of interest relevant to this paper to disclose. bangladesh journal of bioethics 2016; 7(3) editorial philosophers and ethicists have long neglected moral questions that arise from our interaction with non-human animals. most assumed that human beings have a higher moral status than other animals, and that it is therefore morally permissible to use non-human animals as a source of food, clothing, and entertainment, and for scientific purposes. in recent decades, however, that assumption has been challenged, and the moral status of non-human animals is now the subject of a lively and controversial academic debate. advances in sciences, particularly the advent of evolutionary theory, made us realize that human beings and other animals are more similar than different, and force us to rethink our place in nature. we are no longer justified in thinking of ourselves as the crown of creation. we now understand that we are just one species among others, and we must ask ourselves anew – with an open and critical mind and without bias – which values and principles should guide our interaction with non-human animals, and how we should weigh our interests against those of other animals. recognizing this important trend in moral thinking, the bangladesh journal of bioethics invited me to edit a special issue on animal ethics. the interest was so great that one issue became two, of which this is the first. i am grateful to professor shamima parvin lasker and ms. tahera ahmed for giving me the opportunity to serve as a guest editor, and for their assistance during the editing process. i also thank our contributors for choosing this journal to publish their excellent work, and the reviewers for their insightful comments and suggestions. this, the first special issue on animal ethics contains the following five articles: robin attfield and rebekah humphreys (“justice and non-human animals”) challenge the widely held belief that non-human animals are not included within the scope of the principles of justice, and suggest that the interests of non-human animals sometimes take precedence over the interests of human beings. the implications of their argument for our interaction with other animals are profound: e.g., it is a matter of justice and fairness to prevent avoidable and unnecessary animal suffering, rather than a mere matter of compassion. eric x. qi (“special relations, special obligations, and speciesism”) develops an account of the moral significance of special relations, and uses it to argue for a modest form of speciesism that steers a middle ground between anti-speciesism and crude speciesism. unlike anti-speciesists, he maintains that species co-membership grounds special moral obligations among the members of the same species. in contrast to crude speciesists, however, he holds that our special obligations to fellow human beings do not warrant that we always attach more weight to their interests than to the comparable interests of non-human animals. bangladesh journal of bioethics 2016; 7(3) yamikani ndasauka and grivas m. kayange (“existence and needs: a case for the equal moral considerability of non-human animals”) argue that the existentialist view that human beings have a higher moral status than other animals rests on a weak foundation. they consider a number of arguments that have been made in support of this view and conclude that none of them holds up to critical scrutiny. they then suggest that human beings and other animals in fact deserve equal moral consideration, and – drawing from martin heidegger and abraham maslow – ground that claim in two important commonalities between them. sreetama chakraborty (“animal ethics: beyond neutrality, universality, and consistency”) explains how the postmodern approach to animal ethics departs from the traditional approach, particularly its emphasis on the principles of neutrality, universality, and consistency, and draws attention to the pernicious hierarchy of domination that separates human beings from other animals. building on the insights of postmodernism, she takes first steps towards a new, non-anthropocentric paradigm, in the hope to achieve a sustainable balance between human interests and the interests of non-human animals. gabriel vidal quiñones (“singerian vegetarianism and the limits of utilitarianism: a path towards a meaning ethics”) takes a critical look at peter singer’s utilitarian argument for vegetarianism, and argues that the conceptual resources of utilitarianism only allow for an incomplete moral understanding of our relationship with other animals. what is lacking, he suggests, is an ethical vision. he argues that, without an ethical vision, human action threatens to degenerate into mere automatism without meaning. he proposes a “meaning ethics” that he thinks is better equipped to help us decide how we ought to treat other animals. i hope you, dear reader, will enjoy reading through this remarkable collection of articles as much as i enjoyed putting it together. maybe you will even be inspired to do some thinking of your own about issues of animal ethics and put your thoughts down on paper. if so, i sincerely hope that you will choose the bangladesh journal of bioethics to publish your article. warm regards and best wishes for the new year, rainer ebert guest editor department of philosophy university of johannesburg south africa rainerebert@gmail.com http://www.rainerebert.com mailto:rainerebert@gmail.com http://www.rainerebert.com/ microsoft word involving human volunteers in phase 1 trials-revision(1)(1) bangladesh journal of bioethics 2017; 8(2):19-22 19 ethical justification of involving human volunteers in phase 1 trials zoheb rafique lecturer department of community medicine, liaquat university of medical and health sciences (lumhs), jamshoro sindh. email: scorpionzoheb@hotmail.com introduction: tremendous development in recent medical science and the consequent discoveries resulting in successful prevention and also cure of different diseases are shared by clinical research involving the human volunteers. preceding the trials in the human subjects, and to ensure safety, the proposed drug and other interventions are either tested in animals (vivo) or in laboratory (vitro) to evaluate initial safe starting dose for the human beings and to key out the benchmarks for the clinical monitoring for the potential unfavorable effects. these pre human trials might not necessarily protect against the untoward effects in the human beings as happened in the case of thalidomide tragedy, which caused disability and killed thousands of babies born to the mothers, those who took this medicine. use of healthy human volunteers in the preliminary experiments or phase i clinical trials either reduces or excludes risks of subsequent undesirable effects in the future trails (1). phase-1 trials are conducted in order to test the safety, reactions and immunogenicity of vaccines in volunteers. novel treatments for the cancer are first tested in phase 1 trials enrolling the patients with advanced disease, who have exhausted the standard treatment options. phase-1 oncology trials are the pivot point in the translation of new cancer therapies from bench to bedside. nevertheless, these trials remain ethically controversial. the controversy stems from the fact that, classically, phase-1 oncology clinical trials involve first-inhuman testing of experimental treatment candidates in patients with a terminal diagnosis, who typically have exhausted standard treatment options. commentators on the ethics of phase-1 clinical trials make diametrically opposed claims about the prospect of direct medical benefit from participation in these trials-benefits that can be attributed to receiving the experimental treatment intervention. one camp of benefit skeptics, inhabited mainly by bioethicists, characterizes this form of research as lacking any reasonable prospect of direct medical benefit. they see an ethical cloud hovering over phase-1 trials, because the vast majority of patients volunteer for phase-1 trials out of a motivation to receive medical benefit. in the view of these skeptics, such patients therefore harbor a ‘therapeutic misconception’ about research participation. this misconception calls into question the validity of informed consent and thereby undercuts the ethical basis of these trials (2). in this paper, i will discuss the ethical justification of the participation of human volunteers in phase-1 trials. key words: ethical justification, human volunteers, phase 1 trials discussion: it is now widely accepted that medical research designed for the benefit of populations in developed countries should not be conducted with subjects recruited from populations in economically underdeveloped countries (3). indeed, it is ethically objectionable to recruit from populations in resource-poor settings, even in developed countries, unless those bangladesh journal of bioethics 2017; 8(2):19-22 20 populations are particularly susceptible to the condition the research is designed to relieve. in one study, there was proposal to conduct a phase-1 vaccine study recruiting subjects from the united states when the purpose is to assist the population of mali, in sub-saharan africa, to overcome the pervasive local consequences of malaria. the ethical principle of justice, which requires a fair allocation of the risks and benefits of medical research, provides that the risk of research should not be planned to affect subjects from one population when benefits of the research are primarily directed to another population. it may accordingly appear, at first assessment, that the malian government’s requirement that all phase-1 testing of the antimalarial vaccine be conducted in the united states is as unethical as it would be for the united states government to require that all phase-1 testing of a vaccine or other product intended primarily to benefit the population of the united states be conducted in mali. yet codes of ethical conduct are less consistent on this point than commentators usually require being. the world medical association’s much-cited declaration of helsinki: ethical principles for medical research involving human subjects provides that “medical research is only justified if there is a reasonable likelihood that the population in which the research is carried out stand to benefit from the results of the research.” by this criterion, conduct of the phase-1 study in the united states appears unethical. in the context of hiv/aids, however, the who’s global program on aids (1989) provided that, “in general, initialphase-1 trials should be conducted in the country of origin of the vaccine”. by this criterion, phase-1 testing in the united states is appropriate, if a vaccine would originate and initially be governmentally approved in the united states. the situation would be otherwise, of course, if the nih was funding the study for production of the vaccine in mali. the ethical remains of where the initial phase-1vaccine trials can be conducted most equitably, with least risk of exploitation and most protection of the interests of study subjects (4). most clinical research trials today require the informed consent. concern however is raised that subjects of phase 1 trial studies might not provide valid consent. in particular, few commentators worry that subjects of phase 1 oncology trials have an exaggerated idea of any chance of the therapeutic benefit. the empirical studies tells that phase 1 trial participants are highly optimistic and hopeful about their chance of personal benefit and also are motivated by hope for the clinical improvement. altruism, on other hand is much less often identified as driving the decision to enroll, when quoted as motivating factor; and it typically is not the prime reason for the participation. in one research study, sixty one (61 %) of phase 1 oncology participants were doubtful about altruism would motivate the advanced cancer patients to enroll in the non-beneficial research and several phase 1 volunteers in another study showed “surprise” at idea of research participation based exclusively on altruism. some studies find, however that the individuals in some other types of research trials often participate in the hope of helping others (5). as an example, schaeffer and colleagues describe that “hope others benefit” is one of the two most common motivational factors for the healthy volunteers (6). the research participants should be fully informed about the difference between research and therapy and also risk-benefit ratio. the researcher should offer patients substitutes other than participation in the trials and also vulnerable population should not be included in the trials at any cost and bangladesh journal of bioethics 2017; 8(2):19-22 21 especially in thephase-1 trials. cioms guideline 7 talks about inducement of participation in research. according to the guideline the research subjects can be reimbursed for their needs such as transport and other expenses, and also lost earnings, that is associated with participation in the research. those persons who receive no any direct benefit from research may also get a small amount of money for their inconvenience due to the participation in research. all volunteers may get the medical services unrelated to research and could have tests and procedures performed free of cost. payments in terms of money or in kind to the research subjects may not be so huge as to carry them to take unwarranted risks or volunteer against the better judgment. incompetent persons are vulnerable to the exploitation for financial gain by the guardians. a subject who withdraws himself/herself from the research for various reasons related to research study, such as unacceptable side-effects of a study drug, or who is withdrawn on health grounds, should be paid or recompensed as if full participation had taken place. for all biomedical research involving human subjects, the investigator must ensure that potential benefits and risks are reasonably balanced and risks are minimized. the declaration of helsinki deals with the wellbeing of research subjects and the avoidance of risk. thus, considerations related to the well-being of the human subject should take precedence over the interests of science and society, clinical testing must be preceded by adequate laboratory or animal experimentation to demonstrate a reasonable probability of success without undue risk, every project should be preceded by careful judgment of predictable burden and risks in comparison with the foreseeable benefits to research subjects or to others; physician-researchers must be confident that the risks involved have been adequately assessed and can be satisfactorily managed; and the risks and burdens to the subject must be minimized, and reasonable in relation to the importance of the objective or the knowledge to be gained (7). conclusion: the first basic principle of the declaration of helsinki requires biomedical research involving human subjects to be based on “adequately performed laboratory and animal experimentation and on a thorough knowledge of the scientific literature.” this implies that human subjects should not be used unless and until successful experiments in animals, as well as in vitro, have been completed. the declaration might allow proceeding to clinical trials if adequate animal studies demonstrated the inapplicability irrelevance, or absence of a useful animal model. if animals died immediately after receiving a vaccine, this would undoubtedly prohibit using the vaccine in human subjects (8). i will conclude this paper by saying that research is the only way of getting rid of various diseases through proper treatment and also benefiting future patients from those diseases which have no cure at present or any medical treatment available, so research should not be stopped. in my opinion, human volunteers can be involved in phase-1 trials but following all international guidelines and all other aspects of biomedical ethics. author contribution: i am the only author of this manuscript conflict of interest: no conflict of interest bangladesh journal of bioethics 2017; 8(2):19-22 22 references: 1. inayat ullah memon. justification of participation of human subjects in phase 1 clinical trials: an ethical analysis. bangladesh journal of bioethics 2011;2(2):26-29. 2. franklin g miller and steven joffe. benefit in phase 1 oncology trials: therapeutic misconception or reasonable treatment option? clinical trials. 2008; 5: 617-623. 3. james v. lavery et al. ethical issues in international biomedical research. a casebook by oxford university press. 2007. 4. bernard dickens. reverse exploitation in the baltimore malaria vaccine study. commentary 11.2: a casebook by oxford university press. 2007. 5. emily abdoler, holly taylor, and david wendler. the ethics of phase 0 oncology trials. clin cancer res. 2008; 14(12): 3692-3697. 6. schaeffer mh, krantz ds, wichman a, masur h, reed e, vinicky jk. the impact of disease severity on the informed consent process in clinical research. am j med 1996; 100: 261–268. 7. international ethical guidelines for biomedical research involving human subjects. cioms 2002; 1-113. 8. wendy k. mariner. why clinical trials of aids vaccines are premature. public health and the law. ajph. 1989; vol. 79, no. 1: 86-91. bangladesh journal of bioethics 2014; vol. 5 issue 1 editorial bangladesh bioethics society (bbs) started the course on ethical and regulatory aspects of clinical research in collaboration with national institute of health (nih), usa from 2010. bbs also organized this course in 2013. this three month course is designed to provide an overview of the important issues in the ethics of human subject research for clinical investigators and others who participate in the conduct of research. by the end of the course participants take part in research for in-depth understanding of ethical issue in clinical research. this issue of the journal is designed by articles of ethics course participants. an article mentions about the strategy for ethical research in randomized clinical trials (rcts). bias free subject allocation may be a way to establish the research result in randomized clinical trials is his point of view. for this reason strict ethical guidance is necessary from selection of participants to the analysis of trial results. some important aspect of ethical research, roles and responsibilities of irb/erc and its challenges and national/institutional research strategies has been discussed by a researcher. the systemic review of the researcher identifies several challenges in monitoring function of irbs on ongoing research in terms of annual review, consent, adherence to protocol, data integrity, auditing and quality assurance. a researcher has evaluated the bioethics education in research in developing countries. article reveals major gaps in clinical trail and has seen that there are still many ethical issues needed to be considered in research in developing countries. he also mentions that actions should require to move ahead in this field, e.g. strengthening bioethics capacity in developing countries and increasing communication between scientists and ethicists in industrialized and developing countries. informed consent is a vital part of the research process. a paper reviews the guidelines for obtaining informed consent and also discusses prevailing views on current controversies, ambiguities and problems with these guidelines and suggests potential solutions. he states that researchers or investigators must be educated to ensure that they can reach a truly informed decision rather than obtaining a signature on the consent form. ethical and historical regulations of research with children are depicted in an article. she highlights that the effort should be made to involve children actively as participants in the research process. therefore utmost care must be taken to protect the rights and welfare of children and special attention should be made for specific groups of children. bbs will organize this programme in 2014 as well. interested are requested to contact to bbs office. prof shamima parvin lasker (professor & head of anatomy, city dental college, dhaka) executive editor bangladesh journal of bioethics microsoft word r attfield & r humphreys justice and non-human animals part i bangladesh journal of bioethics 2016; 7(3): 1-11 1 original article justice and non-human animals robin attfield1 and rebekah humphreys2 1. emeritus professor of philosophy, cardiff university, email: attfieldr@cardiff.ac.uk 2. lecturer in philosophy, trinity st. david’s university, email: r.humphreys@tsd.uwtsd.ac.uk part i abstract: it is widely held that moral obligations to non-human beings do not involve considerations of justice. for such a view, nonhuman interests are always prone to be trumped by human interests. rawlsian contractarianism comprises an example of such a view. through analysis of such theories, this essay highlights the problem of reconciling the claim that humans have obligations to non-humans with the claim that our treatment of the latter is not a matter of justice. we argue that if it is granted that the basic interests of nonhuman beings sometimes count for more than the peripheral interests of humans, then our understandings of obligation and of justice must be aligned, so that what we say about obligation is not countered by assumptions about the invariable priority of humans in matters of justice. we further consider whether such a conclusion can be endorsed by those who adopt certain alternative theories to contractarianism. we conclude that adherents of a range of theories including sentientism and biocentrism must accept that human interests can sometimes be superseded by animal interests, and that this applies not least in matters of justice. keywords: justice, contractarianism, animal interests, moral theory, rawls, moral agency note: this essay is being published in two parts, part i in the current number and part ii in the next number (bjb 2017, vol. 8, issue 1) of this journal. introduction: it is widely held that human beings alone are beneficiaries of principles of justice, even if moral agents can have obligations with regard to non-human beings. this stance prioritises (sometimes even trivial) human interests in matters of distributive justice, making other interests pale into insignificance. the theory of justice of john rawls supplies one example of this stance, and the works of many living writers supply further examples. our aim in this essay is to cast doubt on the assertion that justice does not apply to nonhuman beings, claiming instead that non-human animals (like other creatures temporarily or permanently lacking a sense of justice) are to be included in, rather than excluded from, the realm of justice. in particular and in the light of this aim, our discussions will focus on an analysis of contractarianism as a theory which tends to exclude animals from principles of justice, whilst giving animals some moral weight. our objective is to highlight the problem of bangladesh journal of bioethics 2016; 7(3): 1-11 2 reconciling the claim that moral agents have moral obligations with regard to non-human beings with the claim that our treatment of non-human animals is not a matter of justice. anthropocentrism, justice and animals: most people agree that it is possible to be cruel towards non-human animals, to neglect them, and to cause them to suffer, but is it possible to be unfair or unjust to them? could it be unfair (say) to a goat to sacrifice it in order to film a comoro dragon having a meal, and unfair to (say) a chicken to keep it cramped in a cage so small that it cannot spread its wings, and could it even be unfair to (say) flightless birds to allow them to go extinct by introducing predators such as cats to their last remaining habitats? justice is commonly taken to be about treating individuals fairly, taking into account what they are due (for examples, see the next two sections); conceptualised as such, justice seems readily applicable to animals, for they have interests the fulfilment of which is conducive to their own good and which are capable of being unfairly overridden. nevertheless, it is widely held that justice relates to inter-human dealings and relationships, but not to humans’ relations with non-human beings, for the latter beings, it is claimed, are not (and cannot be) recipients of justice. the theory of justice of john rawls supplies one example1 as does the work of brian barry, and many other writers, such as tim scanlon and darrel möllendorf, say much the same2 3 4 5. some of them say that only humans have rights, and can thus be owed justice, while others either maintain that deserving justice depends on having a capacity for a sense of justice or depends on whether one can be classed as an autonomous, rational person who has relations with other such persons. in this way many writers tie their theory of obligation to a kantian conception of personhood such that animals are excluded from being beneficiaries of certain obligations associated with justice. others make justice depend on being able to enter into a contract, however hypothetical, something that non-human animals cannot do, with many claiming that duties of justice comprise a narrow part of morality that applies to moral persons only, both as recipients of and as deliberators employing principles of justice. indeed, möllendorf claims that ‘duties of justice are a subset of all moral duties. justice is not the whole of morality; its objects and scope are narrower. in order for one to be bound by a duty of justice to another, that other must be the right sort of thing and must be in the right relation to the one bound’ (möllendorf, cosmopolitan justice, p. 31). the right sort of things in question here are moral persons, and the right sort of relations in question are ‘associational’ relations arising from certain social and political activities (cosmopolitan justice, pp. 19-21, and 31-3). indeed, the seriousness many philosophers attach to matters of justice compared to other moral matters is expressed by mary midgley when she states that ‘if one concentrates one’s attention on justice, everything outside it begins to look slight and optional. the boundary of justice becomes that of morality itself. duties like mercy and compassion then begin to seem like mere matters of taste, aesthetic preference, luxuries, delightful and desirable no doubt in times of leisure, but not serious’6. but, as will be shown in the next section, far from accepting such a conception of justice, there are reasons to consider it to be a distortion of the truth. bangladesh journal of bioethics 2016; 7(3): 1-11 3 brian barry is another philosopher who regards non-human animals as part of the wider moral sphere, and thus as beings to which we have obligations, yet at the same time, like rawls, he excludes animals from the sphere of justice. as he says, ‘i take it that it is uncontroversial that we can act wrongly in relation to non-human animals… in contrast, it does not seem to me that the concept of justice can be employed intelligibly outside the context of relations between human beings. the reason for this, i suggest, is that justice and injustice can be predicated only of relations among creatures who are regarded as moral equals in the sense that they weigh equally in the moral scales’ (barry, ‘sustainability and intergenerational justice’, p. 95). his exclusion of animals, then, from principles of justice is based on a theory of obligation that assumes that human beings are somehow weightier in a moral sense than non-human beings. further discussion of issues related to the claim that animals weigh less on the ‘moral scale’ will be reserved for the sections below (particularly the section ‘contractarianism and animals’). suffice it to say here that this, in itself, is not a sufficient reason for excluding animals from fair treatment, or from the scope of justice more generally. indeed, some traditional ethicists who (similarly to barry) consider humans to be more morally important than animals plausibly argue (contrary to barry) that animals (both wild and domesticated) are proper candidates for consideration in matters of justice. marcel wissenburg is one such ethicist; he argues that ‘sentience… is the emotional basis of morality and justice’, and on this basis ‘[sentient] animals can legitimately be called recipients of distributive justice’7. the very fact that sentient animals can be harmed and benefited provides a good reason for including such animals in the sphere of justice, since they can be affected for better or for worse by human deliberations in matters of justice, including the distribution of goods and benefits. that said, so firm is the acceptance of the claim that while animals are owed some obligations, they are not entitled to fair treatment as a matter of justice, that even some philosophers who are sympathetic to peter singer’s claim that equal interests should be given like consideration (whether they belong to humans or non-humans), and to its implication that some interests of non-human animals should be prioritised over lesser human interests8 sometimes still hold a theory of justice that relegates non-humans to a wider and less demanding domain of morality than justice, such as that of less stringent obligations or that of compassion, taking the view that justice still relates strictly to inter-human relationships only. thus their theory of moral obligation, neutral between species as it is, can end up with the proper treatment of animals being overridden by an unquestioned traditionalist theory of justice, for obligations of justice appear to override both other moral obligations and other moral considerations such as ones of compassion. we have no inclination to deny that there are moral requirements to act or to forbear that are not normally regarded as requirements of justice; examples include obligations to keep promises, tell the truth, and to refrain from neglect and cruelty. the problem is that the requirements of justice are widely held to trump moral requirements such as these, as well as moral expectations such as those based on compassion, love and sensitivity. bangladesh journal of bioethics 2016; 7(3): 1-11 4 but this problem is most strongly encapsulated in rawls’s theory of justice, to which we now turn. rawls’s contractarianism excludes animals from deserving fair treatment on the basis that they are unable to enter into a contract, whereby questions of justice are answered by those who are rational in their decision-making, and can make deliberations behind ‘a veil of ignorance’ (theory of justice, pp. 118-23). for rawls, only humans can be included in the sphere of justice, humans being the only species capable of moral agency. moral agents are defined as those persons who have ‘a capacity for a sense of justice and for a conception of the good’9. (see also his theory of justice, p. 442.) given that animals lack a sense of justice, they are excluded from being beneficiaries of principles of justice (theory of justice, pp. 442 and 448). contractarianism and animals: certainly, for rawls the capacity for a sense of justice is not a necessary condition for being entitled to just treatment, but a sufficient one. however, while he states that ‘i have not maintained that the capacity for a sense of justice is necessary in order to be owed the duties of justice’, he still excludes animals as candidates for recipients of justice, claiming that ‘we are not required to give strict justice anyway to creatures lacking this capacity’ (theory of justice, p. 448). nevertheless, rawls certainly believes that we have at least some duties towards animals, including ones of ‘compassion and humanity’, and that we should not treat them in any way we please, but he also claims (in the same passage) that the moral treatment of animals is an area of inquiry outside the scope of a theory of justice: a conception of justice is but one part of a moral view… certainly it is wrong to be cruel to animals… the capacity for feelings of pleasure and pain and for the forms of life of which animals are capable clearly imposes duties of compassion and humanity in their case. i shall not attempt to explain these considered beliefs. they are outside the scope of the theory of justice, and it does not seem possible to extend the contract doctrine so as to include them (theory of justice, p. 448). as we have seen above, rawls is not alone in his view that obligations of justice comprise a small or narrow part of a wider moral field, which latter incorporates what are usually deemed to be weaker duties of compassion, mercy, care and the like. however, it is far from clear that such a conception of justice should be accepted, for, while this narrow sense of justice may sometimes be useful, justice is best examined against a background of a range of moral virtues, some of which may well conflict with justice (thereby suggesting that obligations of justice, at least in this limited sense, may not always override other moral obligations). certainly though, duties of justice are usually regarded as more binding on moral agents and as morally weightier than those duties or obligations that are thought to be bound to notions of care and to moral sentiments such as mercy and compassion. however, rawls’s exclusion of animals from principles of justice is not without its problems, and has implications for animals and their treatment. rawls’s theory is a liberal one, and liberalism is standardly committed to the idea that each person should have the freedom to form their own conception of the good, as long as that conception does not harm other bangladesh journal of bioethics 2016; 7(3): 1-11 5 humans10 11. now, if our treatment of animals is an area of inquiry precluded from principles of justice and relegated to a broader sphere of morality where (other obligations aside) people are free to pursue their own conception of the good with minimum interference, then it could be that, as robert garner points out, ‘the treatment of animals becomes a matter of individual moral choice rather than a matter of justice. thus, my conception of the good might include a commitment to the well-being of animals, but i am not entitled to impose it upon others, and likewise, others must respect my conception of the good whilst not having to follow it themselves’ (garner, ‘political ideology and the legal status of animals’, p. 88). the agent’s liberty to pursue her own conception of the good, as long as doing so does not harm the interests of other humans, is ‘always likely to trump attempts to protect the interests of animals, where such attempts conflict with the liberty of humans’ (garner, theory of justice for animals, p. 26). it appears then that there may well be a tension between rawls’s liberalism and his belief that we should not treat animals in any way we please. on the one hand, animals are due moral consideration, at least in terms of considerations arising from feelings of compassion and empathy, yet on the other, animals’ interests, even vital ones, could be (are often are) overridden where such interests conflict with those of humans; for consideration of the latter’s interests is considered to be a matter of justice, and obligations of justice are thought to supersede our weaker obligations toward animals. as such, liberal theories may not be able to offer sufficient restrictions on the way animals are treated, restrictions, that is, which could secure the proper protection of animals’ interests (where that which is in a being’s interests is taken to mean that which is conducive to that being’s own good), as well as promote the fair treatment of animals in general. even if there is a moral case for such restrictions, the obligation to respect them may not be strong enough to override the entitlements arising from liberal freedoms of a rawlsian kind (see garner, theory of justice for animals, ch. 2)12 13. as we have seen in the previous section, the exclusion of animals from the sphere of justice is in part based not only on a particular understanding of justice, but also on a particular value assumption regarding animals; that assumption being that animals ‘weigh less’ on the moral scales than humans. however, saying that humans are more morally important than animals, although problematic, is very different from saying that the vital or basic interests of animals should be overridden when they clash with the interests of humans, no matter how trivial those human interests may be, and few would want to endorse the claim that the peripheral interests of humans should in general override the vital or basic interests of animals. (not even rawlsian contractualists would subscribe to this claim as a general principle.) and yet one of the implications of rawlsian liberalism (in excluding animals from the sphere of justice) seems to be that where an animal’s interests clash with a human’s interests (where the furthering of the latter’s interests is considered a matter of justice), then the animal’s interests could indeed be overridden by the human’s even where the human interests in question are less weighty than those of the animals, unless further human interests intervene and supplement the weight of the animal’s interests. (such an implication is reflected in commercial practices which use animals to such an extent that their basic interests—such as bangladesh journal of bioethics 2016; 7(3): 1-11 6 an interest in not suffering, in functioning, and in well-being—are overridden by arguably less weighty human interests.) besides, to say that humans’ interests are always more important than animals’ interests is not a neutral assumption, and no one could reasonably hold that, say, my interest in using a particular detergent (if it can be described as an ‘interest’ in the philosophical sense; indeed ‘preference’ may be a better word than ‘interest’ here) is more important than the interests of animals, despite their lack of a sense of justice, in not being subjected to suffering in toxicity tests. that said animals’ basic interests, including their interest in not suffering, are commonly overridden by less weighty ones (such as the ‘interest’ in using a new cosmetic or detergent). indeed, the practice of animal experimentation provides numerous examples of cases in which animals are routinely burnt, poisoned and mutilated for relatively insignificant purposes, and while the justifiability of this practice is debatable, the fact that the practice is widely accepted even though experiments often involve sacrificing the vital interests of animals for peripheral human ones (despite statutory laws against cruelty to animals and laws which provide some, albeit limited, protection for animals) exemplifies the problem with which garner is concerned in relation to liberalism. however, in spite of the fact that animals’ basic interests are routinely overridden by less basic human ones, when the conflicting interests of humans and animals are considered, such as in the aforementioned example, it is reasonable to say that sometimes the relevant animals’ interests may be morally more significant than the human interests at stake, especially when the human interests under consideration are of a trivial kind or better described as preferences, wants or desires, rather than interests of a basic kind (such as an interest in not suffering, or an interest in continued existence). basic interests do not become less basic, or less significant, when not harnessed to a capacity for a sense of justice. but if we take the view that the basic interests of non-human animals sometimes count for more than the peripheral or trivial interests of humans, then our understandings of obligation and of justice need to be brought into line, so that what we say about obligation is not countered by assumptions about the invariable priority of humans in matters of justice. for justice, at least in our view, concerns the satisfaction of needs among sets of individuals capable of affecting such satisfaction in others, with basic needs as a priority14 15, and this means that human interests cannot in matters of justice take invariable priority, where animal needs and interests are of equal or greater significance (an implication which warrants acceptance in any case even by those reluctant to endorse our theory of justice in general). nor does justice always require reciprocation, for there can be justice between different generations even where no reciprocation is possible. similarly, we contend, there can be justice between members of different sentient species (even in the absence of reciprocation), requiring the basic needs and interests of non-human animals to be heeded and not to be neglected. indeed those who grant that animal needs and interests sometimes take priority over human interests, and that we therefore sometimes have overriding obligations to animals, are in danger of appearing inconsistent if they proceed to deny that these are obligations of justice. bangladesh journal of bioethics 2016; 7(3): 1-11 7 such, at any rate, is the theory of justice proposed in this essay. while the implications of such a theory are beyond the scope of this essay (focusing as it does on a critique of contractarianism and on bringing to light the problem of reconciling the claim that humans have obligations to non-humans animals with the claim that our treatment of the latter is not a matter of justice), some practical implications are worthy of mention here (but it is the authors’ intention to reserve a fuller discussion of this for another time). in matters of justice we should bear in mind that different animals have different interests and, therefore, will require different treatment. domestic animals will need to be treated differently from wild animals, and where we have made ourselves responsible for the quality of life livable by particular animals (by making them captive or by using them as a means for our own purposes), then treating them fairly will involve giving their interests due consideration, arduous as the implications may be. with regard to those beings who have interests the fulfilment of which is dependent on human beings giving those interests due consideration, areas of most obvious concern include the practice of factory farming—a practice which involves vast amounts of humanly generated and avoidable suffering, as writers such as peter singer have brought to attention (peter singer, animal liberation) — and the long-distance transport of live animals for slaughter, as well as the practice of animal experimentation. in relation to the latter (and as suggested above), while some of this is thought to be indispensable for discovering and testing medicines intended for human use, much of it is conducted rather to test cosmetics and cleaning products, and could be discarded without significant loss to human interests. from the perspective of justice, the non-intensive rearing of domestic animals for food is less clearly unjustified, as long as these animals are allowed to enjoy a good life (unlike veal calves), although it may be held unjust to deprive self-conscious animals (as pigs may well be) of the futures they were capable of entertaining. as far as the suffering of wild animals in captivity is concerned (for example, bears in bear-bile farms, and wild animals kept in barren conditions in zoos), such suffering is also avoidable, as well as morally significant, and in such cases there are obligations to assist the relevant animals, by, for example, putting pressure on governments for change, and calling for the release of these animals into an environment or sanctuary that will allow them to exercise their species-specific tendencies. but the position is very different where the treatment of wild animals (other than those in captivity) is concerned, for the quality of life livable by such creatures is, contrary to domestic animals, usually dependent on interference being minimal if not absent altogether. (we are assuming that the quality of life of wild animals is not characteristically negative.) treating them fairly would involve, for example, ensuring that their habitats are sufficiently protected at least to the extent that they are able to fulfill their basic needs and further their own interests, and could involve refraining from acting in ways which may be considered to undermine their significant interests, even when our own interests are at stake, although this is not to say that comparative judgments of moral weight cannot be made. justice towards wild animals does not, in any case, involve protecting them from predation, even when this bangladesh journal of bioethics 2016; 7(3): 1-11 8 would be possible, and despite such protection seeming to be implied, since such a policy would undermine the entire pattern of life of both predators and prey alike. although there will be occasions on which injured animals, such as whales stranded on beaches, can and should be rescued, no comprehensive policy of intervention is remotely justifiable, nor, for that matter, seriously possible. indeed, singer suggests that, as far as wild animals are concerned, we should adopt a policy of noninterference (‘except in a few very limited cases’), and should not attempt to ‘police all of nature’ (singer, animal liberation, pp. 225-26). justice towards wild animals involves avoidance of human cruelty towards them, and of culpable neglect, but not attempts to subvert the very system of evolution through which they have evolved. a further practical implication arising from the claim that deliberations of justice are owed to non-human beings is that we should make more strenuous efforts than would otherwise be required to mitigate carbon emissions and stabilise levels of greenhouse gases in the atmosphere. strong efforts are in any case required to do all this for the sake of human interests. but humanity may well be outlived on this planet by many non-human beings, possibly for billions of years, as long as we curtail greenhouse gases in the present. even if we do not, some non-human beings would probably survive, but a great many would not, since these emissions are already driving many to extinction. if taking seriously the interests of non-human beings is a matter of justice, then facilitating the survival of species that are in danger of being driven to extinction, both for the duration of the survival of humanity and for the period beyond, is itself a matter of justice. those who believe in animal rights will usually have no difficulties accepting at least many of these implications or the conclusion that animals are proper recipients of justice, as long as these rights are regarded as of comparable strength to at least some human rights. but many ethicists hesitate to affirm animal rights, in some cases because rights characteristically can be claimed and non-human animals are almost entirely unable to make claims, and in some cases because they reserve the language of rights for the relations of parties who can enter into agreements with each other, something that, once again, animals cannot do. in other cases, ethicists are hesitant to affirm animal rights because they are reluctant to base everything in morality on rights in the first place. rights, they may hold, figure in moral conclusions, rather than comprising moral presuppositions. or they may argue that the claim that animals deserve moral consideration does not imply that we should treat them in the same way as we treat humans, recognise that they have the same rights as humans, or, indeed, recognise that they have any rights at all. this, however, makes them potentially vulnerable to those who claim that justice applies to human beings only. yet it remains possible to affirm that non-human animals deserve fair and just treatment without endorsing animal rights, for having (or being capable of having) rights is not necessary for deserving such treatment. as an aside, it is worth noting here that many writers express either reservations or scepticism regarding moral rights, including peter singer who considers rights talk to be valuable but merely rhetorical (animal liberation, pp. 6-8), r. j. frey who doubts whether there are bangladesh journal of bioethics 2016; 7(3): 1-11 9 rights16, and raymond gaita who suggests that talk of rights adds little in terms of enabling one to determine what makes an action just or unjust17. (and of course jeremy bentham famously declared rights to be ‘nonsense upon stilts’18.) but it is beyond the scope of this essay to address the details of these authors’ claims. it is sufficient to explain here why the authors emphasise that matters of justice are not dependent on rights claims. we distinguish between a weak and strong sense of rights (as at attfield, value obligation and meta-ethics, pp. 142-44). while there are certainly rights in a weak sense—in the sense of a being having interests which are deserving of moral consideration—the strong sense may be said to refer to an overriding or inviolable reason to take a being’s interests into account, and since the authors believe that interests should be weighed appropriately and given due consideration, they are hesitant to accept the latter sense of rights (the sense that most philosophers use when appealing to rights). besides this, one could claim that animals’ interests should be given serious if not equal consideration without anything about their rights being held to follow. in talking of those beings that deserve moral consideration one here is talking of those beings ‘to whom principles of morality apply’19, where moral consideration should be taken to include, as kenneth goodpaster claims, ‘the most basic forms of practical respect (and so is not restricted to “possession of rights”)’20. in relation to the example of animal experimentation above and to the case against experimenting on animals for trivial purposes, no reference to rights is required for this case to be made. the practice of animal experimentation causes animals to suffer acutely and chronically; animals are subjected to sufferings and pains that would be considered immoral and barbaric if inflicted upon humans. the very fact that animals are made to endure such sufferings requires that we take experimental animals’ interests seriously and give them due consideration. doing this would no doubt mean that, at the very least, many experiments should be abolished, but such an implication need not be construed as dependent on the claim that animals have rights21. returning to rawls’s contractarianism, we have thus far outlined a tension within the liberal moral and political theory. however, rawls’ exclusion of animals poses a further problem; a problem which relates to the idea that only those with either the capacity for moral agency or the potential to develop it are to be included in the contract. obviously, in line with such an idea, it would initially seem that rawls has to exclude not only non-human beings, but many humans who lack such a capacity. as such and as a human-centred theory with regards to matters of justice, it could be argued that it undermines itself, for not only does it exclude some humans, but it would seem that it has to exclude those very human beings that we usually consider to be most vulnerable (permanently and severely mentally-disabled people, for example, who lack the potential to develop moral personhood) and consider to be capable of being recipients of justice. admittedly, rawls is aware that the exclusion of such humans is not without its problems. as he says, ‘those more or less permanently deprived of moral personality may present a difficulty’ (rawls, theory of justice, p. 446. similarly, rawls later claimed, ‘there is the question of what is owed to those who fail to meet this condition’ (political liberalism, p. 21), while some of his followers have made efforts to tackle this bangladesh journal of bioethics 2016; 7(3): 1-11 10 problem from the contractualist perspective). that said, rawls includes some humans that lack moral agency, such as babies and infants, on the basis that they have the potential for moral agency, and yet animals, many of which have more developed cognitive capacities than babies and arguably some infants, are excluded. the latter’s exclusion then appears inconsistent in the light of rawls’ inclusion of most humans, many of whom possess what might be called ‘lesser’ mental powers than some animals22. however, it could be claimed that some animals do indeed possess the capacity for moral agency, implying that they can be included in the contract, albeit with some revisions. however, as will be outlined in the following section and further discussed in the section on ‘contractarianism revised’, problems with contractarianism as a theory of justice cannot be resolved by merely trying to overcome its apparent inconsistency—they cannot be resolved by, for example, either including those animals who are at least as cognitively developed as babies and infants, or by excluding marginal humans along with animals. nevertheless, insofar as claims regarding the capacity of some nonhuman animals for moral agency may be thought to overcome at least this issue of inconsistency, they are worthy of attention, even though the resulting revision would still make no provision for the just treatment of millions of other sentient animals. this essay is due to be completed by the publication of part ii in the next issue of the bangladesh journal of bioethics (volume 8, issue 1, 2017). authors’ contributions: the first author presented a related paper at a conference, and the second author expanded the argument of that paper significantly in the light of the recent literature. both authors then contributed revisions, and the first author adjusted the references in line with the journal’s requirements and added responses to the comments of an anonymous referee. conflict of interests: no conflict of interests arises in connection with this essay. acknowledgement: the authors would like to acknowledge the helpful academic advice of simon robertson, jan deckers and an anonymous referee of bangladesh journal of bioethics, and the practical assistance and encouragement of david lockwood and of steven goundrey. bangladesh journal of bioethics 2016; 7(3): 1-11 11 references: 1 rawls, j. a theory of justice, revised edition (oxford: oxford university press, 1999 [originally published 1971]). 2 barry, b. ‘sustainability and intergenerational justice’, in fairness and futurity: essays on environmental sustainability and social justice, ed. andrew dobson (oxford: oxford university press, 1999); see, for example, p. 95. 3 scanlon, t.m. what we owe to each other (cambridge, ma, and london: the belknap press of harvard university press, 1998); see especially pp. 177-87. 4 möllendorf, d. cosmopolitan justice (boulder, co: westview press, 2002); see especially pp.31-36. 5 möllendorf, d. ‘cosmopolitan and compatriot duties’, the monist 94, 4 (2011): 535-54. 6 midgley, m. animals and why they matter (harmondsworth: penguin, 1983), p. 50. 7 wissenburg, m. ‘the idea of nature and the nature of distributive justice’, in the politics of nature: explorations in green political thought, eds. dobson a. and lucardie p. (london: routledge, 1993), p.11. 8 singer, p. animal liberation, second edition (london: pimlico, 1995). 9 rawls, j. political liberalism (new york, and chichester, uk: columbia university press, 1993), p. 109. 10 garner, r. a theory of justice for animals: animal rights in a nonideal world (new york: oxford university press, 2013), p. 26. 11 garner, r., ‘political ideology and the legal status of animals’, animal law 8, 77 (2002): 77-91 (see pp. 88-89). 12 see further abbey, r. ‘rawlsian resources for animal ethics’, ethics and the environment 12, 1 (2007): 1-22. 13 garner, r. ‘rawls, animals and justice: new literature, same response’, res publica 18, 2 (2012): 159-172. 14 see attfield, r. a theory of value and obligation (london, new york and sydney: croom helm, 1987), pp. 135-53. 15 see further attfield, r. value, obligation and meta-ethics, value inquiry book series, vol.30 (amsterdam and atlanta, ga: editions rodopi, 1995), pp. 133-48. 16 frey, r.g. interests and rights: the case against animals (oxford: clarendon press, 1980), ch.1. 17 gaita, r., the philosopher’s dog (london: routledge, 2002), p. 200. 18 see bentham, j. ‘anarchical fallacies’, in the works of jeremy bentham, volume 2, (edinburgh: w. tait, 1843). 19 warnock, g.j. the object of morality (new york: methuen, 1971), p.148. 20 goodpaster, k. ‘on being morally considerable’, journal of philosophy 75 (1978): 308325 (p. 309). 21 see further humphreys, r. ‘animal rights, interests and moral standing: a critical examination of the dialogue between regan and frey’, in vyas, m. (ed.) issues in ethics and animal rights, (delhi: regency publications, 2011); see pp. 132-133. 22 see further humphreys, r. ‘contractarianism: on the incoherence of the exclusion of non-human beings, percipi 2 (2008): 28-38. microsoft word zoheb 1 bangladesh journal of bioethics 2018; 9(2):22-25 22 public health research ethics and clinical research ethics. how we differentiate? zoheb rafique department of community medicine, liaquat university of medical & health sciences (lumhs), jamshoro, pakistan email: scorpionzoheb@hotmail.com abstract: this article talks about both clinical research ethics and public health research ethics. clinical research ethics are defined as set of relevant ethics considered necessary for the conduct of clinical trials in field of the clinical research. while public health research ethics is mainly aimed at finding out what is best for the communities and the populations rather than the individuals. research ethics is mainly focused on the protection of individual participants and some of the research norms and accepted principles may be challenging when applying in some of the research contexts. key words: public health; research ethics; clinical research ethics introduction: the field of biomedical ethics arose in late 1960s in response to some emerging ethical dilemmas and issues of that era. this field for many years focused on dilemmas generated by the high technology medicine, rather than on the issues of the population health and the ethical problems of public health programs. the discipline bioethics received the initial stimulus from abuses and issues of human subject’s research, also the emergence of patient’s rights movement, and the drama of high technology medicine. the research involving human subjects has often been a central ethical issue and problem for the biomedicine for at least hundred (100) years now, and particularly since the world war 2. just as the public health is broad in the scope, the range of the ethical issues in this field is uncommonly wide (1). in past twenty (20) years, the research base of the clinical ethics has gained tremendous strength appreciably. however the main research opportunities didn’t come under broad heading of the clinical ethics, but instead through the specific programs such as human genome project and end of life movement (2). in this paper, i will discuss the differences between public health research ethics and clinical research ethics. discussion: the public health research ethics include ethics regarding the community participation in the research, while the clinical research ethics include the ethics regarding the clinical patient research. this is major difference between these two scenarios, now i will discuss it in detail. most of the research has focused on the clinical and the experimental medicine (efficacy, safety and the mechanism of action, and also regulatory issues regarding general neglect of the public health dimensions. the public health ethics, which is defined as identification, analysis, and the resolution of the ethical problems occurring in the public health practice and also public health bangladesh journal of bioethics 2018; 9(2):22-25 23 research. it has different domains than those of the medical ethics. the ethical concerns in the public health often relate to dual obligations of the public health professionals to apply and acquire the scientific knowledge that aimed at restoring and also protecting public health while respecting the individual autonomy. ethics in the public health involves interplay between safeguarding welfare of individual, as in medicine, and also the public health goal of protecting public welfare. some other ethical concerns in the public health relate to need to ensure just and fair distribution of the public health resources. the public health ethics has broad scope that includes the ethical and the social issues arising in the health promotion and the disease prevention, the epidemiological research, and also public health practice. the main professional roles of the epidemiologists are design and the conduct of the scientific research and public health application of the scientific knowledge. this includes reporting the research results and also maintaining and promoting the health in communities. it also functions in carrying out the professional roles. the epidemiologists often encounter many ethical issues and some concerns that require the careful consideration. many of those issues have been highlighted and addressed in literature on ethics in the epidemiology and public health including the ethics guidelines. the ethical and the professional norms in the epidemiology have also been clarified in the ethics guidelines for the epidemiologists and also the public health professionals. the ethics guidelines such as those developed for industrial epidemiology forum, international society for the environmental epidemiology, and american college of the epidemiology also provide useful accounts of the epidemiologists’ obligations to the research participants, employs, society, and colleagues (3). the epidemiological studies can provide the descriptive data that can lead scientists in the future to develop some interventions that can result in the reduction in morbidity and mortality; the health education program can be one of the multiple interventions that together reduce the risks and ill health. the argument here, however, is that the public health programs, studies, or interventions, must be designed with the awareness of relationship between that program and ultimate reduction in the morbidity and mortality. the public health programs may result in high employment, as well as some less tangible benefits such as coalition building and strengthening of the communities. today, the public health practitioners use some tools in addition to the epidemiology to register their work, still aiming primarily on community wide. it also typically uses prospective methods and approaches to improve health. in addition, the practitioners investigate the outbreaks, provide health education, conduct contact tracing, and some other preventive interventions, and also organize research related to the public health (4). the public health agencies require the identifiable health information for conducting different public health activities. the increasing number of the functions, including the public health surveillance, and outbreak and incident investigations and program implementation, and some direct health services, such as the clinical public health activities and services and the research, maintenance, and the bangladesh journal of bioethics 2018; 9(2):22-25 24 storage of the personal health information. the successful execution of all these functions depends on the data quality and the accessibility. heightened security is very necessary and paramount to maintain the public confidence; also good health care and it depends on the patients providing the accurate and sensitive information to their care providers in a very timely manner. placing restrictions on the data acquisition, use, and the disclosure also poses some risks, particularly if those restrictions impede acquisition of the key surveillance data, which would otherwise be used to prevent the disease, investigate the causation, and enable the interventions to protect the exposed population. additionally, electronic data could potentially permit real time public health surveillance and also can facilitate the faster emergency response (5). advances in the science, technology and the biomedical research have pushed the boundaries of belmont principles and stimulating the need for the communities to be involved in informed consent process. changes in the food and the drug administration regulations allow the waivers of the informed consent in life threatening emergencies. the rights of the unconscious participants are assumed to be accorded degree of the protection through mechanism of the “community consultation” which requires the prior consultation by the investigators and the institutional review boards with the community representatives and public disclosure to affected community both before and after that research (6). now i will discuss the clinical research ethics, and we will see how it is different from public health research ethics. taking into account the sound and the increasing emphasis of recent years that the experimentation in man must precede the general application of the new procedures in the therapy, and also there is reason to fear that these requirements and the resources might be greater than supply of the responsible investigators. medical schools and the university hospitals are increasingly dominated by the investigators. every young man knows that he will never be promoted to some tenure post, and to a professorship in a major medical school, unless he has proved himself as an investigator. if the ready availability of the money for conducting the research is added to this fact, one can see how great the pressure is on the ambitious young physicians (7). a taxonomy was developed for the clinical ethics research, based on the method rather than the clinical area. this divided research in different terms of whether it used theoretical or any empirical methods. first, we will see the theoretical methods of the clinical ethics research. philosophy (e.g., how should the decisions on setting the priorities be made legitimate and also fair?). law (e.g., what practices in setting the priorities in regional health authority might constitute discrimination?). policy (e.g., what policy should the governments follow in funding the new technologies in medicine?). now let’s see the empirical methods of clinical ethics research. social sciences (e.g., how do the regional health authorities in the developing countries make the decisions on setting the priorities?). decision analysis (e.g., how do you trade-off considerations of equity and efficiency in the decisions on setting priorities?). clinical epidemiology (e.g., what are the criteria used to allocate the liver transplant?). health services research bangladesh journal of bioethics 2018; 9(2):22-25 25 (e.g., how does the delivery of the cardiac surgery vary by patient gender and ethnicity?). within empirical research, there is some growing recognition that the quantitative methods alone are not adequate. since many of the phenomena examined by the ethics researchers are deeply entwined into fabric of professions, organizations, and the human lives, qualitative methods have begun to play an important role. for example, one investigator performed the observational research on how physicians discuss do-notresuscitate orders and also advance care planning. the role of the qualitative methods is increasing to include not only the content analysis but also grounded theory, the ethnography, and the case study designs. when we review the field of the clinical ethics a decade from now, we hope that the focus will be shifted from the ethics courses, committees and the consultants to an understanding on the part of most physicians and medical students that ethics is an inherent and inseparable part of the good clinical medicine. we hope that clinical ethics will achieve its rightful place at the interstices of relations between the patients who are sick and physicians who profess to be able to heal and comfort them. clinical ethics has made progress towards this vision in the past some years. the challenge remains for the research to become a mainstream concern for the funding agencies around the world. conclusion: in conclusion, it is stated that although public health research and clinical research are different from each other, but ethical dilemmas are faced by both and also they are same in many situations. while considering the public health research ethics, the researcher must show respect for culture of the community, also take community input on the protocol development, and ensure that research is useful to community, and should respect the knowledge and experience of the community, and ensure that the informed consent is correctly taken before starting any of the research (8). while considering the clinical research ethics, two components are most important. the first being the informed consent, and the statement that informed consent has been obtained has very little meaning unless the participant or his/her guardian is capable of understanding what is to be undertaken and all of risks/benefits are explained clearly. secondly, there is more reliability provided by the presence of intelligent, informed, compassionate, conscientious, and responsible investigator. references: 1. daniel callahan and bruce jennings. ethics and public health: forging a strong relationship. american journal of public health. 2002; 92(2): 169176. 2. peter a singer et al. clinical ethics revisited. bmc medical ethics. 2001; 2:1. 3. steven s coughlin. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology. biomed central. 2006; 3:16. 4. nancy e. kass. an ethical framework for public health. public health matters. 5. julie myers et al. privacy and public health at risk: public health confidentiality in the digital age. american journal of public health. 2008; 98(5): 793801. 6. sandra crouse quinn. protecting human subjects: the role of community advisory boards. american journal of public health. 2004; 94(6): 918-922. 7. henry k. beecher. ethics and clinical research. the new england journal of medicine. 1966; 274(24): 1354-1360. 8. c. weijer and e.j. emanuel. protecting communities in biomedical research. science. policy forum: ethics. 2000; 289: 1142-1144 microsoft word waseem public health bangladesh journal of bioethics 2016; 7(2):25-30 25 review article ethics in public health research and clinical research muhammad waseem khan1, afrasiab khan tareen2, imrana niaz sultan2 1. department of biotechnology, faculty of life sciences & informatics, balochistan 2. university of information technology engineering & management sciences (buitems) quetta balochistan, pakistan. email: muhammad.waseem@buitms.edu.pk mwaseem.tareen@yahoo.com abstract: research conducted with ethical values is the need of modern world and great benefit to the society in general and human beings in particular. clinical research basically focuses on improving human health individually by improving current trends, methodologies and identifying innovative methods of treatment. public health research is mainly concerned with the health of the entire populace. no standard rules can be formulated for conducting any form of research ethically; however following some basic ethical values can assure ethical conduct of research. in any research study whether that is public health research or clinical research, the importance is need to be to recognize an ethical standard that respects individual’s autonomy and community’s wellbeing. ethical values in research studies can be achieved by requiring individual’s and community’s collective collaboration for the protection of individuals autonomy, dignity and wellbeing. keywords: clinical research, public health research, bioethics, autonomy, justice introduction: research has been defined as an activity that is designed to test a hypothesis for the conclusions to be drawn for the development of new treatment and knowledge. research promises great blessings of science to human beings but, great care should be taken to ensure that it should not violate human dignity. for this purpose the researchers are ethically and morally bound to respect human life and people’s autonomy. research ethics aims to achieve fundamental objectives of how we ought to act in any situation or scenario, and to provide strong bangladesh journal of bioethics 2016; 7(2):25-30 26 reasons and justification for doing so. research ethics plays an important role, striving to make possible that any research study is conducted after following the due ethical procedures1. discussion: there is no standard way of organizing the ethics of public health, clinical practice and biomedical science. there are some basic ethical concerns that are focused for both types of research whether that is public health research or clinical research to be ethical, the study design must be scientifically sound, it should have sufficient power to test the hypothesis etc. although these distinguishing characteristic concerns are often captured under the broad umbrella term of bioethics, sometimes bioethics is presented as the equivalent of medical ethics or in contrast to population level bioethics or public health1. public health research ethics object of concern is the whole populations, not individual human being, concerning to maximize welfare of the whole population. public health research ethics follows a consequentialist approach that is promoting public health by seeking to improve good health and to avoid bad health outcomes of overall population. promoting public health involves a high degree of commitment to the deterrence of disease focusing mainly on preventive aspect, involves diagnosing and treating illnesses, with all the attendant clinical services that those activities require. public health addresses the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. on the other hand, clinical research refers to the subset of individual human subject’s research that focuses on improving well-being and human health, normally by identifying better methods to treat, or prevent individuals from diseases. the potential expected benefits of clinical research are only expectations based on hypothesis, but the risks and burdens of clinical research are present in the current study participants2. public health research ethics has a broader spectrum than clinical research ethics, public health research is, as what we do as a society collectively to guarantee better conditions for people of society to be fit and healthy. the field of public health is concerned with disease prevention and health promotion throughout the society. unlike clinical research, public health research is less interested in clinical interactions between health care professionals and the individual patient, and it is more interested in developing broader strategies to prevent diseases2, 3. bangladesh journal of bioethics 2016; 7(2):25-30 27 in bio medical and clinical research ethics, much emphasis is placed on autonomy, the freedom of the individual human being but, in public health research ethics the focus is on the overall public. for public interest some measures might cause minor infringements of a person’s freedom but, that is to achieve significant benefits for a large number of people3. two theories of ethical perspective have commonly been cited in the literature of public health research ethics and clinical research ethics. the duty based deontological theory of immanuel kant and the consequences based utilitarian theory of jeremy bentham and john stuart mills. kantianism or deontological theories hold that indiviuals should not be treated just as mere means to an end and that some actions are judged right or wrong regardless of the results and consequences. deontological theories based on duty provide robust support for defending research subjects as an individual and whole community of people of individuals; it strongly focuses individual’s autonomy and respect. its great deal of focus is based on duty which asks for autonomy, individual respect and risk benefit ratio despite of consequences that may be great but, as far as these matters are concerned, it has to be followed in any and every case of clinical research ethics and other fields of life4. on the other hand for the benefit of community and public health research ethics the utilitarian theories focuses to maximize beneficial consequences regardless of any harm to individuals. the principle of utility requires aggregate or collective benefits rather than individual benefits to be maximized from study participants to the future population. it balances the current risks and potential harm to individual’s autonomy and individual respect with the benefits for future population. from a utilitarian perspective, based on utility the principle of utility is the ultimate ethical principle of concern that is focused to derive all other principles. utilitarian theories provide strong justification and support for public health research programs such as obligatory vaccination programs for the safety of public health particularly children and the drinking water fluoridation of public water sources and public water supply system, which may be of no benefit or even harm to some individuals in that specific population or society2, 4. bangladesh journal of bioethics 2016; 7(2):25-30 28 as it is broadly understood, that public health research is concerned with promoting and protecting the health of populations. public health research is mainly concerned with the health of the whole population as an aggregate, rather than the health of individuals. public health research emphasize on the prevention of diseases and promotion of overall public health. in developing effective interventions it interacts with behavioral, social, biological, environmental and economical factors4. the foundation of public health research ethics is social justice contributing to the society. balancing individual’s liberty and autonomy has been the main ethical issue in public which is not addressed due to its broader scope for society that causes inequality. on the other hand the fundamental ethical concern raised by clinical research ethics is whether and when it can be acceptable to expose some individual to risks and burdens for the benefit of others. the answer to this question depends crucially on the benefits to future population, and their relationship to those who are being currently exposed to the risks participating in the current research study2, 4. in clinical research ethics, risk and benefit ratio is assessed focusing on the current patient. to asses, whether to harm someone for the future benefits of others or for future population is ethically and morally acceptable or not, while public health research ethics assess risk and benefits ratio for the benefits of future population and society as whole. from clinical research ethics perspective the issues will probably remain even after having a valid inform consent from the participant as inform consent does not remove the associated risks but only a procedure to be followed. the participant may face some risks due to new intervention, the risks which may not be avoided even after testing has occurred in the laboratory, and in animals5, 6. clinical research ethics concerns with the issue of therapeutic misconceptions, the distinction between clinical care and clinical research which arises between researcher who is the physician and the participant who is the patient for the physician participating in that research study. in any clinical research the patient sometimes participates in the research study due to his physician involved in that study. sometimes the patients misconceive the research as the treatment. the inquiry of how to discriminate between research and treatment is still a grey area that is to be focused. on the other side in public health research ethics the issue of therapeutic misconception may not be of great deal but still cannot be totally neglected, there are fewer chances of bangladesh journal of bioethics 2016; 7(2):25-30 29 therapeutic misconceptions that still remain. some people worry that doctors conducting randomized controlled trials studies confront situations of dilemma in clinical research ethics; on the grounds that offering patients access to a trial in which they have a high chance of receiving placebo or no treatment seems to involve the doctor in prescribing and recommending treatment of suboptimal nature to his own patient5, 6. in any research study whether that is public health research or clinical research, it is important to recognize an ethical standard that respects individual’s as well as community’s autonomy. it can be achieved by requiring individual’s and community’s collaboration to protect against exploiting vulnerable populations, to ensure fair terms of cooperation, and to minimize potential misunderstandings about the research5, 7, 8. conclusion: the four basic ethical principles of justice, beneficence, nonmaleficence and respect for individual’s autonomy can be used as a scaffold for ethical decision making in any form of research. these principles ensures individual’s and community’s dignity, researchers obligations to individual and community, avoiding and disclosing conflicts of interest, minimizing risks and providing benefits, privacy and confidentiality that all are the fundamentals of every research study. acknowledgement: the authors would like to acknowledge the generous support and guidance of dr. arshi farooqui, aga khan university hospital, karachi, pakistan. competing interests: the authors declare that they do not have any competing interests. funding: the authors declare that the current study was not funded authors’ contributions: all authors have contributed substantially to the conception and design of the manuscript. muhammad waseem khan is the 1st and corresponding author. afrasiab khan tareen, and imrana niaz sultan are 2nd authors and they have contributed equally. muhammad waseem khan has critically revised the manuscript. all authors have read and approved the final manuscript. bangladesh journal of bioethics 2016; 7(2):25-30 30 references: 1. kalantri, sp. ethics in clinical research. indian journal of anesthesia 2003; 47(1): 30-32. 2. beauchamp t, childress j. principles of biomedical ethics. oxford university press, 5th edition, new york; 2001. 3. krebs j. the importance of public-health ethics. special theme – ethics and public health: bulletin of the world health organization 2008; 86 (8). 4. coughlin, ss. ethical issues in epidemiologic research and public health practice. emerging themes in epidemiology 2006, 3:16. 5. kevin, p et al. disclosure of financial relationships to participants in clinical research. n engl j med 2009; 361(9): 916–921. 6. khan mw, sultan in, khan a, khan mb. issues of research ethics and clinical ethics in developing world, possible solution: a way forward. bangladesh journal of bioethics 2012; 3(3):12-15. 7. buchanan dr, miller fg. a public health perspective on research ethics. j med ethics 2006; 32:729-733. 8. khan mw, khan sz, khan a, sultan in. standard of care in clinical research involving human subjects: a perspective from developing world. bangladesh journal of bioethics 2014; 5(2):68-72. bangladesh journal of bioethics 2017; 8(1): 7-20 7 original article the chicken fallacy and the ethics of cruelty to non-human animals akande michael aina 1 and ofuasia emmanuel 2 1. department of philosophy, lagos state university, ojo, lagos, nigeria, email: ainaakande@yahoo.com 2. department of philosophy, olabisi onabanjo university, ago-iwoye, ogun, nigeria, email: ofuasia.emma@gmail.com abstract: the ideological underpinning that guides our interaction with non-human animals needs revision. the traditional outlook, according to which humans have a higher moral status vis-à-vis non-human animals, is now otiose. if these claims are to be justified, what ideological framework would serve this end? what are the moral implications of endorsing the view that humans possess no higher moral status than non-human animals? this work takes as foundation charles darwin’s theory of evolution, which affirms that humans emerged from the long chain of evolutionary history, where non-human animals have been the carriers of the genes that shaped humans. a revisit to the discourse on the moral implication of humans’ cruelty to their ancestors and neighbours becomes pertinent. this essay goes against the mainstream and dominant perspective that non-human animals exist to serve human ends and as such can be treated with disdain. the thesis of this paper goes beyond peter singer’s submission that sentience is the basis for conferring moral worth on non-human animals. it affirms that in addition to sentience, good neighbourliness is a factor in determining the moral worth of non-human animals. it submits that cruelty to reared and domesticated animals may produce violent and wild species of these animals’ kind in a future evolution, thereby endangering the lives of future human generation, through negative alteration of genes. in the end, this paper proposes the principle of biological altruism as a suitable norm for determining the moral worth of non-human animals. keywords: chicken fallacy, moral worth of non-human animals, darwinism, cruelty to animals, domestic animals. introduction: in the problems of philosophy, bertrand russell provides a very useful anecdote whose consequence extends to the relation between non-human animals and humans on the one hand and the foundation and limitations of inductive reasoning on the other hand. whereas russell intends to show the problems arising out of inferring uniformity of behavior in nature, his narrative also point to a very serious problem regarding the relationship between human and non-human animals, especially the domesticated animals who are our neighbours. this essay tells an anecdote which we shall refer to as the chicken fallacy 1. the chicken fallacy derives from the fourth chapter of the afore-mentioned book, where russell ponders: mailto:ainakande@yahoo.com mailto:ofuasia.emma@gmail.com bangladesh journal of bioethics 2017; 8(1): 7-20 8 domestic animals expect food when they see the person who usually feeds them. we know that all these rather crude expectations of uniformity are liable to be misleading. the man who has fed the chicken every day throughout its life at last wrings its neck instead, showing that more refined views as to the uniformity of nature would have been useful to the chicken…the mere fact that something has happened a certain number of times causes animals and men to expect that it will happen again. thus our instincts certainly cause us to believe that the sun will rise tomorrow, but we may be in no better a position than the chicken which unexpectedly has its neck wrung 2 . although the chicken fallacy clearly outlines that man and animals can reason inductively, it does wish away the moral issue of whether or not animals should be thus treated (i.e. having the neck wrung or be killed), after exhibiting traits of loyalty and protection as it is with other domestic animals like cats and dogs. in other words, the discernment in the anecdote instigates the tendency to conclude that animals are not rational; that they are lacking in value outside those that promote human good. peter singer’s lamentation that “the view that the effects of our actions on nonhuman animals have no intrinsic moral significance” 3 has hitherto become canonical and immaculate. in the foregoing excerpt from russell and from other similar real cases, the dispute over the moral worth of animals is roused. hence, it is pertinent to query: do humans not betray the trust, albeit in whatever crude sense, reposed in them by domestic non-human animals? will the fallacious reasoning of the chicken make other chickens within the cage or those of the future evolutions become cautious or preventive in their relationship with humans or not? these probes dovetail further into some other more pernicious moral posers: firstly, which values and principles should guide our interaction with non-human animals? secondly, how do we weigh our interests against those of other non-human animals as fellow occupants of this planet? more importantly, is the employment of non-human animals for research and food justifiable? through the use of the method of analysis and interpretation, the above crucial questions will be discussed in five divisions, the first being this introduction. in the second section, the paper exposes the popular views on the moral status of non-human animals. when the section critically assesses the popular arguments over the moral status of non-human animals, the study agrees with arthur l. caplan that “purposiveness rather than sentience is a property that suffices for conferring moral worth upon entities” 4 but goes further in the third part to justify this stance from darwin’s principle of natural selection 5 . in the fourth section, our theoretical framework (evolutionism) is assessed critically. the section maintains that the values and principles guiding human interaction with non-human animals need revision from a darwinist perspective. the paper then concludes that the interests of non-human animals as fellow earthly occupants need to be given befitting consideration so that our actions do not endanger the survival of domestic species and that of future homo sapiens. on the moral status of non-human animals: the debate over the moral status of nonhuman animals is not a recent development. it seems trivial and commonplace to believe that humans do not have any moral obligation towards non-human animals. for the sake of clarification, this paper employs the term ‘non-human animals’ to indicate animals both in the bangladesh journal of bioethics 2017; 8(1): 7-20 9 domestic and wild sense. it also suggests that the difference between humans and non-human animal is a matter of degree rather than kind. now, the judeo-christian and islamic traditions made the verdict that in any circumstance humans have more worth than non-human animals (gen. 1:28, al-qur’an 2:47). aside references to passages of the revealed scriptures for support, some church fathers have promoted this outlook. st. augustine claims that animals are lesser beings compared to humans when he denies that the law of god does not apply to them but “altogether for our sakes.” 6 further, st. augustine believes that animals are lacking in the possession of a rational soul. st. thomas aquinas holds a similar stance that human treatment of animals is a matter of irrelevance since god has already given the former dominion over all entities 7 . philosophers are not left out of this discourse. aristotle, for instance, sees nature as a hierarchy where the most rational occupies the summit. according to him: plants exist for the sake of animals, brute beasts for the sake of man – domestic animals for his use and food, wild ones (or at any rate most of them) for food and other accessories of life, such as clothing and various tools. since nature makes nothing purposeless or in vain, it is undeniably true that she has made all animals for the sake of man 8 . as a consequence of the foregoing, aristotle, “made anatomic dissections of animals for scientific study and teaching” 9 which ushered in another trend of moral inquiry: whether or not animals ought to be used for scientific experiments. aristotle would not have even considered this query seriously. rene descartes denies animals the gift of sentience as he viewed them as nothing but complex machines 10 . descartes just like st. augustine denies animals the presence of an immortal soul which involves the capacity to use language 11 . however, it is worth stating that another popular philosopher, immanuel kant, although he seems to see animals as food, maintains the outlook that cruelty to animals may lead to cruelty to fellow humans. in the end, this regurgitates the view that non-human animals are means to human ends. in his own words, kant submits that “so far as animals are concerned, we have no direct duties. animals are not self-conscious and are there merely as a means to an end. that end is man.” 12 even when it seems commonplace to regard animals as human ends, there are a few who still treat animals with respect and dignity. st. francis of assisi seems to be outstanding in this mould. thomas of celano reports that: one time as [francis] was passing through the spoleto valley, he came upon a place near bevagna, in which a great multitude of birds of various kinds had assembled. when the holy one of god saw them, because of the outstanding love of the creator with which he loved all creatures, he ran swiftly to the place. he greeted them in his usual way, as if they shared in reason. as the birds did not take flight, he went to them, going to and fro among them, touching their heads and bodies with his tunic 13 . bangladesh journal of bioethics 2017; 8(1): 7-20 10 the report in the foregoing reveals that the existence of neighbourliness and positive relations between humans and non-human animals should lead to mutual respect among them. it also portrays the tendency of reasoning in the chicken fallacy routine as an excuse for animal brutality or cruelty. the view we have briskly considered, ranks humans over other animals and perceives, in most instances, the relation between them, biologically speaking, as parasitic. even when humans seek to treat non-human animals kindly, this kindness is calculated to further the interest of humans. the moral thrust of the foregoing view is thus: aside the necessity to service the interest of humans, do non-human animals have intrinsic moral significance? at the basic level, non-human animals cannot be ‘reasoned with’ or instructed in the same way we could, as humans. non-human animals cannot be held responsible for their actions or sue for redress in law court as humans might. some may want to argue that non-human animals cannot even claim rights and this makes the question of moral worth and significance an instance of flogging a dead horse. this line of reasoning, albeit very common, has some problems. joel feinberg counters this idea by arguing that, if it is true that nonhuman animals do not have right because they cannot reason or seek redress, then neither human idiots nor wee babies would have any legal rights at all. yet it is manifest that both of these classes of intellectual incompetents have legal rights recognized and easily enforced by the courts. children and idiots start legal proceedings, not on their own direct initiate, but rather through the action of proxies or attorneys who are employed to speak in their names. if there is no conceptual absurdity in this situation, why should there be in the case where a proxy makes a claim on behalf of an animal? people commonly enough make wills, leaving money to trustees for the care of animals. is it not natural to speak of the animal’s right to inheritance in cases of this kind? 14 feinberg’s argument has its problem because one could still protest that the formal relation between trustees and those they represent may not hold between humans and non-human animals since legal proceedings hardly admit it. however, such clings on norms is escapist. it is clear that non-human animals are denied rights and moral status even when they fare better than human babies in terms of what they do. our argument is that fetuses and comatose patients that are being protected are no better than non-human animals in terms of power for inductive collaboration with their neighbours and owners. in evolutionary biology, the behaviour of domestic animals in terms of their usefulness will be seen as altruistic because in the course of assisting humans, sometimes they risk their own lives. if this altruistic behavior is taken into consideration in comparison with wee babies and comatose patients, then animals too deserve better treatment. in other words, when the moral rights of fetuses and comatose patients are usually upheld even when they are not morally conscious, nonhuman animals should not be denied the same consideration when their faculties are functioning at their optimal level. bangladesh journal of bioethics 2017; 8(1): 7-20 11 the quandary of whether or not non-human animals have moral significance has inspired peter singer. singer accuses the human society of what he calls “speciesism” 15 . countering the stance that non-human animals exist to serve human interests, singer avers that “the moral basis of equality among humans is not equality in fact, but the principle of equal consideration of interests, and it is this principle that must be extended to any non-humans who have interests” 16 if we are to be consistent. singer proceeds to defend the view that nonhuman animals have interests because they are entities capable of experiencing pleasure and pain. he concludes that “consciousness, or the subjective capacity for subjective experience is both a necessary and sufficient condition for having an interest.” 17 in a nutshell, singer grants that non-human animals are moral patients in a better category than wee babies and comatose patient, and their interests deserve to be given due consideration when policies that will affect them are tinkered. singer’s objection to the denial of moral significance to non-human animals founders on two grouses: the one with his principle of sentience and the other with his classical utilitarian approach. his position would logically imply that we do not confer moral worth on nonhuman animals that lack the capacity for sentience. according to arthur l. caplan, singer’s stance “would seem to permit experimentation on any creature which cannot, for whatever reason, suffer or feel pain.” 18 caplan’s objection, however, could also be disputed. one may contend that in the case of humans, a temporary cessation of sentience through illness, coma, neurological disorder, tranquilizers, or the administration of drugs would not diminish moral worth, perhaps because of their potentiality to regain consciousness. however, what it means is that animals such as ants that are likely non-sentient entities may not be lucky. does this mean that ants could be denied moral worth because they are likely non-sentient and beings without interests? we think not. ants, like other insects that are non-sentient, could be considered based on utility. when importance to environment is considered above sentience, the role of ants becomes overwhelmingly indispensable. this study suggests that the most plausible alternative to surpass the dilemma between consideration of sentience and importance to environment may be deduced from charles darwin’s theory of evolution which inadvertently promotes biological altruism. the theory endorses non-human animals as beings with purpose tacitly, reposed in them by the process of natural selection. if this is the case, the problem or implication present in the sentience factor of singer no longer presents itself as an insurmountable impasse. darwin’s evolutionary theory and purposiveness in entities: it is not an error to state that darwinism has garnered a parochial and a broad reference over the years. in the former sense, it refers to the organic evolutionary theory propounded by charles darwin and others who have developed strands of his ideas. in the latter sense, it connotes a compendium of sociological, theological, and even philosophical thought that was initiated and substantiated by the former. this paper shall move from the former sense to the latter sense as it exposes the main kernel of darwinism and its implication for the relation between humans and nonhuman animals. bangladesh journal of bioethics 2017; 8(1): 7-20 12 charles darwin’s aim in the origin of species is “to accomplish three things: (a) to show that evolution has in fact occurred; (b) to describe the mechanism of evolution; and (c) to account for the major facts of morphology, embryology, biogeography, paleontology, and taxonomy on the evolutionary hypothesis.” 19 whereas darwin informs us that we do not directly observe the process of evolution, he cites the shortness of human life as one out of many obstacles. he is, however, optimistic that certain facts and conclusions about reality force this thinking upon us. he invites his readers to try the hypothesis only to affirm that hitherto unconnected facts may in fact have a uniform elucidation. the mechanism of evolution plays the role of the hypothesis in question and consists of three components: natural selection, sexual selection, and the inheritance of characteristics attained during the lifetime of an organism. we shall gloss each of these very succinctly, just to highlight areas that are relevant to the argument of this thesis. natural selection is that principle upon which darwin places the greatest weight of his evolutionary theory. in the words of edward wilson, “natural selection is the process whereby certain genes gain representation in the following generations superior to that of other genes located at the same chromosome position.” 20 the theory proposes that (1) populations of animals and plants display variations; (2) some of the variations provide an organism some sort of advantage over the rest of the population in the constant struggle for survival; (3) variations that are favourable are transmitted to the offspring; (4) given the fact that population usually produce more offspring than the environment can support, the proportion of favourable variations that survive and produce offspring would be larger than the proportion of the unfavourable variations; and, thus, (5) a population may experience endless evolutionary change whose consequence can be the development of new varieties. darwin admits that the cause for variation and natural selection is a matter of conjecture. however, it is admitted that changing environmental situations enormously promote variability by acting on the reproductive system and, consequently, providing material for natural selection when and where necessary 21 . edward wilson advances further that the individual organism is only a vehicle for the preservation and transmission of favourable variations. he argues that “in a darwinist sense, the organism does not live for itself. its primary function is not even to reproduce other organisms; it reproduces genes, and it serves as their temporary carrier.” 22 charles darwin accounts for the rationale behind sexual selection as the catalyst in mating rituals, sexual behaviours, and characteristics. the intent of sexual selection is to influence the probability of having offspring. writing on the sexual behaviours of ring doves, d.s. lehrman reveals that the sight and sound of the male alone stimulates the pituitary gland to secret gonadotropins 23 . these substances induce an increase in estrogen, which triggers bestbuilding behavior and progesterone which initiates incubation behaviour 24 . what we call ‘sight’ and ‘sound’ is a deeper communication and language among doves. it is, therefore, not an error to ascertain that non-human animals have their linguistic and communication techniques aboriginal and unique to them. with regards to the evolution of humans, m.w. fox informs us that sexual selection was the auxiliary motor that drove human evolution all the way to the homo grade 25 . edward wilson expands this line of thought in his words thus: bangladesh journal of bioethics 2017; 8(1): 7-20 13 polygyny is a general trait in hunter-gatherer bands and may also have been the rule in the early hominid societies. if so, a premium would have been placed on sexual selection involving both epigamic display toward the females and intra-sexual competition among the males. the selection would be enhanced by the constant mating provocation that arises from the female’s nearly continuous sexual receptivity. because of the existence of a high level of cooperation within the band, a legacy of the original australopithecus adaptation, sexual selection would tend to be linked with hunting prowess, leadership, skill at tool making and other visible attributes that contribute to the success of the family and the male band 26 . if there is any truth in the above excerpt, the weight is on humans to therefore re-evaluate their relation with non-human animals. this becomes pertinent given their role as the vehicle preserving the genes that led to homo sapiens. this is true if we remember that, in darwinist parlance, the organism does not live for itself, but as a temporary carrier of genes. if this is the case, then it calls for caution on our part when engaging in actions that will breed unfavourable genes in non-human progenitors. at this point, a critic may object that, since evolution has no aim or purpose, there is no reason to deduce that non-human animals are purposive beings with aims that must not be cavalierly frustrated. the response one may proffer here is that even if the critic is not incorrect in saying that evolution has no intention or purpose, this does not downplay the possibility of giving meaning and purpose to it. after all, a bulk of human life involves interpreting and giving existence meaning through deliberations and actions. for instance, humans may marvel at the complex things of the phenomena and propound the existence of god (teleological and cosmological arguments for the existence of god are popular instances). in other words, humans do attribute aims and purpose to nature, including non-human creatures, if persistent regularity is observed. darwin observed through fossil evidence and record of animals’ features that lower-grade entities have evolved into higher-grade, complex entities. if darwin’s conjecture is taken, then it would not be an error to say this is precisely the aim of evolution. if this is accepted, nonhuman animals have been used by evolution to bring about the emergence of humanity. this makes them human ancestors. it is the failure to see them as such that presents the difficulty in admitting that non-human animals are purposive entities with moral worth. however, even if the term ‘purposive’ seem inapplicable in the same sense it is applied to humans, the difference in the meaning may be a matter of degree and not kind. a dog that saves his master’s child from drowning in a pool may be said to be faithful just like the cock that crows behind his owner’s window regularly to wake him up for work. whereas the dog did his act once, the cock does his always. the cock may be responding to an inner mechanism but the dog is not. after all, not all dogs will do that. so, their faithfulness differs only in degree but not in kind. furthermore, upon a consideration of the mechanism of inheritance, a deeper appreciation of the position of animals suffices. inheritance of acquired characters is the third pillar of darwin’s evolutionary theory. whereas the modern theory of the origin of genetic variation bangladesh journal of bioethics 2017; 8(1): 7-20 14 in populations was not available to darwin, he suggests that some variations are due to the action of the environment on the germ plasm but the effects of use and disuse cannot be ruled out in variations. one may notice the role of lamack’s theory of use and disuse in darwin’s evolutionism, save for the environmental conditions that the latter added to his element. darwin’s theory invites humans to perceive themselves as purposive creatures brought about through the effect of natural selection on non-human animals. in darwin’s words: when we no longer look at an organic being as a savage looks at a ship, as something wholly beyond his comprehension; when we regard every production of nature as one which has had a long history; when we contemplate every complex structure and instinct as the summing up of many contrivances…when we thus view each organic being, how far more interesting – i speak from experience – does the study of natural history become! 27 as opposed to the foregoing, pre-darwinian taxonomy proposed humankind to be at the summit of all there is. the view that all creatures are individually brought into existence through the unalterable work of god had been accepted before darwin. this among other observations denied non-human animals rationality and moral status. this assessment holds that non-human creatures exist solely to promote the human good, and as such deserve no consideration. it is pertinent to hint that darwin’s origin of species questioned some popular and dominant ways of thinking. darwin’s thought poked at creationism and natural theology, on the ground that “the living world, including man, is due to a single origin of life.” 28 the implication here is the futility in invoking an intelligent deity who has subsumed all other living entities to the whim and caprice of the homo sapiens. by extension, anthropocentrism is probed. this is the belief that man is at the apex of the great chain of being and legitimizes man’s perception of everything in the world from his ‘specialized gaze’. darwin challenges us to view humans as animals, albeit complex ones that have acquired the trait of higher intelligence through evolution. darwin’s idea of common descent proposes that all organisms, including humans, descended from common ancestors 29 . darwin’s origin of species, aside the impact on the afore-stated dominant ways of thinking, also tasked people to review their perspectives with regard to classical mechanics, essentialism, cosmic theology, and determinism. darwin’s evolutionism as an ethical and normative groundwork for a holistic animal-human relation: the deductions from the foray into darwin’s evolutionary theory, with its implications for human relations with non-human animals and their moral worth, are as follows: (1) humans are not essentially different from non-human animals. if there is any ‘real difference’, it is a matter of degree, not of kind; bangladesh journal of bioethics 2017; 8(1): 7-20 15 (2) non-human animals are the vehicles employed by evolution, through natural selection, sexual selection, and inheritance of acquired traits for the appearance of an improved organism, which at the moment seems to be the homo sapiens; (3) all organisms (including homo sapiens) are carriers of genetic materials with altruistic consequence. this indicates that evolution is purposive. if not, the regular process of the emergence of higher-grade species from lower grades may be difficult to explain; and (4) deducing from (1) – (3), it would be morally imprudent for humans to cavalierly frustrate the aims of their progenitors. this confers a degree of moral worth on non-human animals. among humans there is this cherished and cordial relationship towards those who had done us one favour or the other and their kin albeit without any direct benefit. in this regard, human society is challenged to rethink: if we consider blood relation in certain ethical situations, why do we neglect genetic relation? the preceding section lends credence to (1). for if one agrees with the mechanism of evolution, (1) has no misgivings. a critic may grouse about (2) that, despite its emergence, homo sapiens have not been able to evolve into a higher being with higher intelligence and consciousness. this study ripostes that although no one has witnessed evolution yet, facts and anecdotes of variation of species impose it on our intelligence. however, the shortness of human life, among other challenging factors, has been a major impasse in this empirical demand of the critics. just because we do not directly observe natural selection is not enough to wish away the reality. in order to avoid the pitfall of argumentum ad ignoratiam, it would be prudent to admit (2) alongside the caveat that “absence of evidence is not evidence of absence.” 30 the claim in (3) follows necessarily from (1) and (2). the movement from beings that are genetic carriers to purposive beings is entrenched in (3).in the words of samir okasha: altruistic behaviour is common throughout the animal kingdom, particularly in species with complex social structures. for example, vampire bats regularly regurgitate blood and donate it to other members of their group who have failed to feed that night, ensuring they do not starve. in numerous bird species, a breeding pair receives help in raising its young from other ‘helper’ birds, who protect the nest from predators and help to feed the fledglings. vervet monkeys give alarm calls to warn fellow monkeys of the presence of predators, even though in doing so they attract attention to themselves, increasing their personal chance of being attacked. in social insect colonies (ants, wasps, bees and termites), sterile workers devote their whole lives to caring for the queen, constructing and protecting the nest, foraging for food, and tending the larvae. such behaviour is maximally altruistic: sterile workers obviously do not leave any offspring of their own—so have personal fitness of zero— but their actions greatly assist the reproductive efforts of the queen 31 . the above instances are clear cases of biological altruism among animals for the preservation of species. it seems puzzling how natural selection would admit the element of altruism into bangladesh journal of bioethics 2017; 8(1): 7-20 16 its schema. in the words of jonah lehrer: “charles darwin regarded the problem of altruism—the act of helping someone else, even if it comes at a steep personal cost—as a potentially fatal challenge to his theory of natural selection.” 32 even in the face of the seeming contradiction in the personal and selfish struggle for survival and the altruistic tendency latent in both animals and even humans, it is not incorrect to say that non-human animals have purpose and sometimes go out of the line, become generous to fulfill this drive. consequently, one can readily defend (4). when peter singer confers moral worth on non-human animals on the basis of sentience, we believe he overlooks non-sentient creatures with utility value, given that they are carriers of genes. this study diverges by hinging on the purposiveness of the evolutionary process rather than sentience. it maintains that sentience could inadvertently deny non-human animals moral worth if it could be proven that such creatures could be used for pain-free scientific research. this scorching issue shall be assessed shortly. for the moment, this research agrees with arthur caplan who recommends that “purposiveness rather than sentience is a property that suffices for conferring moral worth” 33 for non-human animals. as darwin submits that human beings evolved from non-human animals, this truth places a certain moral responsibility on human beings towards their evolutionary ancestors. the least we can do is to treat these entities with more dignity and consideration than what currently obtains. we must improve our social relations with them since they are like neighbours to us. animals are not meant to serve human ends simpliciter. there are instances where animals have developed the ability to drive automobiles, serve countries during wars, practice yoga, and even assist members of dissimilar species 34 . these attest to what may be the result of a good and positive human-animal relation as opposed to the received view that places the one over the other. to corroborate this claim, research in sociobiology has shown that animals are also social beings and as such are purposive in their behaviours. social behaviours of animals are indicative that they also have interests and goals which should make us replicate the loyalty and good services they render to us as humans. the dogs that fend us from human criminals, the cats that keep our environment clean of rodents, and the chicken that serves as a clock should not be killed like ‘common criminals’. if cruelty to good fellow human neighbours is discouraged, the same treatment should be extended to domestic animals. this empathy may not be extended to wild animals since part of our concern in this paper is to rid the world of cruelty and violence. most wild animals are naturally cruel and violent and killing them may be a way of defense but if any of them has been domesticated and successfully develops friendly genes then our position may admit such. hence, this research lauds implemented efforts of some authorities towards training of wild animals with the purpose to generate neighbourly and friendly relations with them. this is crucial especially for those species that are on the brink of extinction. at this point, it is pertinent to emphasize the emotional bond that domestic non-human animals have built with humans. killing those who have become attached to us betrays their trust even if it is tacitly reposed. an analogy from chinua achebe could prove helpful. chinua achebe, in his book things fall apart, relays a relevant story to this discourse where ikemefuna who was brought to bangladesh journal of bioethics 2017; 8(1): 7-20 17 okonkwo’s house as a sacrificial lamb was kept in the house of the hero of the novel, okonkwo, for a period of time 35 . due to the long stay and familiarity with the house, the boy saw okonkwo as his father. as it was time to sacrifice ikemefuna, other men could not kill the boy because they have grown to love him and his youthfulness. okonkwo whom the boy calls father drew out his sword and killed ikemefuna. the explanation offered is that okonkwo has the fear of failure, but the complex of portraying himself as a brave man. this single act turned his immediate family against him as his fellow chiefs were also disappointed. the chiefs retort: “but the boy calls you father!” in the same vein, our attempt to show superiority on earth should not lead us to treat our non-human neighbours as nonentities. such treatment portrays betrayal on the part of humans. the dog that wags his tail when we are home and the chicken who clucks when we approach deserve to be treated like neighbours, if not friends, since these acts are signs of love or acceptability displayed towards humans. this paper agrees with caplan that “it is wrong to interfere with or deprive animals of the opportunity to fulfill their basic drive.” 36 however, a deep look at our cruelty to animals will show that what we obstruct mainly is the purpose of the force behind evolutionary goals rather than the purpose of creatures. we all may not fulfill our individual purposes since death is inevitable but one should not be killed before the maturity of the genes to maintain evolutionary balance in the world. consequently, we have a duty as humans to lessen cruelty to, and even death of, non-human animals where possible. in other words, cruelty to animals is a means of altering evolutionary process that persistently and consistently strives to produce improved species. this is what (4) also admits. the destructive consequence would be the interference in the ‘preservation processes’ of the genetic materials that are necessary for the sustenance of life and evolution. this implores that if non-human animals are fit for human ends, the best way to show that is to preserve them. animals are not just dumb and non-rational entities lacking in self-awareness. to this effect, there are torrents of research in ethology, sociobiology, and comparative psychology that indicate at least that some non-human animals are capable of some forms of intentionality, language, and self-awareness 37 . what this means is that our attitude towards them goes a long way to shape their world and their progeny. converse attitude from them is not impossible. in spite of these, a critic may counter (4) on two grounds: firstly, it may be stated that animals did not intentionally act as carriers of the genes that led to the emergence of humanity. so it is pointless according reverence to entities that did us a favour when they are not even aware of it. secondly, that animals that are currently existing have done close to nothing to our genetic make-up. hence, there is no justification for taking their existence seriously as we would, for instance, idiots and wee babies. the first objection is countered by offering that, if natural selection allowed non-human animals to do this task intentionally, perhaps humanity would not exist as some of these animals would not want to be the fore-runners of higher-grade entities that would maltreat them, decimate their habitat, and even denigrate the environment. the second objection is even less trivial. even if we admit that present animals have not contributed to our genetic bangladesh journal of bioethics 2017; 8(1): 7-20 18 make-up, we must not wish away how cruelty towards them may impose on their genes the emergence of advanced organisms that may develop adaptive wild behaviours as the principles of survival and selection of the fittest made us to understand. the chicken ignorance will then turn into the chicken rationality as non-human animals that were hitherto friendly, now evolve adaptive but cruel and violent behaviours. through natural selection and preservation of the species, a once friendly but cruelly-treated dog could whelp puppies that would acquire adaptive features that turns them into wild and tenacious breeds. these are some of the consequences of failing to give a proper interpretation to evolution and the moral worth of non-human animals even if they are moral patients. since purposiveness is a criterion for moral worth, what consideration should be put in place if the purposes of humans clash with those of non-human animals, for example in the context of scientific experiments? in other words, there is a gulf between the recognition that nonhuman animals possess worth on the one hand and the question of whether or not they could be subjected to laboratory use on the other hand. however, if humans must fulfill the drive and impulses for medicine, it seems some animals must suffer in the course of the discovery of new drugs. our preference for the utility of non-human animals and humans suggests that they ought to be preserved for maturity of genes necessary for future evolution. it seems helping with drugs is a way of doing this. in this vein, preference is given to those scientific research projects that increase the overall well-being of the human species and non-human animals, in the drive to retrieve some from the abyss of extinction, with the help of drugs borne out of research on them. what we shall have is a win-win situation. this attests to darwin’s thinking that all organisms must survive in the face of scarce and limited resources. as a result, there is an assurance that some non-human animals would have their moral worth and rights transgressed in order to fulfill the goal of evolution. it is the unchecked but indiscriminate killing for food and pleasure that are discouraged. the use of a few animals in the development of drugs and medicines saves more animals from diseases and avoidable demise. this is where singer’s principle of equal consideration of interest is revived, albeit in newer perspective 38 . conclusion: the relations that ought to exist between humans and non-human animals as occupants of the same environment have received attention from different scholars. when some have argued that animals have certain fundamental rights and as such should not be killed for whatever ends by humans, others maintain that cruelty to non-human animals can make humans to develop malignant attitudes to one another. hence, the haphazard and blasé killing of animals for food and research purposes should be discouraged. this study departs from the status quo to propose that cruelty to non-human animals, especially the ones who are domesticated, is a mark of betrayal given the attitude of loyalty to humans. further, this could make domestic non-human animals that were hitherto non-wild to develop adaptive wild behaviours against humans in order to preserve their species. this invariably blurs the zoologists’ demarcation between the wild and non-wild. we should note that what we are writing by our malevolent behaviours in the genes of these domestic animals is the inscription: “dogs, beware of men,” which is the reverse of what we normally place at the entrance of our residence: “beware of dogs.” bangladesh journal of bioethics 2017; 8(1): 7-20 19 author contribution: both authors contributed equally to the paper. conflict of interest: declared none. acknowledgements: special thanks to rainer ebert, ph.d., our dear friend on facebook, who informed us about this journal and encouraged us to write this piece. this acknowledgement is incomplete without a mention of okoro chiedozie, ph.d., who helped with some materials on this topic. references 1 some refer to the illustration as “russell’s chicken”. see deutsch, d. the fabric of reality, the science of parallel universes and its implications. new york: viking adult. 1997. 2 russell, b. problems of philosophy. oxford: oxford university press 1959 p. 63. 3 singer, p. “not for humans alone: the place of nonhumans in environmental issues” in ethics: thought and practice. new jersey: prentice-hall inc. 1985 p. 479 4 caplan, a.l. “beastly conduct: ethical issues in animal experimentation” the ethical dimensions of the biological science. cambridge: cambridge university press 1995 p. 184 5 darwin, c.l. on the origin of species by means of natural selection, or the preservation of favoured races in the struggle for life. new york: modern library edition 1949 6 augustine, st. the catholic and manichean ways of life, (trans.) d.a. gallagher and i.j. gallagher. boston: catholic university press 1966 p. 102 7 rowan, a.n. of mice, models and men: a critical evaluation of animal research. albany: state university of new york press 1984 pp. 1-323 8 aristotle,politics, 1256b. 9 bulger, r.e. “use of animals in experimental research: a scientist’s perspective” the ethical dimensions of the biological science. cambridge: cambridge university press 1995 p. 187 10 levine, c. “should animal experimentations be stopped?”in taking sides: clashing views on controversial bio-ethical issues. guilford: dushkin publishing group 1984 pp. 222-3 11 benjamin, m.“ethics and animal consciousness” in social ethics, morality and social policy. new york: mcgraw hill 1987 pp. 476 12 kant, i. lectures on ethics, new york: harper & row 1963 p. 239 13 thomas of celano, the treatise on the miracle of saint francis (1250-1252) r.j. armstrong, ofm cap, j.a.w. hellmoann, ofm cov, w.j. short, (eds.) the francis theology of thomas of celano. hyde park: new city press pp 329-30 14 feinberg, j. “the rights of animals and unborn generations” in ethics: thought and practice. new jersey: prentice-hall inc. 1985 p. 469 15 singer, p. animal liberation: a new ethic for our treatment of animals. new york: avon books 1975 16 op. cit, singer 1985 p. 479 17 ibid p. 479-80 bangladesh journal of bioethics 2017; 8(1): 7-20 20 18 op. cit, caplan 1995 p. 183 19 “darwinism,” encyclopedia of philosophy. http://www.encyclopedia.com/humanities/. retrieved on 11/12/2016. 20 wilson, o.e. sociobiology: the abridged edition. london: belknap press 1998 p. 3 21 op. cit, darwin 1949 22 op. cit, wilson 1998 p. 3 23 lehrman, d.s. “the reproductive behaviour of ring doves” in scientific american 1964 211(5): 48-54 24 op. cit, wilson 1998 p. 107 25 fox, m.w. “socio-ecological implications of individual differences in wolf litters: a development and evolutionary perspective” in behaviour1972 46(3,4) 298-313. 26 op. cit, wilson 1998 27 op. cit, darwin 1949 28 mayr, e. “darwin’s impact on modern thought” in proceedings of the american philosophical society.1995 139 (4) 317-325 29 ibid p. 319 30 weiss, e.the long trajectory: reincarnation and life after death. unpublished version. 2009 p. 23 31 okasha, s. “biological altruism” stanford encyclopedia of philosophy 2013 http://plato.stanford.edu/entries/altruism-biological/. retrieved on 21/11/2016. 32 lehrer, j. “the paradox of altruism” 2012 https://www.wired.com/2012/02/the-paradoxof-altruism/. retrieved on 21/11/2016. 33 op. cit, caplan 1995 p. 184 34 beres, d. “animal stories: when beasts act like humans” http://www.rd.com/truestories/inspiring/animal-stories-when-beasts-act-like-humans/. retrieved on 24/11/2016. 35 achebe, c. things fall apart, london: william heinemann press 1958 36 op. cit, caplan 1995 p. 183 37 see bowd, a.d. “ethical reservations about psychological research with animals” psyschol. rec. 1980 30 (spring): 201-10; fox, m.s. “experimental psychology, animal rights, welfare and ethics”. psychopharm. bull. 1981; 17(2): 80-4; griffin, d.r. the question of animal awareness. new york: rockefeller university press. 1976; wilson, o.e. sociobiology: the abridged edition. london: belknap press 1998 38 op. cit, singer 1985 p. 479 http://www.encyclopedia.com/humanities/ http://plato.stanford.edu/entries/altruism-biological/ https://www.wired.com/2012/02/the-paradox-of-altruism/ https://www.wired.com/2012/02/the-paradox-of-altruism/ http://www.rd.com/true-stories/inspiring/animal-stories-when-beasts-act-like-humans/ http://www.rd.com/true-stories/inspiring/animal-stories-when-beasts-act-like-humans/ 1 bangladesh journal of bioethics 2013; 4(3):1-10 1 ethical challenges of using bst and transgenic animal a. s. m. anwarullah bhuiyan associate professor, dept. of philosophy, jahangirnagar university, bangladesh e-mail : anwarullah1234@yahoo.com abstract: this article examines whether using bovine somatotrophin (bst) and transgenic animal is compatible with the norms of animal welfare, environment, and public health. we cannot oppose its usefulness all on a sudden. despite the usefulness of animal biotechnology, we cannot ignore the different adverse effects of this technology. all of these bring forth different ethical challenges. what is the environmental impact of this technology? another ethical challenge is related to animal‘s welfare and human‘s health. in order to assessing the ethical challenges, this article has opted for mepham‘s ethical matrix, which is a practical approach for addressing broader policy issues. i have focused on the application of this ethical matrix upon some contexts of animal biotechnology, such as bst and transgenic animal. through the analysis, this article came to the conclusion that there are no short curt ways to reach an agreement on the application of animal biotechnology. key words: ethics, challenges, bovine somatotrophin (bst), transgenic animal introduction: technological development has brought enormous amount of benefit for the mankind. apart from this benefit, human beings are also be concerned about the unintended environmental, social, and health-related consequences. considering this impact, scientists should take into account consequences of any science and accept the greater responsibility for the reasonable application of the scientific result. in doing so, this thesis endeavors to reach the conclusion that biotechnology, specially the field of animal biotechnology, has got a variegated splendor. different sections of this article give us an understanding of the methodology, key concepts of animal biotechnology, and the implication of ethical matrix upon some contexts of animal biotechnology, such as bst and transgenic animal. final section of this article is implication of ethical matrix. it is all concerned that animal biotechnology has wonderful contribution, but, we cannot avoid the dangerous potentials of this technology. in this regard, i will devote the ethical controversy of this technology in the final section. therefore, this article will focus on the application of mepham‘s ethical matrix in some contexts of animal biotechnology, such as bst and transgenic animal. methodology: bovine somatotrophin (bst), transgenic animal is a development of animal biotechnology. as a technology, it is not a single issue. rather, it has become a title for a wide range of environmental, public health, and animal welfare-related concerns. therefore, the solution of the problem is not simple, but complex and multidimensional. to examine the ethical acceptability of animal biotechnology, we need to assess the impact of this technology and its potential effects upon the four interest factors: consumers, farmers and financiers, treated organisms, and environment. in this regard, i have selected ben mepham‘s 1 ethical matrix, which is a practical approach for addressing broader policy issues in this regard. according to me, ethical matrix is such a theory that it can incorporate the demand of science and its existing multidimensional complexity. in order to evaluate the ethical impact of biotechnology in the fields of agriculture and food, mepham provides this method of analysis that would help one for facilitate ethical decision making. mepham‘s method of ethical matrix is two-dimensional i.e. consequence matrix and evaluative matrix. consequential matrix, gives a brief description of the assumed or possible consequences of a decision taken upon every affected value, and evaluation matrix, on the other hand, provides an overall picture of the ethical status of the issue at stake. both the approaches can help us articulate an ethical framework for the technologies applied to the animals. mailto:anwarullah1234@yahoo.com bangladesh journal of bioethics 2013; 4(3):1-10 2 mepham states that it has faced a lot of critiques. he also argues that the approach of four principles is quite applicable only to the realms of biological science, healthcare, and medicine. but, mepham‘s ethical matrix is applicable to the fields of agriculture, biotechnology, and food. not only that ―... the framework [four principles] is not an ethical theory and does not aspire to be decision-making procedure‖ 2 . therefore, he assumes that beachump‘s four principle approaches can hardly satisfy rawls‘s non-intuitive means of moral judgment.‖ due to its limitation, mepham revises the four-principle approach and offers new ethical tools: ―ethical matrix‖. in his works, mepham transforms beauchamp and childress‘s ‗four-principles‘ into three. in the framework of the ‗matrix‘, mepham combines beauhamp and childres‘s the first two principles (beneficence and non-maleficence) and renames it as the ‗respect for well-being‘. there are two ingredients in the framework of mepham‘s ethical matrix: i. prima facie principles and ii. ‗interest groups‘. in his framework of ethical matrix, mepham employs three prima facie principles: well-being, autonomy, and principles of justice. well-being combines the first two principles of beachump and childress: non-maleficeine (avoidance of causation of harm) and beneficence (provision of benefits and balancing them against risks and costs) represent the utilitarian theory. respect for autonomy represents the freedom of choice and respect for the individual‘s rights. theory of justice represents the norms of fair distribution of costs, benefits, and risks. mepham has shown his ethical matrix through following figure (figure 1). figure 1 : mepham‘s ethical matrix 3 mepham states that in the ethical matrix there are twelve individual factors under the following three principles: well being, autonomy, and justice. and there are four stakeholders or interest groups, i.e. treated organisms (animals), producers (farmers), consumers (people), and biota (environment : flora and fauna)) on the vertical axis and three principles on the horizontal axis. clarification of the concepts in order to get a clear idea about the problem, it should be explained well what biotechnology means. the term, ‗biotechnology‘, is first used in 1917 by the hungarian agricultural engineer karl ereky who anticipates the term, ‗biotechnology‘, as a ―spirit of molecular research‖ 4 . in his research, he states that every living organism has got ‗nucleic acids‘ which are different from each other in their structure. in 1918, ereky finds a link between nuclear acids and biotechnology. he takes the term, biotechnology as a ―technology based upon biochemistry‘ 5 . the european federation of biotechnology (efb) accepts the term, ‗biotechnology‘, in the sense of the combination of biology and technology ― where the term biology is treated as a branch of knowledge of living organisms and technology as a scientific knowledge. efb defines the term as an respect for wellbeing autonomy justice treated organism e.g. animal welfare e.g. behavioural freedom respect for telos producers (e.g. farmers) adequate income and working conditions freedom to adopt or not adopt fair treatment in trade and law consumers (availability of safe food) availability of safe food, acceptability respect for consumer choice (labeling) universal affordability of food biota protection of the biota maintenance of biodiversity sustainability of biotic populations bangladesh journal of bioethics 2013; 4(3):1-10 3 ―integrated use of biochemistry, microbiology and engineering sciences in order to achieve technological (industrial) application of the capabilities of micro-organisms, cultured tissue cells, and parts thereof‖ 6 . in order to develop micro-organisms, improved plants or animals, and to modify food-products, biotechnologies have been used in a wide range of production. this technique is used for transgenic animal‘s production, commercial products, food production, plant tissue culture, dna profiling/finger printings, animal tissue culture, pollution control, to safe plants and animal‘s extinction, prevention-diagnosis, and cure of diseases. according to its use, there are different kinds of biotechnologies can be mentioned as following: a. industrial biotechnology, b. environmental biotechnology, c. biotechnology as human application, d. health biotechnology and e. agricultural biotechnology. all these types of biotechnology are not my area of focus. rather, i will focus on bst and transgenic animals as techniques of animal biotechnology. 1. bovine somataotrophin (bst): it is one kind of natural occurring growth hormone. at first, bst was commercially produced in the usa as a gm product to be used in animal agriculture. it is produced by biotechnological engineering through recombinant dna in cultures of the escherichia coli 7 . it helps stimulate milk productivity efficiency. this hormone is injected to a cow once in every two weeks in order to increase 15-25% of the milk it produces. 8 2. transgenic animals: transgenic animals are those which have been altered by genetically engineered with an aim to remove genes from them or to insert genes from other species. there are three techniques for producing transgenic animals: (i) recombinant dna, (ii) retroviruses-mediated gene transfer, and (iii) embryonic stem cellmediated gene transfer. in 1981, biotechnologists produced transgenic mouse by inserting the gene for human growth hormone into a mouse‘s genome 9 . implication of ethical matrix: this section considers ethical issues raised by the application of animal biotechnology in the field of food production and for medical purpose. in order to assess the ethical impact of this technique, i have selected some of animal biotechnologies, such as bovine somatotrophin (bst) and transgenic animal. and, then i have applied ethical matrix in order to ethical evaluation of these technologies. 1. case of bst mepham has chosen the case of bst (bovine somatorophin) for some particular reasons. in the first case, this technology involves four interest groups: dairy cows, dairy farmers, consumers, and biota. all these stakeholders are accorded ethical standing. secondly, in the case of bst there are also opposing factors, such as economic efficiency versus animal welfare, and consumer choice versus public health which characterizes bioethical debate. thirdly, commercial use of bst is also a political issue 10 . mepham applies his ethical matrix for using bst in dairy farming (table 2). table 2 : the ethical matrix applied to use the bovine somatotrophin (bst) in dairy farming 11 respect for well-being autonomy fairness dairy farmers satisfactory income and working conditions managerial freedom of action fair trade laws and practices consumers food safety and acceptability quality of life democratic, informed choice, e.g. of food availability of affordable food dairy cows animal welfare behavioral freedom intrinsic value the biota conservation biodiversity sustainability bangladesh journal of bioethics 2013; 4(3):1-10 4 mepham applies three principles in the case of four stakeholders in respect of the use of bst in dairy cows. by analyzing the table, we can present a brief analysis of the ethical matrix in the context of bovine somatotrophin in dairying cows. in the case of bst, there are four stakholder : a. dairy cows. in respect of well-being, organism (here dairy cows) has rights to claim welfare. now the question is whether the use of bst violates the welfare of dairy cows. mepham states that different studies have shown that the act of using bst in dairy cows increases the risk of the cow‘s health. the monsanto bst production company mentioned in the bst packet label that there are 21 side-effects. some of these are: ―increased cystic ovaries and disorders of the uterus; higher incidence of retained placenta; increased risk of clinical and subclinical mastitis; increased digestive disorders such as indigestion, bloat and diarrhea; increased numbers of enlarged hocks and lesions of the knee; disorders of the foot; and injection site lesions which may remain permanent‖ 12 . the european commission (ec) also shows by referring to different research experiments that the use of bst increases the risk of painful disease which results from the inflammation of the udder, and the risk of clinical mastitis and food and leg disorder, due to long-term administration of bst. the use of bst also reduces the reproductive capability of the cows. a number of other risks are also associated with the use of bst, e.g. increased level of morbidity and mortality. besides, most of the cows loss their bodily strength at the end of the lactation period. furthermore, the act of administrating injection to the cow is quite stressful. 13 there are also adverse side-effects of bst in respect of the principle of autonomy. the act of using bst violates animal behavioral freedom. cows are then fed a high amount of concentrated food which requires to keep them in indoors. so, there occurs the loss of the opportunity of natural grazing. different kinds of diseases, such as lameness, clinical mastitis, foot disorder, and other significant risks infringe the behavioral freedom of cows. does the use of bst infringe the intrinsic nature of animals? respect for an animal‘s intrinsic value does mean that we should not treat them unfairly. this principle claims that a cow as a sentient being should be treated as an intrinsic value. so, we should not merely use it instrumentally. but, ―bst use infringes the nature of the animals‖ 14 . b. dairy farmers. regarding well-being, it should be mentioned that the farmer‘ welfare depends on their satisfactory income and working condition. in order to increase economic benefits, dairy farmers use bst for yielding milk of cows. here economic benefits represent the welfare of dairy farmers. the autonomy of dairy farmers implies that they have got freedom of choosing any farming system. farmers have got freedom regarding the use of bst. mepham, in another study of his with millar et.al, shows that in the united kingdom 79% of the dairy farmers do not consider bst use in dairy cows as ‗ethically acceptable‘. in respect of justice, it can be said that the dairy farmers should be treated fairly by trade laws and practices 15 . it should also be mentioned here that they have got the right to get fair prices for their products. c. dairy consumers. the concept of the consumer‘s well-being refers to the welfare of the consumer. it refers also to the protection of food from being poisoned or by any other harmful agent. mepham mentions that in different studies that respect and infringement of the use of bst has been emphasized. fao and who have jointly found out that bst can be used without any applicable health risks to consumers 16 . but, there are also countervailing effects of bst use upon the dairy cows. igf-1 and related proteins are present in the milk from bst treated cows. igf-1 is responsible ―to gut pathophysiology, particularly of infants, and to gut associated cancers‘ and the association between circulating igf-1 levels and an increased risk of breast and prostate cancer‖ 17 . some other studies have shown that the milk from bst-supplemented cows has got allergic effect upon the human body. in these sense, bstinserted milk is not safe for the health of the body of human being. bangladesh journal of bioethics 2013; 4(3):1-10 5 regarding consumer‘s autonomy, it can be said that consumers have got the right to choose whether or not they would consume bst-used dairy products. according to mepham, consumers‘ autonomy requires two conditions: firstly, there should be ‗voluntariness of consumer‘— it means that one has got the freedom to choose to purchase anything, secondly, s/he prefers that the matter of freedom of choice can be ensured by the producer‘s act of disclosing the information of the products: whether the products are labeled as ‗bst-treated cow milk‘ and ‗non-bsttreated cow milk‘. 18 in order to realize the consumer‘s autonomy, labeling is an important factor while choosing the product. justice of the consumer in respect of the use bst means that there should be affordability of milk at a reasonable price. accordingly, if the use of bst can help our power of afford to buy food, then it can be said that consumers are benefitted by this technology. d. biota. using bst in dairy cows has got both positive and negative impact. first of all, its use affects the natural environment. it encourages the intensification of farming, thus resulting in a fewer number of farms. however, these farmers are much larger in size and, consequentially, these appear as the sources of pollution. the silage run-off and excessive fertilizer from the farm jeopardizes biodiversity and sustainability of environment 19 . on the other hand, it has been claimed that the use of bst can help us in an act of curling environmental pollution. by using ethical matrix, we can reach two diametrically-opposed conclusions: the positive and the negative impact of the use of bst in dairy cattle. a producer can gain more financial benefits by using bst. however, the health risk of the consumers should be taken into account seriously. in the case of dairy cows, the use of bst increases cow‘s milk productivity, and thus, provides economic benefit to the dairy farmer. in respect of the well-being of the dairy farmers, this is the positive ethical impact of bst. this technology helps us getting more benefits from a less number of cows. however, this will have run-off reduced slur and wastage. mepham describes this as the ‗respect for a principle‘ 20 . on the other hand, the use of bst has got some negative impact: giving extra metabolic and other load ‗infringes‘ the welfare of the animals. according to mepham, this is the ‗infringement of a principle‘. for example, the use of biotechnology (i.e.bst) in animal farming affects environmental sustainability in two different ways. according to mepham, firstly, bst is profitable in terms of economy to the farmers and therefore, it leads to a concentration of the highly intensive dairy farms. intensification is also responsible for the existing environmental problem. secondly, bst has got negative effects upon the environment. it depends on the ―fossil fuels, artificial fertilizers, farm and industrial machinery and transportation‖ 21 . the process of ‗finding the facts‘ helps the user identify the problems that have arisen from the use of a particular biotechnology. who will be affected? which of the effects is best-off? the second step in ‗best reasons morality‘ is ‗weighing the facts‘, which deals with the three ethical principles of matrix: well-being, autonomy, and justice. the use of bst use in the dairy cattle raises some ethical debates. the ethical principles can help the users, producers or even policy makers to weigh the problem. in this regard, we can study the example of bovine somatotrophin: 1. using bst in dairy cattle affects their wellfare, 2. question of producer‘s and user‘s financial benefits due to the use of bst, 3. ―ethically concerned producers are economically harmed.‖ 4. ―ethically concerned producers are potentially coerced‖, and 5. ethical issue is related to biotic conservation 22 . case of transgenic animals the development of animal biotechnology has improved transgenic animal productivity, animal breeding, and the treatment of diseases. besides, there is also the utility of this technology in healthcare and food production. transgenic animals, such as cows, pigs, and lambs, have been genetically modified for healthier meat production. it has been claimed that transgenic animals can reduce fat. xenotranplantation is another important use of transgenic animals. in human transplant surgery, tissues and different organs of transgenic animals are tailored as these are very similar to human cells. however, this act involves ethical concerns in respect of animal welfare particularly the ways we cause their harm and sufferings. the application of this technology has got both long or short term bangladesh journal of bioethics 2013; 4(3):1-10 6 environmental and health impact. we can make a clear sense of this problem by applying mepham ethical matrix in this regard (table 3). table 3 : the ethical matrix applied to transgenic animal respect for well-being autonomy justice/fairness treated organism avoid unnecessary pain behavioral freedom intrinsic value producers satisfactory profit democratic, informed choice, e.g. of food availability of affordable food consumers improved quality of life informed consent fair access to genome organs the biota conservation biodiversity sustainability 1. animal. is the act of producing transgenic animals compatible with the concept of animal welfare? through this technology, it is possible to increase animal‘s well-being, which is affected by deleting the critical diseases of animals which can reduce the high range of animal mortality and also reduce sufferings of animal by the practice of castration and dehorning the agricultural animal 23 . by applying dna and antibody-based test, it has become possible to diagnose some infectious animal diseases such as, brucellosis, pseadorabis, blue-tongue, foot-and-mouth diseases, avian leucosis, trichinosis, and so on. farm animal diseases classical swine fever, foot-and-mouth disease, and bovine spongiform can be managed casually through the new improved technology of animal biotechnology. practicing animal biotechnology in producing transgenic animals for livestock purpose is helpful in improving animal health. this technology is capable of preventing and diagnosing poultry and livestock animal‘s diseases. and, quick prevention and diagnosis ultimately improve the well-being of animals. genetic finger-print — a genetic analysis of animal pathogen — is helpful in identifying the sources of the outbreak of diseases, which is quite helpful to monitor the spread of the disease. all these examples show that animal biotechnology offers potential well-being of the animals. some other studies 24 also show that the genetically modified animals are found to be affected by physiological, anatomical, and behavioral abnormalities. such animals have got poor survival rate of fetuses. they also experience short-life span and critical health risk. for example, the introduction of human gh to beltsville pigs results in the high rate of mortality, arthritis, gastric ulcers, infection, degenerative joint disease, and drowsiness 25 . the genetically modified transgenic animals have also been the target of attention while the purpose of public health is taken into consideration. the ethical controversy of killing animals raises the question about its acceptability. ethics as an ecocentric sense that raises some questions as to whether we are allowed to modify the components of ecosystem. one most important question is that does the genetic integrity of (transgenic) animals have an intrinsic value that we should not change the form of them? in respect for telos, genetic engineering infringes the nature of animals and its intrinsic value. justice in respect of animals indicates the telos of animals. the teleological approach to animals refers to ―their design, purpose, or final cause‖ 26 . mepham uses the term, ‗telos‘, in the sense of intrinsic value, which refers to the idea of ‗integrity‘. in different literatures, integrity is used differently. however, the central tenet of this term is ―wholeness, fullness, or ―unalterdeness‖ of the animal...‖ 27 telos is also a reflection of the intrinsic characteristics of animals, but genetic tempering affects the design and purpose of animals as well as their intrinsic characteristics. technological enforcement disrupts the homeostatic processes of animals. in other words, the process infringes the intrinsic nature of the animals by controlling their normal body function. thus, biotechnology is a potential violation of ‗animal integrity‘ as well as intrinsic characteristics 28 . bangladesh journal of bioethics 2013; 4(3):1-10 7 2 producer. animal biotechnology can provide great well-being to the producer in terms of economic benefits. the act of biotechnology providing them with less feed (feed is also biotechnologically developed) bought at reasonable prices results in getting more meat, more milk, more eggs, and more wool. 3 consumer. in everyday life, there are a lot of well-beings that come from the application of animal biotechnology. all these go to the doors of the consumers. transgenic animals are produced for various purposes. first of all, this technology makes a contribution to the improvement of nutritional value and resistance against critical diseases. for example, pigs, rabbits, and horses are used to produce such products as blood, thinner haparin, anti-venoms, and drug protein. through this technique, it is possible to produce such therapeutic proteins or antibodies by modifying animals. transgenic animals are potentially used particularly for curing cancer, hemophilia, rheumatoid arthritis, etc. xenotransplantation is another use of transgenic animals. for kidney, heart, and other organs-related diseases, today there is the solution through the replacement by the donors such as pigs and other transgenic animals whose organs and their apeutic cells can be used for the purpose. during the last few decades, pigs‘s heart valves are successfully used as substitutes for the damaged heart-valves of human beings. however, the risk of xenotranplantation is another problem of animal biotechnology. there are possibilities of transmitted infectious diseases from one species to another. some studies show that in the year 1999, 160 peoples received pig cells as part of treatment and they did not show any health hazards 29 . furthermore, when scientists prepare the organs of animals for xenotransplantation, they are required to give close attention of the health hazards. in order to avoid health hazards, scientists successfully deleted the gene which is responsible for immune activity from transgenic animals. for this reason, the organs of transgenic animals are not infected by the virus or any lethal micro-organisms. thus, in this way consumers‘ well-being can be ensured. safety and informed consent would be the possible requirement for consumers in respect of autonomy. consumer autonomy can be achieved when they get sufficient information about the transgenic animal‘s products. consumer interest can be understood in terms of justice, particularly distributive justice. how are consumers benefited from the application of animal biotechnology in producing transgenic animals? around the world there is inequality, and most of the people are not capable to afford transgenic organs for their treatment, which are necessary for them. in order to work towards better social equity, it is essential to minimize the impoverished condition. john rawls argues that no one knows in which economic conditions one will be born. therefore, every member of the society should wish for equal exposures to risk and that everyone should have the equal opportunity to grow up in an environment that is free from infectious diseases 30 . the theory of justice reveals that every person in the world, irrespective of all conditions, should have the opportunity to use transgenic animals‘ organs while these become a necessary to them. sometimes people do not have had the benefits from transgenic animals due to their economic deficiency. in this situation, consumers can be benefited through the reduced prices of the product and the increase of the level of consumer‘s power to afford such a product. 4 environment (biota). biotechnology in animal sector has brought a dramatic change in the livestock farming in terms of environmental context. the act of improving animal biotechnology offers such developed feed that disposes lower amount of phosphorus and nitrogen in animals‘ slurry and manure. some studies show that the normal feeding of dairy cattle disposing 160 million tones of manure annually with high range of phosphorus and nitrogen causes surface and groundwater pollution. but, genetically modified animals can digest feed and dispose less slurry and manure with minimum pollutants. biotechnologically developed pigs are one such transgenic animals that added gene and enhanced salivary phytose and grown with phosphorus digestibility and retention of phosphorus 31 . in the case of conserving the endangered species, biotechnology shows good results. transgenic animals are bangladesh journal of bioethics 2013; 4(3):1-10 8 environmentally friendly. recently, genetically modified enviropig tm produce less slur and manures and have lower levels of phosphorus contents which are the causes of environmental pollution. reproductive and cloning technology is helpful to conserve the endangered mammals and birds. omha zoo veterinarians used this technology (particularly embryo transfer and animal insemination) on three bengal tigers and siberian tigers (as a surrogate mother). the endangered species of european mouflon, a smallest wild sheep, has genetically multiplied the number of this species at the university of teramo, italy, in 2001. indian ox-like guar, an endangered species, has been saved by the process of cloning. recently, the endangered species, giant pandas, are being reproduced by using trans-species cloning technology. in 2005, water buffaloes, arab‘s champion horses, and monglian gazelles were cloned to multiply their number. limitation of ethical matrix: the potential argument comes back to the philosophy of peter singer 32 and bernard rolin 33 . both the philosophers agree that animals should be considered as moral subjects and that any action causing pain is ethically unacceptable. ege opinion also explicates the sufferings of biotechnologically developed animals which affect animal welfare. some ecocentric philosophers recommend the extension of moral values to other animal species 34 . all these studies defend the view that animal biotechnology affects animal welfare and, therefore, it should not be acceptable. the application of ethical matrix in different cells gives different results. in respect of animals, we have got the opportunity to consider the positive and negative consequences of animal biotechnology for their well-being, behavioral freedom, and physical integrity. and, we can assess negative and positive effects of the biotechnologically developed products upon the environment. in respect of the producer, it may be said that ethical matrix provides a judgment of possible economic benefits. ethical matrix also pays an attention to the consumers‘ rights. on the one hand, it makes us alert about the hygiene and safety of aspects production, transparent information, and free choice by labeling the product. the principles of justice in the matrix are others important factors of balancing different aspects related to the production of animal biotechnology. for example, the principles of justice indicate what kinds of technology the producers should receive. these also ensure their equal rights of fair access to the free market. at the same time, justice also looks at the animals and environmental integrity in the sense of intrinsic characteristics. thus, ethical matrix can consistently help us reach a decision by assessing the negative and positive effects of different stakeholders. however, in most cases ethical matrix discourages to receive any sorts of technology. in this circumstance, where should we stand? should we ban any kind of practice of bst and transgenic animals? or, should we encourage this technology? mepham‘s ethical matrix provides us with a tool to assess the problem. mepham himself also states that ethical matrix helps us to facilitate rational decision-making. different principles of ethical matrix give us different consequences. people can approve the use of bst in cows for yielding milk, producing transgenic for various purposes. we have also observed that ethical matrix warns us that the use of animal biotechnology has both positive and negative impact. for example, (i) diseases like fibrosis, thallassamia, and muscoviscidosis that we might inherit from our ancestors can be detected by using genetic testing, (ii) vaccines and some other medicines such as insulin meant for curing diabetes are produced by introducing human genes into bacteria, (iii) in order to produce organs for human transplants it is introducing human gene into animals: by using such techniques pigs are used for human heart-valves transplant (iv) large use of animal biotechnology can be recommended in food production. for producing food with high protein, for changing the taste of food, and for producing adequate food by investing lower productive prices are the causes of applying animal biotechnology in our day-to-day world. ethical matrix, as an ethical tool, shows us the way through which we can detect its adverse effects and enormous benefits. we can also assess which of the animal biotechnology has got longer adverse effects, and which one has got enormous benefits. ethical matrix provides us bangladesh journal of bioethics 2013; 4(3):1-10 9 with an ethical solution to this problem. in the example mentioned above, it is seen that ethical matrix gives us a judgment as to which of the application should be ethically acceptable 35 . concluding remarks: by observing a number of studies, we can draw the argument that animal biotechnology affects animal welfare, break down the integrity of naturalness and also threat for the public health. on the other hand, animal biotechnology has got various purposes in relation to food and medicine. all of these technologies have given a great opportunity to the human beings. it is also used to experience the use of animal biotechnology for medical purpose. ethical matrix has shown that the process of using bst, transgenic animals, and other biotechnological products involve a number of ethical concerns that come to play when decisions are to be taken concerning the application of animal biotechnology. various problems generated through the application of animal biotechnology can be experienced by ethical matrix. the application of ethical matrix in the case of bst and transgenic animal has shown that there are enormous sideeffects and adverse impact upon the animals and the environment. however, compared to its technological contribution, a transgenic animal has got less effect on different stakeholders. in this regard, we can raise a pertinent question: does ethical matrix provide any concrete ethical decision regarding animal biotechnology? do we accept it or regret it as unethical means? in any of the products or contribution of animal biotechnology, there is the violation of three cells: animal‘s well-being, animals‘ behavioral freedom, and the telos or intrinsic characteristics of animals. in conclusion, it can be said that ethical matrix is based on the weighing of pros and cons of the fact. it leads us to the conclusion that there are no short curt ways to reach an agreement on the application of animal biotechnology. there are various contexts and controversies including the relationship between technology and societal norms, and the relationship between animal integrity and human beings, and the question of substantial equivalence between technologically-developed products and naturally-developed products. references: 1 mepham, t. b., ―ethical analysis of food biotechnologies: an evaluative framework,‖ in b. mepham (ed.), food ethics, london and new york: routledge, 1996, pp. 101–119. mepham, t.ben., ―a frameworks for ethical analysis of novel foods : the ethical matrix‖ , journal of agricultural and environmental ethics, 2000a vol.12, issue : 2 : 165–176. mepham, t.ben, ―the role of food ethics in food policy‖, in proceedings of the natural society, 2000b, 59, 609618. mepham,b., kaiser m, thorstensen e, tomkins s and millar k, ethical matrix manual ,lei, the hague, 2006. http://www.ethicaltools.info/content/et2%20manual%20em%20(binnenwerk%2045p).pdf (accessed at 10 am, 01 april 2010) 2. mepham, 2000a, p. 167. 3 mepham, 1996. 4 fari and kralovanszky, ―the founding father of biotechnology‖, international journal of horticultural science, 2006, 12 (1): 9–12, p.10. 5 fari & kralovanszky, 2006, p.10. 6 becker, gerhold, ―biotechnology—the new ethical frontier: an introduction‖, changing nature's course :the ethical challenge of biotechnology, eds by gerhold k. becker associate with james p. buchanan, hong kong : hong kong university press, 1996, p.1. 7 mepham, kaiser et.al., 2006 , p.32. 8 mepham, 2005, bioethics: an introduction for the biosciences, oxford university press, usa, pp.52-53. 9 bio, guide to biotechnology, biotechnology industries organization, new york, 2007, p.71. 10 mepham, 2005, p.54. http://www.ethicaltools.info/content/et2%20manual%20em%20(binnenwerk%2045p).pdf bangladesh journal of bioethics 2013; 4(3):1-10 10 11 mepham , 2005 : 54. 12 cf mepham, 1996, pp. 108-109. 13 cf. mepham, 2000b, p. 613. 14 mepham, 1996, p.109. 15 millar, et.al., 1995, p. 195. 16 mepham, 2000a, p.96. 17 mepham, 2000a, p.96. 18 mepham, 2005, p.59. 19 mepham, 2000b, p.613. 20 mepham, 2000b, p. 613. 21 mepham, 1996, p. 111. 22 schoreder and palmer, schroeder, doris and palmer, clare, 2003. ―technology assessment and the ethical matrix‖ in poiesis praxis, 1.2003, p.300. 23 bio, 2007, p.71. 24 ege,. european commission group of advisers on the ethical aspects of biotechnology, 1993. the ethical implications of the use performance-enhancers in agriculture and fisheries,( rapporteurs m. warnock and m. sinisalo), 1993. 25 ege, 2008, p.12. 26 munro, l., ―the future animal: environmental and animal welfare perspectives on the genetic engineering of animals‖, cambridge quarterly of health care ethics, vol, 10, 2001, p.315. 27 cebra ―ethics and farm animal cloning risks, values and conflicts‖, from the report project of cloning in public: a specific support action within the 6th framework programme, priority 5: food quality and safety, coordinator: danish centre for bioethics and risk assessment (cebra), (2005). source: http:// www.bioethics.kvl.dk accessed on 30 may, 2010, p.16. 28 bruce, d. should we clone animals ? 1998. http://www.srtp.org.uk/clonan3.htm, accessed on 05 june, 2010. gjerris, m,. ―ethical aspects of animal cloning‖, proceedings from the 21st scientific meeting of the european embryo transfer association, 2005, pp.79-93. 29 bio,. guide to biotechnology, biotehnology industries organization, new york, 2007, p.37. 30 rawls, john, a theory of justice, oxford: oxford university press, 1971, p.448. 31 bio, 2007 , pp.74-75. 32 singer p., 1990. animal liberation n.y.: avon books. 33 rollin b., 1998. the unheeded cry: animal consciousness animal pain and science, oxford : oxford university press. 34 naess a., ―in defence of deep ecology‖, environmental ethics, 1984, 6(3):265-270. 35 see for details : bhuiyan, a. s. m.a, 2010. ―ethical challenges of animal biotechnology‖, mae thesis, published in : url : http://liu.diva-portal.org/smash/record.jsf?pid=diva2:359860, linkoping university, sweden. acknowledgement: i am grateful to professor dr. anders nordgren, prof of bioethics, linköping university, sweden, for comments on my earlier draft of this paper. the paper is the part of my master thesis, submitted (2010) to the center for applied ethics, linkoping university, sweden. http://www.bioethics.kvl.dk/ http://www.srtp.org.uk/clonan3.htm http://liu.diva-portal.org/smash/record.jsf?pid=diva2:359860 26 bangladesh journal of bioethics 2015; 6(2):26-37 human rights: illusion or reality; theological (shiite) perspective ali jamkarani undergraduate student, department of human rights, etrat university, iran email: ali.agigh@gmail.com, online1journal@gmail.com abstract: the discussion is based around these issues, history of human rights, timeline for human rights history, question asked in this regard and enemy and friend of „human rights‟. describing the problems and its resolve from logical reasoning perspective; intellectual argumentation based on logical reason of, what is universal human right, democracy and illegal wars in the world by super powers as example america? attempt to describe the inner construction of a human being-perfection-. introduction to the concept of infallibility in different parts in the article, purify yourself and being purified. what is it, is it possible for a creation named human to be not fallible, is the idea or practicing it impossible or there is a great sphere of being able to practicing it and reaching the status if one finds guidance for the right way with peace and human rights prevailed in the world. majority of the thought in the text, based on hadith-traditionfrom the prophet of islam peace upon him and his family ahl al-bait peace upon them. key words: human right; corruptions; infallibility; spirituality; psychology, fitra-core of human being, democracy; intellect; ignorance; senses; illegal wars *** part 1 of this article was published in bjb 2015; vol 6 issue 1. part 2 democracy: when human rights issues become many and a land want to implement it, democracy is born, but what kind of democracy, a deception! what is democracy? does it allow in the name of human rights conventions do illegal wars as in afghanistan and iraq with libya, syria and somalia recently with excuses and using of the tongue? one can refer to the book by cynthia mckinney, a former african-american congresswoman with title: „the illegal war on libya‟ and steal a vision of how serious these wars are and costly for human perfection in favor of continuation of separation in disunity and deficiencies. the history is to learn, a history we can mention here that is important and necessary that makes the masses in control of world powers as american soil, english soil, saudi soil and united nations. a story that many have heard in different version, but in all versions, one can find this piece of ignorant-art that is lying and promising; to secure the lie to happen. if we take the islamist version of the story of adam and eve that is satan lie to them with a promise that he is a well wiser, the same is happening every time it is ballot time and every moment by the old super powers in their soil. the nine eleven, do not know what, attack, plane crash or game and the holocaust event, why no magazines are publishing, if the events are true with evidence and reviewing history. if gas chambers existed or not, if it was there, was it used to take the people of zionism ideology in it or jewish people, the people of god or no people at all. surprised often in history the killing of hitler, mentioned, but not stalin that killed more people than hitler, more than double, can it be because russia was in the winning side with other super powers at that time, and rewrote history blaming everything on political figure as hitler. is such a group as zionism in existence on earth posing to be jewish people of intellect and faith? does a group wahhabism-salafismexist today on earth, posing to be islamists, in outer appearance, the people of love in the faith? are such people in earth that are misusing the prophet jesus peace upon him teachings and posing as a replacement as the people of devotion in faith. how long will it take to make right the lies and promises made? it depends, one of the strongest reason can be on media, how media picture it, for example as fast something happens in muslim world specially in iran, for example if somebody going to die because of a crime, they make it like, mailto:ali.agigh@gmail.com mailto:online1journal@gmail.com 27 the islamic law is the evil while 3 to 4 dozens from execution with electric chair and other methods only in usa says bye, and it do not get media coverage and becomes big dragon. if israel does a lot of atrocities against palestinians or bahrain government kill its citizens for trying to have human rights it‟s like nothing shows in media. israel, a little force has nukes reaching europe and „us‟ but united nations do not take hard on them to not have nukes while pressuring iran that got recently the technology to use for peace and make the countries welfare go well. thus, this picture is good to see who runs the world. maybe if we see wahabi and salafi in the name of islam commits atrocities as independent while we should look deeper maybe it‟s only a body we see, while its soul the world powers specially israel the inner cause of every extreme occasion. salafi and wahabi need women so they declared jihad, what rubbish, but wondering why didn't they declare anything that would satisfy their need for money or weapons or position, because all this was undercover, they don't need it, they have it. zionism has position in us and europe and saudis with stupid arabian countries have money to support them only women remind and they declared jihad nikah. there is not such a thing in islam, it‟s so stupid, they don't follow islam but they follow who supports them and their own desires. and not to forget uk that is political support for wahabi and salafi movements around the globe, the root cause of their growth. wasn‟t britain the root cause for israel being where it is today in occupied palestine! have you already forgotten the uk fighter jets bombing yemen! israel is maybe a state as other commentators already put some words of israeli injustice towards international law, especially the issue of building illegally in occupied land. israel has zionist ideology in jewish religion, so they have nothing to do with judaism or jewish people, the government at least if not all jewish people in the land have zionist ideology or don‟t know what is going on. the same way wahabi and salafi ideology is present in the name of islam. they say they are muslim, and „do things‟ like muslims, but their mind is poison with salafi and wahabi ideology and not the islamic teachings. the same thing with the government of israel, they are following special goal. why not the wahabi and salafi if they are doing jihad, attack israel and why not israel help us to attack salafi and wahabi in iraq and syria if they are honest, because they are friend with one goal. they oppress women and children. in the prophet mohammad's peace upon him will, when he passed in this world to another journey, he said; mind, take care of women and children, one of his last words. one of their fears are public awareness, and not losing money or honor, and this issue going to court paves the way for media around the world to write about it. this little paragraph refers to the fear of israel to decline the invitation of the international criminal court (icc).they have pride of the devil engraved in their mind! they don't think maybe we are wrong; we should go to the court and see what they have to say against us. as said the main thing is the ignorance of people in societies, they don't want the veil of ignorance in the mind of people to tear apart and see the reality of the world of politics and governance of super powers misusing the word democracy, and „act‟ the way of democracy but no democracy ideology in their heart/mind without capitalism and secular atmosphere occupies it. same as zionist and wahabi and salafi misusing great human concepts in the world, the super powers misusing universal human rights and democracy concepts to work together with zionist and wahabi and salafi. the illegal/dishonest war, in sense of action, wordings and feelings, done by united states of america against countries as afghanistan, iraq, libya, syria, somalia and islamic republic is either theoretical or practical or both, in both direct and indirect sides: exist by means, tools and helpers. the theoretical side has direct and indirect to it as do the practical. corruptive people with corruptive ideas spread the above mentioned corruptions in this article both theoretically and practically. if directly theoretical and practical by means and tools cannot spread their corruption, they do it indirectly. their tool can be the greatest vices and goes even greatest values as such „human rights conventions‟ in the world in their list of means, by a deception of democracy as a lie to advance their way in destroying human sensitiveness, the core/essence of human being, spiritually and psychologically. then again, the question; what is democracy that is, based on human rights or the “universal human rights”? great scholar ayatollah abdollah javadi amoli describes it beautifully and clearly, in a speech, the translation follows down. the prerequisites of a universal morality: why western conception of human rights is not universalayatollah abdollah javadi amoli universal human rights: “globalization”, in theory is a good thing. having unity of thought and having popular unity [is a good thing], being united -being oneis a good thing, but what can act as a catalyst for [this] unity? the market, are the rich and the poor equally endowed in this regard to integrate with one another -on this basis-? http://www.informationisbeautiful.net/visualizations/who-runs-the-world/ 28 politics; the many norms, conventions, traditions, and customs [which exist among humans]? can they [forge this unity]? today, they claim that this [idea of] „human rights‟ is universal. however, you see, this claim has no basis in knowledge [intellect]! what needs to be, said is this: [the delineation of] right just as with [the delineation of islamic] jurisprudential laws – has three stages. this is the case for all legal systems in the world. the legislative, jurisprudential, and judicial laws [in any society], are derived from [specific] principles. these principles are, derived from [specific] sources. [thus] we have a source, a principle [derived from this source] and a law [derived from this principle]. the islamic council majlis [iranian parliament] does just this. everywhere in the world, it is the same. all countries have a constitution, which espouses specific principles, and from these principles, they have laws approved by the legislature, which they use to govern the country. the laws passed by the legislature reference the constitution as their source of legitimacy. however this constitution has to come from somewhere! now let us address [the question of] that source. any legal system must have a hierarchy of three elements: a source, a [set of] principles [and] drafted laws. a faqih jurisprudent does this very job, does he not? a faqih who espouses jurisprudential laws in the form of a practical treatise, he derives these [laws] from principles. in addition, these principles are, derived from a source. our sources are aql -intellectand naql -reference-; our reference is [to] the book -the quranand the sunnah -tradition [of the prophet-sand ahl al-bait-a-]. our source is clear, our [set of] principles are clear, our articles of law are clear. in addition, they have theirs as well. they have a source, which [the articles of] their constitution is derived from, and they have civil laws which their parliament sets in place in accordance with the constitution. the axis of our argument is that in order for a legal system to be universal, [in order for a set of] rights to be universal, the [original] source must be universal. universal principles [must be] derived from a universal source, and [only] from these universal principles [can] universal laws be implemented. otherwise, if the source is regional or local, the principles will also be regional or local, and the [resulting] laws will be [bound to that particular] region or locality. so how can [such a legal system] be called global!? what is, the thing which they call, a universal source? their source of law is the norms, conventions, traditions, customs, and the national and popular culture native to their homeland. well, the world is home to a variety of different regions, races, languages, epochs, and nationalities. each one of these contexts has a specific source [of principles] for itself. moreover, these are useful for the implementation of domestic laws. the norms, conventions, and traditions which are accepted by default in a society, can be a source for the [derivation of the aforementioned] series of principles. this series of principles can be the basis for a series of laws. with these, the country is, governed. however, if these laws are supposed to be universal, a universal source is, needed to derive them. a universal source is neither bound to the epoch nor [to] the land. which culture, which language, which territory, which tradition, which creed? such a system cannot be universal! the universal source must, be extracted from the inner humanity of man, which [in] this [all people] are the same. the 6-7 billion people who inhabit the earth are all equal in humanity. their skin color, their norms, their conventions, and their traditions… differ. nevertheless, their fitra -core human natureis one. if we use this fitra as our source, and skillfully formulate principles rooted from this source, and if we discerningly with wisdom, extract laws from these principles, the result of this process could be termed „universal human rights‟ 6 . description of inner bio of the human being: chest is protecting the heart; the head is protecting the brain. no worldly senses have connection to the heart directly, but indirectly through first having connection to brain. how can the connection be? every sense has a location in the brain that gets enlightened when active, in different parts of the brain. when we see a red rose, the image information of that red rose through eyes go to the brain where vision is located and smelling the same, touching the same to their respective locations in the brain, but from there where does it go. the „memory‟ is it the answer! we can see the image if we close our eyes and remember it, the same with smell and touch. can it go somewhere non-physical-metaphysical-, maybe? is physical-material world inside the non-physical-celestial world-? can it be the opposite! can here be where physical connects with non 29 physical or meets and boundaries dragged or they both are into each other. let us present this inception and spend reflection on it. can we believe that mind exist or not? let us say inside the brain is mind, because of existence of physical brain the non-physical brain mind have capability to manifest it-self through it. the same way the soul with spirit manifest itself through body, and gets worth otherwise if eyes could with help of brain see, than there is human beings that have both but don‟t see physical object because of death. death means moving of the spirit with milder version of us the soul of us, -but with same way of life, ethical characteristics and properties that one earned through having different beliefs and following certain principles, living in earthmoves to purgatory until resurrection day. this mind if define could be the brain of the spirit of human being. remember i did not said soul, why does it matter! it is through this that the non-physical heart of the spirit as in persian „del‟ in english as good translated „devotion‟ gets, affected by all senses and lastly affects the physical heart. these two important organs has two metaphysical sides, but what components, concepts are inside devotion and mind, do an image just come from natural world to sense perception than inside mind and then devotion and heart, for what, why! we have discussed and put some words forward of how it happens, where and when can one figure out by oneself every moment in that place for that moment. however, all these senses active in one, only one moment, what can it do. it can change the properties as, focus and concentration in mind, feeling and emotion in devotion, for a corrupt cause or righteous cause. alternatively, decline a corrupt cause and accept a righteous cause. what is in the mind that holds focus and concentrations respectively in the devotion-delof the spirit that holds feelings and emotions? can it be in the mind, soul and in the devotion, fitra? the form of your body holds all organs together, everything is in its right place; note the same way spirit holds all your non-physical organs; properties, function, characteristics and all that: is called nafs. your physical body is called human, s/he is human, why people say like that because they see the physical form of the body and call it human, whereas islamist believe it has a reality-the bodycalled nafs. it must be also in good shape like the body, and animal part or any part of the creation that do not resemble your physical body, is not present in nafs than its called „spirit‟ of human or perfect human being. sinning makes the soul weak and change its shape differently based on action, word and state of the heart. in mystic of islamist shia sect that are also sunnis following the action, tradition and signature of the holy prophet peace upon him & his family from the time of the prophet-swith imam ali peace upon him as their leader chosen by the lord of the creation, there is famous narrations that example if one backbite, it is like one eat the meat of the backbiter, the reality of those moments one do sin of backbiting another individual in a family or society is thus eating the meat of the same human being with the milder version of yourself the nafs-soul-. nafs is somehow you, when we say you what do we mean, how do you recognize somebody… by face, you remember its face, face is like a summary of you, who you are, by it people recognize all your body; all your body goes under a „category‟ called the face, nafs is like that. another way to reflect upon it, nafs is a system with structure and law and order, red lines, limits, but note-the spirit has not limit in sense of nearness to allah, it is not what i mean by limit-, function, properties, characteristic, works, and all holds together through spirit-ruh-. we should not be bold for this example and let us say maybe it is like this, must read many hadith-traditionof prophet mohammad peace upon him and his household ahl al-bait peace upon themto see, if this way of explanation is right or not. if it is right do it make sense, if yes, is it foolproof, or does it have error somewhere, that means there is room for betterment of the explanation and it is not from an infallible source so at least must make it foolproof; state of the art human intellection. you have probably heard saying: human have three or two dimensions and explained through body mind spirit or body mind soul, or body mind heart, but one should update make it in a way so it makes more sense. your physical existence is called a body; it has outer and inner, its outer is your shape, form, senses, skin these kind of thing, and its inner is all organs, skeleton, blood and so on. the non-physical existence-note here one do not say spirit, nafs, or fitra without using in metaphysical sense word non-physical, of you have also an outer and inner, its outer is called spirit and its inner is called nafs. thus, spirit is outside and around your soul, around your body and not inside your soul or your heart. 30 heart of the spirit is devotion or in farsi-delsource from where emotion and feeling arrives and you feel it in your physical heart, that harbor/manifest feelings and emotion itself through existence of your physical heart to the body and world of matter. brain of the spirit we can call „zehn‟ in arabic, that its equivalent is mind. in mind can be soul-nafs, the psyche of human beingand intellect with its opposite ignorance. in devotion, there can be located core-fitra, inner instincts, pure human natureand softness with its opposite cruelty of the heart. are there two wars in these two realms or cities called mind and devotion? are the realms in connection through focus and concentration from the minds side and feeling and emotion from the devotions side? the war, conflict is not over the mind or devotion, it is about what it contains or what is located in there, fight is about that, fight is about soul, main location head, brain, mind, and fight in inside devotion is about the fitra, with main location in chest, heart, and devotion. ignorance affects the soul in favor of corruptors and corruption, and intellect affects the soul in favor of righteousness and right doers; softness affects the fitra to grow in favor of soul, cruelty affects the fitra to stop on way of perfection as human being and later die in favor of soul and buried either death or alive in the soil of devotion. a word comes to your mind through seeing with your eyes and using sense perception, in the mind there is the thing called nafs-soul, psychethat word affects it, through being a tool, sustenance to ignorance or sustenance, a tool for intellect, if it is good for intellect, the nafs remains in control of intellect. that in turn guides the soul to perfection better than angels, but alas to imperfection worst than animal. intellect and ignorance are fighting for the dominance, taking over of the soul of human being in the head and the devil is only a catalyst-a whisperer, do not force you to do anythingthat helps the ignorance and make trouble for intellect. when this soul, this milder you getting guided by intellect in turn the softness of your heart increases and its cruelty decreases and your core, essence, inner instincts-fitragets alive and starts to grow like a flower, that needs sustenance, the only provider is the soul or right said the intellect through this process. in the chest of a human being is a heart with feeling and emotion in various hues, this heart has devotion of two kinds either negative for the heart that is hardheartedness, cruelty, or positive softheartedness , compassion. these two, like intellect and ignorance affect the fitra a more delicate substance than soul. its existence-essenceis based on goodness and light that needs to grow in good environment and taken care of, not as its „opposite‟ the soul that‟s existence-essenceis going after corruption and must be always held under guard by the intellects power and accountable for everything it does. here we quote again, the great master aya. abdollah javadi amoli that posed a question as “why are there men possessed of knowledge who fail to take action”, and replied: “why do we have men possessed of knowledge who fail to take action? how is it possible for one to read the verse « ل َن ْل َن اِم ِم ْلل یْل ل یُق ُّض ول ِم and teach it in the class and (say to the believing men that they cast down their looks) « ُق ل ِّلِم ْل ُق ْل ِم ِم یَن then refrain from looking at non-mahrams. while we know that it is religiously unlawful to be «ل ِم لُّض ْل ِمل devourers) « َن ُق یَن of what is forbidden), and that bribery is forbidden, why being dirty-handed at times? it is not true that all men possessed of knowledge are men of deeds and action. there are instances both in seminaries and in universities. how is for man with all his knowledge to fail to take action? still, you may see many people and read for them the very same thing and the very verse; and yet they do not abandon their errors. such a man has no problem in his knowledge, he has even taught such words. the problem lies somewhere else. the “somewhere” has to be known (first), and cured (second). to know one who carries out acts of decision making, controlling, management, handling and performing, such a one has to be known separately. before we come to know him separately, let us give an example in the outer space so that to clarify a bit until we reach the inner space wherein we will see how some people, both in seminaries and universities, can be possessed of knowledge yet fail to act accordingly. 31 in the space outside us, certain forces undertake the act of perception; such are the eyes and the ears. no one expects the eyes to run; they are expected to see and perceive. ears are not expected to attract and repel; they are to hear and perceive. such perceptions are for hearing and listening. but running and jumping are for hands and feet. so, from the outer perspective, there are a set of forces which perceive and a set of forces which take action. a group of them become percipient and another moving agent. man is of four types by the outer forces: some are with stronger perception; i.e. their sense of vision and hearing is sharp; they see well and hear well; their hands and feet are also healthy. when they see snakes and scorpions, they perceive well and escape. these are men possessed of knowledge and action both; that is to say, their practical element works well and their feet are not crippled. the second group is those whose perception is sharp yet whose hands and feet are crippled. they see snakes and scorpions yet they do not move. even if they are poisoned, if they are asked whether or not they have seen the snake or the scorpion?! they will reply: yes, we did. eyes and ears cannot escape, can they? right, they had seen them completely, yet that part which has to move and help them escape is disabled. now it becomes clear what is wrong in a man possessed of knowledge without action. the third group is those whose hands and feet are free yet whose eyes and ears are closed; such are the ignorant people who can run well but don‟t know where to go. they can make the proper use of their heads, but they don‟t know how to use it. such an individual has strong hands and feet and head, yet cannot understand how and where to use them. the fourth group is those whose eyes and ears are closed and whose hands and feet are crippled as well. the above were the four physical-perception types. let us go to the tenor of the debate and the true content of our simile. within us there are a set of forces relating to perception and comprehension known as theoretical wisdom. intellect, doing research, imagination and confirmation are for this purpose. there are a set of forces which are totally separate from the part of cognition and which control the motivations. these are administrators of motivations; they possess wills, sincerity, intention, decision, ruling and command. these are at two completely separate levels. a person the two parts of whom are strong, i.e. one who perceives well and decides well will be a just knower. second is one whose knowledge base is strong, one who teaches, delivers lectures, but in practice there is no difference for him what to do, and whether to receive bribery for instance or not; such a one is paralyzed in his practical wisdom whereby he is to make his will and take a decision. no need to recite for him verses of the quran; he has no problem with verses and has no theoretical deficiencies. he is similar to an individual who has healthy eyes and ears but who cannot move as a result of his crippled feet. if he is repeatedly asked whether or not he had seen the snake coming toward him, he would reply: yes, i did. he did see the snake but eyes cannot escape. such a knowledge knower or such a clergy has crippled hands and feet. when imam ali (peace be upon him) said in his illuminating words «ل یلعقٍ لول ٍالت ل یلو ا » (many a wisdom captive under the command of caprice). he meant that in the battlefield of the greater jihad (jihad with the lower self), the decision center is made captive. satan captures the center for their volition, management and decision making and fastens them with chain. the third group is those whose hearts‟ hands and feet are free, those who can act well; they are also free to will, but they don‟t know what they are doing; such are the holy fools. may god bless our master the late scholar allameh tabataba‟i. he used to quote a narration as follows: before aqa sheikh abass wrote mafatih al-jinan -the keys to the gardens of paradise-, zad al-ma‟ad -provisions of the hereafterof marhum majlisi , may god blesses him, was popular. majlisi‟s zad al-ma‟ad includes religious acts and ceremonies for twelve months of the year. according to him, some holy fools would rehearse a complete recital of zad al-ma‟ad during the holy month of ramadan. they thought the book was like the quran. zad al-ma‟ad is on the acts specific to special times all through the year and is not for the month of ramadan alone. such a one does not know and does not understand what he should do; he is, thus, active, yet of little understanding. the fourth group is the profligate ignorant who cannot distinguish what to do and in case he understands, he does not intend to act upon it 7 . 32 conclusion: the possibility to be infallible human being is greater than „universal human rights‟ because the universal human rights must be taken from the essence of human firstly before the means of perfection for a human being arises both psychologically, physically and spiritually as an individual alone, in society and universally. a perfect human being establishes a state, an intellectual democratic state in the whole earth and not as now ignorant democratic state. the soul, psyche, ego or nafs is there to protect the essence of being a human in creation-natureand not something else by control of the intellect over the soul. in this way, the core can flourish and develop natural human instincts. in turn, the development of fitra helps in training the personality and character of the soul-the human beingand the intellect success in having more power and dominance in the mind and over the negative attributes of the soul and promoting the attributes that develop from the fitra. as in the second citation: aya. abdollah javadi amoli mentions the four states of individuals or rather we can expand it to four states of families, or four states of societies or four states of countries and so on. the important is that even if one can‟t run from danger because one‟s hand and feet are chained in the soil, one must cure one‟s eyes to be able to see how one is chained in this so called democratic states, in societies and families and lastly individually, to be able to find a solution through knowledge, intellectual knowledge not ignorant knowledge, to solve the puzzle and free oneself from captivity. with eyes, with senses you learn knowledge, and if these are blind, maybe allah has locked your heart and it is more difficult to reach and fly towards perfection than limps in captivity. and if your limps are crippled maybe its cause are either you or others and you need to see and perceive the situation to reach perfection and this is easier than eyes being blind. there is one common disease in the world, that one should know why, what for is this disease in existence, what is this disease, where is it in existence, when did this disease take place and how to cure it. this disease is that islam is not known in the world. imam khomeini peace upon him did send a letter to the soviet president mikhail gorbachev in that time introducing islam and calling for unity, and now aya. sayyid khamenei may allah prolong his life in this world send a letter to the whole youth in europe and america to know islam from its source holy quran and etrat – the family of the prophet peace upon him and his household. the difference is that gorbachev was one and old and european and american youth that are not muslims, may allah bless them are many in europe and america and they are not old like gorbachev that disappointed the dear imam khomeini peace and blessing upon him in abundant. references: http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team: infallibility of the prophets part 1 part 2 part 3, leadership and infallibility part 1 part 2, the twelve imams part 1 part 2, the holy qur‟an and the pure imams 2 see bibliography for study material, for purpose of adl-justice of god-! 3 “description on the armies of intelligence and ignorance (jonud aqle va jahle) -by imam khomeini peace upon him.-: this is a valuable book by the imam on ethics. the religious (kalami) and ethical opinions and mysticism of the imam are more clearly opened in this book and, like his book "the description on forty narratives", more layers (of people) can benefit by it. currently, the research section of the institute (qum branch) is editing the explanatory footnotes and preparing the related lists and other research works, which it will publish, in two volumes of over 800 pages.” source: http://www.imam-khomeini.com/web1/english/showitem.aspx?cid=1662&h=13&f=14&pid=1794 4 exegesis-tafsir namonah-, aya. makarem, english version, verse 40 chapter 15 5 [nahj al-balagha, saying 32; scales of wisdom chapter corruption] 6 translation by shiatranslate http://en.imam-khomeini.ir/en/c5_3153/book/english/a_call_to_divine_unity http://farsi.khamenei.ir/ndata/news/28731/index.html#en http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/infallibility-prophets-part-3 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/leadership-and-infallibility-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/leadership-and-infallibility-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/twelve-imams-part-1 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/twelve-imams-part-2 http://www.al-islam.org/shiite-encyclopedia-ahlul-bayt-dilp-team/holy-quran-and-pure-imams http://www.imam-khomeini.com/web1/english/showitem.aspx?cid=1662&h=13&f=14&pid=1794 33 7 http://www.portal.esra.ir/pages/index.aspx?kind=1&lang=en&id=mtcxmq%3d%3dzbytgapuo%2fu%3d&skinid=69 bibliography: 1. human rights resources: risalatul huquq a seventh century islamic document on various legal and moral rights of human beings. the english translation was done from the original arabic from shayakh al-harrani‟s book -4 th century of hijra-. http://www.al-islam.org/treatise-rights-risalat-al-huquq-imam-zain-ul-abideen islam, the west and human rights, a collection of articles http://en.imamkhomeini.ir/en/c5_7813/book/english/islam_west_and_the_human_rights islam, humanity and human values sayyid musa sadr message of thaqalayn winter 2011, vol. 11, no. 4 human rights a study of the universla and the islamic declarations of human rights by muhammad ali taskhiri http://www.al-islam.org/human-rights-ayatullah-muhammad-ali-tashkiri woman and her rights in islam a translation of „nizam-e hoqouq-e zan dar islam‟ ayatolah morteza motahari translated by m. a. ansari also see: http://www.al-islam.org/rights-women-islam-ayatullah-murtadha-mutahhari the source of rights philosophical discussion on the origin of rights & and that its source is the will of allah. ayatollah misbah yazdi http://www.mesbahyazdi.org/english/?writen/articales/articales01.htm islamic views on human rights viewpoints of iranian scholars -, http://www.amazon.ca/islamic-views-humanrights-viewpoints/dp/8173915180 the rights of prisoners according to islamic teachings by muhammad shirazi translated by z. olyabek 2. hadith chapters from book „scales of wisdom‟ by aya. reyshahri the heart hadithdatabank.com/preview.php?mod=4&id=244 intellect and some of its armies: the intellect al-aql hadithdatabank.com/preview.php?mod=4&id=231 the good al-kayr http://www.hadithdatabank.com/preview.php?mod=4&id=261 the knowledge al-ilm hadithdatabank.com/preview.php?mod=4&id=213 the inner knowledge al-marifah hadithdatabank.com/preview.php?mod=4&id=226 inner knowledge of allah marifatu-llah hadithdatabank.com/preview.php?mod=4&id=227 the vitality al-afiya hadithdatabank.com/preview.php?mod=4&id=20 the thinking at-tafakkor hadithdatabank.com/preview.php?mod=4&id=31 the love al-mahabbah hadithdatabank.com/preview.php?mod=4&id=207 the wisdom al-hikmah hadithdatabank.com/preview.php?mod=4&id=8 the sincerity al-ikhlas http://www.hadithdatabank.com/preview.php?mod=4&id=61 the asceticism az-zohd http://www.hadithdatabank.com/preview.php?mod=4&id=393 the clemency al-hilm http://www.hadithdatabank.com/preview.php?mod=4&id=334 the conjecture al-zann http://www.hadithdatabank.com/preview.php?mod=4&id=344 the concealment al-kitman http://www.hadithdatabank.com/preview.php?mod=4&id=340 the courage ash-shjaia http://www.hadithdatabank.com/preview.php?mod=4&id=349 http://www.portal.esra.ir/pages/index.aspx?kind=1&lang=en&id=mtcxmq%3d%3d-zbytgapuo%2fu%3d&skinid=69 http://www.portal.esra.ir/pages/index.aspx?kind=1&lang=en&id=mtcxmq%3d%3d-zbytgapuo%2fu%3d&skinid=69 http://hadithdatabank.com/preview.php?mod=4&id=244 http://hadithdatabank.com/preview.php?mod=4&id=231 http://www.hadithdatabank.com/preview.php?mod=4&id=261 http://hadithdatabank.com/preview.php?mod=4&id=213 http://hadithdatabank.com/preview.php?mod=4&id=226 http://hadithdatabank.com/preview.php?mod=4&id=227 http://hadithdatabank.com/preview.php?mod=4&id=20 http://hadithdatabank.com/preview.php?mod=4&id=31 http://hadithdatabank.com/preview.php?mod=4&id=207 http://hadithdatabank.com/preview.php?mod=4&id=8 http://www.hadithdatabank.com/preview.php?mod=4&id=61 http://www.hadithdatabank.com/preview.php?mod=4&id=393 http://www.hadithdatabank.com/preview.php?mod=4&id=334 http://www.hadithdatabank.com/preview.php?mod=4&id=344 http://www.hadithdatabank.com/preview.php?mod=4&id=340 http://www.hadithdatabank.com/preview.php?mod=4&id=349 34 the contentment al-qanaia http://www.hadithdatabank.com/preview.php?mod=4&id=346 the fairness al-insaf http://www.hadithdatabank.com/preview.php?mod=4&id=275 the generosity as-sakha http://www.hadithdatabank.com/preview.php?mod=4&id=258 the humility al-khushu http://www.hadithdatabank.com/preview.php?mod=4&id=253 the humbleness at-tawazuhttp://www.hadithdatabank.com/preview.php?mod=4&id=252 the hope ar-raja http://www.hadithdatabank.com/preview.php?mod=4&id=249 the happiness as-sorur hadithdatabank.com/preview.php?mod=4&id=241 ignorance and some of its armies: the ignorance al-jahl hadithdatabank.com/preview.php?mod=4&id=222 the evil ash-shar http://www.hadithdatabank.com/preview.php?mod=4&id=300 the wasting al-esraf hadithdatabank.com/preview.php?mod=4&id=5 the idleness al-farakh www.hadithdatabank.com/preview.php?mod=4&id=221 the desire al-hawa http://www.hadithdatabank.com/preview.php?mod=4&id=312 the amusement al-lahw http://www.hadithdatabank.com/preview.php?mod=4&id=386 the anger al-khazab http://www.hadithdatabank.com/preview.php?mod=4&id=388 the arrogance al-kebr http://www.hadithdatabank.com/preview.php?mod=4&id=392 the betrayal al-kiyanah http://www.hadithdatabank.com/preview.php?mod=4&id=360 the covetousness al-hirs http://www.hadithdatabank.com/preview.php?mod=4&id=351 the cowardice al-jobn http://www.hadithdatabank.com/preview.php?mod=4&id=352 the delusion al-kohror http://www.hadithdatabank.com/preview.php?mod=4&id=310 the desertion al-hijran http://www.hadithdatabank.com/preview.php?mod=4&id=311 the doubt ash-shak http://www.hadithdatabank.com/preview.php?mod=4&id=323 the despair al-yaas http://www.hadithdatabank.com/preview.php?mod=4&id=327 the enmity al-adawa http://www.hadithdatabank.com/preview.php?mod=4&id=299 the exhortation al-maweza http://www.hadithdatabank.com/preview.php?mod=4&id=302 the falsehood al-batil http://www.hadithdatabank.com/preview.php?mod=4&id=277 the foolishness al-homq http://www.hadithdatabank.com/preview.php?mod=4&id=285 the gallantry al-moruwwa http://www.hadithdatabank.com/preview.php?mod=4&id=256 the hypocrisy an-nifaq http://www.hadithdatabank.com/preview.php?mod=4&id=254 the haste al-ajala http://www.hadithdatabank.com/preview.php?mod=4&id=243 the greed at-tamhe http://www.hadithdatabank.com/preview.php?mod=4&id=271 the fear al-khawf http://www.hadithdatabank.com/preview.php?mod=4&id=281 disbelief http://www.hadithdatabank.com/preview.php?mod=4&id=316 enemy of human rights: music http://www.hadithdatabank.com/preview.php?mod=4&id=190 intoxication http://www.hadithdatabank.com/preview.php?mod=4&id=235 fornication http://www.hadithdatabank.com/preview.php?mod=4&id=286 poetry http://www.hadithdatabank.com/preview.php?mod=4&id=154 bribery http://www.hadithdatabank.com/preview.php?mod=4&id=363 alcohol http://www.hadithdatabank.com/preview.php?mod=4&id=378 corruption http://www.hadithdatabank.com/preview.php?mod=4&id=347 status of human being: angels http://www.hadithdatabank.com/preview.php?mod=4&id=387 animals http://www.hadithdatabank.com/preview.php?mod=4&id=389 spirit http://hadithdatabank.com/preview.php?mod=4&id=69 general: allah http://www.hadithdatabank.com/preview.php?mod=4&id=379 the names of allah hadithdatabank.com/preview.php?mod=4&id=174 http://www.hadithdatabank.com/preview.php?mod=4&id=346 http://www.hadithdatabank.com/preview.php?mod=4&id=275 http://www.hadithdatabank.com/preview.php?mod=4&id=258 http://www.hadithdatabank.com/preview.php?mod=4&id=253 http://www.hadithdatabank.com/preview.php?mod=4&id=252 http://www.hadithdatabank.com/preview.php?mod=4&id=249 http://hadithdatabank.com/preview.php?mod=4&id=241 http://hadithdatabank.com/preview.php?mod=4&id=222 http://www.hadithdatabank.com/preview.php?mod=4&id=300 http://hadithdatabank.com/preview.php?mod=4&id=5 http://www.hadithdatabank.com/preview.php?mod=4&id=221 http://www.hadithdatabank.com/preview.php?mod=4&id=312 http://www.hadithdatabank.com/preview.php?mod=4&id=386 http://www.hadithdatabank.com/preview.php?mod=4&id=388 http://www.hadithdatabank.com/preview.php?mod=4&id=392 http://www.hadithdatabank.com/preview.php?mod=4&id=360 http://www.hadithdatabank.com/preview.php?mod=4&id=351 http://www.hadithdatabank.com/preview.php?mod=4&id=352 http://www.hadithdatabank.com/preview.php?mod=4&id=310 http://www.hadithdatabank.com/preview.php?mod=4&id=311 http://www.hadithdatabank.com/preview.php?mod=4&id=323 http://www.hadithdatabank.com/preview.php?mod=4&id=327 http://www.hadithdatabank.com/preview.php?mod=4&id=299 http://www.hadithdatabank.com/preview.php?mod=4&id=302 http://www.hadithdatabank.com/preview.php?mod=4&id=277 http://www.hadithdatabank.com/preview.php?mod=4&id=285 http://www.hadithdatabank.com/preview.php?mod=4&id=256 http://www.hadithdatabank.com/preview.php?mod=4&id=254 http://www.hadithdatabank.com/preview.php?mod=4&id=243 http://www.hadithdatabank.com/preview.php?mod=4&id=271 http://www.hadithdatabank.com/preview.php?mod=4&id=281 http://www.hadithdatabank.com/preview.php?mod=4&id=316 http://www.hadithdatabank.com/preview.php?mod=4&id=190 http://www.hadithdatabank.com/preview.php?mod=4&id=235 http://www.hadithdatabank.com/preview.php?mod=4&id=286 http://www.hadithdatabank.com/preview.php?mod=4&id=363 http://www.hadithdatabank.com/preview.php?mod=4&id=378 http://www.hadithdatabank.com/preview.php?mod=4&id=347 http://www.hadithdatabank.com/preview.php?mod=4&id=387 http://www.hadithdatabank.com/preview.php?mod=4&id=389 http://www.hadithdatabank.com/preview.php?mod=4&id=379 http://hadithdatabank.com/preview.php?mod=4&id=174 35 the name hadithdatabank.com/preview.php?mod=4&id=168 the creator http://www.hadithdatabank.com/preview.php?mod=4&id=354 creation http://www.hadithdatabank.com/preview.php?mod=4&id=353 general prophethood http://www.hadithdatabank.com/preview.php?mod=4&id=274 prophethood [specific prophets] www.hadithdatabank.com/preview.php?mod=4&id=150 muhammad [s] the messenger of allah http://www.hadithdatabank.com/preview.php?mod=4&id=189 fatima [a] the mother of the imams hadithdatabank.com/preview.php?mod=4&id=291 invoking blessings on the prophet (s) hadithdatabank.com/preview.php?mod=4&id=236 the miracle http://www.hadithdatabank.com/preview.php?mod=4&id=184 the quran hadithdatabank.com/preview.php?mod=4&id=116 the light http://www.hadithdatabank.com/preview.php?mod=4&id=203 the argument hadithdatabank.com/preview.php?mod=4&id=399 resurrection http://www.hadithdatabank.com/preview.php?mod=4&id=105 death http://www.hadithdatabank.com/preview.php?mod=4&id=307 the grave http://www.hadithdatabank.com/preview.php?mod=4&id=270 the return www.hadithdatabank.com/preview.php?mod=4&id=108 leadership http://www.hadithdatabank.com/preview.php?mod=4&id=196 infallibility hadithdatabank.com/preview.php?mod=4&id=224 justice hadithdatabank.com/preview.php?mod=4&id=220 jurisprudence hadithdatabank.com/preview.php?mod=4&id=219 the path http://www.hadithdatabank.com/preview.php?mod=4&id=122 straying from the straight path http://www.hadithdatabank.com/preview.php?mod=4&id=75 3. e-books: they islamic scholars have improved the concept of tawhid -monotheism-; adl -justice of god-; prophetship; imamat -leadershipand day of resurrection with help of the resources of books and hadith -traditionswas left from the 14 infallibles peace upon them. their 12th imam may allah hasten his coming -leaderis in occultation so they have developed the wilaya faqih concept -the jurist as a leader-. they believe the 12th imam, may allah hasten his coming, will come with jesus peace upon him. tawhid-monotheism-: knowing god-booklet-: perfection of faith, seeking god, god and reason, acceptance of the unseen, and materialism. author(s): sayyid mujtaba musavi lari; translator(s): f.j. goulding knowing god: this book is part of ideological collection of “youths and truths” by ayatullah ibrahim amini based on years of delving into religious texts and sources, constant contact with the young generation and pondering over ideological and educational issues. author(s): ayatullah ibrahim amini god and his attributes: belief in god, god in the qur'an, free will, and a discussion of some of attributes of god. translated by, dr. hamid algar. author(s): sayyid mujtaba musawi lari at-tawhid or monotheism: at-tawhid or monotheism as in the ideological and the value systems of islam. a book that delves into the several dimensions and depths of tawhid (oneness of god): the central and core concept of islam. starting from the basic definitions, it then moves onto how one's life and existence revolve around tawhid. author(s): ayatullah muhammad taqi misbah yazdi adl-justice of god-: justice of god: a short text on the nature of allah's attribute of `adl (justice) where the author discusses philosophical issues about its seeming incompatibility with events like natural disasters as well as with allah's own http://hadithdatabank.com/preview.php?mod=4&id=168 http://www.hadithdatabank.com/preview.php?mod=4&id=354 http://www.hadithdatabank.com/preview.php?mod=4&id=353 http://www.hadithdatabank.com/preview.php?mod=4&id=274 http://www.hadithdatabank.com/preview.php?mod=4&id=150 http://www.hadithdatabank.com/preview.php?mod=4&id=189 http://hadithdatabank.com/preview.php?mod=4&id=291 http://hadithdatabank.com/preview.php?mod=4&id=236 http://www.hadithdatabank.com/preview.php?mod=4&id=184 http://hadithdatabank.com/preview.php?mod=4&id=116 http://www.hadithdatabank.com/preview.php?mod=4&id=203 http://hadithdatabank.com/preview.php?mod=4&id=399 http://www.hadithdatabank.com/preview.php?mod=4&id=105 http://www.hadithdatabank.com/preview.php?mod=4&id=307 http://www.hadithdatabank.com/preview.php?mod=4&id=270 http://www.hadithdatabank.com/preview.php?mod=4&id=108 http://www.hadithdatabank.com/preview.php?mod=4&id=196 http://hadithdatabank.com/preview.php?mod=4&id=224 http://hadithdatabank.com/preview.php?mod=4&id=220 http://hadithdatabank.com/preview.php?mod=4&id=219 http://www.hadithdatabank.com/preview.php?mod=4&id=122 http://www.hadithdatabank.com/preview.php?mod=4&id=75 http://www.al-islam.org/knowing-god-sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/fj-goulding http://www.al-islam.org/knowing-god-ayatullah-ibrahim-amini http://www.al-islam.org/person/ayatullah-ibrahim-amini http://www.al-islam.org/person/sayyid-mujtaba-musawi-lari http://www.al-islam.org/person/sayyid-mujtaba-musawi-lari http://www.al-islam.org/person/sayyid-mujtaba-musawi-lari http://www.al-islam.org/tawhid-or-monotheism-muhammad-taqi-misbah-yazdi http://www.al-islam.org/justice-of-god-ayatullah-makarim-shirazi 36 divine will. author(s): ayatullah al-`uzma al-hajj ash-shaykh nasir makarim shirazi what is justice, an excerpt from divine justice: shaheed mutahari https://www.dropbox.com/sh/6rz5f3vgj1rywy0/7kqc9hwhub/what%20is%20justice%20%20an%20excerpt%20from%20divine%20justice%20-%20shaheed%20mutahhari.pdf nubuwah-prophetship-: seal of the prophets and his message: prophethood, miracles, revelation, inerrancy, splendor of prophet muhammad (s), migration, qur'anic themes, and the sealing of prophethood. author(s): sayyid mujtaba musavi lari prophethood and the prophet of islam: this book discusses about general prophethood and particularly to the prophethood of the holy prophet muhammad (s) and the description of his proclamation as well as a sketch of his character and life history. author(s): ayatullah ibrahim amini imamat-leadership-: imamate and the imams: this book is written for the youth about the definition of imamate and privileges of the imams so that we may learn and follow the pattern of the infallible imams -a-. author(s): ayatullah ibrahim amini imamate and leadership: translated by dr. hamid algar, includes leadership in islam, leadership of the prophet and appointment of imam ali, responsibility of the companions, necessity of imamate, and interesting accounts of imam's communication with the unseen including the story of maitham al-tammar. author(s): sayyid mujtaba musavi lari universal government of the mahdi: this text, authored by ayatullah makarim shirazi sheds light on the nature of the universal government that will exist with the reappearance of imam mahdi (afs) at the end of time. his method of government, awaiting his reappearance and the way victory will be achieved by this great peacemaker is discussed and presented. author(s): ayatullah al-`uzma al-hajj ash-shaykh nasir makarim shirazi al-imam al-mahdi, the just leader of humanity: translated by dr. sachedina. includes topics on the belief in the mahdi, pseudo mahdis, leadership of imam mahdi (a), occultation, his long life, and the reappearance of the imam. author(s): ayatullah ibrahim amini mead-resurrection day: resurrection judgment and the hereafter: aspects of death, pleasures of this world, evidence for resurrection, resurrection a manifestation of divine justice, compensation for sins, and criterion for judgment. author(s): sayyid mujtaba musavi lari resurrection (ma‟ad) in the quran: discussions on resurrection and life after death from islamic perspective. author(s): ayatullah ibrahim amini ahl al-bait and wilaya doctrine in shia: taharah;ismah of the prophets, messengers, awsiya and imams (peace be upon them) dr. hatem abu shahba authority and tradition -booklet-: an article explaining the different types of authority (wilayah) in shi'a islam, in particular the religious authority of a jurist in society after the greater occultation. authors(s): dr. ghasem kakaie a cursory glance at the theory of wilayat al-faqih: this work contains a number of speeches, articles, books, and question-and-answer sessions of the erudite professor, haḍrat ayatullah muhammad taqi misbah yazdi (may his sublime presence endure), which have been compiled, edited and published by the author on the subject of wilayat al-faqih. author(s): ayatullah muhammad taqi misbah yazdi http://www.al-islam.org/person/ayatullah-al-uzma-al-hajj-ash-shaykh-nasir-makarim-shirazi https://www.dropbox.com/sh/6rz5f3vgj1rywy0/7kqc9hwhub/what%20is%20justice%20-%20an%20excerpt%20from%20divine%20justice%20-%20shaheed%20mutahhari.pdf https://www.dropbox.com/sh/6rz5f3vgj1rywy0/7kqc9hwhub/what%20is%20justice%20-%20an%20excerpt%20from%20divine%20justice%20-%20shaheed%20mutahhari.pdf http://www.al-islam.org/seal-prophets-and-his-message-sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/prophethood-and-prophet-islam-ayatullah-ibrahim-amini http://www.al-islam.org/person/ayatullah-ibrahim-amini http://www.al-islam.org/imamate-and-imams-ayatullah-ibrahim-amini http://www.al-islam.org/person/ayatullah-ibrahim-amini http://www.al-islam.org/imamate-and-leadership-sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/universal-government-mahdi-makarim-shirazi http://www.al-islam.org/person/ayatullah-al-uzma-al-hajj-ash-shaykh-nasir-makarim-shirazi http://www.al-islam.org/al-imam-al-mahdi-just-leader-humanity-ayatullah-ibrahim-amini http://www.al-islam.org/person/ayatullah-ibrahim-amini http://www.al-islam.org/resurrection-judgement-and-hereafter-sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/person/sayyid-mujtaba-musavi-lari http://www.al-islam.org/resurrection-maad-quran-ayatullah-ibrahim-amini http://www.al-islam.org/person/ayatullah-ibrahim-amini http://www.al-islam.org/articles/taharah-ismah-masumeen-dr-hatem-abu-shahba http://www.al-islam.org/message-thaqalayn/vol10-n1-2009/authority-and-tradition-dr-ghasem-kakaie http://www.al-islam.org/person/dr-ghasem-kakaie http://www.al-islam.org/cursory-glance-theory-wilayat-al-faqih-misbah-yazdi http://www.al-islam.org/person/ayatullah-muhammad-taqi-misbah-yazdi 37 the social dimensions of wilayah-hyperlink; right click on the shore of contemplation, volume 1: this text is a response to some inquiries about the nature and role of the governance of the jurist (wilayatul faqih). the author discusses in this text some of the important issues related to wilayatul faqih; for example, whether the jurist's authority is limited or absolute, whether he is elected or appointed, and whether it is obligatory to follow his orders. author(s): akbar asad ali zadeh conflict of interest: no conflict of interest. http://www.al-islam.org/articles/social-dimensions-wilayah-mohammad-ali-shomali http://www.al-islam.org/shore-contemplation-vol1-wilayatul-faqih-akbar-asad-ali-zadeh http://www.al-islam.org/person/akbar-asad-ali-zadeh microsoft word editorial vol7 issue 1 bangladesh journal of bioethics 2016;7(1) editorial greetings to all our honourable readers and writers of the bangladesh journal of bioethics! this issue of 2016 deals with the topic of ageing and ethical issues related to the caring and respect of the elderly. the issue contains the following articles: abu sadat mohammad nurunnabi et al discusses the ethical issues, in context of principlism, and the means to deal with ethical dilemmas in healthcare of elderly people. the authors point out that to provide the highest level of care, the entire care giver team of family members and health providers need to form a partnership to provide loving, appropriate care to the elders. this will enhance their quality of care, their quality of life and their happiness in the latter days of their lives which is coined as ‘healthy ageing’. michael o.s. afolabi in his paper discusses how the ethics of care offers ethically responsive ways of addressing the individual and social vulnerabilities of patients associated with alzheimer’s disease. this paper deals with the very sensitive and often painful dilemma faced by care givers of ad. the author examines the ethical issues associated with care of patients with alzheimer’s disease, the relevance of a care ethics (ce) perspective in addressing the vulnerabilities, and implications of such an approach. tonmoy biswas in his paper questions whether it is ethical to enroll a person who is not physically or mentally fit to make a decision in risky research or interventional trials. since informed consent is a prerequisite to any research the author queries on whether the rights of the patient has been transgressed when they are involved in research activities as they are physically and mentally not capable to take any rational decision. the author concludes that revision of national medical ethics policies regarding this issue is mandatory and that, health professionals should be informed about the serious ethical matter. antoni barikdar et al provides an overview of the situation of the elderly in bangladesh where the number of people over 60 years is increasing rapidly. the authors view this as an emerging challenge since the elderly will have special needs and require different care-giving services. since bangladesh does not have a social welfare system there will be competition for inadequate resources specially health and medical services. the authors put forward several recommendations including a data base on the number and conditions of the elderly in bangladesh, in order to develop a pragmatic and sustainable support system for the elderly in bangladesh. readers, the health and well being of the elderly is as important as in any other stage of life. the un celebrates the international day of the older persons on 1 october every year and the theme for 2015 was sustainability and age inclusiveness in the urban environment. bangladesh also observed this day though much more needs to be done in terms of information sharing, health services, meeting the basic and special needs of the elderly. in this context i would like to recommend our readers to look into the “ghana country assessment report on ageing and health” by the world health organization 2014. the report provides in depth analysis on the following issues: bangladesh journal of bioethics 2016;7(1) 1) the health of older people in ghana (socio-environmental circumstances, physical health, physical functioning, nutrition, physical activity, risk factors and behaviors, vision and hearing, cognition and mental health). 2) health systems response and policies (health service delivery, universal coverage and financing, leadership and governance, health workforce, policies and laws, implementation of ghana’s national ageing policy). 3) finally practical and honest recommendations have been made. this assessment report could be used as a guide for countries who are on the verge of facing this challenge. it will help them to be prepared and provide the best of care and respect for the older persons who had spent all their young days contributing to the development of their family, community and country. friends, please continue to submit your excellent thought provoking papers to the bangladesh journal of bioethics, which will help towards achieving a rights based society. best wishes tahera ahmed editor bangladesh journal of bioethics 2017; 8(1): 1-6 1 original article wild fish and expected utility bob fischer department of philosophy, texas state university, san marcos, texas, u.s.a. email: fischer@txstate.edu abstract: it’s difficult to process the number of fish killed annually by the fishing industry. nevertheless, governments are encouraging people to eat even more fish—see, e.g., the usda dietary guidelines—and although animal advocates certainly don’t concur with this advice, they generally haven’t prioritized fish in their lobbying efforts. given the influence of utilitarianism on animal advocacy, the odds are good that this is motivated by an expected utility calculation. for those concerned about fish, is there any way to defend them against this calculation? i argue for an affirmative answer: once you factor in an asymmetry between fishing and terrestrial animal agriculture, the expected utility calculation comes out in favor of devoting resources to reducing fishing. keywords: fish; animal advocacy; expected utility introduction: it’s difficult to process the number of fish killed annually by the fishing industry. based on fao statistics from 1999–2007, mood and brooke put the global number between 970 billion and 2.74 trillion (excluding illegal fishing, bycatch, fish that escape from nets, etc.) 1 . what’s more, their estimate is probably low. they base their calculations on average global catches of 77 million tons, but pauly and zeller make the case that the fao’s statistics were far too conservative 2 . they contend that global catches peaked at 130 million tons in 1996, and have only been declining at a rate of 0.38 million tons per year since then— not the 1.2 million tons per year that the fao claimed. if pauly and zeller are right, then a more realistic estimate is 1.64–4.63 trillion fish per year. but even if we stick with the most conservative estimate—i.e., 970 billion—we should note that it’s nearly fourteen times larger than the number of terrestrial animals killed annually for food, which is around 70 billion 3 . the fishing industry is responsible for a staggering loss of life. nevertheless, governments are encouraging people to eat even more fish—see, e.g., the usda dietary guidelines—and although animal advocates certainly don’t concur with this advice, they generally haven’t prioritized fish in their lobbying efforts. the humane society of the united states (hsus), for example, which is the largest animal welfare organization in the u.s., spends a considerable amount on its farm animal protection team. however, none of those funds are specifically devoted to fish, and at present, the majority of resources go toward relieving the suffering of layer hens. in such circumstances, can animal advocates justify focusing on terrestrial species? elder and fischer (forthcoming) argue that they can’t, at least when it comes to farmed fish 4 . but what about wild fish? mailto:fischer@txstate.edu bangladesh journal of bioethics 2017; 8(1): 1-6 2 to answer that question, we need to consider the framework that guides much u.s.-based animal advocacy. granted, there are many considerations relevant to animal advocates. however, whether they are welfarists or abolitionists, nearly all u.s. animal advocacy organizations have a pragmatic bent, demonstrated by their willingness to collaborate with, and sometimes even celebrate, retailers and producers of animal products. instead of insisting on ending the farming of a particular species, or devoting all efforts to vegan education, they’re willing to lobby for relatively small welfare improvements. so, even if they ultimately hope to end the human use of animals, they seem willing to think like utilitarians in the present. this, of course, is one of gary francione’s longstanding complaints about these organizations. i take no stand here on whether this particular complaint is justified. however, given that utilitarian reasoning does seem to guide u.s. animal advocacy, we can approach the question of whether they ought to be more concerned about wild fish within that framework. what’s more, this assumption is a charitable one, as it appears to make sense of their priorities. after all, suppose we run an expected utility calculation. some wild-caught fish suffer for hours or days on long-lines or gill nets, but most don’t: their swim bladders explode as a result of coming to the surface too quickly, or they suffocate on the deck, or they are crushed under the weight of other fish. so let’s just suppose, quite generously, that the average wild-caught fish suffers for an hour before dying. then, it’s relatively easy to calculate the life years of suffering produced by the fishing industry—roughly 110 million, using the most conservative estimate, and 529 million, using the most liberal one. globally, however, six billion layer hens are killed each year, each of whom lives between 12 and 24 months in very unpleasant conditions 5 . so, we don’t even need to factor in broiler chickens— which easily outnumber layers by a factor of six or seven—to see that the life years of suffering due to the chicken industry are much, much higher than those produced by the fishing industry. hsus, peta, and other organizations look to be reasonable in emphasizing the plight of layers, and it makes sense that they are now beginning to shift their attention toward broilers 6 . discussion: is there any way to defend fish against this calculation? i think so: as i’ll argue, expected utility considerations break in favor of fish. granted, that alone won’t show that advocacy organizations ought to shift resources away from chickens—or any other terrestrial animal—and toward fish. however, it will be enough to shift the burden onto animal advocates: they will need to explain the other factors that outweigh the consideration of expected utility. the key move is to consider an important difference between fishing and chicken production. if you reduce chicken consumption, you reduce chicken breeding, and the absolute number of chickens will drop. but if you reduce fish consumption, you don’t reduce the absolute number of fish. you reduce the number of fish in aquaculture, but you extend the lives of some portion of the billions (or trillions) of wild fish who would otherwise have been caught. indeed, you probably get a significant gain in overall utility, as many of those now-uncaughtfish have long lifespans. salmon, for instance, can live 3-8 years; tilapia, 9-11 years; atlantic cod, as many as 25 years; and bluefin tuna, up to 30 years. to see how this goes, let’s just suppose that you’re able to reduce global chicken and fish production by just 1% each. that bangladesh journal of bioethics 2017; 8(1): 1-6 3 would save 700 million chickens from an awful life, but even if we use the most conservative kill estimate, it would save 9.7 billion fish, some of whom can live for thirty years or more. this dramatically shifts the expected utility calculation in favor of fish. there are two objections that someone might make at this juncture. the first involves skepticism about fish sentience. i think the evidence clearly undermines this maneuver—see, e.g., victoria braithwaite’s work 7 —but let’s ignore this. to make this objection work, you need to specify the probability you’re willing to assign to fish sentience relative to chicken sentience. suppose you have a very dim view of fish: you think that fish are—averaging across species—only a tenth as likely to be sentient as chickens. still, fish will win by a huge margin: effectively, we’ll be running the expected utility calculation with 970 million fish as opposed to 9.7 billion, which is still greater in absolute numbers, and we haven’t yet factored in lifespans. a better move is to deny that the lives of fish are, on balance, worth living 8 . if wild fish generally experience lives in which suffering predominates, then it becomes much harder to make a utilitarian case for saving them. how might someone justify this stance on the lives of fish? the standard line seems to be this. first, we underestimate how much suffering occurs in the natural world: many fish suffer due to disease, injury, lack of food, pollution, and as a result of predation. second, the vast majority of fish live short, painful lives, where there are few opportunities for pleasure. this thought is motivated by reflections on the distinction between k and r reproductive strategies. humans employ a k strategy: we have few offspring and we invest a great deal of resources in keeping the ones we have alive. most fish, however, pursue an r strategy: they have hundreds, thousands, or even millions of offspring, invest very little in them, and only a few of them survive. the unlucky offspring starve or are eaten relatively soon after birth, and on the assumption that these beings are conscious, this suggests that they experience considerable suffering before death. third and finally, we tend to be subject to various biases that make it hard for us to appreciate just how bad things are for most sentient beings. for instance, an availability bias leads us to focus on large, mature animals instead of small, young ones; wishful thinking leads us to predict that things are better than the evidence suggests; and a powerful cultural narrative involves idealizing natural environments, despite evidence to the contrary. this pessimistic view isn’t relevant to calculations about the fish that are actually saved, since those fish are the relatively successful ones. (after all, fishing boats aren’t after hatchlings.) however, the worry isn’t primarily about those individuals anyway, but about their offspring. nevertheless, things may not be as bad for the expected utility argument as it might seem. first, whatever the suffering in the lives of unsuccessful offspring, we can’t infer that suffering predominates until we know how much pleasure these animals get from various sources—e.g., having novel experiences, or feeding. to my knowledge, no one who defends the pessimistic view takes up this issue. second, it’s worth noting that the reproductive strategy argument is based on the assumption that suffering is associated with all failures— bangladesh journal of bioethics 2017; 8(1): 1-6 4 i.e., unsuccessful attempts to feed, mate, etc.—while pleasure is associated with successes. since most animals aren’t successful most of the time—as r strategies involve sacrificing most offspring to create the mature individuals in the next generation—it follows that suffering predominates in nature. however, it isn’t clear that the assumption about suffering and failure is justified. suffering is likely to be associated with certain failures—e.g., those that result in organisms crossing some threshold of unsatisfied need—but since organisms can be motivated to satisfy their needs without suffering, it isn’t clear why we should think that suffering will be associated with all failures. and if it isn’t, then the short lives of most organisms may be relatively pleasant until, suddenly, they aren’t—e.g., when a predator gets them—which means that pleasure may dominate. third and finally, the hypothesis that a huge number of animals live net negative lives is bound to have dramatic moral implications. it’s hard to see why we should make a concerted effort to preserve species with r reproductive strategies if we are, thereby, ensuring that the world contains much more suffering than it would otherwise. nevertheless, this is what many of our conservation efforts involve. so, the standard of evidence here should be high: it isn’t enough that there’s a reasonable argument for the pessimistic hypothesis from some general considerations about reproductive strategies, the prevalence of disease and injury, and so on. we need more detailed ethological studies before reaching this conclusion. the upshot here is that it isn’t clear that the pessimistic view is true, and until we have more evidence in favor of it, it seems reasonable to set it aside in our deliberations. so, it seems to me that the expected utility argument still favors devoting more resources to relieving the plight of wild fish. at this juncture, perhaps the best move for chicken advocates (or those otherwise interested in focusing on terrestrial animals) is to abandon utilitarianism for painism—i.e., the view that we ought to minimize suffering, rather than the view that we ought to maximize net utility 9 . this fits neatly with the rhetoric of many animal advocates, who are, in general, much more vocal about reducing suffering than promoting happiness. more importantly, it will get the desired result: if we discount the good in the lives of fish, then the suffering of chickens will dominate. this is not the place to assess the merits of painism. for present purposes, then, let’s grant the chicken advocate this particular moral framework. given that concession, we have to make a more speculative case on behalf of fish. wild fish populations are in rough shape due to overfishing: the fao estimates that 89.5% of wild fish stocks are either fully exploited or overexploited 10 , and worm et al. argues that, absent intervention, we may face a fishless ocean by 2048 11 . that, of course, would result in widespread destruction of marine ecosystems, and it seems likely that such extensive oceanic changes would have ramifications for life elsewhere on the planet. what are the odds that the consequences will be good? presumably, not very high. what seems more likely is that collapsing fish populations would cause immense suffering among the incredible number of other animals who depend on fish for their survival. so, even if our focus is solely on preventing suffering, there is a reasonable case for devoting attention to fish: efforts to scale back fishing are, inter alia, efforts to save the marine ecosystems on which so much life depends. bangladesh journal of bioethics 2017; 8(1): 1-6 5 conclusion: as mentioned earlier, i concede that the above doesn’t show that animal advocacy organizations ought to redirect resources toward fish. the above does show, however, that those organizations can’t rely on an expected utility calculation to justify their current priorities. instead, they’ll need to argue that there’s simply no hope of convincing governments or consumers to limit fishing, or that market forces will check fishing without advocacy work, or what have you. perhaps those arguments will be successful, though i have my doubts. regardless, those are the arguments we now need to hear. author contribution: the author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgement: thanks to max elder, who got me interested in this issue, and to an anonymous referee, who made many helpful suggestions. references 1 mood a brooke p. estimating the number of fish caught in global fishing each year. 2010 http://fishcount.org.uk/published/std/fishcountstudy.pdf (accessed 9/17/2016). such estimates are bound to be imprecise, as the fao doesn’t report head counts. so, head counts have to be generated based on reports about (a) total catches, given in tons, not individual heads, (b) the distribution of species caught, and (c) information about the mean weights of members of those species. 2 pauly d zeller d. catch reconstructions reveal that global marine fisheries catches are higher than reported and declining. nature communications 2016; 7. 3 see: http://www.ciwf.org.uk/media/3640540/ciwf_strategic_plan_20132017.pdf (accessed 9/23/2016). 4 elder m fischer b. focus on fish: a call to effective altruists. essays in philosophy forthcoming. 5 see: http://www.poultrytrends.com/ (accessed 9/23/2016). of course, u.s. advocacy organizations are primarily concerned with u.s. production. however, the relative numbers don’t change if we limit ourselves to the u.s. market, so i’ll keep things simple by using global numbers, as this spares us some complications in estimating how many wild fish are killed to serve american consumers. 6 there would be no problem for fish if we were supposed to factor in the sheer number of lives, and not just life years of suffering. if we were, then as long as lives got some nontrivial weight in the calculation, it would be likely to come out in favor of fish. however, this isn’t likely to be compelling to the relevant organizations: it’s a feature of utilitarianism—not a bug—that it ignores lives per se. if utilitarian reasoning is behind the decisions of animal advocacy organizations, we’ll need to defend fish in those terms. 7 braithwaite v. do fish feel pain? oxford university press, new york; 2010. http://fishcount.org.uk/published/std/fishcountstudy.pdf http://www.ciwf.org.uk/media/3640540/ciwf_strategic_plan_20132017.pdf http://www.poultrytrends.com/ bangladesh journal of bioethics 2017; 8(1): 1-6 6 8 horta o. debunking the idyllic view of natural processes: population dynamics and suffering in the wild. telos 2010; 17: 73-88. ng y-k. towards welfare biology: evolutionary economics of animal consciousness and suffering. biology and philosophy 1995; 10: 255-85. tomasik b. the importance of wild-animal suffering. relations 2015; 3(2): 133-152. 9 less dramatically, they might adopt some variant of utilitarianism that significantly discounts pleasure relative to pain. for independent considerations in favor of this maneuver, see: shriver a. the asymmetrical contributions of pleasure and pain to animal welfare. cambridge quarterly of healthcare ethics 2014; 23(2): 152-162. 10 fao. the state of world fisheries and aquaculture 2016: contributing to food security and nutrition for all. 2016 http://www.fao.org/3/a-i5555e.pdf (accessed 9/28/2016). 11 worm b barbier e beaumont n duffy j folke c halpern b et al. impacts of biodiversity loss on ocean ecosystem services. science 2006; 3(314): 787-790. http://www.fao.org/3/a-i5555e.pdf microsoft word nutritional status of bat on 20.10.17 bangladesh journal of bioethics 2017; 8(2):23-30 23 nutritional status, personal hygiene and health seeking behavior of the workers of british american tobacco company, dhaka, bangladesh m j haque1, a awal2, m rahman3, j sazzad4 1. professor of community medicine. rajshahi medical college; rajshahi. 2. lecturer, dept. of public health; varendra university. email: limonawal@gmail.com 3. food, physio & safety inspector, j&z group company, dhaka. 4. asst. surgeon, charghat health complex; rajshahi. abstract: this cross sectional study was carried out among the workers of british american tobacco company, dhaka with a view to explore their nutritional status, personal hygiene and health seeking behavior as because they are working on a tobacco processing company. the sample size was 179 which were selected purposively. the study showed that out of 179 respondents 89 (49.7%) were in the age groups of 30-39 years and the mean age of the respondents were 31.99 ± 6.01 years. a large number of respondents (55.9%) had monthly family income of taka 10001-20000 and the mean family income was taka 12776.54 ± 5230.13. maximum respondents (73.7%) were muslim, more than half (54.2%) were shift in charge, 39.1% of the respondents consisted of 4 family members, 43.6% respondents were accustomed to other type of eating habit and 38.5% respondents knew that malnutrition was the effect of lack of proper nutrition, 59.8% of the respondents knew that night blindness was the disease due to malnutrition, most of the respondents (91.6%) performed duties to maintain health, majority (62.0%) respondents used to do nothing to maintain healthcare for their children and 35.9% visited doctor’s single time in a month, 40.2% of the respondents told regular tooth brushing as type of healthy habits. majority (64.8%) respondents used to brush twice a day, majority (50.8%) respondents used to wash hand after toileting, majority (62.08%) respondents used to bath daily, 43.0% and 31.8% of the respondents told that dysentery and diarrhea was due to eating without proper hand washing respectively. majority (53.6%) respondents informed that they learned about personal hygiene from television, 45.8% respondents understood that use of safe water in every work as sanitation. majority (50.84%) came from nuclear family; most (84.92%) had exercise habit and 40.22% had education level of class viii. most (75.42%) of the respondents had semi pucca houses and majority (69.83%) of the respondents used only water as materials for hand washing. this study provided some important information which might help the concerned authority to take appropriate measures to improve the health status of the workers. key words: nutritional status, personal hygiene, health seeking behavior, workers, british american tobacco company, bangladesh introduction: health care seeking behavior is one of the important landmarks to uphold the health status of an individual or a community. simultaneously personal health care practice is also an important issue to keep some common infectious diseases away. health care seeking behavior is related with social, economic and cultural factors.1 the sequence of curative actions that an individual seeks to cure perceived ill health is known as health seeking behavior.2-3 bangladesh journal of bioethics 2017; 8(2):23-30 24 healthy practices varies in urban and rural areas, working environment and sometimes traditional believes .4 health care seeking behavior first introduced by the family, community and society.5 women are mostly depends on their husbands for maintaining nutrition and personal gyhiene.6-7 health care seeking behavior is associated with different factors like age, sex, marital status, caste, religion, region/state, family size and parity, level of education, occupation of the head of the family, household wealth/poverty, women’s autonomy8-13, type of illness, number of days of illness12,14,15, awareness of and access to services, perceived quality of service, availability of transport, physical distance of the facility, time taken to reach the facility.12,16-19 materials and methods: the study was cross-sectional and descriptive in design. the target population included all the workers of british american tobacco company, dhaka. sample size was 179 (total number of employee were available at that time). all workers were interviewed (face-to-face) using a semi-structured questionnaire. statistical analysis was carried out using spss program version 16.0. descriptive variables were explained with mean and standard deviation. results: table 1 shows demography among the workers of british american tobacco company, dhaka, bangladesh. table 2 shows that nutritional status, personal hygiene practices and related conditions among the workers of british american tobacco company, dhaka, bangladesh. table 1.the factors assessed in all the study were utilized to describe the nutritional status, personal hygiene practices and related conditions among the studied populations (n = 179). respondents respondents frequency percent frequency percent age group of the respondents in years: (20-24) years group (25-29) years group (30-39) years group more than 40 years designation of the respondents: manager asst. manager supervisor shift in-charge religion of the respondents: muslim hindu christian 22 44 89 24 2 6 74 97 132 41 6 12.3 24.6 49.7 13.4 1.1 3.4 41.3 54.2 73.7 22.9 3.4 no. of family members: 4 persons 5 persons 6 persons 7persons monthly family income taka 10,000 or less taka 10,001-20,000 more than taka 20,000 x ± sd = tk. 12776.54 ± 5230.13 70 51 49 9 69 100 10 39.1 28.5 27.4 5.0 38.5 55.9 5.6 bangladesh journal of bioethics 2017; 8(2):23-30 25 according to the age of the participants about 49.7% participants were between 30-39 years of age and 13.4% above 40 years. the mean age of the respondents was 31.99 ± 6.01 years. majority of the respondents (55.9%) had monthly family income of taka 10001-20000, 38.5% had monthly family income of taka 10000 or less and a few (5.6%) had monthly family income of taka more than 20000. the average monthly family income was tk. 12776.54 ± 5230.13. most of the respondents (73.7%) were muslim. a large number of respondents (54.2%) were shift in charge, 41.3% were supervisor, 3.4% were assistant manager and a very few (1.1%) belonged to manager by occupation. it was found that 39.1% family constituted 4 family members, followed by 28.5%, 26.4% and 5.0% constituted family members of 5, 6 and 7 respectively. among the respondents 22.9% were vegetarian, 20.1% used to eat balanced diet and 13.4% had diet lack of protein. it was found that 38.5% respondents knew that malnutrition was the effect of not maintaining nutrition, 33.5% of the respondents knew infection as a result of not maintaining proper nutrition. majority (59.8%) knew that night blindness was the disease due to malnutrition; dental pain and anaemia was mentioned by 20.7% and 10.6% respondents respectively. it was also found that 8.9% table 2 assessed of nutritional status, personal hygiene practices and related conditions among the studied populations (n = 179). respondents respondents freq uenc y perc ent frequency percent eating habit: balance diet vegetarian diet lack of protein others knowing effect of not maintain nutrition: malnutrition anemia marasmus infection performing duties to maintain health: yes no knowing name of diseases due to malnutrition: night blindness anemia dental pain 36 41 24 78 69 48 2 60 164 15 107 19 37 16 20.1 22.9 13.4 43.6 38.5 26.8 1.1 33.5 91.6 8.4 59.8 10.6 20.7 8.9 diseases affected by eating without proper hand washing: diarrhea dysentery helminthiasis don’t know frequency of tooth brushing: once a day twice a day 3 time s a day time schedule of hand washing: before eating after toileting before eating & after toileting time schedule of bathing: daily 57 77 32 13 62 116 1 2 91 86 111 1 67 31.8 43.0 17.9 7.3 34.6 64.8 0.6 1.1 50.8 48.0 62.0 0.6 37.4 bangladesh journal of bioethics 2017; 8(2):23-30 26 unknown care seeking behavior for the children: monthly doctor visit after six months nothing healthy habits: regular tooth brush daily bathing hand washing before eating & after toileting don’t know 64 4 111 72 39 62 6 35.8 2.2 62.0 40.2 21.8 34.6 3.4 alternate day no fixed day source of learning about personal hygiene: doctor family tv newspaper understanding about sanitation: use of safe water in every work use of sanitary latrines washing hands with soap others 35 20 96 28 82 53 43 1 19.6 11.2 53.6 15.6 45.8 29.6 24.0 0.6 respondents were unknown about the name of diseases due to malnutrition. it was revealed that most (91.6%) respondents performed duties to maintain health and only 8.4% respondents did not perform duties.62.0% of the respondents did not maintain anything for the proper nutrition of their children. regarding type of healthy habits it was discovered that 40.2% of the respondents told regular tooth brushing, followed by hand washing before eating and after toileting and daily bathing constituted 34.6% and 21.8% respectively as type of healthy habits. majority (64.8%) respondents used to brush teeth twice a day. it was found that majority (50.8%) respondents used to wash hands after toileting, followed by 48.0% who wash hands before eating and toileting. only a very few (1.1%) used to wash hands before eating. majority (62.08%) respondents used to bath daily, followed by 37.4% did not bath on fixed day. it was found that 43.0%, 31.8% and 17.9% of the respondents told that dysentery, diarrhea and helminthiasis were the diseases due to eating without proper hand washing and only a few (7.3%) did not know about the diseases affected by eating without proper hand washing. majority (53.6%) respondents informed that they learned about personal hygiene from television, followed by from doctor. use of safe water in every work, use of sanitary latrines, washing hands with soap and others were understood about sanitation that comprised 45.8%, 29.6%, 24.0% and 0.6% respectively. figure – 1: distribution of the respondents by type of family. nuclear joint bangladesh journal of bioethics 2017; 8(2):23-30 27 the above figure showed that majority (50.84%) came from nuclear family and the rest (49.16%) belonged to joint family (fig. no. 01). figure – 2: distribution of the respondents by exercise habit. regarding exercise habit it was found that most (84.92%) had exercise habit and a few (15.8%) did not perform exercise (fig.no.02). figure – 3: distribution of the respondents by educational status. regarding educational status it was found that out of 179 respondents 40.22% had education level of class viii, 32.40% had ssc, 18.99% had class v (fig.no.03). figure – 4: distribution of the respondents by residence. the above figure showed that majority (75.42%) of the respondents had semi pucca house, 13.97% had kancha and the remaining (10.61%) had building as residence (fig.no.04). 0.00% 100.00% yes no 0.00% 50.00% class v class viii ssc hsc 0% 50% 100% buliding semi kacha bangladesh journal of bioethics 2017; 8(2):23-30 28 figure – 5: distribution of the respondents by materials used for hand washing. regarding materials used for hand washing it was revealed that majority (69.83%) used only water, followed by soap, other materials and ash by 18.44%, 7.26% and 4.47% respectively (fig.no.05). discussion: this cross sectional descriptive study was carried out with a view to assess nutritional status, personal hygiene and health seeking behavior of the workers of british american tobacco company, dhaka. the sample size was 179 which were selected purposively. according to the age of the participants about 49.7% participants were between 30-39 years of age and 13.4% above 40 years. the mean age of the respondents was 31.99 ± 6.01 years. in another study mean age of the respondents were 37.3 years.20 majority of the respondents (55.9%) had monthly family income of taka 10001-20000 and the average monthly family income was tk. 12776.54 ± 5230.13. maximum respondents (73.7%) were muslim, followed by hindu (22.9%). it was found that out of 179 respondents, majority (54.2%) was shift in charge and (41.3%) were supervisor. it was observed that (39.1%) family constituted 4 family members. it was found that (43.6%) respondents were accustomed to other type of eating habit, followed by vegetarian (22.9%). it was observed (38.5%) respondents knew that malnutrition was the effect of not maintaining nutrition and infection was opined by (26.8%). most (59.8%) of the respondents knew that night blindness was the disease due to malnutrition. most (91.6%) respondents performed duties to maintain health. it was revealed that majority (62.0%) respondents used to do nothing for their children and (35.9%) used to visit doctor monthly. it was observed that (40.2%) respondents told regular tooth brushing as type of healthy habits followed by hand washing before eating and after toileting constituted (34.6%).majority (64.8%) respondents used to brush teeth twice a day, followed by once a day constituted (34.6%). majority (50.8%) respondents used to wash hand after toileting, followed by (48.0%) used to wash hands before eating and toileting. it was revealed that majority (62.08%) respondents used to bath daily, followed by (37.4%). it was found that (43.0%), (31.8%) and (17.9%) respondents told that dysentery, diarrhea and helminthiasis was affected by eating without proper hand washing respectively. majority (53.6%) respondents informed that they learned about personal hygiene from tv, followed by from doctor constituted (19.6%). it was found that use of safe water in every work, use of sanitary latrine and washing hands with soap comprised (45.8%), (29.6%) and (24.0%) respectively. majority (50.84%) came from nuclear family and the rest (49.16%) belonged to joint family. most (84.92%) had exercise habit. it was found that out of 0.00% 20.00% 40.00% 60.00% 80.00% only water soap ash other bangladesh journal of bioethics 2017; 8(2):23-30 29 179 respondents (40.22%) had education level of class viii, (32.40%) had ssc and (18.99%) had class v level education. majority (75.42% of the respondents had semi pucca and (13.97%) had kancha building as residence. majority (69.83%) of the respondents used only water as materials for hand washing followed by soap comprised (18.44%). conclusion: maintaining nutritional status, practicing health care practice with good health seeking behavior makes a man healthy and wealthy. integrated programs of health promotion in companies should be implemented. the people should be motivated about maintaining personal hygiene and sustain good health habit. occupational health, safety and healthy working environment should be maintained by the authority. author contribution: first, second, third and fourth author contribute in research 35%, 30%, 20%, 15% respectively. m j haque has conceived the idea, conducted literature review, and developed the manuscript. other authors have drafted the first version of the manuscript. all other authors have meticulously edited the manuscript. conflict of interest: there is no conflict of interest (coi) among the authors in relation profession, financial or any other condition. references 1. price nl, hawkins ka. conceptual framework for the social analysis of reproductive health. journal of health, population and nutrition, 2007; 25(1):24-26. 2. christman nj. the health seeking process: an approach to the natural history of illness. culture, medicine and psychiatry, 1980; 1(4): 351-377. 3. ward h, mertens t, thomas c. health-seeking behavior and the control of sexually transmitted disease. health policy and planning, 1997; 12(1): 19-28. 4. nyamongo ik. jealth care switching behavior of malaria patients in a kenyan rural community. social science & medicine 2002; 54: 377-386. 5. delgado e, sorenson sc, stuyft p. health seeking behavior and self assessment for common childhood symptoms in rural guatemala. annales de iasociétébelge de medicine tropicale 1994; 74:161-168. 6. kaona fad, siziya s, mushanga m. the problems of a social survey in epidemiology: an experience from a zambian rural community. african journal of medicine and medical sciences 1990; 19(3): 219-224. 7. yamasaki-nakagawa m, ozasa k, yamada n, osuga k, shimouchi a, ishikawa n, et al. gender difference in delays to diagnosis and health care seeking behavior in a rural area of nepal. the international journal of tuberculosis and lung disease, 2001; 5(1): 24-31. 8. ahmed sm. exploring health-seeking behavior of disadvantaged populations in rural bangladesh (phd dissertation, no. 05/433). karolinska university press, sweden, 2005. 9. goldman n, heuveline p. health seeking behavior for child illness in guatemala. tropical medicine & international health, 2000; 5(2): 145-155. bangladesh journal of bioethics 2017; 8(2):23-30 30 10. rani m, bonu s. rural indian women’s care-seeking behavior and choice of provider for gynecological symptoms. studies in family planning, 2003; 34(3): 173-185. 11. thorson a, hoa np, long nh. health seeking behavior of individuals with a cough of more than 3 weeks. lancet, 2000; 356: 1823-1824. 12. tipping g, segall m. health care seeking behavior in developing countries: an annotated bibliography and literature review. development bibliography 12. institute of development studies, sussex university. 1995. 13. yip wc, wang h, liu y. determinants of choice of medical provider: a case study in rural china. health policy and planning, 1998: 13: 311-322. 14. islam a, malik f. role of traditional birth attendants in improving reproductive health: lessons from the family health project, sindh. journal pakistan medical association, 2001; 51(6): 218-222. 15. sadiq h, muynck a. health care seeking behavior of pulmonary tuberculosis patients visiting tb center rawalpindi. journal pakistan medical association, 2001; 51(1): 1016. 16. fatmi z, avan bi. demographic, socio-economic and environmental determinants of utilization of antenatal care in rural setting of sindh, pakistan. journal pakistan medical association, 2002; 52(4): 138-142. 17. karim ms. socio-economic, demographic and health situation in thatta district. karachi: department of community health sciences, aga khan university. 1987. 18. moazam f, lakhani m. ethical dilemmas of health care in the developing nations. journal of pediatric surgery, 1990; 25(4): 438-441. 19. stephenson r, hennink m. barriers to family planning service use among the urban poor in pakistan. asia pacific population journal, 2004; 19(2): 5-26. 20. ficarra mg, gualano mr, capizzi s, siliquini r, liguori g, manzoli l, et al. tobacco use prevalence, knowledge and attitudes among italian hospital healthcare professionals. eur j public health. 2011 feb; 21(1): 29-34. microsoft word zika paper corrections.docx 12 oct 2017 bangladesh journal of bioethics 2017; 8(2): 11-18 11 zika virus disease as public health emergency and ethics rhyddhi chakraborty 1and edmond fernandes2 1.researcher (bioethics, united kingdom) and visiting faculty of philosophy and global health (american university of sovereign nations, arizona, usa), email: rhyddhi_414@yahoo.co.in 2. founder and ceo, chd group, india and adjunct faculty, dept. of public health, kshema, nitte university abstract: this paper argues that zika virus infection has its ethical implications beyond the reproductive health of women. it claims that zika virus infection like public health emergency exposes the underlying health determinants and health status of women. therefore, ethical mitigation of zika like public health emergencies should consider these underlying health determinants and health status of women. for, undermining and overlooking these underlying determinants and health status of women, during the public health emergencies, enhance the health inequities. the recent zika virus infection in brazil has triggered different ethics consultation and has prompted to outline ethical recommendations. however, the recommendations have either focused on the reproductive health of women or on the core strategies of public health emergency. considering this as a gap in perspective to prepare for zika like public health emergencies, this paper argues that it is the underlying holistic health of women, precisely, health capability, which should be given due ethical consideration. finally, the paper concludes highlighting the fact that focusing on the holistic health of the women during zika like public health emergencies and beyond can bring in long-term benefits for global health equity. key words: ethics, health, women, zika introduction: one of the remarkable incidences of 2016 is the hosting of rio olympics in brazil, a latin american country which was trying to manage and control zika virus outbreak. gradually, as the disease continued to spread to other countries, the potential threat of this aedes mosquito-borne disease, especially its possible association with microcephaly and other neurological disorders, has prompted world health organization (who) to declare it as public health emergency of international concern1. the incidences out of zika virus disease in brazil have also highlighted several novel and known ethical issues, which thereby, prompted international agencies to review ethical considerations and driven them to frame ethical guidance to prepare and act for zika like public health emergencies2,3. given the need of the situation in brazil, ethics consultations have focused much more on the reproductive health of the women and on the strategic responses as any public health emergency demands. however, this paper argues, zika virus-like diseases have the capacity to unveil the underlying health determinants, expose the existing poor health status of women, and have long-term health implications for the affected women. and, when these underlying determinants and health status of women are undermined, especially in ethics consultation, the disease mitigation strategies fall short of addressing health inequity. consequently, the disease then contributes to and enhances health inequities4. therefore, during zika like outbreaks, the paper claims, the bangladesh journal of bioethics 2017; 8(2): 11-18 12 ethical attention, should not just be restricted to strategic responses but should also be driven towards addressing the underlying health determinants and health conditions. the seen and unforeseen impacts of zika virus disease: zika virus disease is an aedes mosquitoes borne infection. symptoms, usually, include mild fever, skin rash, conjunctivitis, muscle and joint pain, malaise, or headache, normally lasting for 2-7 days5. since its first appearance in 1947 in the uganda, zika virus disease surprised the world by its re-emergence in 2015. unlike its previous occurrences, the recent zika virus infection came to be known as the first of its kind associated with human birth defects. it was found to be evidently cooccurring with neurological complications such as guillain-barre syndrome and microcephaly, for which there are no vaccines available6. in between 22 october 2015 and 16 april 2016, brazil reported a total of 7150 suspected cases of microcephaly and/or central nervous system malformations. of these 1168 were suggestive of congenital infection and 246 child deaths occurred after birth or during pregnancy 7 children born with zika congenital complications may reveal no symptoms at birth but later could develop epilepsy, convulsions, cerebral palsy, physical and learning disabilities, hearing loss, vision problems at different stages of their growth and development8. the rising incidences of the association of microcephaly and zika virus disease provoked brazil to declare zika outbreak as a national public health emergency on 11 november 20159. from february 2016 onwards, zika crossed the brazilian border and was found in places such as venezuela where already there were existing menaces of aedes mosquito10. in february 2016, considering the severity of the situations in brazil and other latin american countries, world health organization (who) declared zika virus disease as a public health emergency of international concern (pheic)11. despite being mosquito-borne, zika virus infection gradually turned out to transmit person-toperson infection through the flow of the amniotic fluids of pregnant mothers to the child, the body fluids during sexual intercourse, blood transfusion, and laboratory and health-care setting exposure12. however, it is the mother to child infection that gained momentum, caused most of the transmissions recently, and incurred a huge loss to latin american countries. the world bank (wb) estimated $3·5 billion economic loss out of 2016 zika-related effects in latin america alone13. besides its serious medical complications and economic loss, this recent incidence of zika virus infection had its debilitating impacts on the certain section of women and on their born and unborn children. in brazil especially, as it has been highlighted, thousands of women of child bearing age, who have already contracted or have the plausibility to contract zika, live particularly in northeast part of brazil, the region which has already the heaviest share of the burden of poverty, poor infrastructure, lack of access to health services, and high penetration of aedes aegypti. as became noticeable, the women of the region are living with precarious sanitation and housing, irregular water supply, poor water storage system increasing mosquito breeding and contributing to the spread of zika and frequent outbreaks of dengue, chikungunya14,15. given this precarious condition, when women of the region were particularly affected by zika, a.e.yamin, a pioneer in global health and human rights, rightly reminds that in these zika affected region, it is the “women who have experienced their poverty and bangladesh journal of bioethics 2017; 8(2): 11-18 13 marginalization through their contact with indifferent health systems. it is women who again will pay the greatest consequences of the impacts of the lack of public health measures, inadequate social protection, and discriminatory laws and… may be blamed for getting themselves pregnant”16. in sum, impact of zika virus disease, from brazil and other american countries, brings to notice that given the underlying conditions of health in the regions, given the situation of the places being less enabled and less interactive, zika like public health emergencies, became opportunistic to affect these women, thereby, compromising their life and health expectations. apart from the grave impacts on life and health expectations, the zika virus disease had its devastating impacts on reproductive health and opportunities of some women who continued to live in the zika affected regions. soon after the zika outbreak, alarming calls by national governments were made to plead women to avoid and delay pregnancy. consequently, voices were raised about the impairment of women’s reproductive rights, access to safe abortion services1718. following this line of thought and showing a concern for the right of women, the united nations high commissioner for human rights released a statement criticizing advice to delay pregnancies and affirming that “laws and policies that restrict access to sexual and reproductive health services in contravention of international standards, must be repealed and concrete steps must be taken so that women have the information, support and services they require to exercise their rights to determine whether and when they become pregnant”19. although the un report stands against the local or national governmental injunctions, zika virus disease, however, once again unleashed the fact that it is not just the impoverished who are disproportionately disadvantaged in the face of public health disasters but zika like public health emergencies can also push the rights and choices of the women at stake and in this case, it has been the reproductive rights of some groups of women which were compromised realizing the interdependence of health and human rights amidst zika outbreak, in early april 2016, the pan american health organization (paho) issued a guidance document on the key ethical issues raised by the epidemic that echo the demand of respecting women’s rights to reproduce and include the duty of all governments to provide adequate information, respect the right to choose, and provide access to comprehensive reproductive health care, social support to women and children affected by zika 20. paho specified that the governmental allowances to these women should include allowing each woman to know how to assess whether she wants to continue the pregnancy and whether she is willing to bear a child with the risk of this syndrome, or whether she cannot submit to it, rather than being authoritative to sacrifice the reproductive choices21. even though the paho guidance mentions about respecting the rights of the women, the drastic injunctions and governance principles have provoked some groups of women to comply with the governmental system and response to zika virus disease at the midst of the emergency period. consequently, the sudden reactions and preparedness have compromised these women’s life circumstances, and have shaken their abilities and confidences to continue the reproductive choices further in their lives. bangladesh journal of bioethics 2017; 8(2): 11-18 14 with the severity of the zika, in some places of brazil and other countries, the government had put injunctions to pregnant women to abort the unborn child. with such injunction, the fear of unsafe abortions unleashed in the zika affected regions and unfolded different facts about unsafe abortion and its illconsequences on the health of the women. for instance, according to a 2015 guttmacher institute brief, as many as 67% of poor women in guatemala and mexico, as compared to 38% of well-off women, who have an abortion, experienced health complications leading to the requirement of the medical treatments afterwards22. françoise girard, president of the international women's health coalition, in the context of injunctions of zika related abortions, raised the point that rather than implementing the authoritative injunctions to zika related abortions in brazil and other latin american countries, government could have focused on the fact of improving women’s health and human development by ensuring their reproductive rights, providing affordable reproductive health services (including contraception and safe abortions) and making comprehensive sexual education available to both girls and boys. as he emphasized, there is a need to assure reproductive rights in so-called normal times because next crisis cannot be predicted in advance23. the focus on improving the system and infrastructure for ensuring reproductive rights of women during normal times is reasonable. for, as some researchers pointed, failure of states to implement unrestricted abortion laws violates international human rights treaties, national constitutions protecting the right to health, privacy, human dignity, family planning, gender equality, lives free from discrimination, violence, physical and mental integrity, and free from torture, cruel, inhuman, or degrading treatment or punishment24. this paper supports mr. girard’s and others’ views on focusing on the improvement of the infrastructure of abortion and reproductive health during normal times. for, the paper claims that making ad hoc injunctions of abortions during emergency times, without securing the abortion measures in the concerned society, result in compelling the affected women to compromise their human health securities during the zika virus disease like public health emergencies. with the gaining momentum of zika virus disease, gradually it became noticeable that poor pregnant women being exposed to the zika virus were further discovering themselves to be impoverished with the potential burden of born or unborn zika affected child. for, being a mother of a neurologically disabled child meant they could not work. many pregnant mothers, therefore, conformed to the existing abortion infrastructure. for, they could not bear the fear, anxiety, and stress of having the responsibility of a baby with special needs, as this would place a huge burden on her poor family25. zika affected children, on one hand, while have their unfair burden of disabled childhood, the women, on the other hand, faced the unfair burden of life circumstances, uncertainty to achieve the lives they want to value. these foreseen and unforeseen impacts of zika virus disease on babies, unborn children, and on women, especially in brazil, have triggered different ethics consultation and have prompted outlining ethical recommendations. however, the recommendations have either focused on the reproductive health of women or on the ethics of zika as a public health emergency, overlooking the need to focus on the health, both physical and mental, of the deprived women. bangladesh journal of bioethics 2017; 8(2): 11-18 15 the ethical challenges and guidance for zika: the proliferation of cases of congenital neurological complications of children in brazil raised the challenge to ensure women’s reproductive rights, including the rights to be pregnant and the right to interrupt the pregnancy. therefore, paho came up with zika ethics guidance highlighting the moral duty to give women of childbearing age up-to-date information, the capacity to choose between all relevant reproductive options, access to comprehensive reproductive health care, and social support. supporting this view and categorizing the zika affected women as the first generation and second generation affected persons, some researcher such as diniz argue for strengthened social protection and policies for women and families with affected children, including immediate cash transfer benefits. she emphasized that women, being the main victims of this epidemic, need good science and good social policies to ensure their abilities, basic health needs, and rights as women26. for, women are more than a mother; her health comprises more than her reproductive health; she is a human, a person by herself who has a life of her own27. with the rising cases of zika virus disease, an international panel on zika consultation analysed the gaps in the countries’ health system and recommended increasing public health actions to reduce the risk of the effects of zika virus infection in pregnancy, provide appropriate care and support (for women who have been exposed); reduce exposure to zika virus infection for all people; provide appropriate clinical care and rehabilitation and continuing care for all those with long-term neurological conditions such as acute clinical services and rehabilitation; enhanced surveillance and research into diagnostics, vaccines, treatments and vector control28. in addition to the focus on these infrastructural developments, nuffield council proposes some general and specific ethical considerations. it focuses on ethics of data sharing, public engagement, and communication, mosquito control techniques, and maintaining a proportionate response. in short, this recent public health emergency of zika virus prompted international agencies to delve into and discuss some old challenges for governments in controlling vectors, and dealing with issues of reliability, accessibility, diagnosis, vaccine production, and intensification of basic sanitation policies. however, these consultations overlooked the fact to reflect on why zika like public health emergencies unleashed the old ethical issues of public health emergency preparedness and what have triggered the new issues to arise? thinking along this line of thought, saenz points out that ‘discussion should continue on the reasons why the lessons that could have been learned are still posing challenges, and how to ensure that the same situation does not occur in a future outbreak.’ and she suggests it is where there is a need of reinvigoration of the commitment to integrate ethics in health care29. ethics in healthcare could be inculcated during the emergency on an ad hoc basis and even before and post-disaster phases, that is, during the normal times. ethical actions implemented on an ad hoc basis might not be as sustainable as the ethical actions implemented and practiced during normal times and even carried over to the emergency situations. and to be sustainable, a health-care system needs a vision, precisely a vision of health. an underlying vision of health would not only help in the sustainable ethical actions during the emergency period but could also help to perform fairly, in an open and transparent manner during the normal times. bangladesh journal of bioethics 2017; 8(2): 11-18 16 to point about the vision of healthcare, luna points out that the definition of health by the world health organization, which includes mental health, is also to be remembered during zika like public health emergencies30. however, given, the context of zika like public health emergencies, this paper argues that zika like public health emergencies need to consider about the women as affected agencies, their abilities and confidence to cope with these kind of situations, their enabling environment to ensure them of their health needs, and not the least, their underlying health performances which push them to be better-off and worst-off during the zika like situations. and to consider these, the paper finds that health as capability could be the appropriate vision of health31. under the paradigm of health capability, health is mainly considered as person’s ability to be healthy and has a special moral importance for it signifies more than the simple physiological health. jpruger defines it as, “… the ability of the individuals to achieve certain health functionings as well as the freedom to achieve those functionings” (2010:81)32. for, health when considered as a capability, would consider holistic and comprehensive health of the individuals, would consider the underlying factors of health affecting women, would consider women as health agencies, would compare and check their health performances, both physical and mental during the emergency and normal times, and would also consider the health capabilities of individuals and groups to cope with the circumstances, thereby, making an attempt to address the health inequities. health, when considered as a capability, would focus on the capability of the individuals and groupstheir abilities to cope with the environments; their abilities and confidences to navigate the situations to look for the optimum health, their health values that they want to achieve. however, this also implies a shared governance to enable and ensure the environment to the individuals and groups to navigate through. focusing on the health capabilities, during normal and zika like emergency situations and by acting on the ground of such vision, would also enable the national healthcare system to aim to contribute to global health equity but to address the local health inequities. in the present case, zika affected countries, grounding on the health capability paradigm, could simultaneously address the inequities at the local level and can move forward to contribute to global health equity. and during the public health emergency situations, grounding on the health capability paradigm, the healthcare systems of the affected countries could ensure its citizens, in this case the women, the highest available treatment and diagnostic regimes at the local levels; could assess their capability to meet the demands, their shortfall, and can attempt to contribute to sustainable healthcare systems. conclusion: this paper mainly argues that zika virus infection has its ethical implications to the health of women in general. explaining certain seen and unforeseen impacts of zika virus disease, especially in brazil, the paper has analyzed the ethical situations and has attempted to point why there is a need of the ethical vision of health during zika like public health emergency situations. highlighting the lapses in the current zika ethics consultations and recommendations, the paper claims that zika like public health emergencies needs to focus on the ethical vision of health capability to act and promote sustainable healthcare during emergency times and normal period. finally, highlighting the fact that during zika like public health emergencies, healthcare systems should focus on the health capabilities of women, the paper concludes with the recommendation that the national healthcare systems should be bangladesh journal of bioethics 2017; 8(2): 11-18 17 adequately capable to add infrastructures to be sustainable and to contribute to global health equity. acknowledgement: the authors are grateful to the editorial team of the bangladesh journal of bioethics and acknowledge their hard work behind the successful publication of the articles in the journal. author declaration: rhyddhi chakraborty conceived the idea, conducted literature review, and developed the manuscript. edmond fernandes had drafted the first version of the manuscript. conflict of interests: none. references 1. world health organization (who). who statement on the first meeting of the international health regulations (2005) (ihr 2005) emergency committee on zika virus and observed increase in neurological disorders and neonatal malformations. 1 february 2016. http://www.who.int/mediacentre/news/statements/2016/1st-emergency-committeezika/en/. last accessed 19 april 2017. 2. nuffield council on bioethics. briefing note. zika: ethical considerations.9 february 2016. 3. pan american health organization (paho). zika ethics consultation: ethics guidance on key issues raised by the outbreak. 6-7 april 2016. washington d.c. 4. united nations development programme (undp). a socio-economic impact assessment of the zika virus in latin america and the caribbean: with a focus on brazil, colombia, and suriname.2017. 5. world health organization (who). zika virus.2017. http://www.who.int/mediacentre/factsheets/zika/en/. last accessed 14 april 2017. 6. world health organization (who). the history of zika virus. 2017. http://www.who.int/emergencies/zika-virus/history/en/. last accessed 19 april 2017. 7. world health organization (who). zika virus microcephaly and guillan-barre syndrome. 2016. http://apps.who.int/iris/bitstream/10665/205505/1/zikasitrep_21apr2016_eng.pdf. last accessed 14 april 2017. 8. world health organization (who). microcephaly, media centre.2016. http://www.who.int/mediacentre/factsheets/microcephaly/en/. last accessed 14 april 2017. 9. world health organization (who). the history of zika virus.2016. http://www.who.int/emergencies/zika-virus/history/en/. last accessed 14 april 2017. 10. ibid. 11. world health organization (who). who statement on the first meeting of the international health regulations (2005) (ihr 2005) emergency committee on zika virus and observed increase in neurological disorders and neonatal malformations. 1 february 2016. http://www.who.int/mediacentre/news/statements/2016/1st-emergency-committeezika/en/. last accessed 19 april 2017. 12. centre for disease control and prevention (cdc). transmission and risks.2017. https://www.cdc.gov/zika/transmission/index.html. last accessed 12 april 2017. bangladesh journal of bioethics 2017; 8(2): 11-18 18 13. lawrence og and james gh jr. zika virus and global health security georgetown law faculty publications and other works. 2016: 1802. http://scholarship.law.georgetown.edu/facpub/1802. 14. jacqueline p. women’s reproductive rights and the zika virus epidemic. thematic issue: zika and pregnancy. cad. saúde pública, rio de janeiro 2016;32 (5): e00066016, http://dx.doi.org/10.1590/0102-311x00066016. last accessed 10 april 2017. 15. karla z. 2016. the zika virus disproportionately affects the poor and this is why mosquitos thrive in just the kind of environment that's home to the region's poor.2016. https://www.buzzfeed.com/karlazabludovsky/the-zika-virus-disproportionately-affectsthe-poor-and this?utm_term=.asgammvam#.ngvqbq4qq. last accessed 10 april 2017. 16. alicia ey. n.d. health, human rights, and the zika virus, to fight zika we must fight poverty and powerlessness and ensure that women enjoy their rights. https://fxb.harvard.edu/4941-2/. last accessed 14april 2017. 17. sarah b. zika emergency pushes women to challenge brazil's abortion law. 19 july 2016. the guardian. 18. martha k. why are some countries advising against pregnancy as the zika virus spreads? rh reality check. 1 february 2017. http://rhrealitycheck.org/article/2016/02/01/countries-advising-pregnancy-zika-virusspreads/. last accessed 19 april 2017. 19. office of the high commissioner (ohchr), united nations. upholding women’s human rights essential to zika response zeid. 2017. http://www.ohchr.org/en/newsevents/pages/displaynews.aspx?newsid=17014. last accessed 19 april 2017. 20. the lancet global health. the right(s) approach to zika. 2016; 4: e427. 21. luna f. thematic section: zika and pregnancy. comment on the paper pitanguy. cad. saúde pública.2016; 32(5). 22. karla z. the zika virus disproportionately affects the poor and this is why mosquitos thrive in just the kind of environment that's home to the region's poor.2016. https://www.buzzfeed.com/karlazabludovsky/the-zika-virus-disproportionately-affectsthe-poor-and this?utm_term=.asgammvam#.ngvqbq4qq. last accessed 10 april 2017. 23. peggy m. zika to hit poor women hardest. ucla african studies centre. 2016. http://www.international.ucla.edu/africa/article/164174. last accessed 12 april 2017. 24. marianna l. the outbreak of the zika virus and reproductive rights in latin america. feb 24, 2016. http://www.e-ir.info/2016/02/24/the-outbreak-of-the-zika-virus-andreproductive-rights-in-latin-america/. last accessed 11 april 2017. 25. peggy m. zika to hit poor women hardest. ucla african studies centre. 2016. http://www.international.ucla.edu/africa/article/164174. last accessed 12 april 2017. 26. debora d. zika virus, women, and ethics. developing world bioethics 2016; 16 (2): 62– 63. 27. unfpa. poverty, inequality at the heart of the zika outbreak. 21 july 2016. http://www.unfpa.org/news/poverty-inequality-heart-zika-outbreak. last accessed 14 april 2017. 28. world health organization. zika causality statement, emergencies. 2016. http://www.who.int/emergencies/zika-virus/causality/en/. last accessed on 18 april 2017. 29. carla s. zika virus: ethics preparedness for old and new challenges. the lancet global health. 4; e686. 30. luna f. thematic section: zika and pregnancy. comment on the paper pitanguy. cad. saúde pública.2016; 32(5). 31. jennifer pr. health and social justice. oxford; 2010. 32. ibid, 81. microsoft word clinical pharmacy practice in nigeria roland okoro-revised(1) bangladesh journal of bioethics 2018; 10 (1): 1-5 1 ethics education for contemporary clinical pharmacy practice in nigeria: shortfalls and needs roland n. okoro department of clinical pharmacy and pharmacy administration, faculty of pharmacy, university of maiduguri, nigeria, email: orolandn@gmail.com abstract: the past decade has witnessed a shift in the ambitions of pharmacists away from the core role of dispensing medicines towards more interesting and rewarding relationships and responsibilities with other healthcare providers and patients. the patient-centred role of pharmacists has allowed ethical issues experienced in medical practice to surface in pharmacy practice, resulting in an increase in the number and variety of ethical dilemmas that pharmacists face in their routine pharmacy practice. pharmacy education prepares pharmacy students for practice and must be in tune with the professional dynamics. many countries that provide patient-centered pharmacy services have redesigned pharmacy ethics education while others are in various stages of revision of their curriculum in order to adequately equip future pharmacists with the rudiments required to handle ethical issues in clinical pharmacy practice. in contrast, in nigeria, little or no pharmacy ethics is taught to pharmacy students and the challenge lies with the curriculum design and method of teaching. key words: curriculum, ethics education, nigeria, clinical pharmacy, patient-centred introduction: pharmacy as a profession has undergone several dramatic changes over recent years. pharmaceutical care has allowed the ethical issues experienced in medical practice to surface in pharmacy practice1. these ethical issues include decisions on choices related to drug therapies, uses of drugs for unapproved indications, patient confidentiality, financial relationships with the drug industry, allocation of scarce resources, pain management, death and dying, and so on2,3. ethical issues significantly impacts on patients’ quality of life; therefore, pharmacists are obliged to utilize ethical principles (autonomy, beneficence, justice, non-maleficence), theories (such as utilitarianism, deontology) and/or codes of ethics when necessary. disappointedly, many pharmacists are unable to detect, discuss and resolve value and ethical issues in pharmacy practice. moreover, the increasing collaborative and patient-centred roles of contemporary pharmacists have heightened the need for effective pharmacy ethics education. hence, pharmacy education curriculum should be adequate to prepare future pharmacists for clinical practice and to teach them skills needed to address ethical challenges that may arise in real-world pharmacy practice4. current situation of pharmacy ethics education in nigeria: the nigerian university commission (nuc) which is the bangladesh journal of bioethics 2018; 10 (1): 1-5 2 apex regulatory authority of education in nigeria has described pharmacy ethics in a 2-credit hour forensic pharmacy and pharmacy ethics single course in the just newly approved doctor of pharmacy (pharmd) programme5. however, the university of benin pharmd curriculum described pharmacy ethics as a component of a 2-credit unit pharmacy law and ethics single course with same contents as approved by the nuc (table 1)6. ascertaining what is currently covered in this course will paint a picture of what is being taught and will help to identify needs. table 1 reveals ethics of pharmacy profession in nigeria, and ethics and good business practice as the only ethics topics covered in the pharmd programme shortfalls of the nigerian pharmacy ethics syllabus: the curriculum content and method of teaching affect knowledge, critical thinking and learning skills. to the best of the knowledge of the author, there is still no formal pharmacy ethics syllabus being seriously implemented in nigerian pharmacy schools for both pharmd and bachelor of pharmacy (b. pharm.) programmes. though pharmacy ethics exists as a component of forensic pharmacy and pharmacy ethics course in the curriculum, ethics syllabus is very weak, shallow, not well developed, and grossly inadequate for the present-day clinical pharmacy practice. pharmacy law and ethics single course has traditionally been taught didactically as if it were solely consist of a set of specific rules to be learned and obeyed. additionally, the combination of pharmacy law and pharmacy ethics as a single course has given room for these deficiencies, and pharmacy law predominance. in order to reemphasize the professional code of ethics, the pharmacists council of nigeria (pcn) during pre-induction programmes deems it necessary to give preinduction orientation talk on the code of ethics for pharmacists to about to be inducted pharmacists. though, knowledge of the code of ethics alone cannot necessarily translate to a commensurate level of ethics knowledge7. the implications of the lack of ethics education for clinical pharmacy practice are critical since the absence of internal control provokes external control. in addition, the improvement in pharmacy education in the area of research ethics will go a long way to improve the scope of ethics in clinical pharmacy research. graduates or even post graduate students as in the case in other climes who find themselves in various ethics review boards will be adequately trained for this role. reinventing nigerian pharmacy ethics education for future pharmacists: according to the guideline of the accreditation council for pharmacy education (acpe), “teaching professional behaviour, principles and ethical issues related to the prescription, use of drugs, delivering patient-centred care, performing clinical research, team work, dealing with ethical dilemmas, and conflict of interest among others are essential to the development of pharmacists” 8. these issues are not covered in the current nigerian pharmacy ethics syllabus. current global best clinical pharmacy practice attaches great importance to the practice ethics, and students need to be educated on various aspects of pharmacy practice ethics. therefore, some schools and colleges of pharmacy in other climes have developed enriched standalone ethics course with mixed methods of teaching such as didactic lectures, case studies, class discussions/debates, team-based learning and presentations among others in their curricula. this innovative strategy is to vouch for a minimum level of pharmacy bangladesh journal of bioethics 2018; 10 (1): 1-5 3 table 1: nuc approved forensic pharmacy and pharmacy ethics syllabus for pharmd programme course descriptions (2 credit unit)  history of pharmacy in nigeria  ethics of pharmacy profession in nigeria  ethics and good business practice  laws related to the national agency for food and drug administration and control (nafdac), national drug law enforcement agency (ndlea), standard organization of nigeria (son), pharmacists council of nigeria (pcn), who/fao codex allimentarium commission, united nations narcotic commission, federal environmental protection agency (fepa), etc;  food, drug and cosmetics laws including regulation, inspection, registration, advertising, manufacture, and sale/distribution.  poison, dangerous drugs and pharmacy acts; essential drugs list (edl); fake and counterfeit drug laws; consumer protection council law  policy and legal framework – legal procedure; information service; intellectual property rights and patenting of inventions; risk and insurance; legal aspects of employment; taxation  all other relevant laws related to the practice of pharmacy including those of the pharmacists disciplinary committee and assessors rules, pharmacists registration rules, dispensing of drugs, patent and proprietary medicines, etc.  legislation on animal health products.  national health insurance scheme (nhis) and other health policies, and national drug policy. table 2: pharmacy ethics syllabus of the college of pharmacy, university of texas, us for the pharmd programme course description ethics and values in pharmacy  introduction to ethics, values, and moral reasoning  models for ethical problem solving  model for ethical problem solving  values in health and illness  sources of moral judgments  conceptual framework review – elements, principles, and processes  models for ethical problem solving  team case presentations  the “georgetown mantra” – ethical principles  interprofessional case discussion panel ethical principles in pharmacy ethics  topic clarification: beneficience, non-maleficience, autonomy, and justice  team case presentations  principle application cases: sources of moral judgments – role of professional codes  team case presentations  interprofessional case discussion panel  professional duties of practitioners – applying principles to patient situations  team case presentations honesty, truth telling, and avoidance of killing  dealing honestly with patients  ethical issues in pain management  interprofessional case discussion panel sensitive patient scenarios – application of ethical principles and decision-making models  abortion, sterilization, and contraception  mental health issues  right of refusal  research ethics  principle application cases: avoidance of killing  principle application cases: application of ethical principles in sensitive patient situations  right of refusal and patient autonomy  team case presentations bangladesh journal of bioethics 2018; 10 (1): 1-5 4 ethics knowledge, competencies, skills and, even the character of their graduates. hence, the overall goals of the pharmacy ethics education are to endow students with a set of cognitive and behavioural skills for ethical reasoning that will allow them to recognize ethical dilemmas in pharmacy practiceand research, and equip them to make appropriate, justifiable socio-culturally sensitive decisions to those dilemmas. against this background, this paper proposes a curricular modification with respect to pharmacy ethics to reflect the current reality of global best patient-centred pharmacy practice in nigeria. syllabus content, teaching and assessment methods should be reconsidered and developed to foster deeplevel learning, and achievement of the objectives of this course. in view of this, a model pharmacy ethics syllabus can be adapted from that of the college of pharmacy at university of texas (table 2). unlike the current nigerian model, the proposed model is more patient-centred because it explores ethical issues pharmacists face as a member of the healthcare team and provide a framework for addressing ethical dilemmas. this is so because the proposed model will help students to identify the importance of morality and ethics in healthcare and their role in the provision of pharmacist-directed patient care. it will demonstrate competency in the application of bioethical principles to patients’ situations. also, it will equip students with skills required to apply appropriate decision-making strategies in providing care for patients. lastly, it has the potential to build interprofessional collaborative practice in developing effective interpersonal communication skills required of a pharmacist and reap the benefits of discussing ethical dilemmas with other healthcare team members. conclusion : today, pharmacy ethics contents of the nigerian pharmacy education curriculum of is grossly inadequate and the teaching method too didactic to adequately prepare future pharmacists for the more challenging patient-centred roles with practice environment full of ethical dilemmas. curriculum design and methods of teaching are critical to renewal and progress in any profession. therefore, there is an urgent need to develop an enriched standalone pharmacy ethics course that will include all relevant ethical issues encountered in routine clinical pharmacy practice in nigeria. finally, varieties of teaching methods such as classroom discussions/debates, case studies, and teambased learning approaches should be adopted for effective delivery of this course to the students. references: 1. tekiner h. why teach pharmacy ethics through literary fiction? world j pharm sci. 2017; 5(6):203-206. 2. buerki ra, vottero ld. ethical responsibility in pharmacy practice. 2nd ed. madison: american institute of the history of pharmacy. 2002. 3. wingfield j, bissell p, anderson c. the scope of pharmacy ethics: ann evaluation of the international research literature, 1990–2002. soc sci med. 2004; 58(12):2383-2396. 4. hasan s. teaching ethics to pharmacy students using a team-based learning approach. pharmacy education. 2011; 11(1):99-106. 5. benchmark minimum academic standards for undergraduate programmes in nigerian universities, pharmaceutical sciences. nigerian university commission. 2018. 6. undergraduate and postgraduate programmes prospectus 2000/2001 academic session, faculty of pharmacy, university of benin, benin city, edo state, seevon prints, nigeria, 2001 pp. 49-50. bangladesh journal of bioethics 2018; 10 (1): 1-5 5 7. fadare jo, desalu oo, jemilohun ac, babatunde oa. knowledge of medical ethics among nigerian medical doctors. niger med j. 2012; 53(4):226-230. 8. accreditation council for pharmacy education. accreditation (acpe) standards 2016 accreditation council for pharmacy education. available from: https://www.acpeaccredit.org/pdf/standards2016final.pdf. accessed july 11, 2018. author contribution: author conceive the idea, done literature review and wrote the manuscript and check the manuscript meticulously. conflict of interest: the author declares no conflict of interest. microsoft word y ndasauka & g m kayange existence and needs bangladesh journal of bioethics 2016; 7(3): 23-33 23 original article existence and needs: a case for the equal moral considerability of nonhuman animals yamikani ndasauka1 and grivas m. kayange2 1. department of philosophy, university of malawi, malawi, email: yndasauka@cc.ac.mw 2. chancellor college, university of malawi, malawi, email: gkayange@cc.ac.mw abstract: this paper reflects on the question, “is there a sound justification for the existential view that humans have a higher moral status than other animals?” it argues that the existential view that humans have a higher moral status than animals is founded on a weak and inconclusive foundation. while acknowledging various arguments raised for a common foundation between human and non-human animals, the paper attempts to establish a common ground for moral considerability of human and non-human animals. the first common foundation is based on the existential notion of being in the world, which is common for both human and non-human animals. the second idea is based on the common desire to actualize different needs. the paper demonstrates these common foundations by referring to heidegger and abraham maslow’s hierarchy of needs. keywords: animal rights, existentialism, needs, bioethics, moral consideration introduction: since the onset of human civilization, humans have viewed non-human animals as inferior on the hierarchy of being and have hence treated non-human animals as instruments for promoting the welfare of humans. it is only in the past century that this position has received serious critical attention and has been challenged by an increasing number of scholars. from the distant past, and still dominant currently, scholars such as aristotle, aquinas, descartes, and kant have held the view that only humans have moral standing and moral agency and hence are the only species worth moral consideration. for instance, immanuel kant, considered one of the greatest thinkers in philosophy, in his discourse on whether animals have a moral status to foster the possibility of animal rights, believed that animals have no moral status and rights. for kant, in a section titled of duties towards animals and spirit, the only way to consider animals for morality is through indirect duty – duty directed at other humans only through moral treatment of animals1. the whole of this debate emanates from the idea that human and non-human animals are essentially different. numerous views have been provided to underscore the weakness of this view2. this paper seeks to add to this debate by attempting to find the common themes that run through the human and non-human worlds. specifically, this paper advances two arguments, an argument from existentialism and an argument based on the hierarchy of needs to demonstrate how both human and non-human animals participate and seek to fulfill certain aspirations as their definitive elements. to achieve this, the paper has three sections. in the first section, the paper expounds on the common view that regards humans as having higher bangladesh journal of bioethics 2016; 7(3): 23-33 24 moral status than non-human animals. the paper then draws arguments that have been previously advanced against this view to show that this common view is unfounded and lacks merit in a number of considerations. then finally, the paper presents its main arguments, drawing evidence from science and philosophy to show that in fact human and non-human animals have a lot in common and that they all are worth moral consideration. existentialist justification of humans’ higher moral status: the existentialist argument justifying the supposed higher moral status of humans may be traced in both the greek and judeo-christian (traditional) understanding of existence and in modern existentialism, which reached its climax in the 19th and 20th centuries. determination of higher moral status between non-human and human animals was founded on the exposition of the link between essence and existence. essence referred to “what it is” (it is the definition of a thing) and existence meant “that it is” (to be). the difference between the traditional approach and the modern existentialist approach lies in the explication of existence. in traditional perspective, explication of existence departs from the objective consideration of essence, which is regarded as the primary element that determines everything that can be said about existence. it is the essence of a thing that determines its status and role in the world. in modern existentialism, explication of existence builds on a subjective view, where existence is given preference as coming before the essence of a thing3 4 5. this link is explained depending on either an atheist version of existentialism, which excludes god in existence (jean-paul sartre and simone de beauvoir)6 or on one that accommodates god (karl jaspers and gabriel marcel). in the paragraphs that follow, we discuss arguments that support the higher moral status of humans in the greek and judeo-christian tradition and modern existentialist versions. the first argument used to justify that humans have a high moral status than other animals is based on the famous aristotelian claim that the essence/definition of a human being is “a rational animal”7 8. rationality (form) is therefore a defining element responding to “what it is”. in his ontological hierarchy of the soul, aristotle classifies the soul into three forms, namely, vegetative soul, appetitive soul, and rational soul. vegetative soul describes the nutritional needs of all living beings. this is the basic category of the soul and there are some living things such as plants that only belong to this category. appetitive soul is responsible for emotions and feelings. this category consists of all animals including humans. the rational soul is the highest category that includes all human beings. a human being is hence regarded highly due to the claim that he or she has nutritional, appetitive as well as rational aspects9 10. in addition to the context of existence, the superiority of humans is extended to morality. by having and operating with reason, moral discourse is possible only among human beings. for example, descartes who developed further the centrality of rationality (of course he didn’t want to consider rationality as given, but wanted a scientific foundation for understanding everything), stressed that every possible form of knowledge is founded on reason, which accords humans the ability to act or engage in moral discourse and not other animals who lack reason11. according to descartes, there are two kinds of entities: physical entities and bangladesh journal of bioethics 2016; 7(3): 23-33 25 mental entities. although things in the natural world are closely associated with physical bodies, it is only humans that are not identical with their bodies. rather, they are identical with their souls, or the immaterial, mental substance that constitutes their consciousness. descartes believed that human beings have two characteristics that accord them moral worth, namely, the complexity of their behaviour/actions and speech. speech (language) is mentioned because it is associated with rationality (thought is expressed through language). however, animal behaviour does not require this kind of assumption; besides, descartes argued, “it is more probable that worms and flies and caterpillars move mechanically than that they all have immortal souls”12. the second argument justifying the higher moral status of humans is that the essence of a human being is characterised by his or her status of being an image of god. this comes from the biblical understanding that god created humans just like other living and non-living things but what defines them is the status of being images of god. in genesis 1:26-30, the essence of a human being precedes his or her existence and his or her superiority gets its supporting arguments. in verse 26, the bible indicates: “then god said, ‘let us make mankind in our image, after our likeness, so they may rule over the fish of the sea and the birds of the air, over the cattle, and over all the earth, and over all the creatures that move on the earth’”. the creation of an individual human being is therefore seen as a situation (existence) that instantiates the image of god. thomas aquinas commented further on this in the following passage: i answer that, since man is said to be the image of god by virtue of his intellectual nature, he is the most perfectly like god according to that in which he can best imitate god in his intellectual nature. now the intellectual nature imitates god chiefly in this, that god understands and loves himself. wherefore we see that the image of god is in man in three ways. first, in as much as man possesses a natural aptitude for understanding and loving god; and this aptitude consists in the very nature of the mind, which is common to all men. secondly, inasmuch as man actually and habitually knows and loves god, though imperfectly; and this image consists in the conformity of grace. thirdly, in as much as man knows and loves god perfectly; and this image consists in the likeness of glory13. from verse 28-30, humans are given authority to rule over all the other creatures (including animals). the superiority of man flowing from this essence (image of god) is twofold. first, humans are superior because they are created in the image of god and no other animal instantiates this essence. this image is explained in aquinas with reference to the intellectual nature of a human being. intellect/reason is the nature of god given that god is in some respects defined as logos which refers either to reason or word. god is regarded as perfect reason and has different attributes in the judeo-christian perspective such as omniscience/being all-knowing. by possessing reason, humans are also expected to have attributes similar to god’s. second, superiority entails authority that man was given over all other animals. bangladesh journal of bioethics 2016; 7(3): 23-33 26 furthermore, the dignity of human beings is explained as following from the dignity of the creator. god created all human beings out of his love, and they have unalienable dignity. morality in this context is instructed by god who gave a code of conduct in line with his goodness and demanded that all human beings follow/practice it for their own good. moral consideration is therefore seen as following from god. the third argument justifying the higher moral status of humans may be traced in existentialism with respect to existence and essence. while the traditional conception of existence and essence reflected on rationality and the image of god as given in the understanding of humanity, existentialists of the 19th and 20th centuries argued against this position and departed from the consideration of the meaning of being (heidegger; sartre). essence in existentialism is an outcome of the subjective experience of an individual in the world (essence comes from “to be”). according to sartre, “thrown into an open-ended existence, our essence — who we really are — will be the sum total of all our actions and responses to the circumstances in which we find ourselves”14. essence is therefore what an individual human subject lives (experiences) in a particular environment. this fundamental doctrine of the existentialists is summarised in sartre’s expression that “existence precedes essence”. commenting on this expression, sartre wrote: what do we mean by saying that existence precedes essence? we mean that man first of all exists, encounters himself, surges up in the world – and defines himself afterwards. if man as the existentialist sees him is not definable, it is because to begin with he is nothing. he will not be anything until later, and then he will be what he makes of himself15. the existentialists argue that what makes humans different from other animals or things, is their capacity not only to be but also the ability to subjectively reflect on their own and other properties (conscious beings). humans possess the potential of giving meaning to things and themselves as they are thrown in the world. for example, a human being and a dog can sit on a stone, but the difference is that a dog will not have a subjective experience of reflecting on this stone and produce meaning but a human being can. for this reason, sartre argued that other entities such as animals exist in themselves (etre en soi) and this is what they are (essence), but human beings go beyond this. the potential to go beyond this aspect resides in the fact that human reality exists in itself and for itself (etre pour soi). the existence in itself will make humans similar to all other animals but for itself requires the active experience of self-consciousness as being in the world. the difference between human beings and other objects may be further clarified based on the understanding of the existentialist argument that there are different modes of being. heidegger discussed the difference between the existence of humans and other modes such as zuhanden and vorhanden. zuhanden refers to ready-to-hand meaning that something is available. these are instruments that are defined by a society and whose properties are determined by their usage in a particular society. these apparently get their essence not on their own but are given by the community/society where they are utilised. vorhanden refers bangladesh journal of bioethics 2016; 7(3): 23-33 27 to objects of perceptual experience following from norms that govern perceptual givenness of an object. these apparently have their essence as determined by human scientific elaboration. the zuhanden and vorhanden can be true for all things, animals and human subjects but the speciality of humans consists in their subjective capacity to articulate meaning of these modes of being. for instance, humans have the subjective capacity to coordinate various properties in their actions/experience such as the colour of their physical appearances, the system of their beliefs and their belonging to a certain race. they go beyond (transcend) mere instantiation of properties in their lives as they willingly and consciously provide further interpretation and meaning. against the existentialist justification of humans’ higher moral status: does rationality, the image of god, and humans’ subjective existence (reality to exist for itself/etre pour soi, self-meaning and choosing what one wants to be in the world) justify that humans have a higher moral standing than non-humans? in the following paragraphs, we argue against the existential justification of humans’ supposed higher moral status. firstly, the existentialist emphasis on human higher moral status due to their claimed unique potential for being rational, conscious beings capable of providing meaning to their own actions and being, fails to take into consideration the distinction between moral agency and moral standing. the rational element of human beings accords them moral agency, however, this does not necessarily exclude animals as beings with moral standing16. whilst moral agency pertains to the ability to make sound moral judgments, moral consideration pertains to ability to receive and react to moral treatment, consideration and participation in the moral community, which is not defined in terms of the intrinsic properties that beings have, but in terms of the important social relations that exist between beings17. with this understanding, non-human animals have, since time immemorial, been part of human social relations. more recently, studies have cemented this claim by positing that animals not only possess and develop social relations among themselves and even with humans, but they also have the capacity for “cumulative culture” – the ability to build up knowledge over generations. a study by the french national center for scientific research (cnrs) and the university of edinburgh found that, “like humans, baboons have the ability to transmit and accumulate changes over ‘cultural generations’ and that these incremental changes, which may differ depending on the chain, become structured and more efficient”18. furthermore, rationality is an obscure concept to the point that even when applied to humans it leads to the exclusion of some classes and individuals as irrational. for instance, great thinkers such as hume, immanuel kant, hegel, and ley bruhl have once fallen into the trap of categorising africans as irrational (lacking the rational soul). of course, modern existentialism managed to avoid this problem with the insistence of human essence following from human experience in the world. nevertheless, the same concept though not explicit is central in providing meaning. the third problem is that rationality, while defined as separating humans from other animals, is not definitive for existence. in aristotle, existence, while starting from the nutritive element, matures and becomes evident in appetites where it is directly connected with desire. this desire becomes an explanation of purposive bangladesh journal of bioethics 2016; 7(3): 23-33 28 behaviour19. secondly, the judeo-christian argument based on god’s creation falls short as a justification for humans’ higher moral status as compared with animals20. there are two related problems connected to this, namely, the epistemological and ontological problem of the existence of god. the ontological problem regards the possibility of developing a logical argument that proves the existence of god as a necessary being and creator of superior human beings and other animals. theologians and philosophers such as anselm of canterbury, thomas aquinas, and leibniz have in vain attempted to establish arguments supporting the existence of god. for example, the ontological argument of leibniz tried to establish the existence of god departing from the idea of a perfect being to the existence of such as being21. this argument failed because the existence of an idea of a perfect being does not necessarily imply existence. similarly the five proofs of god’s existence by thomas aquinas are well known to have failed to prove god’s existence. the related epistemological question regards the possibility of “certain knowledge” with regards to the existence of a being known as god. the problem has roots in the possibility of knowledge beyond sense experience. this problem of founding moral considerability on the existence of a being beyond this physical world was worsened further by the kantian epistemological response that it is impossible for human beings to know things beyond sense experience (noumena). it is only the intellectual categories that give humans the possibility of what can exist in the phenomenal world. although kant did not intend to remove god from the possibility of existence, a general tendency of atheists and other thinkers has been that of ignoring the discourse on god. the problem of establishing convincing argument for the existence of god (ontology) and the provision of convincing evidence (epistemology) have led to three groups of thinkers. the first group is that of atheists who have completely eliminated the existence of god in absence of knowledge. the second group has decided to still maintain the existence of god. the last group has decided to remain neutral and indicate that they cannot conclusively know whether god exists or does not exist (agnosticism). based on the existence of these three conflicting positions, basing the superiority of humans on the judeo-christian belief in the existence of god becomes problematic. due to lack of scientific evidence with respect to the knowledge and existence of god, it is reasonable to hold the view of humans’ higher moral status than other animals based on the argument of creation and god. thirdly, the existentialist attribution of a human being as different from non-humans because of its being for itself also fails in two ways. firstly, there is no convincing scientific evidence supporting the fact that only humans experience etre pour soi and that non-humans experience only etre in soi. in fact, animals cannot be reduced to only possessing a set of nutritive and appetitive elements given that humans cannot with certainty claim knowledge of the cognitive experience of animals just depending on experiments. cognition, which plays an important role in etre pour soi, requires a personal experience of being a cognitive animal. for instance, a human can only claim that he or she is a doubting things because of personal experience of doubting as it was in descartes. is it probable to claim that this experience does not occur in animals? are animals deprived of personal experience? existentialism even in its bangladesh journal of bioethics 2016; 7(3): 23-33 29 19thand 20th-century forms falls short because of a lack of adequate understanding of how non-humans become aware of their being in the world. there is no convincing argument to this effect apart from going back to the categorisation of human beings as rational animals, a point that can contradict the core of modern existentialism which is human meaning following from experience in the world. secondly, although the distinction between humans and animals as shown above is problematic, there is also a moral problem that leads us to a form of utilitarian/instrumentalist ethics. this follows from the idea that a human being creates his or her essence through actions and choices (the way of existing). human beings are conscious of objects, values, meaning, etc. as they construct their essence in the world. morality in this context becomes a creation of human beings to serve man’s needs. this is often the case in those existentialist philosophers who exclude god in their idea of existence and its finality (sartre; simone de beauvoir). equality of moral status between humans and animals: the question of the moral status of non-human animals and humans should be based on common moral consideration grounds instead of what is assumed to differentiate them. we hold that human and non-human animals share numerous attributes, more than the attributes they differ on. the shared attributes range from physical to psychological dispositions. to this end, we argue that there is an existential common ground for both human and non-human animals qualifying them as worth of equal moral consideration. there are two important aspects that demonstrate this common existential ground. the first idea springs from an ontological consideration of being in the world. both humans and animals find themselves in a state of being in the world. although heidegger in his existentialism focused more on human subjects who are conscious of being there/their being22, we are arguing that animals also find themselves in this world and they are conscious of their being in their own way. in spite of this, the ontological consideration is difficult to establish as a strong case given that it is hard for humans to understand how animals experience their being in the world. it is only recently that some studies have begun to establish some elements of rationality, which only humans were thought to have. this gives an interesting panorama for exploring the possibility of self-awareness of animals as being in the world similar to what happens in human beings. for instance, lori marino and christina colvin23 note that pigs are mentally and socially similar to dogs and chimpanzees. they write: “what is known suggests that pigs are cognitively complex and share many traits with animals whom we consider intelligent”24. another study found that lowly pigeons provide insight into how young children acquire and learn language. researchers studied pigeons’ ability to name and categorize different objects and found that, like children, pigeons engage in a type of associative learning to learn new words. in an interview with the huffington post, edward wasserman said: our main thesis is that associative learning may underlie the acquisition of complex behaviours, including human language […]. [i]f so, then our view of human language as altogether unique may need revision [...]. what we learn from studying a model animal like a pigeon may not only point to important interspecies parallels, bangladesh journal of bioethics 2016; 7(3): 23-33 30 but also help us find ways for more effectively teaching children language, especially children with language disorders25 26. these studies show numerous cognitive abilities that inform the common experience between human and non-human animals, which may indicate that animals may also be conscious of their being. the second idea comes from the understanding that both human and non-human animals have needs, which they live and seek to satisfy. abraham maslow proposes a hierarchy of needs consisting of basic needs, psychological needs, and self-fulfilment needs27. among the basic needs, there are physiological needs (food, water and shelter) and safety needs. among the psychological needs, there is the need to belong (make friendships and love) and the need for self-accomplishment. finally, under self-fulfilment, there is self-actualization and creativity. a closer look at these needs reveals the common search and desire both human and non-human animals have to fulfil and satisfy these needs. with regard to basic needs, both human and non-human animals require food and water for survival. non-human just like human bodies demand and require important nutrients for continued existence in this world. absence of these nutrients threatens the existence of all living beings. in addition, shelter is a fundamental need for many species, including humans, given that shelter shields their bodies and protects them from harsh weather conditions as well as adversaries. both human and non-human animals have developed an inclination to defend their lives and those of loved ones from outside attack. just as humans develop strategies for protecting life, non-human animals also have defence strategies against their enemies. a simple example is when a cow is being slaughtered; he or she will generally try to defend his or her life, although more often than not humans overpower the animal. further, researchers have observed scouting behaviour in bottlenose dolphins, in that an individual dolphin may investigate novel objects or unfamiliar territories and alert the whole group28. all this justifies that the basic needs of human and non-human animals are similar. with regard to psychological needs, recent studies have shown that different animals have a deep sense of compassion and care for their children and sometimes care for each other. for example, a study on dolphins has shown how they care for their young ones with a lot of affection. according to seaworld29, dolphins exhibit different social behaviours that mirror human social interaction. bottlenose dolphins aid ill or injured dolphins. they stand by and vocalize, or they physically support the animal at the surface so he or she can breathe. similarly, domesticated dogs and cats also show the need for care and friendship as they relate with their caregivers (humans) and among themselves. the desire for self-fulfilment is demonstrated in some animals that show high levels of creativity and cognitive functionality. for instance, most recently, researchers found that ravens demonstrate high cognitive functionality comparable with that of apes, which have for long been studied and found to possess cognitive functions comparable with those of humans. it is reported: “comparative data gives us insights about the building blocks of higher bangladesh journal of bioethics 2016; 7(3): 23-33 31 cognition as well as the relationship between various brain measures and the cognitive performance”30. further, these highly intelligent birds are also known for such evolved behaviours as using tools, forming social groups and recognizing faces31. these forms of creativity and high cognitive functions demonstrate the shared dispositions between human and non-human animals. the argument from needs ought to be understood within the existential argument for the equal moral consideration of non-human animals. as we have argued, rational and/or speech abilities in humans and non-human animals are existentially incomparable. although some scientific studies have been undertaken to measure and assess non-human animals’ ability of self-consciousness, rationality and speech, the studies are in infancy and some results inconclusive. conclusion: in this paper, we have argued that the rationale for the existential view that humans have a higher moral status than other animals is not adequate, and we have demonstrated the weakness of the claim and also the myriad problems that have resulted from holding and promoting such a view. we have proposed that, instead of striving to identify distinguishing elements between human and non-human animals, it is much better to focus on the elements that reveal striking similarities between the species. the similarities that we have advanced in this paper, the existential and needs theses are important and definitive elements of both human and non-human animals. with the advancement of science and research aimed at understanding the animal world, it is becoming apparent that human and non-human animals share a lot of attributes and some misconception of human superiority over non-human animals are being challenged and nullified. a worldview that considers human and non-human animals as having equal moral considerability is envisaged to bring about a better world; built on respect for life. author contribution: both authors contributed equally to the paper. conflict of interest: declared none. acknowledgements: none. references 1 kant i. lectures on ethics (the cambridge edition of the works on kant). peter lauchlan heath, jerome b. schneewind (eds). cambridge university press, cambridge; 1997. 2 keller r. d. environmental ethics: the big question. willey-blackwell, oxford; 2010. 3 sartre j.p. existence is existentialism. http://homepages.wmich.edu/~baldner/existentialism. 1946. retrieved on 16 october 2016. 4 ricoeur p. oneself as another. tr. kathleen blamey. university of chicago press, chicago; 1992. 5 http://homepages.wmich.edu/~baldner/existentialism.pdf. retrieved on 19 october 2016 bangladesh journal of bioethics 2016; 7(3): 23-33 32 6 beauvoir s. the second sex (1949). tr. h. m. parshley. vintage books, new york; 1989. 7 aristotle. nicomachean ethics. translated by irwin terrence and gail fine. hackett publishing company, cambridge, indianapolis; 1995, 1:13. 8 aristotle. de anima. translated by h. w. hymlyn. oxford university press; oxford. 2002, 3:11. 9 aristotle. 2002, 3:4 10gods have the rational soul but differ from the humans that they do not participate in the other forms. even among the humans, there are different levels of rationality. 11 descartes r. animals are machines. in armstrong s. j., & botzler, r. g., (eds.). environmental ethics: divergence and convergence (pp. 281-285). mcgraw hill co, new york; 1993 12 regan t. the case for animal rights. in peter singer (ed). in defense of animals. basil blackwell, new york; 1985: pp. 13-26. 13 aquinas t. summa theologica. translated by fathers of the english domenican province. http://www.microbookstudio.com/. 2006, question 93, article 4. retrieved on 3 october 2016 14 sartre j.p. being and nothingness. tr. hazel barnes. washington square press, new york; 1992, p.112 15 sartre j.p. 1946, p.13 16 morris c. the idea of moral standing. in tom l. beauchamp and r. g. frey (eds). the oxford handbook of animal ethics. 2011. doi: 10.1093/oxfordhb/9780195371963.013.0010 17 lori g. the moral status of animals. the stanford encyclopedia of philosophy fall 2014 edition, edward n. zalta (ed.). http://plato.stanford.edu/archives/fall2014/entries/moralanimal/. retrieved on 10 october 2016. 18 claidière, k. smith, s. kirby, j. fagot. cultural evolution of systematically structured behaviour in a non-human primates. proceedings of the royal society 2014. doi:10.1098/rspb.2014.1541. 19 aristotle. 2002, 3:11. 20 white l. the historical roots of our ecologic crisis. science 1967; 155 (3767): 1203-1207. 21 leibniz w. the monadology. lowe & brydone, london; (1898) 1965, p.274. 22 heidegger m. being and time. state university of new york press, new york; (1953) 1996. 23 marino l. and colvin c. thinking pigs: a comparative review of cognition, emotion, and personality in sus domesticus. international journal of comparative psychology 2014; 28. 24 marino l. and colvin c. thinking pigs: a comparative review of cognition, emotion, and personality in sus domesticus. international journal of comparative psychology 2014; 28. 25 gregoire c. little kids learn the same way pigeons do. the huffington post: 02/09/15. http://www.huffingtonpost.com/2015/02/09/pigeons-learning-children_n_6623562.html. retrieved on 12 october 2016 26 wasserman e. a. brooks d. i. and mcmurray b. pigeons acquire multiple categories in parallel via associative learning: a parallel to human word learning? cognition 2014; 136: 99–122. bangladesh journal of bioethics 2016; 7(3): 23-33 33 27 maslow a. h. a theory of human motivation. psychological review 1943; 50 (4): 370–96. doi:10.1037/h0054346. 28 seaworld. 2016. https://seaworld.org/en/animal-info/animal-infobooks/bottlenosedolphins/behavior. retrieved on 12 october 2016 29 seaworld. 2016. 30 howard j. these birds may rival chimps in their intelligence: when it comes to the brain, bigger isn’t always better. the huffington post, 4/27/16, http://www.huffingtonpost.com/entry/big-brain-cognitivefunction_us_5718f789e4b0479c59d7447e. retrieved on 12 october 2016 31 howard j. these birds may rival chimps in their intelligence: when it comes to the brain, bigger isn’t always better. the huffington post, 4/27/16, http://www.huffingtonpost.com/entry/big-brain-cognitivefunction_us_5718f789e4b0479c59d7447e. retrieved on 12 october 2016 microsoft word editorial environmental ethics_rc 1 bangladesh journal of bioethics 2020; 11 (2) editorial environmental ethics vol. 11 no. 2 cambridge online dictionary offers the meaning of the noun term “environment” as the air, water, and land in or on which humans, animals, and plants reside1. the environment can also be mixture of factors that influence both organic and inorganic ecosystems and their shared coexistence. this co-existence is the last idea that is given significance in the sophisticated and busy life styles of the modern day. in other words, in our own attitudes lies a large portion of causal conditions for outward environmental disruptions and imbalances. the challenges we face globally have their origin in local settings, the threats we face at the surface level of our location have their origins at 'deep level' in our very own way of living, in the very way of our behaviour towards others. with this absence of senses, species of human beings not only put themselves at risk, but also put other species of life in danger all over the world. it can be said that the ecological sufferings what we are experiencing today are seemed to have deep roots in anthropocentric views about the dominion of humans on earth. without major societal changes, including changes in the habits of human beings, these exploitative, consumerist practices cannot be resolved 2. the papers in this issue on environmental ethics emphasize the need of the sense of morality towards the surrounding environment. the first paper entitled environmental ethics through value-based education by ravichandran moorthy and gabriel tyoyila akwen highlights the philosophical roots of environmental ethics to signify that there exists a moral obligation for humans to secure and protect the surrounding non-humans species. as a means to inculcate such attitude from early childhood, the paper implies that value-based education should be part of school curriculum. the second paper on reflections of the ethics on coexisting with disaster by h.w. angela lo, vincent shieh, and yung-jong shiah explores the effectiveness of rehabilitative function of disaster service workers through the action research of typhoon morakot and the 2014 gas explosion in kaohsiung city, taiwan. using the case study, the paper suggests that selfdiscipline is to be prioritized among the human service workers during times of disaster. it also recommends to formulate indicators for a post-disaster “community of health and wellness;” and to establish bioethical principles of heteronomy for disaster service workers. the third paper on detrimental consequences of unethical anthropogenic interventions upon the ecosystem of teknaf peninsula, chattogram, bangladesh by s ahmad argues how the cox bazar coastal zone had declined environmental quality owing to unethical anthropogenic interventions. as a restorative measure, the paper proposes that ethical awareness of the local communities to be enhanced by developing ‘knowledge pool’ about coastal environment and improving moral ethics among the varied stakeholders. the fourth paper on implementation of nagoya protocol and its ethical dilemma – the case study of indonesia by e sukara, s.k. ragamustari, and e. sinaga pinpoints that biodiversity in indonesia depends on the strong connection between people and environment. using the case of indonesia and with reference of nagoya protocol, the paper emphasizes that the mechanism on access, fair, and equitable sharing of the benefit from the utilization of biodiversity and its component are certainly full of ethical dilemma. and to resolve the dilemma, the paper recommends that ethical standards cannot depend solely on rules or bangladesh journal of bioethics 2020; 11 (2) guidelines but also on the recognition on comprehensive rights of stakeholders contributing to the conservation of the biodiversity. the fifth paper entitled the relevance of deep ecological principles in aquatic crisis: a philosophical analysis by osebor ikechukwu monday recommends an ontological shift to address the water pollution affecting aquaculture. drawing on philosophical analysis, the ontological shift, the paper suggests, will bring in the environmental consciousness to protect the common good of the society. the paper argues that for such shift in consciousness, an implementation of deep ecological principles is required by the policy makers to give birth to ethical thinking and judicious use of environment and its resources. the paper concludes with the prescription of the integration of the deep ecological principle into school curriculum, so that citizens can be taught environmental consciousness for the common good of the society from early lives. as the guest editor of the issue, i thank all the authors for selecting the journal and adding value to the journal through your contributions. i convey my heartfelt gratitude to all the reviewers for giving your precious time to review the papers of the issue and also in providing valuable insights and comments for the contributors to improve. i am also grateful to professor shamima parvin lasker and ms. tahera ahmed for their trust on me. finally, i hope readers will enjoy in going through the diverse and insightful papers of the issue. so, happy reading everyone! thank you, rhyddhi chakraborty fhea (programme leader (hnd-health care practice), global banking school, london, uk visiting faculty (philosophy & global health), ausn, usa senior associate member, royal society of medicine, london, uk) guest editor, bangladesh journal of bioethics, vol-11, issue 1-3 references: 1. cambridge online dictionary. 2020. https://dictionary.cambridge.org/dictionary/english/environment. last accessed 15 nov 2020. 2. chakraborty, rhyddhi. insights of hinduism and buddhism: a study of the possible remedies for deep ecological problems. m. phil. dissertation. dept. of philosophy, university of calcutta;2007. microsoft word organ donation in africa bangladesh journal of bioethics 2018; 10 (1): 21-25 21 organ donation in an african culture ayinde jamiu kunle department of philosophy, olabisi onabanjo university, ago iwoye, ogun state, ayindejamiu90@gmail.com abstract: this paper is an attempt to examine the traditional yoruba beliefs about organs donation. organ donation and transplantation remain a rare occurrence in africa, this to a large extent can be as a result of the traditional african orientation on one hand and the advancement in medical research that came with transplanting organs on the other. this paper x-rays the problem of organ shortages in most african countries. it noted that apart from lack of awareness on organ donation, africans traditionally would not be willing to donate their organs after death. this paper critically examines beliefs in some african cultures and their relationship with organ donation. we analyze life after death in the yoruba tradition and the belief in the continuation of the body after death. the paper concludes that african belief in the continuation(reincarnation) of the body in the afterlife contributes to their non-willingness to donate an organ after death. key words: organ donation, african culture, yoruba culture introduction: organ transplantation is one of the recent medical solutions to organ failures. before 1950, the failure of an organ is almost equivalent to a death sentence. today, research in the medical field brought about organ transplantation to solve the problem of organ failures. rainer gruessner (2016) defines organ donation as “the act of giving one or more organs (or part thereof), without compensation, for transplantation into someone else”. however, the availability of organs for transplantation remains challenging since the discovery of organ transplants. babara (2004) said: ever since the first transplants were carried out in the 1950s, there has been an imbalance between the availability of donated organs and the number of recipients. razek et al buttress this point when they said: greater knowledge and technical advances in the field of transplantation have increased the demand for organ donationbeyond the current capacity to supply them. for example, the transplant waiting list in the united states in 1999 was 65 793 patients growing at an average rate of 16% per year as against the cadaveric increase of 5.6% in 1998 (razek, olthoff & reilly, 2000). a major ethical issue in organ transplantation today arises in the process of generating organs for transplantation. there are four major processes of generating organs for transplant. the first is livingorgan donation. this is a process where an is organ generated from donors who are still alive. it can be family, relatives, friends or strangers. livingdonors are classified as the givers of life. they are not selfish with their body organs. they will that someone else who is dying can benefit from the unused or unimportant organ in their body. such living donor donates an organ that does not cease life. an example of an organ donated by a living donor is the kidney, where one of the two kidneys possessed is donated to bangladesh journal of bioethics 2018; 10 (1): 21-25 22 someone who has kidney failure. dunstan (1997) has this to say: with transplantation from living donors the notion of 'donation', 'gift', becomes a reality: a willed, conscious gift. it extends from the giving of expendable or renewable resources like blood, bone marrow, and neural stem cells, to paired organs, kidneys, and segments of single organs, liver, spleen, and lung. it can save lives and improve the quality of lives, and so it can exert its emotional appeal directly on the potential donor some ethical issues arise from living donors. one of such is the sales of organs. it is the opinion in some quarters that the gift of an organ is a “gift that kills”. another way of generating organs for transplantation is called xenotransplantation. this is the process of generating organs from animals. this process raises some ethical issues. animal rights ethics frown at using the animal organ to cure human beings. however, the research in this aspect has not been perfected. advance research in medical ethics has also brought about technological solutions to generating organs. there are several approaches to generating organs without considering natural existing organs. regenerative medicine remains a prominent advanced medical research where organs are generated technologically from the stem cell of the patient in need of the organ. this process is yet to be perfected and there are only a few successes recorded in using advanced medical research in solving the problem of organ donation. organs generated from cadaveric donors provided a major solution to the problem of organs shortage. cadaveric organ donors can donate a more useful organ to cure the patient on the waiting list. the major challenge of generating organs through cadavers is the consent of both the cadaver and the family of the cadaver. the discussion on consent leads to the issue of autonomy. it has been argued that every individual has autonomy over his body, if such a body should be used after the death of the person, such person’s consent should be sorted. generating organs from cadaveric donors requires educating the masses and government providing policy on how consent will be given by the citizen on organ donation. government policy on organ donation consent can fall into one of these three categories. presume consent, which is the assumption that the citizens will approve their organ to be donated for a patient in need of such organs. the policy only allows people who are not willing to opt-out by either signing a document or notifying a center of not agreeing with such presumption. the policy assumes that everyone would be willing to donate an organ. presumed consent is defined according to the medical dictionary as the assumption that a particular action would have been approved by a person or party if permission has been sought. daniel also has this to say about presume consent. presumed consent is also referred to as the “opt-out” system because individuals would have the option of opting out of the system and not donating their organs. (daniel: 7) the second policy option is called presumed refusal where the government assumes that people are not willing to donate an organ. the policy gives room for those who wish their organ to be donated after death to sign a document or put down their wiliness in a program record. bangladesh journal of bioethics 2018; 10 (1): 21-25 23 the third of the organ donation consent policy is a mandated choice which mandates every living person to take a position without any assumption. no doubt organ failure is a phenomenon that occurs in all countries either third world countries or first world. today, organ failure treatment in africa is giving low attention. even though crowd funding is the launch, a very few african are willing to donate their organs after death. most african country till date don’t have organ bank nor do they have a waiting list of patients in need of organ transplant. some traditional african beliefs do not give room to exercise a gift of life. africans and organs donation: the tripartite belief in the nature of human being as constituting the body, soul and mind also exists in africa. however, the belief that when death occurs, the body becomes useless and separated from the soul seems not to be in consonance with african belief about the body after death. most africans believe that there is life after death, however such life which they usually refer to as the ancestral world requires them to have a good body and soul. africans believe that when someone dies in a mysterious way, or not buried properly with all his or her body intact, such a person would not be accepted by ancestors or as ancestor in the life after death. on this, thembelihle ggogqoni, an elderly community member and also a traditional healer averse that, it is against black culture to remove the organs of a deceased person as it is believed their spirit continues to roam and will not be accepted by ancestors. the completeness of the body and proper burial has a relationship with the acceptability of the spirit of such a person in the life after. the way africans respect their body and spirit while alive is the same way the body and spirit are respected after death. the body needs to be accorded adequate respect and put in good condition so that the spirit of the deceased will be accepted by the ancestors. thembelihle further posits: as a traditional healer, i have a strong belief in the existence of ancestors and i directly communicate with them. if i die and have missing organs i will not be accepted by my ancestors. the body of the deceased has to be treated with respect the belief that body and soul need to be intact for the soul to be accepted by the ancestors affects the traditional african community’s orientation on organ donation. organ donation will remain alien to traditional africa belief as it cannot exist alongside the belief of body usefulness in life after death. on this zizozikali said: while thousands of south africans are currently waiting for a life-saving organ transplant, it remains a difficult task to convince rural black communities to donate organs because of their cultural beliefs. the attitude of africans towards organ donation will remain low as long as the cultural belief is considered. traditionally, africans will not be willing to donate an organ. when we consider the responses, we get from rural communities in african as regard organ donation, we will realize that cultural belief has grossly affected the willingness to donate an organ by traditional african. mr ngurewa mwachofi, an expert in social behavior and communication, says religious and cultural beliefs are to blame for the negative attitude towards organ donation. bangladesh journal of bioethics 2018; 10 (1): 21-25 24 it is this belief that prevents africans from donating their corneas to patients in need. mr. ngurewa further said base on his experience in africa that: we'd like them to pledge their corneas but because of their religious beliefs, they say they have to see heaven. still, we've tried to talk to them to donate their corneas so they can help someone see this world. the major argument for organ donation is convincing the donor the fact that what he or she intends to donate is not useful to him or her but to the patient that is in dire need of it. in the area of a cadaveric donor, the argument remains that the dead is no longer in need of the body vis a vis the kidney, bone marrow, liver among others. etheredge et al rightly identified the reason for the decrease in the willingness of africans to donate an organ in their research on organ donation when they say: a decrease in willingness to donate heart, liver, and corneas was expressed by the black african population. this is consistent with cultural beliefs that emphasize the role of the ancestors after death, and the notion that the body should remain intact for spiritual reasons. however, the traditional africa belief that such body is very much needed by the donor, it is a necessary condition for the donor to be accepted to the ancestral world. in the other examples that were given, the traditionally society believes that if cornea was donated to a patient the donor will not see heaven. this shows that it is only when traditional beliefs about body uselessness after death are resolved, that is when we will have more traditional africans ready to donate organs to the patients in need of it. yoruba and after world: yoruba culture as one of the traditional africa culture is not exempted from the belief in the usefulness of the body in the ancestral world. the yoruba believe that the body needs to be intact for the ancestors to accept such a person into their world. the belief in the fusion of the body and the soul in the yoruba belief system can be seen in their understanding of abiku. the yoruba believe that abiku can be prevented from coming back by defacing the body of the dead child. this belief also leads them to the belief that if such a child is to be given birth to again, the mark of the defaced part will appear in the child’s body. this is explained by umpire abey when he posits about the yoruba on abiku that: owing to the ephemeral nature of abiku's life, abiku completes several consecutive life-cycles with one mother. in some reality cases, the yorubas, in one of their traditional ways of deterring abiku from death after reborn deface such children either by cutting their finger, ear or a deep mark in the face or back. to a great surprise in most cases, the abiku on reborn would have those marks whether on the face or back. this shows that the body and the soul have some fundamental relationship and that relationship does not end at death. the yoruba just like other traditional africa belief does not accommodate organ donation. although africans are communitarian in nature, they don’t believe that the body is part of their property that they can give away. the body is a necessary condition for living while alive as well as a necessary condition for acceptability in the ancestral world. bangladesh journal of bioethics 2018; 10 (1): 21-25 25 conclusion: this paper concludes that owing to the african belief system of life after death, organ donation cannot be successful in the traditional africa community. this paper raises a new dimension to the discussion on community acceptance of organ donation. traditional africa will rather prefer adequate efforts to perfect the advance medical research in donating organs through regenerative medicine rather than calling on the people to donate an organ for the patient on the waiting list. the apathy to organ donation experience in african is not only a result of lack of awareness or education, but the traditional african belief also contributes to the dearth of organs availability. reference: barbara k pierscionek. what is presumed when we presume consent? bmc medical ethics, 2008; 9:8 anonymous. the yoruba concept of abiku and emere in yorubaland. http://www.ekimogundescendant.org/the-yorubaconcept-of-abiku-and-emere-in-yorubaland/ (access on july 2018) anne soy. why is organ donation taboo for many africans? bbc africa, nairobi 2015. https://www.bbc.com/news/world-africa-31350463 (access on 10 february 2018) zizo zikali. cultural beliefs discourage organ donors. health news 3rd january 2018. https://www.healthe.org.za/2018/01/03/cultural-beliefs-discourageorgan-donors/ (access on 10 february 2018) daniel, s. “organ donation: autonomy, presumed consent, and mandated choice”. oakland university 2016. http://www.oakland.edu/upload/docs/philosoph y/springer_essay.pdf (access on 10 february 2018). dunstan g. r., the ethics of organ donation in british medical bulletin 1997: 53:4: etheredge h. r, r. e. turner and d. khan, attitudes to organ donation among some urban south african populations remain unchanged: a cross-sectional study (1993 – 2013) in samj 2014; 104,: 2. rainer, g. (2016). “organ donation”, available at <http://www.britannica.com/topic/organ-donation> (accessed on 30th of january, 2018) razek, t, olthoff, k & reilly p. issues in potential organ donor management. surgical clinics of north america 2000; 80:(3):1021 1030. author declaration: the author conceived the idea, did the literature review and wrote the manuscript. he also checked the manuscript meticulously. conflict of interest: no conflict of interest. microsoft word palharessantosastroethics bangladesh journal of bioethics 2017; 8(2):1-10 1 astronomic bioethics: terraforming x planetary protection dario palhares1 and íris almeida dos santos2 1. university of brasília, brazil dariompm@unb.br 2. bureau of education of distrito federal, brazil irisalmsan@gmail.com. abstract: a hard difficulty in astrobiology is the precise definition of what life is. all living beings have a cellular structure, so it is not possible to have a broader concept of life hence the search for extraterrestrial life is restricted to extraterrestrial cells. earth is an astronomical rarity because it is difficult for a planet to present liquid water on the surface. two antagonistic bioethical principles arise: planetary protection and terraforming. planetary protection is based on the fear of interplanetary cross-infection and possible ecological damages caused by alien living beings. terraforming is the intention of modifying the environmental conditions of the neighbouring planets in such a way that human colonisation would be possible. the synthesis of this antagonism is ecopoiesis, a concept related to the creation of new ecosystems in other planets. since all the multicellular biodiversity requires oxygen to survive, only extremophile microorganisms could survive in other planets. so, it could be carried out a simulation of a meteorite by taking to other planets portions of the terrestrial permafrost, or ocean or soil, so that if a single species could grow, a new ecosystem would start, as well as a new natural history. as a conclusion, ecopoiesis should be the bioethical principle to guide practices and research in astrobiology. key words: invasive species, ecology, oxygen, sulphur. introduction: technological advances in space sciences, expanding borders of knowledge and understanding of the universe, have widened our knowledge and deepened philosophical questions such as the origin of life, whether on earth or on other planets. research on extraterrestrial life as a scientific field was consolidated by nasa (national aeronautics and space administration), the us space agency, with the creation of a programme on astrobiology in 19981. galante et al.1 consider this policy to be a strong popular appeal for large funding required by this kind of research, that is, astrobiology, which was created as a scientific and technological discipline by interaction among scientists, society, political and economic groups. looking from the universe, it is possible to highlight some important aspects of the terrestrial ecosystems, especially when human activities have produced unprecedented pollutants, disturbing climatic balance. astrobiology also has bioethical nuances reflecting on the best for research on the universe and on some terrestrial practices. definition of life and delineation of the objectives of research: the first difficulty in the field of astrobiology is to precisely define what life is. although the recognition of a life being is simple, intuitive and instinctive, the formal definition of life is very bangladesh journal of bioethics 2017; 8(2):1-10 2 complex2. life beings are distinguishable from the mineral due to their spontaneity and admirable ability of self-replication. they are fragile, perishable and doomed to death, but as they self-replicate, they show that life is strongly resilient: basically, where there is liquid water, life begins. science can describe life in operational words, but not in essential words2. if there is a definition, life is closer to a verb than to a noun. the autotrophic life beings transform the brute mineral into themselves, that is, they give life to the brute environment. so, it is possible to infer an undefined border between brute minerals and life. indeed, since 1924, biochemical research oparin had shown that small simple molecules such as carbon dioxide, ammonia, sulphur, water, etc., and random chemical reactions produce complex molecules such as amino acids, lipids and even polymers that combine in coacerved structures that somehow resemble a living cell1. however, despite the countless chemical reactions that occur inside a living cell and the possibility of laboratory synthesis of practically all chemical compounds of a living cell, the vital organization is something transcendent to the mere concrete matter3. living is a metabolic and physiological adjective that describes a living being. overall, a living being can be in the stage of ‘living’, of ‘dormancy/latency’ or ‘dead’. a dead living being will never return to life. some species produce propagules—seeds, spores, buds, etc.—that can remain latent (or dormant) for thousands of years, but when exposed to favourable environment can grow and self-replicate (living stage)4. however, the simple preservation of a living being in liquid helium, formalin, conservatives, etc. can maintain the skeletal structure but clearly it is a dead one . until now, life remains an abstract and an unknown concept, a mysterious force at the same time existing and transcending to a living being2.3. all living beings, with no exception, have a cellular structure. so, with absolute ignorance of a living being not organised in cells, it is not possible to have a broader concept of life, and in astrobiology the search for extraterrestrial life is restricted to extraterrestrial cells. such epistemic positioning is related to concrete questions. space exploration must be restricted to mere observation of planets, under the belief that there are life forms that are not structured in the same way of the terrestrial cells? or on the contrary, the living cell is considered so wonderful so that efforts must be made for colonisation with terrestrial living beings? origin of living beings: fossils show that living beings existed on the terrestrial surface at least for 3.8 billion years1,5. considering that the age of earth is approximately 4 billion years, it means, in astronomical terms, that as soon as the earth was formed and contained liquid water on its surface, living beings began appearing. terrestrial biodiversity is based on the cell with the genetic code of dna/rna, whose metabolism is based on the breakage of atp. this points to what would be the first terrestrial microbe, or luca—last ultimate common ancestor—from which all the terrestrial biosphere originated1. bangladesh journal of bioethics 2017; 8(2):1-10 3 this geological aspect brings up deeper questions. if, according to the theory of spontaneous generation, the cell originated on the terrestrial surface from random reactions on mineral substrates, then were there other patterns of cells? if so, what were they? was luca a single event or had it been repeated several times? were there other genetic systems supplanted by dna/rna? why such primitive patterns are not seen nowadays? on the last question, darwin wrote in 18711: "it is often said that all the conditions for the first production of a living being are now present, which could ever have been present. but if (and oh what a big if) we could conceive in some warm little pools with all sort of ammonia and phosphoric salts—light, heat, electricity present, that a protein compound was chemically formed, ready to undergo still more complex changes, at the present such matter would be instantly devoured, or absorbed, which would not have been the case before living creatures were formed". indeed, the strong relation between liquid water and the presence of living beings is significant. however, no life form is found only in extremely arid deserts; otherwise, wherever there is liquid water there are living beings, including apparently hostile environments. this intrinsic relation guides the astronomical observation of what would be a habitable planet: the one with liquid water on the surface. in this sense, earth, the water planet, is an astronomical rarity1,5. although water is a common and abundant substance in the universe, for a planet to show liquid on its surface a certain set of parameters, such as adequate distance from the star, the presence of a magnetic field that protects the atmosphere from the star winds, adequate concentration of glasshouse gases in the atmosphere, etc., are required. apparently, the space probes sent up now suggest that the planet mars and the moons europa and ganimedes that orbit jupiter have liquid water in their subsoil, below an ocean of ice1. the moon europe has an atmosphere rich in oxygen, similar to the terrestrial one, suggesting that liquid water on the surface is undergoing photolysis and releasing the gas. moreover, the moons of saturn, titan and enceladus, the uranus moon titanus and the neptune moon triton perhaps have liquid water under ice in the subsoil1. since the ancient greece, the origin of terrestrial life has been imagined as the result of a panspermia—that the universe has living beings that are transported somehow from one planet to another6. anaxagoras mentioned this idea as early as 500 bc, and this concept was recirculated at the end of the 14th century by scientists devoted to organic chemistry and biochemistry6. in 1908, the physicist arrhenius published a book in which he discussed the theory of panspermia7. according to it, the living beings are one of the elements of the universe, who would be transferred from one galaxy to another via comets and asteroids until they reach a favourable planet to grow. indeed, recently, some rocks were found on the earth, which originated from mars and had traces of ancestral organic matter5,8. bangladesh journal of bioethics 2017; 8(2):1-10 4 the stronger criticism against the theory of panspermia is that it does not clarify about the exact mode of origin of the living cell. however, it has deep bioethical impact on it, if panspermia is a phenomenon intrinsic to the universe, the living beings of each planet would have somehow gone to the neighbouring planets, and in the case of the earth humans are the only species with the ability spread living beings outside earth. planetary protection: astronomer huygens had described channels on the surface of mars as early as 16591. arrhenius7 considered it plausible that there might be life on mars, which however has not yet been confirmed. with effectively conquering space by the 1960s, with astronauts going to the orbit, it appeared as concern the physiological effects of microgravity and, in parallel, a fear of contraction of infectious diseases spreading from space and/or other planets that could cause massive human mortality9. fearing cross-infection, and on the bioethical principle of planetary protection, the study and observation of neighbouring planets would be via sterilized equipment to avoid any interplanetary contamination. indeed, studies on space have been confined to the study of the planets with probes and robots with no reports of intentional colonisation of neighbouring planets by terrestrial living beings. in the interests of planetary protection, it is important to highlight some aspects of the terrestrial natural history. about 1.5 billion years after the appearance of the first living cells, the first photosynthesising living beings appeared and, after catalysing the photolysis of water, strongly enriched the terrestrial atmosphere with oxygen1. so, about 2.1 billion years ago, the first multicellular living beings appeared. now a days, all the multicellular mega biodiversity breathes and obtains energy from controlled combustion of organic compounds1. all the species that do not require oxygen are unicellular1. oxygen is a highly reactive gas, so the living beings evolved to biochemically control this dimension10. in comparison, sulphur belonging to the same family in the periodic table is also highly reactive, but is also highly toxic: in human beings, its inhalation at a concentration of 0.001 ppm is irritant to the respiratory mucosa, while it is lethal at a concentration of 0.01 ppm11. the atmosphere of the moon io of jupiter is highly rich in sulphur, and any terrestrial multicellular organism that went inside that moon would immediately be corroded by that strong oxidant1. hypothetically, if a living being from io went to earth, it would be quickly oxidised by the corrosive oxygen. so, it is clear that the eventual biological colonisation of the neighbouring planets would be feasible only with microbes adapted to the environmental conditions in the colonising planets. so, one of the sub-disciplines of astrobiology is the study of the socalled extremophile microbes, that is, microbes adapted to some terrestrial environments whose physico-chemical characteristics are similar to other planets5. the principal categories of extremophiles are: thermophilic and hyperthermophilic (adaptation to extreme heat, close to the boiling point of the water); psychrophylic (adaptation to cold), acidophilic, alkaliphilic, barophilic (adaptation to acid, alkali and high pressure) and halophilic (adaptation to high saline concentrations)1. some of these groups are of bangladesh journal of bioethics 2017; 8(2):1-10 5 particular interest like the ecosystems inhabiting the gabbroic rocks from 1,400 m below the ocean floor and the polar ecosystems living at a freezing temperature1,8. beside extremophile microbes, the chemiolitotrophic microbes are also of interest. such microbes are autotrophic and obtain energy from the oxidation of inorganic compounds such as phosphorus, sulphur, ammonia, iron, arsenic, selenium, etc. that is, the entire ecosystems exist in the absence of light. the case of the archea desulforudis audaxvitor is intriguing because it grows in dark mines rich in uranium and obtains energy from the radiolysis of water from the decaying uranium1. anyway, the fear of an eventual interplanetary colonisation with terrestrial microbes is related to the ecological field of invasive species, a phenomenon that is almost totally related to human travels and intentional or occasional transport of living beings from one ecosystem to another. downey and richardson12 listed essential aspects of the ecology of invasive species: data show that ecosystems related to restricted regions (islands, lakes, pools, etc.) are more vulnerable to invasive species, that the documented extinctions were caused by predator animals and the extinction of native plants related solely to the introduction of an invasive plant has not been observed, since the invasive plants often occupy places already disturbed by human activities. anyway, the ecological inter-relationship among native and invasive plants is very complex and the extinction of native plants would take a long period, perhaps hundreds of years12. on the ecological relationship among microbes, veresoglu et al.13 highlight that all living species are doomed to extinction as we know them, either by disappearance or origin of new species. the microbes that lived on the earth 3.8 billion years ago don´t exist anymore, although they are responsible for the origin of all living species today. anyway, the microbial ecosystems have species with great ability to metabolic adaptation, such as microbes that can live in external environments but sometimes live with roots of plants or the guts of animals. on the introduction of new microbes into an ecosystem, veresoglu et al.13 and also guerrero et al.14 say that the microbial ecosystems are very complex and are organised in layers such that the simple presence of a new species would be insufficient to significantly impact them. instead, the human modifications to the environment (asphalt, drainages, etc.) completely change the characteristics of the environment, and would strongly change the microbial ecosystems. so, the group of ecological evidences points to an eventual colonisation of planets with terrestrial living beings that would be feasible only with extremofile microbes, which has little potential of impacting an ecosystem if one is already present in those planets. terraforming: the word terraforming appeared first in science fiction literature in 1942 in the magazine astounding science fiction edited by jack williamson15. from a bioethical position opposed to planetary protection, terraforming is the intention of bangladesh journal of bioethics 2017; 8(2):1-10 6 modifying the environmental conditions of the neighbouring planets, particularly mars, in such a way that human colonisation would be possible. alexandrov9 defends the bioethical principle of terraforming. he has identified the difference between anthropocentrism and biocentrism. anthropocentrism attaches great value intrinsic to humanity, while biocentrism puts humans as a natural enemy of all the biosphere, including the extraterrestrial biosphere, if there was one. so, to alexandrov9, if planetary engineering could be carried out to benefit humanity and create a human colony, then such effort should be made. he believes that if terraforming is feasible, somebody will do it sooner or later. the theoretical steps for eventual terraforming aslisted by haynes and mccay16 are: first, a prospection of the surface of mars; second, colonisation with terrestrial microbes; third, eventual environmental changes with engineering acitivities, for example, with nuclear explosions; fourth, the cultivation of food plants and finally human colonisation. the authors consider that microbial colonisation is relatively plausible with the existing technology, but human colonisation demands unimaginable technological resources17. in earth, the microbes are the beginning and the end of the ecological cycle. the ecological system is cyclical because the wastes of a given living being are substrate to other species, principally microbes. so, human pollution derives from the production of organic waste, principally plastics that, although chemically burnable, are not naturally degradable by any microbial species2. the ideal terraforming would be by microbial species that colonised the other planets and could change the environment, such as has occurred to earth when the first photosynthesising living beings appeared16. so, one of the research fields in astrobiology is to identify and select extremophile microbes and carry out experiments of resistance to space environment and survival in extraterrestrial environments. tarashashvili and aleksidze8 created in laboratory a growing medium similar to what the martian soil would be, then they inoculated samples of extreme environments containing iron-bacteria, silicon-bacteria, sulphurbacteria, mycobacteria and cyanophytes that hadn´t been identified yet. it was possible to see the growth of colonies of those microbes, so the authors suggest cultivation and amelioration to obtain strains considered as promising to colonise mars. horneck et al.4 studied spores of the bacteria bacillus subtilis in experiments carried out on satellites of esa (european space agency) and showed that the spores were highly resistant to vaccum, to freezing temperatures and to radiation from space. although the spores were highly sensitive to ultraviolet light, a thin layer of rock was enough to protect them. those experiments suggest that spores of this bacterial species could survive for an undefined period, perhaps thousands of years, corroborating the theory of panspermia and show that it would be possible to transport viable microbial spores from earth to other planets. bangladesh journal of bioethics 2017; 8(2):1-10 7 friedmann and ocampo-friedmann18 suggested that cyanophycea chroococcidiopsis would be an ideal candidate for transplantation to other planets, since it is ubiquitous on earth, and can be considered as a microbial living fossil. however, thomas et al.19 simulated in laboratory the climatic conditions of mars and tried growing chroococcidiopsis and other photosynthesising microbes, but they did not survive. paulino-lima et al.20 studied the archea deinococcus radiodurans and documented its resistance to radiation and ultraviolet rays, but since this is a heterotrophic aerobic microbe, it has a lesser chance of being a probable candidate to be a pioneer in extraterrestrial colonisation. final consideration: the two bioethical positions—terraforming and planetary protection—are antagonistic. space exploration needs large funding and support and up to now just a few worldwide agencies have invested on this field, and in a paradigm that astronomic biology is concerned with planetary protection. terraforming is still at a stage of hypothesis and bioethical debate but till date, no experiments have been carried out to take microbes purposely to other planets. the fear of space agencies of damage to other planets with terrestrial living beings is not supported by ecological studies of the terrestrial ecosystems. it is clear that an eventual interplanetary colonisation could only be feasible by extremophile microbes, which, in case of matching living beings already existing, would be of great competitive disadvantage. but if those microbes found even minimally favourable conditions, they would create a new natural history on that planet.4 notwithstanding, if anyone of our neighbouring planets has life, or at least life of the same duration as of the earth (around 3.8 billion years), the living beings would have already developed a cover in these planets, occupying earth, depths, atmosphere. after all, life is one of the wonders of the universe, and when established on a planet, will evolve in such a way as to occupy the maximally possible area of the planet2. the living being is born and dies, but after each replicating cycle, the living biomass of the planet increases continuously. however, our neighbouring planets do not have any form of life, either a cell or an unimaginable structure. from this bioethical antagonism, a third concept that synthesises the extremities, ecopoiesis, has emerged. ecopoiesis is a word mentioned by robert haynes in 1984 and published in 198921 and is related to the creation of new ecosystems in other planets. this terminology summarises the former concept of planetary ecosynthesis, first coined in 1979 by averner and macelroy22. that is, neither a radical transformation to allow human colonisation nor the omission facing a scientific-technological ability. if a living being comes only from another living being, then life shows to be a force, something beyond our reach, present in the universe, capable of transforming the inorganic into organic and, in the evolutionary bangladesh journal of bioethics 2017; 8(2):1-10 8 fight for survival, transform a whole planet in an ecosystem each time deeper and more complex23. the theories of origin of life—spontaneous generation and panspermia—are not mutually excluding, and can be complementary. under a cosmogonic perspective, since in a planet some kind of living beings appear, they somehow colonise the other planets, either by random means, such as collision with asteroids, or by means of intelligent forms that do that intentionally5,16,17. moreover, if the theory of panspermia is correct, it is even possible that extraterrestrial microbes hit earth with some frequency, but these life forms would face strong difficulties to resist to the toxicity of oxygen, to the stressful climate, but, foremost, to compete with other life forms already established here. therefore, ecopoiesis is related to the bioethical position of cosmocentrism, that is, planets that house some form of life have an intrinsic value higher than the one with only mineral elements5,16,17. so, mautner and matloff17 and their society for life in space defend that ecopoiesis is the cosmogonic proposal of human existence, that is, one of the tasks to humanity would be one of disseminating terrestrial propagules to the neighbouring planets, as it is the only species able to do that. the idea of ecopoiesis can also guide future expedition to other planets: one line of research can be the complex task of identifying, isolating, cultivating and preserving ‘the’ microbe candidate to colonise another planet. but if panspermia occurs as a meteorite coming from a planet, what reaches the planets is not a single species, but a whole ecosystem preserved in rocks. so, for example, the colonisation of the moon europa of jupiter could be carried out by leaving there, or perhaps burying there, a portion (some kilograms, half a ton, or so ) of the artic or antarctic permafrost. or, samples of the oceans or of the terrestrial soils could also be transported. that is, if a whole microbial ecosystem is transported similar to what would be a meteor to the neighbouring planet, it would be enough if a single species grew to start a new ecosystem. anyway, experiments towards ecopoiesis present high intrinsic scientific value, as to clarify how life beings appeared on earth and if life beings can somehow jump from a planet to another. in conclusion, ecopoieses is based on bioethical principles that should guide space exploration in substitution to the principle of planetary protection. acknowledgments: we thank the indian company content concepts for english review and correction. author contribution: both authors carried out bibliographical research, discussed the ideas and wrote the text. conflict of interest: none bangladesh journal of bioethics 2017; 8(2):1-10 9 references: 1. galante d, silva ep, rodrigues f, horvath j and avellar mg. astrobiologia, uma ciência emergente. são paulo: tikinet edição, iag/usp, 2016. 2. palhares d. biological evolution and evolution of spirits. são paulo: baraúna, 2013. 3. betto f. conversa sobre fé e ciência. frei betto e marcelo gleiser com waldemar falcão. rio de janeiro: agir, 2011. 4. horneck g, rettberg p, reitz g, wehner j, eschweiler u, strauch k, panitz c, starke v and baumstark-khan c. protection of bacterial spores in space, a contribution to the discussion of panspermia. origins of life and evolution in the biosphere 2001; 31: 527-547. 5. mautner mn. seeding the universe with life. securing our cosmological future. lb legacy books: christchurch, 2004. 6. wikipedia. panspermia. available at https://en.wikipedia.org/wiki/panspermia. access april/2017. 7. arrhenius s. worlds in the making. the evolution of universe. harper and brothers publishers: new york and london, 1908. 8. tarashashivli mv and aleksidze ng. microbiological remediation of martian soil for future terraformation of the planet. astrobiology science conference 2010; p. 5229. 9. alexandrov s. planetary protection of mars: time for reconsideration. bangladesh journal of bioethics 2016; 7(2): 31-34. 10.makuch ds. a busca por vida extraterrestre: seríamos todos nós marcianos? available at http://noticias.uol.com.br/midiaglobal/derspiegel/2010/12/18/a-busca-porvida-extraterrestre-seriamos-todos-nos-marcianos.htm. acess april/2017. 11. palhares d. polvilho anti-séptico no tratamento de ectoparasitoses. revista brasileira de medicina 2006; 63(3): 77-78. 12. downey p and richardson d. alien plant invasions and native plant extinctions: a six-threshold framework. aob plants 2016; 8: plw 047. 13. veresoglu s, halley j and rillig m. extinction risk of soil biota. nature communications 2015; 6:8862. 14. guerrero r, piqueras m and berlanga m. microbial mats and the search for minimal ecosystems. international microbiology 2002; 5: 177-188. 16. wikipedia. terraforming. available at https://en.wikipedia.org/wiki/terraforming. acess april/2017 17. haynes rh and mckay c. the implantation of life in mars: feasibility and motivation. advances in space research 1992; 12(4): 133-140. 18. mautner mn and malof gl. directed panspermia: a technical and ethical evaluation of seeding nearby solar systems. journal of the british interplanetary society 1979; 32: 419-423. 19. friedmann ei and ocampo-friedmann r. a primitive cyanobacterium as pioneer microorganism for terraforming mars. advances in space research 1995; 15(3): 243246. 20.thomas d, eubanks lm, rector c, warrington j and todd p. effects of atmospheric pressure on the survival of photosynthetic microorganisms during simulation of ecopoiesis. international journal of astrobiology 2008; 7(3-4): 243-249. 21.paulino-lima ig, pilling s, janot-pacheco e, brito an, barbosa ja, leitão ac and lage ca. laboratory simulation of interplanetary ultraviolet radiation and its effects on deinococcus radiodurans. planetary and space science 2010, 58(10): 1180-1187. bangladesh journal of bioethics 2017; 8(2):1-10 10 22. haynes rh. prospects for establishing a microbial ecosystem on mars. moscow: biotechnology on the threshold of the xxi century, conference proceedings, 1989, p. 85-88. 23. averner mm and macelroy rd. on the habitability of mars: an approach to planetary ecosynthesis. nasa sp-414, 1976. 24.lutzenberger j and gaia, o. planeta vivo. cinco continentes: porto alegre, 2012. microsoft word s chakraborty animal ethics beyond neutrality, universality, and consistency bangladesh journal of bioethics 2016; 7(3): 34-45 34 original article animal ethics: beyond neutrality, universality, and consistency sreetama chakraborty assistant professor, department of philosophy belda college, west midnapore, west bengal, india email: sreetamaphil@gmail.com abstract: this paper reflects a possibility of going beyond the postmodernists’ way of ethically examining non-human animals based on the tripartite pillars of neutrality, universality, and consistency. my concentration focuses on some interrelated queries, such as – what does animal ethics conventionally mean? how did power, hierarchy, and domination separate humans from other animals? how does the fate of non-human animals (whether they ought to be morally considered or not) depend on humans’ moral values? how far is it justified to secure animal rights in the age of perilous animal use, especially for food or during animal experimentation? while examining these issues, i bring into light the several arguments and positions put forward by thinkers such as jeremy bentham, peter singer, tom regan, carl cohen, brian berry, and others. moreover, my search is for a non-anthropocentric sustainable paradigm, to balance human interests and animal needs together, in order to sustain the future generations of human and non-human intimacy. key words: animal ethics, sentience, universality, moral values, animal experimentation, sustainable ethics. introduction: the aim of this paper is to, first, analyze the postmodernists’ approach to animal ethics that is a departure from the traditional way of doing animal ethics adopted especially by the analytic thinkers, and, second, to interpret it in the light of socio-cultural construction. conventionally, the ethical considerability of non-human animals is judged in the context of standard moral ethical theories such as virtue ethics, consequentialism, and deontology. in addition, the tripartite pillars of neutrality, universality, and consistency were held as tools for ethical examination of non-human animals. i will explain how these principles work and how the postmodern approach departs from this trend. neutrality signifies our suspension of biasedness towards anthropocentrism. the principle of universality demands that morality remains the same for all in all events and in all contexts, even when it extends to the case of non-humans. moreover, consistency demands that both humans as well as non-humans are of equal importance and ought to be given due and consistent weight. these principles have been put to challenge by animal ethicists belonging to the postmodernist era. the postmodernists argue that advocating neutrality and universality is a sheer impossibility, especially because all humans are embedded in a web of epistemic situations and socio-linguistic backgrounds, and cannot be bangladesh journal of bioethics 2016; 7(3): 34-45 35 situated apart from it. all praxis of morality and values are also byproducts of social construction, and are in no way given or constructed universally. unlike the earlier trend of animal ethicists, i adopt the postmodernists’ way of looking from an opposite direction, emphasizing emotion, care, responsibility, sympathy, understanding, and so on. it would be more appealing if humans’ emotions and sensitivity towards animals are aroused by making them think as to how non-humans might also consider humans if humans were in that same plane. the whole endeavor of humans is to understand the non-humans in a morally sensitive way and develop a sense in order to accept them, considering their dignity and their right to occupy a place in this beautiful natural world. revisiting the tripartite pillars: with the beginning of the twenty-first century, a new era revitalizing the very contemporary concerns over environmentalism and animal ethics has taken a unique shape. across the world, we place non-human animals in a category different from humans, but an interesting trace could be found in darwin’s project when he reflected on the presence of ‘reason’ at least to some degrees even in non-humans. however, since then the development of animal ethics has been divided into three major stages. the first stage is the 1970s and 80s, when all animal questions were judged based on two major normative ethical principles – consequentialism and deontology. the second stage is the 1990s, when the postmodern approach of commenting on the traditional approach towards animal ethics began, and the third stage emerges with the end of the 20th century, when a new way of looking at animal ethics arose, especially from the perspectives of behavioral psychology and experimental philosophy. however, with the growing popularity of this discipline, animal ethics worked under the umbrella of three principles – neutrality, universality, and consistency. these principles were also considered determining criterions for being an animal ethicist. a human individual who wants to extend his or her moral consideration towards non-human animals must be neutral, universal, and consistent in their thinking and behavior. let me begin by giving a brief analysis of how these principles work. neutrality is the preliminary condition, which demands suspending or withdrawing all anthropocentric attitudes that favor human beings over and above anything else. neutrality is an unbiased principle of fairness, advocating justice for all species. under such a condition, all species must receive equal rights and consideration. human wants and needs ought not to be seen specially or given any particular attention. however, as against this principle, there exists one of the strongest groups advocating anthropocentrism – speciesism, a view analogous to racism and sexism. unlike animal rights supporters, the advocates of speciesism endorse discrimination against non-human animals. the supporters of speciesism treat one species, humans, as superior to all others. many consider speciesism a moral illusion. however, this kind of a prejudicial differentiation that speciesism advocates directs us towards a rigid anthropocentric structure, which is by large dangerous for society. a speciesist might argue that one of the major reasons that justify human privilege is sentience. however, that might also bangladesh journal of bioethics 2016; 7(3): 34-45 36 lead to another inquiry: how can we be sure that non-humans have no sentience? there are undoubtedly several scientific procedures by which it becomes possible to conduct tests and experiments in order to find out how the receptor organs of non-human animals respond, whether they are sentient or not. sufficient proof exists to show that there are vertebrates whose nervous system shows similar receptor functions like that of mentally retarded persons or children, or even more. would it then be justified to equate an infant with a non-human animal? however, even that would cause trouble for both sides, as on the one hand conducting experiments would harm animals and cause an issue for animal and environmental rights activists, and on the other hand harming an infant would go against ‘human rights’ policies. therefore, critics attack the speciesists for being biased in the case of children and mentally retarded persons. humans are incapable of choosing their life as human or to have parents or ancestors of any kind. the same theory applies to all other species of the world. the second principle of animal ethics is universality. the principle holds that morality remains the same for all people (and even for all species) at all times. this principle is tied to the principle of neutrality. neutrality insists on unbiasedness whereas universality demands that this unbiasedness is applied universally to all species at all times. in the context of this universalization principle, tom regan, in the case for animal rights, very well applied the principle of kantian deontology to explain his position in favor of animal rights1. regan took the basic formula of kantian moral philosophy. unlike the utilitarians, regan holds that all subjectsof-a-life have equal inherent value, regardless of their utility. having inherent value implies that one has certain fundamental moral rights. in addition, individuals with inherent value must be treated with equal respect. this universal principle, which also serves as the basis for human rights, provides inherent worth to individuals, regardless of class, caste, race, sex, and gender. however, regan’s uniqueness lies in considering one more element to the above list, viz. species. species distinction must also not be an issue while considering the universalisability principle. regan, along with peter singer, makes the claim that some animals do deserve the same value as human individuals. regan argues that, if the universalisability principle would go according to what kant says, then kant made it very clear that rationality is the criterion for moral worth, and since children, mentally disabled persons lack this quality, then people of this marginal class are disqualified from being the holders of moral worth. therefore, they can also be treated in the same way as non-human animals are (the same point was raised against the speciesist). regan further proposes one more condition to be considered for being worthy of respect and this is the capacity to experience. whoever possess this capacity ought to be considered morally. in this connection, regan distinguishes between moral agents and moral patients. “a moral patient,” regan says, “lacks the ability to formulate… [they] cannot do what is right, nor can they do what is wrong… only moral agents can do what is wrong.”2 so, for regan, since humans give importance to those humans who are not moral agents (i.e., moral patients such as infants and mentally retarded persons), therefore animals also ought to get due consideration by parity of reasoning. however, carl cohen challenges regan’s arguments bangladesh journal of bioethics 2016; 7(3): 34-45 37 claiming that we cannot deprive human infants of their rights, just because they are moral patients (in regan’s words). cohen’s point becomes clearer when he says, it is not individual persons who qualify (or are disqualified) for the possession of rights because of the presence or absence in them of some special capacity, thus resulting in the award of rights to some but not to others. rights are universally human; they arise in a human moral world, in a moral sphere. in the human moral world moral judgements are pervasive; it is the fact that all humans including infants and the senile are members of that moral community – not the fact that as individuals they have or do not have certain special capacities, or merits – that makes humans bearers of rights. therefore, it is beside the point to insist that animals have remarkable capacities, that they really have a consciousness of self; or of the future, or make plans, and so on […]. they [supporters of regan] mistakenly suppose that rights are tied to some identifiable individual abilities or sensibilities, and they fail to see that rights arise only in a community of moral beings, and that therefore there are spheres in which rights do apply and spheres in which they do not.3 cohen definitely admits humans must restrain from showing ‘brutal’ pain to animals because humans are moral beings and must not act inhumanely, yet that does not imply that any and every human activity must not touch animals in any way. the third principle, known as the most technical principle of animal ethics, is consistency. consistency holds that under similar conditions, like interests of all species must be given equal consideration. one of the best references of consistency is portrayed by nature that exists for all entities of the universe in a uniform way, and most importantly, nature treats all entities consistently. nature has systematically arranged the whole of living systems under a web of cyclical relationships, where each species struggles to survive by feeding on the other species and so on. by this process, two things are maintained – first, the relation among different species remains natural, and that species which find it difficult to survive in the whole cycle of natural predation will automatically disappear. this approach sounds extremely interesting, but is subject to severe criticisms. given this theory, in any practical situation, there will arise no scientific/natural problem in this consistency theory. the natural law of cycles has been so systematically arranged that each species can exist by being food for the other. this is definitely acceptable, but when we consider the rampant multiple uses in science and technology of experimenting animals and the destruction of natural habitat for human purposes, then the number of animals living in proper conditions comes down. in one way vegetation is dying out, in the other species are getting extinct. therefore, an ethics for the humans developed. because natural entities, say trees, animals, and wilderness, do not actually create the problem, as they are adaptable to natural changes. the problem arises for men, because men with their extreme use/misuse of power and intellect have continuously tried to dominate nature. therefore, men bangladesh journal of bioethics 2016; 7(3): 34-45 38 have to pay the cost for it. the centre of ethics is humans, not animals. ethical considerations begin from humans. therefore, humans must extend their moral/ethical considerability towards non-humans. if we take the instance of eating, then we must say that humans have a choice, whereas animals do not. humans can choose to eat fruits and other plants, but it would be extremely difficult for a carnivorous animal to think alike, as its biological system would not let him or her behave that way. the consistency principle actually reflects the view of the modern utilitarian animal activist, peter singer. his view, more widely known as preference utilitarianism, focuses on how the best interests of the greatest number of all conscious beings are to be measured, rather than measuring greater happiness. singer actually focuses on minimizing pain, rather than maximizing pleasure. for singer, what counts in animals is their pain and how much they suffer, and not whether they can reason intelligibly or not. this view mostly corresponds to what bentham argued when he said, “the question [about animals] is not, can they reason? nor can they talk? but, can they suffer?”4 in animal liberation, singer argues against prejudiced speciesism and discrimination of animals and calls for equal consideration of animals on the ground that they have the ability to suffer. he adds another element of impartiality to all species, but that must be maintained on utilitarian grounds. while applying impartial treatment to all beings (considering equally the interests of all species), the one whose utility weighs more is to be given preferential treatment. under this preferential treatment equation, as singer says, “when the interests of two ‘persons’ are in conflict, the interest of the being estimated to have the greater value receives priority.”5 singer writes: to avoid speciesism we must allow that beings who are similar in all relevant respects have a similar right to life—and mere membership in our own biological species cannot be a morally relevant criterion for this right [...]. we may legitimately hold that there are some features of certain beings that make their lives more valuable than those of other beings; but there will surely be some nonhuman animals, whose lives, by any standards, are more valuable than the lives of some humans. a chimpanzee, dog, or pig, for instance, will have a higher degree of self-awareness and a greater capacity for meaningful relations with others than a severely retarded infant or someone in a state of [advanced] senility. so, if we base the right to life on these characteristics we must grant these animals a right to life as good as, or better than, such retarded or senile human beings.6 against this principle of singer, judge richard a. posner provides a famous counterexample. suppose a dog threatens an infant in a busy street, and the only way to prevent the dog from biting would be to attack the dog, which might also cause the dog to suffer. singer would say that it is not justified to cause pain and suffering, even though it is a dog. but any sensible being would never ever stand to watch the dog bite the innocent infant. one would counter-attack the animal. this illustration brings out the notion that singer’s hierarchical cognitive capacitiesbased approach is really problematic in many senses, especially in moments of severe crisis, as it bangladesh journal of bioethics 2016; 7(3): 34-45 39 further leads to a problematic dilemma in the expression, “[s]ince neither a newborn human infant nor a fish is a person, the wrongness of killing such beings is not as great as the wrongness of killing a person.”7 this argument stands as a very good support in singer’s argument favoring infanticide and euthanasia. the core principle in support of animal ethics is to go deep into understanding the value of all beings beyond humans. it is to be remembered that humans are not in any way at the centre of the whole living system, rather humans are only one of the species among thousands of living beings in the earth. however, it is only from humans that a sense of moral responsibility develops. this sort of responsibility enables humans to perceive the beautiful presence of not only humans, but of all species and their existence in the universe. a very interesting point may be noted, where animals’ lack of cognition or reasoning becomes one of the very important and significant reasons for humans to respect them. i recall from literature survey a story where a sheep owner and a hunter have very beautifully expressed what animal feels. they said: they [animals] have no human feelings and values, they do what is in their instincts. it is very stupid to hate an animal at the individual level [...]. now i almost have to become a philosopher. they are living beings and you have to respect that. they are not humans. but we do not know for sure what they feel or do not feel. […]. we have a responsibility since we have received a brain that works differently than theirs.8 by this claim, made by very ordinary persons, it is evident that non-human animals’ lack of cognitive capabilities, which we often consider as inferior, is not to be treated so. because animals lack cognitive and reasoning capabilities, a human’s responsibility extends more and we ought to widen our toleration towards them, rather than being vulnerable towards them. quest for values: however, postmodern thinkers have brought a turn towards the very contemporary stance in the philosophy of animal rights. they claim that, given the social and cultural interlinkages in which an individual is embedded, it is extremely difficult to achieve the principles of neutrality and objectivity in reality. neutrality, universality, and consistency are definitely add-ups in ethically considering the animals, but cannot be treated as hard and fast rules or criteria for morally considering non-human animals. but why? many thinkers consider that the principles of absolute neutrality, universality, and consistency are some fixed ideals, which are at large impossible to attain in reality. what the conventional theorists miss while framing this kind of absolute principle is that the bearer of morality is humans, and humans being one of the intelligent species of this creation naturally possess the notions of domination, bangladesh journal of bioethics 2016; 7(3): 34-45 40 supremacy, and audacity towards their own species. human beings across the world vary in respect of their living, cultures, races, sexes, geography, and so on. under such varied conditions, it is difficult to lay such a fixed principle that everyone ought to extend their moral consideration towards animals based on neutral, universal, and consistent principles. but in no way must humans lose hope, since as a morally sensible and responsible species, it must always be human’s motto to shed away speciesism, and adopt a green and non-anthropocentric attitude towards life. human beings always quest for values, and this conception of value makes humanity distinct from other species. values are not something located in the platonic world. if we promote value from a subjective choice, then values are not absolute or fixed ideals, which lay imperatives for humans to follow. humans are tied to multifarious perspectives – social, economic, cultural, geographical, biological, etc. and resultantly each of us has a distinct gender, ethnic and racial identity. that what is considered ethically good in one culture may be considered bad in the other. for an instance, burping after meals is a sign of politeness in some cultures, while in others it indicates being rude or impolite. but that in no way discards the conception of universal value. my point is that there are certain imperatives that tend towards universality. suppose in a case where five patients, each with a different organ failing, are in dying bed. and luckily there is found one healthy man, whose various organs can save the life of the five dying men. should we then promote the life of the five dying men at the cost of the life of one healthy man? obviously not, since it is always immoral to kill an innocent person for the sake of others or use others merely as a means.9 life is precious to everyone, so without the consent of one, we cannot harm one’s life to save others. we ought to apply the same principle towards all sentient beings, and it is how humans’ orient themselves towards life and perspectives that doubtlessly influences how they value life and others, including non-human animals. however, in the postmodern era, especially with the emergence of the linguistic turn in the philosophical domain, humans’ views towards non-humans have also undergone changes. in addition, all social constructions and human relations are dominated mostly by power and hierarchy, which in turn largely affects humans’ relation to the non-human animals. social oppression results due to the family in which one is born into, and depends on one’s caste, class, race, sex, species, etc. i firmly agree with the postmodern feminists that along with this malefemale hierarchical structure, there also developed another classical dualistic structure, the human-animal set-up that has historically tried to separate the two both emotionally and morally. brian berry, in an article entitled “human and nonhuman animal rights and oppression: an evolution towards equality,”10 draws a similarity between oppression of human minorities and non-human animals. he writes: some humans are more oppressed than others; for example, women, racial and ethnic minorities, the poor, the differently-abled, children, the aged, and prisoners. i describe bangladesh journal of bioethics 2016; 7(3): 34-45 41 stereotypes and unfair treatment as they are similarly applied to disadvantaged humans and nonhuman animals. a primary obstacle in discussing nonhuman animal oppression is the seeming absurdity, according to many humans, of the mere notion of nonhuman animals having equal worth relative to human animals […]. prejudice against particular species is partly due to irrational messages passed along through socialization […]. [p]rejudice can be due to historical and present-day accounts of the dangers posed by [humans and even by the] non-human animals11. however, it is seen that many thinkers, such as peter singer, carol j. adams, and others, have shared similar approaches. the postmodern claim is that animal rights violations (including animal experimentation) have expanded primarily because of animals’ lack of participatory abilities in discourse and in social construction. the fate of non-human animals, whether they ought to be morally considered or not, is largely determined through this process of discourse. discourse is a segment of the critical theory of society where practical questions are addressed based on continued rational discussions. the mode of encountering discourses in different societies varies according to the various social constructs of individuals’ lives and their reasoning capabilities. fairclough defines discourse as “a practice not just of representing the world but of signifying the world, constituting and constructing the world in meaning.”12 it is through discourse that the inferiority meted out to animals can be addressed. peter singer sharply points out that the english language reflects the prejudice against non-human animals. singer writes, “[t]he english language, like other languages, reflects the prejudices of its users.”13 singer illustrates this with the word “animal,” which in common day usage excludes human beings. while speaking, we regularly use the phrase “humans and animals” to indicate that humans are something different from non-human animals, but forget that humans are also just a kind of animal. this semantic distinction actually distances humans from non-humans and makes humans irresponsive to animal suffering. peter singer writes: a liberation movement demands an expansion of our moral horizons, practices that were previously regarded as natural and inevitable come to be seen as the result of an unjustifiable prejudice […]. [w]e must be prepared to rethink all our attitudes to other groups, including the most fundamental of them. we need to consider our attitudes from the point of view of those who suffer by them, and by the practices that follow from them. if we can make this unaccustomed mental switch we may discover a pattern in our attitudes and practices that operates so as consistently to benefit the same group – usually the group to which we ourselves belong – at the expense of another group. so we come to see that there is a case for a new liberation movement.14 conventional language has several examples to show how non-human animals as a separate class are completely sidelined, ignored, and treated as inferior. whereas animals are slaughtered, bangladesh journal of bioethics 2016; 7(3): 34-45 42 humans are murdered. while the former is considered to be completely normal, the latter symbolizes brutal, violent, and uncared killing. that animals also feel pain, being fleshed bodies, is not taken into consideration at all. therefore, all of our language and discourses reflects traces of (un)intended animal oppression. this kind of socio-cultural construction dictates what morals an individual ought to possess towards animals and what not. derek ryan points out that our relations to animals depend largely on how we categorize “humans” and “animals,” and how far we can go beyond this categorization and recognize the “unrecognizable” (the animals) without any intention to capture or control them either by power or domination. feminists shun the approaches of neutrality, universality, and consistency, and rather embrace the elements of care, sympathy, kindness, etc. in favor of the neglected class of human society, i.e., women, feminists take such a stance. however, the same is extended even to animals. animals belong to an unspeakable and inexpressible class, and it is our responsibility to hear their cries and feel their pain. animals are also fleshed bodies; hence, we ought to count their sufferings. among the postmodernists’ trend, van plumwood, carol adams, vandana shiva, and many others share this feminist approach. carol adams sharply brings together animals within the socio-cultural framework. in all human endeavors, animals are objectified, commodified, and treated as an element of human consumption. resultantly, there have been many voices that spoke in favor of vegetarianism, so that animals’ presence could be felt, shared, and experienced. they have a common approach, to shun away instrumentality. animals ought not to be considered mere means for attaining something. rather, they must be considered for their own sake. therefore, it is possible for humans to be truly responsible and value non-human animals aesthetically and morally. a web of epistemic relations sets up human society (because humans are aware that they have “reason”) and each individual is tied to each other individual culturally, geographically, and linguistically. each individual or group does possess variations in their internal social structure, but all humans are essentially linked with one another in this web of chained relationships. in such a kind of structure, it is difficult to uphold and conceive moral values that are absolutely neutral, universal, and consistent. humans are the possessors of moral values. hence, all moral values originate from human perspectives and humans consider non-humans from a human perspective only. but human values must not be considered from a human viewpoint only, i.e., moral values of a human must not be anthropocentric in the sense that they must not privilege humans over non-humans. rather, it becomes humans’ responsibility to hold moral values that also reflect their responsiveness towards non-humans. moral values are not given abstractly but are rather constructed according to what human code of ethics guarantees and permits. similarly, it is true that only humans have aesthetic value, but aesthetic value is not only meant for humans. rather, the sense of beauty, truth, and goodness that humans have must extend to all species and ecosystems. through an evolutionary historical process, it has been possible for humans to go beyond the essential features such as animality and rationality and discover the traits of aesthetic beauty and responsibility as unique to them. i agree with the postmodernists when they hold that bangladesh journal of bioethics 2016; 7(3): 34-45 43 humans are already embedded in such a socio-linguistic framework, and that their moral concerns towards other species must be inculcated in a more technical way, which is familiar to the humans, i.e., through bonding. animals ought to be considered as part of human society. humans’ moral considerations and responsibility must extend in similar ways as they extend their considerations towards their fellow human beings, through care, sympathy, justice, kindness, and attention. way out: this paper doubtlessly reflects an appeal to humanity for governing all of their interactions with non-human animals based on love, sympathy, care, kindness, and so on, but parallel to this, an important question that crops up in my mind is how animal rights ought to be seen from the broader context of human rights. how far is it justified to secure animal rights in the age of perilous animal use, especially for food or during animal experimentation? this issue might seem to be a contemporary concern, yet can be traced back to the ideas of the greek philosopher aristotle, one of the earliest reflections of whom admires natural slavery. it becomes clearer from aristotle’s writing in this passage: similarly we must clearly think that after their birth, plants exist for the sake of animals, and the other animals for the benefit of men, the tame ones for service and for food, and the wild ones, if not all at least most, for the sake of food and other needs, so that clothes and tools may be made from them. if then nature makes nothing incomplete or pointless, it must have made all of them for the sake of men.15 to speak in simple words, humans’ interaction with non-human animals takes place particularly at meal times and in research. these are the oldest forms of animal use. in some cases, the practical applicability of animal use in the case of taking food is justified, especially in cases where survival of a human being overrides the loss of a chicken or goat. for instance, we can take the example of the inuit (or those living in extreme cold climatic conditions) who had to take animal flesh for keeping their bodies warm. but considering this case, we cannot justify the rampant killing of animals for flesh. or, in this connection, we can recall how benjamin franklin defends his eating of flesh in his autobiography when he writes, “if you [animals] eat each other, i don’t see why we [humans] may not eat you [animals]?”16 consuming animal flesh on this ground is justified primarily on the grounds of luxury and it reflects humans’ beastly behavior. i agree with peter singer in saying that it is absolutely unjustified to justify human consumption of animal flesh by considering animals’ dietary habits. it is because animals are not yet capable of moral reflection that humans possess. in another way, humans justify animal killing for the purpose of experimentation. being one of the intelligent species of this universe, the urge to know more has led humans to discover the undiscovered. humans continue to invent thousands of products ranging from drugs to cosmetics, leaving a grievous impact upon non-human animals. animals are regularly objectified bangladesh journal of bioethics 2016; 7(3): 34-45 44 in labs due to heavy experimentations done upon them. on one hand, it becomes extremely difficult to see the sufferings inflicted upon our neighbor species, animals, while on the other hand, would we (as opponent of experimentation) be really prepared to let thousands (of human beings) die from a dreadful disease that could be cured if experimented on only a few animals? this is really a moral dilemma, and it calls for writing another paper. nevertheless, today, when the whole world is engaged in upholding the notion of sustainable development, let us be hopeful enough and be prepared to balance human life in ways that do not cause inhumane harm to non-human animals. for a sustainable life, the minimal human interests must be balanced in accordance with the interests and welfare of the animals involved. for the sake of sustainable development, let us meet hands to promote a non-anthropocentric approach in our lives through endorsing animal welfare, a holistic approach, which integrates ethical and environmental considerations of animals. i wind up recalling a poem by kenneth cassar that reflects animals’ cries for a helping human hand: out there is a cry of anguish and of pain out there someone’s suffering for someone else’s blame out there, there is someone who’s lost all sense of hope waiting for some kind of help without which he can’t cope. out there lies a semblance of a once healthy being who’ll die a slow and painful death unless he gets some seeing but out there stands a person who cares for animals, true yes someone who can make a change, that person could be you!17 author contribution: author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgement: i dedicate this work and express my deepest compassion to the suffering of the non-human animals, who are a bigger part of our life. references: 1 tom regan, the case for animal rights, berkeley, los angeles: university of california press, 2004. 2 carl cohen, ‘do animals have rights?’ in ethics and behavior, 7(2), 91-102, 1997, 96. 3 ibid. 97. 4 jeremy bentham, ‘a utilitarian view,’ in animal rights and human obligations, ed. tom regan and peter singer, englewood cliffs, n.j: prentice hall, 1976, 129-30. bangladesh journal of bioethics 2016; 7(3): 34-45 45 5 nicholas h. lee, ‘in defense of humanity: why animals cannot possess human rights?’ in regent university law review, vol. 26: 457, 2014, 465. 6 peter singer, ‘all animals are equal,’ in contemporary moral problems, 9th edition, ed. james e. white, thomson wadswoth, 335. 7 peter singer, rethinking life and death: the collapse of our traditional ethics, 190-91, 1994, 220. 8 paul shepard puts forward this illustration during his interview with derrick jensen. see, derrick jensen, listening to the land: conservations about nature, culture, and eros, vermont: chelsea green publishing, 248-259. 9 it reminds us of a famous kantian imperative, which says not to treat anyone as an means, but always as an end. 10 b. berry, ‘human and nonhuman animal rights and oppression: an evolution towards equality’ in free inquiry in creative sociology, 25 (2), 155-160. 11 ibid. 156. 12 n. fairclough, discourse and social change, cambridge: polity press, 1992, 64. 13 peter singer, animal liberation, 2nd ed. new york: new york review, 1990, vi. 14 ibid. v. 15 richard sorabji, animal minds and humans morals: the origins of the western debate, london: duckworth, 1993, 136. 16 peter singer, practical ethics, 2nd ed. cambridge: cambridge university press, 2003, 70. 17 kenneth cassar, http://www.rabbitadvocacy.com/animal_rights_poems.htm, accessed on 2nd december, 2016. bangladesh journal of bioethics 2013; 4(1):9-19 9 peace, conflict and resolution (good vs. evil) arif hossain vice-president & founding chairman bangladesh bioethics society email: ahossainbbs@gmail.com abstract: the immense structural inequalities of the global social /political economy can no longer be contained through consensual mechanisms of state control. the ruling classes have lost legitimacy; we are witnessing a breakdown of ruling-class hegemony on a world scale. there is good and evil among mankind; thus it necessitates the conflict between the good and evil on earth. we are in for a period of major conflicts and great upheavals. it's generally regarded that mencius (c.371c.289 b.c) a student of confucianism developed his entire philosophy from two basic propositions: the first, that man's original nature is good; and the second, that man's original nature becomes evil when his wishes are not fulfilled. what is good and what is evil? philosophers of all ages have thought over this question. each reckoned that he had solved the question once and for all, yet within a few years the problem would re-emerge with new dimensions. repeated acts of corruption and evil action makes a man corrupt and takes away a man from his original nature. still now majority of the people of the world give compliance to corruption because of social pressures, economic pressures, cultural pressures and political pressures. the conflict between good and evil is ancient on earth and is prevalent to this day. may be the final confrontation between the descendants of cain and abel is at our doorsteps. during the 2 nd world war america with its european allies went into world wide military campaign to defeat germany, italy and japan. when the second world war ended in 1945 the united states of america came out as victorious. america was the first country to detonate atomic bomb in another country. during that period russia fell into competition with america in politically colonizing countries after countries. with the fall of communism russia terminated its desire wanting to be the champion of the oppressed of the world. the situation in russia continues to deteriorate, a country which until only a few years ago was a superpower. russians are deeply disillusioned today with the new politicians in russia, who they says "promise everything and give nothing." the russians still strongly oppose a world order dominated by the united states. if anyone looks at or investigates the situations in other countries it can be seen that at present almost all countries of the world are similar or same in the forms of structures of corruption and evil. the worldwide control of humanity‘s economic, social and political activities is under the helm of us corporate and military power. the us has established its control over 191 governments which are members of the united nations. the last head of state of the former soviet union, mikhail gorbachev on december 2012, at a conference on the future of the middle east and the black sea region in the turkish city of istanbul, has warned the us of an imminent soviet-like collapse if washington persists with its hegemonic policies. mass public protest occurred against us hegemony are mainly from muslim countries of south east asia, south asia, central asia, west asia, north africa and africa. the latest mass protests erupted in september 2012 when the divine prophet muhammad (pbuh) was insulted by america and israel. there were strong mass protests by people from indonesia to morocco and in the european countries by mostly immigrants and australia were there are muslim populations. this worldwide protest had occurred while the rise of the masses is ongoing against corrupt rulers in west asia and north africa. the masses of the people are thirsty and desperate for justice, dignity, economic welfare and human rights. most major religions have their own sources of information on the last age of mankind or the end of times, which often include fateful battles between the forces of good and evil and cataclysmic natural disasters. humans are evolving to a final stage of their evolution towards a ‗new age‘ that is to come which the corrupt does not understand. at present times a final battle of good versus evil on earth will ensue. the world powers (leaders) and their entourages who are really detached from the masses have organized to keep aloft the present world order that degenerates the masses in corruption, keeps the people in unhappiness, and deprives the mailto:ahossainbbs@gmail.com bangladesh journal of bioethics 2013; 4(1):9-19 10 masses from economic well being, education and keeps promoting wars and conflicts to support corruption and evil. we are at the ―end of times‖. the promised messiah will come to set right what is wrong, no doubt. introduction: at the beginning of the second half decade of this century states and ruling classes are unable to hold back the tide of worldwide popular rebellion and resorting to ever more generalized repression. as the crisis of global capitalism spirals out of control, the powers in the global system appear to be unable to propose viable solutions. the immense structural inequalities of the global social /political economy can no longer be contained through consensual mechanisms of state control. the ruling classes have lost legitimacy; we are witnessing a breakdown of ruling-class hegemony on a world scale. there is the concentration of wealth in fewer and fewer hands. corruption has penetrated every spectrum of society and in governments of all countries. humans are being choked by their rulers everywhere. people are losing security and are being threatened everyday by the corrupt systems of their own countries. today with a global population of 7 billion conflicts and upheaval are showing at unprecedented levels. there is a global battle raging between the corrupt and those who want to break free from corruption (good vs. evil). the world is sinking deeper into chaos. global elites cannot manage the explosive contradictions in societies. global elites are confused, reactive, and sinking into the quagmire of their own making. there is unprecedented concentration of control over the mass media and thought control. the global elites are unable to come up with solutions. they appear to be politically bankrupt and impotent to steer the course of events unfolding before them. humans are evolving to a final stage of their evolution towards a ‗new age‘ that is to come which the corrupt does not understand. there is good and evil among mankind; thus it necessitates the conflict between the good and evil on earth. we are in for a period of major conflicts and great upheavals. global rebellion of the masses is a doorstep away and is already taking place in major parts of the world. the "empire of global capital" is definitely not sitting idle. as global elites regroup and assess the threat of mass global revolution, they will and have already begun to organize coordinated mass repression, new wars and interventions to restore global hegemony. the subtle battle of good versus evil has been waged since the earliest times. at present times a final battle of good versus evil on earth will ensue part 1. views of philosophers on humans (good and evil): chinese philosophy consists of two schools of thought: confucianism and taoism. the question of human nature, however, is almost entirely sprung from the confucian school. it's generally regarded that mencius (c.371-c.289 b.c) a student of confucianism developed his entire philosophy from two basic propositions: the first, that man's original nature is good; and the second, that man's original nature becomes evil when his wishes are not fulfilled. 'if you let people follow their feelings (original feelings), they will be able to do good. this is what is meant by the saying that human nature is good. if a man does evil, it's not the fault of his natural endowment' all men, according to mencius, have a mind which cannot bear to see the suffering of others. for example, if you suddenly see a child about to fall into a well, your first reaction is to save him. you don't do this for the sake of befriending the child's parent or to gain praise from the public; you do it out of your original good nature. according to lau: because we are caught off our guard, the case is therefore a true manifestation of our original human nature. according to r. e. allinson, in a hermeneutic reconstruction of the child in the well example, however, such an example is not intended to prove that all men will actually take some action in such circumstances. what mencius intends to show in the child-falling-into-the-well example is that all men will at least be moved to compassion by such a sight. it is not an empirical example. it is more of a bangladesh journal of bioethics 2013; 4(1):9-19 11 phenomenological one. in other words, all we need to prove the statement is that we carry out some sort of self-examination or thought-experiment. once we are convinced, that's the proof. we don't need the results of others to confirm our result. that's a case for science. the way man loses his original good nature is like the trees in a mountain that are being subjected to endless disturbances. mencius said, 'the trees of the niu mountain were once beautiful. but can the mountain be regarded any longer as beautiful since, being in the borders of a big state, the trees have been hewed down with axes and hatches? still with the rest given them by the days and nights and the nourishment provided them by the rains and the dew, they were not without buds and sprouts springing forth. but then the cattle and the sheep pastured upon them once and again. that is why the mountain looks so bald. when people see that it is bald, they think that there was never any timber on the mountain. is this the true nature of the mountain? likewise with human nature if a man is constantly subjected to negative influence, his character is bound to be affected accordingly, despite occasional good education. but that is not his true character, or his original nature. his original nature, as mencius always insists, is good. the evil in him is a result of external influence. thus, by nature, man's original nature must be good. man's original nature becomes evil when his occupation goes against nature. ‘mencius said, 'the nature of man is good; it becomes evil because man destroys his original nature.' there are other chinese philosophers who disclaim this notion of good and evil. `what is good and what is evil?'; philosophers of all ages have thought over this question. each reckoned that he had solved the question once and for all, yet within a few years the problem would re-emerge with new dimensions. in fact, most of the answers would be later found inadequate or unsatisfactory. a few basic questions we need to ask ourselves: (1) are good and evil absolute or are they relative to the conditions associated with time and place? do conditions surrounding a particular situation make an act good and at another time make it evil? does an act appear to be good in the overall perspective, but when torn away from its environment appear to be evil? (2) is the concept of good and evil imbued in the nature of man or has he been given divine guidance? if not, how are good and evil identified? if reason is the only guide, is there some criteria to determine what is good and what is evil? (3) can we see good and evil in society? what do we naturally choose good or evil? do we give compliance to evil because of pressures? social pressures, economic pressures, cultural pressures, political pressures? who controls society, who controls the economy, who influences the culture? (4) if good and evil are independent, do they have the same creator? or is god the creator of good alone? if so, who has created evil? (5) if the knowledge of good and evil is instinctive, there should be uniformity of thought between various nations, religions and groups; but there are vast differences among them in almost every aspect. what are the reasons? socrates (470-390 bc): this great greek philosopher thought that the most important question before man is the determination of good and evil. according to him, knowledge of good and evil and its criteria are imbued in man and he can differentiate between the two if he desires so. with bangladesh journal of bioethics 2013; 4(1):9-19 12 sustained thought and guidance of nature he is in a position to know what is good and what is evil. his well known saying ‗o man! know thyself' also points to the fact that the basic principles of good and evil are innate in man and can be discovered by deliberation. socrates was firmly of the view that there should be basic principles independent of individual desires and beliefs for measuring good and evil and right and wrong. plato (428-348 bc): he thought that man is endowed with the knowledge of good and evil before coming to this world. this knowledge existed in his soul but during the period between his creation and his descent in this world, he forgot most of the things. these forgotten things can be recollected either by wise sermons or through meditation on nature. experience also helps in recollection of the forgotten. all good and evil is innate in man. to plato, the life of reason and good behavior is a happy life. good itself is happiness and the soul's paradise. aristotle (384-322 bc): he thought that reason is the greatest bounty of god, and called it the `divine spark'. if man uses his reason and other capabilities properly, he can attain self-realization after which he hardly needs any measure for good and evil. the position of self-realization is sufficient for his guidance. aristotle also considered reason and nature to be sufficient for human guidance. he said that goodness is in harmony with nature and its principles have been set by reason which a wise man can easily find. arthur shopenhauer (1788-1860 ad): this german skeptical philosopher said that man's will to live is his greatest and fundamental desire and the cause of all the struggle in the world. this is the root cause of all evil and suffering. a world where wild desires are struggling with each other, where the more powerful kill and devour the less powerful, is a world of evil; there is no goodness in it. if, however, one, through self-sacrifice, acts sympathetically with others and lives for them, happiness and peace shall prevail in this world. origin of the conflict of good and evil on earth: cain and abel: according to the book of genesis, two sons of adam and eve. cain is described as a crop farmer ( a land owner) and his younger brother abel as a shepherd. cain was the first human born and the first murderer, and abel was the first human to die. cain committed the first murder by killing his brother. by both ancient and modern commentators have typically assumed that the motive was driven by jealousy. abel's promised wife, aclima, was more beautiful. since cain would not consent to this arrangement, adam suggested seeking god's blessing by means of a sacrifice. whomever god blessed, would marry aclima. when god openly rejected cain's sacrifice, cain slew his brother in a fit of jealousy. abel, the first murder victim, is sometimes seen as the first martyr while cain, the first murderer, is sometimes seen as an ancestor of evil. bible version: adam knew his wife eve intimately, and she conceived and gave birth to cain. she said, "i have had a male child with the lord‘s help." then she also gave birth to his brother abel. now abel became a shepherd of a flock, but cain cultivated the land. in the course of time cain presented some of the land's produce as an offering to the lord. and abel also presented [an offering] — some of the firstborn of his flock and their fat portions. the lord had regard for abel and his offering, but he did not have regard for cain and his offering. cain was furious, and he was downcast. then the lord said to cain, "why are you furious? and why are you downcast? 7 if you do right, won't you be accepted? but if you do not do right, sin is crouching at the door. its desire is for you, but you must master it." cain said to his brother abel, "let's go out to the field.‖ and while they were in the field, cain attacked his brother abel and killed him. —genesis 4:1-8 bangladesh journal of bioethics 2013; 4(1):9-19 13 repeated acts of corruption and evil action makes a man corrupt and takes away a man from his original nature. this change may take place at an early age and then gradually he mostly or completely moves away from the original nature of man and goes through metamorphosis and becomes something other then human. when a group of individuals collectively becomes corrupt or a majority of a society become corrupt the social structure of the society becomes corrupt and in turn they fail to represent any worthy human values and fails to deliver happiness and peace to society. if a league of nations becomes corrupt they fail to deliver happiness and peace to the world. still now majority of the people of the world give compliance to corruption because of social pressures, economic pressures, cultural pressures and political pressures. there are planners and architects of evil and corruption in the world and there are voluntary and involuntary followers of evil and corruption in the world. in a family when parents are corrupt the children grows up to be corrupt, there are exceptions. when a government is corrupt the civil and private administration becomes corrupt, in turn the people becomes corrupt. now, corruption has entered every levels of society. it‘s hard to find a few sectors of society where there is clean administration. all developing countries have more or less the same situations related to structure of corruption. in the present age what humans lacks most is humanity. the conflict between good and evil is ancient on earth and is prevalent to this day. according to the three monotheistic religions we the mankind is the descendants of cain and abel. may be the final confrontation between the descendants of cain and abel is at our doorsteps. current world affairs: during the 2 nd world war america with its european allies went into world wide military campaign to defeat germany, italy and japan. when the second world war ended in 1945 the united states of america came out as victorious. america was the first country to detonate atomic bomb in another country. during that period russia fell into competition with america in politically colonizing countries after countries. although russia fell way short in influencing the world then what america has accomplished. in the 80‘s the then russian president gorbachev when experimenting with new philosophies for the soviet union, communism collapsed along with all its empire. now the ideology of communism rests in the museums of history. with the fall of communism russia terminated its desire wanting to be the champion of the oppressed of the world. now russia plays more of a role of advocacy politics in world affairs then direct engagements in tension ridden areas and hot spots of the world. the changes in russia: organized crime in russia began in its imperial period of tsars, but it wasn't until the soviet era that ("thieves-in-law") emerged as leaders of prison groups in gulags (soviet prison labor camps), and the thieves' code became more defined. after world war ii, the death of joseph stalin, and the fall of the soviet union, more gangs emerged in a flourishing black market, exploiting the unstable governments of the former republics, and at its highest point, even controlling as much as two-thirds of the russian economy. in modern times, there are as many as 6,000 different groups, with over 200 of them having a global reach. criminals of these various groups are either former prison members, corrupt former communist officials, russian military members and business leaders, people with ethnic ties, or people from the same region with shared criminal experiences. also during the 1970s and 1980s, america expanded its immigration policies, allowing soviet jews and criminals to enter the country, with most settling in a new york‘s southern brooklyn area known as brighton beach. russia was branded as a virtual "mafia state" according to the wikileaks cables. there has been a large increase in criminal activity in israel due to the large influx of russian-jews. the russian jewish mafia has cooperated with israeli mafiosi and the likudist, labor parties and kadima parties of israel. now most russian criminal organizations use former kgb agents as hitmen. following the collapse of communism in the soviet union in 1991, the old kgb was replaced by a new, more professional spy agency called the svr, or the state intelligence bureau. the svr was modeled after its western equivalents, the cia and britain's mi-6. but in russia, this reorganization meant that over 200,000 former informers, street detectives and gunmen of the kgb lost their jobs. it is those members of the kgb who the russian mafia now uses all over the world to carry out "special bangladesh journal of bioethics 2013; 4(1):9-19 14 assignments‖. the new russia that emerged was not the democratic state which many had hoped for: gangsterism reigns, and corruption and abuse of power have followed the breakdown of social and civil order. the communist system has been overthrown, but the mafia, not the people, became the new rulers. criminal cartels are believed to control as much as two third of russia's economy. they run their own banks, they manipulate stock exchanges and the real-estate market and they have managed to turn crime into the only really profitable growth-industry in the post-soviet era. the situation in russia continues to deteriorate, a country which until only a few years ago was a superpower. russians are deeply disillusioned today with the new politicians in russia, who they says "promise everything and give nothing." in russia, anybody can have an ordinary person killed there for 200, 400 or 600 dollars. a police chief or a bank director? perhaps as much as 20,000 dollars. but nothing is impossible. people in russia say ‗you just can't imagine how dangerous it is in russia today‘. no one is safe. russian mafia has syndicates in china, vietnam, thailand, europe and america. as of 2009, russian mafia groups have been said to reach over 50 countries. "a russian passport? you're in for trouble at every immigration checkpoint in the world. nobody knows how many russian gangsters or prostitutes there are in vietnam today. the police in bangkok estimate that there are now large numbers of russian prostitutes in thailand, and the numbers are likely to increase the wealthier the country becomes. according to a bangkok-based diplomat: "there's no shortage of local prostitutes in bangkok. but rich thai, chinese, japanese and korean businessmen prefer white girls. it gives them prestige." the americans, europeans and australians visits the prostitutes. the prices they charge us$ 200-400 as opposed to us$ 20-30 for a thai girl contribute to their special value in terms of social status. now that china is rediscovering its capitalist past, russian prostitutes are also back in large numbers in shanghai. the prostitutes share 50-50 of their income with their mafia bosses. almost all the girls sends money to their parents in russia who without that money wouldn‘t survive a month. these girls are innocent and finding no way to survive they take up this profession. they are wrongly exploited by the corrupt social structures. many girls are killed as soon as they return to russia with money which they have saved up in china and elsewhere in the far east. they are killed for their money and with a "fee" to the gunman which may be as little as us$ 200. the russians still strongly oppose a world order dominated by the united states. current russian foreign policies are motivated by political and economic gains. still the russian leader has taken a prudent position against the hegemony of america in the world today. the russian leader criticized the militant foreign policy of the west, arguing that russia‘s repeated warnings went unheeded. vladimir putin said in sept. 2012, "we did warn that prudent action was needed and that it would be wrong to try to achieve anything by force, otherwise chaos would ensue,” he said. “and what do we see today? chaos prevails.” to support his argument, putin recommended western leaders remember the lessons of history so as not to ―destroy carthage again" in their relations with weak countries. he said, "the roman empire not only seized and occupied carthage, but also destroyed it completely, killed everyone and spilled salt so that nothing could grow there," the russian leader further noted, "i would hate to see the events witnessed by mankind many centuries ago repeat themselves now,” he said. “the strong countries are trying to push their rules and their moral code on weak countries, without taking into account the history, traditions and religion of a particular country." if anyone looks at or investigates the situations in other countries it can be seen that at present almost all countries of the world are similar or same in the forms of structures of corruption and evil. is predominance of corruption a permanent structure for societies? all the good actions mankind has taken so far is directly the efforts of men and women everywhere to breakdown the predominant structures of corruptions in societies. the violent and non violent outcries of public protests seen everywhere across the world today are protests to break free from corruption and injustice! now few more questions we need to ask ourselves: 1). are the governments good and free of corruption and the people are corrupt and the government is trying to teach the people to do away with corruption and evil? bangladesh journal of bioethics 2013; 4(1):9-19 15 2). are the governments corrupt and also the people are corrupt. in turn the corrupt people vote the corrupt governments to rule? 3). are the government corrupt and the people are good? 4). are the governments corrupt and the people does not have any way out? 5). have the people become used to corruption in their daily lives or is it that they are fed up with corruption and evil and trying to break free from it? 6). in what stage of human evolution are we now? can we determine? the role of the united states in the world: the worldwide control of humanity‘s economic, social and political activities is under the helm of us corporate and military power. these us sponsored strategies ultimately consist in a process of global subordination. there are more americans dependent on the federal government now than ever before in u.s. history. according to the survey of income and program participation conducted by the u.s. census, well over 100 million americans are enrolled in at least one welfare program run by the federal government. many are enrolled in more than one. that is about a third of the entire population of the country. sadly, that figure does not even include social security or medicare. the strategies used by capitalist enterprises to increase their rates of profit in recent decades have in general caused great suffering for many workers—higher unemployment and higher inflation, lower living standards, and increased insecurity and stress and exhaustion on the job. most american workers today work harder and longer for less pay and lower benefits than they did several decades ago. the distribution of wealth in the us and europe: in the united states, wealth is highly concentrated in a relatively few hands. as of 2010, the top 1% of households (the upper class) owned 35.4% of all privately held wealth, and the next 19% (the managerial, professional, and small business stratum) had 53.5%, which means that just 20% of the people owned a remarkable 89%, leaving only 11% of the wealth for the bottom 80% (wage and salary workers). in terms of types of financial wealth, the top one percent of households have 35% of all privately held stock, 64.4% of financial securities, and 62.4% of business equity. the top ten percent have 81% to 94% of stocks, bonds, trust funds, and business equity, and almost 80% of non-home real estate. since financial wealth is what counts as far as the control of income-producing assets, we can say that just 10% of the people own the united states of america. the united states remains by far the nation with the most wealth, with 101,762 euros ($130,764) per person in stocks, bank accounts and insurance, allianz researchers said. some 39 percent of the world‘s wealth belongs to americans, while western europe accounts for another 31 percent. the gap between rich and poor is still huge. per capita wealth in the richest countries is still 45 times that of the poorest countries. women in the united states and europe have a high total income because on average they are some of the highest paid women in the world. women living in yemen and sierra leone earn 150 to 250 times less per person then the american and european women. in recent times, the world's super-rich have taken advantage of corruption to siphon off at least $21 trillion, and possibly as much as $32tn, from their home countries and hide it abroad (mostly western countries) – a sum larger than the entire american economy. the struggles of the authorities in egypt to recover the vast sums hidden abroad by hosni mubarak, his family and other cronies during his many years in power have provided a striking recent example of the fact that corrupt rulers can use their time to amass immense fortunes while many of their citizens are trapped in poverty. bangladesh journal of bioethics 2013; 4(1):9-19 16 according to unicef, almost half the world over 3.5 billion people live on less than $2.50 a day. at least 80% of humanity lives on less than $10 a day. more than 80 percent of the world‘s population lives in countries where income differentials are widening. for every $1 in aid a developing country receives, over $25 is spent on debt repayment. the poorer the country, the more likely it is that debt repayments are being extracted directly from the people who neither contracted the loans nor received any of the money. consider the global priorities in spending of wealthy developed countries in 1998: global priority $u.s. billions cosmetics in the united states 8 ice cream in europe 11 perfumes in europe and the united states 12 pet foods in europe and the united states 17 business entertainment in japan 35 cigarettes in europe 50 alcoholic drinks in europe 105 narcotics drugs in the world 400 military spending in the world 780 the basic social services in all developing countries combined: global priority $u.s. billions basic education for all 6 water and sanitation for all 9 reproductive health for all women 12 basic health and nutrition 13 race relations in the us: historical racism continues to be reflected in socio-economic inequality in america. racial stratification continues to occur in employment, housing, education, lending, and government. europe has the same race situation; in many cases is in a worse position then america. most people in the u.s. continue to have some prejudices against other races. in the view of the us human rights network, a network of scores of us civil rights and human rights organizations, "discrimination permeates all aspects of life in the united states, and extends to all communities of non american white races." discrimination against african americans, latin americans, non american white immigrants, south asians, south east asians and muslims is widely acknowledged. in america there is a strong belief amongst millions of white people that america‘s success as a world leader is a result of god‘s preferential love for white christians {the new chosen people}. in america one of every nine black families has a close relative in prison over aggressive arrests done by us law enforcement. even though usage of illegal drugs are roughly the same along racial lines, the drug policy alliance network shows that african americans constitute 13 percent of drug users, but are 38 percent of people arrested for drug offenses, and 59 percent of those convicted. a new poll found that 64 per cent of voters now believe that relations between american blacks and whites are getting worse. the survey, carried out recently, suggested that relations between whites and hispanics in the us were even worse. 71% thought they were getting worse, while 24% said they were unchanged. bangladesh journal of bioethics 2013; 4(1):9-19 17 us military control over the world: the us has established its control over 191 governments which are members of the united nations. the conquest, occupation and/or otherwise supervision of these various regions of the world are supported by an integrated network of military bases and installations which covers the entire world. all this pertains to the workings of an extensive empire, the exact dimensions of which are not always easy to ascertain. the us operates and/or controls between 700 and 800 military bases worldwide. the earth surface is being conceived as a wide battlefield which can be patrolled or steadfastly supervised from the bases. the atlantic alliance (nato) has its own network of military bases, thirty in total. the latter are primarily located in western europe. us defense spending (excluding the costs of the iraq war) have increased from 404 billions in 2001 to 626 billion dollars in 2007 according to data from the washington based center for arms control and non-proliferation. us defense spending was 640 billion dollars in 2008. when the budget was signed into law on october 28, 2009, the final size of the department of defense's budget was $680 billion. washington keeps a close eye on countries opposed to us corporate control over their resources. washington also targets countries where there is popular resistance movements directed against us interests. ―the establishment of u.s. military bases should not of course be seen simply in terms of direct military ends. they are always used to promote the economic and political objectives of u.s. capitalism. demonstrations directed against us military presence has developed in spain, ecuador, italy, paraguay, uzbekistan, and bulgaria and in many other countries. moreover, other long-term resistance movements directed against us military presence have continued in south korea, puerto rico, guam, the philippines, cuba, europe, japan and other locations. the us tends to view the earth surface as a vast territory to conquer, occupy and exploit. the fact that the us military split the world up into geographic command units vividly illustrates this underlying geopolitical reality. major elements of the conquest and world domination strategy by the us refer to: 1) keeping all governments of the world under sub-ordination. 2) the taking over of all natural resources (primary resources and nonrenewable sources of energy). 3) the control of the world economy and its financial markets. by the end of 2008, the u.s. had spent approximately $900 billion in direct costs on the iraq and afghanistan wars. indirect costs such as interest on the additional debt and incremental costs of caring for the more than 33,000 wounded borne by the veterans administration are additional. as of june 2011, the total cost of the wars in iraq and afghanistan is approximately $3.7 trillion so far. the united states wields more military power related to other nations then what the world has ever known, including rome at the peak of their empire. the usa's military spending accounted for 41 per cent of the world total military spending in 2011, followed by china with 8.2 per cent, russia with 4.1% and the uk and france with 3.6 per cent each. the us defense spending accounts for 45.7 percent of total national spending by the world's 171 governments. this is the given best form of democracy in america we have for the world. all other european countries have more or less the same structures of economy, politics, social relations, race relations and others. developing countries of the world have worse form of politics, democracy, economy and social structures. social and moral conditions of people at all levels everywhere are deteriorating and at the lowest. families are breaking up because of corruption within families. corruption and evil have infiltrated all level of society in every country of the world. the world today is more in sectarian violence then ever in the history of mankind. the last head of state of the former soviet union, mikhail gorbachev on december 2012, at a conference on the future of the middle east and the black sea region in the turkish city of istanbul, has warned the us of an imminent soviet-like collapse if washington persists with its hegemonic policies. gorbachev noted that disintegration was the atonement that the former soviet union made bangladesh journal of bioethics 2013; 4(1):9-19 18 for its mistakes and the same fate awaits the us if washington continues to repeat similar blunders of aggressions. rise of the masses in regions of the world: on april 24 2010, 100,000 people in okinawa demonstrated against u.s. bases on the island and against the 50-year old "japan-u.s. security treaty". the main demands of the growing movement in opposition to u.s. military presence in japan include an end to the 50-year old "security" treaty which permits u.s. bases and the removal of the nearly 100 u.s. military installations throughout the country. the u.s. military occupation of japan is not only a constant danger and threat to the japanese people, but to the peoples throughout asia. on 29 th january 2012 protesters marched on the us embassy in manila over ongoing negotiations between the philippine and us governments on putting more us troops and vessels in the philippines. in november 2012 south america's largest annual anti-militarization gathering occurred in columbia in an event drawing thousands to protest a us military school that trains latin american military leaders in torture techniques. the base is home to the us army school of the americas, renamed the western hemisphere institute for security cooperation, a training facility that has produced some of latin america's most notorious killers and continues to be implicated in human rights abuses today. mass public protest occurred against us hegemony are mainly from muslim countries of south east asia, south asia, central asia, west asia, north africa and africa. the latest mass protests erupted in september 2012 when the divine prophet muhammad (pbuh) was insulted by america and israel. there were strong mass protests by people from indonesia to morocco and in the european countries by mostly immigrants and australia were there are muslim populations. this worldwide protest had occurred while the rise of the masses is ongoing against corrupt rulers in west asia and north africa. repressive regimes aligned with imperialism have held down the struggle in most countries of the arab world for decades now. there's no doubt that these current upheavals in the middle east and north africa are providing tremendous strength and encouragement to the palestinian people—and fomenting equally tremendous fear and trepidation in washington and tel aviv. the governments of middle east and north africa vehemently violated human rights and reduced to mockery the dignity of the arab citizen. in brief, the arab citizen enjoyed neither liberty nor justice. since hosni mubarak assumed office in 1981 he turned egypt into a family business and instilled corruption in every corner of the country. momentous changes are taking place in the arab world. revolutions have become widespread and their impact has been domestic, regional and global. to the masses no longer is the scary ghost of the tyrants are unchallengeable. the arab world is undergoing a process of massive transformation, necessitated by profound feelings of many years of humiliating national, regional and international injustices, western-supported corruption and subjugation. prince abdulaziz bin abdullah, the saudi deputy foreign minister, recently said gulf arab states must quash any arab spring-inspired unrest or risk threats to their leadership across the oil-rich region. prince abdulaziz has said gulf states "cannot tolerate instability" that could lead to challenges to the western-allied leaders from kuwait to oman. geographically the (nation of the east), iran stands between south asia and west asia. in 1981 when the baathist regime of saddam imposed an eight year of war on iran all arab governments of the gulf and north africa (except syria) banded together who politically and militarily opposed iran and supported saddam. america, european countries, israel and the arab regimes joined their ranks with saddam to thwart the revolution in iran that stood contrary to the present world order. then in 1991 america waged war on iraq, the arab regimes and israel rallied behind america and later after some years america again attacked iraq accusing saddam of having wmd( weapons of mass destruction), whom they themselves equipped with weaponries. this time us captured saddam and later killed him, destroyed the baathist military of saddam, killed scores of iraqi civilians, bombed and destroyed the infrastructure of iraq. why the us and its allies did away with saddam and his military is a question may be even today the us regrets to answer as saddam was iran‘s arch enemy and when america and its allies are demonstrating enmity towards iran and threatening iran now with war. at present again america, israel and behind them the european governments are threatening iran with military strikes and war. with the existing situation in iran and the world once america, israel and the bangladesh journal of bioethics 2013; 4(1):9-19 19 european governments wages war on iran that would be the start of ‗armageddon-apocalypse‘ (world war 3) in the world. the masses of people of the world are thirsty and desperate for justice, dignity, economic welfare and human rights. western style democracies have failed to provide the masses any of that and have deceived the masses with false promises. with western style democracies at present a minority is ruling over the affairs of the world and the majority of the masses remain under privileged. the masses everywhere are fed up with corruption, evil and corrupt rulers. being a target of corrupt politics, corrupt economy, corrupt morality, corrupt law, corrupt administration, and corrupt religion is the prime violation of human rights for all humans. the common cry of humanity is to set the global order on the right path of justice and peace. we are at the juncture of a new age. (to be continued in part 2 (the end of times, armageddon, apocalypse or the last age of mankind) of ‗peace, conflict and resolution (good vs. evil)‘ which is going to be published in june 2013 issue of bangladesh journal of bioethics. this paper has been dedicated to the masses of the world.) microsoft word elderly care ethics bangladesh journal of bioethics 2016; 7(1):1-7 1 elderly care ethics: a glance on principlism abu sadat mohammad nurunnabi1, shaorin tanira2, sadia akther sony3 1. dr. abu sadat mohammad nurunnabi, assistant professor, department of anatomy, osd, directorate general of health services (dghs), dhaka. email: shekhor19@yahoo.com (corresponding author) 2. dr. shaorin tanira, assistant director (health), mch-fp clinic, manabik shahajya sangstha (mss), dhaka. 3. dr. sadia akther sony, mph student, department of public health and informatics (dphi), bangabandhu sheikh mujib medical university (bsmmu), dhaka. abstract: being a low-income country of south asia region, bangladesh has been struggling with its health budget for increasing elderly population over the decades. however, concerns regarding the aging population and its impact on country’s socio-economic status have come to the forefront in the policy making and implementation towards national development in recent years. this paper is intended to discuss ethical issues, in context of principlism, that are likely to arise and the means to deal with ethical dilemmas in healthcare of elderly people involving seniors themselves and their service providers whether professionals or family members. to provide the highest level of care, the entire caregiving team needs to form a partnership having the best interest of the elderly people as their focal point while providing loving, appropriate care to enhance their quality of care, their quality of life and their happiness in the latter days of their lives which is coined as ‘healthy ageing’. key words: elderly people; ageing population; elderly care ethics; healthy ageing; public health introduction: bangladesh is a low-income country of south asia region. for a realistic statistical definition for ageing in this region, particularly taking into account the average retirement age, legislation, national demographic categories, health conditions and so on, the elderly population in the context of south asian countries has been defined as those who have reached 60 years of age.1 the elderly population (aged 60 years and above) in bangladesh in 1911,1951, 1981 and 1991 were 1.37, 1.86, 4.90 and 6.05 million respectively and the projected figures for 2000, 2015 and 2025 are 7.25, 12.05 and 17.62 million. the number of elderly persons in bangladesh was projected to double from 7.8 million in 2001 to 16.2 million by 2025.2 population ageing and the associated growth in the size of elderly populations have a number of troubling policy implications. countries like bangladesh are struggling with the healthcare infrastructure and health budget. still concerns regarding the aging population and its impact on country’s socio-economic status have come to the forefront in the policy making and implementation towards national development in recent years.3 the world health organization (who) has also recognized the critical role of both public and private health care service bangladesh journal of bioethics 2016; 7(1):1-7 2 of older people worldwide and the need for these centers to be accessible and adapted to the needs of older population.4 however, ethical concerns in health care services are universal, and therefore, ethics in health care for elderly population should be addressed in all type of resource-settings throughout the country. ethics and morality are not always equivalents. ethics is frequently known the study of morals and, as such, is the study of what ought to happen, for the elderly and their healthcare providers; however, ethics can mean different things. for the elderly, ethics is about how they want to be treated and allowed to make their own decisions. for family members as caregivers, ethics is about doing what is right even when no one is looking. for professionals providing eldercare, ethics is about adherence to established canons of ethics promulgated by different professional organizations, e.g. in the united states, the american medical association for physicians, the american nurses association and national association of social workers have their own code of ethics. however, in a country like bangladesh where bioethics is still demanding to flourish and get an institutional shape, ethics of elderly care is very crucial to any discussion or reflection on ageing and health care.5 this paper is intended to discuss ethical issues that are likely to arise and the means to deal with ethical dilemmas, in context of ‘principlism’,6 in healthcare of elderly people involving seniors themselves and their service providers whether professionals or family members and the needs of professional ethical framework in elderly care. some important ethical dilemmas in elderly health care settings 1. conflicts of interest: there are several scenarios under which conflicts of interest may arise when family members and professional caregivers assist or represent the elderly people. those include: a) conflicts involving spouse and his/her wishes versus the elder’s wishes and interests; b) conflicts involving family members from different generations and their wishes versus the elder’s interest; c) conflicts involving a fiduciary (such as a guardian, conservator or agent under a power of attorney) who may have interests different than the elder; and d) conflicts involving the care provider’s business interests versus the elder’s interests, well-being and quality of life. 2. confidentiality: in the course of eldercare, family members and caregivers frequently gather a substantial amount of confidential information about the client. they owe a duty of confidentiality to the elder. not only must they not breech the confidence placed in them by releasing that private information to others, but also they must not use that information for their own benefit in such a way as to be adverse to the elder, the source of the private information. 3. decision-making capability: the elder may have capacity (be competent) or may not be competent to properly participate in the process of making decisions, both business and medical. such decisions bangladesh journal of bioethics 2016; 7(1):1-7 3 will likely have lasting effects on the elder’s future, even to his/her end of life. hence, eldercare providers have a duty to focus on the elder’s needs, both present and future. at all times, his/her interests must be considered and weighed heavily in all decision-making, especially when the elder is unable to think clearly about the decisions and the consequences thereof or to express himself/herself clearly about them. 4. veracity, the rule of truth telling: it can sometimes be overridden by other important factors, such as a responsibility to avoid ‘unnecessary distresses. it is also true that some elders do not always wish to be told the full truth. there is no universal agreement as to what extent it is permissible to either lie or to withhold full information from a patient. 5. fidelity or accountability: it is the willingness of the eldercare provider or family member to be loyal to the elder and assume responsibility for the nature and quality of the care the elder needs and receives within limits of the law. caregivers’ primary responsibility is to promote the well-being of clients. however, medical service providers/social workers’ responsibility to the larger society or specific legal obligations may sometimes supersede the loyalty owed clients, and clients should be so advised. health care institutions, state boards regulating professionals, agencies regulating care providers and society as a whole can also hold others accountable. principlism: the dominant ethical framework: the dominant theory or model for modern medical ethics or bioethics is ‘principlism’.6 although arose in the context of medicine, ‘principlism’ seems to be an appropriate framework for guidance in confronting ethical issues and making ethical decisions in situations elder caregivers of all kinds encounter.6 that is why we have considered it in this paper. “medicine, even at its most technical and scientific levels, is an encounter between human beings, and the physician’s work of diagnosing disease, offering advice, and providing treatment is embedded in a moral context.”7 this statement well describes the encounters other professionals involved in eldercare have each day and the proper context for their efforts to provide appropriate care. expanding principlism beyond its medical context, this framework suggests that caregiving ethics begins, initially, with a determination of the condition, an understanding of the situation or a recognition of the problem or conflict, coupled with respect for patient autonomy, followed by the application of the essential principles of beneficence, nonmaleficence, and justice (loyalty and fairness) along with respect for the sanctity of the life of the one being cared for. thus principlism may be understood as a framework within which particular cases (issues or conflicts or moral problems) are analyzed and addressed to an appropriate conclusion. principlism is not merely a set of “rules” per se “because prima facie principles do not contain sufficient content to address the nuances of many moral circumstances.”6 when understood and applied by all members of the team of service providers and caregivers, this principlism framework can be helpful in ethical decision-making to benefit the elder and enhance their bangladesh journal of bioethics 2016; 7(1):1-7 4 quality of life. however, this is particularly true where the elder’s capacity to make decisions or to consent to treatment is questionable. each of the four essential principles in the proposed framework is discussed below: 1) autonomy – respect for the elders’ choices: respect for individuality is a core value in our society and is no less so when dealing with the elderly. in fact, it may be even more needed because the elderly are usually not as able as the younger population to stand up for their rights and their decisions. implicit within any discussion of autonomy is the concept of equality, at least as it relates to human dignity. autonomy is the natural by-product of that value and is therefore an ideal foundation on which to build the principlism ethical framework. eldercare providers owe the elder the duty to respect his autonomy. in the process, health care providers may have to stand in the gap by being an advocate to preserve the elder’s essential autonomy. two conditions are essential for autonomy – freedom i.e. independence from controlling influences; and capacity for independent decision-making and intentional action. autonomy is, therefore, essentially involved in the elder being able to give his ‘informed consent’ to medical treatments as well as to agree to courses of action proposed by caregivers. exercising autonomy depends upon relevant information and implies a capacity to use that information, which is coined as ‘informed consent’.6 the principlism approach to dealing with ethical conflicts, in medicine, begins by educating the clients or patients concerning available options and the probable consequences of each option. unless autonomy is counterbalanced against another principle, the client exercises autonomy by choosing among his options. for an example, a senior citizen diagnosed with cancer, having all his mental faculties and has been fully informed of the benefits and consequences of various treatments, may refuse invasive treatment and elect to have alternative therapies of acupuncture and natural remedies. in this, he is utilizing his rights of autonomy. likewise, an octogenarian with capacity to decide and with necessary information about his options may choose the location for his skilled nursing care despite the recommendation of a health care service provider. autonomy can be expressed, and to some extent be exercised, by the elder through the use of ‘advance directives’ created and signed by the elder under the existing laws in some of the western countries.6 by doing so, the elder can express his intentions and have an assurance that decisions made in his autonomy while having capacity will be maintained and respected when he does not have capacity or when he cannot express his decisions. 2) beneficence – do good: beneficence is defined as the doing of good; active goodness or kindness; charity. eldercare providers of all kinds can do well by doing good. those who embrace and incorporate the principle of beneficence in their ethical decision-making can make a great difference in bangladesh journal of bioethics 2016; 7(1):1-7 5 the quality of life that elders enjoy. when the elder needs assistance, the family members are usually the first to step in – unless the emergency medical situation arises where emergency medical technicians are the first on the scene. in a life-threatening emergency, in which the patient may be unconscious, surgery may be performed before the patient’s consent can be obtained. thus the principle of beneficence is put into practice by saving the elder’s life. this occurs after a determination has been made that without intervention and consent the patient would expire. here beneficence trumps autonomy because it cannot be expressed by the elder. if the situation is not an emergency requiring immediate hospitalization or similar intervention, the elder’s family member, acting as a surrogate, will quite likely seek the assistance of the appropriate healthcare team, be it the hospital, physician, nursing staff or other eldercare providers such a home healthcare or a skilled nursing facility. the problem inherent with beneficence – no matter what member of the eldercare team is trying hard to do good is that beneficence may easily change into paternalism.6 by their superior training, knowledge, and experience, professionals such as physicians, nurses and caregivers may cross the line from beneficence to paternalism. they are better positioned to determine and advocate for the elder’s best interest than is the elder him/herself. however, those superior qualifications are neither a mandate nor permission to overrule the elder’s wishes without respecting the elder’s autonomy. however, sometimes by trying too hard to do good, a care provider may actually do emotional or psychological, if not physical, harm. for example, an old patient is told by his physician that he must have surgery immediately without giving the patient full information about the reason for this surgery, the risks and benefits, and any complications that might result. also, the patient has not been given any options or an opportunity for a second opinion or discussion with others. while the physician may be correct, his beneficence that overrides the autonomy of the competent patient results in paternalism. 3) nonmaleficence – do no harm: eldercare providers who adhere to the ethical framework of principlism incorporate the principle of nonmaleficence by doing no harm. the principles of nonmaleficence and beneficence are particularly significant for the elderly and their future quality of life. however, calculating a cost-benefit analysis of medical treatment for older patients is much more difficult than calculating such an analysis for younger patients. cost-benefit considerations in the elderly are generally more subtle and more complex, as sometimes harm is more likely and benefit is less certain.6,8 for example, a man who was given a knee replacement operation and was allowed to die at his wife’s request; it was not because the knee operation was unsuccessful, rather he developed a pulmonary complication that would have compromised his quality of life to an intolerable degree. sometimes considerations also enter into deliberations about whether or not to hospitalize an elderly patient, e.g. family members of elders want to save money by not spending on nursing home care rather convince to take care by themselves. some service care providers here (as well as the families they are trying to benefit) violate the principle of nonmaleficence. bangladesh journal of bioethics 2016; 7(1):1-7 6 4) justice: the fourth principle is justice which is a broader societal issue concerning the allocation of limited health care resources6. it is not something physicians deal with in day-to-day interactions with patients, nevertheless very important – that is how do you approach giving health care with limited budgets in a resource poor setting in a low-income country. there are two opposing sides, the strictly utilitarian ethical viewpoint and then there’s the idealistic.8,9 the supporters of the utilitarian viewpoint say that limited health care resources should be allocated to do the most good for the largest number of people. supporters of an offshoot of this utilitarian viewpoint would allocate resources where they are most likely to be successful, where the good results will be the most prolonged and where they will help the most people. however, such approach may really impact negatively on older people in terms of health care delivery. this is because the success of interventions is less in the elderly, the length of time the intervention will last is going to be less and, in most areas, the elderly do not constitute the bulk of the population.6,7,9 moreover, we would like to point out that rationing can be detrimental to the aged because it affects women more than men. above age 60, approximately for every 70 men there are 100 women.2 any strictly utilitarian approach to allocating resources based on age is going to willy-nilly have an effect that will be disproportionally felt by women.9 on the basis of the idealistic approach to justice, we should give help to people who need it the most. however, with this approach, the elderly will disproportionally need more health care budget/money than younger people, critically thinking, between these two options, perhaps there is a way to not totally disenfranchise older people and not totally do something using all our health care resources without thinking of the usefulness in terms of prolonged effect for the greatest number of people.9,10 moreover, the principle of justice invokes yet another, related duty to respect the elder’s human dignity.6,9,10 respect for human dignity is also the source of the essential autonomy principle.6,7 we tried here to discuss the ethical concerns and issues in elderly care where one party is elder population and the other one is health care service providers or caregivers; that is how relational ethics perspective refers to the reflection on the challenges encountered in person's relationship with others and on how to fulfil social roles and obligations in a good way. conclusion: ethical professional conduct while delivering eldercare will enhance the stature and credibility of the health professionals and caregivers within their community and encourage others to act in manner alike. most importantly, in the end, the elders will be benefitted the most for their quality of life will be improved as we work in their best interest. concerns regarding the ageing population and its well-being are coming to the forefront in bangladesh in recent years, though they have been less documented and explored than that of the other parts of the world where population bangladesh journal of bioethics 2016; 7(1):1-7 7 ageing has advanced further. last but not the least, to provide the highest level of care, the entire caregiving team needs to form a partnership having the best interest of the elderly people as their focal point while providing loving, appropriate care to enhance their quality of care, their quality of life and their happiness in the latter days of their lives which is coined as ‘healthy ageing. references 1. flora ms. ageing: a growing challenge. bangladesh medical journal 2011; 40(3): 48-51. 2. bangladesh bureau of statistics. population census 2001: preliminary report. dhaka: bangladesh bureau of statistics, ministry of planning, government of the people’s republic of bangladesh; 2009. 3. tanira s, nurunnabi asm, sony sa, khatun r. elderly population of bangladesh: a public health concern. journal of health science, research & policy 2015; 2(1): 2-7. 4. world health organization. active ageing series: towards age-friendly primary health care. france: world health organization. 2004. 5. ludwick r, silva m. ethics column: ethical challenges in the care of elderly persons. online journal of issues in nursing 2003; 9(1). available: www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents /volume92004/no1jan04/ethicalchallenges.aspx (seen on may 2016) 6. beauchamp tl, childress jf. principles of biomedical ethics. 7th ed. oxford: oxford university press; 2012. 7. jonsen ar, siegler m, winslade wj. clinical ethics: a practical approach to ethical decisions in clinical medicine. 7th ed. new york: mcgraw-hill; 2010. 8. meyers c. a practical guide to clinical ethics consulting: expertise, ethos and power. maryland: rowman & littlefield: 2007. 9. brock dw. justice, health care, and the elderly. philosophy & public affairs 1989; 18(3): 297312. 10. callahan d. setting limits: medical goals in an aging society with “a response to my critics”. 1st reprint ed. washington, dc: georgetown university press; 1995. conflict of interest: declared non microsoft word cervical cancer and ethical issues in hpv vaccination_17jan bangladesh journal of bioethics 2017; 8(2):30-37 31 cervical cancer and ethical issues in hpv vaccination fariha haseen1, sadia akther sony2 1. assistant professor department of public health and informatics bangabandhu sheikh mujib medical university. email: farhaseen3@gmail.com 2. research program manager department of public health and informatics, bangabandhu sheikh mujib medical university abstract: human papilloma virus (hpv) infection causes death of 270,000 people die from every year. sexually transmitted hpv was found one of the major causes of cervical cancer. world health organization (who). cervical cancer (cc) is one of the top five cancers that affect women around the world. in june 2006, the food and drug administration (fda) approved a new vaccine for women, gardasil, produced by the pharmaceutical company merck that protects against infection by certain strains of hpv, including the two strains that cause most cases of cervical cancer. vaccinations are counted as one of public health’s important development but there is an ethical dilemma between balancing personal autonomy and protection of the entire at risk population. the vaccine caused very few side effects like local reactions whereas signs or symptoms of greater importance were very. moreover it was considered that the vaccine is has an efficacy of practically 100% in prevention of precancerous lesion caused by the viral genotypes included in the vaccine. bioethicists were not convinced about compulsory vaccination laws as the values of patient autonomy and informed consent to be preeminent to them. not surprisingly, some have expressed wariness about or opposition to mandating hpv vaccination. a critical question is whether achieving a higher level of coverage justifies the infringement on parental autonomy that compulsory vaccination inevitably entails. recommendation of the universal vaccination of girls and young women may evolve ethical challenges which might make it difficult for smooth implementation of the vaccination campaigns. review of the ethical issues in hpv vaccination will constitute the main part of our paper. key words: hpv, cervical cancer, ethical issues background: human papilloma virus (hpv) is common in human. among more than 100 different types of hpv all are not health threatening. some cause common condylomas and others plantar warts, but there is a group of hpvs that mainly infects the mucous epithelium of the anogenital tract and has an oncogenic nature1. cervical cancer is the fourth most frequent cancer in women in the world and in 2012 there were approximately 530,000 new cases which represented 7.5% of all female cancer deaths and around 270,000 people die from human papilloma virus (hpv) infection every year2,3. bangladesh journal of bioethics 2017; 8(2):30-37 32 the incidence is highest in developing countries. the main reasons behind this situation are lack of resources in secondary prevention and treatment of the disease and poor sex education of the population2,3,4,5. according to world health organization (who) sexually transmitted human papilloma virus (hpv) is one of the major causes of cervical cancer. two hpv strains (16 and 18) cause 70% of cervical cancers and precancerous cervical lesions. cervical cancer (cc) is one of the top five cancers that affect women around the world6. the pharmaceutical company merck produces gardasil, which prevents infection caused by certain strains of hpv. the food and drug administration (fda) approved a gardasil as a vaccine for women in june 2006. gardasil prevents two strains (16 and 18) of hpv which cause most cases of cervical cancer7. the hpv vaccine is effective, if it is delivered before exposure to the virus, and preferably, at the pre-pubertal stage of a woman’s life because the antibody responses are higher compared to those of after puberty8. the lifetime risk of cervical cancer can reduce by 44% among 70% of the preadolescent girls (girls below age 12) who are vaccinated against hpv9. the common side effects the vaccine have been mainly local reactions. in rare cases more severe signs or symptoms were found10. moreover it is very important that the vaccine is has a 100% efficient to prevent precancerous lesions caused by the viral genotypes included in the vaccine11. though an ethical dilemma lies in the balance of personal autonomy and choice and the protection of the population from the risk, vaccinations are counted as one of greatest achievements public health. from an epidemiological point of view, due to achieve protection against human papilloma virus (hpv) infection and potential development of cervical cancer among women. hpv vaccine is widely accepted even though it may lead to the neglect of other preventive strategies against cervical cancer6. policy decisions could be evaluated through several ethical theories. utilitarianism, natural law theory via the principle of double effect, and principlism are common among the theories which are used; brief discussions of religious ethics and other possible approaches are added because of the criteria of the policy questions. zikkerman (2006) did a striking analysis that applies ethical theories, such as utilitarianism, rule of double effect and principlism are needed for policy considerations. it was reported from the analyses that hpv vaccination can be recommended universally, including at ages 11–12 years12. bioethicists, who generally hold the values of patient autonomy and informed consent to be dominant, were doubtful about the reinforcement of vaccination. some of them were worried about making hpv vaccination mandatory and some also opposed it. compulsory vaccination encompasses the question, if achieving a higher level of coverage justifies the violation on parental autonomy13. bangladesh journal of bioethics 2017; 8(2):30-37 33 cervical cancer and its prevalence: among the cancers of women in the world cervical cancer (cc) is found in the top five. international agency for research on cancer (iarc) revealed, in 2008 there were 530,000 new cases of cervical cancer worldwide, among these cases 85% were in developing countries13. approximately 47, 000 new cases of cervical cancer and 223,000 deaths occurred in the year 200015,16. though the incidence differs in different localities it is the most common gynecological cancer in developing countries15,17. in india and bangladesh 21-23% of female cancer is reported to be cervical cancer16,18,19,20. in the developing countries the lack of consciousness is one of the most common reason of the death from this fatal cancer. according to world health organization statistics, incidence of cervical cancer cases in bangladesh has been estimated 167 per 100,000 populations and 6,582 women die in the country from this cancer21,22. the development of cervical cancer, anogenital cancers, and oropharyngeal cancers are related with hpv types 16 and 1823,24. according to who cervical cancer is caused by sexually transmitted hpv26. the other risk factors associated with cervical cancer are sexual orientation before the age of 16 years, monogamy, history of sexually transmitted diseases (hiv, hsv-2, genital wart etc), high parity, black race, smoking, low socio-economic status, lack of hygiene and oral contraceptive use27. in 2006, the fda approved the hpv vaccine gardasil (against hr hpv types 16 and 18 as well as low-risk types 6 and 11) for all females aged 9 through 26. in 2009, the fda also approved the use of this vaccine in males aged 9 through23,25. the high income countries have been succeeded to prevent the disease with prophylactic immunization and secondary prevention28,29. the human papilloma virus (hpv) vaccine has recently been introduced (2016)for the first time in bangladesh by the ministry of health and family welfare (mohfw), with support from the global alliance for vaccines and immunizations (gavi). this new vaccine introduction programme will run for two years in gazipur district and if it is successful, gavi will provide support for national introduction of hpv vaccine30. ethical issues in hpv vaccination: like any other vaccines in case of hpv vaccine ethical issues are important to understand, which is sometimes context specific. it is important to review the dynamics of ethics and hpv vaccine. in recent years several countries has introduced hpv vaccine in their national program26. a new round of polarizing debates are started up with the steps taken to make the vaccine mandatory. some religious conservatives were worried and they thought that the availability of a vaccine against a sexually transmitted disease would threaten abstinence-based prevention messages before the vaccine was licensed, this concern created argument for the vaccine. abstinence is one of the approaches to hiv prevention taken by the physician organization. preventive measures include abstinence-based prevention massages like counseling adolescents and their families for being more responsible on sexual decision making including abstinence31. some religious conservatives thought that the availability of the vaccine could affect the promotion of these messages. some advocacy groups agreed availability of the vaccine, but bangladesh journal of bioethics 2017; 8(2):30-37 34 they remain did not agree on making the vaccine mandatory. their perspective was this decision of the state may lead to force a child to undergo an intervention that may be incompatible with her family’s religious values and beliefs13. the producers of the hpv vaccines were also included in the ethical controversy. the expense is huge for the research to introduce a successful product in the market. a balance in safety and efficacy is essential for successful programs. continuous research maintains the chain of new usable products. vigorous monitoring will record the success and failure of these programs globally. the reasonable aspects for hpv vaccine recommendation to people are more important than the ethical issues with any type of vaccination program32. but we cannot completely avoid the ethical issues while recommending hpv vaccine in a national immunization program of any country. holman compiled the different barriers to the vaccine. these barriers were stated by physicians and parents. physicians cite financial concerns and parental attitudes and concerns, while most parents expressed the desire for more information about the vaccine before they agree to vaccinate their children33. whether the vaccine is advisable or not of the universal vaccination program, it is the basic right of the parents to decide about the sex education for their children, so all the information regarding the hpv vaccine must be provided to the parents5. if the parents consider the vaccine inappropriate for their daughters they must have the right to refuse to vaccinate their daughters. the ultimate decision on vaccinate the children should be taken by their parents to ensure parental autonomy34,35,36 . conclusion: in summary, it can be said from the above discussion that proposing a universal hpv vaccination campaign in girls and young women does not entail any particular ethical difficulties, providing that the above mentioned premises are taken into account. however as government of bangladesh has started a two years piloting program of hpv vaccination in 4 sub-districts (upazilas) of gazipur district before scaling up the vaccine in national immunization program, it is very important to document the issues and ethical challenges which might raise concerns among parents and community and also to develop and examine innovative strategies to reduce the dilemma and address the unanswered questions related with ethical issues of hpv vaccination in local context. bangladesh journal of bioethics 2017; 8(2):30-37 35 references: 1. molijn a, kleter b, quint w, van doorn lj. molecular diagnosis of human papillomavirus (hpv) infections. journal of clinical virology. 2005 mar 31;32:43-51.y 2. human papilloma virus (hpv) and cervical cancer [internet]. world health organization. 2017 [cited 14 december 2017]. available from: http://www.who.int/mediacentre/factsheets/fs380/en/ 3. lacey cj, lowndes cm, shah kv. burden and management of non-cancerous hpvrelated conditions: hpv-6/11 disease. vaccine. 2006 aug 21;24:s35-41. 4. yang bh, bray fi, parkin dm, sellors jw, zhang zf. cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. international journal of cancer. 2004 apr 10;109(3):418-24. 5. ferlay j. 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8(2):30-37 37 29. gakidou e, nordhagen s, obermeyer z. coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. plos med. 2008 jun 17;5(6):e132. 30. hpv vaccine introduced in bangladesh [internet]. south-east asia regional office. 2017 [cited 25 september 2017]. available from: http://www.searo.who.int/bangladesh/hpvvaccinelaunch/en/ 31. post sg, botkin jr. adolescents and aids prevention: the pediatrician's role. clinical pediatrics. 1995 jan;34(1):41-5. 32. white md. pros, cons, and ethics of hpv vaccine in teens—why such controversy? translational andrology and urology. 2014 dec;3(4):429. 33. holman dm, benard v, roland kb, watson m, liddon n, stokley s. barriers to human papillomavirus vaccination among us adolescents: a systematic review of the literature. jama pediatrics. 2014 jan 1;168(1):76-82. 34. javitt g, berkowitz d, gostin lo: assessing mandatory hpv vaccination: who should call the shots? j law med ethics. 2008, 36:384–395. 35. horn l, howards c, waller j, ferris dg: opinions of parents about schoolentry mandates for the human papillomavirus vaccine. j low genit tract dis 2010, 14:43–48. 36. sussman al, helitzer d, sanders m, urquieta b, salvador m, ndiaye k: hpv and cervical cancer prevention counseling with younger adolescents: implications for primary care. ann fam med 2007, 5(4):298–304. author declaration: fariha haseen conceived the idea, conducted literature review, and developed the manuscript. sadia akther sony conducted literature review and contributed in the development of the manuscript. conflict of interest: author declared n conflict of interest. bangladesh journal of bioethics 2014; 5(1):36-42 36 ethical considerations in research with children shahanaz chowdhury assistant professor, department of community medicine, bangladesh university of health science, dhaka, bangladesh email: jesmin_70@yahoo.com abstract: ethical concerns and medical advances unique to children and adolescents make pediatric research an evolving endeavor. the current regulations for clinical research are based on a combination of ethical thought and history, some of it being very tragic. this article presents the ethical and historical underpinnings of these regulations, including elaborative discussion on ethical standards in research. in addition, the article highlights that every effort should be made to actively involve children as participants in the research process and care must be taken to protect the rights of all children, as well as specific groups of children, in research activity. key words: rights of all children, regulations for clinical research, ethical standards in research and pediatric research. historical background: the historical origin of current ethical principles for conducting research with children arises from the nuremberg trials, which took place after the second world war, the code, which emerged from these is called nuremberg code . the code sets out statements of certain moral, ethical and legal principles relating to research involving human subjects. “taken literally, research on children would be prohibited. requires the voluntary consent of the subject “as absolutely essential” later, the emergence of the declaration of helsinki in 1964, most recently amended in 1989 and 1996, now includes and examination of the issues of children as research subjects relation to informed consent 1 . the ethics of research with children is a balance. on the one hand, the focus is on ways of preventing and reducing harms in research and ensuring adequate protection of children and young people. on the other hand, there is concern about the risks and harms of silencing and excluding children from research about their views, experiences and participation. there are, however, ongoing debates in the academic literature about the ethics of social research with children, related to different disciplinary perspectives (for example, developmental psychology and the sociology of childhood) and in relation to the differences between children and adults in research. the ethics principles that apply to research with adults – such as that of ensuring freely given fully informed consent, and the right to withdraw from research participation – apply equally to children, but there are four additional provisos specific to research involving children: i. children’s competencies, perceptions and frameworks of reference, which may differ according to factors including – but not only – their age, may differ from those of adults; ii. children’s potential vulnerability to exploitation in interaction with adults, and adults’ specific responsibilities towards children; mailto:jesmin_70@yahoo.com bangladesh journal of bioethics 2014; 5(1):36-42 37 iii. the differential power relationships between adult researcher and child participant; and iv. the role of adult gatekeepers in mediating access to children, with concomitant ethical implications in relation to informed consent 2 . introduction: ‘ethics’ can be defined as 'set of moral principles and rules of conduct'. ethics in research, as one author has put it, relates to 'the application of a system of moral principles to prevent harming or wrong doing others, to promote the good, to be respectful, and to be fair' 3 ethics is a core consideration to most research. this is especially true for research that involves children where there will have to be a balance between the researcher's aims and the protection of any participants. involving children in research can enhance the scope and findings of a study. the united nations convention on the rights of the child is often used as a basis for the need to actively involve children in research, especially when that research may be used to inform and influence policy makers: “states parties shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child. there are some key concepts that should be considered by all researchers who hope to include children in their research, namely: obtaining informed consent; managing the risk of further harm to the child; and, managing what happens to the information given by participants 4 . more recently, pediatric research has come to be seen as a moral imperative 5 . methods: this is a review article done during the participation in the educational activity of national institutes of health bethesda, maryland held by bangladesh bioethics society through video conferencing on september 25, 2013 through november 11, 2013. the search was confined to google search and pubmed published articles. ethical standards in research 6 research ethics are a set of principles about how researchers and research organizations should conduct themselves when dealing with research participants, other researchers and colleagues, the users of their research and society in general. particularly relevant to the social sciences are ethics associated with projects involving human participants, including conducting surveys, focus groups and the use of secondary data. principle 1. non-harmful procedures: the investigator should use no research procedure that may harm the child either physically or psychologically. the investigator is also obligated at all times to use the least stressful research procedure whenever possible. psychological harm in particular instances may be difficult to define; nevertheless, its definition and means for reducing or eliminating it remain the responsibility of the investigator. when the investigator is in doubt about the possible harmful effects of the research procedures, consultation should be sought from others. when harm seems inevitable, the investigator is obligated to find other means of obtaining the information or to abandon the research. instances may, nevertheless, rise in which exposing the child to stressful conditions may be necessary if direct diagnostic or therapeutic benefits to the child are associated with the research. in such instances careful deliberation by an institutional review board should be sought. bangladesh journal of bioethics 2014; 5(1):36-42 38 principle 2. informed consent: before seeking consent or assent from the child, the investigator should inform the child of all features of the research that may affect his or her willingness to participate and should answer the child's questions in terms appropriate to the child's comprehension. the investigator should respect the child's freedom to choose to participate in the research or not by giving the child the opportunity to give or not give assent to participation as well as to choose to discontinue participation at any time. assent means that the child shows some form of agreement to participate without necessarily comprehending the full significance of the research necessary to give informed consent. investigators working with infants should take special effort to explain the research procedures to the parents and be especially sensitive to any indicators of discomfort in the infant. in spite of the paramount importance of obtaining consent, instances can arise in which consent or any kind of contact with the participant would make the research impossible to carry out. non-intrusive field research is a common example. conceivably, such research can be carried out ethically if it is conducted in public places, participants' anonymity is totally protected, and there are no foreseeable negative consequences to the participant. however, judgments on whether such research is ethical in particular circumstances should be made in consultation with an institutional review board. principle 3. parental consent: the informed consent of parents, legal guardians or those who act in loco parentis (e.g., teachers, superintendents of institutions) similarly should be obtained, preferably in writing. informed consent requires that parents or other responsible adults be informed of all the features of the research that may affect their willingness to allow the child to participate. this information should include the profession and institution affiliation of the investigator. not only should the right of the responsible adults to refuse consent be respected, but also they should be informed that they may refuse to participate without incurring any penalty to them or to the child. principle 4. additional consent: the informed consent of any persons, such as schoolteachers for example, whose interaction with the child is the subject of the study should also be obtained. as with the child and parents or guardians informed consent requires that the persons interacting with the child during the study be informed of all features of the research which may affect their willingness to participate. all questions posed by such persons should be answered and the persons should be free to choose to participate or not, and to discontinue participation at any time. principle 5. incentives: incentives to participate in a research project must be fair and must not unduly exceed the range of incentives that the child normally experiences. whatever incentives are used, the investigator should always keep in mind that the greater the possible effects of the investigation on the child, the greater is the obligation to protect the child's welfare and freedom. principle 6. deception: although full disclosure of information during the procedure of obtaining consent is the ethical ideal, a particular study may necessitate withholding certain information or deception. whenever withholding information or deception is judged to be essential to the conduct of the study, the investigator should satisfy research colleagues that such judgment is correct. if withholding information or deception is practiced, and there is reason to believe that the research participants will be negatively affected by it, adequate measures should be taken after the study to ensure the participant's understanding of the reasons for the deception. investigators whose research is dependent upon deception should make an effort to employ deception methods that have no known negative effects on the child or the child's family. bangladesh journal of bioethics 2014; 5(1):36-42 39 principle 7. anonymity: to gain access to institutional records, the investigator should obtain permission from responsible authorities in charge of records. anonymity of the information should be preserved and no information used other than that for which permission was obtained. it is the investigator's responsibility to ensure that responsible authorities do, in fact, have the confidence of the participant and that they bear some degree of responsibility in giving such permission. in complying with requirements for data sharing, researchers need to carefully consider whether they have provided data which, if combined, risks violating participant anonymity. principle 8. mutual responsibilities: from the beginning of each research investigation, there should be clear agreement between the investigator and the parents, guardians or those who act in loco parentis, and the child, when appropriate, that defines the responsibilities of each. the investigator has the obligation to honor all promises and commitments of the agreement. principle 9: jeopardy: when, in the course of research, information comes to the investigator's attention that may jeopardize the child's well-being, the investigator has a responsibility to discuss the information with the parents or guardians and with those expert in the field in order that they may arrange the necessary assistance for the child. researchers need to be aware that they may obtain findings suggesting that a child's health and well-being might be in jeopardy, that these findings may include false positives, and they should be knowledgeable about current human subjects procedures and regulations for informing families of incidental findings. principle 10. unforeseen consequences: when research procedures result in undesirable consequences for the participant that were previously unforeseen, the investigator should immediately employ appropriate measures to correct these consequences, and should redesign the procedures if they are to be included in subsequent studies. principle 11. confidentiality: the investigator should keep in confidence all information obtained about research participants. the participants' identity should be concealed in written and verbal reports of the results, as well as in informal discussion with students and colleagues. when a possibility exists that others may gain access to such information, this possibility, together with the plans for protecting confidentiality, should be explained to the participants as part of the procedure of obtaining informed consent. principle 12. misconception: immediately after the data are collected, the investigator should clarify for the research participant any misconceptions that may have arisen. the investigator also recognizes a duty to report general findings to participants in terms appropriate to their understanding. where scientific or humane values justify withholding information, every effort should be made so that withholding the information has no damaging consequences for the participant. principle 13. reporting results: because the investigator's words may carry unintended weight with parents and children, caution should be exercised in reporting results, making evaluative statements, or giving advice. in some kinds of investigation the giving of advice is ethical if this forms an intrinsic part of the research, is agreed with the participant and has been subject to ethics review in advance. in other circumstances, however, a researcher may obtain evidence suggesting the existence of psychological or physical problems of which a participant may appear to bangladesh journal of bioethics 2014; 5(1):36-42 40 be unaware. in such a case, the investigator has a responsibility to discuss this with the participant if the investigator believes that by not doing so the participant’s future wellbeing may be endangered. where there is an identified risk of such evidence emerging it is good practice to prepare a protocol in advance and establish an appropriate referral route. if, in the normal course of psychological research, or as a result of problems detected as above, a participant asks for advice about educational, personality, behavioural or health issues, caution should be exercised. if the issue is serious and the investigator is not competent to offer assistance, the appropriate source of professional advice should be recommended. 7 principle 14. implications of findings: investigators should be mindful of the social, political and human implications of their research and should be especially careful in the presentation of findings from the research. this principle, however, in no way denies investigators the right to pursue any area of research or the right to observe proper standards of scientific reporting. principle 15. scientific misconduct: misconduct is defined as the fabrication or falsification of data, plagiarism, misrepresentation, or other practices that seriously deviate from those that are commonly accepted within the scientific community for proposing, conducting, analyzing, or reporting research. it does not include unintentional errors or honest differences in interpretation of data. the society shall provide vigorous leadership in the pursuit of scientific investigation that is based on the integrity of the investigator and the honesty of research and will not tolerate the presence of scientific misconduct among its members. it shall be the responsibility of the voting members of governing council to reach a decision about the possible expulsion of members found guilty of scientific misconduct. principle 16. personal misconduct: personal misconduct that results in a criminal conviction of a felony may be sufficient grounds for a member's expulsion from the society. the relevance of the crime to the purposes of the society should be considered by the governing council in reaching a decision about the matter. it shall be the responsibility of the voting members of governing council to reach a decision about the possible expulsion of members found guilty of personal misconduct. different research methods: there are three main kinds of research that can involve children or child protection issues.  asking children about their feelings, opinions and experiences. this can be done either in face to face interviews with children or by questionnaire. data can also be gathered by asking parents about their children's experiences.  observing children's behavior. using monitored experiments or activities or observing children in an uncontrolled environment to see how they react during specific situations.  analyzing information contained in files about children (for example, social care case records, serious case reviews, schools records) 4 . conclusion: in recognition of the benefits of pediatric research, research ethics has evolved from position of excluding children to one of cautious advocacy-acknowledging the critical role of pediatric research, but accompanied bangladesh journal of bioethics 2014; 5(1):36-42 41 by careful consideration of the scientific context, evaluation of risks and benefits, and protection to participants. many countries have adopted regulations or guidelines to protect children in research. typically, this requires a careful analysis of the risk associated with c\each intervention and/or procedure, and evaluation of potential benefits, provisions for child assent, and ensuring adequate parent/guardian permission. the regulatory agencies overseeing pediatric research need to make a careful ethical assessment weighing sometimes complex trade-offs s as to protect children’s welfare and prevent undue risk of harm while generating scientifically valuable information to answer important questions concerning the health and welfare of children 8 . research with, and for, children (defined in ireland as people below the age of 18) is necessary and beneficial, but particular ethical concerns arise in relation to children’s involvement in research and these must be addressed. basic ethical principles apply to all research and these include a commitment to the well-being, protection and safety of participants; a duty to respect the rights and wishes of those involved; a responsibility to conduct high-quality scientific research; and a commitment to disseminate and communicate the results to stakeholders. in addition to core ethical principles, research with children requires that legal and policy commitments in relation to children, especially national and international child protection policies and guidelines, are adhered to and that a child-centred, inclusive approach to research is adopted. parental/guardian consent is required for a child to participate in research, but good practice also requires the child’s agreement or assent. confidentiality is key to research practice, but a limitation exists in child-related research if a child protection issue arises and this restriction in relation to confidentiality must be explained when obtaining consent. to ensure child protection, research with children should be carried out in accordance with children first: national guidance for the protection and welfare of children and research organizations should have a child protection policy in place, as well as a designated liaison person or member of staff responsible for the implementation of this policy. every effort should be made to actively involve children as participants in the research process and care must be taken to protect the rights of all children, as well as specific groups of children, in research activity 9 . references: 1. anne greig and jane tylo. doing research with children (sage publication) 1999 p.148. 2. research with children. http://www.ethicsguidebook.ac.uk/research-with-children-105. (access date:12/11/13) 3. sieber, j. 'the ethics and politics of sensitive research' in renzetti c & lee r m (eds) researching sensitive topics, london: sage.14.1993. 4. conducting safe and ethical research with children http://www.nspcc.org.uk/inform/research/briefings/ethical-research-factsheet_wda97712.html (access date:12/11/13) 5. shaddy re, denne sc (2010) clinical report--guidelines for the ethical conduct ofstudies to evaluate drugsin pediatric populations. pediatrics 125 (4):850-860.doi:peds.2010-0082 [pii] 10.1542/peds.2010-0082. (access date:12/11/13) 6. ethical standards in research. http://www.srcd.org/about-us/ethical-standards-research. (access date:12/11/13) 7. code of human research ethics. http://www.bps.org.uk/sites/default/files/documents/code_of_human_research_ethics.pdf bangladesh journal of bioethics 2014; 5(1):36-42 42 8. ethical considerations in conducting pediatric research. http://www.fda.gov/downloads/advisorycommittees/committees meeting materials/pediatricadvisorycommittee/ucm254315.pdf. (access date:12/11/13) 9. guidance for developing ethical research projects involving children http://www.dcya.gov.ie/documents/publications/ethics_guidance.pdf. (access date:12/11/13) ethical standards in research6 different research methods: there are three main kinds of research that can involve children or child protection issues. bangladesh journal of bioethics 2017; 8(1): 33-43 33 original article animal ethics and india: understanding the connection through the capabilities approach rhyddhi chakraborty visiting professor of philosophy and global health american university of sovereign nations, arizona, u.s.a. email: rhyddhi_414@yahoo.co.in abstract: this paper, unveiling the visionary short-sightedness of animal protection, argues for a just vision towards animals in india. critically analysing the wide range of animal protections in india, the paper finds that in spite of such protections, animals continue to suffer out of unfair and unjust treatments in the country. considering visionary shortsightedness as the reason behind these unfair and unjust treatments, the paper argues that ensuring the rights of non-human animals to basic capabilities is a fundamental and just vision towards delivering ethical and just actions towards animals. for this, the paper grounds itself on the theoretical foundation of the capabilities approach and makes some policy-level recommendations to protect animals in india. key words: animals, capabilities approach, ethics, india introduction you be good, i love you. the great silence, exhibition on making nature, wellcome collection, london, 9 december 2016 these are the last words of alex, the african grey parrot, who has been the subject of research on complex problem, language, and understanding for thirty tears. alex was precious to the world, for, being a parrot, he was able to distinguish colors, shape, and numbers, and share feelings with his researcher. while animals like alex have proved that they are able to communicate, able to aspire, and able to do, very few humans have shown justified attention and realized their aspirations, their potentials, and their entitlements. exceptions are jane morris goodall 1 , dian fossey 2 and other persons who have fought with the odds and extremities to speak on behalf of the nonhuman animals who could not speak for their own entitlements and rights. theoretically, animal rights have been endorsed and propounded by tom regan in 1983. recently, martha nussbaum, supporting the view of the protection of animal rights for the sake of animals, described some basic animal capabilities, which she argues are intrinsic to non-human animals and are needed to be ensured and protected for the sake of animals and for the sake of justice towards their due entitlements. this paper, extending martha nussbaum’s vision of the protection of animal capabilities, explains how the animal capabilities are maintained or thwarted in india. for this purpose, the mailto:rhyddhi_414@yahoo.co.in bangladesh journal of bioethics 2017; 8(1): 33-43 34 paper, first, through the description of practices of animal protection, unveils the shortcomings of the existing indian measures to protect animals and argues for the ethical connection between animal rights and capabilities. second, with the specific foundation of the justice framework of the capabilities approach, the paper argues for the protection of animal capabilities, particularly the right to life, gives reasons why that is vital for india, and explicates how it can be implemented through some policy recommendations in india. reasons to be concerned about animals in india: like many other countries, it has been a continuing tradition in india to sacrifice non-human species for medical research, industrial use, farm production, and human consumption, and also to check zoonotic diseases such as a h1n1 and a h5n1. the common fact underlying these activities is that animals are killed prematurely, mistreated with the consideration of having no dignified existence, and to a great extent unethically to save and secure human lives. in contrast, india has got a deeprooted tradition of concern, affiliation, and respect for non-human animals. for example, the two great world religions of hinduism and buddhism convey messages for the protection of animals with respect, dignity, and compassion. animals in the hindu tradition mostly have been conceived as protectors and companions of gods and humans. being associated with gods, these animals were portrayed to be preserved and conserved, for they have shown to possess the capacities to reason practically, to guide the gods and humans to the path of righteousness 3 . the religio-cultural tradition of buddhism propounded its messages of showing kindness, love, care, and sympathy for all kinds of animals – wild or domestic. gautama buddha, the propounder of buddhism, had always suggested maintaining a harmonious relation to all forms of life. the passage from the sutta nipāta reflects such thought and vision: ye keci pānabhūtatthī, tasā vā thāvarā vanavasesā / dīghā vā ye mahantā vā, majjhimā rassakā nukathūlā // ditthā vā yeca aditthā, ye ca dūre vasanti avidūre / bhūtā vā sambhavesī vā, sabbe sattā bhavantu sukhitattā // (metta sutta, sa, 146147;1974:364). in other words, “metta or loving kindness is to be practiced towards all creatures, timid and bold, great, visible and invisible, near and far, born and awaiting birth.” 4 with inspirations from such heritage, mohandas karam chand gandhi, popularly known as mahatma gandhi, has shown how animals can be protected from the slightest of slight human harm, both intentional and non-intentional. as fischer noted, gandhi propounded the notion that the practice of non-violence towards animals (besides humans) can actually sustain man and can lift the human mind above the status of animal 5 . to gandhi, it was a sin to ill-treat animals, to put animals in deprived conditions. thus, feeding stray dogs was a sin to him, for he believed that making those dogs stray was a sign of the failure of civilization and society 6 . in short, to gandhi, depriving animals of their natural environment was a sign of failure of human obligation and was a matter of injustice. bangladesh journal of bioethics 2017; 8(1): 33-43 35 in spite of such ancient indian custom of being compassionate towards non-human animals, through the historic periods, animals have continued to suffer from inhumane treatments in india. the subsections below point out some vital reasons for animal suffering in india and explain why they are unfounded, unfair, and unjust. 1.animal sacrifice for the sake of religion: in india, non-human animals such as bovines, camels, horses, goats, and chickens continue to be sacrificed for the sake of religious rituals 7 , even though the killing of animals for religious purposes has been declared to be illegal by the wildlife protection act of 1972, the local municipal corporation acts, rule 3, slaughterhouse rules, 2001, and the prevention of cruelty to animal act (pca), 1960 of indian penal code 8 . for instance, in spite of orders from the kerala high court not to trade and sacrifice camels for religious purposes, in 2015, a significant number of camels were smuggled out of rajasthan to reach kerala and were slaughtered during the festival season of eid 9 . even though it is an illegal and cognizable offense to use and incite animals for entertainment and fighting following sections 11 (1) (m) (ii) and 11 (1) (n), pca act, 1960, bulbul fighting continues to be a ritual during assam’s harvest festival of bhogali bihu, especially in the hayagriva-madhava temple in hajo, 30 km from guwahati 10 . overruling the legal rules, as the rituals have continued to meet the needs of human religions, they have pushed many animals, such as camels, to be enlisted as endangered animals in the country 11 . 2. animal sacrifice due to illegal hunting, poaching, and trafficking: in spite of a range of legal protections for animals under the wildlife protection act, 1972, illegal hunting, poaching, and trafficking continue in india, mainly to meet the demand of international agents, as representative of organized transnational crime. in the kaziranga national park, assam, for example, between 2006 and 2015, just under 200 rhinos have been documented as poached. through international cells in several south asian countries, india contributes to these illegal actions for various animal products such as mongoose hair, snake skins, rhino horn, tiger and leopard claws, bones, skins, whiskers, elephant tusks, deer antlers, turtle shells, musk pods, bear bile, and meat, feathers, and nails of birds such as parakeets, mynas, munias, etc. these actions have not only driven the animals to be endangered, but have also changed the morphology of certain geographical locations. acres and acres of wet, luscious rainforest of the north-eastern indian states of nagaland, mizoram, and manipur have witnessed a sharp decline of wild fauna, for they were either trapped or hunted 12 . one of the main obstacles to stop this illegal hunting, poaching, and trafficking, as made noticeable by investigators, is the difference in the legal status of wild animals in various countries. also, as highlighted, several trafficked animals are not protected under the convention on international trade in endangered species of wild fauna and flora (cites), and every year a few countries issue permits for legal sale of a fixed number of wild animals 13 . consequently, the animal population continues to suffer disproportionately and inequitably across the biological hot spots. 3. animal sacrifice for experimentation and research: the use of non-human animals in experiments, research, education, training, and in vivo testing is popularly known as animal testing 14 . worldwide, it is reckoned that every second approximately three animals are used bangladesh journal of bioethics 2017; 8(1): 33-43 36 for the experimentation process 15 . in india, a few years back, the findings of india’s committee for the purpose of control and supervision of experiments on animals (cpcsea) had presented a deplorable standard of animal care, shelter, and treatment in the majority of facilities inspected. such appalling conditions have not only caused inexcusable levels of animal suffering, but have also undermined any pretensions that the research was conducted scientifically, and that the results were reliable 16 . to stop this brutal process of animal experimentation, a number of legal revisions and formation of injunctions took place in the country: amendment of the pca act, 1960 in 1982; formulation of the breeding of and experiments on animals (control and supervision) rules, 1998, amended in 2001 and 2006; provision of guidelines from the committee for the purpose of control and supervision of experiments on animals (cpcsea); formation of rules and procedures by the indian national science academy (insa) and the indian council of medical research (icmr) for the care and use of animals in scientific research as well as in medical colleges, and to utilize non-animal alternatives wherever possible 17 . in 2012, the ministry of environment, forest, and climate change has issued guidelines to the university grants commission (ugc), the ministry of health and family welfare (mohfw), the pharmacy council of india (pci), and the medical council of india (mci) to discontinue dissection and experiments with live animals in universities, colleges, research institutes, hospitals, laboratories, and instead use alternatives like computer simulation to avoid unnecessary suffering or pain in animals. in spite of such legal bans and prohibitions in the country, people for the ethical treatment of animals (peta) reports that procter and gamble india has continued to test on animals in 2016, even after announcing the end of the use of tests on animals for all its current non-food and non-drug products in 1999 18 . such illegal arrangement of animal research and experimentation not only inflicts pain on their bodily health, but also affects the environment where animals deserve to be and obstructs their potentialities to grow and develop. 4. animal sacrifice for public health concerns: besides the above-mentioned causes of animal sacrifice, india complies with international health regulations for the control of zoonotic diseases such as a h1n1 and ah5n1, and culls or puts down animals to prevent the spread of zoonotic diseases in the country. table 1 highlights the number of ducks and chickens killed in india during the past few years to check and stamp out the disease of a h5n1 from the country. bangladesh journal of bioethics 2017; 8(1): 33-43 37 table 1. number of birds culled to make the country free of avian flu (source: http://dahd.nic.in) 19 year place total birds culled (lakh) february 2005 april 2006 maharashtra, gujarat 10.44 july 2007 manipur 3.39 january 2008 west bengal 42.62 april 2008 west bengal 19 november 2008 assam 5.09 december 2008 west bengal 2.01 october 2009 sikkim 4000 january 2010 west bengal 1.56 february 2011 agartala, tripura 0.21 september 2011 assam 15409 september 2012  odisha  meghalaya  tripura  karnataka 0.81 0.07 0.13 0.33 september 2013 bihar 0.06 august 2014 madhya pradesh 0.31 november-december 2014 kerala 2.7 table 1 brings to notice the numbers of birds culled each year during the last few years to check the spread of avian flu in the country. this culling procedure might have helped the country to control the spread of the disease during the respective outbreaks. however, the procedure of culling has neither helped the country to totally uproot the disease from indian soil, nor has it acted as a barrier to restrict the disease in the indian territory. rather, even after culling, the disease has continued, almost annually, and caused repetitive outbreaks and incidences in the country. most recently, there has been a rising public health concern against culling as a public health means 20 . however, without any such deep reflection of relevance and significance of culling as a major public health measure in india, culling has continued to be implemented to prevent animal-vector borne diseases in the country, leaving many animal lives to an unjust end. as the above-mentioned facts highlight, animals, in spite of being perceived as having special senses and capacities in religious traditions, continue to be ignored and continue to be used for different human purposes in india. in spite of the range of legal protections and a rich religio-cultural tradition of showing compassion and respect towards animals, the conditions of non-human animals in india have degraded. they are deprived of their due entitlements and deprived of their due rights to exercise their intrinsic capacities mainly due to inhumane attitudes towards them. the question, therefore, arises, what went wrong that led to such unjust behaviour towards non-human animals? the strive to reveal the answer obviously leads to the question about the underlying vision towards the prevention of animal killing and the protection of animals. and so, in the following part, this paper argues for this vision with bangladesh journal of bioethics 2017; 8(1): 33-43 38 a theoretical foundation on the capabilities approach (ca). there is a need for a theoretical foundation, for any sort of action demands theoretical undergirding, to drive it to proper vision and mission, and to strengthen it to have just and fair implementation, over and above, the legal provisions. the ca has been chosen as a suitable theoretical undergirding for this study, as the ca advocates to confer moral entitlements and intrinsic worth to diverse life forms, including non-human animals. capabilities approach, animals, and india: being part of the global justice requirement, the capabilities approach has been extended towards animal rights and animal welfare for the sake of animals only. as nussbaum writes, it “requires looking around the world, at the other sentient beings with whose lives our own are intrexicably and complexly intertwined.” 21 the core focus of the ca has thus been on the moral responsibilities of humans towards the ecosystem where animals and humans are living in connection with each other. going beyond utilitarian, kantian, and contractarian approaches to justice, the capabilities approach holds that every life form, including non-human animals, deserve due entitlements, dignity, respect, and scope to flourish. differing particularly from the utilitarian approach, the capabilities approach recognizes that animals have got intrinsic rights to utilize their own potentials, rather than depending on humans to use them. as against the kantian approach, the capabilities approach holds that animals have got their due rights and entitlements, for they have their own moral status to live their lives by using the practical reasoning that they possess. and in contrast to the contractarian approach, the capabilities approach conceives that animals do have the potentialities to choose the life they want to have and desire to lead. in short, according to the capabilities approach, non-human animals do have the moral capacity to think about their well-beings, to be and to do and therefore deserve a moral status. the capabilities approach views non-human animals as agents who are capable to flourish and subjects of interaction who share the same resources and space to live with humans in this world. animals, as the ca claims, deserve moral entitlements, rights of not being made to suffer, sacrificed, abused, or mistreated for the sake of animals themselves. being influenced by aristotelian philosophy, the ca admires that “there is something wonderful and wonder-inspiring in all the complex forms of animal life” 22 and argues for a world where the diverse and complex life forms of the world get the opportunity to flourish with humane guidance and responsibility, for the sake of the diverse life forms, not for any human benefits. it, thus, focuses on the welfare of all, and prescribes protection of intrinsic dignity as a basic entitlement of every life form, including non-human animals. the ethical foundation of capabilities approach aims to respect the human-animal relationship from the perspectives of both humans and other animals and follows the following principles:  animals should not be deprived of flourishing. they should be provided positive opportunities to flourish, especially by humans, for they impact pervasively on the opportunities of animals to flourish by affecting habitats, determining opportunities for nutrition, free movement, etc.  animals should be respected, not as spiritual objects, but simply as a member of animal species. bangladesh journal of bioethics 2017; 8(1): 33-43 39  animals should be given their due entitlements, at least of the following core capabilities: o life: all animals, irrespective of their size, sentience, and conscious interest, are entitled to live their lives. o bodily health: all animals are entitled to not just life, but a healthy life with adequate nutrition, and space for movement, free from abuse and violence. o bodily integrity: all animals deserve due protection of their bodily integrity from violence, abuse, and maltreatment. o senses, imaginations, thought: animals, both wild and tamed, should be equipped to manifest excellences as part of their characteristic capabilities. this also means providing proper light, space, and a variety of opportunities for animals to enable them to exercise their entitlements. o emotions: animals are known to have senses and emotions, such as fear, anger, resentment, gratitude, grief, envy, and compassion. such emotional needs of animals are to be given importance and valued. o practical reason: animals frame their life plans and life goals in their own style. this capability of them should be honored in a responsible and reasonable way. o affiliation: animals are entitled to relations with humans and other animals. they are as well entitled to world policies which grant them their rights and legal status as dignified beings, regardless of their understanding of the concerned states. o other species: animals are entitled to be independent, and also to be in interdependent species relationships in which all enjoy a cooperative and mutually supportive relationship with each other. o play: all animals deserve the provision of an adequate space, light, and sensory stimulation to enjoy and exercise their skills and competencies. o control over one’s environment: animals are entitled to own rights to their property, territories, and habitats. they are as well entitled to political participation, ensured by their human guardians who commit not to use them as mere means and to treat them rightly. this list, as nussbaum mentions, is open-ended, with the provision of supplementation and deletion of core capabilities as required 23 . however, with the foundation on these core capabilities, this paper now considers the task to analyse the cases of animal sacrifice in india and the injustice that are imposed on them at the level of their capabilities. in india, when animals are sacrificed in the name of great religions or for public health reasons, the emotions and senses of the animals are ignored and undermined. consequently, animals are made to suffer in their bodily integrities. as a result, even though these animals cannot protest against the injustice, the injustice occurs at the level of their capabilities to live the life they deserve, the treatment they have the right to claim, and in exercising their right to the just provision of their bodily health. bangladesh journal of bioethics 2017; 8(1): 33-43 40 as mentioned before, hunting, poaching, and animal trafficking are still dominant causes of animal sufferings in india, more so because of gaps in international laws. while suffering from these activities, non-human animals lose control of their own environment in a drastic and an unjust manner. they are also made to suffer from their affiliation with humans and in their abilities to live with other members of their part of the eco-system. making them suffer cause injustices at the level of their rights to basic life functions. in india, gaps and lapses in such legal scopes have failed to enable many animals to lead their lives to full forms. as a result, over and above the legal injustice, an ethical injustice is caused at the level of ensuring and enabling the animals’ right to life. for instance, even though the use of animals in research and experimentation has been prohibited in india, in many cases, it has continued for the commercial benefits of businesses in the country. while this has led to the violation of law, it has also caused an ethical injustice; animals, being maltreated for research and experimentation purposes, have been deprived of their intrinsic rights of maintaining bodily health and integrity, as well as exercising their skills and natural competencies to play and affiliate with others. to address such injustices to animals, this paper with its foundation on the ca, claims that the injustices that animals suffer are actually injustices at the level of their core capabilities. to address that, india should adopt the following recommendations. recommendations and conclusion: 1. the animal protection policy of india should adopt a vision of ensuring and enabling protection of animal capabilities to determine the scope of animal sacrifices in the country, to enable and ensure animal rights in the country. 2. the ca also demands that india should disseminate information equitably about the status of non-human animals in the country through proper education and training. this might motivate the growth of a sense of collective and shared responsibility to give up animal sacrifice in the name of religion and experimentation. in this regard, the animal protection policy can involve and engage tribes such as the bishnoi and the soliga who share not only a harmonious relationship with animals but also behave as their protectors 24 . 3. the ca also asks india to undertake a stronger and a more open and transparent collaboration between local and global governments for the proper implementation of just measures to ensure and enable the lives of animals in the wild, to respect the ownership rights of animals, and to guarantee species diversity. it also suggests the strengthening of legal measures to check the international organized crimes of animal poaching and trafficking. it implies an open and transparent animal census, the strengthening of surveillance with enhanced technology, etc. 4. as against culling as a public health measure for zoonotic diseases such as avian flu, this paper, with its foundation on the ca, suggests that india, rather than following the international recommendations, needs to discover whether any indigenous and alternative method can be useful to curb diseases in the country. that implies greater bangladesh journal of bioethics 2017; 8(1): 33-43 41 participatory decision-making, capacity-building, innovations for sustainable smallscale business strategies, and alternative livelihood arrangements for the farmers. 5. individuals, as this paper with its foundation on the ca suggests, should inculcate compassion towards animals, both as individuals and as members of the animal kingdom. it implies that individuals should refrain from buying luxury items made of leather and fur, avoid eating the meat of young animals, forgo animal shows, sports, and games as means of entertainment, avoid any direct and indirect pain on animals, letting them free in natural environment, avoid human-animal conflicts, avoid hitting animals even out of panic, fear, or anxiety, practice not to harm animals in zoos, not to make domesticated animals suffer, not to leave any animal in isolation as well as in confinement, and take a strong stand and responsibility against any form of crimes against animals. in short, the ca prescribes that individuals should enhance the unconditional accountability towards any form of animal life, realizing that animals too have got emotions, senses, and the capacity to think, and so, deserve due entitlement as animals. despite the diverse natural resources in india, the country increasingly suffers from scarcity of natural resources, man-animal conflicts, and the degradation of animal status. additionally, india, which once used to ascribe dignity to both humans and other animals, has lost its vision of treating non-human animals with justice. to address this problem, this paper suggests indian policies on animal protection to adhere to the vision of the ca and to bring about certain changes in its implementation to curb and check animal sacrifices in the country, thereby doing justice to animals, and to their rights and entitlements. author contribution: the author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgement: i am grateful to the anonymous reviewer and rainer ebert for comments that helped to improve the paper in due course of time. references 1. the jane goodall institute, uk. 2016. http://www.janegoodall.org/. last accessed 19 oct 2016. 2. hogenboom, melissa. the woman who gave her life to save the gorillas. 2015. http://www.bbc.co.uk/earth/story/20151226-the-woman-who-gave-her-life-to-save-thegorillas. last accessed 19 oct 2016. 3. chakraborty, rhyddhi. insights of hinduism and buddhism: a study of the possible remedies for deep ecological problems. m. phil. dissertation. dept. of philosophy, university of calcutta;2006. 4. ibid. 5. fischer, louise. the life of mahatma gandhi. london; 1951. http://www.janegoodall.org/ http://www.bbc.co.uk/earth/story/20151226-the-woman-who-gave-her-life-to-save-the-gorillas http://www.bbc.co.uk/earth/story/20151226-the-woman-who-gave-her-life-to-save-the-gorillas bangladesh journal of bioethics 2017; 8(1): 33-43 42 6. op.cit.,241. 7. animal sacrifice in india. 2016. http://www.occupyforanimals.net/animal-sacrifice-inindia.html. last accessed 18 oct 2016. 8. animal protection laws for the guidance of police, hawos, ngos and awos. 2016. http://www.caretrust.in/animal%20laws%20of%20india.pdf. last accessed 20 dec 2016. 9. gandhi, maneka. the sinking ship of the desert. the hindu. sept 21, 2015. http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-thedesert/article7671220.ece. last accessed 10 oct 2016. 10. kashyap, samudra gupta. in assam, a debate over banning bulbul fights. january 14, 2016. http://indianexpress.com/article/india/india-news-india/now-ban-on-bulbul-fight-inassam-temple/. last accessed 16 sept 2016. 11. festivals, like eid-ul-zuha, created a demand for rajasthan’s camels to be slaughtered and approximately 40,000 camels were slaughtered for the event of eid-ul-zuha in 2014 in the country. the demand and crisis that camels of rajasthan face these days, have reduced their numbers to 50,000 in the state and have impelled rajasthan government to declare it as state animal, even bringing it to the list of the international union for conservation of nature and natural resources (iucn) of endangered animals (ramos, jessica. help india’s dying camels before it’s too late. july 16, 2014. http://www.care2.com/causes/help-indias-dying-camels-before-its-too-late.html; gandhi, maneka. the sinking ship of the desert. the hindu. sept 21, 2015. http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-thedesert/article7671220.ece. last accessed 19 dec 2016). 12. times news network(tnn). mass killing of birds reported in mizoram. the times of india. feb 10, 2016. http://timesofindia.indiatimes.com/city/guwahati/mass-killing-ofbirds-reported-in-mizoram/articleshow/50925215.cms. last accessed 20 dec 2016. 13. wwf india. illegal wild life trade in india. special issue. 07 september, 2015. http://awsassets.wwfindia.org/downloads/traffic_panda_8_oct.pdf. last accessed 26 nov 2016. 14. badyal, dinesh k., and chetna desai. animal use in pharmacology education and research: the changing scenario. indian journal of pharmacology 2014; 46(3): 257– 265. 15. animal testing. 2016. http://www.occupyforanimals.net/animal-experimentation-vivisection.html. last accessed 10 sept 2016. 16. creamer, jan, tim phillips, chris brock, and robert martin. animal experimentation in india, unfettered science: how lack of accountability and control has led to animal abuse and poor science. animal defenders international & national anti-vivisection society. london, united kingdom; 2003. 17. badyal, dinesh k., and chetna desai. animal use in pharmacology education and research: the changing scenario. indian journal of pharmacology 2014; 46(3): 257– 265. 18. ethical consumer research association ltd. procter & gamble company animal testing. 2016. http://www.ethicalconsumer.org/companystories.aspx?companyid=19291&categoryid= 207. last accessed 25 nov 2016. http://www.occupyforanimals.net/animal-sacrifice-in-india.html http://www.occupyforanimals.net/animal-sacrifice-in-india.html http://www.caretrust.in/animal%20laws%20of%20india.pdf http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-the-desert/article7671220.ece http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-the-desert/article7671220.ece http://indianexpress.com/article/india/india-news-india/now-ban-on-bulbul-fight-in-assam-temple/ http://indianexpress.com/article/india/india-news-india/now-ban-on-bulbul-fight-in-assam-temple/ http://www.newindianexpress.com/cities/chennai/demand-for-camel-meat-soars/2013/10/15/article1835386.ece http://www.care2.com/causes/author/jessicar http://www.care2.com/causes/help-indias-dying-camels-before-its-too-late.html http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-the-desert/article7671220.ece http://www.thehindu.com/opinion/op-ed/the-sinking-ship-of-the-desert/article7671220.ece http://timesofindia.indiatimes.com/city/guwahati/mass-killing-of-birds-reported-in-mizoram/articleshow/50925215.cms http://timesofindia.indiatimes.com/city/guwahati/mass-killing-of-birds-reported-in-mizoram/articleshow/50925215.cms http://awsassets.wwfindia.org/downloads/traffic_panda_8_oct.pdf http://www.occupyforanimals.net/animal-experimentation--vivisection.html http://www.occupyforanimals.net/animal-experimentation--vivisection.html http://www.ethicalconsumer.org/companystories.aspx?companyid=19291&categoryid=207 http://www.ethicalconsumer.org/companystories.aspx?companyid=19291&categoryid=207 bangladesh journal of bioethics 2017; 8(1): 33-43 43 19. department of animal husbandry, dairying, and fisheries, govt. of india. status of avian influenza in india. 2015. http://dahd.nic.in/sites/default/files/status%20of%20avian%20influenza%20in%20india %20%209.pdf. last accessed 7 dec 2016. 20. lederman, zohar. one health and culling as a public health measure. public health ethics. advanced access. 2016. 1-19. 21. nussbaum, martha. beyond “compassion and humanity”, justice for nonhuman animals. 2003.299-320. 22. op.cit.,306. 23. op. cit.,317. 24. bbc. uk. there are people living with tigers. 2016. http://www.bbc.co.uk/earth/story/20160607-there-are-people-in-india-happily-livingwith-wild-tigers. last accessed 27 sept 2016. http://dahd.nic.in/sites/default/files/status%20of%20avian%20influenza%20in%20india%20%209.pdf http://dahd.nic.in/sites/default/files/status%20of%20avian%20influenza%20in%20india%20%209.pdf http://www.bbc.co.uk/earth/story/20160607-there-are-people-in-india-happily-living-with-wild-tigers http://www.bbc.co.uk/earth/story/20160607-there-are-people-in-india-happily-living-with-wild-tigers microsoft word engaging vulnerabilities of alzheimer bangladesh journal of bioethics 2016; 7(1):8-16 8 engaging the vulnerabilities of alzheimer’s disease: a care ethics perspective michael o.s. afolabi, b.mls, amlscn, c.ce, c.ree, phd (c) center for healthcare ethics, duquesne university, pittsburgh, pa, usa email: curiousmaikl@vahoo.com afolabim@duq.edu abstract: this paper shows that beyond the ethical issues of autonomy and human dignity there some dynamics of vulnerabilities elicited by alzheimer’s disease (ad). it therefore underscores how the ethics of care moral lens offers ethically sensitive ways of engaging the individual and social vulnerabilities of associated with ad. ultimately, the paper highlights some of the social implications of such an approach. keywords: alzheimer’s disease; autonomy; care ethics; vulnerability introduction & background: beyond its desirable aspects, the global increase in life expectancy heightens the possibility that more people will face debilitating conditions towards the end of their lives.1 such chronic conditions include alzheimer’s disease (ad) and cancers. ad elicits a constellation of issues including memory failures a sense of helplessness with attendant psychological and behavioral sequelae.2 although the burdens of ad occur at the individual, family and social nexus;3 its individual layers of burdens are more far reaching in terms of the loss of personality and personhood that increasingly set upon victims of the disease. in this regards, ad foists different degrees of vulnerability on its victims, their family members and the larger society. as such, vulnerability and dependency are key features of those needing long-term care.4 against this conceptual backdrop, this paper examines some of the ethical issues associated with alzheimer’s disease, the different spheres of vulnerability inherent in these, the relevance of a care ethics (ce) perspective in addressing them and some of the implications of such an approach for the care of ad patients. the nature and ethics of alzheimer’s disease: this section examines the nature of ad as well as some of the ethical issues it brings to the fore in the context of healthcare. the pathophysiology of alzheimer’s disease: alzheimer’s disease is a neurodegenerative, long-lasting pathology which progressively erodes mental capacities, accumulated memories and competencies.5 its underlying biological basis involves processes which facilitate the onset of an insidiously progressive loss of intellectual, cognitive and social capabilities.6 it affects multiple cerebral systems and progressively involves more and more brain regions. the resulting cognitive bangladesh journal of bioethics 2016; 7(1):8-16 9 deterioration as well as increased impairment in the activities of daily living leads to an increase in patient dependency.7 in america, the mortality rate for ad is around 100, 00 with more than 5 million americans currently diagnosed.8 this is estimated to reach 13 million by 2050.9 this prevalence probably reflects what obtains in other industrialized parts of the globe. some scholars have however suggested that ad may be higher in african countries where the growth of the proportion of elderly persons is generally greater.10 ad is characterized by neurodegenerative alteration in brain architecture brought about by the accumulation of amyloid peptides in brain neural tissue. at the molecular level, the pathogenesis and progression of alzheimer's disease result from the complex interaction of amyloid on neuroinflammation, cell plasticity and vascular changes.11 although this explanation has been partly challenged on the basis of the discorrelation between amyloid volume and extent of functional brain loss in ad, 12 the observation that mass destruction of neural tissue does not always give rise to loss of functional capacity negates this. on the other hand, this issue reflects the age-long nosological quandary between the symptoms observed in the clinic and the underlying pathologies demonstrated by medical science.13 while the neuronal changes in ad facilitates memory loss, it also fosters loss of intellectual functions.14 to be sure, it is estimated that patients with alzheimer’s generally experience a decrease of 2 to 4 points in mme scores (mini-mental state examination).15 in the western climate which celebrates autonomy and regards it as perhaps the most authentic reflection of the individual personae, this has far reaching implications in terms of selfhood and perhaps personal conception of dignity. however, there would be some variations in less autonomy-driven climates such as the african ubuntu or the asian confusian contexts. whereas this suggests how socio-cultural milieu shape the trajectory of the impacts of ad, the ethical themes associated with ad are broadly the same in terms of autonomy, human dignity and dependency. autonomy & human dignity in alzheimer’s disease: chronic conditions including ad highlight different range of ethical issues as opposed to traditional issues associated with curative medicine.16 as such they demand a different approach. indeed, caring in ad specifically elicits a number of ethical issues such as the use of restraints and how to justify these as well as the dilemmas of making sense of patients’ agitative and defensive behaviors.17 others include loss of selfhood and/or personhood and the question of dependency and how much of sacrifice may be rightly exacted from family, friends and the larger society. these issues may however be examined in terms of autonomy and human dignity. as a notion and praxis, autonomy embed self-governance within a climate of respect for others,18 as well as integrity, conscientiousness and an inherent capacity for judgment and action.19 it thus incorporates the notion of competence —the choice of acceptance or refusal of clinical interventions on the basis of cognitive comprehension20 and consequently approximates veridical accounts of a person’s preferences.21 in ad, the bangladesh journal of bioethics 2016; 7(1):8-16 10 increasing decline in cognition implies a corresponding decrease in potential autonomy. this is indeed the norm rather than the exception in ad where decision making capacities, self-awareness and will of patients become significantly diminished.22 although patient autonomy encompasses allowing each patient to choose what interventions they wish to receive, its reciprocal nature and consideration for equal respect for the autonomy of others23 suggests the contested and negotiated of autonomy in the care of ad patients. hence, patient autonomy in palliative care inevitably involves the professional/clinical judgement of healthcare workers, and depending on context and cultural milieu, the decision making and inputs from family. on the other hand, the notion of human dignity entails an inherent moral worth of persons by virtue of belonging to the community of human beings. in dementia as in ad, there occurs a gradual and irrevocable loss of everything that makes a person a human being.24 this derives largely from the deviation that ad patients increasingly acquire from the “normal” social template of being human. to be sure, patients as well as family are forced into the quandary of dealing with undignifying but characteristic symptoms of ad such as forgetfulness, unwarranted rage, agitation, dysphoria, irritability, delusions and apathy.25 to be sure, patients with alzheimer’s disease generally retain consciousness of their dementia26 which not only heightens the level of existential suffering but also “harms” their dignity. therefore, the moral quandaries associated with ad in relation to loss of autonomy and human dignity underscore some form of vulnerability which the class of patients and their relations friends and care givers experience. the next section engages this theme. vulnerability & alzheimer’s disease: human vulnerability is both connected to the state of being human and tied to the idea of human finitude.27 it is an ontological condition that fosters susceptibility to wounding and suffering from the actions of others. as such, if contextual differences between individuals potentially creates a vulnerable condition, then tangible differences including educational prowess, technological capacities, health conditions, economic clout will engender different types of vulnerabilities for different people.28 alzheimer’s disease however presents a special sort of vulnerability in terms of the fragmentation of individual selfhood and autonomous capabilities and an attendant dependency. this section examines the individual and social dynamics of this vulnerability. individual vulnerability in alzheimer’s disease: healthcare represents an instinctual and institutional response to the changing tides of health and sickness. hence, patienthood entails some degree of contextual vulnerability. if this is true, the degree of vulnerability will vary from sickness to sickness, and for diseases such as alzheimer’s disease the extent will be high. in this vein, patients with ad often suffer shame and insecurity of the uncertainty of appearing demented to others as well as proper social and physiological functioning. this fosters a growing awareness and need bangladesh journal of bioethics 2016; 7(1):8-16 11 for dependency on others and partly shapes the likelihood of their lapsing into bouts of anger, depression and deceptive behaviors.29 indeed, patients with ad are susceptible to delusions most often present in the form of beliefs of theft and infidelity, and visual hallucinations of people from the past, or of intruders.30 the unbearable suffering associated with ad partly underscores how the loss of autonomy and the need to relieve suffering make patients vulnerable to exploring desperate solutions such as euthanasia which is spurred by medical, social and psychological suffering of unbearable proportions.31 one of the paradoxes associated with this involves the relationship between individual autonomy and the relief of suffering as a justifying lens and the increasingly smaller options of good death that become open to patients32 once requests or euthanasia in the context of ad become the norm. for gordijn, the three possible scenarios involve incompetent patients, competent patients and incompetent patients with advance directives.33 however, the common threads to these is vulnerability. another kind of contextual vulnerability inherent in ad relates to the symptoms of the condition. the susceptibility of patients to falls and aggressive and self-hurting behaviors exemplifies this. being aware of this while unable to address the situation obviously constitutes a source of suffering and pain to patients, in terms of diminished intactness and personhood.34 the medical nature of this kind of vulnerability underscores not only the need for dependency on others generally but also the importance of clinical intervention in particular. social vulnerability in alzheimer’s disease: patients and relatives are central actors in palliative care and often need to work together with healthcare providers35 to choose meaningful options from the range of available interventions. this also holds true for ad contexts where the societal burden of the attendant dementia is substantial and increasing, and patients and their caregivers are faced with a range of physical and psychosocial needs.36 also, family members deal with a physically and mentally deteriorating disorder which rob their loved ones of individuality and autonomy.37 as such, there is a social dynamics to the vulnerability inherent in ad. alzheimer’s patients die before their time, but they do not die alone. bennahum captures this by stating that “the family is bereaved while the patient still lives, and that is terribly difficult to bear”.38 in other words, family and friends of ad patients suffer a constellation of psycho-social pains in watching their loved one irreversibly deteriorate, lose their memory and cognitive functions. perhaps, even more grueling is the fact that such suffering can only go away if the patient die. hence, ad presents as a form of double tragedy in terms of the pre-death suffering that families and close associates go through as well as the loss that occurs following eventual death. it is reported, for instance, that some family members of ad patients engage the vulnerability to pain to which they are subject by denying the close ties they have to such patients. a daughter of an ad patient was quoted as saying: “she is not my mother. she is not who i know her to be”.39 this suggests that the depersonization that accompanies alzheimer’s bangladesh journal of bioethics 2016; 7(1):8-16 12 disease is not restricted to the sphere of the patients but often have social sequelae. in addition to this, families and proxies of ad patients confront difficult decisions related to eating problems and recurring infections40 and medical conditions such as aspiration pneumonia, pyelonephritis or other upper urinary tract infection and septicemia.41 on the other hand, care givers are not spared of the burdens of alzheimer’s. it is reported that they may become sleepless worrying about the possibility of their patients wandering off or engaging in activities that may endanger them. this is partly responsible for the high rate of depression diagnosed in ad care givers.42 lastly, professionals in healthcare institutions also share in the social sequelae of alzheimer’s, especially in terms of the high rate of burn out which has been observed in this group.43 finally, the lost productivity and clinical care associated with ad as at 2002 was estimated $61 billion per annum.44 against this background, the last part of this paper examines a care ethics approach to the vulnerabilities o alzheimer’s. care ethics & alzheimer’s disease: persons with ad need palliative interventions focused on relief of suffering, pain control and comfort.45 although this inevitably puts ad patients in states of contextual vulnerability, such a scenario runs contrary and counter to the western cartesian conception of the body in terms of rational capacities.46 yet, the individual vulnerability inherent in ad has at its core a cognitive component which challenges claims to intactness of autonomy. indeed, if being autonomous is not completely built on the fabric of individualism and a congeries of care networks foster security, wellbeing and wellness from cradle to the grave,47 then the superimposed loss in autonomy associated with alzheimer’s necessitates some supportive care. because care ethics subsumes both action and dispositional support, it embeds the means of showing and demonstrating solidarity to ad patients. transplanted to the context of ce, solidarity as the collective action and unity of a group in terms of seeking cooperative action48 implies that family, care givers and health professionals need to provide the exigent rallying point for meeting the varied needs of ad patients. this section engages this as well as some of the implications. care ethics vis-à-vis the vulnerabilities of alzheimer’s disease: the human condition of varying vulnerabilities and frailties usually provoke a sense of compassion from those around the sick (such as family, friends and/or healthcare professionals) who consequently act in ways that foster recovery. the capacity of ce to situate moral behavior via inter-personal relationships and engage contextual and relational sensitivity49 suggests its relevance in relation to the vulnerabilities associated with ad. indeed, if human beings are existentially active and passive seekers and givers of care, it would be expected that ad patients readily respond to care while family members, care givers and professionals readily furnish this. however, how this plays out may be shaped by context. for instance, within the western autonomy-driven healthcare, it has been consistently observed that patients with alzheimer’s exhibit defensive behaviors, resisting specific clinical interventions such as tubes and the use of mechanical bangladesh journal of bioethics 2016; 7(1):8-16 13 restraints.50 however this may be missing or minimal in communitarian-oriented societies such as in africa and asia. as a set of values as well as practice, care embeds having some idea of what an other can and should become;51 thereby facilitating the realization of potentialities. this again offers an avenue through which some of the lost autonomies and dignity of ad patients may be taken up and expressed by those around them. indeed, the normative framework of ce offers a moral parameter for teasing out delicate boundaries between obligationbased ethics and responsibility-based ethics. hence, the depersonalized realm of asking “what obligations do i have to patient x with ad?” may be readily transcended while entering into the humane sphere of seeking “how can i help patient x with ad?” this underscores the idea that the ends of caring include seeking ways to engage our common vulnerabilities. in other words, since humans as individuals and social beings are trapped within the human condition with all its barrage of limitations, the instinct of care has either evolved or been created to foster ways of circumventing our frailties. but since different societies express care in different ways, how ce may ultimately engage the ethical issues associated with ad will be context-dependent. some implications for alzheimer’s disease care: it has been suggested that health policy research is essential to move advanced dementia care forward. a primary goal of such research should be to identify policies that incentivize cost-effective and evidencebased care without comprising the quality of palliative care provided to these vulnerable class of patients.52 although this connotes a move towards exploring better ways of caring for ad patients, the materialistic conception of human experiences dominant in the western context53 continues to nudge patients towards seeking the “easy way out” through advance directive request for euthanasia and physicians-assisted suicide. this is partly driven by the economic burden of rationing and prolonging life via medical technology,54 but is morally problematic due to its tendency to commoditize human life. on the other hand, the different socio-cultural context which operates in the other contexts will probably delay or continue to forestall the tide of public policy favoring the legalization of euthanasia and pas for ad patients in general and ad patients in particular. in nigeria, for instance, it has been reported that the prevalence of alzheimer’s is not as high as that that found in similar ethnic groups due to differing socio-cultural networks.55 indeed, ogunniyi recently reported that while aging populations in certain groups such as the yoruba in nigeria may have the consistent pattern of amyloid deposits in brain tissue, this does not correlate with the extent of symptoms. one possible explanation is the more socially integrated and connected way of living, which naturally facilitates bonding and reciprocal obligations.56 concluding remarks: this paper has teased out some of the vulnerabilities associated with alzheimer’s disease. it argues that the localization of care ethics around family, friends, colleagues and the public sphere57 as well as its rejection of the atomistic notion bangladesh journal of bioethics 2016; 7(1):8-16 14 of the self58 offers a useful approach for engaging some of the contextual vulnerabilities of ad. references 1. ter meulen, r. 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(wh freeman and company new york, 1989). p. 200 15. brumback, "neuropathology and symptomatology in alzheimer disease." p. 25. 16. ter meulen, "ethics of care." p. 48. 17. dekkers, "autonomy and the lived body in cases of severe dementia." pp. 115-116. 18. woods, s. "respect for autonomy and palliative care," in euthanasia: european perspectives, ed. ten have, h. and clarke, d. (2005). p. 146. bangladesh journal of bioethics 2016; 7(1):8-16 15 19. dworkin, g. the theory and practice of autonomy (cambridge university press, 1988). pp. 40-41. 20. kelly, d.f. medical care at the end of life: a catholic perspective (georgetown university press, 2006). p. 29. 21. woods, "respect for autonomy and palliative care." p. 150. 22. dekkers, "autonomy and the lived body in cases of severe dementia." pp. 119-121. 23. woods, "respect for autonomy and palliative care." pp. 153, 158. 24. dekkers, "autonomy and the lived body in cases of severe dementia." p. 118. 25. kaufer, d.i., cummings, j.l., christine, d., bray, t., castellon, s., and masterman, d. et al "assessing the impact of neuropsychiatric symptoms in alzheimer's disease: the neuropsychiatric inventory caregiver distress scale," journal of the american geriatrics society (1998). pp. 1078-1080; ten have and purtilo, "introduction: historical overview of a current global challenge." p.1. 26. o’brien, "darkness cometh: personal, social, and economic burdens of alzheimer’s disease." p.9. 27. neves, m.p. "respect for human vulnerability and personal integrity," in the unesco universal declaration on bioethics and human rights: background, principles and application, ed. ten have, h. and jean, m. (unesco, 2009). pp. 158-162. 28. afolabi, m.o. "a vulnerability/solidarity framework for a global ethic: historical & contemporary applications," revista română de bioetică 13, no. 1 (2015). p. 45. 29. o’brien, "darkness cometh: personal, social, and economic burdens of alzheimer’s disease." p. 9. 30. gauthier et al., "management of behavioral problems in alzheimer's disease." p.350. 31. dees, m. et al., "unbearable suffering of patients with a request for euthanasia or physician‐ assisted suicide: an integrative review," psycho‐oncology 19, no. 4 (2010). p. 250 32. ten have, h. "euthanasia: moral paradoxes," palliative medicine 15, no. 6 (2001). pp. 505-506. 33. gordijn, b., crul, b. and zylicz, z. "euthanasia and physician assisted suicide," in the ethics of palliative care european perspectives, ed. ten have, h. and clarke, d. (open university press, 2002). pp. 232-233. 34. morrissey, m.b.q. suffering narratives of older adults: a phenomenological approach to serious illness, chronic pain, recovery and maternal care (routledge, 2014). p. 10. 35. ten have, h. "palliative care," in the international encyclopedia of ethics, ed. hugh lafollette (blackwell publishing, 2013). 36. mitchell, s.l. "palliative care of patients with advanced dementia," in uptodate. 37. dekkers, "autonomy and the lived body in cases of severe dementia." p. 117. 38. bennahum, "the clinical challenge of uncertain diagnosis and prognosis in patients with dementia." pp. 49-51. 39. hinton, w.l. and levkoff, s."constructing alzheimer's: narratives of lost identities, confusion and loneliness in old age" culture, medicine and psychiatry 23, no. 4 (1999). p. 453. 40. mitchell et al., "advanced dementia: state of the art and priorities for the next decade." p. 46. 41. mitchell, "palliative care of patients with advanced dementia." 42. o’brien, "darkness cometh: personal, social, and economic burdens of alzheimer’s disease." pp. 10-12. 43. gauthier et al., "management of behavioral problems in alzheimer's disease." p. 450. bangladesh journal of bioethics 2016; 7(1):8-16 16 44. o’brien, "darkness cometh: personal, social, and economic burdens of alzheimer’s disease." p.13. 45. ten have and purtilo, "introduction: historical overview of a current global challenge." p.4. 46. kissell, j.l. "the moral self as patient," in ethical foundations of palliative care for alzheimer disease, ed. purtilo, r.b and ten have, h. (johns hopkins university press, 2004), p. 133. 47. robinson, f. the ethics of care: a feminist approach to human security (temple university press, 2011). p. 161. 48. mechtraud, s. "durkheim's concept of solidarity," philippine sociological review (1955). pp. 23, 27 49. vanlaere, l. and gastmans, c. "a personalist approach to care ethics," nursing ethics 18, no. 2 (2011). p. 162 50. dekkers, "autonomy and the lived body in cases of severe dementia." p. 116. 51. groenhout, r.e. connected lives: human nature and an ethics of care (rowman & littlefield, 2004). p. 37. 52. mitchell et al., "advanced dementia: state of the art and priorities for the next decade." p. 48. 53. marcum, j.a. "reflections on humanizing biomedicine," perspectives in biology and medicine 51, no. 3 (2008). p. 398. 54. kelly, d. medical care at the end of life: a catholic perspective. pp. 128-129; ten have and welie, death and medical power p. 158. 55. gureje, o., rodenberg, c.a., musick, b.s. and adeyinka, a. "prevalence of alzheimer’s disease and dementia in two communities: nigerian africans and african americans," american journal of psychiatry 152, no. 10 (1995). pp. 1585-1588 56. ogunniyi, a.o. "teasing out dementia risk factors: from field to bench," in unibadan conference on biomedical research (nigeria, 2014). 57. osuji, p.i. african traditional medicine: autonomy and informed consent, vol. 3 (springer, 2014). p. 58. 58. edwards, s.d. "is there a distinctive care ethics?" nursing ethics 18, no. 2 (2011). p. 187. conflict of interest: declared none bangladesh journal of bioethics 2017; 8(3):18-25 18 an african perspective on surrogacy and the justification of motherhood akande michael aina department of philosophy, lagos state university, ojo. lagos, nigeria. email: ainaakande@yahoo.com abstract: surrogacy as a practice is supported by science, technology, morality and legality. it follows that the issues concerning it cut across all facets of life. and different arguments have being advanced for and against this practice. the belief espouse in this paper is that one cannot discuss successfully the moral, the science or the legality of surrogacy without delving into the cultural question of who is a mother. in other words, it is possible to have simple scientific and legal understandings of the practice and still disagree on the cultural level because of its stronger emotional appeal. the purpose of this work is to expose the yoruba-african religio-cultural beliefs that have bearing on the understanding of motherhood or ownership of a child. this will be done through a critical analysis of yoruba cultural beliefs about personhood and the metaphysical underpinning between birth and the ontology of life itself. theargument here is that given some yoruba ontological belief about life, motherhood and personhood it may be difficult for the products of surrogacy to fit-in into the society in terms of personal and social development. this work goes further to recommend that cultural beliefs should be taking into consideration when making laws to guide surrogacy in order to avoid conflict between the mothers and the child. keywords: african belief, human personality, ikunle-abiyamo, motherhood and surrogacy. introduction: in surrogacy arrangement, there are four personalities which are often mentioned in various debates: the mother and father(sperm and egg donours), a woman who is the womb donour, and the child who is the product of the relationship among the adults first mentioned. this is why it becomes imperative to ask who should be the real mother? though the intention of the couple who hired a surrogate is to have a child of their own yet it is necessary to enquire who best will take care of the child. the relationship among these adults, have consequence to the development and the status of the child and it goes a long way to determine the success and failure of the practice. certain metaphysical and cosmological principles in yoruba–african philosophy do help in determining the type of relationship that should exist among all the parties, during and after the arrangement.1 it can be a life changing experience for a woman to discover that she cannot give birth to a child in the normal way like other women, but it will be joyous for her to know that she can be assisted through technology to have a child she can call her own. while adoption of children provides certain attractive joy, it is incomparable to having a child with the same genes through assisted reproductive technology (art). however, this arrangement is not totally free from certain emotional and legal problems for both the child and the couple, who adopt this technology. the concept of ownership can be problematic in surrogacy just as it is in economic and social spheres. in economic circle if something is paid for then the ownership is transferred to the person that paid. in legal terms the ordinary consent to will or transfer anything to another person is enough justification to possess it. can the same be said in surrogacy arrangement given the emotional attachment among human beings? the cultural dimension to the concept of ownership cannot be ignored in spite of the legal and economic ideas of ownership. mailto:ainaakande@yahoo.com bangladesh journal of bioethics 2017; 8(3):18-25 19 for this reason, this article will discuss some religio-cultural beliefs among the yoruba people of nigeria that have bearing on the decision of ownership of the product of surrogate arrangement. not minding the legality and the moral consent involved in surrogacy arrangement, these religio-cultural factors can create some problems during the developing years or stages of a child who is birthed through surrogacy.the task in this work is to draw attention to these factors with the aim to help strengthen the laws that will guide surrogacy arrangement in nigeria and any other culture where such beliefs exist. but before that is done, there is a need do some conceptual clarifications to foster our understanding of the issue. this will be the foundation of the arguments to be projected here. what is surrogacy? etymologically, the term surrogacy is from the latin word subrogane which means to replace, substitute or stand-in for2. it therefore, suggests that there is an original or natural process or thing to be replaced by another process or thing which is not original or natural. in a situation where what is to be substituted is not about naturalness, it can concern what is legitimate being replaced by what is not. it is this substitution and its attendant consequences that made surrogacy a moral and legal issue, especially because human beings are involved. the act of surrogacy involves helping someone to have a child or to meet the need of child bearing. it has being discovered that giving birth to a child is a natural duty of homosapiens and indeed other non-human animals. the duty of procreation to perpetuate young ones in other to populate the world for the continuity of human race is not something that societies and individuals take with levity especially in africa. however, as important as it is to procreate, it is a fact that not all human beings have the wherewithal to do so, even when they are willing. some men are born impotent; some lost it at a stage of life due to sickness, or accident. also, there are human beings who are fertile in terms of having good eggs and sperms but who have other deficiencies necessary for procreation: ruptured womb, total absence of womb, feeble bodily system or structure, low but active egg sperm count, to mention but a few3 under the above situations, it seems the primary and important factors for procreation are present but the secondary and equally important factors are absent. but the good news is that these secondary factors can be borrowed, bought or negotiated from a willing person, thereby completing the process. what is to be borrowed, bought or negotiated here are another person’s body, womb and time while the sperm and the egg belong to original intending parents who are willing to have babies or a baby. surrogacy then by interpretation is a form of contract between basically two or three people to carry out a form of biological duty or business. for odidika umeora et al (2014) “surrogate motherhood refers to a situation whereby a third party female is commissioned, or elect to carry a pregnancy on behalf of another couple, delivers a baby and hands the child over to the parents at birth”4. the act by the analysis above takes its name from the surrogate (substituted mother) mother who is the carrier of the embryo and the woman who birthed the child. it therefore, seems that it is only women who are surrogates, but it is possible to have circumstances that could make a man to be a surrogate. bangladesh journal of bioethics 2017; 8(3):18-25 20 types of surrogacy: the nature of the problem of a couple most of the times determines the type of surrogacy arrangement. basically there are two types of surrogacy but there are three types of circumstances or conditions for adopting surrogacy. the first type of surrogacy is called traditional surrogacy and the second is called gestational surrogacy. two people are involved in the traditional type. the contract is between a woman who is not a wife and a father who donates his sperm to the woman. in this case, the surrogate mother is equally the biological mother since her egg is the one being fertilized through intrauterine insemination (iui). this process is at times called partial surrogacy5. in gestational surrogacy, three people are involved. in this process, the embryo is created first by fertilizing the egg of the commissioning mother with the sperm of the commissioning father through vitro-fertilization before transferring the embryo to the surrogate mother’s womb. in this process, the surrogate mother is not genetically linked to the child. it can also be referred to as full surrogacy6. in both types of surrogacy, there are moral, legal, economic, psychological, religious and socio-cultural implications. while some surrogacy arrangements are purely altruistic depending on the relationship already established between the surrogate mother and the commissioning couple, others are egoistic. some surrogate mothers consented to carry the fetus for self-financing, and some commissioning mothers run from the pains of birth and motherhood; both circumstances are egoistic in these respects. whereas surrogate mothers that agreed based on friendship and family relationship and commissioning fathers who donate their sperm for free so that someone might enjoy the taste of motherhood are altruistic in that respect. one reason for engaging in surrogacy is the dictates of modern societies where some jobs dictate to women when not to be pregnant, this can make them transfer the duty of given birth to another woman. it has also being observed that some women want to avoid the pain of carrying a pregnancy for 9 months and the attendant painful process of birth. the third reason is the health and biological conditions of the intending couple. surrogacy is therefore multifaceted in terms of the reasons adduced for its practice and the benefits that can accrue from it. the purpose of this work is to explore the religio-cultural dimension especially as it relates to certain metaphysical beliefs of the yoruba people which may discourage the practice or affect the status of the child in that society. it is for this purpose that we shall turn to yoruba cultural beliefs about motherhood and human personality. yoruba idea of human personality and the view about life: the yoruba people are majorly from the western part of nigeria, which is the most populous country in africa. nigeria comprises of about three major ethnic nationalities: yoruba, igbo and hausa with sub-ethnic groups numbering about two hundred and fifty tribes. outside nigeria the yoruba people are found in brazil, cuba, america and some west african countries like republic of benin and togo7. a recent study estimates the population of the yoruba people quite a bit over 25 million8. in yoruba ontology, spirit is the life force which controls the lives of every occupant of the physical world. this belief does not exclude the belief in material life force but it places the spiritual in a vantage position. god, divinities, ancestors, men, animals and plants share in these mythical forces. while god is at the apex of life, the plants are at the base. even non-living things like stones occasionally are possessed by spirits9. bangladesh journal of bioethics 2017; 8(3):18-25 21 inspite of the differences between spirit and matter, yoruba people believe that there is a harmonious relationship between them. this explains chiedozie okoro assertion that african philosophical metaphysics espouse a duality of being rather than dualism10. all these qualifications are attempts to show the interdependency of the material and the spiritual.this philosophy permeates other traditional thoughts especially those of destiny, personhood, which are the focus of this section. components of human personality: in traditional yoruba thought, a person is made up of both spiritual and physical parts. the physical part consists of ara (body),ese (leg), and okan(heart) while the spiritual part has emi (soul), ori (inner head), okan (heart) and ese (inner leg).11though, it may be enough to mention ara, ori and emi as the major components but the yoruba philosophy having found some functions for ese and okan in the development and realization of individual destiny, balogun decided to include them in addition to the main ones. notwithstanding the special function that is unique to each of these components their connections cannot be ignored. for example, ara, carries both the ori and the ese while emi is connected to the ara as the engine house, it is also connected to okan which is the physical representation of the mind. ori and ese and are connected as spiritual components. ara (body) is the physical part of the human person which is responsible for movement and other physical activities. but it is essentially the house of emi (soul) which is responsible for life. without emi, ara is useless especially as it relates to life and bodily movement. ori (inner head) is the carrier of human destiny in conjunction with ese (inner leg). the uniqueness of yoruba traditional thought about human personality is that these components have both spiritual and physical manifestation. every individual in this regard is both a physical and a spiritual being. it is for the above reason that okoro chiedozie describes african metaphysics of existence as a duality, rather than a dualism. while dualism is the belief in two separate entities, duality is the belief in two distinct but inseparable entities. however, from the foregoing, the belief in human personality can be categorized as tripartite conception because it consists of the natural (ara), the supernatural/psychic(okan, ese) and the spiritual (emi).ese and okan are categorized as supernatural here because they have both natural and spiritual manifestations12. whatever anyone is or will become can only be explained by both physical and spiritual factors. the idea of destiny in yoruba thought just like that of human personality mirrored a tripartite approach. there is akunleyan (that which one kneeled down to choose), akunlegba (that which is bestowed on one while kneeling down) and adayeba (which is the destiny (opportunities) of one’s immediate environment in the world). so, what a person will become depends on these three sorts of destiny13. akunlegba represents the destiny of the body which is not a product of choice. it is what the maker of man or nature embedded in the nature of the physical body. akunleyan is the choice an individual makes for himself/herself. this is the one that bestowed responsibility on the human person. adayeba is the social destiny or the opportunities presented by the society. it is this one that connects all choices of different individual who found themselves in the same environment. the destiny(happiness or sadness), opportunities that are shared as a member of a family, organization or society. in other words, the destiny bestowed on a man and the one he chose as a person will only be bangladesh journal of bioethics 2017; 8(3):18-25 22 realized if the opportunities in the society are favourable to the others too. from the above analysis, it can be argued that yoruba traditional philosophy of life is characterized with interconnectedness of existence. it is for this reasonthat yoruba people live a communal life and are utilitarian in moral thinking14.living together as a family with the interests of majority taken into consideration in every step of life isat the fulcrum of yoruba people’s social life. a yoruba perspective on the status of a child in surrogate arrangement: the robustness of debates on surrogacy is not in doubt.nevertheless, nigeria which housesthe largest population of the yoruba has not taken a stand on any of the above consideration. as a matter of fact, the issues in surrogacy have not been placed in the centre of any discussion on motherhood and the birth process, though the practice exists. this work therefore,centered its focus on the religio-cultural or metaphysical implications of surrogacy which is hardly discussed in previous debates either in the west or in africa. the first belief to be considered that borders on the argument about ownership is the belief that blood is sacred. no wonder the saying: ‘blood is thicker than water’ is used to express the bond between family members. the question of ownership is necessary because of the great importance placed on blood in yoruba traditional thought. to an average yoruba person, the life of an animal or person is in the blood. in accordance to this belief, the woman that smearedher blood on the child at birth is the right owner of the child. this concept is called ikunle abiyamo (the pain of motherhood or the authority of motherhood).mothers in yoruba culture always invoke this authority of motherhood to make demand or pray for their children.15 if a woman says emi ni mo da eje si lori (i am the one that pour blood on him/her) she is making a claim of ownership and therefore authority of parenthood is morally and spiritually conferred. another saying of note here is inu mi ni mo fi bi e meaning i bore you from my womb. the authority of the smeared blood and womb invigorate the philosophy of duality of existence subscribed to by the yoruba people. in this wise, the internal and the external factors of procreation is only complete in the surrogate mother rather than the commissioning mother. while the womb represents the physical body, the blood represents the spiritual content of reproductive process. the argument here differs from the western paradigm where the egg and sperm which are physical without the internal spiritual content impose ownership of the child on the commissioning mother. nevertheless, the legality of a contract signed between the surrogate and the commissioning couple is not in doubt, and it must be added that yoruba tradition places emphasis on the honouring of an agreement between two people. yet, when the chips are down, when the child has any spiritual problem that warrant solution through the mother, the surrogate mother will be the first point of call. this leads us to the second issue which is the belief about oro idile (family tradition or taboo). in every traditional yoruba families, there are cultural rites peculiar to each. these rites or family traditions are performed at various stages of development of a person: from birth, during naming ceremony, during marriage ceremony and finally at death. these rites have deep spiritual meaning in terms of protecting a person from evil. in most cases, they have their foundation in ancestral covenant which are sealed with family blood. in surrogacy, it then becomes difficult to know the effectiveness of these rites in a person who only belong to a family partially. since a product of surrogate arrangement has no bangladesh journal of bioethics 2017; 8(3):18-25 23 blood relation with the surrogate mother but has relation in terms of being the one that smeared blood on the child. so, which ancestral covenant will take eminence in surrogacy is difficult to determine. it is not surprising given the factor interconnected existence that in consulting an oracle about a child’s destiny, the soothsayer (babalawo) always asks for the name of the child and the child’s mother. this is predicated on the belief that one cannot be mistaken about who a child’s mother is, because the paternity of a child is uncertain except determined through dna. there is therefore, a great affinity between a person’s destiny and that of the mother16. it then becomes difficult to know which mother’s name will be presented since in surrogacy two mothers are involved. but we feel that the authority of the womb and the smearing of blood may also be applicable here. ifa oracle which is the religious book of the yoruba people also mentioned that “a child who fails to suck the mother’s breast milk, will find it extremely difficult, if not totally impossible, to have the type of spiritual elevations comparable to those of hi/her colleague who had the benefit of sucking their mother’s breast milk17. if a child lost the mother at birth s/he has lost the privilege of breast sucking. such situation may also occur if a mother is hiv positive or having any other disease that can be transferred through body fluid. surrogacy itself presents such situation if the baby is transferred immediately to the commissioning couple after birth. though, the western science takes the dna and genes as the determinant of personality, the yoruba people do not dwell on this physical attributes alone, the spiritual dimension of birth and growing processes are of utmost importance or else one ceases to be a ‘normal’ or ‘full person’. and this is where surrogacy becomes a problem in yoruba philosophy. in the shakespearean novel titled macbeth, macbeth who is the hero in this play boasts to macduff that he cannot be killed by macduff because the gods already told him that macbeth cannot be killed by any man born of a woman. macduff replied him that technically he was not born (of a woman) in the natural way but was given birth to through a cesarean operation18. this made all the three factors that could lead to the death of macbeth complete. macbeth dies in the battle between him and macduff. it shows that some of the metaphysical beliefs about birth, motherhood and life in general have serious implications for the status of the surrogate mother and the child who is a result of surrogate arrangement. this is in line with mary douglas’s assertion that the “understanding of religious symbols helps in selecting experiences for concentrated attention”. for her, this will further help in the mysterious coordination of brain and body.19 conclusion: the strength of the link developed through gestation and birth seems stronger than that of genetic link between the fetus and the commissioning parents. yoruba seems to realize that carrying an embryo and giving birth give stronger emotional and spiritual ties from the surrogate mother to the child than the one developed through genetic means by the non-pregnant commissioning biologic-mother. according to nancy reame(1991:153), acog (american college of obstetricians and gynecologists) in 1983 set up a committee on ethics and part of the recommendations that lend credence to the yoruba position is that the surrogate mother should be treated as the natural mother20. the committee however arrived at this due to the fact that surrogate mothers deserve autonomy on their bodies, health and the need to prevent negative psychological health risk various researches (kennel &mcgrath, 2002 and palmer, 2002)21, 22have also corroborated that biological bonds are established between bangladesh journal of bioethics 2017; 8(3):18-25 24 mothers and her fetuses during pregnancy through the following means: a. oxytocin homone b. skin-to-skin contact c. eye gazing d. breast feeding all these socio-cultural beliefs and scientific facts show thatthere is a form of bonding between mothers and children and these factors are complete only in the surrogate mother. and one ought to be concerned about the disruption of this boding which surrogacy attempt to cause by acknowledging the commissioning parents over and above the surrogate parent. the belief in this paper is that such acknowledgement will create a kind of genealogical bewilderment,that is, a confused family structure for the child which may affect the child’s development. so, the question: is parenthood grounded in biology, contractual agreement or religiocultural arrangement, will be better addressed if the answer considered both the biologic and religio-cultural factors concerned. these factors in the thinking of this work are complete in surrogate motherhood. it is not then out of place to recommend that any legal or moral framework must be seen to maintain good relationship between the surrogate mother and the commissioning couple in order to respect the dignity and welfare of the child which enhances physical development, and to avoid spiritual underdevelopment of the child. ifthere is no such good relationship between the parties, and economic consideration is the reason for agreeing to be a surrogate mother, it could lead to extortion when situation arises in future; where the help of the surrogate mother is needed as it affects the child’s destiny and development in life. any legal framework of agreement should envisage this and take care of it. conflict of interest: none acknowledgement: i thank rainer ebert for the information he placed on facebook about this edition. grateful heart! references 1 douglass, m.purity and danger. london: penguin, 1966, p.63 2 umeora, odidika et al. “surrogacy in nigeria: legal, ethical, sociocultural, psychological and religious musings” in african journal of medical and health sciences.2014. vol. 13 no. 2 retrieved at http://www.ajms.org 3 llewellyn-jones, d. everywoman: a gynecological guide for life. ibadan: safari books. 1998. p.89-91. 4 umeora odidika et al op. cit 5 coste b. “the ethics of surrogacy: a list of the pros and cons of surrogacy” retrieved at http://www.positive-parenting-ally.com 6 coste, b. ibid. 7 oduwobi, t. & obi, i. “nigeria: an ethnic historical survey” in akinjide and olukoju (eds.) nigerian peoples and culture. ibadan: davidson press. 1997 8 jemiriye, f. “yoruba understanding of sexuality” 2015, retrieved at http://tfjemiriye.org 9 dukor, m. theistic humanism of african philosophy..saarbrucken: lap lambert. (2010). 10 okoro, c. “the notion of integrative metaphysics and its relevance to contemporary world order” in integrative humanism journal,2011.vol. 2 no. 2: pp. 3-28. 11 balogun o. “ori as the sole determinant of human destiny in traditional yoruba-african thought” in lumina, 2010 vol. 21, no. 2.p.1-9. http://www.ajms.org/ http://www.positive-parenting-ally.com/ http://tfjemiriye.org/ bangladesh journal of bioethics 2017; 8(3):18-25 25 12 gbadegesin, s. african philosophy, traditional yoruba philosophy and contemporary african realities. chicago: gateway. 1991, p. 28. 13 oladipo, o. “predestination in yoruba thought: a philosopher’s interpretation” in orita: ibadan journal of religious studies. 1992 vol. xxiv, no. 1&2, p.43. 14 oluwole, s. “the rational basis of yoruba ethical thinking” in the nigerian journal of philosophy 1984 vol. 4 no. 1&2. 15 popoola, s. and oyesanya, f. ikunle abiyamo: the ase of motherhood. ibadan: ifa works. 2015. 16 awala, v. “10 fascinating superstitious beliefs common with yoruba people” retrieved at http://www.informationng.com 17 popoola and oyesanya, op. cit. p.172. 18 shakespeare w. macbeth. act 5, scene 1-11 19 douglass m. op. cit. p.63. 20 reame, n. “the surrogate mother as a high-risk obstetric patient” in the journal of the jacobs institute of women’s health.1991, vol.1 no. 3 summer. 21 kennell j. and mcgrath s. “starting the process of mother-infant bonding” in acta paediatrica, 2002, vol. 94 no. 6. 22 palmer, l. “bonding matters: the chemistry of attachment” in attachment parenting international news, 2002. vol. 5 no. 2 retrieved at http://www.babyreference.com http://www.babyreference.com/ microsoft word e qi special relations, special obligations, and speciesism bangladesh journal of bioethics 2016; 7(3): 12-22 12 original article special relations, special obligations, and speciesism eric x. qi phd candidate, philosophy department, rice university, u.s.a. email: xqi@rice.edu abstract: this paper develops a general account of special relations and special obligations, and uses it as a framework to argue for a modest form of speciesism – mitigated speciesism – based on an understanding of species co-membership as a thick concept. mitigated speciesism steers a middle ground between anti-speciesism and crude speciesism. unlike anti-speciesists, i maintain that species co-membership is a morally relevant special relation, which indeed grounds special obligations among the members of the same species. but unlike crude speciesists, i argue that our special obligations to our fellow human beings do not warrant that we should always count their interests more than comparable interests of nonhuman animals. instead, special obligations based on species co-membership are subject to three constraints. keywords: special relations, special obligations, speciesism, animal ethics introduction: in the ethics of marginal cases literature, special relations and special obligations often occupy an important place. two types of special relations figure in the debate most prominently: family relations and species relations. few scholars deny that family relations warrant special obligations to our family members, but they are divided on whether species co-membership should also ground special obligations which would give greater moral considerations to the interests of its members. one group, by understanding species co-membership in a certain way, gives an affirmative answer to that question; and the other group answers it negatively. the second group often accuses of the position of the first group as speciesism. according to peter singer, speciesism “refers to discrimination on the basis of species, not to discrimination on the basis of cognitive capacities”1. if x and y are members of the same species, that would count as a special relation between them and ground a special obligation to one another. that is, x has special obligations to y simply because y is a member of x’s species. this paper attempts to shed new light on the debate about speciesism by taking a close look at the propositions that each group is committed to. i distinguish between two forms of speciesism– crude speciesism and mitigated speciesism, and argue for mitigated speciesism and against both crude speciesism and anti-speciesism. my arguments build on the general account of special relations and special obligations that i will develop in the first two sections, in which i claim that one’s special obligations to others who share a group membership with him or her are subject to three constraints. crude speciesism is wrong in neglecting the three constraints, and anti-speciesism is unacceptable in its overly narrow bangladesh journal of bioethics 2016; 7(3): 12-22 13 interpretation of species co-membership and its denial that group co-membership can count as a special relation which ground special obligations. mitigated speciesism, on the other hand, avoids the problems facing crude speciesism and anti-speciesism, and steers a middle path between them. special relations: how we should define special relations turns out to be surprisingly complicated. we stand in a relation with almost everything. for example, everyone stands in a biological relation with his parents and siblings; every school child has schoolmates. when we go to work, we have colleagues. when we live in a place, we have neighbors. we also make friends with others. we share membership of the species homo sapiens with other people. we share the same planet with all things on earth. after we have purchased a thing, we stand in an owner-property relation with it. but what makes a relation special in the moral sense? there are at least two components of such kinds of relations: the specialty component and the moral relevance component. on the first component, we need to know what makes a relation special. one necessary condition for a relation to be special is that x stands in a relation with y but not with z. a special relation is a three-place relation: x stands in a special relation with y only in comparison to z. the comparative part grounds the “special” part of the special relation. x and y have a relation, and x and z could also have a relation. but what makes the x-y relation special is that there is something in the x-y relation that is not shared in the x-z relation. in this case, we would say that x bears a special relation with y relative to z. the other necessary condition for a relation to be special is the hierarchical structure of it. an adult man stands in a father-son relation with his son, which is not shared in his relation with his colleagues, so the father-son relation is a special relation for him. but his relation with his colleagues is not shared in his relation to his son either, meaning that his colleague relation is a special relation for him, too. but which one is more special when it comes to moral obligations? it seems that relations as characterized by group membership are different in intimacy and emotional attachment. family relations are relations among family members, and family membership is more important than friend membership. similarly, friendship seems to be a closer and more intimate relation than colleague relations, which are closer than relations with strangers. some types of special relation warrant special moral obligations, other types do not. if they do, they are morally relevant – they are special relations in the moral sense. family relations may be the most typical examples of morally relevant special relations, as most of us agree that one has special obligation to one’s family members just in virtue of the fact that they are members of one’s family. more generally, if x stands in a morally relevant special relation with y compared to z, i.e., x stands in a closer relation with y than she does with z, then x has special obligations to y compared to z. if x has a morally relevant special relation with z relative to w, then x has special obligations to z compared to w. like special relation, special obligation is also a comparative concept. bangladesh journal of bioethics 2016; 7(3): 12-22 14 special obligations: there is little controversy that special relations warrant special obligations, but it is crucial for our purposes to understand what the scope and content are of special obligations that special relations warrant. if x has special obligations to y compared to z, does it mean that x should give priority to y’s interests over z’s, as commonly believed? i believe the unrestricted version of special obligations cannot be justified. if an evil person chose to murder his neighbor’s wife over his own wife, for instance, his wrongdoing is equally blameworthy as it would be had he chosen to murder his own wife instead, even though technically he was favoring the interest of his wife as a member of his family. he has equal obligation not to murder his wife as he does to his neighbor’s wife, and his special relation with his wife does not make a difference in this case. so special relations warrant some kinds of special obligations, but not all kinds, and we need to impose some constraints on the scope and content of special obligations that special relations legitimately justify. the first constraint concerns the scope of interests of relevant parties. if x has special obligation to y relative to z, x may have reason to give priority to x’s comparative interests over y’s comparative interests, but it is not the case that any interest of y counts more to x than any of z’s interests. for instance, when my child and a stranger’s child have equal cravings for a piece of chocolate cake, my special relation with my child gives me a reason to prioritize his interest in getting the chocolate cake over the stranger’s child’s if the piece of chocolate cake could satisfy only one child’s. however, at least in some situations, if the piece of chocolate cake could only satisfy my well-nourished child’s cravings but can save the life of a starving stranger’s child, morality seems to require the chocolate cake be given to the stranger’s child2. this constraint shows that special relations do not give lexical priority to all interests of the person to whom we have special obligations. some of his less important interests can be outweighed by more significant interests of others who do not stand in special relations with us, as in the cravings-starvation case. lexical priority applies to comparative interests, but may not apply to cases where the interests of relevant parties are so different that morality requires special obligations be overridden. i will call it the comparable interest constraint. the second constraint on special obligations is that special obligations are legitimate only in the private domain, but not in the public domain. by public domain i mean cases where public decisions are being made that involve or have an impact on public resources. private domain refers to cases where decisions are only private, i.e., involve resources that are privately owned by the decision maker. the most typical type of public domain is public offices. officeholders are morally (and legally) forbidden to distribute public resources in favor of those who stand in special relations with them compared to others. for instance, it is morally wrong to offer a job to one’s adult child who is less qualified than other job candidates. only privately owned resources could be subject to special obligations. i have reason to spend my own money on my child rather than others’, but there is no moral reason for me to distribute public resources in my child’s favor if i manage public resources. special obligations are subject to the constraint of public justice. bangladesh journal of bioethics 2016; 7(3): 12-22 15 the third constraint is the positive obligation constraint. special obligations are positive obligations, as opposed to negative obligations. positive obligations are obligations to do what is morally praiseworthy, and negative obligations are obligations to refrain from doing what is morally forbidden. for instance, our special obligations to our beloved ones should not be met at the cost of unjustly frustrating others’ comparable interests. if a father could only save his starving child’s life by robbing an equally starving stranger’s child of her food, which will cause the latter to die of starvation, he would do the morally wrong thing if he robs her. this is different from the drowning case. when the two children are drowning and the father could only save one, his special obligations to his child warrant that he saves his own child rather than the stranger’s child. his positive obligation to the stranger’s child is overridden by his special positive obligation to his own child since both cannot be met. the private domain constraint is relatively uncontroversial. when one in charge of public resources uses them in favor of those who stand in special relations with him, he is acting against public justice. no special relations could ever justify misusing public resources for the interests of those with whom he has special relations. the widespread policy on conflict of interests gives voice to this constraint. the comparable interest constraint may be controversial. some may deny that morality requires us to forgo insignificant interests of ours and our beloved ones for the sake of more significant interests of others to whom we do not have special obligations. if the comparable interest constraint is legitimate, then we would not even be permitted to spend 20 dollars on a movie to entertain ourselves or our children, which would otherwise save a life of a starving child somewhere in the world. this is a familiar objection that morality delivered by this constraint is too demanding. in response, i would say that morality does not require us to sacrifice all of our own insignificant interests (and those of our family members) for the sake of charity under all circumstances. when one is in a position that his benevolent action will have singly decisive and direct effect on a stranger’s significant interests, as in the cravingstarvation case, morality does require him to forgo his special obligation to the insignificant interests of those who have special relations with him. imagine a child has a toy that could only be used by her father to save a stranger’s child from drowning to death. nobody else is around to help, and if the father does not act, the stranger’s child would surely die. despite his child’s resistance to having his father take her toy, the father should act against her interest in keeping her toy and use it to save the stranger’s child. similarly, let’s revise the 20-dollar movie case this way. suppose you are on your way to buy a movie ticket for your child and run into a dying stranger who needs food and water to survive. should you use your 20 dollars to buy food and water to save his life instead of moving on to get a ticket? there is little controversy that you should. if so, then the comparative interest constraint is indeed justified. the negative obligation constraint seems also controversial. isn’t the case that we have more special obligations to those with whom we have close relations even in the negative sense? the answer is no. it seems equally forbidden for a person to harm those to whom he has bangladesh journal of bioethics 2016; 7(3): 12-22 16 special obligations and those to whom he does not. if a man considers whether to murder his wife or his neighbor’s wife and decides to murder the latter, the moral wrongness of his action will not be lowered by his choice. his neighbor’s wife’s interests are not less (and no more) protected than his wife’s. every morally capable agent has an equal obligation not to violate anyone’s interests. when it comes to negative obligations, special relations do not seem to matter. a more complicated case regarding special obligations involves the mix of positive and negative obligations. since our positive special obligations to those who are closer to us can be overridden by our positive obligations to others, can our negative obligations to others be overridden by our positive special obligations to those closer to us? this is an issue that deeply divides traditional deontologists and classical consequentialists. traditional deontologists insist that our negative obligations can never be overridden even if this would bring about better outcome. the trolley problem, organ transplant case, and similar thought experiments are all designed to reject classical consequentialism. it is not my intention to settle the dispute here. rather, i merely want to point out that traditional deontological approaches face similar problems as classical consequentialism, because it does not seem right to say that our negative obligations to others should never be overridden by desirable consequences. in cases of moral catastrophe, it seems right to violate our negative obligations to others for the greater good. for example, if an individual has a highly contagious deadly disease and there is nothing we can do about it except quarantining him (and hence violating his rights to freedom of movement), we would be justified in doing that3. however, even we accept the consequentialist principle that our negative obligations can be overridden, it does not mean that they can be overridden by our special obligations to those who are closer to us. special relations and positive special obligations do not play a role in overriding our negative obligations to others. that is, our negative obligations to others can be overridden not because it will produce greater good to those who stand in special relations with us, but because it will produce greater good for anyone who will be potentially affected. again, this is an issue related to public justice. if the basis for violating our negative obligations to others is built on our special relations with those who will benefit from that violation, morality would have a shaky foundation. this is actually the requirement of the private domain constraint on special obligations. we have no moral reason to violate our negative obligations to others merely because that will bring about greater good to those to whom we have special obligations. what matters are the interests of all those who will potentially be affected: whether they have special relations with us or not is not a morally relevant factor. we have seen that our negative obligations and some of our positive obligations to others are not grounded in our special relations with them. and in the public domain, special obligations should not even be allowed a space. if there are moral obligations that are not grounded in special relations, where are they grounded? this is a contested issue, and i am not committal on any specific theory. however, i do think that there is at least one necessary condition for the grounds of non-special obligations – the capacity to suffer. i am using the word “suffer” bangladesh journal of bioethics 2016; 7(3): 12-22 17 in a broad sense. sufferings include pain, frustration, and other kinds of negative attitudinal states. as long as an entity possesses this capacity, there will be a reason not to impose avoidable sufferings on it, whether it bears a special relation to morally capable agents or not. our positive special obligations to our beloved ones can be overridden by our positive obligations to prevent avoidable sufferings from happening to those with whom we do not bear special relations. the basis for our overriding positive obligations to them also lies in their capacities to suffer. the reason that every morally capable agent has for respecting an entity’s interest in avoiding unnecessary sufferings is agent-neutral. mitigated speciesism: the above account of special relations and special obligations provides a useful framework to think about the issue of speciesism. there are at least three propositions that are relevant to the speciesism debate: (p1) species co-membership is understood as saying nothing more than being members of the same species; (p2) species co-membership is a morally relevant special relation, which grounds our special obligations to our fellow human beings; (p3) our special obligations to our fellow human beings justify us always giving greater moral weight to the interests of our fellow human beings than to the similar interests of other animals. anti-speciesists accept (p1) and reject (p2) and (p3). (p1) represents the anti-speciesist interpretation of species co-membership in the context of animal ethics. it seems to understand species membership in a minimalist way; that is, say, a being is a member of human species if and only if it possesses the biological features that are characteristic of a human being. this minimalist interpretation of species co-membership leads to the antispeciesist rejection of both (p2) and (p3). for them, x’s merely being a member of the human species in virtue of its biological features does not constitute a morally relevant special relation and entitle it to greater moral considerations of its interests. we do not give greater moral consideration to its interest simply because it is a member of human species. speciesism in this sense is analogous to racism and sexism, which base the strength of moral considerations merely on one’s skin color and gender, respectively. crude speciesists reject (p1) and accept (p2) and (p3). they reject the minimalist interpretation of species co-membership and read it as a thicker concept instead. usually, they do not think that we give greater moral considerations to human interests simply because they are co-members of the same species in the minimalist sense. rather, co-membership in the human species in the context of animal ethics can be understood as a misleading label for a thick notion such as personhood, human dignity, or communal relationship4. if human interests count more, that is only because of their personhood, dignity, or communal relationship that lower animals do not possess. once they adopt a different conception of species co-membership, their arguments are no longer vulnerable to the charge of speciesism in the minimalist sense that anti-speciesists use5. bangladesh journal of bioethics 2016; 7(3): 12-22 18 i believe both anti-speciesists and crude speciesists get things wrong. anti-speciesists get it wrong when they reject (p2) and the thick concept of species co-membership. if they were right, our giving more considerations to the interests of our family members would hardly ever be justified. but crude speciesists are wrong to accept (p3). even if we do have special obligations to our fellow human beings in virtue of their unique qualities or their special relations with us, this does not entail that we should always count their interests more in all circumstances. mitigated speciesists reject (p3) as well as (p1), and accept (p2). like crude speciesists, mitigated speciesists view species co-membership as a thick concept: it means the sharing of qualities such as rational autonomy and self-consciousness, and some common values, commitments, emotional attachments, and social bonds, actual or potential. however, the main strength of mitigated speciesism lies in its rejection of (p3) by subjecting special obligations to the three constraints introduced in the second section. by rejecting (p3), it retains the plausible part of anti-speciesism; but unlike anti-speciesism, it does not reject (p2), which leaves it space to accommodate familism. i will spell out what mitigated speciesism is like by discussing each constraint in turn. firstly, our special obligations to our fellow human beings are legitimate only in the private domain. that is, only when it comes to the distribution of resources that are ‘privately’ owned by individual human beings, one is entitled to give priority to the interests of his or her fellow human beings over the interests of animals. in the public domain, on the other hand, there is no reason for us to distribute public resources in favor of our fellow beings to which we have special obligations. for example, it would be immoral if we destroyed all natural habitats of animals for the benefit of humans. the natural habitats and environment are ‘public resources’ for all species on earth. even in the private domain, our special obligations to our fellow beings are not unrestricted; they can be overridden by greater interests of non-human animals. not all human interests are more significant than animal interests. our interest in not getting wet may be outweighed by a cat’s interest in surviving the drowning in a river. sometimes it can be a difficult issue to compare the relevant importance of interests between human beings and other animals. for instance, it is hard to know whether we should forgo our special obligations of feeding a slightly hungry human child over our obligations of giving the food to a dog that would otherwise die from hunger, as the two interests are not easily comparable. however, this issue need not worry us too much. as a principle, our positive special obligations to fellow beings can be overridden by our positive obligations to animals. we have negative obligations to both human beings and other animals. but the positive obligation constraint shows that our species co-membership does not give a boost to our negative obligations to our fellow humans. our negative obligations and some positive obligations to humans and other animals are grounded in the fact that they have the capacity to suffer. this capacity gives us agent-neutral reason not to impose avoidable sufferings upon them. bangladesh journal of bioethics 2016; 7(3): 12-22 19 these constraints show that our species co-membership only justifies the priority of our interests over animal interests when (1) our interests are comparable to animal interests, (2) the resources we are distributing are ‘private’, and (3) our species-bounded special obligations are positive. under these conditions, if both a non-human animal and a human being are starving to death, our special relation with the human being gives priority to his interest. this is even true for cognitively severely impaired human beings. since they possess the capacity to suffer, their interests of, say, being well nourished should be given priority over the comparable interests of animals, even if their cognitive levels are only comparable to those of animals. mitigated speciesism steers a middle path between anti-speciesism and crude speciesism. unlike anti-speciesism, it maintains that under the three conditions, species co-membership understood as a thick concept warrants the priority of human interests over animal interests. this captures our intuition that a human being, whether he or she is cognitively severely impaired or even in vegetative state, has dignity that should be respected. they have certain interests that require to be given priority over comparable animal interests in the positive obligation sense. this intuition is what bernard williams calls “the human prejudice”6. unlike crude speciesism, however, mitigated speciesism holds that beyond the three conditions species co-membership does not matter; the human prejudice is not justified in all circumstances. when it comes to negative obligations, for example, species co-membership as a special relation plays no role in deciding whether human interests or animal interests should be given greater moral consideration. rather, all that matters is how human interests are compared to animal interests. for instance, we have negative obligations to not impose pain on a person with the intention of doing harm to her; we also have similar obligations to a non-human animal. but isn’t it more morally forbidden to harm her than to harm the animal? the answer is yes, but that’s not because she bears special relations to us, but because her relevant interest is greater than the animal interest. given the fact that a person’s mental life is richer than an animal’s, the harm intentionally caused to her is greater than the harm intentionally caused to the animal. the aggregate amount of the physical and mental pain and the post-trauma stress on her may well exceed those on the animal7. therefore, the reason for us to favor her interest over the animal interest is independent of her species co-membership with us. in mixed cases of positive and negative obligations, species co-membership does not matter either. in those cases, we often find ourselves in a situation where animal interests will have to be sacrificed for human interests. if the only way to advance our medical knowledge is by performing animal experiments, sacrificing animal interests while causing minimalist sufferings seems to be justified8. it is justified not because animal experiments promote greater benefits for human beings as members of a special species, but simply because they promote greater benefits no matter whoever the beneficiaries would be. imagine that many animal species come down to an unknown disease and are dying, and suppose that the only way to save them is by doing animal research. most of us would agree that it is morally permissible to sacrifice some animals in order to save much more of them. if this is the case, bangladesh journal of bioethics 2016; 7(3): 12-22 20 then what matters is the greater good, not species co-membership in the minimalist sense. it makes no difference whether the beneficiaries are human beings or animals. it should be noted that while the utilitarian principle plays an important role in overriding cases involving negative obligations, it is not the only decisive factor. we do not want to say that whenever violating an animal’s or a person’s interests produces greater benefits, it will be morally permissible to do so. there must be more requirements of moral permissibility besides the greater utilitarian gains. for instance, one additional requirement could be that if entity x has more interests than y, which are contextually equally available for the unavoidable violation of their interests produces the same amount of benefits, it would be morally wrong to violate x’s interests for greater benefits. yet another additional requirement could be that the unavoidable violation of y’s interests must be kept at the minimum; it would be morally wrong to impose more sufferings on y than necessary. a possible anti-speciesist objection to mitigated speciesism is this: if species co-membership grounds special obligations, as mitigate speciesism maintains, then wouldn’t race comembership or sex co-membership also ground special obligations? if so, then we would have mitigated racism and mitigated sexism, which do not seem to be justified9. i do not want to say that mitigated racism or mitigated sexism is a correct or defensible view; rather, i would like to point out that within the scope of the three constraints, mitigated racism/sexism might not be so bad. in the domain of purely private resources which one has positive obligations to allocate to others on a voluntary basis, it does not seem so objectionable for an individual person to allocate them based on race or sex membership understood as a thick concept. for instance, an adult woman might choose to save a drowning girl’s life and let the drowning boy die, if she can save only one. in this scenario, her “sexist” choice does not seem so blameworthy. i think our strong intuitions against racism and sexism are based on issues that go beyond the scope of the three constraints. but once we understand race comembership and sex co-membership as thick concepts and restrict them to those constraints, racism and sexism in mitigated form no long seem so objectionable. conclusion: special relations occupy a legitimate place in ethics, but their scope is limited to the private domain, positive obligation, and comparable interests. both family relations and species relations are subject to these constraints. crude speciesists mistakenly neglect one or more of the constraints when they defend the priority of human interests, and anti-speciesists unacceptably reject the plausible thesis that we have special obligation to our fellow beings within the scope of the three constraints. mitigated speciesism, by understanding species comembership as a thick concept, maintains that species co-membership warrants special obligation to our fellow human beings by giving priority to their interests over equal interests of other animals when it comes to private decisions on how to distribute ‘private’ resources. but our special obligation to respect the interests of our fellow human beings could be overridden by our obligation to respect the interests of other animals if the latter are far greater than the former. if some non-human animals’ interests have to be sacrificed for far greater benefits of human beings or animals, that’s not because species co-membership matters, but because of the greater good this will produce10. bangladesh journal of bioethics 2016; 7(3): 12-22 21 author contribution: author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgement: i thank baruch brody, jeanine campsall, rainer ebert, and especially an anonymous referee for the bangladesh journal of bioethics special issue on animal ethics for very helpful comments on an earlier version of this paper. rainer ebert and jeanine campsall also helped to correct spelling and grammatical errors in an earlier version, and i am very thankful for that. i bear the responsibility for remaining errors, if any. references: 1 peter singer, quoted in rosamund raha, animal liberation: an interview with professor peter singer, the vegan 2006, 18-19. 2 it might be debatable whether we should donate a substantial amount of money to famineaffected children in a poor country: peter singer (1971) argues that we should and some deny that (e.g., kekes, j., on the supposed obligation to relieve famine, philosophy 2002, 77 (4):503-517). i will address this issue shortly. before that, i am just adding the qualification “in some situations” here. i will specify what those situations amount to shortly after. 3 in response to the challenge of moral catastrophes, some deontologists (moore, m., placing blame: a general theory of the criminal law, oxford university press, 1997, ch. 17; alexander, l., deontology at the threshold, san diego law review 2000, 37(4): 893–912; ellis, a., deontology, incommensurability and the arbitrary, philosophical and phenomenological research 1992, 52(4): 855–875) endorse threshold deontology, according to which deontological principles apply below the threshold but they may be overridden by consequentialist considerations above the threshold. i am neutral regarding the plausibility of threshold deontology. what i am trying to do here is merely pointing out that traditional deontological absolutism is untenable due to moral catastrophes. for a good brief review of the threshold deontology literature, see alexander, larry and moore, michael, "deontological ethics", the stanford encyclopedia of philosophy (winter 2016 edition), edward n. zalta (ed.), url = http://plato.stanford.edu/archives/win2016/entries/ethicsdeontological/, section 4. thanks to the anonymous referee for suggesting to me the threshold deontology literature. 4 see kagan, s., what’s wrong with speciesism? journal of applied philosophy 2016, 33 (1):1-21; kittay, e. f., at the margins of moral personhood, ethics 2005, 116 (1):100-131. 5 since such a move rejects the minimalist reading of speciesism in favor of an alternative reading, writers who make the move are not really crude speciesists in the standard (i.e., minimalist) sense. singer (why speciesism is wrong: a response to kagan, journal of applied philosophy 2016, 33 (1):31-35) points this out explicitly in his response to kagan’s criticism of his arguments. therefore, the label of crude speciesists might be not a good choice. however, readers should bear in mind that this not-so-good label should not mislead bangladesh journal of bioethics 2016; 7(3): 12-22 22 them into thinking that those writers support speciesism in the standard minimalist sense. rather, they are not against speciesism only in the alternative sense that they stipulate. 6 williams, b., the human prejudice, in a. w. moore (ed.), philosophy as a humanistic discipline, princeton university press, 2006. 7 there is a complication here. many philosophers (singer, p., practical ethics, cambridge university press, 2011, 52; rollin, b. e., animal rights & human morality, prometheus books, 2006, 89; linzy 2009, 17; scully, m., dominion: the power of man, the suffering of animals, and the call to mercy, st. martin's press, 2002, 7) point out that a lack of rationality often makes suffering worse, as animals without rational capacities cannot anticipate an end of suffering, and pain without understanding is even more blunt. in response, i’d like to point out that understanding what is going on may add mental stress to the upcoming physical pain. even if understanding could reduce the intensity of pain by anticipating it in some cases, the prolonged psychological stress based on understanding might outweigh the benefit of anticipated pain, which makes suffering overall worse. for instance, when one knows that one’s illness is incurable and one will die in 10 days, the feeling of desperation could be tremendous. also, it does not seem to be the case that anticipated pain will always have lower intensity than unanticipated pain. for example, the bodily pain caused by a surgery with knowledge of it does not seem to be less intense than without knowing it. thanks to the anonymous reviewer for pointing out this issue and referring me to the relevant literature that i have cited in this footnote. 8 it is controversial whether using animals in medical research is the necessary means to advance medical knowledge. i remain neutral on this issue. i am just using the hypothetical sentence here to make my argument. 9 thanks to the anonymous reviewer for raising this objection. 10 in addition to the literature mentioned earlier, i also consulted the following three publications during the preparation of this article: brody, b., defending animal research: an international perspective, in jeremy r. garrett (ed.), the ethics of animal research: exploring the controversy, the mit press, 2012; linzey, a., why animal suffering matters: philosophy, theology, and practical ethics. oxford university press, 2009; and mcmahan, j., our fellow creatures, journal of ethics 2005, 9 (3-4):353-380. bangladesh journal of bioethics 2017; 8(3):26-32 26 surrogacy and the motherhood question in yoruba culture oyekan adeolu oluwaseyi1 and ani amara esther2 1 & 2. department of philosophy, lagos state university, ojo, nigeria. email: adeoluoyekan@gmail.com and amaraesther35@gmail.com abstract: one of the arguments against surrogacy is that it is harmful to both the surrogate mother and the child. numerous strands of this argument are collectively referred to as the ‘harm factor’. a version of the argument says that surrogacy interrupts the mother-fetal affection which develops between the surrogate mother and the child. if this is true, what implication does it have for the concept of motherhood? does the biological connection between the fetus and the surrogate put the latter in a better position as a mother than the commissioning mother? this paper examines the relationship between surrogacy and motherhood within the context of yoruba culture. it argues that the culture emphasizes the sociological dimension of motherhood more than the biological. this, the paper argues, is because of the culture’s emphasis on the significance of nurture and care to the development of a meaningful and stable life. the paper thus concludes that while yoruba traditional society lacked the scientific wherewithal to undertake a successful surrogacy procedure, its conception of motherhood, prevalently held even in contemporary time, is normatively compatible with surrogacy. key words: surrogacy, motherhood, fetus, yoruba, culture. introduction: the debate on the normative nature of surrogacy, for sometimes now, has been controversial. all manner of hyphenated versions of harm factor have been invoked to trash the hard nut of surrogacy. a strand, for instance, holds that surrogacy disrupts and undercuts the genetic-maternal affection existing between the surrogate and her child. if this is true, what implication does it have for the concept of motherhood? does the biological connection between the fetus and the surrogate put the latter in a better position as a mother than the commissioning mother? this paper views surrogacy through the prism of yoruba culture, and asks questions such as: what is the yoruba conception of surrogacy? does this conception presuppose a yoruba understanding of surrogacy? if it does, what is the contribution of this yoruba understanding of surrogacy to the moral discourse? in a bid to answer these questions, the paper will first present the main ideas of surrogacy. then, it will discuss the notion and nature of motherhood in yoruba culture. and finally, while presenting the harm argument, the paper will also discuss the notion of surrogacy implicit in yoruba traditional belief. it aims to establish that the yoruba surrogacy is morally compatible with surrogacy. defining surrogacy: surrogacy is “a practice whereby a woman becomes pregnant with the intention of giving the child to someone else upon birth.”i in a surrogacy arrangement, an agreement or understanding is entered between a woman (surrogate) and another person(s) (intending parents or commissioning couples). this memorandum of understanding includes: (a) the consent of the woman (surrogate) to become pregnant, with the intention that—(i) a child born as a result of the pregnancy is to be treated as the child of the other person(s); and (ii) the woman will relinquish the custody and guardianship of the child born as a result of the pregnancy to the other person(s). (b) the consent of the other person(s) to become permanently responsible for the custody and guardianship of a child born as a result of the pregnancy.ii in the past, surrogacy arrangements were generally confined to kith and kin of close relatives, family, or friends, usually as an altruistic deed. in such a traditional surrogacy arrangement, the surrogate is the donor of the egg through a sexual intercourse with the male of the intending parents. earliest examples are recorded in the bible. according to the bible, sarah beseeched her husband to take in hagar, her maidservant, in order to bear a child. the arrangement was successful but met a tragic end mailto:adeoluoyekan@gmail.com mailto:amaraesther35@gmail.com bangladesh journal of bioethics 2017; 8(3):26-32 27 when hagar refuses to relinquish the child, ishmael.iii the bible also recorded rachel giving her maidservant, bilhah, to her husband, jacob, as a surrogate because of her infertility. bilhah bore two sons, dan and naphtali, for joseph and rachel.iv however, surrogacy assumed an entirely new face around 1976, with the success of artificial insemination. under this procedure, the surrogate is either injected with the egg or the sperm or both, depending on the agreement. in such an arrangement, the surrogate has no genetic link to the child; and she is being paid to carry the baby to term. with the commercialization of surrogacy, the process has extended its network beyond family, community, state, and across the world. motherhood: a yoruba perspective: in order to have adequate understanding of the whole idea of surrogacy among the yoruba people, it is imperative to briefly discuss their beliefs about motherhood. yoruba people, found in south-west of nigeria, occupies the whole of ogun, ondo, oyo, ekiti, lagos and some part of kwara state.v a fraction of yoruba people can also be found in republic of benin, dahomey, togo and côte d'ivoire. yet, quite a number of yoruba cultural practices are preserved in some parts of the carribean and south america, particularly in cuba and brazil, as well as in north america.vi in yoruba culture, motherhood is considered critical to family and lineage survival.vii it must be said that in traditional yoruba society, where orality was the means of preservation, proverbs are the means of documenting ideas. a yoruba proverb says; iya ni wura iyebiye (mother is a precious gold) ti a ko le fowora (that cannot be purchased with money) o poyun mi f’osu mesan (she carried me in her womb for nine months) o pon mi f’odun meta (she nursed me for nine months) iya ni wura iyebiye (mother is a precious gold) ti a ko le f’ owora (that cannot be purchased with money).viii this symbolism of motherhood with gold shows loveliness, attractiveness, prettiness, gorgeousness, magnificence and fineness. every file and rank in the society wants gold, they want to be associated with gold because of the joy, praise, respect and happiness it brings. that is how motherhood is celebrated in yoruba culture. just like owners of gold are considered rich and very important in the society, in the same vein mothers are revered and celebrated in yoruba culture. this can be well epitomized with these traditional yoruba adages; “iya ni wura, baba ni jigi” (mother is gold and father is a mirror).ix now, motherhood being concomitant with gold shows that traditional yoruba culture considers motherhood to be among the highly ranked on the ladder of social importance. some yoruba proverbs that throw more light on this point are; “omo k’oni ohun o ye, iya ni ko gba (a child survives and thrives only at the mother’s will),”x “orisa bi iya ko si, ta ni o je se omolomo lo re? (there is no supporting divinity greater than one’s mother; who dares be a benefactor of another person’s child).”xi this shows that the continuous existence of a child lies in her palms. she guides, leads and directs the affairs of the child towards a certain goal. also, ifa corpus succinctly explains this as follows: ogbe to’mo pon (ogbe adjusts the support of your baby) abiamo sun’mo si (mothers should cuddle their babies) agbapon o lere (helping as a baby carrier has no benefit) bomo ba n sunkun (when a baby cries) iya laa kee si. (it is the mother who is called out to attend).xii the above excerpt from ifa corpus explains the importance and the role of a mother. as a mother, she has the responsibility of cuddling, caring, nurturing, singing and playing with her child. she also has the responsibility of teaching her morals. if her child turns bad, the mother is held responsible. yoruba do say that a bad child is a carbon copy of her mother (omo buruku ni ti iya). bangladesh journal of bioethics 2017; 8(3):26-32 28 primarily, what bestows motherhood to a wife is her ability to bear children or as oladele balogun puts it, being a “mother is tied to child birth.”according to traditional yoruba songs; kórí yá re o bùn ọ lómọ – may your mother’s head give you children (repeat) èsúrú kí yàgàn o – the trifoliate yam is never barren (repeat) aşọ àrà ọrùn re – the beautiful dress on your body omọ niwọ yó fi gbé – you will use it to carry children kórí yá re o bùn ọ lómọ – may your mother’s head give you children èsúrú k.í yàgàn o – the trifoliate yam is never barren.xiii also, omọ ni n ó rà o! – i will buy children (repeat) níjó mo bá kú laşo şègbé – the cloth will perish on the day that i die omọ ni n ó rà o! – it is the child that i will buy.xiv in the first song, a prayer is made on behalf of the bride that she will bear children like her mother did. this is because, in marriage, children are sources of joy. the second song tells us how important childbearing is to a wife that she will give up the best things of life for it. in yoruba culture, children largely determine the relations between one generation and the next; children are replacement; they will one day stand in their parents place. this unilineal and partrilineal descent system can be well captured with this proverb; “olomo lo loko” and, “bi ina baku, afi eru boju bi ogede ba ku afi omo re ropo” (when fire is put out, it is survived by ashes, when banana plant dies, it replaces itself with its sweater). thus, children sustain the patriarchal kinship system: “omo ni ere aiye; omo eni nii jogun eni ni ojo ti a ba ku” (children are the gains of this world; it is one’s children that inherits one at death).xv thus, it becomes a challenge for a woman not to have children. as captured in this song; “omo l’okun, omo n’ide, enia t’o wa saye ti ko bimo, aye asan lo wa” which literally means “child is a coral bead; a child is silver, a person who has none has not lived a fulfilled life.”xvi when a woman bears no child, she is left dejected, and seriously troubled. this challenging situation makes her feel like an incomplete woman because she has failed in bringing a child into the marriage. she is metaphorically naked, and has no child to cover her nakedness. a yoruba proverb says; “omo eni laso eni” (one’s child is ones cloth). in yoruba traditional society, an infertile couple is believed to have chosen a bad orí (destiny). according to yoruba creation mythology, after emi (the active element of life) has been put in ara, the newly created human being proceeds to the house of ajala for the choice of orí. it is the orí that one chose that determines his or her personality.xvii hence, when a couple is met with the bad fate of infertility, the orí is faulted since it is regarded as “an individual’s personal destiny that caters for their personal interest.”xviii as explained in this traditional yoruba song: emi o mo ibi ol’ori yan ori o (i do not know where people with good destiny chose their destiny). mba lo yan temi (i would have gone to choose mine there). ibi kannaa l’ati yan ori o (but no! we chose our destiny from the same source). kadara ko papo ni. (it’s only that our destinies are not identical).xix in addition however, witchcraft, evil spirits, juju, curse by ancestors or deities, aran ginisa (womb worm) have been identified as various secondary causes of infertility by the yoruba.xx in order to remedy infertility, sacrifices are made to oludumare through the ifa priest that appeals on behalf of the bearer of a bad destiny. through this process, a couple may be asked to give alms to beggars with babies or care and cater for an orphaned child; or in some cases the husband is asked to take in a second wife. the essence, of this as gbadegesin has noted, is to bring blessings of childbirth into the family. also, the couples will be given herbal medicines to ingest in order to stop infertility. but in cases where these interventions fail, couples are regarded as parents through the care and nurture of other children. this is because yoruba people bangladesh journal of bioethics 2017; 8(3):26-32 29 believe that a child does not belong only to the mother but, also, to the whole community. in this light, every member of the society can be a parent to the child next door. this sociological conception of parenting includes those without children into the family of parenthood. it then entails that genetic link or biological link is necessary but not sufficient in capturing the totality of motherhood in yoruba culture. hence, motherhood inculcates caring, nurturing and responsibility. yorubas will say;“obi’ni ko lo lomo bi kose on’ woni.(child ownership resides not only in biological motherhood but also in child mothering).”xxi when a couple is caring for a neighbor’s child or an orphan, the child refers to them as his/her parents. in essence, motherhood goes beyond the gamut of genetic link to the realm of care and nurture in yoruba culture. surrogacy, harm and motherhood: one of the most frequently expressed worries with respect to surrogate motherhood is that it harms both the child and the surrogate mother. this is captured in matthew tieu’s argument, for instance, that; a major concern with surrogacy is the potential harm that may be inflicted upon the surrogate mother and the child. therefore, any legislation….which would permit altruistic surrogacy arrangements, must be considered in relation to the possibility that the commissioning couple’s choices may harm the surrogate and the child she carries.xxii this means in effect that “the link created through gestation and birth is “more weighty” than the genetic link between the fetus and the commissioning parents.”xxiii the reason adduced is that during pregnancy, the placenta, which controls the transfer of hormones from mother to the fetus, bonds mother and child. this hormonal transfer from mother to the child adds a uniquely different size, proportions, development, cell differentiation, and congenital normality or abnormalityxxiv to the child’s biological makeup. this argument seems to be faring well with the recent discovery of epigenetics and microchimerism which shows that “postgestational michrochimerism, the existence of foetal cells in the mother (child--‐mother) or of mother cells in the child (mother-child) after pregnancy, is real. “child-mother migration is more abundant than mother-child, and foetal cells are found in the mother’s body several decades after giving birth.”xxv however, surrogacy makes little or nothing of this bond by introducing another mother, the commissioning mother. in the words of tieu; “surrogacy ruptures this bond, and such is the importance of the emotional attachment between the surrogate mother and the child she has carried…”xxvi a problem with tieu’s argument is the over-emphasis on genetic link as a determinant factor in motherhood. he assumed that the essence of a human being is the gene which acts as a determinant of who we are. that is why he wrote that we “ought to be especially concerned with any process that disrupts the important bond between mother and child, which derives from both biological and cognitive/psychological aspects of human nature, beginning during gestation and continuing after birth.” but this need not be the only determinant of motherhood. while we do not deny the importance of a child’s link to his gestational mother, we are saying that motherhood embodies other things, among which is the intent to be a mother. the intent to be a mother prepares the intended mother to be ready for the seen or unseen consequences of her moral decision. this intent carries the responsibility to cater for the child’s social and moral well being. as john l. hill avers; “biological parents are considered legal parents in our culture not because of their biological relationship with their children, but because of what the biological relationship evidences—namely, the intention to raise the child, the means to bring the child into existence, and the ability to care for the child after birth. where couples lack the physical capacity to bear a child but possess the more fundamental indicia of parenthood, their status as parents should be recognized and honored even above those who claim a biological relationship with the child.”xxvii thus, contrary to tieu, we hold that gestational link is not morally significant in terms of surrogate motherhood, and does not constitute a sound argument against it. bangladesh journal of bioethics 2017; 8(3):26-32 30 it has also been argued that surrogate motherhood, with its attendant separation of the surrogate mother from the baby, causes suffering to the child. two scenarios have been painted to capture the suffering the child undergoes under surrogate motherhood. on the first hand, a child that has been successfully handed over to the intended parent might develop a feeling of maternal abandonment. on the second hand, the fate of a deformed child is unjustly decided within surrogacy arrangements. surrogacy arrangement makes it a burden to the surrogate to decide the fate of a deformed fetus. in cases where abortion is ruled out, the surrogate mother is left with the responsibility of nurturing and caring for a deformed child, a task for which she is not psychologically ready. in such a state of affairs, the child might not be well taken care of and might possibly grow up with the belief that he is not wanted because of his deformity. in these circumstances, the child is vulnerable to “(…) depression, anxiety, various physical symptoms of psychological distress, feelings of insecurity or suicidal tendencies.”xxviii besides, marcus johanson agafors argues that fetuses are not blank states.xxix they are aware and responsive to the environment outside the womb; which means that they begin to develop attachments prenatally. truncating the developing attachment by handing the baby over to the commissioning parents therefore amounts to harming the child, “since such attachment is crucial to successfully developing social and emotional functioning.”xxx the point being made, though quite unsuccessful in our view, is that surrogacy creates an identity problem for the baby, mainly as a result of the transfer from the surrogate mother to the commissioning parents. we believe that while the fetus may be sensationally aware of its environment, there is nothing to show that such awareness informs the sort of consciousness salient to the formation of an identity. in other words, there is no possibility of interpreting and associating meanings to the change in the environment by the fetus. it is perhaps for this reason that, as agafors himself conceded, empirical evidence suggests that surrogate babies do relatively well when observed years later. it is one thing to prove that fetuses and babies are aware of changes around them, it is yet another thing to prove that such changes constitute harm, especially at the long run. the changes to which they grow accustomed as fetuses and newly born infants are cumulatively less significant to their long term stability as individuals, compared to the environment of nurture. biological bonds tend to fade as people grow and form relationships that are more psychologically and sociologically cogent. surrogacy and yoruba culture: the question at this point is whether yoruba culture is compatible with surrogate motherhood. segun gbadegesin provides an insightful answer to this question. in his works, bioethics and culture and bioethics and an african system, gbadegesin made a claim that surrogacy is compatible with yoruba culture. he argues that yoruba culture accommodates things that promote the common good of the people and jettisons those that negate the communal wellbeing.xxxi this pragmatic aspect of yoruba culture makes it amenable with surrogacy. he mentions two scenarios where surrogacy practice is evident in yoruba culture. the first is when a “husband is advised, sometimes by the first wife, to marry a younger woman in the hope that the spirit of the child so born into the family, will attract a child for the first wife too.”xxxii again, an infertile woman “arranges for her husband to marry another woman of her choice on the understanding that she will carry the first wife’s child.”xxxiii however, gbadegesin’s argument is somewhat problematic. the weight he placed on yoruba appropriation of a second wife has, in fact, no significance to surrogacy in the sense in which it is widely conceptualized. if a husband marries another woman in order to bear a child, both of them are the parents of the child. the second wife does not relinquish the child to the husband and the first wife, and neither is she paid for her service. besides, the first wife only becomes a step mother to the child in question. this being the case, what gbadegesin parades as surrogate motherhood in yoruba culture is actually obtaining a second wife, due to inability of the first wife to bear a child, in order to keep the family tree alive. consequentially, gbadegesin implicitly denies what he is trying to affirm and affirms what he is trying to deny: surrogacy is incompatible with yoruba culture. moreover, it is not in all cases that the appropriation of a second wife brings a child to the bangladesh journal of bioethics 2017; 8(3):26-32 31 home. and gbadegesin failed to tell us what happens in such a situation. does the husband appropriate more wives? if yes, what if the appropriation of more wives yields no result? or does he resign to fate and be condemned to childlessness in the biological sense? fayemi and akintunde have also argued that “surrogacy and adoption as presented by gbadegesin in traditional yoruba culture presupposes so many complications if it is adopted in contemporary times. this is because the rationale behind these issues in traditional setting cannot hold water in contemporary times.”xxxiv they supported this with the instance that gbadegesin’s argument ruled out a greater possibility of the surrogate requesting for her child or failing to fulfill her surrogacy contract as obtainable in modern surrogacy. thus, according to them, to refine yoruba surrogacy method in the furnace of modern surrogacy method will be highly detrimental. given the failure of gbadegesin to demonstrate how compatible yoruba culture is with surrogacy, how then are we to proceed? the link, in our view, lies in the normatively superior consideration accorded to the sociological dimension of motherhood. as we have shown, considerable effort is invested into biological procreation. but when such efforts fail, the one who is not able to bear a child is not considered barren in the social sense. there is a yoruba proverb that says; “eni bimo, omo lo maa sin, eni ti o bimo, omo lo maa sin.” it means that he who has children will be buried at death by children. he who doesn’t have children will equally be buried by children at death. the idea is that even if such persons are biologically barren, they are sociologically fruitful through the nurture and care of other children. this social parenthood is anchored on the belief that motherhood transcends the genetic bond (between the mother and the child) to responsibility, care and nurture. so an infertile couple who takes the responsibility of feeding, clothing, sheltering and moral building of orphans is regarded as a parent. surrogacy in this sense is therefore more normative than descriptive. on a last note, it is important to examine the problem of the bastard, illegitimate child in yoruba culture, even if in passing. the legitimacy of a child is paramount to marriage stability in yoruba culture. as a result, every family wants to prove that a child is their direct offspring. it thus becomes abominable for a family to go out of wedlock to have children.xxxv it must be stated that there exists a clear difference between an illegitimate child, often a product of a secretive liaison between a wife and another man; and a surrogate child, genetically related to the commissioning parents, and brought to life, though a third party, but out of mutual consent nonetheless. the surrogate child can therefore not be rightly described as an illegitimate child. it then implies that in contemporary times, surrogacy can be an addition to the hitherto limited pathways to parenthood. those who contract a third party to carry a baby for them are still socially legitimate parents, for as long as they discharge the responsibility expected of them to the child, irrespective of the manner of conception. conclusion: thus far we have been able to establish that in yoruba culture, having a child is considered critical to family and lineage survival. while in the traditional society there was no technology to make surrogacy possible, great efforts are made to overcome challenges relating to fertility, including propitiation, or the acceptance of a second wife in the hope that the arrival of children through such means will pave way for the first wife. but when these fail, the couples make recourse to caring and catering for other children who awards them the medal of parenthood. society regards as a mother, a woman who though unable to conceive, has nonetheless demonstrated the capacity to nurture and raise children. while expectations of procreation by an interested community of friends and relatives put a challenged couple under pressure and undue attention, such a situation is countervailed by the eventual acceptance of such a woman into the class of mothers, in spite of the biological limitations, upon the manifestation of the requisite sociological qualities. to address the challenge of infertility in contemporary time, surrogacy, within a culture which has a normatively sociological conception of motherhood offers promises that are quite enormous. this way, the gap between the biological and sociological demands of motherhood becomes further bridged, through the scientific procedure of surrogacy. bangladesh journal of bioethics 2017; 8(3):26-32 32 competing interests: none author contribution: 1st author conceived the idea, outlined the literature review and edited the manuscript. 2nd author guided to develop the manuscript and check same meticulously. references 1. mengual, a. & wolfie, n. surrogacy.white paper,2015; p.2. 2. surrogacy act 2010. 3. kjv, genesis, 16 vs. 3-6. 4. kjv, genesis, 30 vs. 1-2. 5. balogun, a. the concept of ori and human destiny in traditional yoruba thought: a soft deterministic approach. nordic journal of african studies,2007; 16 (1): 166-130. 6. lawal, b. the gelled spectacle: art, gender, and social harmony in an african culture. washington: university of washington press 1996 p. xiv 7. makinde, t. motherhood as a source of empowerment of women in yoruba culture. nordic journal of african studies, 2004; 13 ( 2 ) : 164 – 174. 8. balogun, a. o. authentic motherhood: traditional yorubaafrican perspective. international journal of philosophy, 2012; 41 (2):3. 9. op. cit, makinde, 2004 p.165. 10. ajibola, j. owe yoruba. ibadan: oxford university press.1977 p.23. 11. op. c.t, balogun 2012 p.4. 12. salami, a. ifa a complete divination. lagos: nidd publishing and printing limited 2002 p.36. 13. op. cit, balogun 2012 p.3. 14. ajibade, g. o. is there no man with penis in this land? eroticism and performance in yoruba nuptial songs. african study monographs, 20005; 26 ( 2 ) : 99-113. 15. op. cit, ajibola 1977 p.30. 16. op. cit, makinde 2004 p.167. 17. gbadegesin, s. “eniyan: the yoruba concept of a person” in p. h. coetzee & a. p. j. roux (eds.), the african philosophy reader. new york: routledge. 1998 p.155. 18. abimbola, w. the yoruba concept of human personality. la notion de personneen afrique noire colloques internationale de centre national de la recherche scientifique, 1971; (544): 69–85. 19. op. cit, gbadegesin 1998 p.162. 20. koster-oyekan, w. infertility among yoruba women: perceptions on causes, treatments and consequences. www. a jolly. info/inde.php/ajrh/…/3831. retrieved on 3/ 11/2016. 21op. cit, balogun 2012 p.3. 22. tieu, m. oh baby baby: the problem with surrogacy. in: bioethics research notes, 2007; 17 (1):2 23. reame, n. e. the surrogate as a high-risk obstetric patient. whi, 1991; 1(3):151-154. 24. rothman, b. k. “reproductive technologies off hope and serious risks.” in david bender & bruno leone (eds.), biomedical ethics: opposing views. u.s.a.: greenhaven press, inc. 1994 p. 50. 25. de la hougue, c. & roux, c. surrogate motherhood and human rights analysis of human, legal and ethical issues. surrogate september, 2015; issue 1: 10. 26. op. cit, tieu 2007 p.2. 27. hill, j. l. the case for enforcement of the surrogate contract. politics and the life sciences, 1990; 8(2):147-60. 28. comece. “opinion of the reflection group on bioethics on gestational surrogacy: the question of european and international rules.” http://www.comece.eu. retrieved on 10/12/2016. 29. agnafors, m. the harm argument against surrogacy revisited: two versions not to forget. medicine, health care and philosophy, (2014); 3(17): 357-363. 30. ibid p.9. 31. gbadegesin, s. bioethics and culture. in helga, k and singer, p. (eds.), a companion to bioethics. maiden: blackwell publishing ltd. 2009 p.13. 32. op. cit, gbadegesin 1993 p.260. 33. ibid p.260. 34. fayemi, a. k. & akintunde, f. a. on the myth called ‘african bioethics’: further reflections on segun gbadegesin’s account. bangladesh journal of bioethic; 2012; 3(3):4-11. 35. jegede, a. s. & fayemiwo, a. s. (2010). cultural and ethical challenges of assisted reproductive technologies in the management of infertility among the yoruba of southwestern nigeria. african journal of reproductive health, 2012;14(2):121. http://www.comece.eu/ bangladesh journal of bioethics 2017; 8(3):26-32 33 microsoft word emmanuel(1) bangladesh journal of bioethics 2018;9 (2):6-21 6 on the interests of non-human animals in traditional yorùbá culture: a critique of ọ̀ rúnmìlà ofuasia, emmanuel doctoral fellow, department of philosophy, lagos state university, lagos, nigeria. email: ofuasia.emma@yahoo.com abstract: traditional yorùbá culture admits the hegemonic locus that humans rank above all else on the planet. the outlook received decisive ratification several millennia ago in one of the odùs of their ifá corpus. specifically, in odù ògúndá otura, one of the numerous chapters of the ifá corpus, ọ̀rúnmìlà, the founder and primordial deity of ifá discloses his authorization, the use of non-human animals for sacrifice and other human ends interminably. in this study, we engage the ifá chapter that upholds this outlook. we riposte that the age long supercilious perspective among the yorùbá that humans rank higher and over non-human animals, as documented in the said odù is no longer tenable on biological and moral-legal grounds. if the biological and moral-legal thrusts are not invalid, what framework is plausible when the interest(s) of non-human animals clash with the interest(s) of ifá tradition and yorùbá culture? on what basis will it be appropriate to jettison the interest(s) of the one for the interest(s) of the other? in the light of these posers, we employ kai horsthemke’s ethical individualism as the suitable groundwork that considers the interest of animals recommended for sacrifice in ifá obeisance. keywords: ifá, non-human animals, ọ̀rúnmìlà, biological sciences, moral philosophy. introduction: it is interesting to begin with the truth that moral discourse(s) centered on the status of non-human animals, regardless of situation and place will sometimes, divulge “…the conflict between the interests of animals and people’s interests in culture.”1 incidentally, this inquiry attempts to unravel the conflict between the yorùbá interest in ifá propriety and tradition on the one hand and the interests of non-human animals in same culture on the other hand. the conflict or contradiction between these two spheres of understanding should not be perceived as a sign of failure. in other words when “in formal logic, contradiction is the signal of a defeat: but in the evolution of real knowledge it marks the first step in progress towards a victory.”2 when ifá is consulted and animal sacrifice is recommended this is seen by the yorùbá to be normal and in tune with the tradition and customs of the land. however, this interest in culture is now confronted by developments and advancements in the academia that non-human animals too have “interests that should not be cavalierly bangladesh journal of bioethics 2018;9 (2):6-21 7 frustrated.”3 a contradiction therefore ensues: oughtn’t we sacrifice the interest of the one for the other? on what grounds can the people’s interests in culture be sustained in the face of the conflict with the interests of non-human animals? are we to let it pass and place the one arbitrarily over the other? in this regard, alfred n. whitehead instructs: “we should wait: but we should not wait passively, or in despair. the clash is a sign that there are wider truths and finer perspectives within which a reconciliation of a deeper religion and a more subtle science will be found.”4 this is the core of this inquiry. in what follows, an effort will be made to argue that the justification for the killing of non-human animals in ifá and other variants of òrìṣà propriety founders on biological and moral-legal bases. for the fulfillment of its objective, the study has five parts, including this introduction. in the succeeding part, the case for the justification of non-human animals for human use and their surbordination to human beings as validated by ọ̀rúnmìlà in odù ògúndá otura (one of the chapters of the ifá corpus) is uncovered. but before this, an attempt will be made to provide an introductory but terse analysis of what ifá connotes and does not. in the third section, the biological and moral-legal arguments that render odù ògúndá otura antediluvian are comprehensively disclosed. in the fourth part, we propose a plausible framework to unknot the quagmire between the yorùbá interest in ifá tradition and status of nonhuman animals that had been deemed as nothing but entities fit only for human ends. the fifth part concludes this intellectual drudgery. ifá and ọrúnmìlà: the justification for the killing of non-human animals for human ends: it is imperious to state from the outset that attempts to give a univocal definition to ifá have not yielded results. there are as much understanding of the concept as there are scholars and practitioners of ifá. for e.m. lijadu, ifá is “the word of divination which issues from the mouth of ọrúnmìlà.”5 in a related development, william bascom puts that “the word ifá is used to mean both the system of divination and the deity who controls it; and this deity is known also as ọrúnmìlà.”6 similarly, nicholaj de mattos frisvold who is a practicing babaláwo appends: “ifá is a philosophy, a theogony, theology and cosmology rooted in a particular metaphysic that concerns itself with the real and ideal, the world and its beginning. it is rooted in the constitution of man the purpose of life and naure of fate. ifá is a philosophy of character. the philosophy of ifá lies at the root of any religious cult organization involving the veneration of òrìṣà.7 from the frisvold’s position, it seems the portrayal of ifá as a philosophy of character has been the notable attitude advocated by many babaláwo (i.e. male ifá practitioner) and ìyanifá (i.e. female ifá practitioner). hence, it does not come as a surprise that even nicholaj de mattos frisvold, being a babaláwo is not excluded from the trend. and this idea that ifá passes muster as a philosophy of character is one of the bangladesh journal of bioethics 2018;9 (2):6-21 8 fundamental truths embedded in some of the verses in odù ogbè-yọ̀ nú (another ifá chapter) which is rendered in the english thus: nothing comes from getting angry patience is the father of character an elder who has patience has everything. this is why divination was casted for orí, and for character (ìwà) it is only cultivating character that is hard there is not one bad ori in ilé-ifẹ it is a consequence of the foregoing odù (a term for ifá chapter) and similar ones that may have inspired fayemi ademola kazeem to assess the ethico-sociological interpretation of ifá as a paragon for building positive character and human personality in contemporary times.8 hence, the perception that ifá is a philosophy of character is not misplaced. however, another crucial issue that needs to be addressed is the tendency to “use of ifá and ọ̀rúnmìlà”9 to mean one and the same. for this reason, it is important to expatiate and expound further to see if we can deduce why this is the case. according to kola abimbola: “ifá, who lived for hundreds of years, and visited many parts of the world, bequeathed the ifá divination system to humanity. another name of ifá is ọrúnmìlà. the word ifá however, is used to refer to the orisa (divinity) himself, his instruments of divination as well his system of divination and literature. the name ọ̀rúnmìlà refers solely to the divinity himself… ifá priests and priestesses were counselors, physicians, historians and philosophers of ancient yorùbá land.”10 in this study, we shall admit and employ the perspective that ifá includes a body of ancient, oral, yorùbá poetic literature with metaphysical significance. but we are not the first to entertain this position. several years ago, ola longe who endorses this locus chronicled that ifá “…was originated and codified by ọrúnmìlà, who lived in ìléìfè,̣ several centuries ago.”11 ìlé-ìfè,̣ in present day osun state, nigeria is the cradle of yorùbá civilization. the ifá corpus constitutes the storehouse of yorùbá thought system. it is the ground of validation for yorùbá cultural practices and social cohesion. ifá corpus contains accounts of yorùbá cosmology, of the founding of major yorùbá towns and the relationship of deities with humans.12 though records of yorùbá lived experiences are found in ifá, the corpus is not static. as a body of intellectual material, ifá is simultaneously conservative and dynamic. accounts recorded in ifá chapters (odù), provide us with explanations for certain practices in yorùbá land. ifá may be described as the compendium of yorùbá life and practices. ifá is composed of sixteen major chapters (odù) and two hundred and forty derivatives, giving a total of two hundred bangladesh journal of bioethics 2018;9 (2):6-21 9 and fifty-six chapters.13 and people consult these odùs for diverse reasons. but mainly, the reason why people consult ifá is based on the assumption that the answers to what they seek can be provided by the divinity. hence, it needs no elaboration that: “when people consult ifá, they do so because they are convinced that ifá has answers and that knowing those answers will enable them to solve, or at least make sense of, the problem or the circumstances that have led them to the babaláwo’s door.”14 one point to note is that for whatever the problem may be, solutions range within the recommendation to change behavior, make new life choices, make fruit offerings/rituals, and in most cases, use nonhuman animals for rituals. however, the use of non-human animals is indispensable especially during initiation into ifá and other cults. we arrive at the boiling point! the use of non-human animals for sacrifice was clearly articulated by áwo fáladé òsúntólá in these words: “but there’s more to animal sacrifice than actively recharging an orisa’s cosmic ase-battery. animal sacrifice also nourishes us with the meat thereby completing the cycle and affirming our connection to our earthly and heavenly egbe (community). sacrificing an animal nourishes the spirits (with blood) and the community (with meat) thereby indexing the powerful link between humanity and the orisa as they are both nourished by a single ritual process. offerings of fruit, amidu, and even drinks all recharge our orisa’s ase but they perform this task slowly and with coolness. blood sacrifice, on the other hand, recharges an orisa quickly and with heat.”15 the foregoing is a clear indication that animal sacrifice is a crucial aspect in ifá tradition. awó fáladé òsúntólá maintains that unless animal sacrifice is performed for initiation, such an initiation is not authentic. in his words: “it is – in part – the intensity and “heat” produced from animal sacrifice that makes animal sacrifice mandatory in all orisa and ifa initiations. simply put, if you were initiated without the act of animal sacrifice your orisa was not fully birthed and by now your orisa has dissolved back to the earth from which it came. blood is not just symbolic of “birthing,” the intensity of blood sacrifice also has a practical purpose – it charges – or electrifies – the struggling ase of a newly incarnated orisa so that it may endure on earth.”16 the above thrusts endorse the outlook that the use of non-human animals for food and sacrifice is commonplace not only in ifá initiations but other cult initiations among the traditional yorùbá. however, it needs to be asked: is there any endorsement in the ifá corpus for animal sacrifice? in this regard, odù ògúndá otura, which is replete with a justification for the use of animals for sacrifice and surbordination of animals to humans, by ọ̀rúnmìlà will now be explored. a fair rendition in the english language is simplified thus: bangladesh journal of bioethics 2018;9 (2):6-21 10 ọ̀rúnmìlà said: “it is a matter of running helter-skelter” ifá says “it is a matter of being troubled” the children of the rat were running helterskelter they were troubled i asked why they were running helter-skelter and troubled the children of the rat said: “it was because of children” ọ̀rúnmìlà asked them: “would you be my devotee?” “what are we asking for?” the rat answered “what is baba akeyo (the great teacher) saying” but ọ̀rúnmìlà declared that the children of the rat may reproduce they divined and provided solutions to the children of the rat the children of the rat started having children two points are imperative for the embellishment of the main thrust of ògúndá otura, in the fore rendered ifá chapter. firstly, by using the phrase ‘children of the rat’, one is tempted to counter that if the rat already has children why it be troubled? but hermeneutically speaking, the phrase is merely representative of the rat species. the second point relates to the antecedent factors that informed the interchange. ọ̀rúnmìlà had come from the celestial realm, touring all the terrestrial species, when they were having challenges. in each of the places he toured, he discerned serious travails. he therefore asked what their problems were. the first place, which was the house of the rat (cited above), ọ̀rúnmìlà learned that the problem was due to lack of children. ọ̀rúnmìlà demanded the rat species be devoted to him, to which they showed reluctance. in order words, the rats were not ready to lose anything in exchange for the good things they wanted from olódùmarè, (the higher god/supreme diety) through ọrúnmìlà. this is evident in their question: “what is baba akeyo (the great teacher) saying?” the rat species was pondering over the lack of tandem between being devoted to ọ̀rúnmìlà on the one hand and the present agony and dilemma of childlessness, on the other hand. nevertheless, ọ̀rúnmìlà declared that they have children and it was so. ọ̀rúnmìlà repeated the same feat in the house of the fish, and all other animals until he encountered homo sapiens. ọ̀rúnmìlà asked them the same question. meanwhile humans benefitted from the advice of èsù, another primordial divinity (that is, òrìṣà in traditional yorùbá theology) who had secretly told them to affirm devotion toward ọrúnmìlà. in addition, ọ̀rúnmìlà granted them too, the ability to multiply. sixteen years later, ọ̀rúnmìlà returned to check if they were doing well. one after the other he visited he abode of each animal species. he entered the house of the rat. the multitude of children did not even know him. they did not remember it was he who made it possible for them to multiply. they were even spitting at him. the same bangladesh journal of bioethics 2018;9 (2):6-21 11 happened in the house of the fish, and other animals. the birds even defecated on him. however, when ọ̀rúnmìlà approached the house of humans, they recognized him from afar, ushered him in to be offered drinks and food. they provided him a place to sleep and he dwelt with them. consequently, ọ̀rúnmìlà who had hitherto been offended by the actions of the children of rat, fish, and other animals, prayed for humans and decreed that all those who revolted against humans shall henceforth be used as the exchange, substitute, buy back (i.e. ìrarí) for the problems that manifest in human lives. in his pronouncement ọ̀rúnmìlà harps: “they will be ìrarí that is, ‘a buy-back’ for you and your children till eternity.” this is the final verdict in odù ògúndá otura which both debunks the vantage that non-human animals and humans are partners and fellow occupants of the planet. secondly, it simultaneously serves as a thrust for their use as food and sacrifice, a perspective upheld by áwo fáladé òsúntólá in a foregoing excerpt. undoubtedly, odù ògúndá otura contains the instance where humans conceded and accepted this hegemony. being the devotee of ọrúnmìlà, they chorused thus: what then would be the buyback of a devotee? the children of the rat are the buy-back of a devotee the children of the rat what then would be the buyback of the devotee? the children of the fish are the buy-back of the devotee the children of the fish what then would be the buyback of the devotee? the children of the bird are the buy-back of a devotee the children of the bird what then would be the buyback of a devotee? the children of animals are the buy-back of a devotee the children of animals one does not need too much intellectual willpower to detect that odù ògúndá otura endorses the use of non-human animals for rituals and sacrifice toward the amendment of human absurdities. another point that must be amplified is that each of the species of fish, rat, and bird has significance that is not rendered explicit in the passage but demands a hermeneutic interpretation. odù ògúndá otura justifies the use of all animals that creep on land (symbolized by the rat species) for food and sacrifice. it endorses the use of all animals that fly (symbolized by bird species) for food and sacrifice. it also admits all animals that reside in water (symbolized by the fish species) for food and sacrifice. all these are calculated by the odù to validate the locus that non-human animals are not perceived as beings with interests that must not be frustrated or sacrificed needlessly for human ends. this also contradicts the proposal that “the yoruba recognize that animals have their own emotions, and that their pains are worthy of care consideration but not equal consideration with humans…”17 clearly, the fore odù sees animals as fit for human end bangladesh journal of bioethics 2018;9 (2):6-21 12 as immanuel kant18 will come to admit several centuries later. now that it has been established how non-human animals are used both as food and for rituals by ifá injunction, it is now pertinent to examine the moral-legal and biological implications of odù ògúndá otura. ọ̀rúnmìlà and the status of non-human animals: exposing the biological and moral-legal limitations: ọrúnmìlà’s sanction that non-human animals are ìrarí that is, ‘a buy-back’ for human problems for eternity, lacks moral cum legal justification on the one hand, but also vitiates the realities and truths about emergence and hierarchy of life as hold by the biological sciences on the other hand. but before exploring these perspectives, it is vital to reveal that the traditional yorùbá had for several hundred years held an outlook that several philosophers in the academic history of the west will later admit. aristotle, immanuel kant, st. augustine for instance concluded as ọ̀rúnmìlà did that the existence of other lives on the planet is sorely for the utility of humans. whereas renowned and erudite persona such as peter singer19; tom regan20; joel feinberg21; arthur caplan22 and recently rainer ebert23 have shown the slips why such position is no longer sustainable, it is important to therefore revise odù ògúndá otura too for a finer perspective. the revision of ọrúnmìlà’s injunction on non-human animals in traditional yorùbá philosophy is imperative because “in this respect, the old phraseology is at variance with the psychology of modern civilizations. this change in psychology is largely due to science, and is one of the chief ways in which the advance of science has weakened the hold of the old religious forms of expression.”24 with the foregoing preliminary statements, we now state in clear terms, our counterarguments against the justification in odù ògúndá otura. from the biological parlance, we glean that non-human animals can live fairly well without humans but the converse of this proposition cannot hold. in a related development, modern biology has also offered that non-human animals are the progenitors of humans through the process of evolution by natural selection.25 these revelations though implied in the yorùbá creation story are usually depreciated even when they are crucial for revising ọrúnmìlà’s sanction in odù ògúndá otura. let us explore the creation story to justify the biological locus that non-human animals can live even without humans, the converse being impossible. according to an oral tradition, olódùmarè the supreme deity in yorùbá belief, resided in heaven, and below was a watery surface. he then sent his right hand man, ọbàtálá the god of purity or morality with a snail shell (or a napkin in other accounts) filled with loose earth, a hen (some traditions say it is a rooster) and a pigeon.26 while this attests to events before the advent of humans on the planet, it is clear that non-human animals do not depend on humans rather humans depend on not only them but also other biotic and abiotic factors. for instance, the bangladesh journal of bioethics 2018;9 (2):6-21 13 same tradition buttresses further that ọbàtálá poured out the sand while the hen and the pigeon spread it with their claws on the watery surface so that land appeared. a chameleon was then sent to inspect the work and it brought back a report to olódùmarè that the earth was wide enough, ilé-ifẹ or the place of spreading.27 the place where this took place thus became known as ilé-ifẹ (or ifẹ), which is for the yorùbá, centre of creation from where humans, began their dispersal. later, obàtálá was sent back with ọrúnmìlà, another òrìsà, to equip the earth. this creation story serves the biological evidence that before humans, there was nonhuman animal life on the planet. the story reveals the role played by non-human animals in the creation of a world that will soon be occupied by humans. are we morally justified to admit non-human animals as nothing more than entities fit for human ends? are we justified to treat with disdain, entities that assisted in the creation of the world? as provoking as the posers are, it needs to be stated that traditional yorùbá theogony has some semblances with the one from some religious traditions of the world like judaism, christianity and islam.28 by placing humans the last in the order of creation, as chronicled in their sacred texts the semblance needs no expatiation. this necessarily implies that all other things that will sustain humans (non-human animals inclusive) were in place. but even as these stories inform the belief and attitude of the yorùbá, it lacks scientific basis. it is therefore important to engage with the scientific basis for our claim that: “nonhuman animals can live even without humans, the converse being impossible.” development and research in biology from the time of charles darwin attest that nonhuman animals have been living millions of years before the emergence of homo sapiens and served as the medium of the preservation and transmission of favourable variations leading to the homo grade.29 this is in line with evolution’s perspective that “…the organism does not live for itself. its primary function is not even to reproduce other organism; it reproduces genes, and it serves as their temporary carrier.”30 edward wilson’s claim is more imposing when we recall, biologically speaking that the emergence of organisms was around 3.8 billion years ago whereas the evolution of the genus homo, was not observed not until about 2.5 million years ago.31 while presenting his fact that homo sapiens must have evolved from pre-existing animals, israeli erudite personae yuval noah harari chronicles: “homo sapiens, too, belong to a family. this banal fact used to be one of history’s most closely guarded secrets. homo sapiens long preferred to view itself as set apart from animals, an orphan bereft of family, lacking siblings or cousins, and most importantly, without parents. but that’s just not the case. like it or not, we are members of a large and particularly noisy family called the great apes. our closest living relatives include chimpanzees, gorillas and orangutans. the chimpanzees are the closest. just 6 million years ago, a single female ape had two daughters. one bangladesh journal of bioethics 2018;9 (2):6-21 14 became the ancestor of all chimpanzees, the other is our own grandmother.”32 however, for the purpose of this study, it is important to elucidate that all modern day non-human animals and humans evolved from common ancestors instead of the erroneous and accentuated tendency to tinker that humans evolved from apes and monkeys. this distinction is crucial as nanda and worms attest: “saying that humans evolved from gorillas or chimpanzees suggest that humans are more evolved than these animals. however, no creature can be any more evolved than another. we can only imagine that we are more evolved if we believe that intellect or ability to alter the environment is the most important criterion of evolution. however, that is an extremely humancentered way of looking at biology. we could as easily say that producing the greatest number of related species or the greatest number of individuals is the best measure of evolution. if we were to take these criteria seriously, it would be clear that insects are far more ‘evolved’ than humans.”33 this human-centered way of looking at biology is redolent in odù ògúndá otura. ọ̀rúnmìlà’s injunction that non-human animals are fit only for human ends alone impresses that they exist simply for the sake of humanity. immanuel kant will later share ọ̀rúnmìlà’s anthropocentric perspective too when he brings in the notion of consciousness to the discursive fray. for kant, “so far as animals are concerned, we have no direct duties. animals are not selfconscious and they are merely as a means to an end. that end is man.”34 but this outlook that non-human animals lack consciousness is no longer valid. in 2012, a group of renowned scientists proclaimed through the cambridge declaration on consciousness that: “[c]onvergent evidence indicates that non-human animals have the neuroanatomical, neurochemical, and neurophysiological substrates of conscious states along with the capacity to exhibit intentional behaviors. consequently, the weight of evidence indicates that humans are not unique in possessing the neurological substrates that generate consciousness. nonhuman animals, including all mammals and birds, and many other creatures, including octopuses, also possess these neurological substrates.”35 what is suggestive of the foregoing is that we cannot dismiss non-human animals as entities without consciousness fit for human ends. regardless of the status quo, rainer ebert suggests that “…with a reasonable degree of certainty…at least mammals and birds have the capacity for phenomenal consciousness. on my view, that makes relevantly normal, developed members of these taxonomic classes intrinsically valuable subjects of experience whom it is no less seriously wrong to kill as it is to kill you or me, other things being equal.”36 with these findings, it is appropriate to ascertain that there will be no buy-back in ifá propriety if non-human animals cease to bangladesh journal of bioethics 2018;9 (2):6-21 15 exist or become extinct through poaching and/or use for sacrifice as validated by ọ̀rúnmìlà. incidentally, it had been documented that “the extinction rate of species ranges from approximately 1,000 to 10,000 times higher than natural extinction rates.”37 elsewhere we glean: “…if this trend continues, as many as 2 million species of plants and animals will be exterminated worldwide by the middle of the next century.”38 so is it not the case that for the interest in ifá culture to be sustained, the interest in continuous existence of animals can be compromised? is it not the case that if the interest of the former is pursued it will adversely affect the latter? given this reality, what is to be done? we consider the other arm of the limit before engaging with a plausible framework. in showing the limit of odù ògúndá otura from the moral-legal angle, we commence with the role played by èsù to strengthen the anthropocentric ties redolent in the odù. one must not wish away the corpulent role of informant played by èsù that humans concede to be devoted toward ọ̀rúnmìlà. the species of the rat, fish and bird did not have the benefit of this information. this is played out in the innocence latent in the poser by the rat species: “what is baba akeyo (the great teacher) saying?” the rats obviously did not see the connection between the seemingly irrelevant request to become a devotee on the one hand and the burning challenge of childlessness on the other hand. the anthropocentric outlook of the odù is exhibited given that only humans had prior knowledge to concede devotion to ọ̀rúnmìlà but not any other non-human animal. firstly, it is the conviction of this research that no moral agent should be held responsible eternally because of an action borne out of ignorance or lack of adequate or prior information. the species of the rat, fish and bird, have been unfairly treated, given their lack of prior information which informed their reluctance to be devoted to ọ̀rúnmìlà. the scene where ọ̀rúnmìlà was angered because the rat species failed to recognize him and where the bird species defecated on him, though aimed to justifying the inferiority of non-human animals to humans is very weak one. we hypothesize that had they been given a similar ‘help’ by èsù, perhaps they would not have behaved so unruly to upset ọ̀rúnmìlà. furthermore, the species of animals that encountered ọ̀rúnmìlà’s wrath no longer exist. is it not morally blameworthy to bestow on a later generation the sins or misdeeds of their ancestors? the injunction of ọ̀rúnmìlà is a direct affront to the yorùbá maxim: iká t’obá ṣe l’ọ̀ ba ń ge (it is only the offender that is punished by the authority). this brings us to the discourse on the proportionality between crime and punishment. adebayo aina has successfully demonstrated that the western traditional punitive theories cannot handle the proportionality factor. he labours to show that traditional yorùbá perspective takes cognizance of this lacuna. in his words: the yorùbá belief is that it is he who commits a crime that should be sanctioned. bangladesh journal of bioethics 2018;9 (2):6-21 16 and, whoever commits a crime cannot escape no matter how long he hides. this strictly provokes the judicious imposition of punishment on criminal as a means of establishing responsibility for human conduct without any extraneous inclination. even, after the criminal admits his wrongdoing and is punished for that he remains in the memories of the people as a wrongdoer.39 in a similar fashion, david hume had tinkered on the proportionality factor in crime and punishment when he pens: “punishment, according to our conceptions, should bear some proportion to the offence. why then eternal punishment for the temporary offences of so frail a creature as man?”40 even when david hume was preoccupied with diminishing the possibility of life before or after physical death, his bearing on punishment may still be used for the purpose of this study. it is therefore a grave moral and legal oversight for ọ̀rúnmìlà, not to have taken proportionality seriously before his injunction. his oversight is a direct erosion of the respectable, holistic and comprehensive yorùbá culture which is in the words of oladele abiodun balogun: “…a composition of knowledge, beliefs, art, moral, religion, customs, politics, technology, law and other living capabilities acquired by the individual as an indigenous member of the yoruba race. as with other aspects of the culture, the legal arm is undoubtedly important to the dynamism and vitality of the yoruba culture as a whole.”41 in this section, the biological and morallegal limitations of ọ̀rúnmìlà have been revealed. however, we are still faced with a crucial issue – peoples’ interest in culture will make them consult ifá. and when divination recommends animal sacrifice, it must be observed. the interest in the existence of non-human animals is also crucial as the perspective that they are of no more worth other than for human ends is now a weak thesis. it is therefore important to patent a framework for this clash. this is hub of the next section. ọ̀rúnmìlà and the status of non-human animals: why ethical individualism matters: what is ethical individualism? how does it assist toward a truce when the interest in culture clashes with the interests of non-human animals? how does ethical individualism initiate an improved rendition or revision of ọ̀rúnmìlà in ògúndá otura? these three questions will be the focus in the remainder of this study. the main thrust of ethical individualism is to evince “who counts morally, why and how.”42 in the words of the foremost proponent of this outlook, kai horsthemke, we glean that “ethical individualism is stimulated by the idea of a copiously branching network in which individuals interact and coexist and cooperate with other forms of life.”43 we discern right away that this theory takes cognizance of all forms of life. it is the case that there may be levels of gradation from simple to complex among these individual forms of life, ethical individualism however upholds that “these bangladesh journal of bioethics 2018;9 (2):6-21 17 individuals resemble one another and differ from one another in multitudinous ways with the characteristics associated with one variety typically overlapping those associated with another variety.”44 the main thrust of ethical individualism has to do with the unique identity and characterization of each organism but not the genus or species that they are commonly subsumed. to make this point clear, a little bit of elaboration is pertinent. ethical individualism does not discriminate organisms on the grounds of belonging to the class of mammals, reptiles or aves. this taxonomy, it needs to be mentioned, is a derivation of human intellectual willpower. ethical individualism is focused principally on each unique and distinct organism. kai horsthemke makes this amplification more obvious: “ethical individualism is a view that is sensitive to particular characteristics and to the complex pattern of similarities and differences that exist between individuals, a complex web of identity, similarity and diversity. what matters, on this view, is the individual characteristics of organisms, and not the classes within which these organisms are commonly subsumed.”45 if ethical individualism contends that each organism be accorded recognition outside their taxonomy, then equality enters the discursive fray. ethical individualism holds that the idea of equality does not necessarily imply ‘identity’ in treatment and consideration but that it is compatible with the idea of diversity in treatment and consideration.46 it acknowledges that the (conceptual) distinction between ‘moral agent’ and ‘moral recipient’ may be morally significant and may be the basis for sanctioning differential treatment and consideration. ethical individualism denies that morally relevant differences between agents and recipients are exclusively or primarily relevant to the question of moral status. it denies also that these differences sanction unequal treatment and consideration.47 given the fact in the outlook that individuals are similar in several ways and also different in diverse ways, this does not make one organism more or less a being with higher interest over the other. in the attempt to see how non-human animals can benefit from this intellectual approach, from the framework of ethical individualism, it is important to make a distinction between basic and non-basic rights. this distinction was developed by kai horsthemke wherein he insists: “all morally considerable individuals have the same basic rights, although their non-basic rights may differ. second, basic rights are “basic” in the sense of being “irreducible” or “underived”. that is, they are not reducible to or based on duties, obligations, responsibilities etc., as they would be in duty-based theories— insofar as these theories permit talk of rights. basic rights generate duties, responsibilities, non-rights, and indeed other rights. these rights, then, will be “nonbasic”, in the sense of being “derived”, or dependent on basic rights. they are instances of “core rights”. non-basic or derivative rights, it should be noted, are not bangladesh journal of bioethics 2018;9 (2):6-21 18 generated by or derived from duties, obligations, responsibilities or non-rights. there exists an intimate relationship between non-basic rights and all of these but it is not one of direct derivation.”48 this intimate relation must not be seen from the anthropocentric perspective. there is therefore no synchrony between the basic and non-basic rights of non-human animals when their lives are cut short for human ends interminably as endorsed by ifá tradition. unfortunately, for non-human animals, “it matters only that they are not made to suffer and that their lives are not cut short for reasons that have very little, if anything, to do with them, their own wellbeing and interests.”49 this truth is even made more appalling by the inference that “as far as animals are concerned, we are not different races and different cultures. we are one race; one culture; one oppressor; one bully; one killer.”50 from the foregoing, it is clear that the distinction between the killer and the killed is now vague. this is the inner kernel of ethical individualism. so, what happens when the interests of ifá ‘devotees’ clash with the interests of non-human animals? we deduce from ethical individualism that the sacrifice made by the devotee using animals is an injury against life and everything that it represents. this is owing to the understanding in ethical individualism that all organisms even when they exhibit similarities and variations are unique in their own distinct way. hence, the life of a human on this view is equal to the life of a tilapia. however, for these ‘non-devotees’ of ọ̀rúnmìlà – we are fellow occupants of the planet, “…one culture; one oppressor; one bully; one killer.”51 it is precisely for this reason that ethical individualism cautions and demands for a revision of the verdict or injunction in odù ògúndá otura as it is no longer tenable in contemporaneous times. we have been able to establish that for nonhuman animals, they are as unique as humans albeit with a lower gradation but this does not vitiate their equality and basic rights. we also recognize that sacrifice in ifá propriety when recommended by divination must be observed. however, a pivot achievement of ethical individualism is the repudiation of the anthropocentric and hegemonic outlook in ògúndá otura. it cautions and counters the outlook that nonhuman animals exist merely as ìrarí (i.e. buy back) for human challenges. with ethical individualism, we may then demand that “the state or animal rights groups might negotiate with members of a culture, say, to integrate stunning into their slaughter practice, so that, while there would still be animal killing, suffering would at least be minimized.”52 another course of action could be to bring to the knowledge of humans, (or shall we say ‘devotees’?) the archaic outlook in ògúndá otura, and then start exploring other aspects of sacrifice that will reduce the shedding of blood of non-human animals. it is clear that an easy resolution will still be far off. one can only start negotiating because of the difficulty in transgressing established bangladesh journal of bioethics 2018;9 (2):6-21 19 traditions and the gradual awareness that non-human animals too are beings with “interests that should not be cavalierly frustrated.”53 it is the strain in arriving at an outright resolution that informed thaddeus metz’s conviction that his “aim is not so much to resolve the conflict between our duties to animals and our rights to culture, but rather to understand it, precisely as one that is extremely hard to resolve for involving comparably strong considerations that, despite their common moral foundation, pull in different directions.”54 conclusion: the entirety of this intellectual graft seems to have attained two agenda. first, it disinters that the injunction by ọ̀rúnmìlà in ògúndá otura that non-human animals are for human end simplicter, is no longer tenable in the light of revelations from biology and moral philosophy. indeed, it needs no elaboration that “the old phraseology is at variance with the psychology of modern civilizations.”55 furthermore, we already showed that ọ̀rúnmìlà’s injunction lacks biological, moral, logical and legal thrusts. secondly, this study has also attempted to provide a context for resolution in ethical individualism that takes cognizance of peoples’ interests in culture as well as the interests of non-human animals. it therefore calls for negotiation when the interest of the one intersects with the interest of the other, pending when the consciousness and awareness that non-human animals are nothing but ìrarí (buy back) gradually becomes a widespread and accentuated perception among ifá adherents. author contribution: the idea that evolved into this research was ‘prehended’ and codified by the author. conflict of interest: there is no conflict of interest. acknowledgements: i wish to acknowledge the thought-provoking comments provided for the initial draft of this research by ademola kazeem fayemi (ph.d.), department of philosophy, university of lagos, nigeria. without the colossal time and effort provided by ‘booda kaso,’ this essay will not have evolved into the present state. i am eternally grateful sir! in addition, the effort and constructive criticisms from professor helen lauer, department of philosophy, university of dar es salaam, tanzania were very helpful toward the evolution of the initial draft of this essay to its present state. references 1thaddeus metz. “duties toward animals versus rights to culture: an african approach to the conflict in terms of communion.” in l. cordeiro-rodrigues & l. mitchell (eds.). animals, race and multiculturalism. (london: palgrave macmillan 2017), p. 269. 2alfred n. whitehead. science and the modern world. (new york: pelican mentor books 1948), p. 186 3arthur l. caplan. “beastly conduct: ethical issues in animal experimentation.” the ethical dimensions of the biological science. (cambridge: cambridge university press 1996), p. 183 4op. cit., whitehead., p. 184 5e.m. lijadu. ifá, imole re ti ise ipinle isin ni ile yorùbá. (exeter: james townsend & sons 1923), p. 1 bangladesh journal of bioethics 2018;9 (2):6-21 20 6william r. bascom. ifá divination: communication between gods and men in west africa. (indiana: indiana university press 1969), p. 14 7nicholaj m. frisvold. ifá: a forest of mystery. (paris: bibliotheque rouge 2016), p. 13 8kazeem d. fayemi. “human personality and the yoruba worldview: an ethico-sociological interpretation.” africology: the journal of pan african studies. 2009 vol. 2 (9): 166-76. 9oladele o. balogun & kazeem d. fayemi. “the relevance of ifá to jurisprudence and human rights discourse.” (the international conference on philosophy and the law in africa 2008), p. 37 10kola abimbola. yorùbá culture: a philosophical approach. (birmingham: iroko academic publishers 2006), p. 119 11ola longe. ifá divination and computer science: an inaugural lecture. delivered at the university of ibadan on thursday, 22 december, 1983. (ibadan: w. giradet press (w.a) co. 1998), p. 15 12bolaji idowu. olódùmarè: god in yorùbá belief. (london: longmans 1962) 13see daniel o. epega. iwe ifá ati itumo ala. (lagos: the hope rising press 1931), p. 15 & wande abimbola. ijinle ohun enu ifá. (ibadan: oxford university press 1969) 14olufemi taiwo. “ifá: an account of a divination system and some concluding epistemological questions.” in kwasi wiredu (ed.). a companion to african philosophy. (new york: blackwell 2004), pp. 305-6 15áwo fáladé òsúntólá. “is animal sacrifice important.” 2013. available at http://iyaifagbemi.blogspot.com.ng/2013/03/isanimal-sacrifice-important.html?m=1. accessed on 12 january, 2018 16ibid 17ebun oduwole & kazeem ademola fayemi. “animal rights vs. animal care ethics: interrogating the relationship to non-human animals in yoruba culture.” in j. chimakonam (ed). african philosophy and environmental conservation. (london: routledge 2018), p. 77 18immanuel kant. lectures on ethics. (new york: harper & row. 1963) 19peter singer. animal liberation: a new ethic for our treatment of animals. (new york: avon books 1975); peter singer. “not for humans alone: the place of nonhumans in environmental issues”. ethics: thought and practice. (new jersey: prentice-hall inc.1985) 20tom regan. the case for animal rights. (berkeley: university of california press 2004) 21joel feinberg. “the rights of animals and unborn generations.” ethics: thought and practice. (new jersey: prentice-hall inc. 1985) 22arthur l. caplan. “beastly conduct: ethical issues in animal experimentation.” the ethical dimensions of the biological science. (cambridge: cambridge university press 1995) 23rainer ebert. the wrongness of killing. unpublished phd thesis. rice university. 2016 24op. cit., whitehead, p. 191 25charles l. darwin. on the origin of species by means of natural selection, or the preservation of favoured races in the struggle for life. (new york: modern library edition 1949) 26see op. cit., idowu, pp. 18-21; o. awolalu. yoruba beliefs and sacrificial rites. (essex: longman 1979) 27funmi olojede. “the exodus and identity formation in view of the yoruba origin and migration narratives.” scriptura. 2011, 108 p.343 28see genesis 1: 28 and al-qur’an 2:47. 29edward o. wilson. sociobiology: the abridged edition. (london: belknap press 1998), p. 3 30ibid., p. 3 31yuval n. harari. sapiens: a brief history of humankind. (canada: random house 2014), p. 7 32ibid., p. 11 33s. nanda & r.l. warms. cultural anthropology. (california: wadsworth 2010), p. 7 34op. cit., kant, p. 239 35the cambridge declaration on consciousness (cambridge, july 7, 2012) available at http://fcmconference.org/img/cambridgedeclara tiononconsciousness.pdf retrieved on 1st april, 2018. 36op cit., ebert, p. 212 37r.s. keller & o.e. wilson. the biophilia hypothesis. (washington: island press 1993) 38s.l. pimm, g.j. russell, j.l. gittleman, t.m. brooks. “the future of biodiversity.” science. 1995 (269) pp. 347-50. 39aina a. adebayo. “crime, punishment and the proportionality factor in contemporary society: the yorùbá experience.” philosophia africana. 2016 18 (1) p. 16 40david hume. an enquiry concerning human understanding. edited and with an introduction by peter millican (edinburgh: edinburgh university press 2007), p. 149 bangladesh journal of bioethics 2018;9 (2):6-21 21 41oladele o. balogun. “a philosophical defense of punishment in traditional african legal culture: the yoruba example.” africology: the journal of pan african studies. 2009 3(3) p. 44 42kai horsthemke. “animals and the challenges of ethnocentrism.” in l. cordeiro-rodrigues & l. mitchell (eds.). animals, race and multiculturalism. (london: palgrave macmillan 2017) 43ibid., p. 141 44ibid., p. 141 45ibid., 141 46ibid., p. 142 47ibid., p. 143 48kai horthemske. the moral status and rights of animals. (pinegowrie: porcupine press 2010) 49op cit., horthemske 2017, p. 142 50g. francione. “the abolitionist approach to animal rights.” available at https://www.facebook.com/abolitionistapproach/ posts/530170923669333 retrieved on 2nd april, 2018 51ibid 52f. zuolo. “the priority of suffering over life: how to accommodate animal welfare and religious slaughter.” the ethics forum. 2014 (9), p. 180 53op cit., caplan, p. 183 54op cit., metz, p. 292 55op cit., whitehead, p. 191 microsoft word 1. pharmaceutical_promotion_in_bangladesh_assessing_the_strength_of_regulatory_documents edited bangladesh journal of bioethics 2018; 9 (3): 1-10 1 pharmaceutical promotion in bangladesh: assessing the strength of regulatory documents fatema johora1* and md sayedur rahman2 1. assistant professor, department of pharmacology, army medical college bogura, bogura cantonment, bangladesh. email: fatemajohora.0801@gmail.com; orcid id: http://orcid.org/0000-0002-9030-5224 2. professor, department of pharmacology, bangabandhu sheikh mujib medical university, dhaka, bangladesh. email: srkhasru@bsmmu.edu.bd ; orcid id: https://orcid.org/0000-0002-5960-0161 corresponding author: fatema johora, email: fatemajohora.0801@gmail.com abstract: pharmaceutical promotion is a negative influencing force for prescribing. however, very few regulatory initiatives are taken to overcome this unwarranted influence. the present research was conducted in such context with an attempt to review the regulatory documents related to pharmaceutical promotion in bangladesh including code of pharmaceutical marketing practices (cpmp), and to compare cpmp with different global guidelines. the studied guidelines demonstrate effort to regulate promotion, though that varies to a great extent, particularly in enforcement aspects. clearly defined ethical and legal prohibitions, provisions of punishment for violations and entrusted agency with defined authority are crucial. key words: ethical pharmaceutical promotion, code of pharmaceutical marketing practices, drug policy, laws, regulation of promotion, bangladesh situation background: pharmaceutical promotional activitiesissue of concern from the very beginning and are highly successful to alter physicians’ prescribing habit [1]. the impact of promotion on physicians prescribing practice is enormous, ranging from the selection of inappropriate, unnecessary, costly medicine to low prescribing quality [23]. frequent interactions with industries and positive attitudes towards them have been related with less evidence-based prescribing of physicians [4]. and weak control over promotional activities has been linked to poor prescribing [5]. there are lots of controversies and no resolution or consensus yet achieved towards this direction. various interventions have been taken throughout the world to control and regulate pharmaceutical promotional activities [2], [5]. international federation of pharmaceutical manufacturers & associations (ifpma) and world health organization (who) acted as pioneers to introduce and develop guidelines to support and encourage the improvement of healthcare through rational use of medicinal drug. in many countries, national guidelines exist, which usually specify that the promotional information should be accurate, complete and good in taste. guidelines also cover the use of samples, gifts and participation in promotional bangladesh journal of bioethics 2018; 9 (3): 1-10 2 conferences as well as in clinical trials [6-8]. however, mere presence of guidelines is not sufficient to control promotion [9-10]. the market size of pharmaceuticals in bangladesh is around us$ 1.68 billion [11]. 276 companies have marketed around 27000 products in our country [12] and pharmaceutical companies conduct promotional activities to increase market share of their products. from time to time, bangladesh formulated several policies, acts and code to promote rational use of medicine. in 1994, code of pharmaceutical marketing practices (cpmp) was approved to promote and support continuous development of and strict adherence to the ethical principles of marketing of pharmaceutical products [13-14]. the present study has attempted to explore current regulatory documents regarding pharmaceutical promotion and compare with global documents in this particular issue. for analyzing national regulatory documents of bangladesh regarding pharmaceutical promotion, following related policy and regulatory documents of bangladesh were reviewednational drug policy 1982, the drug (control) ordinance, 1982, national drug policy, 2005, the consumer rights protection act, 2009, and code of pharmaceutical marketing practice, 1994. later, during selection of national guidelines, two countries from high income group, two from the middle income group and two from the low income group were selected. national guidelines/ code of conducts of australia (medicines australia ‘code of conduct’), united kingdom (abpi ‘code of practice for pharmaceutical industry’), malaysia (phama ‘code of conduct’), india (‘uniform code of pharmaceuticals marketing practices’), nepal (guidelines on ethical promotion of medicine) and zimbabwe (advertising guidelines) were analyzed and reviewed in order to evaluate status of ambiguity and inadequacy of the existing code of pharmaceutical marketing practices of bangladesh. regulation of pharmaceutical promotion around the world: ifpma published ‘ifpma code of pharmaceutical marketing’ in 1981 to regulate the promotional activity of pharmaceutical industries, and extensively revised in 2006 and 2012 [6]. this code is now considered as an international model for effective development of local codes. it is a requirement of ifpma membership that the member associations acknowledge and adhere to the conditions of the ifpma code. in addition, they need to adopt codes that meet local requirements, which are consistent with and as comprehensive as the ifpma code [15]. who published ‘ethical criteria for medicinal drug promotion’ in 1988 [7]. and this was intended as guidance for countries to use when developing their regulations and practices around medicinal drug promotion. the document is still used by regulators, governments, and academics as a yardstick for measuring the acceptability of promotional activities. who guidance document is particularly playing important role in countries where local regulation is absent or insufficient [5]. in most of the countries, pharmaceutical promotion is regulated through selfbangladesh journal of bioethics 2018; 9 (3): 1-10 3 regulation approach. under self-regulation, government is the legislative authority to control promotion in some or all aspects along with national industry associations. these associations voluntarily formulate their own codes or guidelines, and the members of the associations are obliged to follow these. in this approach, monitoring of promotion has been maintained by the complaint system, from both physicians and competing companies, and publication of complains. issuing a corrective advertisement, withdrawal of promotional materials, fines or expulsion from the association and publication of sanctions are used to control promotional activities. government can take steps, only if serious violations occur. australia, sweden and the uk are examples of self-regulation approach [5], though the success of this approach is not out of question [16]. in australia, promotional activities of pharmaceutical industry were strictly controlled and regulated by both government and national industry association, and industries were repeatedly fined for violations of code of conduct [17]. the pharmaceutical association of malaysia (phama) adopted “code of pharmaceutical marketing practices” in 1978, for selfregulation of pharmaceutical marketing and promotion in malaysia. this includes separate codes of conduct for prescription and otc products. the codes has been amended from time to time [18], though the effect of this regulatory framework was never evaluated. in india, department of pharmaceuticals introduced “uniform code of pharmaceutical marketing practices” in 2014 to detect and stop malpractices in pharmaceutical marketing and/or promotion, which includes provision prohibiting gift to physicians [19]. beforehand, organization of pharmaceutical producers of india (oppi) introduced “code of pharmaceutical practices”, which was the guideline for pharmaceutical industry [15]. nepal is a country where domestic pharmaceutical companies share only 35% of the total market and remaining portion is met through import. in 2007, department of drug administration (dda) of nepal introduced “guidelines on ethical promotion of medicine” to encourage ethical promotion of medicine. the same department is authorized to regulate promotion and/or advertising of medicines. yet, there is no national code of conduct concerning advertising and promotion of medicines formulated by the industries [20]. nevertheless, harper et al. [21] revealed significant presence of unethical promotion in nepal. in zimbabwe, 14 domestic pharmaceutical manufacturers share 47% of market. transnational (tncs) innovator and generic competitor companies have no direct presence in zimbabwe. they are all represented either by distributors or wholesalers and there are 104 pharmaceutical wholesalers who are permitted to import. medicine control authority of zimbabwe (mcaz) introduced “advertising guidelines for medicine” in 2011, which includes promotional materials but does not mention anything about other forms of promotional activities [22]. another related regulatory guideline named bangladesh journal of bioethics 2018; 9 (3): 1-10 4 “medicine and allied substances control act” was found ineffective to control and regulate drug advertisements [23]. the usa and france are among the few countries where government directly regulates pharmaceutical promotion. usfda by its office of prescription drug promotion (opdp) regulates pharmaceutical promotion. opdp regulates and monitors promotional activities. also, by administering opdp bad ad program, opdp educate healthcare providers to recognize misleading promotion. enforcement was done by notices of violation, warning letters injunction, consent decree seizures and criminal action, civil and monetary penalties [24]. the big pharmaceuticals were repeatedly fined and penalized in billions for illegal off-label marketing of drugs and paying kickbacks to healthcare professionals to encourage them to prescribe promoted drugs. but the financial penalties were actually a small amount in comparison to company profits [25].later on, an act named ‘the sunshine act’ was passed in 2010 as part of the “affordable care act” that requires manufacturers of drugs, devices, biologicals and medical supplies to report annually every payment and other transfers of value to physicians and teaching hospitals [26]. a project supported by propublica provided a unique opportunity for every citizen of the usa to know their doctor’s financial relationship with industry through a program titled ‘dollars for docs’ [27]. regulation of pharmaceutical promotion in bangladesh: current laws and the code of pharmaceutical marketing practices provide the regulatory framework for the control of advertising and promotion of medicines in bangladesh. code of pharmaceutical marketing practice (cpmp) was developed according to global standards including the who ethical criteria for medicinal drug promotion, ifpma code of pharmaceutical marketing practices, and abpi code of practice for the pharmaceutical industry [13]. studies [14, 28] found that the code of pharmaceutical marketing practices (cpmp) was ineffective in improving the quality of information provided in advertisement published in medical journal as well as in pharmaceutical promotional literature. in 2010, who and later on, usaid-funded systems for improved access to pharmaceuticals and services (siaps) program explored the regulatory framework for pharmaceutical promotion, specified the weaknesses and recommended some changes [13], [29]. table i. review regulatory documents of bangladesh related to pharmaceutical promotion indicators national drug policy 1982 drug control ordinance 1982 national drug policy 2005 consumer protection act 2009 code of pharmaceutical marketing practice 1994 form of promotion not stated not stated not stated not stated clearly defined monitoring of promotion not stated not stated not stated not stated not stated interpretati on and implementa tion procedure for regulation of promotion not stated clearly defined not stated not stated not stated bangladesh journal of bioethics 2018; 9 (3): 1-10 5 table ii. structured review of national guidelines and code of conducts about ‘background information’ and ‘form of promotion’ points bangladesh australia uk india malaysia nepal zimbabwe a.background information i)edition 1 18 16 3 19 1 1 iii)types of regulation govt. self self self self govt. govt. iii)regulatory body dgda tga, ma mhra, abpi cdsco, oppi mab, phama dda mcaz b.form of promotion i)printed promotional materials a)standards of information clearly defined clearly defined clearly defined clearly defined clearly defined clearly defined clearly defined b)text/ font size ambiguously defined clearly defined not mentioned not mentioned clearly defined not mentioned not mentioned ii)gift a)types of gift allowed clearly defined clearly defined clearly defined clearly defined clearly defined not mentioned not mentioned b)types of gift prohibited not mentioned clearly defined clearly defined not mentioned clearly defined not mentioned not mentioned c)monetary value of gift not mentioned not mentioned clearly defined not mentioned clearly defined not mentioned not mentioned iii)sample quantity of sample not mentioned clearly defined clearly defined not mentioned not mentioned not mentioned not mentioned iv)symposia & other scientific meeting not mentioned clearly defined clearly defined clearly defined (prohibited) clearly defined clearly defined not mentioned v)hospitality not mentioned clearly defined clearly defined clearly defined (prohibited clearly defined clearly defined not mentioned abpi: the association of the british pharmaceutical industry; cdsco: central drug standard control organization; dda: department of drug administration; dgda: directorate general of drug administration; ma: medicine australia; mab: malaysia advertisement board; mcaz: medicine control authority of zimbabwe; mhra: medicines and healthcare products regulatory agency; oppi: organization of pharmaceutical producers of india; phama: pharmaceutical association of malaysia; tga: therapeutic good australia. bangladesh journal of bioethics 2018; 9 (3): 1-10 6 table iii. structured review of national guidelines and code of conducts about ‘systems required for monitoring of promotion’ and ‘systems required for enforcement of regulation of promotion’ points bangladesh australia uk india malaysia nepal zimbabwe c.systems required for monitoring of promotion i) governmental system for monitoring not mentioned not mentioned not mentioned not mentioned not mentioned not mentioned not mentioned ii)mechanism of monitoring not mentioned clearly defined clearly defined not mentioned not mentioned not mentioned not mentioned ii i)body responsible for monitoring not mentioned clearly defined clearly defined not mentioned not mentioned not mentioned not mentioned iv)complaint system not mentioned clearly defined clearly defined clearly defined clearly defined not mentioned clearly defined v)publications of complaints not mentioned clearly defined clearly defined clearly defined clearly defined not mentioned clearly defined d.systems required for enforcement and regulation of promotion i)responsible body for enforcing and regulation of promotion clearly defined clearly defined clearly defined clearly defined clearly defined clearly defined clearly defined ii)sanctions not mentioned clearly defined clearly defined clearly defined clearly defined not mentioned not mentioned iii)publication of sanctions not mentioned clearly defined clearly defined clearly defined clearly defined not mentioned not mentioned iv)appeal mechanism not mentioned clearly defined clearly defined clearly defined clearly defined not mentioned not mentioned policy and regulatory documents of bangldesh in context with global documents: : : : in 2011, the medicines transparency alliance (meta) and the health action international (hai) global program, under the guidance of an advisory group of international experts, has developed a methodology to help countries gain an overview of the national regulatory framework regarding medicines promotion, and a ‘data compilation tool’ has been developed [30]. this data compilation tool was divided into four categories (background information, scope of bangladesh journal of bioethics 2018; 9 (3): 1-10 7 regulation, monitoring of promotion and enforcing medicine promotion). as these national guidelines and code of conducts were drafted on the socio-economic and cultural background as well as setting and market size of pharmaceutical industry of those particular countries, selected indicators (background information, forms of promotion, systems required for monitoring and regulation for enforcement) of hai/meta ‘data compilation tool’ were used to review them. and findings were categorized as ‘not mentioned’, ‘ambiguous’ and ‘clearly defined’. in bangladesh, code of pharmaceutical marketing practices is the only regulatory document to address pharmaceutical promotion although interpretation and implementation procedure was only clearly defined in drug control ordinance 1982 (table i). countries like australia, malaysia and uk regularly updated their regulatory framework, whereas cpmp of bangladesh was never updated after introduction (table ii). a recent study revealed that majority of the physicians and medical representatives of bangladesh are not aware about the existing cpmp, and the conflicting relationship between physician and pharmaceutical industry was labeled as ‘unholy alliances’ [31]. the national guidelines have tried to guide or regulate pharmaceutical promotion, which is an indirect acknowledgment about it’s detrimental influence. the studied guidelines demonstrate that there was effort to regulate promotion and bring those activities under the framework of scientific justification. this study revealed that the regulatory measures of different countries particularly differ in enforcement aspects (table iii). among the documents, presence of clear directive for punishment in case of unethical promotion varies greatly among countries. in countries like australia and uk, in every occasion, there are some instructions and provisions in the documents that prohibit the industry from doing certain activities and there are definite punishments mentioned in the laws and regulations in case of violations. in addition to those laws, different countries adopted special measures like sunshine act in usa [32] and voluntary reporting by competing companies and healthcare professionals or consumers in australia. moreover, the monitoring approaches are found to be effective because of existence of supporting laws to ensure the punishment for violations [33]. the present study found that the frameworks of bangladesh, india, malaysia, nepal, and zimbabwe only mentioned the areas but the authority of the entrusted agency after identifying any violation was not defined (table ii and table iii). this deviation is crucial because whether there is commitment of the relevant bodies stated in the document or not, whether specific activities are referred as prohibited or not, whether some appropriate criteria are mentioned in the document or not, more importantly whether the violating industry will be punished or not, and finally whether the regulatory authority is authorized to punish the case of violation are the key determinant for the regulation of pharmaceutical promotion in any country. if these are not mentioned clearly in the regulatory documents and are not supported by law, actually these documents are not that bangladesh journal of bioethics 2018; 9 (3): 1-10 8 effective [34]. possibly, this incompleteness of regulatory frameworks responsible for weaker enforcement. conclusion and recommendations: the regulatory frameworks to control pharmaceutical promotion vary to a great extent from country to country. clearly defined prohibitions, specific legal provisions for violations and entrusted agency with defined authority to punish in case of violations are absent in the related code of bangladesh. code of pharmaceutical marketing practices of bangladesh requires updating which should include the limit of acceptance of gift or other support from the industry along with specific prohibitions and legal provision of punishments for violations. references: 1. griffith d. reasons for not seeing drug representatives. british medical journal. 1999; 319: 69-70 2. norris p, herxheimer a, lexchin j. dru g promotion: what we know, what we have yet to learn. world health organization/health action international, geneva, switzerland, 2005. available at:http://www.who.int/medicines/areas/rational_use/d rugpromodhai.pdf [accessed on 15th january 2016] 3. spurling gk, mansfield, pr, montgomery bd, lexchin j, doust j, othman n, vitr ai, et al. information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: a systematic review. public library of science (plos) medicine. 2010; 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manufacturers’ compliance with drug bangladesh journal of bioethics 2018; 9 (3): 1-10 10 advertisement regulations in zimbabwe. american society of health-system pharmacists. 2004; 61: 2678-81. 24. u.s. food and drug administration (fda). the office of prescription drug promotion (opdp). u.s. food and drug administration (fda), 2016. available at: http://www.fda.gov/aboutfda/centersoffices/offic eofmedicalproductsandtobacco/cder/ucm090142 [accessed on 19th may 2016] 25. almashat s, wolfe s. public citizen report: pharmaceutical industry criminal and civil penalties: an update. public citizen’s health research group, 2012. available at: http://www.citizen.org/documents/20731.pdf [accessed on 30th march 2016] 26. american medical association (ama). sunshine act: physician financial transparency reports. american medical association, 2013. available at: https://www.amaassn.org/sites/default/files/mediabro wser/specialty%20group/washington/sunshine-actbrochure.pdf [accessed on 30th december 2016] 27. ornstein, c., groeger, l., tigas, m., jones, r.g., 2013. dollars for docs: how industry dollars reach your doctors. available at: https://projects.propublica.org/docdollars/ [accessed on 22nd february 2016] 28. johora f, rahman ms. snapshot of the pharmaceutical promotional literature of bangladesh: a critical review. bangladesh journal of pharmacology. 2018; 13: 214 -21. 29. nwokike j, choi hl. assessment of the regulatory systems and capacity of the directorate general for drug administration in bangladesh. submitted to the us agency for international development by the systems for improved access to pharmaceuticals and services (siaps) program. management sciences for health, arlington, va, 2012. available at: http://apps.who.int/medicinedocs/documents/s21824e n/s21824en.pdf [accessed on 11th december 2015] 30. health action international/ medicines transparency alliance (hai/ meta). medicines promotion: assessing the nature, extent and impact of regulation, report and preliminary methodology for pilot testing. health action international/ medicines transparency alliance, geneva, switzerland, 2011. available at: http://apps.who.int/medicinedocs/documents/s18658e n/s18658en.pdf [accessed on 10 february 31. mohiuddin m, rashid, sf, shuvro mi, nahar n, ahmed sm. qualitative insights into promotion of pharmaceutical products in bangladesh: how ethical are the practices? bmc medical ethics. 2015; 16: 80. 32. american medical association (ama). sunshine act: physician financial transparency reports. american medical association, 2013. available at: https://www.ama-assn.org/sites/default/files/mediabrowser/specialty%20group/washington/sunshineact-brochure.pdf [accessed on 30th december 2016] 33. medicines australia (ma). code of conduct annual report 2015-2016. medicines australia, canberra, australia, 2017. available at: https://medicinesaustralia.com.au/wpcontent/uploads/sites/52/2014/02/20161020-finalcoc-annualreport-2015_2016-revised.pdf [accessed on 27th march 2016] 34. world health organization (who). effective drug regulation: a multi-country study. world health organization, geneva, switzerland. 2002. available at:http://www.who.int/medicinedocs/pdf/s2300e/s230 0e.pdf [accessed on 15th august 2016] conflict of interests: md sayedur rahman was one of the contributors of code of pharmaceutical marketing practices. researchers got funding from research grants committe of bangabandhu sheikh mujib medical university. author contributions 1st author conceive the idea, done literature review and wrote the manuscript. 2nd author guide to the conception of idea, manuscript writing and check the manuscript meticulously microsoft word swazo scnt method final nks bangladesh journal of bioethics 2016;7(2): 1424 14 original article scnt method and the application for patent eligibility on cloned animals norman k. swazo, ph.d., m.h.s.a. professor of philosophy, department of history and philosophy school of humanities and social sciences north south university dhaka, bangladesh email: norman.swazo@northsouth.edu; mobile: +8801746881234 abstract: patents recognize economic right and are important for both individual and social economic benefit. nonetheless, mere economic right does not eliminate the requirement for moral assessment when adjudicating intellectual property claims, especially in the case of claims associated with applications of biomedical technology [e.g., somatic cell nuclear transfer (scnt) methods]. this is so for applications for patent in the case of live-born animal clones, as governed in the setting of the judicial system of the usa. here recent federal court decisions in the usa are reviewed, and the ethical ambiguities of this judicial review are engaged in light of the current prohibitions on human reproductive cloning. it is concluded that the legal proscription of patents on animal clones bodes well for human accountability to present and future generations in the event of human reproductive cloning. keywords: scnt; intellectual property; live cloned animals; human reproductive cloning; us federal court decisions introduction: “patents cannot issue for the discovery of the phenomena of nature…” ---u.s. court of appeals for the federal circuit according to positive law, a patent is a legal entitlement to intellectual property that is intended “to promote creation,” i.e., to provide an incentive to invention1. “a patent confers the right on the holder to prevent anyone else from using, making, selling or distributing their invention. no one else will be able to make use of the invention, during the term of the patent, without obtaining the right from the patent holder…an invention, which is eligible for a patent usually has to be something that is new, useful and not obvious. it can be an improvement on an earlier device or process, or it can be a completely new invention.” patents are important for both individual and social economic benefits. as audrey chapman put it, “intellectual property regimes seek to balance the moral and economic rights of creators and inventors with the wider interests and needs of society. a major justification for patents and copyrights is that incentives and rewards to investors result in benefits for the society” 2. but, of course, mere economic right is not sufficient to outweigh the need for further moral evaluation bangladesh journal of bioethics 2016;7(2): 1424 15 associated with claims to intellectual property, despite whatever may be said about the scientific grounds or legal basis for adjudicating intellectual property claims. consider the question of application for patent in the case of live-born animal clones, in the setting of the judicial system of the usa. a decision issued on 08 may 2014 from the united states court of appeals for the federal circuit affirmed an earlier decision of the patent trial and appeal board (hereafter, “board”) that live-born animals cloned by way of the somatic cell nuclear transfer method (scnt)—including here cattle, sheep, pigs, and goats—are themselves not patentable, in which case a scientist using the method is not eligible for a patent claim on the animals3. this decision has ethical implications related to deliberation about and resolution of the moral status of cloned animals. the legal background: the ruling from the federal circuit court (fcc) is not surprising, given the decision from the u.s. supreme court (ussc) in “association for molecular pathology et al. v. myriad genetics, inc., et al.,” issued on 13 june 20134. in the myriad case, the ussc recognized that myriad’s “principal contribution” in its scientific research was to uncover “the precise location and genetic sequence of the brca1 and brca2 genes” (i.e., the genes involved in breast cancer oncogenesis). referencing diamond v. chakrabarty (447 u.s. 303), the ussc considered the central question whether myriad’s research involved a legitimate claim on a “new and useful…composition of matter” (both novelty and utility being essential elements of claim eligibility for what is supposedly “a nonnaturally occurring manufacture or composition of matter”) or instead a claim on “naturally occurring phenomena.” the former clearly has to be (1) “a product of human ingenuity ‘having a distinctive name, character [and] use” and (2) an action that is new “with markedly different characteristics from any found in nature.” if myriad’s argument were successful, then it would have a right “‘to exclude others from making’ its patented composition of matter under the patent act.” anyone who did so would infringe the patent and thus be legally liable. the ussc reasoned that although myriad “found an important and useful gene,” it nevertheless “did not create or alter either the genetic information encoded in the brca1 and brca2 genes or the genetic structure of the dna.” at issue here is the legally governing taxonomy, in this case what counts as “a product of nature” in contrast to an “invention,” the latter characterized by the manufacture of “something new.” delivering the opinion of the ussc, justice clarence thomas clarified that myriad’s petition required the ussc “to resolve whether a naturally occurring segment of deoxyribonucleic acid (dna) is patent eligible under 35 u.s.c. §101 by virtue of its isolation from the rest of the human genome.” the ussc also considered the question of patent eligibility of “synthetically created dna known as complementary dna (cdna), which contains the same protein-coding information found in a segment of natural dna but omits portions within the dna segment that do not code for proteins.” justice thomas held that, “a naturally occurring dna segment is a product of nature and not patent eligible merely because it has been isolated, but that cdna is patent eligible because it is not naturally occurring.” for the purpose of entitlement to patent, discovery (no matter how “iterative” the research process), in short, does not entail invention. that said, however, it is noteworthy that the ussc left open the question whether “scientific alteration of the genetic code,” i.e., “dna in which the order of the naturally occurring nucleotides has been altered,” presents a different inquiry…” bangladesh journal of bioethics 2016;7(2): 1424 16 in the fcc’s opinion, an animal cloned by way of scnt “is an exact genetic replica of the adult mammal from which the somatic cell nucleus was taken.” at issue in the earlier board decision was whether the claimed clone “may be called a composition of matter or a manufacture.” this disjunction is not clearly dispositive so as to represent accurately the ontological status of such an animal, since the former refers to a naturally occurring substance while the latter refers to human agency and an action that manipulates a natural substance in a process of manufacture. thereby, one distinguishes conceptually two distinct categories, viz., substance and process. according to the applicable federal statute (35 u.s.c. § 101), both a “composition of matter” and a “manufacture” are allowable categories of “subject matter” for a patent claim to be issued. but, there are exceptions to eligibility—(1) “laws of nature,” (2) “natural phenomena,” and (3) “abstract ideas.” thus, a “naturally occurring organism” falls into the category of natural phenomena and is, therefore, not patentable. in oral argument before the fcc, counsel for roslin insitute emphasized the idea of infringement on a patent claim in the case of a production of a clone of a clone, accounting for “obvious” phenotypic presentation that differentiates individual animals. however, the main point for substantiating the patent claim was the fact of “time delay” in the process of production, i.e., the time frame from donor to copy/clone produced, which then ostensibly allows the claim that the clone is an invention and, therefore, eligible for patent against infringement on the manufactured “product.” but, the fcc insisted on the fact of genetic identity (genetically donor = clone, despite individuation of donor and clone and time delay) as controlling for the purpose of argument, rather than the factor of time delay privileged in argument by roslin. dna, according to the ussc decision in myriad, is not patentable subject matter; in which case, an animal having genetic identity (i.e., identical dna, such as a clone has) is thereby not patent eligible. the scientific ambiguity: the foregoing legal determinations presuppose a reasonably clear conception of what counts as an organism and what is meant by ‘naturally occurring.’ this seems, at least prima facie, to be a matter of scientific proposition and only thereafter a legal definition, since it is the science of biology and not positive law that is to govern the validity of an empirical claim that is then taken up into legal discourse for a purpose such as that of adjudication of patent claims. but, then, the scientific claim itself presupposes an ontological commitment as to the being of the organism, which is by no means clear for either theoretical or experimental biologists. and, where “ontological status” of an organism is ambiguous, more often than not there is associated ethical ambiguity about the morally permissible disposition of the organism in question. indeed, stephen talbott correctly reminds that, “biologists have gone on for decades using the language of meaning while remaining content never to reckon with it… 5.” as pepper and herron notes yet more basically, “among biologists, there is no general agreement on exactly what entities qualify as ‘organisms’ 6.” in fact, given the ambiguity of the concept among biologists, rather than speak of “organism” in terms of distinct categories, pepper and herron construe organisms to be “continuously variable.” to put the point differently, as talbott explains, “because every local activity of the organism must find its meaningful place within the encompassing activity of a striving, developing, self-transforming whole, there can be no fixed syntax, no mechanical constancy of relations among the parts.” bangladesh journal of bioethics 2016;7(2): 1424 17 the above claim is meaningful also in terms of a position advanced by philosopher of biology michael ruse, who has considered the status of organisms so as to be understood in three senses—ontological, methodological, and epistemological 7 . by ‘ontological’ ruse means “the ultimate status of the entities of the organic world;” by ‘methodological’ he “refers to the question of organization;” and by ‘epistemological’ he intends that sense that “refers to the relationship between theories,” e.g., “in particular whether the theories of the biological sciences can be shown to be logical consequences of the theories of the physical sciences.” bearing ruse’s distinctions in mind, consider, for example, schneider and grosschedl (2007) observing that, “the clarification of the cause-and-effect relationship of nuclear organization and the function of the genome represents one of the most important future challenges. further experiments are needed to determine whether the spatial organization of the nucleus is a consequence of genome organization, chromatin modifications, and dna-based processes, or whether nuclear architecture is an important determinant of the function of the genome8.” surely, this question of cause-effect relationship remains unanswered in the case of the somatic cell that is used by an investigator in the context of scnt method. such an investigator is aware of the nuclear architecture of the somatic cell, understands to some degree the spatial organization of the nucleus of this cell in relation to the whole of the cell, removes the nucleus in view of any number of empirical claims about that cell’s genome organization, chromatin modifications, and dna-based processes, etc. indeed, there would be no scnt method were it not for the hypothesis at the base of this method that assumes much of this without, however, being precisely clear as to cause-effect relations and determinants. randall prather reminds us that when hans spemann first described the concept of cloning, “he wanted to test the theory that cells become irreversibly differentiated because they inherit an unequal amount of ‘nucleoplasm’ and thus are not totipotent,” otherwise understood as the concept of “nuclear equivalence9.” subsequent research has continued investigations of “nuclear remodeling” and reprogramming by way of transfer of nuclei into the cytoplasm of oocytes, the operating assumption being that “structure confers function,” i.e., there is an “exchange of proteins between the donor cell nucleus and the oocyte cytoplasm” which then “remodels the chromatin such that the nucleus is reprogrammed to behave as though it were a pronucleus 10.” in their original paper outlining the experiment that resulted in dolly, wilmut et al., explained the purpose of their method: “an opportunity to investigate whether cellular differentiation to that stage [of fertilization of a mammalian egg] involved irreversible genetic modification11.” the dolly experiment investigated “whether normal development to term is possible when donor cells derived from fetal or adult tissue are induced to exit the growth cycle and enter the g0 phase [i.e., quiescence] of the cell cycle [of replication] before nuclear transfer.” for these scientists, the experiment confirmed that, “differentiation of [an adult cell] did not involve the irreversible modification of genetic material required for development to term.” further, for them the results “indicate[d] that nuclei from a wide range of cell types should prove to be totipotent after enhancing opportunities for reprogramming by using appropriate combinations of these cell-cycle stages.” finally, the authors opined, “birth of the lamb shows that during the development of that mammary cell there was no irreversible modification of genetic information required for development to term. this is consistent with the generally accepted view that mammalian differentiation is almost all bangladesh journal of bioethics 2016;7(2): 1424 18 achieved by systematic, sequential changes in gene expression brought about by interactions between the nucleus and the changing cytoplasmic environment 12.” one may, therefore, ask: is it reasonable to assert that an un-manipulated “natural state” somatic cell (a) counts as an organism and that (b) it is naturally occurring, consistent with the evidential empirical claims of cell biology? surely, such a cell is naturally occurring. but, whether it counts as an organism in and of itself depends on meaning in use. cell biology identifies its domain of investigation, viz., cell structure and cell function, premising “the cell” as “the fundamental unit of life.” from the perspective of cell biology, a single cell can count as an organism, e.g., when one has in mind a unicellular entity13. in the context of scnt, a somatic cell is taken from a multicellular organism, yet it can be said that this cell has its own “physiological independence” or “physiological discreteness” for the purpose of cell biology, even as a cell is “physiologically integrated” with the multicellular organism from which it is extracted. one can consider, thus, whether a somatic cell that is to be used for the purpose of scnt counts as a “unitary organism” (in the sense articulated by santelices) or as a “paradigm organism” (in the sense expressed by wilson) 14, 15. either way, it seems that, “many of the commonly used organism criteria are in fact descriptions of various boundaries on functional integration,” so that “the essence of the organism syndrome is a discrete package of functional integration.” a somatic cell would then, in this sense, be construed as such a discrete package. the latter proposition, taken as probably true, therefore yields a practical definition for ‘organism’: “a complex structure of inter-dependent and subordinate elements whose relations and properties are largely determined by their function in the whole16.” but, when one examines reports of ongoing dna studies, the discourse suggests ongoing dynamics further complicating the question of definition17. in the latter discussion, at issue is what contemporary science understands from the genetics, of course; but also, what they do not understand currently from the epigenetics in organismal development. thus, talbott comments, “the activity of individual genes reflects the choreography of chromosomes, which reflects the larger choreography of the nucleus, which reflects the choreography of the cell and organism as a whole. who, then, is sculpting whom?” accordingly, there is ample reason for us to say, as talbott summarizes, that biological research informs us of “the importance of organismal context, and of the organism’s plasticity, and of its dynamism, and of the complexity of its interweaving process, and of the causal ambiguity of our explanations.” what this means in terms of the taxonomy at issue, is that, “organisms cannot be fully elucidated in terms of the definitive lawfulness so satisfactory to the physicist—a lawfulness lend in itself to the application of mathematics and other reduced ‘skeletons’ of language18.” “organisms,” properly understood, “are revealing themselves as intentional wholes not governed by any particular parts19.” thus, despite the technologies with apparent successes of scnt method in the case of animal cloning, “epigenetics and the organism’s almost unfathomably complex and intricate skill in managing its genes” require us to reconsider and disabuse ourselves of “the notion that dna embodies a linear code that spells our destiny”—or, indeed, the destiny of any other biological organism at whatever level of organization and complexity. but, once a somatic (diploid donor) cell (e.g., a mammary epithelial cell with complete genome of the individual animal, e.g., a finn dorset ewe as in the case of dolly the sheep) is “manipulated” by way of the scnt method, with the cell’s nucleus and genetic content bangladesh journal of bioethics 2016;7(2): 1424 19 extracted (enucleated at metaphase ii), and the cell nucleus and genetic content transferred into another cell (i.e., into the recipient cytoplasm of an unfertilized ovum from which its own haploid nucleus has been removed, e.g., as in the case of the ovum taken from a scottish blackface ewe for the dolly experiment), and then these two cells juxtaposed and subjected to an electric pulse to fuse them and start cell division, then it may be said that a process of manufacture surely occurs thereby. it is a process of asexual reproduction that contrasts to “normal mammalian sexual reproduction,” with the otherwise natural process of “sperm-mediated fertilization…subverted in scnt 20.” the scientist in this case manipulates what is a naturally occurring composition of matter and alters it according to the intent of the scnt method. rather than a natural substance that is a naturally occurring composition of matter, one now has a substance the material composition of which has been altered by way of scnt method in a way that does not occur naturally. this is why one says the clone is both novel and useful. it is reasonable to assert, then, that the “product” from the scnt method is no longer in se “naturally” occurring, even if it cannot be said (as a matter of contrast) that this is an “artificially constructed life form” such as pertains to genetic engineering techniques of synthetic biology. the latter allows for a distinction of “synthetic dna” and “natural dna,” thus a distinction of a synthetic or semisynthetic “artificial” life-form and a natural life-form21. it is, therefore, important to ask the question (the implicature of which is legal, ethical, and scientific): does the fact of mixture of naturally occurring cell components constitute an “invention?” the scnt method itself is already patented, of course; so, this is not at issue in present case as reviewed by the ussc and the fcc. what is at issue is whether the end product of a scnt application, viz., the live-born cloned animal (as distinct from the manipulated/altered somatic cell)—is the “equivalent” of an invention even if it remains a composition of matter. if the method of scnt merely discloses “a secret of nature,” e.g., discloses the natural mechanism of genetic replication despite the alteration/substitution of the nucleus as a cell component, then this is not an invention per se but only a disclosure of the way nature operates at the level of the cellular organism. under the applicable statute in the usa, as noted above, such disclosure is not patentable— “patents cannot issue for the discovery of the phenomena of nature.” indeed, the building blocks of the animal clones involved in the patent application are still the “natural dna” codified in the base-pairs (“chemically joined nucleotides”) of cytosine-guanine (c-g) and adenine-thymine (a-t); and not, e.g., a composition such as results from the most recent “artificial dna” base pair of “x-y” that has been added to these natural base-pairs to create a new genetic content and, thus, a new synthetic life-form. the latter product of synthetic biology may count ontologically, legally, and, insofar as any ethical issue arises, as an invention rather than as a process of human ingenuity that merely duplicates a natural process. given the contrast, it is not surprising that the board “concluded that the claimed subject matter was ineligible for patent protection” under the defined statute, “because it constituted a natural phenomenon that did not possess ‘markedly different characteristics than any found in nature.’” arguably, then, the distinction here provides a central criterion by which to determine what counts as “manufacture”—simply, an item of manufacture must be markedly different in characteristics from those characteristics found in a naturally-occurring entity. where the two are “identical” or “substantially identical,” or are “produced by identical or substantially identical processes”—each of these predicates by no means transparent in its bangladesh journal of bioethics 2016;7(2): 1424 20 meaning—then there is no legitimate patent claim for the item produced, even if the prior item (e.g., the donor animal) is a naturally occurring animal. moreover, the fcc (as did the board) accounted for prior artificial cloning methods, viz., embryotic nuclear transfer and in vitro fertilization, to hold that the cloned animals were both “anticipated” and “obvious,” despite the difference in method (scnt), and thus indistinguishable from a product issued from these methods. ethical ambiguities at issue: given the foregoing overview of legal and biological elements of the question before the courts in the usa, the judgments taken, while important generally for animal cloning per se, can also be considered presumptively guiding in any moral question involving human reproductive cloning, just in case researchers should be inclined to translate such results into the clinical setting of human reproduction (including here any goals associated with human fertility by way of in vitro technologies and associated prospects of genetic enhancement). we may be reminded that stanford university nobel laureate joshua lederberg has already (in 1966) written in favor of human reproductive cloning. commenting on the scientific desideratum of a “new evolutionary theory needed to model a self-modifying system that makes imperfect plans for its own nature,” lederberg championed the goal of human eugenics against “the cultural process” that “poses contradictory requirements of uniformity (for communication) and heterogeneity (for innovation)” and, thus, an impediment to eugenic goals 22. “humanistic culture rests on a definition of man which we already know to be biologically vulnerable,” lederberg observed. “inevitably,” therefore, so he opined, “biological knowledge weighs many human beings with personal responsibility for decisions that were once relegated to divine providence.” commenting on “tempered clonality,” lederberg anticipated that “we would at least enjoy being able to observe the experiment of discovering whether a second einstein would outdo the first one.” indeed, taking a global perspective on the implications of developments in molecular biology, specifically “any conceivable program of calculated eugenics,” lederberg asked: “western culture and its limited population is being succeeded by a much broader world culture. is there much point in setting eugenic standards relevant only to a small minority of the world’s population even as we watch the unprecedented breakdown of intercultural barriers?” writing in 1994, and accounting for developments in the period since lederberg’s contribution to the periodical literature on the subject, john a. robertson allowed that, “the idea of splitting off cells from embryos to clone human beings sounds so bizarre and dangerous that one would think the practice should not be permitted 23.” yet, at that time robertson argued that such cloning promised to be ethically acceptable. noting that the scientific procedures had not succeeded with mammals (and only with frogs at the time) and appeared “highly unlikely to be accomplished in even the mid-range future,” even so, were scientists so inclined, robertson remarked, “if this form of cloning were possible, scientists could fabricate as many copies as one wished of any available human genome, subject only to the limits of uterine or artificial gestation” (emphasis added). accounting for various uses of cloning, robertson argued that, this scientific enterprise was “neither so harmful nor so novel that all research and development should not stop until the ethics of the practice are fully aired, or that governmental restrictions on cloning research or applications are needed.” that, of course, changed with the production of dolly (1996-1997); and the near-term prospect of human reproductive cloning moved the matter center-stage as a bangladesh journal of bioethics 2016;7(2): 1424 21 matter of public policy and government regulatory intervention. leon kass and james wilson, surveying the scene of public opinion at the time, underscored the fear: “ ‘i a child and thou a lamb,’ despite our differences, have always been equal candidates for creative making, only now, by means of cloning, we may both spring from the hand of man playing at being god 24.” granted, at our point in time, applicable national and international regulatory instruments continue to proscribe human reproductive cloning. in june 1997, following president bill clinton’s ban on federal funding that might support human cloning research, the us national bioethics advisory commission recommended a moratorium on reproductive human cloning25. any legal decision to permit patenting in the case of human reproductive cloning would contradict international commitments to “democratic principles of dignity, equality, and mutual respect of men,” as stipulated in the preamble of unesco’s constitution and as reiterated in the universal declaration on the human genome and human rights (1997) hereafter udhghr)26. so long as rights recognized under international law are considered to be “human” rights (thus distinguished in principle from social, political/civil, economic, cultural rights) reproductive human cloning would entail a morally problematic situation: viz., in the case where “patented” “human clones” may not be recognized ontologically to have the status of the naturally occurring human being and so be diminished in moral status so as not to be permitted a claim to the ordinary human entitlements of dignity, equality, and mutual respect. the united nations convention on biological diversity of 1992 anticipated the probability of ongoing scientific research and developments in biomedical technology so as to emphasize the genetic diversity of humanity, with the expressed injunction that there must be no interpretation of a social or political nature that would call into question “the inherent dignity” or “the equal and inalienable rights” of “all members of the human family27.” the introduction of a “human clone” into the natural human population that now expresses this genetic diversity would presumably add to that diversity but also raise any number of moral and political questions. clearly, a human clone having the legal status of a patented entity would have neither inherent dignity (intrinsic worth, rational nature, etc.) nor equal and inalienable rights such as the naturally occurring human being has—and, importantly, has not only as a matter of conventions of law (thus civil right) but as a matter of natural right. patenting in the case of human reproductive cloning would open the door to prospective discrimination against human clones in any number of ways, contrary to article 2(b) of the udhghr that, “dignity makes it imperative not to reduce individuals to their genetic characteristics and to respect their uniqueness and diversity.” here, ‘uniqueness’ may not be interpreted negatively so as to authorize or justify the reductive argument according to which a human clone would be identified merely or primarily genetically. hence, research integrity is a matter of anticipation (e.g., the moral virtue of prudence, having forethought that precludes vice on the side of scientific excess or scientific deficiency) as well as currently permitted practices under both national and international regulations. the undhghr (article 10) aptly stipulates that, “no research or research applications concerning the human genome, in particular the fields of biology, genetics and medicine, should prevail over respect for the human rights, fundamental freedoms and human dignity of individuals or, where applicable, groups of people.” thereby, developments in human genetics may not proceed merely for the sake of advancing knowledge and must maintain the scientific integrity so expressed in bangladesh journal of bioethics 2016;7(2): 1424 22 the declaration. therefore, as article 11 of the declaration states the point explicitly: “practices which are contrary to human dignity, such as reproductive cloning of human beings, shall not be permitted.” the judicial assessments in the usa, deliberating and deciding on the question of patenting of animal clones, provide important barriers to human reproductive cloning research. thereby, they safeguard the long-standing and time-honored moral and legal commitment to human dignity that would otherwise succumb to hubris or to posit of merely instrumental ends. it is meritorious indeed that, were human reproductive cloning to be permitted, as a matter of moral and legal principle patenting of human clones would be proscribed even more so, ensuring human accountability to present and future generations. author’s contribution: author developed the conceptual idea, data collection, data analysis and manuscript writing. conflict of interest: declared none. 1 fedcirc.us patent law information, “the definition of a patent,” http://www.fedcirc.us/definition-patent.php, accessed 13 may 2014. 2 chapman, a.r. (no date) ‘a human rights perspective on intellectual property, scientific progress, and access to the benefits of science’, http://www.wipo.int/edocs/mdocs/tk/en/.../wipo_unhchr_ip_pnl_98_5.doc; accessed 20 november 2014. 3 united states court of appeals for the federal circuit, “in re institute (edinburgh), 20131407, appeal from the united states patent and trademark office, patent trial and appeal boar in serial no. 09/225,233,” decided 08 may 2014; 13-407.opinion.5-6-2014.pdf. 4 supreme court of the united states, no. 12-398, association for molecular pathology et al., petitioners v. myriad genetics, inc., et al., on writ of certiorari to the united states court of appeals for the federal circuit, 13 june 2013. 5 talbott, s.l. (2012) ‘from physical causes to organisms of meaning’, toward a biology worthy of life, the nature institute, http://natureinstitute.org/txt/st/mqual/genome_6.htm, accessed 09 may 2014. 6 pepper jw, herron md. (2008) ‘does biology need an organism concept?’ biological reviews, 83. http:// eebweb.arizona.edu/grads/mherron/publications/br_08.pdf. 7 ruse, m. (1989) ‘do organisms exist?’ integrative and comparative biology, 29/3: 106166. bangladesh journal of bioethics 2016;7(2): 1424 23 8 schneider r, grosschedl r. (2007) ‘dynamics and interplay of nuclear architecture, genome organization, and gene expression’, genes and development, 21, 3027-43. 9 prather, r.s. (2007) ‘reprogramming for making transgenic pigs by nuclear transfer’. in: sutovsky, p. (ed.) somatic cell nuclear transfer, landes bioscience and springer science+business media. 10 prather, 2007, p. 2 11 wilmit i., schnieke a.e., mcwhir j., kind a.j., campbell k.h.s. (1997) ‘viable offspring derived from fetal and adult mammalian cells’, nature, 385/6619, 27 february; pdf version. 12 however, see jaenisch r. and wilmut, i. (2001) ‘don’t clone humans’’ science, 291/5513: 2552. the authors here evaluate the many failures in animal cloning, and on those grounds oppose reproductive human cloning. 13 ilona miko, i. (no date) ‘cell biology’, scitable, http://www.nature.com/scitable/topic/cellbiology-13906536, accessed 09 may 2014. 14 santicles, b. (1999) ‘how many kinds of individual are there?’ trends in ecology and evolution, 14:152-155. 15 wilson, jw. (1999) biological individuality: the identity and persistence of living entities. cambridge: cambridge university press. 16 mish, fc. (1983) webster’s ninth new collegiate dictionary. springfield mo: mirriamwebster. 17 pearson, h. (2003) ‘na: beyond the double helix,’ nature, 421:310-12, http://www.nature.com/nature/journal/v421/n6921/full/421310a.html; accessed 13 may 2014. 18 talbott, s.l. biology worthy of life, the nature institute, http://natureinstitute.org/txt/st/org/index.htm, accessed 09 may 2014. 19 talbot, 2014 20 u.s. food and drug administration, ‘animal cloning: chapter ii: technology overview: somatic cell nuclear transfer and other assisted reproductive technologies,’ http://www.fda.gov/animalveterinary/safetyhealth/animalcloning/ucm124765.htm; accessed 09 may 2014. 21 see here: malyshev, d.a., dhami, k., lavergne, t., chen, t., dai, n., foster, j.m., correa, i.r., romesberg, f.e. (2014) ‘a semi-synthetic organism with an expanded genetic alphabet’, nature, http://www.nature.com/nature/journal/vaop/ncurrent/abs/nature13314.html, accessed 09 may 2014. zimm, a. (2014) ‘scientists build life form adding letters to genetic alphabet,’ bloomsberg businessweek, 08 may, http://www.businessweek.com/news/2014-05-07/scientists-build-life-form-that-adds-lettersbangladesh journal of bioethics 2016;7(2): 1424 24 to-genetic-alphabet, accessed 09 may 2014. alysia judge, a. (2014) ‘ai or a-dna? scientists create a first living organism with artificial dna,’ itproportal, 08 may, http://www.itproportal.com/2014/05/08/scientists-engineer-first-artificial-life-form-capableof-procreating/, accessed 09 may 2014. 22 lederberg. j. (1966) ‘experimental genetics and human evolution,’ the american naturalist, 100/915: 519-31. 23 robertson, j.a. (1994) ‘the question of human cloning’, the hastings center report, 24/2: 6-14. 24 kass, l. and wilson j.q. (1998) ‘the wisdom of repugnance,’ the new york times, http://www.nytimes.com/books/first/k/kass-cloning.html. 25 shapiro, h.t. (1997) ‘ethical and policy issues of human cloning,’ science, 11 july, 277/5323: 195-196; http://www.sciencemag.org/content/277/5323/195.short. 26 unesco, universal declaration on the human genome and human rights, http://www.unesco.org/new/en/social-and-humansciences/themes/bioethics/human-genome-and-human-rights/ 27 un convention on biological diversity, 1992, https://www.cbd.int/doc/legal/cbden.pdf. bangladesh journal of bioethics 2017; 8(1): 21-32 21 original article animal citizenship, phenomenology, and ontology: some reflections on donaldson’s & kymlicka’s zoopolis iván ortega rodríguez universidad pontificia comillas, madrid, spain email: iortega@comillas.edu, ivan.ortega79@gmail.com abstract: this paper is a dialogue with sue donaldson’s and will kymlicka’s book zoopolis: a political theory of animal rights. my thesis is that, despite the authors’ reticence, considerations in first philosophy regarding humans and nonhumans are relevant to their goal of building a more comprehensive animal rights philosophy. what is more, i believe that first philosophy actually can be of help for their proposal, specifically in the form of phenomenology and phenomenological ontology. for this purpose, i first summarize the basic outline of zoopolis’s position and indicate some questions that arise from a strictly internal consideration of its theses. and secondly, i introduce some aspects in which phenomenological research would be relevant, along with some particular and provisional analyses carried out from the standpoint of a phenomenologically-based ontology. especially, there is a theme that stands out: the intersubjective realms between humans and nonhumans. key words: animal rights, animal philosophy, phenomenology, ontology bioethics, ecology. introduction: animal philosophy received a decisive impulse with sue donaldson’s and will kymlicka’s book zoopolis: a political theory of animal rights 1 . it offered a comprehensive theory that, to a great extent, creates a new theoretical framework for thinking the moral status of nonhuman animals. in fact, it is not an understatement to say that zoopolis is already a reference so unavoidable as peter singer’s animal liberation. it has acquired one of the greatest relevance statuses: that of being an inevitable part of the discussion. this contribution wants to engage in this now inescapable dialogue with zoopolis. my starting position is that of a basic acceptance of its positions, as well as an acknowledgment of donaldson’s and kymlicka’s achievement. nonetheless, as the authors know very well, the greatest act of philosophical admiration consists in engaging a dialogue that does not shy away from possible suggestions or corrections. in this regard, i want to defend the relevance of first philosophy, in the manner of phenomenological analysis and phenomenology-based ontology. contrary to the authors’ suspicions, i defend that this discussion does not necessarily undermine the case for animal rights but may even strengthen it. a brief overview of zoopolis: the first step in my argument is an assessment of zoopolis’ great theses. the main argument of zoopolis has a clear structure: the quality of selfhood and self-interest, unquestionably present in nonhuman animals, justifies their deserving the same mailto:iortega@comillas.edu mailto:ivan.ortega79@gmail.com bangladesh journal of bioethics 2017; 8(1): 21-32 22 moral status as humans. the combination of this fundamental thesis with a consideration of the different possible relationships between nonhuman and human animals results in three further theses concerning the moral status of nonhumans, specifically the political status they deserve as part of the same planet and thus in some form of interrelation with us. for the authors, these statuses are citizenship for domestic animals, sovereignty for wild animals, and “denizenship” for “liminal” animals. thus, firstly, domesticated animals share our same space, are dependent on us and can interact even to the point of contributing to the institutional shaping of our community. consequently, zoopolis states that they must be considered as full citizens. secondly, wild animals live in their own habitats and their behaviour unmistakably indicates that their self-interest includes not entering into contact with humans and keeping their autonomy in the areas where they have for a long time developed their lives (or also the routes along which they have migrated and those realms where they have seasonally dwelt since time immemorial). consequently, they must be taken as sovereign inhabitants rightfully living in their territories. thirdly, there is another category of animals who are neither domestic nor wild, and who zoopolis refers to as “liminal”, namely those who are not domesticated but live in our midst. they live among us for a variety of motives: either because their habitats have been enclosed by human settlements, or because of the introduction of exotic species, either because they are former domesticated animals who have become feral or their descendants, or also because they are niche specialists, opportunistic animals and synanthropic species, whose existence is more narrowly dependent on us. in all cases, they have in common that they are dependent on humans in a non-specific way: they need human beings to get food or shelter but are not dependent on any individual human being —at least qua species. for these animals, donaldson and kymlicka consider that a new category has to be created: “denizenship” 2 . with this term they refer to those inhabitants who live in the same space as us but cannot or have no interest in being part of our political community. they cannot have the same rights and duties as citizens, especially those referring to participation in the communal life, but they still have rights of justice, especially concerning their physical integrity and their right to develop their lives. consequently, for example, not any solution for human-nonhuman conflicts is acceptable, not even in the case of our animal denizens. in this regard, donaldson’s and kymlicka's book is full of beautiful examples of solving coexistence problems without recurring to extermination procedures, which are not only immoral but also largely inefficient. concentrating now on their defence of citizenship for nonhuman animals, donaldson and kymlicka take into account the main objection: nonhumans are incapable of language, and therefore of engaging into dialogue, understanding the sense of norms and even less of participating in the public deliberations to make decisions regarding our coexistence 3 . in particular, they consider the three “moral powers” required for the exercise of citizenship: bangladesh journal of bioethics 2017; 8(1): 21-32 23 (i) the capacity to have a subjective good, and to communicate it; (ii) the capacity to comply with social norms/cooperation; and (iii) the capacity to participate in the co-authoring of laws 4 . these three requirements seem to discard citizenship for domesticated animals. indeed, without the use of language — in any conceivable symbolic form, we could add—, many consider it impossible for animals to participate in citizenship. however, donaldson and kymlicka believe that in this refusal there is a flaw in the description of these powers: we do not dispute this basic list. we do, however, dispute the way in which these three capacities are typically interpreted 5 . to support their thesis, they refer to recent disability theories of citizenship and claim that their fundamental tenets can also be affirmed for animals 6 . disabled people too have often been seen from a paternalistic perspective, considering that they had to be “well treated” but not believing that they could be full citizens. however, recently the expression of the point of view of people with disabilities (either by themselves or by their caretakers) has questioned this assumption; and their questioning lies in objecting to the idea that we have to exercise all our intellectual powers to be an active part of the political community. if we do not take such a narrow concept of agency, and admit that one can express oneself with some assistance, participation becomes conceivable. we can think of someone having a subjective conception of good as expressed by certain nonverbal indexes, who can comply with norms and who is able to defend their perspective when elaborating regulations 7 . but now, if we have a look at domesticated animals, we verify that at least in many species they can also exercise the moral powers with some assistance. therefore, zoopolis concludes, citizenship is an adequate concept for their participation in our shared community. an internal difficulty and the possible usefulness of phenomenology and ontology: along their reasoning, the authors of zoopolis are insistent on refusing to consider the ontological question concerning the animal/human divide. with this, they reject any metaphysical consideration or, as i prefer to say, first philosophy. in particular, they explicitly criticize the use of “personhood” to deny citizenship rights — or even any right whatsoever— to nonhuman animals 8 . the authors are right, in my view, to “reject any attempt to distinguish personhood from selfhood as the basis for inviolable rights” 9 and they are also right to qualify these attempts as “conceptually unsustainable, morally unmotivated, and radically destabilizing of the very idea of universal human rights.” 10 nonetheless, they seem to consider that no more considerations in first philosophy are necessary to pursue their argument. in my view, this is a mistake, mainly because it undermines their capacity to face a serious internal difficulty; and also because they may have missed an intellectual tool in favour of their positions. bangladesh journal of bioethics 2017; 8(1): 21-32 24 this becomes clear in my view when we consider the “internal” difficulty that arises if we analyse the “communicative requirements” of political participation. above all, it is true that zoopolis persuasively establishes that animals do have the “prerequisites” not only to claim “negative” rights but also for the exercise of “positive” rights, such as those of political participation. nevertheless, we may consider that, after all, there is a difference between the participation which involves reflection and language 11 , and that which does not include them. this distinction goes mostly along the divide between humans and nonhumans 12 . and it may be asked whether this different form of participation may have consequences regarding different participation rights. thus, animals for sure can make their needs and interests conveyed, but generally it is humans who know them, have learned to understand their signs, and, as the authors themselves recognise, must interpret them. animals need humans to make their claims heard; and they need humans to use arguments “on behalf” of them, not as if they had told them previously but rather in the sense that some humans design arguments that animals would possibly have made if they had been able to. in sum, for this discursive and argumentative political participation, animals need some humans to be their voice. in my view, this “communicative difference” poses a problem for the use of “citizenship” for domestic animals 13 . referring to the “modified” and “amplified” notion of participation, which includes other ways of having your case be taken into account, does not solve this difficulty, as donaldson and kymlicka seem to believe 14 . indeed, this “wider” notion makes it clear that animals’ participation has to be conceptualised, but not necessarily by the same concept we use for humans. therefore, it may be asked whether “citizenship” can be applied to participants that take part in so different ways, or if rather this “amplification” would in fact change the notion of citizenship in such a way that it would be deprived of its usefulness in political theory. in sum, the communicative difference leads us to ask whether zoopolis’ use of citizenship, in the name of a just cause, would not finally use it too vaguely, blurring important differences, and thus denaturalizing an important concept for thinking political participation, a denaturalization that would possibly undermine not only rights for humans, but also for nonhuman animals. thus, if my considerations are correct, zoopolis has a problem that must be faced. however, i believe that a full assessment of this problem needs to go beyond the framework of donaldson’s and kymlicka’s book. in my view, it is necessary to go beyond the domain of political philosophy and carry out some analyses in first philosophy. we need to see in more detail how this communicative difference is structured and what this means with regard to a possible ontological distinction between humans and non-humans. if our attempt was successful, then we would have a more clarified conceptual landscape of the relationship between humans and other animals, at least in some important cases (some of the most common and closest human/animal interactions) 15 . and this, in turn, could help develop a bangladesh journal of bioethics 2017; 8(1): 21-32 25 moral reasoning and decide on the pertinence of participation rights for animals and if this participation has to be conceptualised as citizenship in the case of domesticated animals. different realms and different types: being-in-the-world and being-in-an-environment; phenomenological and ontological considerations: in my opinion, the considerations in first philosophy need to consider firstly the different realms established in the interactions between humans and other animals — we leave aside the realms constituted by nonhuman animals among themselves, within the same species or between different ones —; and secondly, we need to study the problem of the type of being that each of us is, humans and nonhumans, according to their belonging or not to each realm 16 . there are of course different methods in first philosophy. here i assume a phenomenological approach. certainly in a longer paper i should make a lengthier justification, but given the scope of this paper i propose phenomenology as a method that is particularly useful to describe what happens in the interactions between humans and other animals, particularly with regard to the realms that become constituted by virtue of their interaction. from there, we could draw some ontological hypotheses. certainly, it may be argued that phenomenology is firstly a method and ontology goes beyond its domain. but this passage is part of the phenomenological tradition. it is present in husserl himself, when speaking about consciousness as the transcendental realm, and also well beyond husserl; for example, jan patočka gives an interesting distinction, between phenomenology and phenomenological philosophy, whereby phenomenology deals strictly with the analysis of appearance, while the latter derives “metaphysical consequences” from these analyses, which makes possible a phenomenological ontology 17 . as is also known, there are as many directions in phenomenology as there are phenomenologists. indeed, for the question of humans and other animals there are some very interesting authors, like renaud barbaras in france, to mention a contemporary thinker. for my purpose, and considering the communicative problem i take as a basis, i propose to the reader to follow here one development that i have found particularly helpful: the analysis of transcendental intersubjectivity according to edmund husserl, the founder of phenomenology 18 . for husserl, the subjective transcendental realm is inescapably intersubjective. subjects are given to us as opposed to pure objects. indeed, when being referred to other subjects, i know from the phenomenon itself, “directly” that they are “i”s with their own lives. however, this does not entail that i “enter” their conscious lives and somehow become one with them. there is a special form of presentation of subjects in which we immediately take certain traits of the other as pertaining to an inner life. husserl calls this form of presentation “appresentation”. it is a form of apperception, a mode of perception in which there is more than what is actually perceived. in this case, we perceive a body making certain gestures, but we go beyond towards the apperception and appresentation of another “i”: bangladesh journal of bioethics 2017; 8(1): 21-32 26 to apperceive means to grasp something over and above what is actually perceived […]. in apperception, there is a sense that the object is mediated through something else that is presented immediately. for instance, in all perception of a physical object, direct perception is of the facing side of the object, the hidden sides of the object are apperceived or appresented in an empty manner […]. when i perceive someone's living body, i perceive it as a living organism but i apperceive it as someone else's living body 19 . now, concerning the possible appresentations between humans and other animals, there are two things that might be said for the moment. firstly, it seems clear that between humans there is apperception and appresentation in a much profounder way than between humans and other animals, as well as probably between nonhuman animals themselves. however, secondly, nonhuman animals and humans are together opposed to vegetables, other life forms and inert beings in that between them there is some form of appresentation. we perceive in them some signs of a living body and thus we apperceive a living self; and in turn, animals make clear signs of doing a similar process with us. let us consider an example: i now see my cat “leo” in the corridor. he looks excited. i can tell this from how he has his ears and how he moves his tail. as he also moves in a confident way, i know that his excitement is because he wants to play; in turn, he sees me and hears the tone of my voice. this is the tone i normally use when i am about to start playing, and so leo gets more excited and even jumps a little. i have seen in leo some signs of a living body and a living subject who is able to know himself well enough to be aware that he wants to play. conversely, it seems that leo knows and acknowledges in his manner that i am a subject with a living body, and a subject who wants to play with him. leo and i are carrying out appresentation processes. this interaction between leo and i is not for sure the same i may have with my human friends or with my human students; but anyone can see that with other “lower” animals this interaction is impossible, not to speak of inanimate things, like the poor toy i use to play with leo. our phenomenological analysis can go further, and we can see that in this interaction there is something more going on: the constitution of a realm within which leo and i are interacting, some sort of “space” where we develop our appresentation processes 20 . however, there is also a difference regarding the realms constituted. firstly, we may say that humans among themselves constitute a realm which in my opinion has to be described as world. the world is not primarily the sum of all entities but rather the all-encompassing realm within which everything else is included. it is given in experience as a horizon necessarily present whenever consciousness is referred to any object. husserl gives a very famous example in the first volume of ideas 21 . in this example, i am sitting on my desk writing philosophy, but simultaneously and inevitably i co-perceive the room around me; also, in a more blurred way, i notice my wife and children in the dining room. in these co-perceptions, i am “referred” and “led” from one object to the other. further, these references do not stop at the co-perceptions, as from the dining room and my house i am also bangladesh journal of bioethics 2017; 8(1): 21-32 27 referred to other objects that are not perceived but of which i know; this is “a ‘knowing of them’ which involves no conceptual thinking and it changes into a clear intuiting only with the advertence of attention.” 22 but this is not the end, as from there i am finally remitted to the all-encompassing horizon: what is now perceived and what is more or less clearly co-present and determinate (or at least somewhat determinate), are penetrated and surrounded by an obscurely intended horizon of indeterminate reality [wirklichkeit] 23 . in contrast, it does not seem that animals have a world in the sense described. as we observe them, they do not seem to behave as if they are related to an all-encompassing world. they have rather an “environment,” a more or less extended field which is finally limited: a house, a garden, a forest, or even two areas linked by a migration route. in all these cases, the realm is determinate. and especially, when we interact with them — and as far as we interact, within the interaction itself, but also within each interaction we may have —, we are not being referred to a common “world” that the animal and i would share; we are also in an environment. i myself am for sure referred to the “world,” but only if i get out of the interaction with the animal and the common realm constituted when i (or we) interact with him or her. and this is true, i think, no matter how large the environment can be. returning to my previous example: when i play with leo, he and i are for sure in a common realm; but as we interact, it is not the world that is in perspective (in our common perspective, that which we are sharing as we play). playing together, we are in a house, and the domain of our playing is enclosed within the house; in our playing we have not the “world” in perspective. i may have it, but for this i have to get out from the interaction with leo, even if for an instant. there are, consequently, two different realms: the human realm that is the world and the human-animal realm that is an environment. these realms are qualitatively different. firstly, the environment is limited and determinate while the world is indeterminately extending to the infinite. but there is more, as the human realm is one where humans linguistically interact; the world appears to humans who interact using complex language. on the other hand, the human-animal realm is one where we interact exclusively by bodily signs that indicate our interests and requirements. i as a human may have language, but interacting with leo i am attentive to his bodily signs (tail movement, miaow, etc.). even when i speak to him, my words are bodily signs: my “no” addressed to him as he has done something he shouldn’t have is intended to be a bodily sign. from this difference of realms we may further conclude that different kinds of subjectivity are exercised in each realm. i say here “exercised” because i am not dealing now with what animal or human subjectivity is “as such” but in how animals and humans concretely develop their subjective life when situated in one or another realm (we may put it by saying that i am here on the plane of phenomenology, while the other consideration would already belong to ontology). on one hand, it is clear to me that in both realms we are dealing with bangladesh journal of bioethics 2017; 8(1): 21-32 28 selves, that is. more importantly, in both realms the self shows signs of being aware and “in possession” of its needs and wants as to say that this self has interests. these interests, in turn, given the interactive nature of the realms, are ones which will take a part in any confrontation and decision, whether mediated by language (in the human realm) or by other bodily signs. on the other hand, however, it seems clear to me that there are differences. the key element here is the presence of language. in the case of the human realm, the world, the subjects use language to make sense of their needs and wants; this enables them to carry out more elaborate connections among these needs, confronting them with others with high detail and eventually modifying them by virtue of this confrontation. especially, this means that their interests are confronted within complex reasoning processes that indispensably involve language. this means that any agreement requires, at least ideally, agreements based on discussion and reasoning using language, as for example habermas has so well described. thus, it may be said that although humans and animals live and interact in their realms as selves, they “exercise” them differently. however, this does not lead to deny animals’ subjectivity, reducing them to purely present sensorial stimulation. animals may “exercise” their subjective life differently, but in my view there is undeniably a true subjective life and a true self. my point is that, phenomenologically speaking, we need to speak of different kinds of exercising subjectivity, not that there is not subjective life in animals 24 . now, from these phenomenological descriptions, we may draw some ontological conclusions. thus, firstly we may establish a difference between human beings and other animals. on one side, we have humans, those beings between whom linguistic communication and complex reasoning is necessary, and between whom a realm called “world” is constituted. on the other side, we have animals — or at least many animals —, characterised by bodily signs which seem to point to some sort of embodied self which we perceive as similar to us but also distinct from any human being; among them (and among them and us) the realm constituted is enclosed and excludes language, at least most times. this means that we humans are ontologically different from animals, although we may have an ontological common realm, the environment (or rather, environments). however, this first ontological thesis, which stresses the distinction, has to be balanced with a second thesis according to which animals and humans are together in the same class as opposed to the rest of realities, as among them there can be some form of “appresentation,” unlike in the other cases. the previous considerations are also relevant for an important conclusion regarding the types of subjectivity that each of us are, humans or animals. now we are no longer on the plane of phenomenology as when speaking about the “exercising” of subjective life, but on that of phenomenological ontology. in this sense, it seems clear to me that we need to speak of two kinds of subjectivity: one of them (humans) is capable both of linguistic interaction within the world and within an environment; and the other is only capable of the non-linguistic interaction within an environment. going back to the previous example: when interacting bangladesh journal of bioethics 2017; 8(1): 21-32 29 with leo, i am exercising a subjective life like his. this is why we can understand each other. but at any moment i can pass into my other possibility, which leo cannot. and in my view, this has to be interpreted as he and i being different kinds of subjective beings. conclusion: the ontological difference and the affirmation of participation rights for nonhuman animals; a preliminary thesis in moral philosophy: our previous considerations point to an ontological difference between humans and nonhumans. nonetheless, establishing of this distinction is one thing and inferring rights and duties is quite another. now, for the moral argument, and taking into account the hypotheses described above, we need to consider that in both realms the participants are selves with their own necessities and interests. consequently, if we accept as a moral criterion that morally correct decisions require an equitable assessment of everyone’s positions, then in both cases their interests matter, in both they need to be taken into account and in both they have to be expressed and included in discussions. however, the differences we have remarked make us see something crucial for the moral argument: animals can only express their needs and interests through direct bodily nonlinguistic signs, but their interests need to be taken into account in the language-mediated interaction within the human realm. from there, i think that a first moral conclusion can be drawn, namely: that animals not only depend on us being their voice, but also that we are under the moral obligation to be their voice and take them into account. we may also draw some other conclusions, which of course are provisional and open to discussion. firstly, we agree with zoopolis’ authors that from selfhood it may be inferred that nonhuman animals are subjects entitled to have both positive and negative rights. however, we may say that a phenomenological and ontological distinction is clear between animals and humans, and that this must be reflected in the use of moral and political concepts. therefore, from a conceptual perspective, we may state as a second ethico-political thesis that some sort of concept must be used whose intension adequately reflects the relevant features of animals and humans with regard to political participation, and whose extension is univocally referred to both animals and humans. closely related to this second thesis, and also within the “conceptual” sphere, our third thesis states that another concept must be used to speak about the ethical status, rights, and duties of those who can engage in a more elaborate form of political participation made possible by the shared world constituted through human intersubjective re-presentation mediated by language. however, fourthly, we may for the moment leave open the question whether we use citizenship for domesticated animals and a new concept for humans, or rather if we create a new concept for animals and humans. in my view, both options are defendable: using citizenship for humans and animals may have the advantage of providing the symbolical force of this concept to non-humans; and restricting citizenship for humans could help avoid the risk of diluting the force of the concept of citizenship while encouraging our moral imagination to design another concept for positive participation. bangladesh journal of bioethics 2017; 8(1): 21-32 30 furthermore, i believe that our phenomenological and ontological reading of the human/animal relationship may help overcome the possible insufficiency of zoopolis with regard to the communicative difference. indeed, if our theses are sustainable, then we could defend the idea that “citizenship” can be applied cogently to domesticated non-human animals despite their belonging to different types of being. and even if we think that citizenship has to be applied only to humans, at least our considerations would make sure that positive participation rights, whatever the name we use for them, are granted to non-human animals, in spite of the phenomenological and ontological differences. there are many other subjects that should be addressed. for instance, as i have already indicated, a further development should take into account the possible ontological differences between what we may have too overarchingly called “nonhuman animals.” there should be a justification of the phenomenological method. and for sure, the integration of data from the different sciences would be pertinent; in this regard, mary midgley's wide use of ethology is to me a referent despite the years passed 25 . ethical progress has historically taken the form of enlarging the scope of those who matter morally. those who before were aliens, and thus without rights, were deemed later “like us” and entitled to the same rights. the animal rights movement is decidedly part of this movement. still, maybe here we will not be able to reject all differences but simultaneously see that this is no reason to deny rights. i know that this may sound like the classical “separate but equal” argument that has been so rightfully refuted in the past when speaking about humans. however, here i cannot help thinking that this difference must be kept; and as i am persuaded of the justification of participation rights for animals, i believe that we need to find some operative notion of a distinction compatible with equality. still, even if my views are contested or refuted i will be happy if that means a clarification of the discussion, as well as effective progress for the animals with whom we share the planet. author contribution: the author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgements: none. dedicated: to leo, my cat companion and my best teacher in animal philosophy. notes and references 1 sue donaldson, & will kymlicka. zoopolis. a political theory of animal rights. oxford university press, oxford; 2011. 2 the use and etymology of the term “denizen” is in itself revealing. according to the merrian-webster dictionary, its first meaning is simply “inhabitant”, but the second one is “a bangladesh journal of bioethics 2017; 8(1): 21-32 31 person admitted to residence in a foreign country; especially: an alien admitted to rights of citizenship”. this last meaning points to the inner strength of the concept of denizenship for liminal animals: they are within us although they are not “one of us,” they might even be called resident aliens, though donaldson and kymlicka could find this expression objectionable as being vulnerable to the false assumption that liminal animals “do not belong here.” in fact, we agree with them: they may be “alien” to us, but they definitely “belong here.” (http://www.merriam-webster.com/dictionary/denizen, seen on september 10 th , 2016). 3 cf. zoopolis, pp. 102 ff. the discussion on pp. 57 ff. is also relevant: it highlights the fact that the concept “citizenship” is not restricted to “democratic political agency”, but also to “nationality” and “popular sovereignty”; this means that we could even consider some form of citizenship for nonhuman animals without ascribing to them some form of political agency. however, for my aim here, it is more interesting to consider the authors’ thesis of political agency for animals. 4 ibidem, p. 103. 5 loc.cit. 6 cf. ibidem, pp. 105-108. 7 the authors admit the difficulties present in this approach: there is a risk of manipulation by the caretakers who assist them in expressing their points of view. but this for them is not an insurmountable obstacle. 8 cf. ibidem, pp. 27-33. 9 ibidem, p. 32. 10 loc. cit. 11 this is the kind of interaction considered in most of contemporary political philosophy, especially in habermas or rawls. 12 i leave aside the problem of limit cases. i find that to sort out the problem we should make other considerations in detail, especially the fact that the appresentation between a human being and another human being who is unconscious still point to a human subjectivity, which is not the case in animals. as i say below, explaining appresentation, this is mediated by bodily signs that speak of a human lived corporeality in spite of the circumstances. 13 or, for that matter, sovereignty or denizenship. although some differential qualifications could be necessary, i do believe that what i say about citizenship can also be said of the other two possibilities. i will not repeat it, as to not to be too reiterative. 14 cf. ibidem, pp. 57-59. 15 i express here my gratitude to an anonymous reviewer of an earlier version of this paper, who remarked that i had to be precise in what sense ontology could be useful. as a result, i have seen that firstly it can help clarify the conceptual landscape; and secondly i have insisted more on the role that phenomenology strictly speaking can play before getting into ontology. 16 i insist on the qualification that these “types” are established with regard to the belonging to the realms described. other types of being according to other criteria could be established, and for sure in some of them humans and some animals would be together. i do not claim to propose here an exclusive classification. 17 cf. plato and europe. stanford university press, stanford (cl); 2002, pp. 15-37. http://www.merriam-webster.com/dictionary/denizen bangladesh journal of bioethics 2017; 8(1): 21-32 32 18 i do not use husserl’s analyses of animals, which are of course very interesting. for husserl’s treatment of the animal question, see for example sara heinamäa. “transcendental intersubjectivity and normality: constitution by mortals”, in rasmus thybo jensen and dermot moran (eds.). the phenomenology of embodied subjectivity, springer, heidelbergnew york-dordrecht-london; 2013, pp. 83-103, particularly p. 91. 19 dermot moran and joseph cohen. the husserl dictionary, continuum, london-new york; 2012, pp. 39-40. 20 there is also a temporal dimension. however, the question of time is one of the most difficult ones in phenomenology and i think that for my purpose here it may be enough to concentrate on the realms from the point of view of spatiality. 21 cf. edmund husserl. ideas pertaining to a pure phenomenology and to a phenomenological philosophy. first book: general introduction to a pure phenomenology. translated by f.kersten. martinus nijhoff publisher, the hague-boston-lancaster; 1983, pp. 51-52. 22 ibidem, p.52. 23 ibidem, p. 52. i change the translation of wirklichkeit. the translator chooses “actuality” but i prefer here “reality”. 24 at least among many animal species. among them we count those with whom we interact more, like the most typical domestic animals (cats and dogs), farm animals (cows, horses, etc.), along with many animal denizens (rats, squirrels, etc.), and wild animals (eagles, lions, etc.). thorough research would have to consider the different interactions and realms with different animals, but in this contribution i have restricted myself to the group of animals with whom a closer interaction seems possible. 25 mary midgley. beast and man. routledge, london and new york; 1995 (original edition: 1978). microsoft word bbs news bangladesh journal of bioethics 2018; 9(2):41 bbs news shamima parvin lasker secretary general , bangladesh bioethics society 20th asian bioethics conference (abc20) will be held on 22-25 nov, 2019 at dhaka, bangladesh, organized by bangladesh bioethics society (bbs) and in the cooperation with dghs, ministry of health and family welfare, people republic of bangladesh and in conjunction with aba and eubios ethics institute, thailand, new zeeland’s and japan. it provides opportunity for all scholars around the world to gather feedback on their research, maximize networking opportunities, and learn the latest news and information and methodologies on bioethics. it is our great honor to welcome you to the twentieth asian bioethics conference (abc20) in dhaka, bangladesh. bangladesh bioethics society (bbs) is the pioneer in bioethics, has been promoting integrity for sustainable development of bangladesh since the beginning of 21st century. these actions reflect the nation’s effort as a member of the global community in developing science and biotechnology as well as in societal reform for protecting civil rights in ethical, legal, and social senses. the conference brings together scholars and policy makers from many disciplines all around the world (beyond just asia and the pacific) to discuss and deliberate on the latest issues facing humanity. the previous conferences was held in china, japan, korea, turkey, thailand, malaysia, indonesia, india, iran, the philippines and taiwan. http://www.abc20.bioethics.org.bd/index.html abstract submission will be open from 1st march, 2019. abstract submission deadline: august 15, 2019. please send your abstract to prof ma shakoor at: shakoor.abc2019@gmail.com and rafe.dr@gmail.com and cc to splasker04@yahoo.com for your all communication policy brief 01 microsoft word editorial policy ethics bangladesh journal of bioethics 2020; 11 (1) editorial public health system always requires an advanced level of awareness and a comprehensive policy. however, as is often the case, expectations and actualities do not match. in order to understand the situation, planning and other related initiatives, and to assess the adequacy in terms of the expectations borne out of experiences, the papers in this volume detailed the issues and the need of ethics in formulating the policies and contributing in the vision of the development of the country. in order to have a comprehensive ethical policy and planning, a concern for the initiatives and development deep down in the policy formation is required. despite the fact that there is need of ethics in such formulation, the need is yet to be acknowledged in the relevant policy documents. the five papers in the volume emphasise such need. the first paper entitled why is family-oriented organ transplantation policy and practice necessary for bangladesh? by m.s. siraj address that the in terms of the donation of organs for transplantation in the west, the notion of individual rights and freedom is compatible with secular culture and biomedical perspectives, but such biomedical policy and practise is comprised with the muslim culture, socio-economic reality and biomedical perspective of bangladesh. it highlights the need and importance of family-oriented biomedical policy and practice in bangladesh. the second paper policing ethics: context bangladesh, authored by m.s. adil, focuses on the need of ethics for policing actions in bangladesh. grounding on the fact of the ongoing discussion about the ethical principles and the code of conduct of police practitioners in the country, the paper discusses police misconduct due to the lack of principles and also highlights the mindset of the public towards the police. the third paper on child marriage in bangladesh: policy and ethics, written by arnab, a. t. arnab & m.s. siraj examines the way the religious cultural and socio-economic realities influence child marriage practice in bangladesh. bringing the experiences from the ground, the paper reveals that bangladeshis does not support marriage at early ages but socio-economic reality often pushes poor into getting their children married at early ages. therefore, the paper comes up with the suggestion that the country should strengthen its policy on child marriage. the fourth paper on justice for children in bangladesh: legal and ethical issues, authored by n ferdousi, highlights the backdrop of the justice system for children in bangladesh. highlighting the children act 2013, the paper makes it noticeable that justice for children requires an ethical code of conduct along with the legal responsibility to protect child rights and the childhood in the country. the fifth paper on ethics in social research and its impact on policy implication, planning and development, co-authored by p.c. sarker & u.k. das discusses the importance of data bangladesh journal of bioethics 2020; 11 (1) driven research for evidence-based policy formulation. and for the appropriate data driven research, the paper highlights that trustworthy research studies should be guided by the ethical intentions and actions. recognizing the importance of ethics in different aspects of research and policy, the issue of the bangladesh journal of bioethics invited me to edit the issue on policy ethics. i am grateful to professor shamima parvin lasker for giving me the opportunity to serve as the guest editor of the issue. and i hope readers will enjoy in going through the diverse and insightful papers of the issue. thank you, rhyddhi chakraborty fhea (programme leader (hnd-health care practice), global banking school, london, uk visiting faculty (philosophy & global health), ausn, usa senior associate member, royal society of medicine, london, uk) guest editor, bangladesh journal of bioethics , vol-11, issue 1 microsoft word editorial bjb vol. 8 (1) bangladesh journal of bioethics 2017; 8(1) editorial do you remember harambe, the 17-year-old silverback who was shot dead after a boy fell into the gorilla enclosure at the cincinnati zoo, cecil, the lion who was shot with an arrow by an american dentist in zimbabwe, and marius, the giraffe who was killed and fed to other animals at the copenhagen zoo? every once in a while, a news story about the human-caused death of an animal sparks global outrage, briefly lights up the comments sections on the internet, and reminds us of the inconsistency in how think about non-human animals. according to the food and agriculture organization of the united nations, we kill approximately two thousand animals for food per second, not including fish and other marine animals. all of these animals have rich emotional lives that matter to them, and what we do to them is as bad, and often much worse, than what was done to harambe, cecil, and marius. most farm animals are raised in filthy and unnatural conditions, and are subject to routine mutilations and other mistreatment. they are transported in ways that are at best unpleasant and at worst horrific, and they die violent deaths. yet, most of us – while expressing our moral indignation about the treatment of harambe, cecil, and marius – rarely spare a thought for the animals we eat. morally speaking, there does not seem to be much of a difference between what happened in cincinnati, zimbabwe, and denmark and what happens in factory farms and slaughterhouses in every part of the world, every day. if anything, there was a better reason to kill harambe – namely, to avert danger from a child – than there is to kill animals for food. we do not need to consume animal products to live a healthy and fulfilled life. in fact, careful studies have found that a well-balanced plant-based diet decreases the chances of suffering from diseases such as diabetes, heart disease, stroke, and some cancers, and benefits the environment. the way we think about and treat non-human animals is deeply confused, and scholars are in a unique position to provide some clarity. the bangladesh journal of bioethics hence decided to dedicate two special issues to the relationship between human beings and other animals, and asked me to be the guest editor. this is the second of the two special issues, and contains the following five articles: the number of fish killed annually by the fishing industry, even on the most conservative estimate, is more than ten times larger than the number of terrestrial animals killed annually for food, and yet animal advocates largely focus on the latter in their efforts to reduce animal suffering. bob fischer (“wild fish and expected utility”) does the math and argues that considerations of expected utility call that focus into question. he concludes that animal advocacy organizations owe an explanation of why they are not directing more of their resources to fish. bangladesh journal of bioethics 2017; 8(1) akande michael aina and ofuasia emmanuel (“the chicken fallacy and the ethics of cruelty to non-human animals”) challenge the common view that non-human animals are mere resources that we can use as we please, and ask whether peter singer’s ethics of animal liberation is a plausible alternative. they think it is not, in part because it denies moral status to non-sentient life, and take another approach that draws from charles darwin’s theory of evolution. they argue that cruelty to non-human animals, with whom they claim we are on an equal moral footing, betrays our trusting and neighborly relationship with them. iván ortega rodríguez (“animal citizenship, phenomenology, and ontology: some reflections on donaldson’s & kymlicka’s zoopolis”) provides a brief summary of the position sue donaldson and will kymlicka defend in their ground-breaking book zoopolis, and argues that they are mistaken in failing to consider an important metaphysical difference between human beings and other animals. while human and non-human animals share a common environment, only human interaction constitutes what he calls a “world.” that difference, however, does not undermine the case for animal rights but rather strengthens it. rhyddhi chakraborty (“animal ethics and india: understanding the connection through the capabilities approach”) takes a critical look at a wide range of legal provisions in indian law designed to protect non-human animals. she argues that, despite such provisions, nonhuman animals continue to suffer greatly at the hands of human beings in india, which is partly due to the lack of a comprehensive ethical vision. she suggests that the capabilities approach can provide such a vision, and concludes by making a number of policy recommendations to improve animal welfare in india. robin attfield and rebekah humphreys (“justice and non-human animals”) complete their argument for the claim that our treatment of non-human animals is a matter of justice, the first part of which can be found in the previous issue of this journal. i thank the contributors for choosing this journal to share their exciting ideas, and the reviewers for their insightful comments and suggestions. i am also indebted to professor shamima parvin lasker and ms. tahera ahmed for their cooperation and trust. if you, dear reader, are new to the academic debate over the moral status of non-human animals, and if the two bangladesh journal of bioethics special issues on animal ethics have made you curious, as i hope they did, i would like to recommend to you two classics of the animal ethics literature: peter singer, animal liberation: a new ethics for our treatment of animals (new york: new york review/random house, 1975); and tom regan, the case for animal rights (berkeley/los angeles: university of california press, 1983). i hope you will enjoy reading through this issue, and i am sending you my warm regards. rainer ebert guest editor bangladesh journal of bioethics department of philosophy university of johannesburg south africa rainerebert@gmail.com http://www.rainerebert.com bruchure-2.cdr th20 asian bioethics conference theme: bioethics for humanity, dignity and solidarity date: 22-25 nov, 2019 venue: national economic council (nec) conference hall, agargaon, dhaka (22 & 23 nov.) directorate general of health services (dghs) auditorium (new building), tb gate, mohakhali, dhaka (24 & 25 nov.) in collaboration with asian bioethics association social science research council, bangladesh planning division, ministry of planning, agargaon, dhaka directorate general of health services (dghs) mohakhali, dhaka eubios ethics institute, thailand, new zeeland's and japan bangladesh medical research council (bmrc) mohakhali, dhaka bangladesh bioethics society organized by category of participants bbs member non bbs member bbs student member (undergraduate) student member (undergraduate) bbs international life member aba member non aba member student accompanying person early bird registration 1 mar-20 sept bdt 1,000/bdt 1,000/bdt 300/bdt 300/usd 100 usd 170 usd 200 usd 100 usd 200 late bird registration 21 sep-21 nov bdt 1,000/ bdt 1,500/ bdt 400/ bdt 400/usd 150 usd 250 usd 270 usd 200 usd 270 onsite 22-24 nov bdt 1,000/bdt 2,000/bdt 500/bdt 500/usd 200 usd 300 usd 350 usd 250 usd 250 bangladeshi delegates foreign delegates registration fees: fee includes: l certificate of participation l conference kit l program/abstract book l access to scientific sessions l meals: morning and evening refreshment and lunch l access to cultural programme registration: you can bkash or bank transfer for registration. download the registration form from website and send to dr. sharmin islam at sharmin320@hotmail.com (phone & bkash: 0088 01813 33 5842) and cc to or vice versa dr. moshiur rahman khasru at drkhasrumrkhan@yahoo.com (phone & bkash: 01716045646) along with payment confirmation document. website: abc20.bioethics.org.bd please send sms if phone is busy prof. shamima parvin lasker phd professor & head, dept of anatomy, mh samorita medical college, dhaka, bangladesh secretary general, bangladesh bioethics society. phone: 88-01712522627 email: splasker04@yahoo.com website: abc20.bioethics.org.bd professor dr. md. humayun kabir talukder publicity secretary, bangladesh bioethics society email: hktalukder@yahoo.com cell: 01711534774 dr. rajib biswas project research physician, icddr,b phone: 88-01834615002 email: ashonko@gmail.com bank specification: bangladesh bioethics society janata bank ltd dhaka sheraton hotel & corporate branch, dhaka, bangladesh account no.: 0100005693904 swift: janbbddh contact: abstract submission is now open. the deadline date of abstract submission is sept. 15, 2019. 1. bioethics and life 2. medical ethics 3. research ethics 4. bioethics: history and future 5. bioethics and culture 6. bioethics and gender 7. bioethics and education 8. bioethics and human rights 9. bioethics in global economy 10. ethics in science and technology 11. ethics and religion 12. ethics in public health 13. nursing ethics 14. bioethics and human reproduction 15. bioethics and social responsibility 16. bioethical challenges and responses 17. bioethics, human security and sustainability 18. bioethics and environmental justice 19. animal ethics 20. publication ethics 21. media ethics 22. advancing social development and civic engagement 23. others bangladesh bioethics society (bbs) pioneer in bioethics, have been highlighting ethics and morality in biomedicine, biotechnology, science and social science since 2009. motto of bbs is promotes intigrity for peace, denighty and sustainability. it is our great honor to welcome you to the 20 asian bioethics conference (abc20) in dhaka, bangladesh. abc20 will be held in dhaka, bangladesh, in cooperation with social science research council, bangladesh, planning division, ministry of planning; directorate general of health services (dghs), ministry of health & family welfare; bangladesh medical research council (bmrc); asian bioethics association (aba) and eubios ethics institute, thailand, new zeeland and japan. it provides opportunity for all scholars around the world to gather feedback on their research, maximize networking opportunities, and learn the latest information and methodologies on bioethics. the previous conferences have been held in china, japan, korea, turkey, thailand, malaysia, indonesia, india, iran, the philippines and taiwan. the conference will bring together scholars and policy makers from many disciplines all around the world (beyond the asia and the pacific) to discuss and deliberate the latest ethical issues in biomedicine, biotechnology, science, social science and education facing today for humanity. background: prof. ravichandran moorthy (malaysia) prof. bang-ook jun (korea) prof. darryl macer (usa) prof. hasan erbay (turkey) prof. cong yali (china) prof. aruna sivakami (india) prof. endang sukara (indonesia) prof. manjae kim (korea) prof. latifah amin (malaysia) prof. ananya tritipthumrongchok (thailand) dr. sumaira khowaja-punjwani (pakistan) prof. firuza nasyrova (tajikstan) professor leonard le blanc iii (usa) prof. nader ghotbi (japan) prof. irina pollard (australia) dr. gregor wolbring (canada) dr. rainer ebert (germany) prof. buujian tsai (taiwan) confirmed speakers: topics: page 1 page 2 microsoft word svetoslave-29-march-19 bangladesh journal of bioethics 2018; 9(2):1-5 1 bioethical considerations for algal biotechnology ivanina vasileva, juliana ivanova, svetoslav alexandrov* department of experimental algology, institute of plant physiology and genetics, bas, acad. g. bonchev str., bldg. 21, 1113, sofia, bulgaria *corresponding author’s e-mail: saturn@gbg.bg abstract: in this manuscript we discuss different aspects and applications of algal biotechnology and how they are seen through the prism of bioethics. we review how algae have been considered to solve problems on earth and to ease human suffering. we also take a look at the current state of the production of algal biomass and we offer our suggestions and considerations based on the fact that the biomass is an expensive product and yet its quality is very good. keywords: microalgae, cultivation, biomass, bioethics, growth, biochemical composition introduction: although the term “bioethics” was first used by potter in the early 1970s [1], long after the cultivation of microalgae became a common practice, we could argue that some of the driving principles of the use of algae in the biotechnological industries have been bioethical since the early beginning. it is undeniable that the ecological impact of people on nature has been huge since the start of the industrial revolution in the nineteenth century, with the human population increasing from 1 billion in 1835 to 6 billion in just a little more than 150 years [2]. this growth in population has been positively influenced by the so called green revolution – research and development in agriculture between the 1930s and the late 1960s, which led to an increase in agricultural production worldwide [3]. yet, in the 1950s, it was argued that the supply of food will not be enough, as the population was increasing more rapidly than the output of agriculture, and several alternatives were considered – one of which was the cultivation of green algae like chlorella and scenedesmus for food [4]. such an argumentation could nowadays be considered as bioethical, as it touches many important issues related to the subject – the growth of the human population, its potential impact on nature, and the question of what the good things are that can be done in order to support the exponential growth of the population, without putting too much stress on nature and agricultural resources. since the 1950s, the prospects of the cultivation of microalgae received support from many proponents with regards to their potential applications. with the coming of the space age in the 1960s and 1970s, it was considered that the algae could be used to feed cosmonauts, as well as to terraform planets of the solar system [5]. these prospects have raised many bioethical issues on their own, such as whether it is good or bad to spread life beyond the cradle of the earth, whether we have the right to endanger extraterrestrial species or whether human expansion to the solar system is justified [6]. another argument for the necessity of microalgae cultivation which was presented during the early years of algal biotechnology is that most of the studied algal species contain important biologically active substances and as such could be used bangladesh journal of bioethics 2018; 9(2):1-5 2 in medicine and pharmacy [7], which is undoubtedly bioethical as it is in favor of easing human suffering. during the last 15-20 years, microalgal cultivation once again received considerable public attention, because some supporters suggested that algal biomass could be used for the production of biofuels [8]. this idea has also been analyzed through the prism of bioethics. certain researchers have claimed that developing biofuels could be treated as an ethical duty, and algae are one of the potential biofuel sources [9]. algae biofuels have also been considered to be part of the second generation of biofuels because it is thought they do not compete with land and food resources and they do not negatively affect the environment and local populations, compared to conventionally produced biofuels [10]. standard biofuels are often viewed as ethically controversial, because arable land instead of being used to grow food would be used to grow fuel [11]. the advantage of algae is that they are being grown in photobioreactors and thus could hopefully help to avoid the abovementioned dilemma and in the meantime, offer a viable solution. in this manuscript we will discuss the current state of the production of algal biomass in the light of its bioethical implications. discussion: no matter how algae are considered to help humanity or are involved in solving ethically controversial issues, there is one simple fact that defines the current state of algal biotechnology – it is the truth that the algal biomass remains an expensive product. cultivation of microalgae is a challenging process – they need to be provided with a suitable nutrition medium, co2 also ought to be ensured, cultures need to be stirred and, in the end, water must be evaporated if we want to obtain dry biomass. the high cost has dire consequences on certain algal applications and most notable of these is biofuels. it is calculated that a kilogram of biodiesel is obtained from 12 kg of microalgal biomass, and just for producing this quantity 2kg urea, 0.530 kg kh2po4, 0.370 kg mgso4 and some other micronutrients are needed – the overall cost of these salts is close to the cost of 1 kg of conventional diesel [12]. back in 2017, the price of wheat on the market in chicago was estimated to be $151.90 per ton and for corn – $134.48 [13]. it is difficult to calculate the exact production cost of algal biomass, as projected economics from public literature range from $270-$2450 per ton [14]. but even if we take the lowest value, which is hardly achievable, produced algal biomass would still have a very high price compared to most commonly used crops worldwide. it would only be ethical and morally right to present this fact, rather than give false hopes about certain prospects. is it feasible to replace conventional food and biodiesel with algae? no, it is not yet possible according to the current state of technological development, and the price of algal biomass has always been high even though the technology for algal cultivation has existed for decades. stating this fact does not mean that the application of microagal biotechnology has no ethical basis at all. in order to provide a sound ethical justification, however, the focus ought to be shifted. algal biomass, while being expensive, is a product of high quality. as such, the priorities are altering as well – in the food industry, the asset of algal biomass is not as a basic product, but rather as a supplement [15]. here we ought to bangladesh journal of bioethics 2018; 9(2):1-5 3 stress that the food supplement industry is well developed and dates back to the 1960s, starting in japan, usa, taiwan, australia, and china [16]. it is well known, for example, that spirulina as a food supplement contains a variable combination of substances, including ones that are absent in common food, and dry biomass of this alga has 60-70% protein, 10-20% carbohydrates, 1-14% lipids, 4% nucleic acids and 4-6% minerals [17]. the high protein content is well-balanced in amino acids and this alga is also a source of beta carotene and iron, and it is thought to be the world’s richest natural source of vitamin b12 and essential fatty acids [18]. these qualities cannot be underestimated and they are what makes algal biomass such an important product in the food industry, even if it is expensive. the high quality of biomass makes it applicable in other biotechnological fields as well. certain species are able to accumulate highly valuable compounds – for example – dunaliella salina produces beta carotene, hematococcus pluvialis produces astaxanthin, porphyridium cruentum – polysaccharides, lyngbya majuscule – immunomodulators [19]. the fact that the biomass is a costly product does not disprove the fact that it is a good source of these products, and, as such, does not downplay the critical role of algae in medicine, pharmacy and cosmetics. moreover, even if those valuable compounds are contained in other species, algae are still the primary natural source of these compounds in many food chains. a very good example can be given with longchain pufas. pufas can be obtained from fish and fish oil, yet, safety issues have been raised because of the possible accumulation of toxins in fish. there are also problems with unpleasant taste, fishy smell and poor oxidative stability, and that is why algae are considered to be a promising and advantageous source [20]. once again, the focus is on quality of the algal biomass as a justification for its use. when we discuss biotechnology and bioethics, it is also important to consider the public awareness of the subject. people in developed countries, an example of which is japan, have been strongly influenced by the usage of the prefix “bio” in the industry, government and marketing [21]. the socalled “bio”products have gained extreme popularity, because they are considered to be healthier, safer and ecologically clean. the high quality of the compounds produced by algae, which have applications in cosmetic, food production and pharmacology can be described with the term “bioproducts” [22]. to sum it up, microalgae can not only be useful and practical in certain biotechnological fields, but they can be attractive as well. conclusions: an ethical dilemma, or an ethical paradox, is defined as having to choose between two possible moral imperatives. choosing either one of these would breach a moral principle. in the case of algal biotechnology, the dilemma is between quality and quantity. should we pursue production of large quantities of algal biomass, or rather we should focus on the quality of the product? choosing the first one is a requirement if we want to feed the hungry or save the world from the eventual depletion of fossil fuels, but that would mean ignoring more realistic and economically feasible applications. choosing the second one means that we will give up on solving the problem of poverty or obtaining biofuels, but instead we can pursue new opportunities in medicine and bangladesh journal of bioethics 2018; 9(2):1-5 4 pharmacology, which, however, will be sustainable. our solution to the ethical dilemma is: pursue quality over quantity. this is the driving ethical principle which should push the algal biotechnology and production in the days ahead. our review of the scientific literature, which we have done in the previous chapter, shows that algae are not a sustainable way to feed the hungry, because the biomass is expensive. neither will they fuel our transport for the same reason. this could change if there is a major breakthrough leads to a drastic decrease of the biomass cost, but the current prospects for this continue to be very slim [23]. the ethically right decision in this case would be to re-evaluate our priorities about the prospects of algal biotechnology and to acknowledge that certain efforts during the past 10-15 years have failed. it was reported in 2016 that algae biofuels programs, such as the one run by exxon mobil corp., fell flat due to their lack of success to achieve economically viable results [24]. it is not to say that such programs have been scientifically useless. quite the opposite, many important scientific papers have been written in the pursuit for a better, ecologically cleaner world. but the expected practical results have not come. it is high time the world faced the truth. we suggest that the focus that should drive fundamental research is to work on new ways to lower the cost of the biomass – this is a noble and ethical goal that is worth pursuing in the years and decades to come. this does not justify investing in unrealistic and futile projects and constructing large facilities just to meet certain aims, while we are still waiting for the future. meanwhile microalgae are finding their realistic application in healthcare, medicine and cosmetics, where they are already helping to make our world better. microalgal cultivation is a promising branch of biotechnology and the benefits are already in use. contributions: all authors have contributed equally to the birth of the idea and conception of the manuscript. ivanina vasileva is the lead author, she checked the whole manuscript meticulously, corrected critical errors and greatly improved the written language. juliana ivanova checked the whole manuscript meticulously and reviewed the application of algae in medicine and cosmetics. svetoslav alexandrov guided the writing of the manuscript and is the corresponding author. conflict of interests: none references 1. potter vr. bioethics, the science of survival. perspectives in biology and medicine 1970; 14(1) : 127-153. 2. chiarelli b. man, nature and ethics: global bioethics. global bioethics 1992; 5(1): 13-20. 3. hazell pb. the asian green revolution. intl food policy res inst; 2009. 4. geoghegan mj. unicellular algae as a source of food. nature 1951; 168(4271): 426. 5. alexandrov sd. algal research in space: history, current status and future prospects. innovare j life sci 2016; 1: 1-4. 6. alexandrov s. planetary protection for mars: time for reconsideration. bangladesh journal of bioethics 2016; 7(2): 31-34. 7. borowitzka ma. microalgae as sources of pharmaceuticals and other biologically active compounds. journal of applied phycology 1995; 7(1): 3-15. 8. chisti y. biodiesel from microalgae. biotechnology advances 2007; 25(3): 294-306. 9. buyx a, tait j. ethical framework for biofuels. science 2011; 332(6029): 540-541. 10. buyx am, tait j. biofuels: ethics and policy‐ making. biofuels, bioproducts and biorefining 2011; 5(6): 631-639. bangladesh journal of bioethics 2018; 9(2):1-5 5 11. gui mm, lee kt, bhatia s. feasibility of edible oil vs. non-edible oil vs. waste edible oil as biodiesel feedstock. energy 2008; 33(11): 1646-1653. 12. petkov g, ivanova a, iliev i, vaseva, i. a critical look at the microalgae biodiesel. european journal of lipid science and technology 2012; 114(2): 103111. 13.fermer.bg.2017. https://fermer.bg/novini/kakvi-sa-tsenite-naosnovnite-zarneni-kulturi-po-svetovnite-borsi 14.davis r, markham j, kinchin c, grundl n, tan ec, humbird d. process design and economics for the production of algal biomass: algal biomass production in open pond systems and processing through dewatering for downstream conversion. technical report nrel/tp-510064772, national renewable energy laboratory, golden; 2016. 15. ivanova j, kabaivanova l, petrov p, yankova s. optimization strategies for improved growth, polysaccharide production and storage of the red microalga rhodella reticulata. bulg chem commun 2015; 47(1): 167-174. 16. thomsen l. how ‘green’are algae farms for biofuel production? biofuels 2010; 1(4): 515-517. 17. milasius k, malickaite r, dadeliene r. effect of spirulina food supplement on blood morphological parameters, biochemical composition and on the immune function of sportsmen. biology of sport 2009; 26(2): 157. 18. mosulishvili lm, kirkesali yi, belokobylsky ai, khizanishvili ai, frontasyeva mv, gundorina sf et al. epithermal neutron activation analysis of blue-green algae spirulina platensis as a matrix for selenium-containing pharmaceuticals. journal of radioanalytical and nuclear chemistry 2002; 252(1) 15-20. 19. pulz o, gross w. valuable products from biotechnology of microalgae. applied microbiology and biotechnology 2004; 65(6): 635-648. 20. spolaore p, joannis-cassan c, duran e, isambert a. commercial applications of microalgae. journal of bioscience and bioengineering 2006; 101(2): 8796. 21. macer d. bioethics: perceptions of biotechnology and policyimplications. international journal of biotechnology 2001; 3(1-2): 116-133. 22. yu x, chen l, zhangw w. chemicals to enhance microalgal growth and accumulation of high-value bioproducts. frontiers in microbiology 2015; 6: 56. 23. alexandrov s, iliev i, gacheva g, krоumov a, pilarski p, petkov g. could algae be a real source of fuel. genetics and plant physiology 2015; 5(2): 105122. 24. aghbashlo m, demirbas a. biodiesel: hopes and dreads. biofuel research journal 2016; 3(2): 379379. microsoft word bbs news bangladesh journal of bioethics 2017; 8(3):33 bbs news: shamima parvin lasker, phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd) professor & head of anatomy, mh samorita medical college, dhaka, bangladesh visiting professor of clinical anatomy & bioethics, american university of sovereign nation, usa. training programme on “research methodology” planning, monitoring & research division of dghs with technical support of bangladesh bioethics society (bbs) and american university of sovereign nation (ausn, usa) organized a three days training programme on “research methodology” on 3-5 december, 2017 at conference room, dghs (1st floor, old building). graduation ceremony: following members of bbs have been graduated from ausn, usa in 2017 and honored by bbs through a programme. phd (bioethics, sustainability and global public health) prof shamima parvin lasker, professor & head of anatomy, mh samorita medical college, dhaka – she is the 2nd phd holder and 1st female phd from ausn. master of bioethics and global public health dr tonmoy biswas tanya ahmed tamjida ahmed ausn graduates with prof darryl macer, president, ausn, december 2017 microsoft word editorial surrogacy around the world bangladesh journal of bioethics 2017; 8(3) editorial surrogacy around the world surrogacy is an encouraging management for many childless couples and can hypothetically resolve many unbearable pain that they are confronted1. initially surrogacy treatment was frowned upon, however, surrogacy is more popularly accepted now a day 1. perez (cited in svitnev) reported that different states of usa have different rules and regulations on surrogacy2. most of the states have laws allowing surrogacy. but surrogacy is totally prohibited in washington dc, new jersey, michigan, louisiana, and new york 3. one the other hand, idaho, wyoming, nebraska, iowa, mississippi, tennessee, virginia, indiana and arizona have law on surrogacy but practices are potentially hurdles3. it is interesting to note that through there is no law on surrogacy in california but surrogacy is permissible in this states2. south america ban surrogacy 4. like the usa, different states of australia has different law on surrogacy. surrogacy is allowed in western australia, new south wales and australia capital territory. conversely, victoria, south australia and tasmania have law on surrogacy but it is very hard to carry out the procedure in these states5. in european, surrogacy is allowed in uk, belgium, netherlands, holland, finland, portugal, ukraine 6 greece and russia 2. commercial surrogacy is prohibited by law in uk. some charitable organizations such as surrogacy uk, issue, child, cots are working for surrogacy in britain under human fertilization and embryology act 1990 7. italy was one of the pioneer on surrogacy in the world. however, in 2004, surrogacy was banned by the legislation. matorras (2005 cited in inhorn 2010) reported that officially traditional catholic spain prohibits surrogacy but per see it is not prohibited and it is one of the european epicentre of reproductive tourism8. switzerland, sweden have no law for surrogacy. “israel legalized surrogate motherhood in 1996. the surrogate can be paid only for legal, insurance expenses and compensated for her time, loss of income and pain” 9. in south africa, surrogacy is allowed including partial, genetic and commercial. court of south africa gives unprecedented liberty to surrogate mother to terminate surrogate agreement even within genetic parent at any time by filing a written notice 2. in asia, although surrogacy is a grey arena nonetheless a news published by the southern metropolis weekly and reported that around a quarter million (25,000) babies were born in china by commercial surrogacy arrangement. surrogate industry challenges the country’s strict one child birth laws2. reuters (2009 cited in svitnev 2006) said guangzhou authorities for the first-time held three young surrogate mothers and forced them to abort their fetuses2. only india has law in favour of surrogacy among asian countries. even commercial surrogacy is popular from 1992 2. however, korea operates the art without statute and guideline10. all 62 muslim countries disapprove surrogacy11, e.g. united arab emirates, kuwait, qatar, bahrain, saudi arabia, syria, egypt, sudan, morocco, sub sahara muslim country, turkey, indonesia, malaysia, afghanistan, india, bangladesh journal of bioethics 2017; 8(3) pakistan, bangladesh etc. 12, 13. in 1999, iran issued a verdict electively permitting surrogacy. this ruling achieves acceptance in parts of the shi'ite population e.g. iran, lebanon, and part of saudi arabia, bahrain, iraq, syria, afghanistan, india and pakistan 14. surrogacy is not recognized by 199 country in the globe. different country has different regulations on surrogacy. however, “there are some indication of the degree of divergence between official discourse and actual practice of surrogacy throughout world” 9. there are positive changes in attitude toward surrogacy has been seen for some countries. this special issue of bangladesh journal of bioethics has been organized on surrogacy to see the current thinking of surrogacy around the world and how people come out from the social, religious and political framework. references: 1. lasker sp. infertility treatment in developing country. bangladesh bioethics society 2011; i (2) :3. 2.svitnev k. legal control of surrogacy– international perspectives. 2006; p149-163. http://www.jurconsult.ru/publications/ethical_dille mas/13_legal%20control%20of%20surrogacy%2 0-%20international%20perspectives.pdf (accessed on may 2012). 3. creative family connections. gestational surrogacy law across the united states. surrogacy agency & law firm https://www.creativefamilyconnections.com/ussurrogacy-law-map/ (accessed on may 2012). 4. utian wh sheean l goldfarb jm. successful pregnancy after in vitro fertilization-embryo transfer from an infertile woman to a surrogate. n engl j med 1985;313:1351-1352). 5. leeton, j. the current status of ivf surrogacy in australia. aust. nz j. obstet. gynecol. 1991; 31: 260-262. 6. cohen, j. and jones, h. (1999) assisted reproduction. rules and laws. international comparisons. contracept. fertil. sex., 27, i-7. 7. brinsden rp. gestational surrogacy. human reproduction update 2003; 9(5):483-491. 8. inhorn mc, patrizio p, serour gi. third-party reproductive assistance around the mediterranean: comparing sunni egypt, catholic italy and multi-sectarian lebanon. reproductive biomedicine online 2010; 21, 848– 853. 9. lasker sp. surrogacyin encyclopedia of global bioethics, edition: 2016, springer international, pp:1-8. https://link.springer.com/referenceworkentry/10. 1007/978-3-319-05544-2_409-1 (seen on august 2016) 10. fasouliotis sj and schenker jg. social aspect of assisted reproduction. hum. reprod. update 1999;5(1):26-39. 11. hussain fa. reproductive issues from the islamic perspective. hum. fertil. 2000; 3: 124-28. 12. inhorn mc. making muslim babies: ivf and gamete donation in sunni versus shi’a islam. culture, medicine and psychiatry 2006; 30: 427– 450 13. meirow, d. and schenker, j.g. the current status of sperm donation in assisted reproduction technology: ethical and legal considerations. j. assist. reprod 1997; 14: 133–138. 14. abbasi-shavazi mj, inhorn mc, razeghinasrabad hb and toloo g. the iranian art revolution: infertility, assisted reproductive technology, and third-party donation in the islamic republic of iran. j. middle east wom. stud. 2008; 4:1–28. shamima parvin lasker phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd) executive editor, bangladesh journal of bioethics professor & head of anatomy, mh samorita medical college, dhaka, bangladesh visiting professor, clinical anatomy, dentistry, and bioethics, ausn, usa. sectary general, bangladesh bioethics society. treasurer, world association of medical editors (wame) chairperson, ethics & publication, asian pacific association of medical editors (apame) email: splasker04@yahoo.com microsoft word editorial bangladesh journal of bioethics 2019; 10(3) editorial vol 10 issue 2 good care is the reflection of care ethical. to improve the ethical quality of care, moral behavior is needed in addition to law and regulation. personal involvement and motivation of care providers are considered an important element of good care. thus, health care provider must change their perspective. their education on medical ethics needs to be more practical oriented rather than theory. in addition, ethical reflection is contextual and experiential learning process. bioethics training must be needed to foster inter alia and moral power of imagination of care providers. in this issue, the first paper entitled ethical implication of genetic gender manipulation for economic recession written by osebor ikechukwu monday and stephen cc chukwuma esq expressed their concern about scientific manipulation of the fetus to determine the gender of the offspring. unbalance sex ratio and manipulation of genome linked to economic recession. they concluded that genetic gender manipulation should be regulated by strong law. miliva mozaffor, mariya tabassum, mohammad tipu sultan, shamima parvin in their article of ethical considerations in clinical biochemistry and laboratory medicine: a discussion based on ‘the belmont report’ highlighted the role of laboratory physicians in patient care and focused the ethical issues encountered during the pre-analytical, analytical and post-analytical phases of laboratory medicine practice and discussed those issues in the light of ‘the belmont report’. the third paper, therapeutic contract and ethical practice in counselling and psychotherapy written by sunjida shahriah, sunjida islam, khalid arafat deliberated the ethical dilemmas faced by psychotherapists and counsellors to provide effective care. they debated the necessity of ethical demand of therapeutic contract in counselling and psychotherapy practice. both the counsellor, the psychotherapist and the client and each member of the system should collaboratively agree the goals. shamima parvin lasker phd professor & head of anatomy, shahabuddin medical college, dhaka, bangladesh executive editor, bangladesh journal of bioethics microsoft word genetic gender manipulation for economic recessionxx 1 bangladesh journal of bioethics 2019; 10 (3): 1-4 1 ethical implication of genetic gender manipulation for economic recession osebor ikechukwu monday1 stephen cc chukwuma esq2. 1. lecturer: department of arts and humanities delta state polytechnic ogwashi-uku pmb 1030, nigeria email osebormonday1@gmail.com, osebordarry@yahoo.com, orchid: https://orcid.org/0000-0002-2642-662x 2. senior lecturer: department of arts and humanities delta state polytechnic ogwashi-uku pmb 1030, nigeria doi: https://doi.org/10.3329/bioethics.v10i3.50393 abstract: a recession is a significant decline in economic activities. the effects of economic recession include general economic decline, drop in the stock market and increase in unemployment. while some have argued that bilateral relationship among nations is an ethical response to problem of economic recession but it does not solve the problem. the paper suggests genetic gender determination. genetic gender determination is an agent-based ethics. it involves the scientific manipulation of the fetus of a woman to determine the gender of her offspring. ethical issues linked to genetic gender determination, unbalance sex ratio, manipulation of genome, and possible spread of infectious or communicable diseases. the paper concludes that the genetic gender determination would help to cushion the effects of economic recession. keywords: genetic gender determination, infectious and communicable diseases, economic recession and common good. introduction: the effects of economic recession include; inflation, bankruptcies, death, the rise in the price of goods and services, abnormal increases in unemployment, falls in the availability of credit, shrinking output and investment, reduction in the amounts of trade and commerce, as well as volatile relative currency value fluctuations. in addition, the effect of economic recession is intimate partner violence. the intimate partner violence (ipv) is the “behaviors perpetrated by a person’s spouse or romantic partner that include physical violence, sexual violence, or psychological/emotional violence, including behavior designed to control a victim’s movements, interpersonal contacts, and access to financial resources”1. the intimate partner violence (ipv) has led to the reproduction of babies, which one may be able to care. the economic benefits of a policy, legalizing genetic gender determination enable couples to determine their family size and balance the gender of their children. gender determination might be nevertheless justified, if it addresses adequately the negative side effects of gender imbalance in society-the gender crisis. we maintain that it is morally justified to choose the gender of one’s offspring with the end of mitigating the harmful effects of an economic recession. bangladesh journal of bioethics 2019; 10 (3): 1-4 2 however, the blame for a recession generally falls on the federal leadership of a country2.governments do not manage the economic recession, through the approach of genetic gender determination. while some argue that genetic gender determination discourages reproductive autonomy but it discourages unplanned family hood. recessions can alter family life by constraining the choices that individuals and couples make concerning their family lives and by activating the family’s role as an emergency support system 3. genetic gender determination could lead to the manipulation of human genome for patriarchal reasons. men centric society portrays memorable inconsistent force relations between woman and men.4. gender determination is ‘to pick a male child, which in turn perpetuates gender preference5. the objection to genetic gender determination is the irrational of a sexist society. in a men centric society, productivity and performance of men is assumed generally to be highly rated, to women6. while we support the permissibly of gender selection, men-centric society is unethical, it repudiates human dignity and such a policy might be discriminatory against women. there are many solutions linked to problem of economic recession, increase bilateral relationship, devaluation of currency, consumption of homegrown food and many others. in this paper, we are concerned with the ethical implication of genetic gender determination for economic recession. first, let us discuss the background of gender determination. background: the instinct to determine the gender of an offspring is as old as man is. in ancient greece, it’s believed that if a man had sex with a woman, raising the right side of his legs, a boy will be conceived. in the eighteenth-century, it is also mythical that if a man ties off his left testicle while having sex with a woman, the woman will conceive a boy7. christina et al. presented mythical views on gender determination; (a) preceding ovulation with an intercourse (b). a water and heating soft drink before intercourse (c) 2 tablespoons of soft drink (d) profound entrance of male at the hour of climax8. a female child will be born if the following steps should be taken [a] intercourse should stop 2 to 3 days before ovulation. (b)intercourse before corrosive vaginal douche (c) 2 tablespoons of white vinegar per quart of water (d) no female climax. (d) shallow entrances by the male at the hour of discharge (e) no restraint until definite intercourse 2 to 3 days before ovulation4. timing of sexual intercourse is referred as shettle’s method of gender determination. the calculation of women (ovulation) before sex helps to determine the gender of an offspring5. gender of an offspring is dogged by strong and weak sperm cells. "strong" sperm cell fertilizes an egg, the result is a male child and when "weak" cell sperm cell fertilizes an egg, the offshoot is a female child 5. the question is, how can we know the empirical distinctions between weak or strong sperm cells? we contend that the claims of the ancient philosophers on gender determination are myths and probabilities. sperm sorting: sperm sorting is a genetic method of gender determination. sperm bangladesh journal of bioethics 2019; 10 (3): 1-4 3 sorting is the separation of x or y-sperm cells. the sorted sperm cell artificially inseminated into a woman uterus for the desired gender9. in spite of the fact that hundreds of healthy children have been born using sperm sorting, it is raises ethical issues, manipulation of human genome, long-term safety against infectious and communicable diseases. pre-implantation diagnosis (pgd): "in vitro" is a latin word for "within the glass"5. pre-implantation diagnosis (pgd) involves in vitro fertilization of an egg to determine the gender of a baby. the mother's eggs and father's sperm are collected for fertilization in the laboratory. after three days of development, the fertilized eggs are examined for clinical re-implantation into the mother's uterus 10. the pre-implantation diagnosis is almost 100% effective, but the procedure seems invasive, expensive, and controversial11. "in some of the fertility canters in nigeria, pgd is in place and can be assessed, but we advise our patients that it is done in patients with a high index of the possibility of a sex-linked disorder" 9-12. suppose the significant risk of gender determination will result a child with a disease or disability13. the objection to gender determination we assume that the risk is significantly greater than the risk in normal pregnancy ethical issues: genetic gender determination could lead to "gender eugenics” and the spread of virulent disease, which could lead to a tragedy of civilization14. it is an attempt to create a child as a means to an end. while we acknowledged the above assertion, now there is no evidence of the spread of virulent disease or design babies with human characteristics due to genetic gender determination. critics would say that gender determination is akin to "playing god." it is unnatural for a human being to interfere with the natural process of reproduction. we contend that if nature had balanced the genders in a family hood, humankind wouldn’t strive for a balance. the human distortions of nature is the human desires for satisfaction and picking a balance for survival15. gender determination is an ethical response to avert x-linked genetic diseases among children. “sex detection of fetus before delivery in the first trimester of pregnancy will prevent babies with abnormalities being born”16. however, the above assertion negates disability right but we maintain that it is morally right to adhere to the best consequence, for the common good of the society. conclusion: a thorough examination of the pros and cons of gender determination, one would say that gender determination be approved to mitigate the effects of the economic recession. however, if it is approved by governments, it does not mean it cannot be regulated to avoid unethical practice among researchers, manipulating of the genome, gender preference or sex discrimination are obnoxious practices that must be regulated by law. references: 1. .lisa m, sara h. the great recession, families, and the safety net. industrial bangladesh journal of bioethics 2019; 10 (3): 1-4 4 relations: a journal of economy and societ.y. december 19, 2018 available https://irle.berkeley.edu/the-greatrecession-families-and-the-safety-net/ (14 september 2019). 2. what is economic recession? definition, causes & effects. https://study.com/academy/lesson/what-iseconomic-recession-definition-causeseffects.html (14 september 2019). 3. andrew c, erin c, philip m. the effects of the great recession on family structure and fertility. the annals of the america academy of political and social science. september 25, 2013. https://doi.org/10.1177/0002716213500643 4. ademiluka s. patriarchy and women abuse. ote 2018; 2(31):339-362 5. osebor i. decriminalizing social sex selection is a negation of the sociological jurisprudence. research & reviews: research journal of biology, 2018; 6(2): 1-5. http://www.rroij.com/openaccess/decriminalizing-social-sex-selection-is-anegation-of-thesociologicaljurisprudence.php?aid=87131 (14 september 2019). 6. julian s. making better babies: pro and con. centre for human bioethics2013; 1-3. https://researchmgt.monash.edu/ws/portalfiles/po rtal/252673815/2317892 (14 september 2019). 7. the president's council on bioethics: working paper 3a. 2012;1-9. https://bioethicsarchive.georgetown.edu/pcbe/ba ckground/sex_selection.html (14 september 2019). 8. christina r., veit, m. and raphael j. gender preselection: facts and myths the american fertility society 1999; 49 (6):2-4. available from https://www.fertstert.org/article/s00150282(16)59940-3/pdf (14 september 2019). 9. q & a on sex gender selection 2018. available from https://louismedhospital.com.ng/q-a-onsex-gender-selection/ (14 september 2019). 10. richard e. and kristin h. gamete transport and fertilization, in human reproductive biology. 2014; 1-6. available from https://www.sciencedirect.com/topics/agricultura l-and-biological-sciences/sperm-sorting (14 september 2019). 11. sparrow r, gender eugenics? the ethics of pgd for intersex conditions. american journal of bioethics. 2013, 13(10):29-38. doi: 10.1080/15265161.2013.828115. 12. world health organization family planning/contraception. 2018; 1-3. https://www.who.int/news-room/fact(14 september 2019) 13. michael l. sperm sorting method could prevent girls being born. 2019;1-5. https://www.newscientist.com/article/2213377sperm-sorting-method-could-prevent-girls-beingborn-scientists-warn/ (14 september 2019). 14. michelle l. and richard r. justice in the context of family balancing. science technol human values, 2013; 1(2): 38. https://doi.org/10.1177/0162243912469412 15. matthew l. reproduction the ethics of using genetic engineering for sex selection. journal of medical ethics, 2003 (3)30: 465–71. http:.//dx.doi.org/10.1136/jme. 16. amir ar, mohammad h s, ghasem a, and jalal i m.prenatal sex determination in suspicious cases of x-linked recessive diseases by the amelogenin gene iran j basic med sci. 2014 feb; 17(2): 134–137 author contribution: the 1st author osebor ikechukwu monday conceived the idea, did the literature review and wrote the manuscript. the 2nd author stephen cc chukwuma checked and edited the manuscript meticulously. conflict of interest: no conflict of interest microsoft word editorial medical ethics 1 bangladesh journal of bioethics 2021; 12 (1) 1 editorial vol 12 no 1 (medical ethics) with its origin in the hippocrates oath (5th-3rd century bc), the nuremberg codes (1947), and the declaration of helsinki (1964), medical ethics set the rules of the professional conducts for the physicians and other medical specialists. it amounts to the deployment of bioethical concepts, values (autonomy, non-maleficence, beneficence, and justice) and methods within medical set up to suggest the day-to-day decision-making procedures by combining theory and practice. it is a multidisciplinary study as it seeks to develop a set of guidelines for moral decision-making utilizing the resources of not only medicine and biology, but also of law, philosophy, theology, and the social sciences. as the branch of bioethics, it investigates the complex ethical problems which arise for human life and society from sophisticated medical-technological usages and biological practices. the problems specifically include the nature and distribution of treatment and medical resources, the informed consent and authority of the patient, the physician and others involved in the medical practices, the scope and limits of confidentiality, the limits of acceptable intervention and experimentation, and the propriety of research involving humans and their applications. it also deals with the questions of moral dimensions and professional responsibilities involving all forms of ‘life-related’ issues such as research involving foetal tissues, withdrawal of life-sustaining medical treatment, issues over death, prenatal diagnosis and abortion, the storage of frozen embryos. medical ethics is intricately linked to the culture and glocal values. to emphasise such aspect, the following papers come together to enrich this volume. the first paper entitled religious, cultural and legal barriers to organ donation: the case of bangladesh by farid, m., & naim mou, t draws the attention of the readers to the fact that although organ donation can save a great many lives, there is a differential view points of the bangladeshi muslim clerics against organ donation. combined with other cultural and legal issues including the bangladesh organ donation act (1999, amended in 2018), these differential viewpoints cause major obstacles and reduce the donor pool in the country. the second paper on the case of doctor-patient relationship in bangladesh: an application of relational model of autonomy by ahmed, t. (2021) proposes that relational model of autonomy better suits the doctor-patient relationship in the context of bangladesh. highlighting the potential obstacles for the implementation of such model, the paper reasoned that once the obstacles are worked upon, the relational model has greater scope to work better since it considers keeping “care” as the focal point of the service. the third paper on understanding of authorship by the post graduate medical students at a center in bangladesh by lasker, s., begum, m., hossain, a., matin, m. a., islam, s., & macer, d. (2021) studies the understanding of the knowledge, skills and attitude of post graduate medical students on authorship. it highlights a general lack of understanding of the basic concept of authorship ethics among the targeted group. the paper also indicates that the education on authorship of research papers helps in improving the awareness of such concept. the fourth paper on ethical issues in biomedical research in nigeria: a systematic review by ikeagwulonu, c., uneke, c., & uchejeso, o. (2021) assesses the various ethical issues that have bangladesh journal of bioethics 2021; 12 (1) 2 been associated with biomedical research in nigeria. the paper identifies that the most common ethical issue that has been widely investigated is the issue of informed consent. the paper also identifies that varying degree of understanding of rights of research subjects exist in the population. as a result, the paper suggests to enhance the capacity of investigators to better understand these issues and also increase their explanatory skill to help participants achieve complete understanding of the rights and various process of the biomedical research in nigeria. this volume of the journal has also received two short commentaries which added value to the journal through their unique views. the first commentary on covid-19 pandemic: ethical and medical issues arising for people with disability in bangladesh by uddin, t., mohammad, h. t., & siddiquee, n. (2021) emphasises that disability rights need to be considered in the inclusive pandemic preparedness and responses. the commentary opines that such comprehensive and ethical pandemic preparedness is essential especially in the developing countries where doctorpatient ratio varies and the country has access to limited medical resources. else, with enhanced suffering of the particular groups during the pandemic like disaster, the social justice is violated. hence, pandemic preparedness needs to be ethical and inclusive. the second commentary on why a new ethical framework is needed to eliminate disability discrimination? a new learning from the pandemic by ranju, g., & serice, t. (2021) highlights that existing ethical frameworks are unable to address the issues of the fairness and justice especially when the dilemma involves prioritising the rights of the disabled and nondisabled during the pandemic. the commentary recommends the need of new ethics-based research, policy directions, and frameworks to eliminate the discrimination between rights of disable and non-disable people even in hospital admissions during the pandemic. as the guest editor of the issue, i thank all the authors for focusing on the different aspects of medical ethics and selecting the journal, thereby, adding value to the journal through their varied contributions. i convey my heartfelt gratitude to all the reviewers for giving your precious time to review the papers of the issue and also in providing valuable insights and comments for the contributors to strengthen their arguments for the topic. i am also grateful to professor shamima parvin lasker and ms. tahera ahmed for assigning the role to me for the volume. finally, i hope readers the papers in the volume would help our readers to think differently to address the ethical issues arising in the domain of the medical ethics. thank you, dr. rhyddhi chakraborty fhea (programme leader (hnd-health care practice), global banking school, london, uk visiting faculty (philosophy & global health), ausn, usa senior associate member, royal society of medicine, london, uk) guest editor, bangladesh journal of bioethics, vol.12, no. 1 references chakraborty, rhyddhi. ethics in pandemic influenza preparedness plan: a perspective from social justice uri: http://www.idr.iitkgp.ac.in/xmlui/handle/123456789/5051 date: 2014-12 microsoft word relavence of deep ecological principal bangladesh journal of bioethics 2020; 11 (2): 42-48 42 the relevance of deep ecological principles in aquatic crisis: a philosophical analysis osebor ikechukwu monday lecturer. department of arts and humanities delta state polytechnic ogwashi-uku pmb 1030, nigeria email osebormonday1@gmail.com or osebordarry@yahoo.com orcid number: https://orcid.org/0000-0002-2642-662x doi: https://doi.org/10.3329/bioethics.v11i2.50392 abstract: ethics is a branch of philosophy that analyzes right or wrong of an action. ethics studies all aspect of human activities; which water pollution is one. water pollution is the emission of waste or chemicals into water bodies at a quantity that is harmful to man and the aquatic organisms. the effects of water pollution include mass extinction species, decrease in the biodiversity, and scarcity of fresh water. the question to ask is “how can water pollution be ameliorated if not totally eradicated?” using the method of philosophical analysis, the paper suggests that the implementation of deep ecological principles by policy makers would be abatements and environmental consciousness for the common good of the society. keywords: aquatic crisis, relational ethics, "i and thou", vital needs, anthropocentricism, aquaculture, biocentric equality, selfrealization and ukama philosophy introduction: aquatic crisis is one of the environmental challenges facing humanity. in the last decades, human habits have been conditioning the normal functioning of life on the planet1. mother earth is in great perils. human activities and the demand for resources have created enormous pressure and stress on the sustainability of earth. resource depletion and environmental devastation have plagued the world in the last several decades, creating havoc to the environment and the life of species inhabiting it, which includes the human2. aquaculture is the rearing of aquatic animals and the cultivation of aquatic plants for food3. aquaculture covers the farming of both animals (including crustaceans, finfish and mollusks) and plants (including seaweeds and freshwater macrophytes)4-5. with the improvement of science and technology, the traditional method of fishing has changed to aqua-mechanization. aquamechanization is concerned with the use of sophisticated farming techniques6. bottom trawling is a method of fish harvesting. it is aimed at creating wealth for farmers. the implication of commercial fish harvesting, nature is conceived as a means to an end. we maintain that aqua-mechanization has played important role in the aquatic crisis. the industrial sector had produced jobs, profits, expanded the quality of life, but it equally alienated human beings from nature7. bangladesh journal of bioethics 2020; 11 (2): 42-48 43 however, aquaculture accounts for over 50% of the world food market for protein, fish products and it provides income for farmers but alienated man from the environment. environmental problems have developed chiefly because of man's rapaciousness. the belief that natural resources are inexhaustible characterized the early development of this nation, a period replete with examples of extravagant waste of forests, land, minerals, water, and wildlife. human behavior in this decade contributes litter, pollution, improper use and depletion of resources, and a continuing destruction of natural balances and cycles essential to life8. a reflection the negative relationship between human and nature, there is need for an ontological shift, from the anthropocentric perception of nature to what nature is; the (essence)9. the ontological shift would lead humankind to reconsider environmental and agricultural ethics. in light of the aquatic crisis, strong anthropological views of nature would give birth to ethical thinking and judicious use of environment and its resources. cyanide fish harvesting is a negative attitude of the aquatic farmers9.this approach is typically used in the aquariums. it involves the application of sodium cyanide into a fish habitat. the cyanide-fishing technique does not just kill the desired fish. it kills other aquatic organisms such as coral reefs. apart from the killing of the non-desired organisms, cyanide-fishing harvesting pollutes the non-targeted habitat, which causes the aquatic crisis. dayanthi nugegoda and golam kibria argue that disruption of fish thyroid function by environmental stressors has the potential to result in deleterious effects including the inhibition of sperm production, reduction in egg production, gonad development, ovarian growth, swimming activity, fertilization and increase in larval mortality10. the aquatic stressors could lead to the extinction of humanity. a critical question is, how can an intelligent species such as human, seek to harvest a few species of fish, using a method that contaminated the entire environment? we contend that human hurtful relationship with the environment forwarded a pessimistic view and a blind symbiotic history of interactions. this is alarming! it is a distortion of the food chain. the unsystematic application of chemicals, pesticides, wild fish harvesting, and the use of explosives in a habitat affects the access to fresh water and its resources. human assaults upon the environment would lead to a possible destruction of the biotic and abiotic communities11. now, the human race is challenged than before, to exhibit our mastery, not over nature but ourselves. the fight to preserve the environment must continue and this is the focus of the deep ecological principles. carson did not oppose the use of chemicals for the exploration of nature, but the acceptable methods should be used to avoid the environmental crisis: "i contend that we have put poisonous and biologically potent chemicals indiscriminately into the hands of persons largely or wholly ignorant of their potentials for harm11. we have allowed these chemicals used, with little or no advance investigation of their effects on the soil, water, wildlife, and the man himself, future generations are not possible to condone our lack of prudent concern for the integrity of the natural world that supports all life"11. we maintain that environment education that focuses on deep bangladesh journal of bioethics 2020; 11 (2): 42-48 44 ecological principles would be a panacea to the aquatic crisis. anthropocentrism: anthropocentrism is an idea that most environmental philosophy is opposed. etymologically, anthropocentrism is a derivative of two greek word" ανθρωπoς (anthropos, or human being) and κ́εντρoν (kentron, or centre)2. anthropocentrism is the human-centred philosophy in the hierarchy of beings2. the biblical assertion; the earth is there for humans to gain dominion over. genesis (126) god said, “let us make man in our image, after our likeness. and let them have dominion over the fish of the sea and over the birds of the heavens and over the livestock and over all the earth and over every creeping thing that creeps on the earth”12. this view of course, would be the foundation of strong anthropocentrism. ikeke cites van tassel that humans are much higher and above nonhumans species13. humankind exercises dominion over nature, and nature is there to serve human needs14. we maintain that environmental ethics shares a dislike to humancentered philosophy lynn white further asserts that christianity is the most anthropocentric religion the world had seen. christianity is absolute contrast to ancient paganism. it establishes dualism between man and nature. for christianity, god's will, for man to exploit nature for his proper ends14. lynn white holds that the christian dogma of creation, which is found in the first clause of all the creeds, has another meaning for our comprehension of today's ecologic crisis. by revelation, god had given man the bible, the book of scripture. but since god had made nature, nature also must reveal the divine mentality14. the dualistic mindset is a hindrance to the flourishing of organisms in an environment. the danger of the dualistic mindset is that it separates human beings from the earth13. in our opinion, the notion of dominion over non-humans is an ecological misrepresentation. how can man take dominion over creation and rule over them? this assertion is could be misrepresented because the aquatic crisis is not solely explicating the teachings of dominion over nature. there are some christian teachings such as the mystical and sacramental universe. the mystical and sacramental universe affirms that all beings have an intrinsic value, and they are participating in divine beauty; each being is a "cosmic christ." today many christian bodies are unable to apply this teaching for environmental protection and preservation13. is deep ecological principles a panacea to the aquatic crisis? in april 1984, george sessions and arne næss developed the principles of deep ecology15. deep ecological principles entail that humans recognizes the intrinsic worth of all life forms, and the right of non-humans to flourish in an environment. deep ecological principles are moral obligation for humankind, to preserve and care for the nonhuman world. in addition, deep ecological principles are rooted in naturalistic ethics, concerned with respect and duties of humankind towards others. deep ecological principles are normative ethics aimed at cleaning up the aquatic crisis for sustainable development. the peace and survival of humanity, is halt, by the degradation of the environment. the bangladesh journal of bioethics 2020; 11 (2): 42-48 45 security of life and property, cannot be achieved by mounting weapons (the popular concept of “defense” in a narrow sense), but through the recognition of the positive aquatic relativity. humankind should provide the basic conditions for solving non-military problems, which threatens humanity. the survival of humanity does not only depend on the military balance, but global environmental cooperation for sustainable environment. the teaching and implementation of deep ecological principles, such as the richness and diversity of all life forms, environmental self realization, biocentric equality, environmental relatedness (ukama philosophy), and the exploration of nature only for vital needs would boast the learning of environment ethics to saving humanity from ecological disaster. there are many deep ecological principles; in this paper will we discuss selected ecological principles that would be relevant to this study. self-realization: the philosophical aphorism man ‘knows thyself 'is attributed to socrates. the concept of ‘man knows thyself implies self-development, selfunderstanding, self-examination, selfinterpretation16. the inner message of the ‘self acknowledgement, is the realization of the self, as a part of a whole. i am because of nature, is the likelihood that human existence is impossible without a symbiotic relationship with others. selfrealization is not self-sufficiency, but the preservation of others for posterity sake16. self-realization is not the ‘ego' of wide fish harvesting, but a diminishing ego, and a gradual reduction in the hedonistic attitude of humans towards nature17. the self-realization is not selfcenteredness, but inextricably linked to, as well as the individual dissolved into the greater self. self-realization is a metaphysical condition, which nobody can ever reach because of its ontological nature. nevertheless, it is the richness and diversity of life forms, which is value and values in themselves15. luca maintain that self-realization is the identification of the ecological self and the asymmetrical relationship between human beings and nature. the ecological selfexpounds the ontological processes of human relationship with the cosmos17. the ecological self would help to reshapes the environmental ethics, starting with environmental ontology, and the recalling of the primacy of human relationship with nature. from an ecological standpoint, selfrealization is the complexity and symbiotic conditions for the maximizing of ecological diversity15. the above assertions are ringing affirmations that no ontological divides between humans and nature7. there is ultimately only one substance; reality is a unity, which we may call god or nature, we are aware that we are united to the whole, alienation drops when we identify that we are parts of a whole18. biocentric equality: 'biocentric equality is one among the principles of deep ecology. it affirms that all beings have equal intrinsic value. there is no ontological part separating human beings and nature15. here, human beings have no greater worth, than any other creature. human being has no rights more than plants or animals. richness and diversity bangladesh journal of bioethics 2020; 11 (2): 42-48 46 of life forms contribute to the realization of these values in themselves15. this is an affirmation of species egalitarianism. species egalitarianism is characterized by the inherent worth of beings, regardless of their instrumental and utility. humans have no reason to assume that species do not have equal moral standing, all species command equal respect. we argue that respect for nature is not negotiable because we are parts of a whole. george sessions et al mentioned that the flourishing of human life and cultures is compatible with a substantial decrease in the human population15. the flourishing of nonhuman life requires such a decrease. we maintain that human and nature should flourish without moral superiority. the ‘vital need': the concept of vigorous need entails that humans have no right to reduce the richness and diversity of nature, except for the satisfaction of the vital needs. "vital need;" is an ecological principle, which is broad and dense, owing to its vague nature. frances stewart refer vital need as basic needs, thus a basic needs (bn) approach to development is one, which gives priority to meeting the basic needs of all the people. the actual content of bn have been variously defined: they always include the fulfillment of certain standards of nutrition, (food and water), and the universal provision of health and education services. they sometimes also cover other material needs, such as shelter and clothing, and non-material needs such as employment, participation and political liberty19. the term "vital need" is deliberately vague to allow considerable latitude of judgments 15. the "vital need" is nature inherent in value. the intrinsic worth of all life forms can only be reducible for imperative need. the vital need implies two strands of anthropocentrism-the weak and strong anthropocentrism. weak anthropocentrism is the view that human beings should explore nature only for vital needs. while strong anthropocentrism, on the other hand, believes that human beings explore nature as a means to an end2. a vital need is open to rational interpretations. to some schools of thought, vital need is an imperative need, which is the opposite of "other" needs15. we argue that the meaning ofvital need requires a moral interpretation to determine the difference between vital need and other needs. concept of ukama: from the african perspective, ukama is a traditional value. it is a shona word among the people of zimbabwe. ukama is a philosophy that has strong biocentrism. it is a philosophy, which deconstructs the anthropocentric perception of nature. ukama is concerned about the well-being of the environment, kinship/relatedness and the immortality of soul20. ukama is an environmental ethics. it teaches moral relationship among organisms21. ukama is a inter-relational ethics that encourage co-existence of humanity in the bio-network. the existence of humans is dependent on the established positive relationship with others. otherwise, humankind could face extinction21. "what has become the most frightening reality about our human existence is that the world that is extremely interconnected and the pursuit of self-interest have resulted in a rampant pollution of the environment”20. ukama rejects the superiority of humans in the hierarchy of beings. it calls for crossbangladesh journal of bioethics 2020; 11 (2): 42-48 47 fertilization in the relationship between organisms. the philosophy of crossfertilization, affirms that there is no separation between thou and "i and thou.” this affirms that there is no ontological understanding that human beings not separated with others21. conclusion: in light of the above, we could answer the question "how would the aquatic crisis be ameliorated if not eradicated? this review suggested that the teaching and implementation of the deep ecological principles would help humankind to frame a positive ecological attitude in the exploration of nature for posterity sake. we suggest that deep ecological principle be integrated into school curriculum, so that citizens can be taught environmental consciousness for the common good of the society. references 1. ainara s, naiara r,jon a, loli e, josune a. european journal of sustainable development (2020), 9, 4, 22-32 . doi:10.14207/ejsd.2020.v9n4p22. 2. ravichandran m, and gabriel t a. environmental ethics through value-based education. bangladesh journal of bioethics 2020; 11 (2): 19. https://doi.org/10.3329/bioethics.v11i2.49257. 3. akinbi, j. (2012): the niger delta environmental crisis in nigeria journal of international multidisciplinary, 5(63): 150-164 4. aquaculture (n-d). http://www.fao.org/3/x6941e/x6941e04.htm ([14 august 2019]) 5. stephen, m.(2016) gardiner and allen, t. “introducing contemporary environmental ethics” the oxford handbook of environmental ethics, moral philosophy, social and political philosophy, (2016), p. 1. 6. sustainability for all destructive vs sustainable fishing (n-d) available from https://www.activesustainability.com/environme nt/destructive-vs-sustainable-fishing (14 august 2019). 7. luca, v.(2018) ecological self and selfrealization: understanding asymmetrical relationships through arne næss's ecosophy. journal of agricultural and environmental ethics, 5( 1), p.1-8). available from https://doi.org/10.1007/s10806-018-9715-x([14 august 2019]). 8. environmental crisis.(n-d): “journal of educational leadership” available from http://www.ascd.org/ascd/pdf/journals/ed_lead /el_197012_romine.pdf(14 august 2019) 9. olawande, f. (1998): harmful fishing practices in the coastal belt of nigeria: use of nonselective fishing gears” available at http://www.fao.org/3/a-an681e.pdc (14 sept 2020) 10. dayanthi n. and golam k. (2016): “effects of environmental chemicals on fish thyroid function: implications for fisheries and aquaculture in australia.” general and comparative endocrinology, p. 244. available from 10.1016/j.ygcen.2016.02.021. 11. carson, r. (1962): silent spring: with an introduction by vice president al gore. (new york: houghton mifflin. available from https://www.amazon.com/silent-springintroduction-vice-president/dp/b00600z7o8(14 august 2018). 12. the holy bible. genesis, 1-26. available from https://www.bibleref.com/genesis/1/genesis-126.html (14 august 2018). 13. ikeke, m. (2015): the ecological crisis and the principle of relationality in african philosophy. philosophy study, 5(2): 179-186. available from http://www.doi: 10.17265/21595313/2015.04.001 14. lynn, w. “the historical roots of our ecological crisis”. science, (1967), p. 155: 12031207. available at http://www.cmu.ca/faculty/gmatties/lynnwhitero otsofcrisis.pdf (14 august 2019). 15. naess, a. and sessions, g. “basic principles of deep ecology” (1984). available at https://www.deepecology.org ([14 august 20219). bangladesh journal of bioethics 2020; 11 (2): 42-48 48 16. talukder, h. (2016) for "self-realization." the ultimate norm of arne naess's ecosophy .t. symposium. p.219-235. available from https://philarchive.org/archive/talos.frican. 17. zimmerman, m. (1998): deep ecology, ecoactivism and human evolution. available from https://ogigaya.wordpress.com/think-sangha/tsj3html/zimmerman-htm.(14 august 2019). 18. david, s. (1998): “are all species equal”? journal of applied philosophy. available from http://rintintin.colorado.edu/~vancecd/phil3140/ schmidtz.pdf.( 14 august 2019). 19. frances s. (1985): a basic needs approach to development. in: planning to meet basic needs. palgrave macmillan london p.1-13. available from https://doi.org/10.1007/978-1-349-177318_1. 20. murove, m. “an african commitment to ecological conservation through the concept of ukama and ubuntu. mankind.” quarterly, (2004), p. 40. 21. osebor, i. (2012): african concept of ukama: appraisal (unpublished b.a project, department of philosophy and religious studies delta state university nigeria, abraka. pp.38-49. author contribution: the manuscript is an unpublished phd seminar paper, written by osebor ikechukwu monday, supervised by prof. ikechukwu ogugua. department of philosophy, nnamdi azikiwe university awka, anambra state nigeria. conflict of interest: no conflict of interest. microsoft word right to privacy vs right to know 1 bangladesh journal of bioethics 2020; 11 (3): 1-8 1 a survey on the attitude of college students to the privacy right as opposed to the right to know nader ghotbi, md, phd professor, college and graduate school of asia pacific studies ritsumeikan asia pacific university (apu), beppu city, japan email: nader@apu.ac.jp https://doi.org/10.3329/bioethics.v11i3.50591 abstract: there are times when two essential human rights may appear to be in conflict, or need to be balanced against one another. this paper examines the right of a party, such as officials, a group of people or an individual, to ‘privacy and confidentiality’ when others may have a conflicting ‘right to know’ about them. although similar conflicts have been studied by other researchers, there is still controversy over the rightful balance in situations driven by new information and communication technologies. i conducted a survey on the attitude of college students to the privacy right versus the right to know using an actual case at the university. first, i asked the students if they believed protecting the privacy of a married teacher who had fathered a child with a student was more important than the right of the school to know. second, i asked if they believed a child born to a single mother in such a relationship has the right to know about his father, or the single mother has the right to keep that information confidential. third, i asked the students if they believed in general that the ‘right to privacy and confidentiality’ was more important or the ‘right to know’. this paper reports on the results of this survey on 222 students at an international university in japan. keywords: college students, human rights, right to know, right to privacy, survey research. (some part of this article has been presented at the 20th asian bioethics conference, 22-25 november 2019, dhaka, bangladesh). introduction: in usa, the public ‘right to know’ was first suggested as a specific legal concept by cooper in 1956 who was the director of a news agency at the time1. the right to know in his view meant ensuring that citizens would have access to information essential for protecting democracy. emerson emphasized on the right to know as the basis for acquiring the needed information, and the communication of the information to others so that the freedom of expression would be realized2. john de mott discussed the necessity of citizens’ access to governmental and public information for scrutiny while protecting the privacy of citizens from unwanted exposure3. he also emphasized that there could be situations of conflict between the two in which finding a balance could be a difficult task. however, according to him, the us constitution did not provide assurance for neither of these rights and courts could have their own interpretation, except for one general rule: citizens’ privacy must be protected unless disclosure of information is in the public interest. situations may change; therefore, setting laws may not satisfy the dynamic need to balance the right to privacy against the right to know in every instance. an example is provided by baker who referred to the need bangladesh journal of bioethics 2020; 11 (3): 1-8 2 of the schools to access students’ data to deal with increasing acts of violence in school while a recent law had limited such access to ensure educational data of students would not be misused by third parties4. viano pointed at factors that influenced the activity of media regarding criminal information related to individuals who needed to protect themselves against unwarranted exposure5. viano emphasized on the role of social, cultural, and political forces in moving the balance to one way or the other which underscores the need of the society to develop policy based on a code of ethics. it can be said that the media play a significant role in gauging the public view as well as the legal system’s ruling over an acceptable line between the right to know versus the right to privacy. as harris has noted, hippocrates stressed on the physicians’ responsibility over the confidentiality of their patients’ medical issues in the 4-5th century b.c6. that is why the hippocratic oath includes a statement on the privacy of patients’ medical information. without this sort of medical privacy, it is hard to create the needed trust in patients to provide the physician with all private information needed to make a diagnosis. however, the modern systems for management of medical information are far too complex to be maintained by a physician’s oath; meanwhile, these systems help provide the benefit of integrated access to the information by various healthcare departments. wyld et al. discussed the challenges in the delicate balance of the privacy and confidentiality rights of hiv positive people versus the right to know of other patients and anyone else who might be affected by the risk of exposure to hiv7. pape examined the situation where the public may benefit from access to more information about their doctors’ record of practice, while that might cause a change in the practice of physicians towards defensive medicine and finally leave the patients worse off, with a general decline in healthcare quality8. borna and avila discussed the issue of the need for confidentiality of citizens’ genetic information and its delicate balance, including the right of insurance companies to know about them to manage their risk9. however, access to such information might lead to significantly higher cost of health insurance or its denial from high-risk individuals because of their genetic makeup. gross discussed the fragility of democracies and the need for continuous vigilance to protect them through the right to know and access to information, though that may conflict with the citizens’ right to privacy in some instances10. the important issue would be finding the right balance to the periled situation of safety and security in countries where terrorism became a real threat after the september 11 terrorist attacks on the us. on the other hand, many countries around the world have used the terrorism threat as an excuse to downplay the citizens’ right to privacy and confidentiality over their personal information and in some cases even legal entities have infringed on the rights of citizens. such examples demonstrate the challenges facing ethical philosophers in balancing the right to privacy versus the right bangladesh journal of bioethics 2020; 11 (3): 1-8 3 to know in a dynamic, modern and technologically driven world where information plays an important role in every aspect of the life of citizens. deloney pointed to the result of studies that showed most adopted children as well as their birth parents wanted to have access to birth records while many us states limited such access to protect the privacy rights envisioned by law11. banisar has suggested that the right to privacy and the right to know may together help hold governments accountable to citizens, but the potential conflict between them may lead to controversial situations where mechanisms are needed to reduce conflict and balance the rights12. symons discussed the 2016 change in australian law whereby donor-conceived children were given the right to access information of anonymous donors, including their name, date of birth, ethnicity, physical characteristics and genetic conditions, even if the donor had requested anonymity13. apparently, the right to know won over the right to privacy in this case. but there are other cases arising in both the healthcare sector as well as social policy, information security and governance14. some laws may already exist to help clarify the rightful balance in situations where a conflict arises between the right to privacy versus the right to know, such as leaning on the right of the community ‘to know’ about a sex offender having a criminal history who takes residence in a neighborhood15. however, the law may not specify what should be done in countless other examples. for instance, researchers in pakistan examined whether a nurse should notify others to sexual abuse of a housewife by her husband when the hospital and local tradition insisted on keeping silent about it to presumably protect the privacy of the married couple16. this example demonstrates the role of culture and cultural differences in determining the right balance, and other complex issues which need to be considered before arriving at an ethical decision. research method: a survey was electronically distributed among 229 college students enrolled in the course of bioethics in 2018. they were asked to examine an actual case and answer three essay questions that followed the description of the case study. the survey was designed to require responders to reflect on the case and use arguments in order to support their answer, rather than immediately choosing from among 4 or 5 possible choices. the essay format was an attempt to receive well thought responses rather than reflex answers. the description of the case was as follows: “assume you are a university professor. a female student from a different school has contacted you to report that your colleague, a married man with a child, has deceived her into an affair and then left her with nothing after getting her pregnant. she is now a single mother with little income to support her child and, at the same time, to keep studying at the university until graduation while she cannot ask her family to support her because in her culture (as a kazakh) it is shameful to have a child without a father. she is heart-broken and resource-less.” question 1: with enough proof that she is bangladesh journal of bioethics 2020; 11 (3): 1-8 4 telling the truth, is the right of the teacher to privacy and confidentiality more important, or the right of the school to know? explain your choice. with a little investigation, you realize the same story happened to a japanese lecturer by the same man. she is also a single mother now working in another school in tokyo but is upset that she was deceived into an affair with a married man teaching at your university. both women have chosen not to reveal the identity of the father to their child because they don’t want their children to have any relation with an evil man, as they say, in the future. question 2: do you think the children have a right to know who their father is, or the mothers have the right to keep this matter as a private issue and keep it confidential? explain your choice. question 3: with this case as an example among tens of other examples, how would you discuss the right to know versus the right to privacy and confidentiality? which one is more important and why? the use of an actual case study helped motivate the students to discuss it seriously and work on arguments that would support their view on the matter. by providing two different perspectives, the privacy right of the teacher (toward the school) and the privacy right of the mothers (toward their children) against the right of the school and the children to know, respectively, the survey enabled the students to consider the conflict from many angles. finally, they would suggest which right seemed more fundamental to them in general. findings and discussion: out of 229 students, 222 (%97) responded to the survey questions. the results of the survey have been summarized in table 1. as seen in table 1, the majority of students believed that the school’s right to know dominated the right of the teacher to his privacy; 148 students (%66) considered the right of the school to know more important. their arguments included the potential of harm to other students including a similar risk to female students, the responsibility of the school to provide a safe environment and to protect students from possible abuse, the social responsibility of teachers to demonstrate higher standards of moral behavior considering the special merits of a professor’s position in a university, and the use of deceptive behavior that could have legal ramifications. however, 64 students (29%) considered the right of the teacher to his privacy more important. their arguments included the fact that the student was an adult and thus responsible for her own actions, the matter had not happened on the campus and was thus a personal matter, and that law had not envisioned similar cases of deception as illegal, even though they may not be ethical behavior. there were 10 (%4) students who wanted both the school to know and the privacy of the female student to be protected. five students (%2) believed that the right to privacy and the right to know as in case of the first question were equally important, and thus suggested using a third approach where mediation could be used to reach a satisfactory compromise solution for both the teacher and the single mother, including teacher’s financial support for the bangladesh journal of bioethics 2020; 11 (3): 1-8 5 child. the responses of 5 students were not clear and were thus disregarded. as for the second question regarding the right of the mothers to keep the identity of the father hidden versus the right of the children to know the identity of the father, 144 students (%65) in total believed that children had the right to know their father. their arguments included the inalienable right of every individual to know both their parents, the emotional strain on a fatherless child, and the potential of keeping good relations between a father and his children in the future. among this group of students, 28 (%13) students believed that children should know their father but only later when they reached a level of maturity that enables them to understand the complicated situation. however, 59 students (%26) believed the mothers’ right to privacy dominated the children’s right to know their biological father. their arguments included protecting the mother from more emotional burden and stress, the futility of a father who would not financially support his biological children, and possible further risks to both the mothers and children. sixteen (%7) students considered both rights to be equally important and thus recommended the use of counselling for the mothers (and also children) to help them make a decision. three students did not provide a clear response to this question. as for the third question over the choice of the right to privacy and confidentiality versus the right to know, in general, an overwhelming number of students (125 students, %56) responded that both rights were important and the decision in each case needs to be reached after careful consideration of circumstances especially the possible consequences, the parties involved, and the nature of conflict. for example, many students referred to the right of privacy over the use of the internet by people versus the right of the governments to search for terrorism suspects, and the right of people to know about corrupt officials and businesses free of governmental interference. having stated their concerns, 34 students (%15) believed that in general the right of individuals to privacy would be a more important issue, and 50 students (%22) believed that the right to know would provide more benefits and would thus be more important than the right to privacy. thirteen students (%6) provided no clear response to the third question, which might be related to the difficulty they had in choosing a side; however, their answers were too vague and were thus disregarded. a question in this research was whether students would be able to discuss and argue over the complexity of balancing the right to privacy against the right to know. i hypothesized that the extremely common use of social media platforms such as facebook among college students would enable them to be familiar with the privacy versus publicity issues over the internet. the rich arguments and debates submitted by the wide majority of students confirms this point. in the case of facebook, as an example, when a user determines the level of privacy of his/her own page, and every time he/she decides to confirm or reject a friend request for access to his/her page, and so on and so forth, there bangladesh journal of bioethics 2020; 11 (3): 1-8 6 is a need to balance privacy against the will to publicize one’s personal information, sociopolitical views, interests and friendships. the majority of college students in this survey demonstrated their familiarity and recognition of the significance of a balance between the right to privacy and the right to table 1: results of a survey on 222 college students over the right to privacy and confidentiality vs. the right to know q1: teacher’s right to privacy and confidentiality vs. school’s right to know about teacher’s actions 64 (%29) students support teacher’s right to privacy 138 (%62) students support school’s right to know 10 (%4) students also want extra care for victim’s privacy in total 148 (%66) students want the school to know 5 (%2) students consider both rights equally important and suggest mediation instead (5 students provide no clear answer) q2: mothers’ right to privacy and confidentiality vs. children’s right to know their father 59 (%26) students support mothers’ right to privacy 116 (%52) students support children’s right to know their father 28 (%13) students recommend waiting for child maturity in total 144 (%65) students want the children to ultimately know their father 16 (%7) students consider both rights equally important and suggest counseling instead (3 students provide no clear answer) q3: right to privacy and confidentiality in general vs. right to know in general 34 (%15) students see right to privacy as more important 50 (%22) students see the right to know as more important 125 (%56) students consider both rights equally important and suggest case by case decisions (13 students provide no clear answer) bangladesh journal of bioethics 2020; 11 (3): 1-9 7 know. however, no student referred to another approach for achieving such balance, which is in fact a basic discussion when the general topic of rights versus responsibilities is debated. let me elaborate; one may try to balance the right to privacy against the responsibility one has regarding transparency. it is not only the government, which should be transparent about its policies and financial transactions. for example, any individual who engages in starting intimate relations with another individual should be transparent about his/her marital status and step by step over other aspects of his/her life in an intimate relationship. moreover, one may try to balance the right to know (by publicizing information) against the responsibility to respect other individuals and their autonomy to live as they choose. following on this approach may help us avoid the conflict between the two rights, while maintaining a healthy balance in the execution of these rights regarding the responsibility that comes with them. conclusion: this survey demonstrated the ability of college students to engage in serious discussions over complex and controversial situations where the right to privacy and the right to know are in conflict. the majority of students (%65) stated that both the right to privacy and the right to know are important, and a balanced decision would depend on the specific situation in each case and the possible consequences that may be envisioned. interestingly, the students had come up with various lines of argument including a reference to the existing laws, social norms, and a consideration of possible consequences to any decision. for example, some students referred to the futility of informing the school system as it would probably just try to cover it up to protect its image which turned out to be true. it is possible that college students are well aware of the many instances that the right to privacy is constrained by the right to know, as they are facing such decisions on an everyday basis using social media platforms such as facebook, instagram, etc. it is important to consider that while the majority of students had picked a side answering to the first and second question, they had realized that it was not possible to make a general ruling on the third question without having the specifics of the case and the situation in hand. as the majority of students have stated, both of these rights are important in a democratic society and when conflicts appear, the specific circumstances and particularly the consequence of a decision need to be carefully examined. the responses also show that the law does not provide an answer in many instances and therefore, there is a need for ethical debate and decision-making to resolve conflicts. references: 1. cooper, kent. the right to know: an exposition of the evils of news suppression and propaganda. new york: farrar, strauss and cudahy. 1956. 2. emerson, thomas i. legal foundations of the right to know, wash. u. l. q. 1. 1976 3. de mott, john. the people’s right to know versus right of privacy. speech: talk presented to the fineman discussion group. philadelphia, pa. 1978. bangladesh journal of bioethics 2020; 11 (3): 1-9 8 4-. baker, m. the teacher’s need to know versus the student's right to privacy. journal of law education, 1987; 16(1), 71-92. 5viano, e. c. the news media and crime victims: the right to know versus the right to privacy. in e. c. viano (ed.), critical issues in victimology: international perspectives. (pp. 24-34). new york, ny, us: springer publishing company.1992. 6harris, r. e. the need to know versus the right to know: privacy of patient medical data in an information-based society. suffolk university law review. 1997; 30(4): 1183-1218. 7wyld d. c., cappel s. d., and hallock d. e. the right to know and the right to privacy: hiv testing and health care management. the health care supervisor. 1992; 10(3):56-66. 8pape, j. physician data banks: the public's right to know versus the physician's right to privacy. fordham law review, 1997; 66(3), 975-1028. 9borna, s. and avila, s. genetic information: consumers’ right to privacy versus insurance companies’ right to know a public opinion survey. journal of business ethics. 1999; 19(4): 355-362. 10gross, e. the struggle of democracy against terrorism protection of human rights: the right to privacy versus the national interest the proper balance. cornell international law journal. 2004; 37(1): 27-94. 11deloney, w. unsealing adoption records: the right to privacy versus the right of adult adoptees to find their birthparents. whittier journal of child and family advocacy. 2007; 7(1): 117-144. 12banisar, david. the right to information and privacy: balancing rights and managing conflicts. the world bank. governance working paper series. 2011. 13symons xavier. the right to know versus the right to privacy: donor anonymity and the assisted reproductive treatment amendment act 2016 (vic). the medical journal of australia. 2017; 207(9): 377378. 14-pandiani, john a, banks, steven m. and schacht, lucille m. personal privacy versus public accountability: a technological solution to an ethical dilemma. the journal of behavioral health services research. 1998; 25(4): 456-463. 15crane, a. e. the right to know versus the right to privacy. annual survey of american law. 1986; 3: 645-666. 16hirani, afshin a. a. and rafiq, nasreen. silence in violence: a curse or a goodwill? eubios journal of asian and international bioethics. 2019; 29(3): 109112. author contributions: the author conceived the idea, did the literature review and wrote the manuscript. he also checked the manuscript meticulously. conflict of interests: no conflict of interest in this study to declare. microsoft word taiwan reflections of the ethics on coexisting with disaster 1 bangladesh journal of bioethics 2020; 11 (2): 10-20 10 reflections of the ethics on coexisting with disaster h.w. angela lo 1, vincent shieh 2 , yung-jong shiah 3 2. ed.d., associate professor, school of medicine, kaohsiung medical university, kaohsiung. taiwan. email: loha@kmu.edu.tw 3. ed.d., professor, graduate institution of gender education national kaohsiung normal university kaohsiung, taiwan. email: vshieh@nknu.edu.tw 3. phd, professor, graduate institute of counseling, psychology and rehabilitation counseling, national kaohsiung normal university, kaohsiung, taiwan. email: shiah@nknu.edu.tw doi: https://doi.org/10.3329/bioethics.v11i2.49259 abstract: with the increasing number of human disasters in recent years, disaster service workers are faced with an ever-growing challenge of criticism concerning their professional competence. the workers also realize the limitation inherent in their practice, as well as bioethics problems regarding autonomy and heteronomy. therefore, professionals and researchers of human service devote to the issue of post-disaster rehabilitation of the people so as to identify an effective way and practice to aid the post-disaster individual, family and community. this study explores the effectiveness of rehabilitative function of disaster service workers through the action research of typhoon morakot and the 2014 gas explosion in kaohsiung city, taiwan. the case studies serve as a platform for the discussion of principles of bioethics and the analysis of the process of self-discipline of the workers of human services in hope of ultimately establishing bioethical principles for heteronomy during disasters and work indicators for post-disaster community restoration. discuss issues are 1. how can selfdiscipline in bioethics be achieved for the human service workers during times of disaster? 2. in post-disaster reconstruction, how does the human service worker take into account bioethical principles to serve and partake in the restoration of the postdisaster life of community residents? 3.during the process of a disaster research, what are the bioethical considerations to be taken into for the test subjects? conclusion and suggestions are to formulate indicators for a post-disaster “community of health and wellness;” to establish bioethical principles of heteronomy for disaster service workers. key words: disaster, reconstruction, human services, bio-ethics, selfdiscipline, heteronomy definitions: 1. autonomous ethics: national education institute (2012) the term “autonomy” means self-discipline in greek1. the concept of autonomous ethics originated in the seventeenth and eighteenth century by british scholars. they hypothesized the existence of a special sense of morality that is independent of one’s social experience and material needs. immanuel kant very specifically described autonomous ethics as the derivation of principles from intrinsic ethics, which emphasizes the individuality and inherent value of such ethics. kant believes that only by respecting the categorical imperative of morality can one be truly ethical and free from extrinsic moral motivations, such as selfishness, pursuit of joy, and social status. bangladesh journal of bioethics 2020; 11 (2): 10-20 11 from a marxist standpoint, the dilemma between autonomous ethics and heteronomous ethics is superficial. the origin of ethics is beyond its limits and in this sense, ethics is both heteronomous and autonomous, has its own peculiarity and logical development, all of which cannot be inferred from objective economic factors1. 2. heteronomous ethics: “heteronomous ethics” means the discipline of others. it is achieved by establishing morality on others, such as hedonism, eudemonism, and utilitarianism. the concept of autonomous ethics is opposite of heteronomy. heteronomous ethics then refer to the derivation of moral principles that are never dependent on the extrinsic factors of free will (such as god’s will, social norms, and instinctual feelings)2. 3. bioethics: the definition of bioethics concerns with the issues that arise from the interrelationship among fields such as biology, medicine, politics, law and sociology. the degree of ethical judgements that biological issues should be subject to is controversial. some experts of bioethics limit the ethical judgement to the ethics involved in medicine, technological innovations, and the medical treatment received by the human body, whereas other scholars extend their ethical judgement to the entire biological entity that is capable of experience a gamut of emotions, such as fear and pain3. 4. the definition of a humanized disaster service: the united states department of health and human services (hhs) determines that the concept of disaster human services lie in providing humanistic service through coordinating and guiding public policy and its services, as well as taking preventive measures in preparation for disasters and sudden public health events 4. background: disasters are capable of inflicting destruction on a massive scale, causing much damage and casualty, occupying much of the local resources, and often times requiring additional aid and manpower in reconstruction. such process can lead to challenges faced by disaster service workers on a bioethical level. the bioethical principles and beliefs of disaster service workers revolve around promoting the wellbeing of mankind and the health of communities and the environment, making right decisions in human aid and minimizing potential hazards. nevertheless, in times of disasters, many ethical dilemmas may arise and thus, more effort is needed to achieve an optimal balance between individual and collective rights. there are different types of workers (professional and non-professional, go and ngo) that devote to different stages of disaster service (such as emergency rescue, post-disaster settlement, post-disaster reconstruction). the interaction between workers and disaster victims can be complex and diversified. decisions are frequently made based on the limited resources that are available and potential problems may often develop. this article serves to explore the bioethical principles behind the effectiveness of disaster service workers in restoring community function based on the action study of the typhoon morakot disaster and bangladesh journal of bioethics 2020; 11 (2): 10-20 12 the 2014 gas explosion in kaohsiung, taiwan in hope of inspecting some of the bioethical quandaries inherent in postdisaster community reconstruction. when it comes to disaster service workers and disaster victims, in addition to the objective and subjective discrepancies in their bioethical values, differences also exist in the time, location, and degree of the disaster itself. therefore, there must not be a universally standardized answer for bioethical questions. pertaining to disaster laws and regulations that govern professional disaster service organizations, the most important steps are to put forth a guideline and restorative plan for medical personnel and disaster service workers, to establish a committee dedicated to community reconstruction, and to train local service workers (through bioethical empowerment). heteronomous autonomy in disaster prevention law should be outlined by the government, especially in crisis management of disaster prevention and preparation, to minimize the damage of disaster on society. research questions and discussion: 1. how can disaster service workers achieve autonomous bioethics in face of disaster? action with autonomous bioethics has always been a focus in the training of disaster service workers. therefore, as mark s. putnam (2006) had mentioned, if the worker can have a firm grasp of the abstract concept of work life of autonomous ethics, the resultant disaster restoration work that follows can become more ethical 5. as outlined by mark s. putnam (2oo6), the authors of this article shall explore the ten principles of autonomous ethics through a case study in hope of shedding light on how a service worker can act in line with autonomous ethics in times of disaster5: 1.) respect for human life: one’s attitude and action in autonomous bioethics shall determine one’s work effectiveness. autonomy can make one fulfill one’s wishes and make the right choice. autonomous ethics can only be realized through a sincere desire to help others with a victim-centered mindset. 2.) learning bioethics: educating oneself in the principles of bioethics to prevent making ignorant mistakes. learning the highest moral standards of bioethics may be more important than learning the law and regulations, policies, and standard operating procedures. however not knowing what the rules are will never allow one to make the right bioethical decisions. 3.) sharing of responsibilities. service workers of post-disaster reconstruction must be willing to shoulder responsibilities and accept setbacks without casting blame on others. the covering up of mistakes can only worsen and even result in a personal ethical crisis. 4.) taking action: autonomous ethics is a part of the self-discipline required of postdisaster service workers. self-discipline is never an observer’s activity. it requires taking action, overcoming personal obstacles, learning from mistakes and successes, and doing the right things. 5) eradicating destructive habits: there are countless suboptimal individual habits. as service workers, everyone has their own habits and ways of doing things. no matter what one’s style or habit is, a major bangladesh journal of bioethics 2020; 11 (2): 10-20 13 principle is to eradicate all harmful habits from the workplace. 6.) setting and completing goals: a primary goal is to engage victims of the disasterstricken community in collective learning and nothing else if more satisfying and allbeneficial. the service worker must act according to the expectations of the community residents and be courageous enough to stand firm on moral grounds. 7.) clear explanation of service work: postdisaster human service worker must achieve communication and mutual understanding with residents of the local community on community restoration. dependability is a valuable trait at the workplace as it reflects one’s moral honesty. 8.) ignoring peer pressure: peer pressure among disaster victims and service workers is often neglected by the service workers themselves. no matter how seemingly independent or irrelevant, every task in community reconstruction always concerns with individual participation and collective learning to a certain extent. challenges and variability are present, even in the most seemingly fair activities such as resource allocation. one must adhere to one’s bioethical principles. 9.) engage in activities that reinforce selfdiscipline: service workers must understand that other than relieving stress, one must also pick up activities that one enjoy, whether it be sports or playing a musical instrument. a spiritually-healthy service worker can more effectively help and contribute to post-disaster reconstruction. in other words, selfdiscipline can instill energy and eventually empower the local residents. 10.) persistent passion: service workers must realize that bioethical principles are not shallow. all the work must be centered on the victims and humanitarianism must always be present. after all, the most fundamental principles of bioethics shall never change and therefore, post-disaster community restoration can be expected5. 2. in the process of post-disaster reconstruction, how should a “human service worker” consider the principle of bioethics to serve the disastrous community and help inhabitants to join the recuperation of healthy life? in the process of post-disaster reconstruction how should a human service worker consider the principle of bioethics as a primary service for “disastrous victims” in each individual case? intuitive to say, how shall the human services worker in postdisaster reconstruction exercise the principle of bioethics to serve the disastrous community and assist inhabitants in joining the rehabilitation of healthy life, and how to consider and verify the bioethical value and unequivocal principle, as well as its applicable manners6? the conception of bioethical principle is that the human services worker in the process of post-disaster reconstruction shall center on the “damaged community and inhabitant” to proceed with humanistic care, thus, most inhabitants in disastrous district convince and appreciate the human services workers’ contribution towards the post-disaster reconstruction. the said workers shall enact and participate the rehabilitating project of healthy life, the purpose of which is to differentiate from other opponents’ groups and the substitutions for inhabitants in the postbangladesh journal of bioethics 2020; 11 (2): 10-20 14 disaster reconstruction district; the idea to provide the maximum benefit seems rational and self-evident if inhabitants may join in the recuperation of healthy life 7. furthermore, the recuperating project of healthy life is enacted prior to the promulgation of post-disaster reconstruction. it is an opportunity for inhabitants in disastrous district able to join the rehabilitation of healthy life that makes him or her comprehend the importance to participate in such an activity and consent to perform the said project. in addition, the human services worker shall have inhabitants in disastrous district understand and value the living reconstruction welfare, and shall fairly and justly distribute the service resources in accordance with the personal requirement and healthy life. 1.the principle of respect for autonomy: the notion of moral policy decision is presuming that all rational acts are deriving from volunteering decision. the policy adopted by human services worker must be respect for autonomy of the inhabitants in disastrous district, which means, the inhabitants shall have the option whether to participate in the recovering action or not. the social workers cannot violate inhabitants’ principle of autonomy and create any impact on their free and volunteer behaviors. the said principle is also inclusive of the “informed consent” in the process of post-disaster reconstruction to interflow with human services worker /inhabitants in disastrous district, basic upon the practice of healthy community and hygienic health 8. case 1: during the typhoon morako, village shiaolin was perished with a death toll of 498 persons and more than onehundred survivors. thereupon, many ngo organizations, professionals and volunteers crowded into this area; as one of the professionals told villagers that “he wants to help them to do the psychological therapy”, everybody was running away and no one would accept the offer. why? discussion and analyses: villagers’ cognition is, “this is an act of god /my house is gone/my relatives are dead…” i am a normal person, and surely will cry, or feel miserable and sad. i am in my right mind -“not mad”, and my psychology is out of question; why should i be treated by psychological therapy? it’s peculiar… the social worker x said, they must have psychological problem… trauma~ must have pdst’s issues! they just don’t understand~ they must accept the psychological treatment! i help them to do the psychological therapy with good intentions, but they bite the hand that feeds them----. we may clearly see the difference of cultural significance between race and religion. the human services worker shall always respect inhabitants’ autonomy; the respecting behavior is not a simple attitude, he forget the rule of professional ethics. “to respect every one and each autonomy” and “center on individual case”. regretfully, in this case, the professional is simply “centering on his own expertise” 2. the principle of non-maleficence: the principle of practicing charity demands human services worker, through act or omission, not to cause any damage intentionally or to hurt the inhabitants in disastrous district. according to the bangladesh journal of bioethics 2020; 11 (2): 10-20 15 language of common ground, we assumed, an offence is to impose a negligence or unreasonable risk onto others. jesus and michael argued, the offer of an appropriate virtue and humanistic care can avoid or reduce the damage risk, and the standard support is not only for our prevalent moral belief, but also for the social law (please refer to law and medicine ethics)9. to clarify this principle needs to provide the professional capability, obviously, it may appear with the hypocrite who takes advantage of the prestige of good deeds to publish others’ privacy onto its articles, however, the principle of practicing charity expounds that social worker shall provide benefits and protect the inhabitant in disastrous district from injury. case 2: after village shiaolin was perished, some school teachers were deployed to accompany survivors. two months later, these teachers held a seminar to make public of survivor’s oral history and life story; is this behavior not respectful enough to the deceased and the survivor? is it violating the studying morality? why? discussion and analyses: in the duration of disaster, many social workers (go & ngo; school, hospital, and enterprise) made use of the name of “accompanists” to collect the variously oral histories and interviewing paper data. the survivor who accepted the interview knows that this is a research, and that his words of “personal privacy, sadness, and misery” are being published at the seminar --this is what we called “in violation of researching morality”. in another words, the researcher shall prudentially consider the equity issue of the vulnerable interviewees (survivors who had experienced the disaster); there four moral principles in terms of consideration: respect for autonomy (informed consent/confidentiality), in favor of interviewee, and no harm to interviewees. it is applicable to the principle of dual effects: 1). nature of the good deeds shall not be itself error; 2). it shall be a good, or at least a favorable behavior in terms of ethical morality; even it is foreseeable as a good result, it shall still be not to cause any evil influence. in the aforesaid case, there is a professional difference between hypocrites and professionals who keep survivors company in the process of therapy. we conclude, it is a harmful action if a professional not specialized in psychology is doing the psychological job. it will surely cause the secondary harm onto the survivor and the inferior influence which is not the good deeds but the evil job made by human services worker. 3. the principle of beneficences: common significance of the favorable principle is that human services workers have the responsibility to provide benefits for inhabitants in disastrous district, and shall adopt the active measures to prevent and eliminate jeopardies on them 10. the duties of post-disaster reconstruction and recuperating job is regarded as reasonable and self-evident to serve as an appropriate target for post-disaster reconstruction. the favorable principle is that the human services worker facing the inhabitant in disastrous district can enter and join the reconstruction, healthy life service, and medical services provided by authorized organization. good deed in favor of affected inhabitants is a constant obligation, thus, human services worker shall always do the right thing rather than jeopardize another individual while human services bangladesh journal of bioethics 2020; 11 (2): 10-20 16 workers’ good deed is a kind of limited obligation, which is to work for inhabitants in disastrous district. case 3: upon occurrence of the gas explosion many ngo organizations, experts, and volunteers, or even artists (home or abroad) were deployed in this area, the purpose of which is to help victims to join in the artistic treatment. nevertheless, inhabitants in disastrous district joined the project with low willingness, hence, the artists or student volunteers can only paint the graffiti by themselves. will these images appearing on public space have the curative effect onto inhabitants? discussion and analyses: the original intention is very good, but inhabitants’ willingness to join the project is pretty low; isn’t it specified the inhabitants’ requirement variety? in the project of rehabilitating work, what human services worker have done is no other than the unilaterally wishful thinking; if the inhabitants don’t like those images, will the picture cause visual interference or show no deference? besides, the wrong service strategy and timing may also affect the inhabitants’ daily living. are these artists really doing good deeds? if only the victims fail to participate in the graffiti, it represents, as a matter of fact, they cannot perceive the benefit or curative effect another evident example consists in hygienic health. the benefaction principle is preferential to take care of the patients living in disaster area and respect their autonomy. the case is coming from the disaster medicine; as the inhabitants are seriously affected by gas explosion and becoming disabled or ill, our government is based on the humanism to provide medical care actively and reasonably, and enacts the rehabilitation act to rescue wounded personnel and provide benignant interference in favor of victims. 4. principle of fairness and justice: in the process of post-disaster reconstruction, human services workers’ bioethics principle is commonly defined as a professional morality to help others. the principle of fairness and justice is exactly as what aristotle said, “each service we attentively provided is what the victim (who lives in disaster district) deserved”11. it means, the fair distribution of social resources is demanding us to provide the deserved equity for victims, the issue of which is seemingly to hinge on the fair distribution of some resources and services, not but that the supply is unable to meet. case 4: upon occurrence of air blast, lots of the ngo organization, professional, volunteer, human services worker, and the church group crowded into the disaster district to help victims. as to the church elders’ healthy living care, nonparishioners were indifferent to join the church activities, thus, the church groups opened the volunteer quota for residents who are not living in disaster district. is it fair to the inhabitants who living in disastrous district when the said residents are using the resources that belong to the disastrous district? discussion and analyses: for taiwan contains the diverse, complicated, and rich society implications, social workers must learn of the disparity amid the factors of culture, race, hierarchy, gender, and age. only the diverse culture thinking can help human services worker to achieve the bangladesh journal of bioethics 2020; 11 (2): 10-20 17 service job basic upon the fair and just society value in the process of collecting research information while the experience and wisdom accumulated in these disastrous events can be used as references of the disaster prevention, alleviation, and preparedness. the bidding-type research and the human service work have caused unwholesome influences onto the straitened victims; for the temptation of money and materials compels victims having no choice, which is not only causing harms to the studying participants, but also twisting the human service expertise and the studying significance and value. the human services worker with administrative resources and academic halo sometimes may form a habit to use strong-hand tactics in persuasion, therefore, the harmful servicing habit must be eliminated, otherwise, it could seriously affect the rehabilitation of disastrous district and violate the morality of human service job. 3. in the duration of disastrous research, is the bioethics principle being considered while victims participate into the studying process? the participant or statutory agent in disastrous researches is entitled to learn of the possible risk and potential consequence. exercising the right of informed consent, the researchers shall expound the studying purpose onto the message provider, participant, and statutory agent, and submit the application to the committee, so as to accept the assessment and investigation. the testees joining in the disastrous research are the vulnerable group according to the bioethics principle, hence, a lot of particularities shall be strictly in accordance with the statute of researching morality to make a judgment on the integral value assessed by human behavior12. in addition to the consideration of bioethics principle, the testee joining in the studying process is inclusive of the morality and statute acceptable to the testee (either human or human body). there are four principles involved in human testee’s bioethics research, respective as the respect for autonomy, good deeds, no harm, and the principle of fairness and justice. 1. respect for autonomy. respect for autonomy at least includes two bioethics convictions; 1). disastrous research--the testee has the right of informed consent, and 2). the disabled person (loss of autonomy) shall be well protected. the principle of respects for individuals can be divided into two requirements respectively as 1). acknowledge the autonomy; 2). protect the disabled personnel. the information provider and the studying participant are entitled to keep the confidentiality. the legal research shall adopt appropriate measures to protect participants and relevant information; even the absolute confidentiality is unable to be achieved, the research shall keep the participant informed of the protective restriction, and try to his best endeavor to protect the achievement. the information provider and the research shall be advised --even we have done our best to protect the confidentiality, it still has many possibilities to be revealed. beneficence deeds: use the highest morality level to treat the human researching testee. in addition to doing things in favor of the research testee, we shall respect their decision, protect their equity to avoid any harm, and safeguard their wellbeing; this is the principle of good deeds, including the benevolent behaviors that transcend the extent of obligation. bangladesh journal of bioethics 2020; 11 (2): 10-20 18 no harm: not to harm the testee represents the responsibility and obligation. there are two basic principles being used to supplement the description of good deeds: 1). no harm; 2). try every possible to increase the benefit and reduce the potential jeopardy. fairness and justice: “who shall assume the liability and enjoy the benefit brought by researching findings?” the justice principle is to explore the fair distribution and the issue whether it shall be deserved or not. there is no reason to refuse a deserved beneficiary while excessive duty assignment will cause harms. another manner to perform the justice principle is equality (that shall be fairly treated). in another words, who is the equal party, who is not, and how to verify the fair distribution? conclusion and suggestions: in response to the abovementioned issues, the author suggests to enact an explicit statute of the “disaster prevention and protection act” in respect of the post-disaster reconstruction. the statutory research on disaster prevention and protection is very important policy foundation, and the government must effectively record all experiences and lessons, and shall enact a set of the “system of disaster prevention and protection” and the policy in relation to post-disaster recuperation, inclusive of the assessing index and enforcement rule in regard to the community recovery or the healthy and blissful community. the policy and the enforcement rules shall also be established to aim at the spirit to face disaster, the pdst, medicine, individual psychology therapy, and the community-mental hygiene. law and order in the disaster period is very important, which is the lowest (standard) demand. without sources of law to serve as a foundation, the moral autonomy or heteronomy shall still be limited, even with the higher moral criteria to demand social workers to observe the rules. in conclusion, the author would like to present the human services workers’ “bioethics heteronomy norm” to our government for references to conclude the content of “disaster prevention and protection act” and to those social workers for references to practice the works of post-disaster reconstruction. human services worker s’ moral heteronomy is primarily to establish an exterior norm. bioethics shall be a branch of moral tradition outside the law; it concerns with the application of human bioethics value and theory. as to the moral heteronomy, it is aiming at the good or evil of human morality to serve as an index norm. the code of conduct in the volition exercise will become a popular and feasible law, then, the heteronomy must not be affected by any personal benefit. the bioethics heteronomy norm is proposed with following opinions for human services workers and researchers: 1) human services workers and researchers’ human subject experiment shall not use other researches or implements, but can adopt only under the deliberate and essential circumstance. 2) human services worker and researchers shall be designed for serving people, helping human health and life, benefiting learning, or using knowledge of other life experiences and issues in researches, then, allowing the expected result able to prove the principle of reciprocity in the researching experiment. 3) human services bangladesh journal of bioethics 2020; 11 (2): 10-20 19 worker s and researchers shall avoid any unnecessarily physical and psychological pain and damage. 4) human services workers and researchers themselves can act as the teste; no researching experiment is allowed if there is a reason beforehand to believe it could cause the damage. 5) human services workers and researchers’ risk shall not surpass the importance of human consideration in respect of the issue that can be resolved by service. 6) human services workers and researchers shall have the proper facilities to protect victims or testees, or even to safeguard the rarely mental and physical injuria. 7).only the qualified person who has accepted the scientific training in terms of the humanity, psychology, and social medicine can conduct, as the human services worker, the researching experiment in the disastrous district. principal investigator or the researcher shall have the high-level humanistic communicating skill and the caring bosom in each phase of the researching experiment. 8) if the victim or testee in the duration of studying period feels his/her mental and physical status impossible to hold on, then, the victim or testee can freely make a decision to terminate the participation in this research. 9) in the process of researching experiment, personnel in charge of the said experiment, or the human services worker can immediately stop the experiment under his/her sincere and prudential judgment if he/she assumed, according to the reasonable factors, that continuance of the researching experiment could cause victims or testees’ injury, disablement, or death. references: 1.national education institute (2012 ) http://terms.naer.edu.tw/detail/1305179/?index=38 (accessed on july 2019) 2. mobile phone interactive encyclopedia http://www.baike.com/wiki/%e8%87%aa%e5%b e%8b%e4%b8%8e%e4%bb %96%e5%be%8b (accessed on oct 2019). 3. bioethics, wikipedia, the free encyclopedia https://zh.wikipedia.org/zhtw/%e7%94%9f%e7%8 9%a9%e5%80%ab%e7%90 %86%e5%ad%b8 (accessed on july 2019). 4. disaster human services.hhs disaster human services concept of operations for official use only march 27, 2014 "http://www.phe.gov/preparedness/planning/abc/pa ges/at-risk.aspx). (accessed on oct 2019). 5. mark s. putnam ethics through self-discipline: 10 tips for success; global ethics university (2006). http://www.globalethicsuniversity.com/articles/ethi csthroughdisc10tips.htm (accessed on oct2019). 6.beauchamp t, childress j. principles of biomedical ethics, 7th edition. new york: oxford university press, 2013. 7. mccormick, tr. ethical issues inherent to jehovah’s witnesses. perioperative nursing clinics 2008; 3(3): 253-259. 8. mccullough, l.b. “ethically justified limits on the obligations of physicians and health care organizations in response to epidemics and bioterrorism”, in balint, j., philpott, s., (2006), 9. jesus, m.d. and michael, g.e. “ethical considerations of research in disaster-stricken populations”, prehospital and disaster medicine, 2009; 24(2):109-14. 10. jensen a, siegler m, winslade w. ethics, 7th edition. new york: mcgrawhill medical, 2010. 11. trotter g. the ethics of coercion in mass casualty medicine. baltimore: johns hopkins university press; 2007. 12. conan, n. “how the ethics of triage play out in haiti”, talk of the nation, npr, washington, dc, february 10 (2010). literature discussed: 12.bostick, n.a., subbarao, i., burkle, f.m. jr, hsu, e., armstrong, j.h. and james, j.j. (2008), “disaster triage systems for large-scale catastrophic events”, disaster medicine and public health preparedness, vol. 2 no. 1, pp. s35-s39. 13.brosnan, d.p., kahn, c.a., brooke, e.l. and cone, d.c. (2010), “triage”, koening and schultz’s disaster medicine comprehensive principles and practices, cambridge university press, ny, pp. 174-83. 14. community recovery and emergency planning for further advice contact: lifeline 13 11 14 canberra connect 13 22 81 community recovery and emergency planning bangladesh journal of bioethics 2020; 11 (2): 10-20 20 http://www.communityservices.act.gov.au/ data/assets/pdf_file/0003/4926/human _f ace_disaster.pdf (accessed on sept 2019). 15. hogan, d.e. and lairet, j.r. (2007), “triage”, in hogan, d.e. and burstein j.l. (eds), disaster medicine, wolters kluwer/lippincott williams & wilkins, philadelphia, pa, pp. 12-28. 16.international federation of red cross and red crescent societies (2010), “annex vi: the code of conduct for the international red cross and red crescent movement and ngos in disaster. 17. gert b, culver cm, clouser kd,(1997) bioethics a return to fundamentals. new york: oxford university press, 1997. 18 national organization on disability. (2008) prepare yourself; disaster readiness tips for people with disabilities. washington, dc: national organization on disability. 2008 19. o'laughlin, d., and hick, j. (2008). ethical issues in resource triage. respiratory care. 53(2):190-200. 20. rawls j. (1999) a theory of justice. cambridge, ma: harvard university press, 1999. 21. sara kathleen geale, (2012),"the ethics of disaster management", disaster prevention and management, vol. 21 is: 4 pp. 445 – 462 permanent link to this document: http://dx.doi.org/10.1108/09653561211256152 http://www.fiamc.org/bioethics/ethics-of-disastermedicine/ 22. thomas r. mccormick, doming., senior lecturer emeritus, dept. bioethics and humanities, school of medicine, university of washington https://depts.washington.edu/bioethx/tools/princpl. html (accessed on oct 2019). author contributions: the 1st author h.w. angela lo conceived the idea, did the literature review and wrote the manuscript. the 2nd author and vincent shieh guideded the conception of the idea, the manuscript writing, and checked the manuscript and 3rd authors yung-jong shiah involved in manuscript writing, and checked the manuscript meticulously. conflict of intereste: the authors declare that there is no conflict of interest in this study bangladesh journal of bioethics 2020; 11 (2): 10-20 21 microsoft word shamima and morshad bangladesh journal of bioethics 2018; 9(2):40 38 bioethics for peace and sustainable development of bangladesh shamima parvin lasker 1 md morshadur rahman 2 1. professor & head of anatomy mh samorita medical college, dhaka and secretary general , bangladesh bioethics society 2. senior reporter, bangladesh sangbad sangstha abstract: bioethics is a vital part of a sustainable development. in this paper we discuss why developed country incorporate bioethics along with development of science and technology; and why bioethics decision-making is important to long term development of bangladesh. introduction: for the past 20 years, bangladesh has made significant progress in several major areas of human development. some of the indices increase the score of human development index (hdi), e.g., life expectancy, literacy rate and nutritional status. life expectancy and literacy rate are higher in bangladesh than the neighboring counties such as india and pakistan. a report says that nutritional status of under five year children in bangladesh has increased and is stood second position after sri lanka among south east asia region. in contrast, the economic development of bangladesh remained much below that of many developing countries in the area. one of the main reasons for less than expected economic growth is the lack of good governance and ethical practices. since the 1990s, a global discourse has been growing that ethical education is vital for the improvement of governance and development in developing countries. the need for ethical education has been emphasized by almost all international organizations and the members of the international assistance community. meaning of bioethics: ethics means moral value, norm and attitude. it is the understanding of human behavior in relation to values. it determines which behaviors are good and acceptable and which are bad. bioethics is the understanding of right, responsibility, justices and moral interaction with the living being. the simplest way of defining bioethics is ethical issue raised by questions involving life (bio) in every day living. as for example: what food should we eat? how is food grown? where should i live? how much disturbance of nature should i make? what relationship should i have with fellow organism, including human being? how do we balance the quality of our life? bioethics is based on four basic principles, e.g. a. respect of person, b. beneficience, c. non malficience, and d. justice. bioethics teaches how to balance between different benefits, risks and duties. it includes medical ethics, environmental ethics and ethics in science, business, law, social science and decision making. concepts of bioethics can be seen in literature, art, music, culture, philosophy and religion. bioethics can be use as synonyms of professional ethics. now a day bioethics has gained immense important in whole of the bangladesh journal of bioethics 2018; 9(2):40 39 world due to rapid advancement in science and technology, drastic changes in macroeconomic planning and globalization. discussion: though bioethics has existed in every religion and in every region through out the ages but in the 1970s it emerged as a discipline of academic in usa due to the increasing complexity of medical advances. van r potter proposed the theory of bioethics for preventing possible threats to the accepted principles of equity and social justice in life especially in human. since its inception, the field has grown exponentially in its scope and importance. today, there are bioethics departments in over 60 u.s. academic medical centers. many hospitals are now employing bioethics experts to guide on such issues as allocation of scarce resources, how to care for terminally ill patients and dilemmas of doctors facing everyday for advancement of new technology. there are at over 95% of u.s. hospitals has ethics committees for helping physicians, nurses and families on bioethical issues on a case-by-case basis. thus today bioethics is not only a reasoned discourse but a matter of crisis management. unesco, a leading agency of united nation addresses the ethical issue on recent advancement in sciencs and technology. the regional unit for social and human science (rushap) of unesco is working in asia-pacific region on ethics of science and technology. in bangladesh, unesco dhaka in partnership with the rushap and with the enterprise of prof. shamima p lasker and dr arif hossain took initiative to support the constitution of the first ever bioethics society in bangladesh. as a result, bangladesh bioethics society (bbs) was established in 2009 that was launched by h.e. nurul islam nahid, former minister for education, people republic of bangladesh. over the last couple of years bbs has organized a number of seminars and workshops, courses and international conference to familiarize the idea of bioethics and encourage the research on bioethics issues in bangladesh. bangladesh is a pluralistic society with a wonderful diversity of values and ethical ideals. but poverty, natural calamites, lack of proper and substantial education and rapidly advancing technology people are forced to deal with one crisis after another. rapid growth in population has put a tremendous pressure on the resources needed to meet the basic needs of the people such as food, housing, education and health. in a result bio-ethical decision, sanctity of life is deemed to be less important than the quality of life. people are forgetting to reason soundly and coherently. corruption, nepotism, selfishness, misconduct and malpractice are becoming the common phenomena in bangladesh. it gives the impression that we don't able to tell which values need to be employed when and which ethical dilemmas need our most immediate attention in our society. as a result, morality and ethics are defeated by the greed. we are living through a time as if material gains take precedence over righteousness. actually, there is huge gap in teaching of ethics in all level to coup with recent development human mind and psychology with the advance of science and technology. bangladesh journal of bioethics 2018; 9(2):40 40 ethicists carefully and critically explore how we think and determine right and wrong. they investigate what motivations that govern personal and group action. ethics forms the basis of almost all personal decision-making, whether we are aware of it or not. the same is true of decision-making in professional life, including business, law, and medicine; in civil and political life and in questions of social justice. in reality, deficiency in proper and substantial moral education and lack of practice of ethics in society corruption, nepotism, selfishness, misconduct and malpractice are becoming the common phenomena in bangladesh. bangladesh achieved independence in 1971 under the leadership of the father of the nation, bangabandhu sheikh mujibur rahman through a historic struggle and a nine-month-long war of liberation. the driving force behind the struggle was the dream for a happy, prosperous peaceful and harmonious society. but, during the last forty-four years, this dream was thwarted. different laws, rules, regulations, policies, and a number of organizations are established by the governments to curb the corruption for free from hunger, illiteracy, unemployment, deprivation and poverty. but nothing is improved the condition of bangladesh rather then holding championship in corruption thrice in 1990s. however, present prime minister, daughter of banglabandhu sheikh hasina recently understand that enforcement of law and punishment may not the suffice to eradicate corruption. she realized that a movement has to be launched to prevent corruption, exploitation to ensure human rights and freedom, equality and justice for the citizens. she recognized that the behavioral excellence influenced by ethics, morality and honesty can make a society free from corruption and good governance. therefore, she has taken national integrity strategy under vision 2021 to encourage the culture of ethics and morality among the people in the society. conclusion: bioethics education may change the people’s outlook in the society. to establish a happy, prosperous and peaceful society by changing the people’s mindset is a great challenging. hope prime minister, sheikh hasina can establish ethics and fulfill the dream of banglabandhu’s sonar bangla and make bangladesh free from hunger, illiteracy, unemployment, deprivation and poverty. author contribution: 1st author evolved the idea & wrote the 1st draft. 2nd author flourish the idea further and meticulously draft the manuscript. conflict of interest: there is no conflict of interest to declare. microsoft word rashed mbgph bangladesh journal of bioethics 2016; 7(2):1-13 1 original article a study on service availability and readiness assessment of noncommunicable diseases using the who tool for gazipur district in bangladesh running title: service availability and readiness assessment of ncds mohammad rashedul islam1, shamima parvin laskar2, darryl macer3 1. assistant director, research and training monitoring department, bangladesh college of physicians and surgeons, mohakhali, dhaka, bangladesh. email: mrislam96@gmail.com 2. professor & head, department of anatomy, mh samorita hospital & medical college, 117 tejgaon, love road, dhaka-1208, bangladesh. 3. president, american university of sovereign nations, san carlos, arizona, usa. abstract: non-communicable diseases (ncds) disproportionately affect low and middle-income countries where nearly three quarters of ncd deaths occur. bangladesh is also in ncd burden. this cross-sectional study was done on 50 health facilities centres at gazipur district in bangladesh from july 2015 to december 2015 to introduce sara for better monitoring and evaluation of non-communicable diseases health service delivery. the general service readiness index score was 61.52% refers to the fact that about 62% of all the facilities were ready to provide general services like basic amenities, basic equipment, standard precautions for infection prevention, and diagnostic capacity and essential medicines to the patients. but in case of non-communicable diseases, among all the health facilities 40% had chronic respiratory disease and cardiovascular diseases diagnosis/ management and only 32% had availability of diabetes diagnosis/management. overall readiness score was 52% in chronic respiratory disease, 73% in cardiovascular disease and 70% in diabetes. therefore, service availability and readiness of the health facilities to provide ncd related health services were not up to the mark for facing future targets. a full-scale census survey of all the facilities of the study area would give a better understanding of the availability and service readiness. key words: service availability, service readiness, non-communicable diseases, sara tool, bangladesh introduction: the four main types of non-communicable diseases are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. non-communicable diseases (ncds) kill 38 million people each year. ncds already affect lowand middle-income countries disproportionately where nearly three quarters of ncd 2 deaths occur. responsible risk factors include ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. for example, globalization of unhealthy lifestyles like unhealthy diets may show up in individuals as raised blood pressure, increased blood glucose, elevated blood lipids, and obesity. these are called 'intermediate risk factors' which can lead to cardiovascular disease, a ncd1. all people irrespective of age, sex and regions are affected by ncds. but evidence shows that 16 million of all deaths attributed to non-communicable diseases (ncds) occur before the age of 70. of these "premature" deaths, 82% occurred in lowand middle-income countries. children, adults and the elderly are all vulnerable to the risk factors that contribute to ncds, whether from unhealthy diets, excess salt intake, physical inactivity, exposure to tobacco smoke or the effects of the harmful use of alcohol2. ncds threaten progress towards the un millennium development goals and post2015 development agenda (sustainable development goals). poverty is closely linked with ncds. the rapid rise in ncds is predicted to impede poverty reduction initiatives in low-income countries, particularly by increasing household costs associated with health care3. vulnerable and socially disadvantaged people get sicker and die sooner than people of higher social positions, especially because they are at greater risk of being exposed to harmful products, such as tobacco or unhealthy food, and have limited access to health services4 . in low-resource settings, out pocket expenditure for cardiovascular diseases, cancers, diabetes or chronic lung diseases can quickly drain household resources, driving families into poverty. the exorbitant costs of ncds, including often lengthy and expensive treatment and loss of breadwinners, are forcing millions of people into poverty annually, stifling development. in many countries, harmful drinking and unhealthy diet and lifestyles occur both in higher and lower income groups. however, high-income groups can access services and products that protect them from the greatest risks while lower-income groups can often not afford such products and services5. a comprehensive approach for all sectors including health is needed to lessen the impact of ncds on individuals and society. an important way to reduce ncds is to focus on lessening the risk factors associated with these diseases. low-cost solutions exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol) and map the epidemic of ncds and their risk factors. other ways to reduce ncds are high impact essential ncd interventions that can be delivered through a primary health-care approach to strengthen early detection and timely treatment. evidence shows that such interventions are excellent economic investments because, if applied to patients early, can reduce the need for more expensive treatment. these measures can be 3 implemented in various resource levels. the greatest impact can be achieved by creating healthy public policies that promote ncd prevention and control and reorienting health systems to address the needs of people with such diseases. lowerincome countries generally have lower capacity for the prevention and control of ncds. high-income countries are nearly four times more likely to have ncd services covered by health insurance than low-income countries. countries with inadequate health insurance coverage are unlikely to provide universal access to essential ncd interventions1. who proposed global action plan for the prevention and control of ncds 20132020 to reduce the number of premature deaths from ncds by 25% by 2025 through nine voluntary global targets such as tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity that increase people's risk of developing these diseases6. bangladesh faces double burden of diseases – both cds & ncds. but, in bangladesh ncd burden is rapidly increasing due to social transition, unhealthy dietary habit & rapid urbanization. in terms of the number of lives lost due to ill-health and disability, ncds account for 61% of the total disease burden. the under-privileged communities in the country are bearing the heaviest toll of this burden7,8. core to the sara framework is the strengthening of a common platform for monitoring, evaluation and review for national health system. sara is designed to function as a systematic tool to support annual verification of data and service delivery at the facility level. sara provides evidence based data on health system progress to inform the annual health sector review, identify gaps and weaknesses responsible for suboptimal service provision and intervention coverage that need to be addressed, provide a baseline for planning and monitoring scale-up intervention for service delivery improvement9. no assessment has been conducted so far in bangladesh to monitor, review and evaluate ncd related health service delivery using sara. thus, the present study aimed to introduce sara for better monitoring and evaluation of ncd related health service delivery in gazipur, bangladesh. research question: what is the status of service availability and readiness assessment on non-communicable diseases for gazipur district in bangladesh? general objective: the objective of this assessment is to strengthen monitor-reviewact system for non-communicable diseases health service delivery in gazipur using sara. specific objectives • to find out service availability for providing ncd health services using sara tool. • to assess facility readiness for providing ncd health services using sara tool 4 ethical implication: this study is very much important regarding to ethical aspects. health is a basic need and according to goal 3 of sustainable development goals (sdgs) “ensure healthy lives and promote well-being for all at all ages”10 must warrant. so, health service delivery should be made affordable and accessible to all. methodology: this cross-sectional study was done from july 2015 to december 2015 on 50 health facilities during masters of bioethics and global public health (mbgph) in ausn. two upazila’s (kapasia and sreepur) from gazipur district were considered as assessment area. different types of health facilities (upazila health complex [uhc], union sub-centers [usc], community clinic [cc] and private hospital [ph]) were included in the study11-13. this two upazilas were selected by multistage sampling. then a sampling frame was done from both upazilas including public and private facilities. from this stratified random sampling was done. private clinics having both inpatient and outpatient departments were included in this study. private clinics with only diagnostic facilities were excluded from this study. brief description of assessment tool: service availability and readiness assessment (sara) indicators: the service availability and readiness assessment (sara) survey is used to measure progress in health system strengthening over time comprising a set of core indicators on key inputs and outputs of the health system. tracer indicators aim to provide objective information about whether or not a facility meets the required conditions to support provision of basic or specific services with a consistent level of quality and quantity. summary or composite indicators, also called indices, can be used to summarize and communicate information about multiple indicators and domains of indicators. indices can be used for general and service specific availability and readiness. service availability refers to the physical presence of the delivery of services, encompassing health infrastructure, core health personnel, and service utilization. this does not include more complex dimensions such as geographic barriers, travel time, and user behavior, which require more complex input data. service availability is described by an index using the three areas of tracer indicators. this is made possible by expressing the indicators as a percentage score compared with a target or benchmark, then taking the mean of the area scores. general service readiness refers to the overall capacity of health facilities to provide general health services. readiness is defined as the availability of components required to provide services such as basic amenities, basic equipment, standard precautions, laboratory tests, and medicines and commodities. general service readiness is described by an index using the five general service readiness domains. a score is generated per domain based on the number of domain elements present, then 5 an overall general readiness score is calculated based on the mean of the five domains. service specific readiness refers to the ability of health facilities to offer a specific service and the capacity to provide that service measured through selected tracer items that include trained staff, guidelines, equipment, diagnostic capacity, and medicines and commodities. sara is a health facility assessment tool designed to assess and monitor the service availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system. sara is designed as a systematic survey to generate a set of tracer indicators of service availability and readiness. the survey objective is to generate reliable and regular information on service delivery (such as the availability of key human and infrastructure resources), on the availability of basic equipment, basic amenities, essential medicines, and diagnostic capacities, and on the readiness of health facilities to provide basic health-care interventions relating to ncds. data collection: data collection was done for two weeks from april 01 to april 15, 2015 using paper based questionnaire. total 50 health facility was visited from which 25 were from kapasia and the other 25 were from sreepur. from these 50 facilities, there were 2 upazila health complex, 4 union sub-centers, 30 community clinics and 14 private clinics. administrative head of every health facility was interviewed thoroughly. as an example, upazila health and family planning officer (uh&fpo) was interviewed at uhc and community health care provider (chcp) was interviewed at cc. moreover, people related with different health services were also asked detailed questions where needed. for example, in upazila health complex, epi technician was asked questions on vaccine carrier and temperature monitoring of refrigerator, whereas storekeeper was asked question on availability and stock out of medicines. at community clinic, chcp were asked questions about antenatal care and family welfare assistant (fwa) gave information on family planning services. data that was collected from community clinics and union sub-centers were cross verified at upazila health complex with statistician who is responsible for entering data in district health information system-2 (dhis-2) software. the interviews were done in such a way that almost all the unions of both upazilas were covered. data entry and quality assurance: before formal data collection, the questionnaire was modified according to the feedback from the consultative meeting with the steering committee members. to ensure data quality, sara team conducted a pretest in gazipur upazila health complex and its surrounding villages for facility assessment and community readiness. data collectors were trained at two stages to 6 ensure quality data collection, firstly before pretesting to familiarize and how to use the tools and secondly, immediately prior to the main survey with the tools adapted based on field experience. senior team members monitored and rechecked data on random basis at different check points-data collection, data entry and cleaning. finally, data were entered on microsoft excel immediately after the data collection which helped to guard against wrong data entry. for facility assessment, calculation of different domain score and readiness score was done manually. ethical consideration: ethical aspects of the study were taken into account in a fairly linear way. at first, ethical review committee of american university of sovereign nations reviewed this study proposal. on the other hand, verbal consent was taken from every key informant prior to data collection. all questionnaires were kept in a safe and secure place in order to ensure confidentiality. coding was done. only the researcher has access to those questionnaires in case of cross checking or validating any data if needed. limitations and challenges: one of the limitations of the present study is that the study sites of this assessment were one of the high performing areas in terms of health indicators and it might introduce selection bias. as we have selected a sample of health facilities from the study area instead of a census of all the facilities, service availability data might not give us accurate measure. we had to face a few challenges while conducting the assessment. some community clinics and the union sub centers are located in hard to reach area where transports were not available and communication system was very poor. managing time was a hard job because the government facilities work up to 2.30 p.m. so, interviewing the doctors were challenging because of the interruption of the patients. so, each interview took more time than we expected. it was hard to interview the key informants (ki) as we had to go to their work place to take their schedule and then go to them again for taking interview. results: general service readiness index includes basic amenities, basic equipment, standard precautions for infection prevention, diagnostic capacity and essential medicines. tracer indicators for basic amenities are power source, improved water source within 500 meters of facility, consultation room with auditory and visual privacy for patient consultations, access to adequate sanitation facilities for clients, communication equipment (phone or sw radio), computer with email/internet access and emergency transportation. tracer indicators for basic equipment are adult scale, child scale, thermometer, stethoscope, blood pressure apparatus and light source. tracer indicators for standard precautions for infection prevention are safe final disposal of sharps, safe final disposal of infectious waste, appropriate storage of sharps waste, appropriate storage of infectious waste, disinfectant, single use standard disposable or auto-disable syringes soap and running water or alcohol based hand rub latex gloves and guidelines for standard precautions. tracer indicators for 7 diagnostic capacity are haemoglobin, blood glucose, malaria diagnostic capacity, urine dipstickprotein, urine dipstickglucose, hiv diagnostic capacity, syphilis rapid test and urine test for pregnancy. tracer indicators for essential medicines are amitriptyline tablet, amoxicillin suspension, amoxicillin tablet, ampicillin injection, gentamicin injection, ceftriaxone injection, salbutamol inhaler, beclomethasone inhaler, enalapril tablet or alternative ace inhibitor, amlodipine tablet or alternative calcium channel blocker, simvastatin 20 mg capsule/tablet, glibenclamide tablet, metformin tablet, insulin regular, omeprazole tablet or alternative, oral rehydration solution, paracetamol tablet, zinc sulphate tablet, ibuprofen tablet and fluoxetine tablet. the general service readiness index for kapasia and sreepur upazila was 62% where highest contributor was basic equipment domain (89%) and lowest contributor was diagnostic capacity (36%) of all the health facilities [figure 1]. general service readiness index score by facility type was highest in upazila health complex that was 90% and lowest in community clinic that was 46%. no diagnostic mean score was noted in union sub center [figure 2]. diabetes service availability means types of service offered: diabetes diagnosis and/ or management. tracer indicators for diabetes service readiness are trained staff and guidelines guidelines for diabetes diagnosis and treatment and staff trained in diabetes diagnosis and treatment; equipmentblood pressure apparatus, adult scale, measuring tape (height board/ stadiometre); diagnosticsblood glucose, urine dipstickprotein, urine dipstickketones; medicines and commoditiesmetformin tab, glibenclamide tab, insulin injectable and glucose injectable solution. cardiovascular disease service availability means types of services offered cardiovascular disease diagnosis and/or management. tracer indicators for cardiovascular disease service readiness are trained staff and guidelines guidelines for diagnosis and treatment of chronic cardiovascular conditions and staff trained in diagnosis and management of chronic cardiovascular conditions; equipment stethoscope, blood pressure apparatus, adult scale; medicines and commodities ace inhibitors (e.g. enalapril), thiazides, beta blockers (e.g. atenolol), calcium channel blockers (e.g. amlodipine), aspirin cap/tabs, metformin cap/tabs and oxygen. chronic respiratory disease service availability means types of services offered chronic respiratory disease diagnosis and/or management. tracer indicators for chronic respiratory disease service readiness are trained staff and guidelines guidelines for diagnosis and management of crd and staff trained in diagnosis and management of crd; equipmentstethoscope, peak flow meter, spacers for inhalers; medicines and commoditiessalbutamol inhaler, beclomethasone inhaler, prednisolone cap/tabs, hydrocortisone cap/tabs, epinephrine injectable and oxygen. 8 the bar graph shows that about half of the health facilities in gazipur district offered cardiovascular and chronic respiratory disease diagnosis/management (40%), one third offered diabetes diagnosis/ management (32%) [figure 3]. the bar graph shows that overall readiness score was only 52% in chronic respiratory disease, 73% in cardiovascular disease and 70% in diabetes. but readiness score about staff and guideline was very poor only 5% for both chronic respiratory and cardiovascular diseases and 13% for diabetes [figure 4]. general service readiness index and domain scores (n=50) 61.52% 72.57% 88.66% 67.78% 35.50% 43.11% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% general service readiness index basic amenities mean score basic equipment mean score standard precautions mean score diagnostics mean score essential medicines mean score d o m a in s co re general service readiness index and its domain figure 1: general service readiness index and domain scores general service readiness index and domain scores, by facility type (n=50) 61.52% 72.57% 88.66% 67.78% 35.50% 43.11% 89.72% 100% 100% 100% 87.50% 61.11% 53.17% 71.43% 83.33% 77.78% 0% 33.33% 45.68% 71.43% 83.33% 44.45% 12.50% 16.67% 86.07% 71.43% 100% 71.43% 87.50% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 d o m a in s co re general service readiness index and its domain, by facility type total uhc usc cc private clinics figure 2: general service readiness index and domain scores, by facility type 9 availability of non-communicable disease services 32% 40% 40% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% diabetes diagnosis/management cardiovascular disease diagnosis/management chronic respiratory disease diagnosis/management percentage of availability n o n c o m m u n ic a b le d is e a se s e rv ic e s figure 3: availability of non-communicable disease services readiness to provide non-communicable disease services 70% 13% 79% 100% 69% 73% 5% 95% 80% 52% 5% 50% 72% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% o v e ra ll r e a d in e ss s ta ff & g u id e lin e e q u ip m e n t d ia g n o stics m e d icin e s a n d c o m m u d itie s p e rc e n ta g e o f re a d in e ss readiness domain diabetes diagnosis/management cardiovascular disease diagnosis/management chronic respiratory disease diagnosis/management figure 4: readiness to provide non-communicable disease services 10 discussion: for facility readiness assessment, basic amenities domain readiness score of 73% indicates that about two-third of the facilities in the study area had basic conveniences including adequate sanitation facilities, room with privacy, improved water source etc. although 100% facilities had communication equipment and 64% had computer with internet, only 40% (2 uhc, 4 usc and 14 private hospitals) had adequate power source to use them properly. overall readiness score for basic equipment domain 89% refers that most of the health facilities had necessary equipment needed to provide services to the people. however, uses of that equipment were not seen by the study team while observing the health care providers when patients came to seek any service. only 4% facilities of kapasia and sreepur had guideline which is need for standard precautions for infection prevention. this is reflected in their daily practice as well. although almost 92% facilities had appropriate storage of infectious and sharp waste, many of them told that they submitted their used needle to the upazila health complex for final disposal. overall domain score of 43% for essential medicine indicates that in the present area 43% facilities had essential medicines. but it is alarming that only 28% had all the essential medicines available at the time of this assessment. the reason for this shortage was inadequate supply of medicines for a quarter. in every community clinic in kapasia upazila there was no supply of any medicine over last three months. however, in some cases unnecessary use of medicine by the patients could also cause shortage of medicine. for example, a 60-year-old woman in a community clinic came to take medicine. then the chcp asked her what was her problem? women replied, “i have no problem right now, just wanted to take some medicine as i did not take medicine for last three weeks”. patient was happy for getting treatment and the community clinic was known to every person of the community. chcp could not give answer appropriately how many drops make one milliliter (field observation). general service readiness index score 62% refers to the fact that 62% of all the facilities of the study area were ready to provide general services like basic amenities, basic equipment, standard precautions for infection prevention, and diagnostic capacity and essential medicines to the patients. as only 2 uhc and few private hospital had diagnostic capacity and all basic amenities, the overall percentage became low. but in case of non-communicable diseases, among all the health facilities 40% had chronic respiratory disease and cardiovascular diseases diagnosis/ management and only 32% had availability of diabetes diagnosis/management. overall readiness score was only 52% in chronic respiratory disease, 73% in cardiovascular disease and 70% in diabetes. according to “iceberg of phenomenon” of disease, a great portion of people are undiagnosed or underdiagnosed14. we all know that most of the chronic diseases are 11 not curable, but in most cases these are preventable. so, primary prevention should be adopted initially15. due to epidemiological transition of diseases non-communicable diseases are increasing day by day16. community clinics should be strengthened. it may be a better center of preventive care. in this study, according to sara guideline we did not consider community clinic. because still now these community clinics are not functioning in many cases due to proper logistic support. in many cases these are functioning only in paper document. in case of sara questionnaire, we consider here primary care physician. in case of cancers-there is no answer. only via test for cervical cancer screening is done in upazila health complex. in case of mental health issue, we didn’t get proper data. conclusion: despite all the bottlenecks identified in the study area, overall service availability and readiness of the health facilities to provide ncd related health services were below the acceptable range. at the same time community people were also aware of services that were available related to ncd related health services. a full-scale census survey of all the facilities of the study area would give a better understanding of the availability and service readiness. thus, the findings could significantly contribute to the overall improvement of ncd related health not only in bangladesh but also in global platform. finally, all these efforts will act as a catalyst in achieving the better health for future bangladesh. recommendations: strengthening accountability of the supervisor/inspectors who visit community clinics and union sub-centers. because, often they do not comment about capacity of the health worker to deliver certain services and also do not care about the stock out of medicines. persuade the policy makers to create a mandate for private health facilities in order to share their data with government mis departments and also for public view. standardizing and modifying all different types of registers according to the format they are supposed to fill up in dhis-2. introduce strict rules that make health workers preserve guidelines of training at health facility rather than their own home. all chcp should be trained up properly regarding their service. some community clinics have no medicine more than three months. it is necessary to ensure proper supply of medicine for maintaining treatment whole the year. treatment should be given by at least primary care physician at all levels. more frequent training on dhis2, especially for ha to enter data in dhis-2 and did not get adequate training. enhance coordination among chcp, ha and fwa. equipping all community clinics with electricity or any other alternative power source. for example, solar panel establishment. author’s contribution: 1st author developed the conceptual idea, data collection, data analysis, compilation of results and manuscript writing. 2nd author develops the manuscript for publication and meticulous corrections of the article. 3rd author gives intellectual inputs in developing the concept of the manuscript. 12 conflict of interest: declared none. acknowledgement: special thanks to dr. md. hafiz uddin, uh&fpo, kapasia uhc and dr. s.m mahmudul haque, uh&fpo, sreepur uhc, ms. samsunnahar, head assistant of kapasia uhc, ms. jakia sultana jesmin, ssn of kapasia uhc and mr. md. aman ullah, statistician of sreepur uhc, ms. farida yeasmin, ssn of sreepur uhc for their support during the data collection period. i would like to express my thanks to all respondents and all others who were directly and indirectly help me. references 1. world health organization. non-communicable diseases. url http://www.who.int/mediacentre/factsheets/fs355/en/ accessed 01.02.2016 2. beaglehole r, bonita r, horton r, adams c, alleyne g, asaria p, baugh v, bekedam h, billo n, casswell s, cecchini m. priority actions for the noncommunicable disease crisis. the lancet. 2011 apr 29;377(9775):1438-47. 3. mirelman aj, rose s, khan ja, ahmed s, peters dh, niessen lw, trujillo aj. the relationship between non-communicable disease occurrence and poverty—evidence from demographic surveillance in matlab, bangladesh. health policy and planning. 2016 feb 3: 134. 4. link bg, phelan j. social conditions as fundamental causes of disease. journal of health and social behavior. 1995 jan 1:80-94. 5. babu rb, alam m, helis e, fodor jg. population-based versus high-risk strategies for the prevention of cardiovascular diseases in low-and middleincome countries. indian heart journal. 2012 oct 31;64(5):439-43. 6. world health organization. global action plan for the prevention and control of noncommunicable diseases 2013-2020. 7. national institute of population research and training (niport), bangladesh demographic and health survey 2011. dhaka, bangladesh and calverton, maryland, usa: niport, mitra and associates, and icf international. 8. abegunde do, mathers cd, adam t, ortegon m, strong k. the burden and costs of chronic diseases in low-income and middle-income countries. the lancet. 2007 dec 14;370(9603):1929-38. 9. who. service availability and readiness assessment (sara). url http://www.who.int/healthinfo/systems/sara_introduction/en/ accessed 01.02.2016 10. sustainable development goals united nations.url http://www.un.org/sustainabledevelopment/health/ accessed 01.02.2016 13 11. health bulletin. management information system (mis). directorate general of health service (dghs). ministry of health and family welfare (mohfw), 2015. 12. local health bulletin. kapasia upazila health complex. management information system (mis). directorate general of health service (dghs). ministry of health and family welfare (mohfw), 2015. 13. local health bulletin. sreepur upazila health complex. management information system (mis). directorate general of health service (dghs). ministry of health and family welfare (mohfw), 2015. 14. last jm. the iceberg:‘completing the clinical picture’in general practice. international journal of epidemiology. 2013 dec 1;42(6):1608-13. 15. waxman a. why a global strategy on diet, physical activity and health? innutrition and fitness: mental health, aging, and the implementation of a healthy diet and physical activity lifestyle 2005 sep 8 (vol. 95, pp. 162166). karger publishers. 16. miranda jj, kinra s, casas jp, davey smith g, ebrahim s. non‐communicable diseases in low‐and middle‐income countries: context, determinants and health policy. tropical medicine & international health. 2008 oct 1;13(10):1225-34. microsoft word 5 editorial vol 9 issue 3 , 2018 bangladesh journal of bioethics, 9; 3: 2018 bangladesh journal of bioethics vol 9 issue 3 2018 editorial welcome to all readers of the bjb vol 9 issue 3, 2018! the bjb team together with authors, reviewers and wellwishers have contributed their all-out support to bring out this issue despite many challenges. this issue spans several topics of bioethics beginning from complementary feeding patterns, ethical beliefs and vaccine, the regulatory documents related to pharmaceutical promotion in bangladesh and intimate partner violence. all these topics are very important for bangladesh as well other countries. fatema johora1 and md sayedur rahman in the paper titled “pharmaceutical promotion in bangladesh: assessing the strength of regulatory documents” observed that pharmaceutical promotion is a negative force for prescribing. the authors found that there were few regulatory initiatives to overcome this unwanted influence. their research was conducted to review the regulatory documents related to pharmaceutical promotion in bangladesh including code of pharmaceutical marketing practices (cpmp), and to compare cpmp with different global guidelines. though the guidelines showed efforts to regulate promotion, enforcement of these guidelines varied. the authors recommended the need for clear, welldefined ethical and legal prohibitions, and punishment for violations and an setting up of an agency with defined authority as crucial. the paper by abu sadat mohammad nurunnabi, miliva mozaffor, mohammad akram hossai and sadia akther sony ,titled, “mass vaccination programme: public health success and ethical issues – bangladesh perspective” looks the ethical issues involved in mass vaccination programme and challenges in public health programmes in bangladesh. this is because ethical issues like informed consent, benefits vs. risks, and disparities in access to vaccination are closely related to vaccination programmes. the authors’ concluded that related ethical issues be closely reviewd when starting any mass vaccination programme. in the paper titled “intimate partner violence in bangladesh: a scoping review” by jhantu bakchi , satyajit kundu, subarna ghosh, and sumaiya akter an attempt has been made to study the different literatures related to intimate partner violence in bangladesh. the authors found that the main risk factors of ipv in bangladesh were women being younger, from low socioeconomic reputation, from low academic attainment and low education of husband, child marriage, and other issues arising from the key role of women’s empowerment. the authors’ concluded that with increasing empowerment of women could be crucial for developing interventions to reduce ipv and its consequences. bangladesh journal of bioethics, 9; 3: 2018 in the paper titled “levels and determinants of complementary feeding pattern exclusive of minimum meal frequency and dietary diversity among children of 6 to 23 months in bangladesh” the authors naznin pervin, darryl macer and shamima p. lasker estimate the level of complementary feeding pattern (cfp) among children between 6 to 23 months to identify the determinants in individual, household and community level in bangladesh. the authors found that more than 95% of the children experienced either no (2.9%) or inadequate (92.7%) cfp level. disaggregated data revealed that cfp was lower among children of the youngest age group, uneducated parents, unemployed/laborer fathers, socio-economically poor families, food insecure families and rural areas. limited exposure to mass media revealed meaningful associations with cfp. the authors observed that is ethical to improve the overall situation of cfp in bangladesh by the government and other concerned stakeholders wishing all a safe and healthy time and looking forward to your continued contributions and support. warm regards professor dr. tahera ahmed editor microsoft word rehabilitation ethics covid19 bangladesh journal of bioethics 2021; 12 (1): 49-53 49 covid-19 pandemic: ethical and medical issues arising for people with disability in bangladesh taslim uddin1, hassan tasdeed mohammad2, naima siddiquee3 1. professor and chairman, department of physical medicine and rehabilitation, bangabandhu sheikh mujib medical university, dhaka. bangladesh. email: taslimpmr@gmail.com (corresponding author) 2.asstt surgeon, colonel malek medical college hospital, manikgonj. dhaka. bangladesh. email:drtasdeed@gmail.com 3. department of physical medicine and rehabilitation, united hospital, dhaka. bangladesh. email: drnaima_2008@yahoo.com doi: https://doi.org/10.3329/bioethics.v12i1.51901 abstract: the disability viewpoint is the fundamental for understanding social justice in a given population. disability rights need to be obeyed in the inclusive preparedness and response to all the disasters or during the crisis period including covid-19 pandemic. covid-19 pandemic jeopardized the health and rehabilitation services globally. the impact is much more in low resource developing countries like bangladesh. in general, people with disability (pwd) suffer from multiple medical and rehabilitation complications and they need frequent rehabilitation consultations or hospital admissions in comparison to people without disability. as a developing country, bangladesh has poor ratios of doctors, nurses and technologists of 1:0.4:0.24 (who: 1:3:5) to face the covid-19 challenge. rehabilitation services have been disrupted in almost two-thirds (63%) of countries of the world. even though rehabilitation is the key to recovery following severe illness from covid-19. there are many concerns and debates about the preparedness, response and mitigation the process of covid-19 on the part of the national government. according to recent study reports, the lives of about 100% of pwd have been impacted by the covid-19 pandemic. covid-19 national technical advisory committee is working for strategic planning, response and mitigation process but omission of a representative of pwd or a rehabilitation physician in the committee has created much dissatisfaction. the difficult covid-19 testing process due to country wide shutdown of rehabilitation essential services and central pulling of rehabilitation physicians have side lined the pwd inclusiveness. it is expected that the rehabilitation preparedness, response and mitigation of the pandemic should be based on an ethics driven process. key words: covid-19, bangladesh, ethical issues, medical issues, people with disability, introduction: during march 11, 2020 the world health organization (who) declared the outbreak of the novel coronavirus disease (covid-19) to be a pandemic1. in bangladesh first case of covid-19 was detected on 08th march 2020, it reached 100 cases on april 9th and exceeded 200 cases (case doubling time) within next two days. as of october12, 2020, there were 379,738 confirmed cases including 5,555 deaths with the case fatality rate (cfr) 1.85% and recovery rate 77.5% respectively2. recent survey reports show that about 100% of the people with disability lives have been changed by covid 19 pandemic 3. it is talk of the town that the 2nd wave of covid-19 should learned lessons from the worse 2nd wave of the 1918 spanish flu. during the covid-19 pandemic there were resource constraints at emergency e.g. central oxygen supply, rationing ventilators and intensive care beds4. great concerns about the covid-19 preparedness, health and rehabilitation response for people with disability (pwd) in bangladesh bangladesh journal of bioethics 2021; 12 (1): 49-53 50 were given. covid-19 related rehabilitation challenges were highlighted and strategy to adapt during the pandemic was documented but issues in relation to people with disability were not addressed5. an attempt was made in this communication to examine the key concerns and issues affecting health care and life of pwd impacted by covid-19 pandemic in this low resource developing country. covid-19 preparedness: recently, three ethical duties for health care leaders as part of covid-19 pandemic preparedness are proposed e.g. (a) the duty to safeguard (supporting workers and protecting vulnerable populations), (b) the duty to plan (managing uncertainty), and (c) the duty to guide (contingency levels of care and crisis standards of care) 6. as a useful source of updated information, a “covid-19 dashboard” has been developed in the webpage of the directorate general of health services. “bangladesh preparedness and response plan” (bprp) for the coronavirus disease 2019 document was published during july 2020 with the goal to prevent and control the spread of covid-19 in order to reduce its impact on the health, to scale up its core capacities, wellbeing and economy of the country and to set out the framework to treat the infected people.7 the health ministry has established a high-level national technical advisory committee consisting of government and independent experts to advise covid-19 health related issues. however, there was no mentioning of the most vulnerable group of pwd. although about 14 million people live with some form of disability in the country, omission of representation from disability and rehabilitation sector is a concern. the government has recruited an additional 2000 doctors and 5000 nurses to start addressing this situation but no news or indication was available on escalation of members from the rehabilitation team7. covid-19 testing: according to the number of covid-19 cases, bangladesh is positioned 16th in the world. the numbers of new cases are added on regularly. the strategic recommendation of covid-19 preparedness and response was to detect the virus with increasing the testing capacity following the health guidelines provided by who and endorsed by the government. however, there was a great public health concerns and criticizing of the lowest corona virus testing capacity with charging a fee for the test.8 that hampered covid -19 responses as many of the poor or pwd had disadvantages. most of polymerase chain reaction (pcr) testing facilities were based mostly concentrated in the capital city dhaka that required an online pwd non-user-friendly appointment system. another issue was test results, in some cases it was a week-long delay or in some other cases it did not at all arrived to the patient 8. many of the patients with non-communicable diseases (ncd)s or with disabilities could not be admitted in hospitals because of the delayed covid-19 test results. there was a delay for permitting covid-19 serological tests in bangladesh. according to the drafted government policy, the rapid antibody testing kit can be used for serosurveillance, convalescent plasma therapy and research9. bangladesh and disability & rehabilitation health sector. bangladesh is a small country with about 165 million populations. it is the most densely populated country in the world. the load was further burdened with the largest pakistani and rohinga refugees with the fear of mass infections by the corona virus agent.10 bangladesh has poor ratios of doctors nurses and technologists of 1:0.4:0.24 (who: 1:3:5) 11. it is a lower-middle-income developing country (lmic) with less than 3% of gdp is spent on health sector 10. it has poor emergency treatment facilities including hospital beds, central oxygen supply and has limited rehabilitation facilities. bangladesh journal of bioethics 2021; 12 (1): 49-53 51 quality of services at these facilities, however, is quite low due to insufficient allocation of resources, institutional limitations and absenteeism or negligence of providers. according to the who about 15% of bangladesh's total population is disabled. because of lower immune protection they are more likely prone to be infected with corona virus than others. bangladesh had few rehabilitations works forces with mal-distribution of the therapists and rehabilitation physicians5. article 11 of the united nations convention on the rights of persons with disabilities (uncrpd) requires that every state shall adopt all necessary measures to ensure the protection and safety of pwds in situations of risk, including situations of armed conflict, humanitarian emergencies and the occurrence of natural disasters.12 in bangladesh, according to a recent country wide survey, 28.4% of the pwd did not know anything about the coronavirus. this survey also reports that 47% of persons with disabilities are the sole earners in their families and due to covid -19 lockdown restrictions the income of 61.6% of working persons with disabilities decreased13. the report recommended completing the disability identification (and registration process) survey of 2012 with prioritizing the women and children. another report states that about 50% of bangladeshi pwd did not have access to personal protective equipment (ppe) at family level and at works to protect the family members and themselves3. this papa is better suit under heading of bangladesh and disability & rehabilitation health sector. covid-19 disability impact and ethical issues: pwd with major disabling events like traumatic brain injury (tbi), spinal cord injury (sci), limb amputations, or other neuromusculoskeletal disorders including stroke have need more health and rehabilitation care and require frequent hospitalization and rehabilitation team care14. the problem was further intensified when rehabilitation health care professionals were pulled in to the centrally administered covid-19 emergency duty roster then the rehabilitation opds were shutdown5. no record available for reference about the number of pwd affected by covid-19, but the sufferings including child hood disabilities are much more than it was thought15. the entire health system including rehabilitation services were jeopardized by covid-19 which raises challenging bioethical dilemmas16. understanding of disability rights is central in an all-inclusive covid-19 preparedness; which was not obeyed by the policy makers. this has created significant disruptions and additional risks to their autonomy, health and daily living activities. limited and selective rehabilitation therapies were available to pwd resulted to gross reduction of previously attained functional capabilities of the neuro-musculo-skeletal and cardiorespiratory system.17. health care workers had to work hard under lot of anxiety and agony during the pandemic; still there were arguments about their prioritization at the work places18. pwd are not always patients and service seekers; it requires a recognition that doctors and nurses serving pwd have been working at the frontline in this pandemic19. pwd in bangladesh are regularly subjected to discrimination and they suffer greatly during the covid-19 crisis period. many of them could not get reliefs provided by the different public and private agencies because they could not stand in queues or compete with crowds13. maintenance of social distancing and using masks remain as a barrier for blind and deaf person. “social distancing” is not a better term for pwd, it may be replaced with “physical distancing” 20. there was a threat on patientrehabilitation health care worker (rhcw) relationship during the covid19 crisis period. unlike acute and short-term illnesses and disease, this relationship is long term bondage of trust based on moral rules and bangladesh journal of bioethics 2021; 12 (1): 49-53 52 principles. while examining the covid-19 related prevailing ethical issues following recommendation are provided in the box 1. conclusion: there was limited application of existing frameworks of emergency planning for pwd in the covid-19 pandemic. covid-19 rehabilitation preparedness, response and mitigation should be based on ethics driven process. the right of vulnerable populations in the areas of equality of access to health care and supports should not be forgotten during the crisis periods or at peace. access to covid-19 information system and a special response inclusive plan for pwd is of paramount importance. box: 1 recommendations for pwd inclusive covid-19 preparedness and response 1. inclusion of representatives of rehabilitation team members and pwd in the national technical advisory committee (ntac). 2. ntac working groups should explicitly recruit physiatrist, pwd and chronic illnesses in rehabilitation response strategies. 3. increase rehabilitation capacity building with empowerment of pwd21. 4. improved information for pwd and establishing mandatory sign language in all crisis information. 5. establishing special dedicated high level control cell 24 hours services for pwd. 6. to follow the who’s advice for disabilityinclusive covid-19 considerations to mitigate the barriers for pwd22. 7. providing accommodations to pwd who work in a distant place. 8. more online job market should be created for pwd so as to they can work staying at home. references: 1. world health organization. https://www.who.int/docs/defaultsource/searo/bangladesh/covid-19-whobangladesh-situation-reports/who-ban-covid-19sitrep-10.pdf?sfvrsn=c0aac0b8_4. (accessed october15, 2020.) 2. world health organization, bangladesh. https://www.who.int/docs/defaultsource/searo/bangladesh/covid-19-whobangladesh-situation-reports/who-covid-19update-33-20201012.pdf?sfvrsn=8e5f58c7_2 accessed october 14, 2020 3. http://www.edf-feph.org/sites/default/files/i2icovid19-survey-accessible.pdf. (accessed october15, 2020.) 4. white db, lo b. a framework for rationing ventilators and critical care beds during the covid-19 pandemic. jama 2020. doi: 10.1212/wnl.0000000000009936 5. uddin t, siddiq ab, islam mt strategies to adapt covid-19 impacted low resource rehabilitation services. int j phys med rehabil 202 ; 8:558. doi: 10.35248/2329-9096.20.08.558 6. berlinger n, wynia m, powell t, hester dm, milliken a, fabi r, et al. ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: managing uncertainty, safeguarding communities, guiding practice the hastings center 16 march 2020 available from: https://www.thehastingscenter.org/ethicalframew orkcovid19/ (accesses on september 30,2020) 7. bangladesh preparedness and response plan for covid-19. government of the people’s republic of bangladesh. july 2020. file:///c:/users/user/downloads/covid%20sin gle%20plan_approved.pdf (accessed october16, 2020) 8. sophie cousins. bangladesh’s covid-19 testing criticized. the lancet, world report. august 29, 2020. 396(10251): 591.doi:https://doi.org/10.1016/s01406736(20)31819-5 9. government of bangladesh. https://mofa.portal.gov.bd/sites/default/files/files /mofa.portal.gov.bd/page/836e2514_cd8d_48d1_ b4c3_ff51cd37ebd0/bangladesh%20finalises%2 0antibody%20test%20policy.pdf. (accessed october15, 2020) 10. uddin t, rahman ma. covid 19: importance of physical rehabilitation medicine capacity building. mymensingh med j. 2020;29(3):496497. pmid32844784. bangladesh journal of bioethics 2021; 12 (1): 49-53 53 https://pubmed.ncbi.nlm.nih.gov/32844784/ (accesses on september15,2020) 11. http://www.searo.who.int/entity/asia_pacific_obs ervatory/publications/hits/hits_ban_0_executive_ summary.pdf?ua=1. (accessed october15, 2020) 12. united nations. convention on the rights of persons with disabilities. vienna: united nations; 2006. https://treaties.un.org/pages/viewdetails.aspx?sr c=treaty&mtdsg_no=iv15&chapter=4&clang=_en (accessed on september 13,2020) 13. swarna moye sarker. how covid-19 is affecting persons with disabilities. 12 june 2020. https://tbsnews.net/thoughts/how-covid-19affecting-persons-disabilities-92416. accessed october15, 2020. https://tbsnews.net/thoughts/how-covid-19affecting-persons-disabilities-92416 (accessed on september 13,2020) 14. kibria g, islam t, miah s, ahmed s, hossain a. barriers to healthcare services for persons with disabilities in bangladesh amid the covid-19 pandemic. public health in practice. 2020; 1:100027. doi:10.1016/j.puhip.2020.100027 15. unicef data: monitoring the situation of children and women. child hood disability and covid-19. april 2020 https://data.unicef.org/topic/childdisability/covid-19/ (accessed october 21,2020) 16. maya sabatello, teresa blankmeyer burke, katherine e. mcdonald, paul s. appelbaum, “disability, ethics, and health care in the covid-19 pandemic”, american journal of public health 110, no. 10 (october 1, 2020): pp. 1523-1527. doi:10.2105/ajph.2020.305837 17. uddin t, islam m t, rahim r h, et al. rehabilitation perspectives of covid-19 pandemic in bangladesh. journal of bangladesh college of physicians and surgeons 2020; 38 7681. https://doi.org/10.3329/jbcps.v38i0.47345 (accessed october15, 2020). 18. mark p. aulisio & thomas may. why healthcare workers ought to be prioritized in asmr during the sars-cov-2 pandemic? the american journal of bioethics 2020, 20:7, 125128, doi: 10.1080/15265161.2020.1779411 19. newz hook. disabled healthcare professionals stand shoulder to shoulder in the fight against coronavirus march 2020. available from: https://newzhookcom/story/doctors-disa bilitiesdisabled-healthcare-professiona ls-coronavirus/ (accessed october 20,2020.) 20. singh s. disability ethics in the coronavirus crisis. j family med prim care. 2020;9(5):21672171. published 2020 may 31. doi:10.4103/jfmpc.jfmpc_588_20 21. uddin t, rahman ma. covid 19: importance of physical rehabilitation medicine capacity building. mymensingh med j. 2020;29(3):496497. pmid32844784. https://pubmed.ncbi.nlm.nih.gov/32844784/ (access on september 10,2020) 22. world health organization. disability considerations during the covid-19 outbreak, 26 march 2020. world health organization; 2020. available from: https://wwwwhoint/whodocuments-det ail/disability-considerations-durin g-the-covid-19-outbreak. (accessed october21,2020.) author contribution: 1st author taslim uddin conceived the idea, designed of the manuscript, performed the literature search, wrote the initial draft, checked the manuscript meticulously and gave final approval of the manuscript for submission. 2nd author hassan tasdeed mohammad did the critical revision of the article, performed the literature search and gave the final approval of the manuscript for submission. 3rd author naima siddiquee performed the literature search, revised the article critically and checked the manuscript meticulously and gave final approval of the manuscript for submission. conflict of interests: no conflict of interest in this study to declare. microsoft word full article genetic gestational surrogacy hope for muslim shamima bangladesh journal of bioethics 2017; 8(3):1-8 1 genetic gestational surrogacy: hope for muslims shamima parvin lasker1, marcello ghilardi2 1. phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd); professor & head of anatomy, mh samorita medical college, dhaka, bangladesh. visiting professor of clinical anatomy & bioethics, american university of sovereign nation, usa. founding chairman & sectary general, bangladesh bioethics society. treasurer, world association of medical editors (wame) chairperson, ethics & publication, asian pacific association of medical editors (apame) email: splasker04@yahoo.com 2. phd, assistant professor, university of padova, italy. email: ghilardimarcello@gmail.com abstract: more than half a million couples may be suffering from infertility in the world. when in vitro fertilization is unsuccessful, surrogacy may be a substitute choice for many couples. literature shows that ten million muslims are infertile worldwide. according to islamic theology the concept of surrogacy is null and void as formation of blastocyst constitutes from sperm that is transferred to the uterus of a woman who is not married to him. in islam, marriage is the only legal procedure to procreation for preservation of lineage, inheritance, prevention of adultery and prevention of possibility of incest among the half-siblings. genetic gestational surrogacy (sperm of husband and ovum of wife is fertilized by ivf procedure and transfer the embryos to the surrogate mother) may be free from social, legal and moral complications. some islamic countries have reluctant law in favour of surrogacy, as for example iran, lebanon and sporadic parts of the muslim world. this article has attempted to find out a valid notion for accepting genetic gestational surrogacy in major part of the muslim world that may reduce the peril of women who can not give a birth baby. key words: surrogacy, islam, bioethics 1. introduction: assisted reproductive technology (art) has been fascinated by the public after the news of “louise brown, the first test tube baby”, in 19781. infertile couple are inclined to art including donation of gamete (sperm / egg) and surrogacy in an immense expectation 2. however, this new technology for infertility generates debate worldwide. the main ethical, social and legal problem are raised from natural, partial and unrelated gestational surrogacy. fundamentally, there is no the social, legal and moral complication in genetic gestational surrogacy. it is the last alternative for infertility treatment who wants their own genetic baby 3. nonetheless, the widespread uses of such technologies are prohibited by muslim. sunni and shiite are the two main schools of thought in muslim 2. sunni scholars disallow surrogate motherhood, since surrogate mother will carry the baby formed by other man’s sperm to whom she is not married 2,4. they consider the union of ova/sperm other than wife/ husband is as adultery. according to islamic jurisprudence, legal marriage is the only precept for the procreation and a child is illegitimate if marriage is null and void 5. therefore third party reproduction is challenging in islam. on the other hand, shiite scholars do permit surrogate motherhood only for legal couples as the treatment of infertility. therefore, surrogacy is being practiced by shiite population in iran, lebanon and few other part of the muslim world 2,6,7. according to shiite theology, self of embryo is seen totally different from the sperm. they do not consider implantation of embryo bangladesh journal of bioethics 2017; 8(3):1-8 2 into the surrogate mother’s uterus as similar as “sperm of man to whom she is not married” 8. basically, they consider surrogate procedure as transferring of foetus from one uterus to another and they do not see any sin in this practice 9. it is obvious that surrogacy was not mentioned in the qur’an and was not practised at the time of mohammad. but qur’an asserted the significance of family formation, marriage, and procreation 9. some sunni scholars feel that the use of surrogate motherhood is permissible in sunni. because according to islamic law, preservation of the human species is one of the primary objectives of islam 2. moreover, hadit says allah provided a cure to every suffering as he promises 10, 11. with the advancement of science and technology this promise is now become real. although infertility cannot be totally eradicated, but researchers can able to help childless couples to have a child of them. however, there is a gap between the islamic scholars regarding the notion of surrogacy. this article has discussed about the islamic philosophy and theology on surrogacy and has evaluated the main problems, the presuppositions and the conviction involved in the controversy about the genetic gestational surrogacy in islamic culture under the research question “can genetic gestational surrogacy be ethically possible to accept in major part of muslim world?” research methodology: literature review is the basis of this retrospective normative research. articles on surrogacy were thoroughly searched from the year of 1990. google scholar, pubmed, web of science and embase were the possible search engine. key words were islam, surrogacy, ethics and bioethics respectively. this article was written as the requirements for the degree of erasmus mundus master of bioethics at ku leuven, belgium in 2011. social condition of infertile people: infertility may cause intolerable situation for many couples by their family, particularly, who have come from conservative and traditional islamic family13. procreation potentiality dignifies the muslim women, increases their social status, their dignity and self-esteem. it is their social commitments to the family to give birth and rear up children in addition to biological and social functions. moreover, islamic family law envisage wife’s infertility is the major ground for divorce and vice versa. therefore, childless women are always in psychological pressure that their marriages will breakup. however, marriage is usually not end up in the ground of male infertility 4. although in about 50% of cases, male is the cause of infertility, but social burdens are carried disproportionately by the female14. interestingly, some infertile men marry again as a solution of infertility. however, this marriage brings more suffering for the first wife like a two edge saw13 due to negligence and domestic violence15 which ultimately violate the basic human rights of first wife. in some society childless women are excluded from family functions such as birthdays, marriage ceremony and other event of children16 in some countries, infertile couples are regarded as a socioeconomic burden due to loss of continuity, rights to property and inheritance, and discontinuity of family name15. in some culture, childless couples suffer from insecurity. in this culture, children supports economically and socially to family and provide reversible duty to parents when they become old17. “in egalitarian societies, people want children as part of their life plan and they suffer when they cannot fulfil their wish”18. therefore, importance of infertility treatments particular in the muslim world is needed. definition and classification of surrogacy: dictionary meaning of surrogacy is alternate, substitute or proxy. surrogate mother is she who carries the embryo on her womb to term and gives birth a baby on behalf of another couple. if surrogate mother is impregnated with the semen of other man by national process of body contact is known as traditional surrogacy or straight surrogacy. if an ovum or a sperm is collected from a third person and then fertilized in the laboratory and resulting embryo is transferred to the couples’ wife is known as partial surrogacy. when both the ovum and sperm are fertilized in vitro and transfer to surrogate mother, is known as gestational bangladesh journal of bioethics 2017; 8(3):1-8 3 surrogacy. gestational surrogacy are two types. when both the ovum and sperm are donated and fertilized in vitro and the resulting embryos are embedded to the uterus of surrogate mother, is known as full surrogacy or unrelated gestational surrogacy. if sperm and ovum are taken from intended couple and fertilization in vitro and the resulting embryo is transferred to the surrogate mother is known as genetic gestational surrogacy3. in gestational surrogacy, surrogate mother is not genetically related to the child. she has no responsibilities to rare up child after delivery. islamic jurisprudence on surrogacy: islamic jurisprudence (sharia law) regulates the daily living of the followers and shapes the people life to safeguard the peace, contentment and welfare in the society 19. sharia law is based on four source. the first and the most vital source is the qur’an. the second basis is hadit or sunna, the act was done or approved by prophet muhammad (died 632 ad). the third foundation is the agreement of doctors of law (mufti, fuqaha) and islamic scholars (ulama, aimma) is called ijma, and the fourth is analogy (qiyas), act as similar as arab tradition during mohammad period 8. muslims access the hadit if there is no guidance in qur’an. if the hadits have no guidelines for a particular enquiries for clarification, muslim seek guidance from doctors of law and islamic scholars in the form of consensus. in certain situations, islamic scholars clarify the rules analogy to situation of mohammad period. if none of three provides an answer, muslim scholars must depend on individual intellect (ijtihad) to make a judgment in view of necessity, public interest and the principle of “no harm” 20,21,22 . despite, the qur'an categorically presents all the guidelines and directives of life, but it does not explicitly focus on every possible situation a muslim may face now a day. as for example art. islamic scholars address the art and provide verdicts. usually verdict comes from al-azhar university in egypt, the oldest and most important religious university for muslim and the international islamic fiqh academy in jeddah, saudi arabia23. in 1980, grand shaykh of al-azhar university, issued the first bioethical decrees on art. it permits treatments of all kind of art but third-party reproduction in any form is rejected including surrogacy 4. ideological difference between sunni and shiite: sunni are the followers of mohammad and shiite are the follower of ali. imam ali was the cousin of mohammad and fourth successor / ruler of islam after mohammad died. majority (90%) muslims are sunni in the world 8. sunni examines all the contemporary critical social, legal, ethical and medical issues mainly in the light of sharia law, though they have tradition to use ijtihad. on the other hand, shiite deals the newly emerging issues by use of individual intellect (ijtihad) in addition sharia 24. ijtihad has led to a great difference between shiite and sunni 25. shiite religious authorities exercise ijtihad a grater extends in question of moral goodness and badness on the basis of individual intellectual reasoning. consequently, contemporary emerging ethical issues are discussed and categorized in the light of both scripture and intellect and provide verdict (fatwa). highest-ranked religious authorities (grand ayatollahs) can only issue a fatwa13. in 1999, ayatollah ali hussein khamanei, the supreme leader of iran, issued a religious verdict on reproductive technology that permitting the donor technologies including surrogacy. prevention of breakage of marriage and psychological disputes have prioritized in this verdict 6. though shiite, is powered by authoritarian systems in some cases, however, all bioethical verdicts do not basically vary from the sunni positions 26. islamic philosophy on surrogacy: two years after the birth of 1st test tube baby, islamic scholars issued bioethical decrees on medically assisted reproduction, permitting treatment for all type of art, but prohibited third-party reproductive technology, including surrogacy. philosophical interpretations for prohibition of the third-party reproductive assistance are as follow: adultery: according to islam, marriage is an agreement of sex and procreation between couples. third person is not allowed into the connubial functions 5. qur’an describes bangladesh journal of bioethics 2017; 8(3):1-8 4 “those who guard their private parts except from their spouses... but whoever seeks to go beyond that, these are they that exceed the limits” (quran sura al-mu’minun 23: 5 & 7) 27. “reproduction outside of marriage is considered as adultery (zina)” 27. the moral implication of the embryo transfer other than wife is tantamount to adultery. sperm/ eggs donation is prohibited in islam as it annihilates the lineage5. ”islam noted adultery as a punishable crime in order to preserve the lineage “ 5. lineage: the legal importance of family, lineage and blood relations is markedly noticeable in islam 28. the qur'an mentions “it is he (allah) who created mankind from water, then has he established the relationship of lineage and marriage for your lord has power over all things” (qur'an sura al-furqan 25: 54) 29. destruction of genealogical lineage (especially patrilineal) may have two way devastating interference for kinship and inheritance 5. third-party donation is difficult in islam as it destroys a child’s lineage, which may have psychologically suffering for the child in one hand. on the other hand, father may be reluctant to do his duties and responsibilities to the child if he knows that the child does not genetically belong to him specially during social and economical hardship. in addition, child may face domestic violence. moreover, in islam, child has right to inherit the property of his or her genetic parents only30. therefore children conceived in third party arrangement may have devastating consequences. some may argue that the third party donation should be seen as similar as child adoption thereby, a child can use surname from adoptive parent 31. however, the quraan encourages kind upbringing of an orphan but explicitly prohibits adoption 32. “if a child is not the person’s real child, it cannot become so merely by virtue of a declaration. claiming an adopted child as one’s own deprives the real heirs of certain rights. he has not made your wives whom you declare unlawful your mothers. and he has not made your adopted sons your [true] sons. that is [merely] your saying by your mouths, but allah says the truth, and he guides to the [right] way. call them by [the names of] their fathers; it is more just in the sight of allah . but if you do not know their fathers then they are [still] your brothers in religion and those entrusted to you. and there is no blame upon you for that in which you have erred but [only for] what your hearts intended. and ever is allah forgiving and merciful (qura’n sura al ahzab 33:4-5)32. islam implies purity of lineage and significance of information of one’s personal familial lineage 33. hiding from child true genetic lineage and heredity, islam considers it as deceit 34,35. islam gives right to know one’s parentage fully. lack of information of one’s lineage may cause one to marry a half-brother, half-sister 4. incest among the half-siblings: qura’n explicitely defines certain relationships between which there cannot be any marriage at all 36. “forbidden unto you are your mothers, and your daughters, and your sisters, and your father's sisters, and your mother's sisters, and your brother's daughters and your sister's daughters, and your foster mothers, and your foster sisters, and your mothers-in-law, and your step daughters who are under your protection (born) of your women unto whom you have gone in but if you have not gone in unto them, then it is no sin for you (to marry their daughters) and the wives of your sons who (spring) from your own loins. and (it is forbidden unto you) that you should have two sisters together, except what has already happened (of that nature) in the past. lo! allah is ever forgiving, merciful.” “lawful unto you are all beyond those mentioned, so that you seek them with your wealth in honest wedlock, not debauchery. so wed them by permission of their folk, and give unto them their portions in kindness, they being honest, not debauched nor of loose conduct.” (qur’an surah an-nisa 4: 23)36. anonymous donors may cause potential “incest among the half-siblings”. third party reproductive technology may harm not only to the individuals involved, but in a long run to the society as a whole 37. discussion: islamic bioethics, theology, philosophy or jurisprudence is scriptural; therefore, amendment is critical along with bangladesh journal of bioethics 2017; 8(3):1-8 5 paradigm shift. according to islam, the third party donation of procreation is prohibited. adultery, possibility of “incest among the halfsiblings” from unknown donors and genealogical lineage are the concern in partial and genetically unrelated surrogacy. therefore, third party donation and unrelated surrogacy are virtuously wrong and banned from the standpoint of islamic ethics. genetic gestation surrogacy may have still room to discuss. in genetic gestational surrogacy, breakdown of lineage is impossible as the biological parents are already known. actually surrogate mother is not engaged in any act of adultery in this procedure, as there is no involvement sexual body interaction of adulterous relations, hence, the punishment of adultery is not applicable. by virtue, introducing an extramarital third party engagement may threaten the marital bond of husband and wife 37. only question can arise from genetic gestational surrogacy is “who is the real mother, the genetic mother or the birth mother?” qur’an defines motherhood as their mothers are only those who conceived them and gave birth to them (waladna hum) (al quran surah al-mujadalah 58: 2)38. the arabic word “walada hum” means the whole procedure of pregnancy from fertilization to perturation. it is not just act of carrying (haml) or delivery (wad’) 37-40. thus, qur’an denies unconditionally any rights to genetic mother in surrogate arrangement. actually, the islamic bioethics is based on four doctrines of “necessity, public benefit, local custom, and justice”21,26,41. but if one is compelled by necessity, neither craving nor transgressing—there is on him no sin, for indeed god is clement, merciful. (quran sura al bakara 2:v. 173)42. in context of absolute necessity, islam sometimes allows forbidden actions suspending the sharia law if there are no religiously legitimate alternatives exist. as for example the insulin and heart valves. insulin is manufactured from pork and a heart valve is made from pig. qur’an repeatedly prohibits consumption of pork for muslim. however, islamic scholars allow medical treatment with pork insulin and pig heart valves on the principle of necessity and public benefit 35. further, maturation is prohibited by qur'an27. “the successful believers] who abstain from sex, except with those joined to them in the marriage bond, or (the captives) whom their right hands possess, for (in their case) they are free from blame, but those whose desires exceed those limits are transgressors … (qur'an, sura almuminun 23: 5-7) 27. but masturbation is allowed for the collection of sperm for art with substantial arguments of necessity and public benefit.43. another, the donation or transplantation of sexual organs is haram (forbidden, sinful) by qur’an 44,45,46. however, in april 2000, first uterus transplantation has been successfully attempted in saudi arabia and the second human uterus is transplanted in turkey in august 2011 44,46. though the donation or transplantation of sexual organs is prohibited by qur’an but it is allowed to fulfil the islamic principle of procreation and maintaining the family lineage. in favour of argument of uterus transplantation, it is explain that the main function of the uterus is holding a developing fetus to maturity, it is not something that relates directly to the carrying of the inherited genes of the infant45. in genetic gestational surrogacy, surrogate mother is merely carrying baby in her womb till birth. there is no chance of carrying of the inherited genes of the infant in this case as well. there are many more example in islam where prohibited action become permissible violating the primary source (qur’an) for greater necessity and public benefit. these do not generate any legal and moral problem vis a vis islamic guidelines. moreover, qur’an repeatedly encouraged marriage, family formation and reproduction. wealth and progeny are the allurements of this world (al quran, surah 14:46)47. or bangladesh journal of bioethics 2017; 8(3):1-8 6 we did send apostles, before thee, and appointed for them wives and children" (quraan sura al-ra'd 13:38) 9. preservation of the human species as one of the primary objectives (maqasid) in islam. therefore, if a married couple enable to give birth a child, their inability should be overridden by treatment. if genetic gestational surrogacy is one method, ban can be adjourned in light of principle of primary objective that is procreation. however, qur’an acknowledges significant hardship of infertility. examples of two childless prophets e.g. abraham and zacharyyia has been described in quran and depected how they longed to allah and pray sincerely and continuoiusly with faith to have a child of their own, even as they grew old. god answered their prayers and they had had themselves son with knowledge. and those who pray, our lord, grant unto us spouses and offspring who will be the comfort of our eyes (al quran sura al furqan 25:74). 48 moreover, prophet muhammad says, for every disease, there is a cure except senility (hadit, bukhary and muslaam) 10. prof abul fadl moshin ebrahim, emeritus professor of religious, philosophy and classic, university of kwa zulu-natal, durban, argued that if the state of infertility is think of a “disease”, then it should be allowed to seek tratment to overcome infertility 49. as the genetic gestational surrogacy has no moral and socio-legal complications, it should be permitted to childless couples whose family continuity is always an impossible. still, motherhood has seen problematic in genetic gestational surrogacy. who is the real mother? according to definition of motherhood in qur’an, mother is she who carry and gives birth baby. however, in may 2004, ezyptian sheikh abdel rahman al adawy, head of the council jurisprudence research committee, raise question, who is the mother of the child in case of uterus transplantation? does mother can donate uterus to her daughter or vis versa 8? same questions may rise again whether it is allowed where introducing of “sperm of a man into the uterus of a woman to whom he is not married”. political motivation weighing the necessity and public benefit overcomes the above mention question in case of uterus transplantation. however, the notion of milk mother or wet nurse (hiring a breast feeding woman to feed a child whose mother enable to breast feeding to child or died during delivery) is an acceptable practice in arab tradition even practised in prophet mohammad himself situation 37.39,40. this can be used as an analogy model for the genetic gestational surrogacy. surrogate mother is merely carrying baby in her womb in hardship of other sister who is unable to give birth baby due to cancer or disease. genetic mother will provide tissues (ova and sperm), whereas the gestational mother will be responsible to provide nutritional input to build up in her womb like the milk mother. it protects human rights to life, so this practice will not bring any psychological and social harm to achieve final good. basically, genetic gestational surrogacy has no social, ethical, legal and theological impediment. a political approach of motherhood is only problematic in this method. as both the biological and genetic mother does not commonly satisfied the definition of motherhood, so justice can be employed to genetic mother as the lineage is already proofed. quran says islam is not religion of hardship (usr) but a religion of ease (yusr) 49. furthermore, “the sharia is not a rigid law rather it is flexible enough” to accommodate different honest opinions that have direct benefit of humanity 22. only the political motivation is needed in case of genetic gestational surrogacy to over ruled the prohibition. conclusion: available literature shows that the artificial reproductive technology is allowed in islam but it disallow all type of third party assistance reproduction as it encompasses adultery, destruction of lineage, inheritance problem and incest among the half-siblings. in these four grounds natural, partial and bangladesh journal of bioethics 2017; 8(3):1-8 7 genetically unrelated full surrogacy actions have brought out debate, disagreement, and controversy. there is no questions of above mentioned four problems in genetic gestation surrogacy except question of motherhood. justice can be employed giving the motherhood to genetic mother for preservation of lineage. only the political motivation is needed in the case of genetic gestational surrogacy. limitation: many books and articles have been published in arabic, farsi and other language locally that are not included in this brief manuscript. articles written also remain outside of discussion due to inability of access foreign language. only english and translated literature has been considered for this article. competing interests: the authors declare no competing interests. author contribution: 1st author conceive the idea, done literature review and wrote the manuscript. 2nd author guide to write the manuscript and check the manuscript meticulously. references: 1. norhayati ha. assisted reproduction islamic views on the science of procreation. eubios j of asian and intern bioethics 2003; 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30(1):147157. 31. clarke m. shiite perspectives on kinship and new reproductive technologies. isim review 2006; 17: 26–27. 32. al qur’an, sura al ahzab 33: v. 4-5 . 33. serour gi. ethical considerations of assisted reproductive technologies: a middle eastern perspective. opinion. middle east fertile soc j 2000; 5:1:13-18. 34. serour gi. bioethics in infertility management in the muslim world http://www.islamic-world.net/sister/h12.htm (access in 2011 december 2). 35. gatrad a r and sheikh a. medical ethics and islam: principles and practice. arch dis child 2001; 84:72–75. 36. al quran, surah an-nisa 4: v. 23 37. kholwadia sma. the islamic ruling on surrogate motherhood, http://www.ilmgate.org/the-islamic-rulingon-surrogate-motherhood/ (accessd on 27th feb 2012). 38. al quran surah al-mujadalah 58: v. 2. 39. kabir m and az-zubair b. who is a parent? parenthood in islamic ethics. j med ethics 2007; 33:605–609. 40. zuhur, sherifa 1992 of milk-mothers and sacred bonds: islam, patriarchy, and new reproductive technologies. creighton law review 25:1725–1738. 41. weber as. bioethical reasoning in islam. international journal of arts and sciences 2010; 3(15): 607-617. 42. al quran. sura al bakara 2:v. 173. 43. sharmin i, rusli bn, rani a and hanapi bmn. ethics of artificial insemination: an islamic prospect. jima 2007; 39: 29-32. 44. amel alghrani. regulating novel methods of reproduction: womb transplantation and islamic bioethics. qscience proceedings: vol. 2012 . http://www.qscience.com/doi/abs/10.5339/ qproc.2012.bioethics.5.7 (access january 2013) 45. morgan clark. fertility, reproduction and sextuality. in vol 16, islam and new kinship, reproductive technology and sharia in lebanon, berghan books, 2009 page 107 oxford. 46. al-qardawi, yusuf (1999). the lawful and the prohibited in islam. american trust publications. p. 82. 47. al quran, sura al-shura 14:v. 49-50. 48. al qur’an sura al furqan 25:v.74. 49. ebrahim afm. biomedical issues: islamic perspective. kuala lumpur: a.s. noordeen; 1993. microsoft word dignity community and albism in malawai bangladesh journal of bioethics 2018; 10 (1): 6-10 1 dignity, community and albinism in malawi vitumbiko nyirenda university of the witwatersrand, johannesburg, south africa. email: vitumbikoh@gmail.com abstract: thaddeus metz, “african conceptions of human dignity” (2012), presents an african conception of dignity that he relates to human rights. in this paper, while ignoring metz’s discussion on human rights, i specifically look at how this conception can be applied to one of the problematic moral issues, killing of persons with albinism. that is, how metz’s view would account for exclusion and wrongness of killing of persons with albinism. i argue that the killing of persons with albinism is acting in violation of their dignity. this comes from the view that persons with albinism are human beings with a dignity, and therefore ought not to be killed. i offer a discussion on how dignity as capacity for community based on shared identity and good-will is not reflected in the way persons with albinism are treated in malawi. keywords: albinism, dignity, shared identity, solidarity, thaddeus metz, community. introduction: thaddeus metz in his paper, “african conceptions of human dignity” (2012), presents an african conception of dignity that he relates to human rights. in this paper, i look at how this conception can be applied to one of the problematic moral issues, killing of persons with albinism (pa ). that is, how metz’s view would account for exclusion of persons with albinism in malawi. the paper answers the following question, “can metz’s conception of dignity based on community offer an explanation about the wrongness of killing of persons with albinism?” i offer a positive response to the question by showing that killing of pa(s) is acting in violation of their dignity. dignity under metz’s conception is understood as the capacity for community, and he defines community as based on shared identity and solidarity1. i will cash out theviolation of dignity as capacity for community in terms of failure to acknowledge a sense of shared identity with pa(s) as well as lack of solidarity or goodwill. the paper has three sections. in the first section, i will present metz’s conception of dignity. in section two, i will show how this understanding of dignity can be applied to explain the killing of pa(s). in the last section, i will present some alternative worries in relation to the arguments provided in the paper. i metz begins his paper by making a distinction between a concept of dignity and a conception of dignity. by concept, he means that which “makes a given theory one of dignity as opposed to something else,” whereas a conception of dignity “aims to account for an underlying structure of the myriad things with dignity by invoking few properties as possible”1. a concept of dignity he comes up with is the “idea of what it is about a human being that makes them objectively good for their own sake to an equally incomparable degree entitling them to respectful treatment in the form of bangladesh journal of bioethics 2018; 10 (1): 6-10 2 recognizing human rights” 1. there is a lot to be unpacked here. firstly, the phrase “objectively good,” means that dignity is not dependent on one’s mental states or that it is not a social construction. thus, a human being has a dignity and it is neither because of what one believes, thinks and desires about a human being, nor dependent on social factors. however, it is a “natural property of an individual that ought to be recognized” 1. this means that dignity is dependent on a natural property of some feature of human nature 2. secondly, “for their sake” according to metz is to have noninstrumental value, thus, human beings are not good as a mere means to something else but as an end 1. thirdly, “incomparable” means that “whenever one must choose between something with dignity and mere price, a person must choose one with dignity” 3 “price” here refers to the view that “something else can be put in its place as an equivalent” and dignity has no equivalent 3. therefore, dignity is something irreplaceable. lastly, because people have a dignity, this gives them moral worth and value; thus, they are to be treated respectfully 1. it is this concept of dignity that metz works with to present his african conception of dignity based on vitality and community. the term “vitality” refers to the idea of life force. it is difficult to state exactly what it is, but traditionally, it is understood as “valuable spiritual or invisible energy that inheres in physical or visible things” 1. this meaning has religious underpinnings and metz ignores this religious understanding. instead, he presents a naturalist idea where life force is understood as liveliness or creative power 1. he states that liveness is manifested in the “degree of health, strength, reproduction, self-motion, courage” and the lack of life force characterized by “presence of disease, weakness, barrenness, destruction” 1. for the sake of brevity, i will ignore this vitality-based view of dignity. nonetheless, i will use a traditional view of life force in discussing some views on african ontology below. this leads me to another conception of dignity provided by metz, the communitybased view. according to metz, a human being may be said to have a dignity based on their capacity for community 1. for metz, community is understood in terms of shared identity and solidarity or good-will 1. shared identity for metz is for individuals to think of themselves as the “we”1. this presupposes an identity an individual has with her community. a better way to understand what this entails is to refer to john mbiti who has written extensively about individual and community. mbiti discusses a relationship an individual has with her community. according to mbiti, the individual is defined by her community and cannot exist outside it. the individual sees herself as a product of the community. for mbiti, a person says to her/himself, “i am because we are, and since we are, therefore i am” 4. thus, by “we,” he means to see oneself within the context of a community where one is defined and is a product. this point is echoed in neal and paris who describe such type of identity as an essential share relation in which the community penetrates the identity of individuals 5. thus, the “identity of each self in the community in partially or wholly constituted by the communal relations” 5. secondly, according to metz, by identifying oneself to be part of the group, that group should also consider that individual to be part of it. thus, if one considers oneself as the “we”, the “we” should consider the individual to be part of it 6. this expresses the reciprocal nature of identity, where one does not just claim to be part of the group but the group also recognizes the person to be its member. although metz does not express the point in this way, it would mean bangladesh journal of bioethics 2018; 10 (1): 6-10 3 that the individual is equally important just as the group one belongs to. furthermore, being a member of a group means sharing goals or ends with them. it also includes working together to accomplish these ends. this is the view of shared identity metz presents. however, he argues that it is hard to see the moral significance of shared identity. therefore, he turns to another view of community, solidarity or good-will 6. on good-will, metz talks about mutual support. he lists a number of actions in which good-will might manifests. for metz, this is when a person, wishes another person well (conation); believes that another person is worthy of help (cognition); aims to help another person (intention); acts so as to help another person (volition); acts for the other’s sake (motivation); and, finally, feels good upon the knowledge that another person has benefited and feels bad upon learning she has been harmed (affection) 6. in other words, part of good-will is the desire to see others succeed or benefit. this is also accompanied by the belief that other people are worthy of this benefit (whatever that is). an individual may also act in a way that she sacrifices herself for the benefit of others 6. this is explained by those who would put their lives on the line with the hope of rescuing the person in a dangerous situation. central to this is the notion of care. that is, caring for one another whose duties may be grounded in common humanity 7. as pointed out above, part of shared identity is to share goals or ends, and under the notion of good will, metz explains this idea in terms of helping others achieve their ends, sympathize with them and helping them for their sake 1. this may be grounded in the view that achieving or acting in ways that promote the ends of others is one way of promoting one’s ends. failure to show good-will is to be hostile or cruel to others 1. according to metz, a proper account of community requires both shared identity and good-will 6. this is because one could think of shared identity without good will, as well as goodwill without shared identity but in defining a community both are important. in relation to dignity, metz argues that human beings have a dignity through their capacity for community. this is different from being in actual relationships or exercising this capacity 8,9. merely having it gives one a dignity. therefore, human beings have a dignity in virtue of their capacity to be in relationships where they share an identity with others and act in good will or solidarity. this is a capacity plants, inanimate objects, and other some nonhuman animals lack 1. metz connects his idea of dignity to human rights. he argues that to respect human rights is to respect dignity (capacity for community) and to violate human rights is to degrade this capacity 1. but my paper ignores a discussion on human rights and only engages with his conception of dignity based on community. my aim is to show how it can be used to explain the violation of dignity when pa(s) are killed. i cash out violation of the capacity for community by showing that there is lack of shared identity and good will. the major assumption i am working with is that pa(s) are human beings with a dignity and value. it then automatically follows that they ought not to be killed (ceteris paribus), where killing is a violation of their dignity. ii in this section, i would like to explain (briefly) what albinism is and offer a bangladesh journal of bioethics 2018; 10 (1): 6-10 4 discussion on how people with albinism are treated in some african communities especially in malawi. thus, i will discuss why pa(s), despite being people with a dignity and value, present a problem to the community. i will discuss how pa(s) are negatively treated, the worst being murder. this will be supported by beliefs people hold related to albinism. i will later show how these beliefs indicate people’s actions that violate pa(s) dignity, hence, manifesting lack of shared identity and good will. albinism is a “group of genetically determined disorders of the melanin pigmentary system characterized in man (humans) by congenital hypopigmentation (loss of color) of hair, skin, and eyes (oculocutaneous albinism) or apparently limited to the eyes (ocular albinism)” 10. albinism can be found in other animals, but i will only focus on human beings. as described in the definition, melanin disorder brings about the phenotypical distinctions in pa(s). these distinctions are in terms of the color of the skin, eyes and hair. as i will show, these distinctions have partly perpetuated the killings of pa(s). in any case, it is arbitrary to take these differences in appearance as reasons for perceiving pa(s) as non-human beings, and therefore, without a dignity and value. if phenotypical differences are a factor, then one would wonder why it is these differences in pa(s) that are taken seriously unlike any other differences in people without albinism (nonpa) such as age, height and body shape (skinny or plump). in any case, it raises an interesting question that despite the fact that they are human beings with a dignity, which follows that they ought not to be killed, they still get killed. to answer this question, i will look at community perceptions of pa(s). one of the reasons to explain negative perceptions is by appealing to the notion of alterity or otherness. alterity or otherness can be defined as “the quality of being different, unusual or alien from the conscious self or a particular cultural orientation” 11. in other words, as elvis imafidon also puts it, it is “being different from the status quo” 11. imafidon has not explained how the notion of “the other” comes to be. in other words, how something comes to be perceived as the other. a point i think is important in understanding why distinctions in appearance for pa(s) are of special interest than that of non-pa(s). my proposal here is to appeal to the notion of normality. normality understood in terms of what the society has considered as the status quo or what they have taken to be normal. in this sense, the “other” would be what is considered as different from what is normal. furthermore, what is normal is defined by certain characteristics that the society has taken to be important 12. the central question to ask here then is why it is this or that particular characteristic that defines what is normal? part of the response would be that it is what people are used to (familiarity), and find interesting or important in bringing about their desired end (whatever that might be). in other words, there are certain categories that society has accepted as important, these define what is normal and are usually prima facie based on (but not limited to) appearance 13. what may be worrisome is that much of what may be desired as normal (prima facie based on appearance), people go ahead to act on it before they question what lies beyond mere appearance. for instance, disability was for so long considered as a curse in some traditional african communities because a person with a disability looked different from what people considered as normal body, without a disability 11. it is until recently that in some bangladesh journal of bioethics 2018; 10 (1): 6-10 5 communities, people understand disability to be a genetic condition. but without a deeper understanding (facts about the condition), one of the ways people tried to explain the differences in appearance, has been to appeal to myths or beliefs. in any case, this should also explain why pa(s) are maltreated based on their appearance, as different from other human beings especially in predominantly black communities 11. this is because in such communities, people take a category of “normal” skin for a person to be “black.” however, since albinism, as imafidon shows, is regarded as “otherness” in african communities, it would be helpful to look beyond the notion of normality, and uncover something deep that comes with it. to understand albinism in this latter context, it would help to refer to african ontology. polycarp ikuenobe and placide tempels have provided a picture of african ontology where african ontology is understood as holistic. reality is taken to be a “continuum and a harmonious composite of various elements and forces” 14. however, with this continuum is the natural and the supernatural. understood from tempels, perspective, common to both the natural and supernatural is possession of life force 15. life force is the essential to the understanding of being. for tempels, being is considered as force and force is likewise considered as being. meaning to say that, what people see as the interactions of different of beings, can be understood as the interaction of different forces 15. furthermore, there is a hierarchy of being or what can be called the hierarchy of forces. thus, there are degrees of life force where the possession of life force is different from one being to another, with god at the top of the hierarchy possessing a great amount of life force and decreasing as one goes down the hierarchyspirit beings or deities, human beings, non-human animals, plants, and at the very bottom are inanimate objects 14,15. i will not go into details on these insights, but what is presented is enough to ground my discussion below. nonetheless, what the hierarchy shows is that the natural and supernatural are part of the same reality. another important point to consider is that “reality and the human place in it, always seeks to maintain equilibrium or harmony among the network of elements and life forces” 11,14. equilibrium here can be associated with continued existence. disequilibrium or lack of harmony can be associated with threats to existence such as “human illness, natural disasters or disruption 14. a question remains as to how this relates to albinism in a human community. it is important to note a picture of reality presented above as encompassing the natural and supernatural accounts for all that is believed to exist. however, according to imafidon, there are other entities that are excluded. what is excluded is considered as a threat to the balance reality seeks to maintain for its continued survival 11. one way to understand imafidon’s point is to state that “exclusion” here does not mean that it is not an entity or something that can be described as part of reality possessing life force, instead it only means that it is a threat to harmony. hence people seek to eliminate it from their understanding of what reality is since it is taken to oppose the purpose of reality, by bringing about disharmony. community members perform certain actions to maintain balance or harmony to deal with what they perceive as a threat. according to imafidon, any human community would want to protect itself from extinction, and this makes it discriminate or isolate what threatens its existence 11. in most communities, “otherness” is considered as a threat. this is because it does not fit with the established standards or status quo underlying a bangladesh journal of bioethics 2018; 10 (1): 6-10 6 particular understanding of harmony (whatever that is). in most african communities, albinism as “otherness” is taken as that which threatens or bring about disharmony. in this group, one also finds twins or triplets, witches and wizards, sorcerers, and the morally bankrupt 11. as a threat, common actions facing the groups just listed include banishment or being exiled, discrimination by being denied certain services and getting killed 11. the range of actions i have just listed including being called de-humanizing names, more especially among pa(s) can all be considered as violations of their dignity. they are not respected as human beings with a dignity. some beliefs about albinism illustrate this point. for instance, the first time i heard one of the beliefs people hold about pa(s) in malawi, was that they do not die but vanish or disappear. this means that they are not buried and one cannot find a corpse of a pa. there are various moral implications of this belief which i will explain below. nonetheless, i will ignore the various practices associated with treatment of corpses that portray the kind of respect given to a person. instead, i will take a different angle looking at what this means with regard to human nature. a related but somewhat different point is the belief that a baby with albinism is a ghost. it is believed to be a ghost of dead person who has now returned in the form of a pa, “white baby”. the vernacular name for “white person” is “mzungu,” which means “caucasian” in chichewa language. some parents caution their children not to look at babies with albinism because doing so would make the child disappear. sometimes parents of children with albinism are banished from the community 16. in some instances, a pregnant woman is told to spit after looking at a pa. failure to do so would lead to giving birth to a child with albinism 17. in any case, there are conflicting views regarding the color of the skin. a child with albinism is called a ghost because of whiteness, yet on the other hand (probably associated with a history of colonialism), “whiteness,” is associated with admiration, a very interesting and disturbing point. most people tend to associate a white person with certain privileges or high status in a society 17. in most rural areas of malawi, people see a white person as having a better or higher social-economic status, and yet the same name given to pa(s) seems not to have a positive impression. this is partly because “whiteness” in pa comes within the context of a predominantly black community and more especially being born from both black parents, hence creating all different beliefs around it, as a way to explain how this possible. furthermore, other beliefs some people hold about pa(s) have much to do with suing them for instrumental purposes. for instance, there are those who believe that having sex with a pa would cure hiv/aids 17. similarly, some people believe that pa(s) bones are believed to be important in money-making rituals 18. this has been the belief that has perpetuated much of the harm done to them in malawi. as a result, some pa(s) have had their limbs mutilated, graves of pa(s) exhumed to get bones, and worst of all, they are killed for their bones. the question remains as to what to make of these beliefs in relation to a previous discussion of otherness. one part of the response is that these beliefs are motivated by differences in appearance and also reveal maltreatment of pa(s). however, i think there is something underlying the beliefs in relation to otherness. otherness here seems to be more than being a mere phenotypical distinction. one way of cashing out this idea, as imafidon does, is that the myths point to an implicitly perceived ontological difference 11. in other words, the beliefs illustrate the idea that pa(s) are taken to be ontologically different from other human bangladesh journal of bioethics 2018; 10 (1): 6-10 7 beings. for instance, calling pa(s) “ghosts” indicates that they are ontologically different from human beings. this is because if one locates ghosts within african ontology, ghosts are not in the same realm as human beings. ghosts are believed to be spirits, hence they are found within the supernatural realm, just like ancestors. but unlike ancestors the idea of ghost in most communities has negative connotations. people venerate ancestors by offering sacrifices, but they tend to fear ghosts because they are associated with harm and they have various means (whatever these may be) of dealing with them. furthermore, the belief that pa(s) vanish says something concerning beliefs about their nature, considered different from that of a human being, based on events a human being experience. the two major events are the time of birth and death. in the african context, these events are significant and are followed by certain rituals 4. a belief that pa(s) vanish eliminates the idea of natural death (as opposed to being killed). however, it is not clear at what point in their life they vanish, whether when a person is about to die or at a certain age. in any case, if a human being is associated with birth and death, then the absence of death may lead to belief that a pa is not human. in addition, the belief that pa(s) are a means to making money and cure to hiv/aids points to the kind of treatment they receive. this means that they are a means to further some end. in communities where poverty is a major issue as well as the lack of a cure for hiv/aids, it means that pa(s) live in fear. fear that comes from seeing themselves as a potential murder or rape victim, they are likely to be killed for their bones or raped as a cure for hiv/aids. the latter behavior can be cited as a cause for the spread of hiv/aids among pa(s). nonetheless, the belief that they are a mere means to some end, points to the attitude that pa(s) are taken to be at a level lower than that of a fellow human being (with a dignity) to which this belief is not ascribed. this means they are perceived to be at a level, like an instrument or object that can be merely used in a similar way (to make money or as a cure) to which the concept human being may not apply. a further point to consider now is how all this relates to metz’s idea of community in terms of shared identity and good will which is the framework of this paper. as pointed out, shared identity implies a sense of “we.” if the “we” is a group of human beings, and a pa is the “other,” it follows that the “other” being ontologically different is not part of the “we.” secondly, part of being the “we,” is not just saying one is a member of the group, but that the group should recognize you as its member. a pa may consider oneself to be a human being (with dignity), but fellow human beings, as understood from the beliefs explored above, seem not to recognize a pa as a human being. furthermore, according to metz, part of sharing an identity, is sharing ends or goals and working together to achieve them. but to treat a pa as a non-human and a means to make money with their bones, shows a lack of shared ends. thus, there is failure to recognize that pa(s) are human beings who share the same ends with other humans. instead, they are seen as a means to some further end, money. this means that they (pa and non-pa) are not working together to achieve the same end (say promoting each other’s humanity or dignity), since they do not share the same end. therefore, there is lack of shared identity with the pa(s). a similar approach of showing lack of shared identity with pa(s) can be applied to showing lack of good will or solidarity. earlier on, i argued that a community deals with threats to preserve its own existence and survival. in other words, the community bangladesh journal of bioethics 2018; 10 (1): 6-10 8 aims at preserving harmony for its own survival 11. albinism as an “other” and identified as a threat, it is a threat to the harmony of the community. therefore, certain actions may follow to preserve or promote this harmony. such actions are considered or may be justified as morally right. according to metz, “an action is right just insofar as it produces harmony and reduces discord; an act is wrong to the extent that it fails to develop community” 2. it follows then that, if pa(s) are regarded as a threat to the harmony of the community, actions toward pa(s) are likely to be justified as morally right. in other words, maltreatment of pa(s) may find justification within the context of a community in the name of promoting of harmony 11. for instance, a community that sees a baby with albinism as a ghost (where ghosts are considered dangerous), such a community will have no problem killing such a child or banishing the parents and their child. banishment or killing of pa(s) may be justified as morally right by the community. as previously cited, good will (and dignity) involves wishing others well, helping them become successful, feeling good that they are benefiting, feeling bad about them being harmed and seeing that they are worthy of help 1. actions such as treating pa(s) as a mere means to getting rich by selling their bones or using the bones in money making rituals, as a mere means to cure hiv/aids, taking them to be ghosts, and every other belief cited, not only do they show lack of identity, they also show a lack of good will (and dignity). there is failure to recognize pa(s) as human beings who need help such as protection. instead of seeing a pa to be in need of help from the community, some members of the community kill the pa. thus, pa(s) find themselves helpless because the people who are meant to protect and promote their wellbeing are the very same people who are a threat. this is also reflected in actions of dehumanizing the child with albinism as a ghost or chasing the parents away from a society. this denies the child an environment for growth or resources required for her development which are found in the community and at the same time, parents suffer a punishment for something they did not have a choice. the pa(s) in general, are seen as not worthy of help for their own benefit or success in life. hence, they are mistreated and such actions are a reflection of lack of solidarity. furthermore, part of lack of solidarity is failure to feel bad about the harm done to pa(s). for instance, mutilating their limbs to get the bones or killing them is a failure to feel bad about the harm done to them. even when one would argue that people do feel bad about harm, it just means that those causing harm put their interests (money or curing hiv/aids) above the interest of a pa (more importantly, his or her life). this implies that pa(s) dignity is taken to be comparable to money, making it a mere price that can be replaced with anything, an idea i find disturbing when it comes to how people think or understand dignity as shown in section one where dignity is something incomparable. to sum up, i have shown why pa(s) are killed and beliefs that perpetuate this kind of violence. i have also shown how the beliefs reflect lack of shared identity and good will for pa(s). i have shown that lack of shared identity comes with seeing pa(s) as the “other.” as an “other,” they are taken to be a threat to the harmony of the community. as a threat, people feel obliged to take action to eliminate it, and such actions are justified as morally right. actions are taken may include banishment, murder, or mutilation of their limbs. these actions also reflect a lack of solidarity. part of explaining lack of solidarity is also that they are considered as a mere means to some further end. all these are an indication of failure to see pa(s) as bangladesh journal of bioethics 2018; 10 (1): 6-10 9 worth of help and failure to feel bad about the harm done to them. therefore, lack of shared identity and good will as defining features of a community, is failure to respect pa(s) capacity for community, a violation of their dignity. iii there is alternative worry in relation to the arguments presented. it would be helpful to consider it in this section. it is possible for one to argue that people in the community always speak of pa(s) as human beings and not as non-human beings as some of my arguments suggested. thus, when they call pa(s) names, it does not mean that they take them to be non-humans; rather they are just making fun of them, just as people call each other nick names. furthermore, this could be shown in the way people in the community interact with pa(s), that they interact with them in ways they do with anyone else, and different from the way they interact with non-human animals. however, there is a way to respond to this objection. it is true that pa(s) are called several names just like people call each other nicknames. however, it does not end there; people go on to act in accordance with the ascribed name. for instance, calling a pa a “ghost” does not stop at the level of utterance; people start acting in accordance with what they believe about the name, “ghost”, as shown in the paper. thus, there is an attitude and belief that comes with the name ascribed to pa(s). furthermore, arguing that people in a community interact with pa(s) in a way that they interact with anyone else is not the whole story. thus, there are indeed those who see pa(s) as human beings but still use them as a means to making money, which involves killing them. however, this is where the problem lies. such an action reflects a failure to treat a pa as a human being with a dignity and value. this is placing a price or replacing their dignity with something else. but the dignity of a human being (ceteris paribus) is irreplaceable. therefore, even if one would interact with a pa as a human being, such an attitude is negated if that person is willing to kill them by not respecting pa(s) dignity and value as human beings. from the above discussion, there is a problem that is worth considering. i have alluded to the view that there is a sense in which pa(s) are perceived as human beings but actions of people rendered towards pa(s) seem to negate it, not as fully human. therefore, it might be useful to think about how people manage to hold contradictory beliefs or exhibit contradictory attitudes. that is, as i say, many people do sometimes treat pas as human beings, just everyone else who is not a pa, and at the same time also view them as not fully human. one way of responding to this view is to say that this is strictly speaking a psychological issue. this a quick supposition i would offer, but it would be more interesting to offer a helpful response. therefore, one way of thinking about it is that it is possible for people to hold these inconsistent beliefs but they seem to be resolved in different ways. i will only focus on one, where a person undermines one of the beliefs 19. thus, if there are two inconsistent beliefs, one chooses to undermine either of the two. therefore,one way of resolving the problem of inconsistent beliefs about pa(s) is by undermining the belief that pa(s) are human beings with a dignity. this belief may be undermined by a belief in taking one’s interest as more important than a pa’s life. here, the ends (benefits) for which people kill pa(s) are considered as of primary interests to their life. thus, the benefit one gets from killing a pa is more important that the life of a pa itself. hence it is easy to understand why even though pa(s) are human beings with a dignity and ought not to be killed, they are still killed. it is the undermining of the belief bangladesh journal of bioethics 2018; 10 (1): 6-10 10 that they are humans with a dignity, that makes such actions allowable. in conclusion, i have argued that metz conception of dignity can help us explain why pa(s) are killed. metz takes dignity to be the capacity for community. he defines community in terms of shared identity and good will. i was working under the assumption that pa(s) are human beings with dignity and therefore ought not to be killed. but pa(s) are killed in a community. to explain why they are killed, i argued that they are not taken to be human beings capable of being in a community. i argued that there is lack of shared identity and good-will when it comes to pa(s). this lack or failure shows failure to respect their capacity for community, hence a violation of their dignity. i supported this point by citing several beliefs to do with albinism in malawi. references 1. metz, t. african conceptions of human dignity: vitality and community as the ground of human rights. human rights review 2012; 13(1): 19-37. 2. motsamai, m. personhood and rights in an african tradition, politikon 2018; 25(2): 217231. 3. hill, t.e. humanity as an end in itself. ethics 1980; 91(1): 84-99. 4. mbiti, j. african religions and philosophies. new york, doubleday and company; 1970. 5. neal, p., & paris, d. liberalism and the communitarian critique: a guide for the perplexed. canadian journal of political science/revue canadienne de science politique 1990; 23(3): 419-439. 6. metz, t. toward an african moral theory. journal of political philosophy 2007; 15(3): 321-341. 7. gyekye, k. “african ethics.” in the stanford encyclopaedia of philosophy 2010, edited by e. d. zalta. http://plato.stanford.edu/archives/fall2011/entries /african-ethics 8. ikuenobe, p. a. the communal basis for moral dignity: an african perspective. philosophical papers 2016; 45(3): 437-469. 9. oyowe, o. a. an african conception of human rights? comments on the challenges of relativism. human rights review 2014; 15(3): 329-347. 10. kinnear, p. e., jay, b., & witkop jr, c. j. albinism. survey of ophthalmology 1985; 30(2): 75-101. 11. imafidon, e. dealing with the other between the ethical and the moral: albinism on the african continent. theoretical medicine and bioethics 2017; 38(2): 163-177. 12. davis, l. j. constructing normalcy, in: l. j. davis (ed.) the disability studies reader. new york, routledge; 1997. 13. braathen, s.h. & ingstad, b. albinism in malawi: knowledge and beliefs from an african setting, disability & society 2006; 21(6): 599611. 14. ikuenobe, p. philosophical perspective on communalism and morality in african traditions. lanham, lexington books; 2006. 15. tempels, p. bantu philosophy. paris, presence africaine; 1959. 16. nyirenda, m. stories about albinism in malawi: an ‘intruder’ in my village, lund, p. (ed). aimz 2013, albinism in malawi and zambia. 17. bearak, m. albinos are being killed in record numbers for their body parts. the washington post, 7th june, 2016. retrieved from https://www.washingtonpost.com/news/worldvie ws/wp/2016/06/07/albinos-are-being-killed-inrecord-numbers-for-their-bodyarts/?noredirect=on&utm_term=.9035e2f2e28c 18. amnesty international. “ritual murders of people with albinism in malawi,” 2 february, 2017. retrieved from https://www.amnesty.org.uk/ritual-murderspeople-albinism-malawi 19. festinger, l. a theory of cognitive dissonance (vol. 2). stanford university press; 1962. author contribution: author conceive the idea, done literature review and wrote the manuscript and check the manuscript meticulously. conflict of interest: the author declares no conflict of interest. microsoft word psychotherapy shahriah et al corrected bangladesh journal of bioethics 2019; 10(3): 11-15 11 therapeutic contract and ethical practice in counselling and psychotherapy sunjida shahriah1, sunjida islam2, khalid arafat3 1. professor & director, phoenix wellness centre, dhaka, bangladesh. email: sshahriah@yahoo.com (corresponding author) 2.. counsellor and psychologist, phoenix wellness centre, dhaka, bangladesh. 3. coordinator, phoenix wellness centre, dhaka, bangladesh. abstract: psychotherapists and counsellors confront several ethical dilemmas as they tend to provide effective services. there has been much debate among psychotherapists and counsellors alike around the utility of therapeutic contracts. some view contracts as being restrictive to the therapeutic process and often hindering the work done in sessions. in contrast, many counsellors and psychotherapists use those agreements to revisit specific therapeutic topics and establish the guidelines necessary for this professional arrangement. no matter the opinion or preference of contracts, the development of written and/or verbal consent of specific topics in psychotherapy remains essential. this remains one of the formal features of the arrangement and starting relationship in current counselling and psychotherapy practice. this paper aims to discuss the necessity and ethical demand of therapeutic contract in counselling and psychotherapy practice. key words: therapeutic contract, counselling, psychotherapy, ethics. introduction: therapeutic contract is a mutual agreement in counselling or psychotherapy, among the therapist and the client. it indicates the rights and responsibilities of both to ensure target treatment goal. contracting also ensures that “the counseling process will be performed in a good and safe manner and, as a written document, provides the necessary space for legal intervention if the responsibilities outlined are not met”1. specific contract is mandatory to assess the output of individual session to ensuring both ethical concerns and the therapeutic process. a practitioner evaluates the situation and context of a contract for better management of the client. the practitioner and client are related to each other as equals. hence, they share responsibility for the change the client wants to make2. there are already considerable discussions and debate on the utility of contracts among psychotherapists and counsellors alike. some see contracts as restricting the healing process and often hindering the work conducted in sessions. the agreement can restrict both the capacity to perform specific treatment procedures and the scope of the role of the therapist. the innovation and ability for clients to extend their limits of freedom could be undermined by defined protocols or contracts3. on the contrary, those arrangements are used by certain therapists to revisit specific individual therapy subjects and create the appropriate criteria for this professional structure3. contracts create an equilibrium of power and balance for sessions very often4. no matter the view or desire of contracts, it remains important to develop written and/or verbal agreement for a particular bangladesh journal of bioethics 2019; 10(3): 11-15 12 psychotherapy subject/patient. this part is one of the official aspects of the psychotherapy agreement and original partnership, whether in private practice, community clinics, hospitals, schools, or in the legal system3. this paper aims to discuss the necessity and ethical demand of therapeutic contract in counselling and psychotherapy practice. theoretical concepts: psychotherapists differ widely in the utility of contracts in practice, beyond the theoretical origins of psychotherapy contracts3. traditionally from the psychoanalytic field, the first contracts used formally in therapy emerged, where the arrangement was used mostly like a one-way negotiation with the client's desires that the therapist had. in freudian perspectives, both the client and the therapist are allowed to break a contract at any point, as this “separation was not seen as a negative reaction, but rather a choice to leave certain problems unresolved”4. family structures and ecological constructs were the first to incorporate contracts as an integral method of boundary setting, as the utility of a therapeutic contract grew over time. contracts not only offered protections between other family members but from individuals involved in the treatment process outside of therapy5. in the 1960s, during the development of brief therapy approaches and treatments, therapeutic contracting became more prevalent in psychotherapy6. the use of contracts as a critical aspect of treatment has been highlighted by short-term models, as described by tudor7. the method that therapy can occur over time has always been determined by contracts that are organized and precise in course of care and nature. it is especially applicable for those who are placed in residential treatment, hospital or short-term rehabilitation settings and have specific contracts to address certain medical or mental health issues7. however, more recently, psychotherapists and counsellor from the postmodern perspective see therapeutic contracts as a socially constructed process, as they came into the therapeutic agreement with preconceived notions about what the contract looked like or what the expectations for therapy entailed, along with the goals for therapy most often phrased in the “language of the clients, where more strengths, solutions, and narratives are emphasized in the initial contract”3. therapeutic contract and ethics: it is not surprising that the intentions and usage of contracts in sessions vary among counsellors and psychotherapists. typically, counselling contracts begin with a short overview of the services that are offered to the clients, as highlighting the treatment specifications delivered by the professionals8. commonly, psychotherapists are seen as facilitators with basic therapeutic objectives, expected to focus with during the process of mental health care for individuals. however, in the therapeutic process, clients sometimes may feel unnoticed or unheard, jeopardizing their desire to address broader problems beyond the expectations agreed upon3. historically, psychotherapists have used three forms of therapeutic contracts. firstly, an administrative contract which deals with therapy's logistical supports, such as location, venue, length, details of the organization, and secrecy. to highlight the bangladesh journal of bioethics 2019; 10(3): 11-15 13 setup and configurations of the counseling process, this is regarded as a fundamental text9. secondly, a written contract, the document that the therapist has formulated for a particular cause or intent that helps to describe treatment. this establishes trust and confidence that the therapist will work in psychotherapy/counselling on a particular topic or that in meetings the therapist will honour a clear ethical/legal issue9. finally, the purpose and focus of therapy is established by a professional contract. on what the emphasis of the job will be, the therapist and client share a legally binding arrangement. here collaborative and mutually agreed attempts are taken to set targets9. there are some ethical facets of a traditional contract with counsellor/psychotherapist that should be addressed in therapeutic contract:3 1) the treatment type/style that the counsellor/psychotherapist is offering; 2) the types of resources given and what exists in a normal session; 3) how long treatment will take and over what specified time frame; 4) payment procedure/arrangements and how postponed appointments are dealt with; 5) how to discuss questions of secrecy and their boundaries in counselling and psychotherapy; 6) how to deal with unforeseen events during treatment. the relationships between the client and the counsellor/psychotherapist also more subjective and less formalized, as goals are typically co-constructed and chosen, and counsellor/psychotherapist works as facilitator providing fresh insights and visions on what objectives are to be accomplished. however, one of the disadvantages of such contracts is that in times of distress or turmoil, it also does not arrange the lives of clients and families efficiently. moreover, to decide what progress happens in the counselling phase and when cessation of care is implemented, the therapist can experience some uncertainty1,3,10. the body of a contract should start with confidentiality statements, positive words and continue to the specifics of the meetings, how the therapy will commence, how long it will last, how it will be completed, facts about missing meetings, where and how the sessions will take place. information on reimbursement, rates, and how various conditions impact these rates (e.g. missed visits, forms of psychotherapy delivered) should be concluded in contracts3,9,10. in order to outline the rules and steps for mandatory documentation and other legal responsibilities, counsellor and psychotherapists should be motivated enough to state the ethical code(s) of their assigned occupation or professional code of ethics as followed by the corresponding national association11,12. for the safety and ethical clearance, appropriate informed consent from clients about the process, procedures, plan, and risks vs. benefits of the treatment is mandatory3,11,12. all professional counsellors and psychotherapists must also get written consent about any videotaping, audio recording, or permitting third-party observation taking place11,12. moreover, for authorizations to release or obtain information to outside parties, the they must bangladesh journal of bioethics 2019; 10(3): 11-15 14 obtain consent from each individual competent to execute this waiver. verbal contracting is usually not enough consent for in the ethical codes11,12. from the ethical point of view, the therapeutic contract should address how information will be either shared with or kept confidential from other members of the system. data from cannot be published without permission from client involved in therapy3,11,12. for some families, there may be good reasons for information to be kept confidential (e.g., safety for a partner in a violent environment, establishing rapport with an adolescent in a family system)3,9,13. besides, other therapeutic systems may benefit from a “no secrets” policy within the contract to protect the best interest of the system (the identified patient in a systemic approach) from information that might be in conflict with therapeutic goals3,13. with a “no secrets” policy stated directly in the contract, the therapist is able to exercise his or her clinical judgment regarding the need to share privately disclosed information with the system. while information may be ethically shared with other members in the therapy process, any communication with third parties (e.g., individual therapists, physicians, schools, attorneys, and other family members outside the therapeutic system) requires an authorization to release information. information from a couple’s or family’s treatment may not be released without permission from each person involved in therapy, while for minors, parental permission should be mandatory13,14. conversely, in case of minors, besides parental consent and contract, an assent should be taken from the minor patient to make it ethically sound14,15. there have been debates in the mental health field regarding the use of “no-harm contracts” for decades. these contracts are sometimes used when a partner or family member struggles with suicidal ideation or other self-harming behaviors, like cutting or over-medicating16. a variety of reported risks have been advocated against the use of no-harm or no-suicide arrangements with depressed clients3,16. some clients may feel a sense of faith in their protection, knowing that the contract protects the therapist rather than the client. others could withhold information about a recent suicide attempt or actions, fearing that disclosure of this information may jeopardize their therapy status16. alternatingly, many have also used safety planning as a way to recognize early risks of self-harm, protect the home environment, and use other services. a “nosubstance use contract” can facilitate productive explorations of the addictive behaviors of individuals. allowing the substance abuser to identify the parameters of this contract (e.g., abstinence vs. limited use of the substance, length of time) places responsibility on that family member and, in many cases, can help him or her acknowledge addictive behaviours17. it may imply in any ethical or self-harm issues such as drug abuse, pornographic addiction, gambling, practicing unsafe sex, cyber bullying threat, sexual harassment, etc. such as emergency medical or legal support need must be notified immediately to a safe person declared by the client earlier16,17. conclusion: in professional practice, both the counsellor/ psychotherapist and the client should integrate concrete expectations bangladesh journal of bioethics 2019; 10(3): 11-15 15 into the treatment contract with an awareness of the problem. the therapist and each member of the system should collaboratively agree on goals. it will be important for the counseling system to determine how many sessions will occur. there must be a clear agreement how both client and therapist will understand the measurable and observable change that desired treatment contract has been fulfilled. the therapist is free to exercise his or her professional maturity on the need of the patients, to act on the best interest of the patients and adopt policies specified explicitly in the contract on possible ethical issues that may arise during sessions. references: 1. beahrs jo, gutheil tg. informed consent in psychotherapy. am j psychiatr. 2001;158(1):410. 2. stewart i, joines v. ta today: a new introduction to transactional analysis. nottingham: life space publishing; 1987. 3. zubatsk m, hiefner a. therapeutic contract in couple and family therapy. in: lebow j, chambers a, breunlin d. (eds). encyclopedia of couple and family therapy. philadelphia: springer; 2017. 4. sills c. contracts in counseling and psychotherapy. newbury park: pine forge press; 2006. 5. gray a. an introduction to the therapeutic frame. new york: routledge; 2013. 6. elton-wilson j. integration and eclecticism in brief time-focused therapy. in: palmer s, woolfe r. (eds.). integrative and eclectic counselling and psychotherapy. london: sage publication; 1999. 7. tudor k. (ed.). transactional analysis approaches to brief therapy: what do you say between saying hello and goodbye? thousand oaks: sage; 2002. 8. beall l. the corrupt contract: problems in conjoint therapy with parents and children. am j orthopsychiatr. 1972;42(1):77-81. 9. croarkin p, berg j, spira j. informed consent for psychotherapy: a look at therapists' understanding, opinions, and practices. am j psychother. 2003;57(3):384-400. 10. barnett je. the ethical practice of psychotherapy: easily within our reach. j clin psychol. 2008;64(5):569-575. 11. canadian counselling and psychotherapy association (ccpa). the code of ethics. 2017. (available at: https://www.ccpa-accp.ca/wpcontent/uploads/2014/10/codeofethics_en.pdf). (accessed on february 14, 2019). 12. american counseling association (aca). aca code of ethics. 2014. (available at: https://www.counseling.org/docs/defaultsource/default-document-library/2014-code-ofethicsfinaladdressc97d33f16116603abcacff0000bee5e 7.pdf) (accessed on february 15, 2019). 13. lebow j. integrative family therapy for disputes involving child custody and visitation. j fam psychol. 2003;17(2):181-192. 14. redding re. children's competence to provide informed consent for mental health treatment. wash lee law rev. 1993;50(2):695-753. 15. mccabe ma. involving children and adolescents in medical decision making: developmental and clinical considerations. j pediatr psychol. 1996;21(4):505-516. 16. farrow tl, o'brien aj. 'no-suicide contracts' and informed consent: an analysis of ethical issues. nurs ethics. 2003;10(2):199-207. 17. diamond j. narrative means to sober ends: treating addiction and its aftermath. new york: guilford; 2000. authors’ contribution: s shahriah was involved in concept and design; s shahriah, s islam, k arafat were equally involved in the literature search, compilation, manuscript writing and revision. conflict of interest: none declared. microsoft word profullah policy bangladesh journal of bioethics 2020; 11 (1): 40-50 40 ethics in social research and its impact on policy implication, pragmatic planning and development profulla c. sarker1, uttam kumar das2 1. phd. professor of social work. vice chancellor, royal university of dhaka, banani, dhaka, bangladesh. email: pc_sarker@yahoo.com 2. phd. joint secretary, & director, director of primary education, government of bangladesh, mirpur, dhaka. bangladesh. email: das.druttam@gmail.com (corresponding author) doi: https://doi.org/10.3329/bioethics.v11i1.49325 abstract: this paper is an attempt to discuss how ethics is related to social research in connection with the collection of authentic and reliable data, use of appropriate data process and impartial data analysis for preparing an acceptable research report. ethics is closely related to moral integrity, and values associated with appropriate methods and techniques applied for collection of reliable and authentic information that ensure the trust worthy research findings. this paper is based on secondary data collected through reviewing the relevant literatures. main focus of this paper is to examine to what extent the research findings contribute to the knowledge of planners and policy makers in formulating the appropriate policy, pragmatic planning and finally thus may affects on development. keywords: ethics, social research, policy, planning, development (some part of this article has been presented at the 20th asian bioethics conference, 22-25 november 2019, dhaka, bangladesh). introduction: research is common parlance refers to search for knowledge. it is an art of scientific investigation. advanced learners dictionary of current english lays down the meaning of research as “a careful investigation or enquiry especially through search for new facts in any branch of knowledge”. the main thrust of research is to discover new information and modify the old one. more specifically, research is a process of searching, discovering and investigating information as well as collecting, editing, processing, evaluating, analyzing and interpretation of information to find answer to question1. on the other hand, ethics is rooted in the ancient greek philosophical inquiry of moral life. ethics refers to a system of principles which can critically change previous consideration about choices and actions2. theoretically, ethics is a branch of philosophy which deals with the dynamics of decision making concerning what is right and what is wrong. what we should to do and what we should not. under the circumstances, the scientific research along with all human activities is governed by ethics across the east and the west. ethics in research involve requirements on daily work, the protection of dignity of subjects and the publication of the information. however, the ethical attitudes of social researchers drawn the interest of society only after 1940's because of human exploitation in several cases. professional codes and laws were introduced since then in order to prevent abuses of human lives3 has always been part bangladesh journal of bioethics 2020; 11 (1): 40-50 41 and parcel of social research in order to get authentic and reliable information as well as quality of research report4. on the other hand, research is a process which involves a lot of resources, ideas, human interaction, challenges, rules and regulations that govern all the activities done. each and every time when human participants are involved in a primary research, the researcher must take ethical issues into account. all the way through history, numerous studies benefited from participants as sources of data, but in some cases causing death, physical trauma and mental trauma. as a result of this, every researcher who wants to conduct primary research nowadays has an obligation to follow certain research ethics to avert such damages from recurring. it is very vital for researchers to familiarize themselves with the basic ethical principles and up-to-date knowledge on policies around ethics and research to ensure that the research participants’ safety is guaranteed and to avert finding themselves on the wrong side of the law and ethical guidelines. the advent of technology that is, the shift from digital photography and audio-and video-recording to the analysis of virtual materials from the internet has made life easier for people to exchange information including data collection by researchers. therefore, this gave rise to need for researchers to stick to certain rules and regulations that govern aspects such as from who, where, why, how and when they get information in their thirst for knowledge through research. hence this paper aims to bring to light the issues and obligations that researchers have to bear and consider when carrying out research, with particular focus on social research. ethics in social research is started at the very beginning of the selection of the topic of the research whether the topic is ethically sound and it may not creates problems for the normal functioning of the people either at the individual or family or community or societal level. appropriate methods and techniques applied for collection of data that may not be harmful for the informants. the main focus of this paper is to examine to what extent ethics is closely related to moral integrity, and values associated with appropriate methods and techniques applied for collection of reliable and authentic information that ensure the trust worthy research findings for policy, planning and development. research methodology: this is study based on secondary and tertiary data. the authors carefully reviewed the relevant research reports of the different scholars who have already done research on ethical issue in social science research. the researchers have had access to a few research works conducted by the scholars on ethical consideration in social science research across the east and the west. the researcher is not able to incorporate sufficient data both quantitative and qualitative due to paucity of research work on this subject. in this research paper emphasis has been given on qualitative analysis. the new dimension of this research paper is to explore the impact on policy, planning and development of ethics in social research. philosophical approaches to ethics: the catchphrase ‘social research ethics’ means the set of ethical doctrines that should be justified when doing social research or the set of ethical ideologies believed by social researchers universally. according to bangladesh journal of bioethics 2020; 11 (1): 40-50 42 welman et al. ethical behavior and ethical considerations are very rigorous when doing research in the field of human under takings5. ethical considerations in research are concerned with minimizing harm to all participants while in turn boosts benefits in research6. in undertaking research, the researchers get data from respondents who are usually not part of the inquiry process, so it is vital to consider their wellness in the research process. there are three types of ethics according to 7which are: (1) metaethicswhich deals with scrutinizing the linguistic and logic of proper intellectual, (2) normative ethicswhich study what is honorably or morally acceptable and why they are acceptable and why are they intolerable and (3) descriptive ethicswhich describes or elucidate the ethical practice of particular groups7. it is very important when a researcher is conducting research, to be mindful of ethical and data protection issues. it is unethical for a researcher to deliberately make use of a technique or practice the researcher knows to be unsuitable to prove or disprove something that you want for instance, using invalid instrument or by drawing wrong conclusions8. there are some philosophical approaches to ethics which can help researchers to have deeper understanding of ethics and they are elaborated below. the theoretical discipline of ethics is the study of how we should conduct ourselves, or how to govern the right thing to do in our relations with others. ethics can be understood as the study of good conduct for constructing judgments around what is good behavior9. the philosophies that come from ethical studies afford a guide to inspecting ethical circumstances and to articulating desired customs of living and conducting yourself as a researcher. as our sympathetic of the world, the nature of human behavior and social interactions has improved or transformed, ideologies advanced it is crucial to keep an eye on how these changes shape our lives as researchers. one crucial alteration in the numerous methods to ethical judgment making has to do with the target of the action, aimed at what or on behalf of whom are we interested in doing the right thing, is it for ourselves, a coworker, certain individual, a household, a government, a communal, a country, or the universal. regrettably, what might appear for one person to be the right thing to do or group possibly will not be the right thing for the next person or society. under the circumstances, which are branded by contradictory rights or responsibilities are known as an ethical dilemma. the circumstances turn out to be more multifaceted when we endeavor to evaluate individual moralities and rights alongside assessments of what is paramount for a bigger group. horn proposes those considerations that contest in our careful ethical propensities and our ethical decision processes consist of justice in dissemination, the participant’s wellbeing level, or contentment, the participant’s aspirations, and the societal role of the participant10. one approach to increasing competence in dealing with ethical matters is to begin with clarification of your own values and identifying and understanding the values by which other people live11. there are three broad types of ethical approaches or theories which are as follow: consequentiality theories, non-consequentiality theories and agent-centered theories12. bangladesh journal of bioethics 2020; 11 (1): 40-50 43 consequentiality theories: utilitarian theories: doing the right thing for the more peoplephilosophers of this approach cited john stuart mill (1806-1873) who viewed ethics as the action that makes the majority of people to be happy and causes the least harm to the fewest people. for them the most vital thing is not about your good will towards others, but instead they were concerned with the consequences which come from your deeds. defining which action to take necessitates that all conceivable actions in the circumstances and the impending results of each be scrutinized for all people or cluster that may be included. subsequently diverse results are evaluated and equated the action that resulting in the finest conclusion for the utmost general public is carefully chosen because what is good varies across cultures13,14. the egoistic approach: in this approach, an individual frequently utilizes practical crafty to yield the paramount aggregate of good for him or herself. primordial greek sophists for instance, thrasymacus (459-400 bce), who legendarily claimed that might makes right and the (1588-1679) philosophers such as thomas hobbes could be considered as the harbingers of the egoistic approach. one of the utmost modern powerful advocates of ethical egoism was the russian-american philosopher ayn rand (1905-1982), who in the book “the virtue of selfishness” (1964), argues that self-interest is a prerequisite to self-respect and to respect others. there are several counterparts between ethical egoism and laissez-faire economic theories, in which the tracking down of self-interest is viewed as leading to the assistance of the society, even though the advantage of the public is perceived only as the auspicious by-product as a result of individual self-interest, not its aim. non-consequentiality theories: the dutybased approach: it is concerned with balancing rights and obligationsthis was propounded by immanuel kant (1724-1804), who was of the view that whether an action is ethical is influenced by the action itself and essentially by the original motive for the action. he further suggested that the foundation for our main philosophy of deontological ethics in his endeavor to express a rational for ethical behavior is grounded on wholesome motive, instead of the tradition or imposing assertion. for kant, individuals start their own moral rules grounded on the benchmark that the allencompassing purpose of their actions could relate to every person that is it could turn out to be a law11. the right -based approach or principle ethics: this approach views ethics as a set of beliefs advanced by cautious intellectual and it includes ideas about “who has what kinds of rights and which rights or responsibilities have priority over other rights and obligations” 15. this can be traced back to works of john locke (1632-1704) who was a british empiricist philosopher who believed that the best action is that which protects the ethical rights of those who are affected by the action. locke further asserts that all humans have a right to dignity. he was also supported by kant’s categorical imperative that says: “act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means to an end.” this gave birth to some debatable ethical rights in research where many are arguing that even bangladesh journal of bioethics 2020; 11 (1): 40-50 44 non-humans and other animals including robots have rights as well. the fairness of justice approach: the law code of hammurabi in primeval mesopotamia (1750 bce), was of the view that all unrestricted men should be treated the same, just as all slaves should be treated similarly. once joint with the generality of the rights methodology, the justice method can be used to all human subjects. the work of american thinker john rawls (19212002), is seen as the greatest influential description of this approach today who maintained, along kantian outlines, that just ethical doctrines are those that would be selected by free and normal people in a first condition of impartiality. this theoretical agreement is considered impartial or unbiased because it affords a process for what sums as a rational action and does not distress itself with the aftermath of such actions. justice of initial opinion is the standard for what is regarded as fair and ethical. in the same manner, all research participants should be treated equally without any biasness. the divine command approach: as its name proposes views what is right as the similar as what god commands and ethical principles are the foundation of god’s will. doing god’s will is understood as the very delineation of what is ethical. since god is seen as unstoppable and controller of free will, god can change what is now deliberated as ethical and god is not limited by any principle of right or wrong tiny rational ambiguity. the most dominant intellectual in this tradition was william of ockham (12851349) who was the medieval christian philosopher and his writings aided as a guide for protestant reformers such as martin luther (1483-1855) and jean calvin (15091564). the danish philosopher soren kierkegaard (1813-1855), in praising the biblical patriarch abraham’s preparedness to slaughter his son isaac at god’s command, demanded that truthfully right action must eventually go further than ordinary morality to what he termed the “teleological suspension of the ethical,” once more signifying to a certain degree questionable connection concerning religion and ethics stated previously. given the above, it is crucial for researchers to know the type or religious background of the society in which they want to conduct their studies so as to avoid acting in an unethical way. for example in south asia the population is categorized based on the religious affiliation, caste, sect, etc. each of these groups have diverse cultural, linguistic and religious beliefs16. the reason being that, different societies uphold diverse religious beliefs and cultures, so some things which are considered ethically as right, might be considered ethically wrong in some societies. agent-centered theories: virtue ethics: aristotle was of the view that, the eventual aim of life is to attain satisfaction, which emanates from brilliance of thinking. for him, the significant characteristic of brilliance of thinking is fineness of selecting virtuous action-the “golden mean”. a righteous deed is ethical only when it is executed from an inspiration of doing the correct thing15. good action, for those of noble personality is knowledgeable as time passes by and it is followed by righteous actions. the application of moral principles and rules is viewed as less ethical behavior, bangladesh journal of bioethics 2020; 11 (1): 40-50 45 than as the researcher adopting ethical standards13. virtues are somewhat distinguished from seeing cases of continuous exemplary behavior by prototypes. furthermore, beauchamp and childress came up with four types of virtues they deliberate as crucial to research ethics and these are as follows16:  compassion: it is an idea linked to kindness, comprises of being distressed for others and a mindfulness of their discomfort or sorrow. it contains robust emotional mechanisms attached between the researcher and the researched or human subjects who are involved in the study.  discernment: it is the ability to take a decisive action grounded on perception as a result of a history of pure judgment plus sympathetic. this is a situation whereby one is able to make ethical decision without being overly prejudiced by other specific, personal biasness or political influences. when conducting a research this is very vital, the researcher’s personal biasness or interests should not divert the research objectives as this will affect the findings. the researcher has to avert ethical weakness or mistake generally acknowledged as “conflict of interest”. thus, a discerning person should be in a position to comprehend what should to be executed, in which manner, and where, when dealing with ethical considerations matters.  trustworthiness: it is a personality that offers other folks assurance that an single person may reliably do the correct thing for ethical motives. this is the most influential factor in research which can motivate participants to give you honest response. integrityresearchers should not compromise their ethical principles; they must maintain core values and beliefs of research to avert moral distress which may lead to people not accepting your researching findings. it is for this reason that researchers should always uphold the beliefs and values of research so that other people can trust their work. the feminist approach-this approach to ethics has been developed and used as supplement to the virtue approach in recent years. the feminist approach is of the few that women and other marginalized group’s experience should be included when deliberating on ethical issues in research15. this approach is more concerned about the involvement of vulnerable group in research and this was further discussed in one of the sections of this work. it can be construed that, all these theories together with the medical experiments of the german physicians during world war 2 the nuremberg code, the helsinki declaration, the belmont report of 1979 and the cumulative advancement in the use of technology in research gave birth to ethical considerations which all researchers are encouraged to be mindful when conducting any research that involve human subjects as sources of data. principle of ethics in social research: the important starting point for this treatise is to clarify the relations, connections, and variances concerning morals, ethics, ethical approaches, ethical bases, ethical regulations and legal regulations which researchers normally come across on their journey of conducting social research which involves human subjects. however, there is also bangladesh journal of bioethics 2020; 11 (1): 40-50 46 secondary research which exclusively depends on the use of data gathered for a different research usually do not need to undergo formal ethics review given that no identifiable information is generated in the process17. whether it is primary data or secondary, every researcher should know what is ethical and not pertaining to their research and they believe that they can uphold ethical standards, but history unfortunately, keeps a reminder that not all researchers conduct research responsibly 10. the inception of current research ethics is instigated by a desire to safeguard human subjects intricate in research projects and it can be traced back to the 1930s and 1940s. the social researchers need to keep in their mind set to apply the following principles at the time of conducting research.  in any study participants must willingly consent to partake.  the aims of the research ought to work for the good of the society.  research must be grounded on comprehensive theory and before used for human beings it must be tested on animals in case of experimental research.  unnecessary mental and physical suffering must be avoided in research.  where serious injury and or death are potential outcomes those research projects must be terminated immediately.  the extent of danger or hazard considered with research participants should not surpass expected benefits of results.  research should be conducted in a suitable atmosphere which safeguards participants.  only scientifically qualified personnel should conduct experiments with human subjects.  human subjects must be permitted to withdraw their participation any time they feels to do so.  if there is a reason to believe that prolongation will be dangerous or end in injury or death, scientists must be ready to stop the experiment.  reduction of harm, researchers should not deliberately disenchant or hurt the research subjects, irrespective of whether they volunteered to take part in the study or not,  in research there is voluntary participation which denotes that, participants are free to exercise their will in determining whether to participate or not to participate in a research action18.  non-published are not included in the results because they do not support the desired outcome. such data may be considered as bad data, but bad data ought to be recognized during gathering process or during analysis.  fabrication of data is when the researcher makes up either data or results then records or reports them, whereas falsification is when the researcher manipulates materials, process, equipment or changes or omits data such that the research is not represented accurately. bangladesh journal of bioethics 2020; 11 (1): 40-50 47  finding data from a participant whom the researcher is aware that this participant does not meet the requirement of your primary research is unethical.  there is need for the justification of benefits to the participants, their community and or the broader society at large. it is at times problematic to foresee the risks or harm when crafting a proposition particularly in qualitative research.  publish in order to advance research and scholarship, not to advance just your own career. avoid wasteful and duplicative publication19. theoretical framework: ethics is a topic that covers questions relating to what kinds of lives people should lead, what counts as a good society, what actions are right and wrong, what qualities of character they should develop and what responsibilities of humans have for each other and the ecosystem. in the context of social research, ethics as a subject area traditionally covers topics such as the overall harms and benefits of research, the rights of participants to information, privacy, anonymity, and the responsibilities of researchers to act with integrity. an ‘ethical principle’ is a general standard or norm that promotes what is regarded as worthy or valuable for the flourishing of humans and the whole ecosystem. in social science research, the researchers need to be neutral in data collection, data processing, data analyzing, report writing along with drawing conclusions. it should be noted most of the ethical issues have to do with the scientist's obligations and the limits on permissible scientific activity. perspectives on these issues are informed by ideas drawn from a variety of intellectual traditions, including philosophical, legal, and religious. political views and cultural values also influence the interpretation of researcher conduct. ethical questions about scientific activity are considered external to the research endeavor. ethics in social research: there are several meanings that are attached to the word ethics as was elude by 20. they defined ethics as a field of study that has to do with examining what is good or right in the eyes of the community and how people should govern this. on this understanding, social research ethics denote the study of what the researchers must do or not do and how this should be considered. ethics talk about a set of values that symbolize or demonstrate what is good or right or permit people to classify what is bad or wrong. the social science research concerns with the social structure in terms of individuals, family, kinship, marriage, community, and society and its economic and political situation that affects the way of life of the people. it also deals with the culture of the people in terms of customs, beliefs and value system in which they born, brought up and die. in social science research different methods and techniques have applied to collect authentic and reliable information. these are survey using schedule or fig. -1: model on ethics in social research bangladesh journal of bioethics 2020; 11 (1): 40-50 48 questionnaire, observation, case study, fgd, use of key informants, etc. at the time of data collection, the emphasis should be given on following ethical issues so that the respondents should not be subjected to harm in any way.  respect for the dignity of research participants should be prioritized.  full consent should be obtained from the participants prior to the study.  the protection of the privacy of research respondents has to be ensured.  adequate level of confidentiality of the research data should be ensured.  anonymity of individuals and organizations participating in the research has to be ensured.  any deception or exaggeration about the aims and objectives of the research must be avoided.  affiliations in any forms, sources of funding, as well as any possible conflicts of interests have to be declared.  any type of communication in relation to the research should be done with honesty and transparency.  any type of misleading information, as well as representation of primary data findings in a biased way must be avoided. challenges to ethical considerations: research ethics takes a particular interest in analyzing the aspect of what is right or wrong in carrying out social research. it is vital for researchers to be aware of all the ethical considerations pertaining to social research as they have impact on the integrity of whatever research project. de vos states that every researcher must have knowledge of what is right and what is wrong when doing research, and hence must endeavour to observe all those aspects laid out by the research community21. however, in so doing researchers often face numerous challenges.  firstly factor in the issue of social researchers facing problems because the issue of ethics is being mostly derived from the biomedical sciences. social research has its own different, but very important issues and obligations for researchers. ethical considerations are designed to play a preventative and guiding function in research. they provide information about what researchers must or must not do in order to produce responsible research.  in as much as there are codes and ethical guides for research conduct, it still boils down to the researchers’ decision making because in some instances of social research, guidelines and codes become contradictory. for instance conflicting rules such as giving informed consent where the researcher cannot disclose the true intentions of the research or of the researcher needs to do an observation without alerting subjects of that fact for the untainted results. howard purports that often researchers are faced with difficult decisions and ethical challenges throughout their research process22. bangladesh journal of bioethics 2020; 11 (1): 40-50 49  sometimes they are faced with ethical dilemmas to decide on what constitutes right and wrong in some situations. hessse-biber states that some researchers fail to fully disclose all the risks and full extent of consequences of participating of participating in a study to their participants because of fear of losing their participants23. also for trying to avoid the hurdle of going back and forth to the institutional review committees whenever there is a change in the collection of data. the extent to which a research is deemed ethical is dependent on the continuous effort to ensure that the rights of subjects are protected at all times.  ethical issues in social research are usually less serious than those faced in medical research; however that does not mean that social researchers can neglect such issues, they still need to uphold them. research with vulnerable groups poses some serious ethical issues, however the agreement within the research community is that research with these groups is needed in social research24. extra care just has to be given when dealing with these groups. kirk argues that the most ethical issues to be looked out for in these groups are informed consent, confidentiality and power relations25. impact of social research: the findings of the research in social science laid the groundwork implementing policy, planning and development for the wellbeing of the people in order to improve their quality of life. to uphold ethics in social research which involves human subjects but its impact is universal (jones, 1994)? research is an activity that relies on the support of the society, the public; hence it is very vital for researchers to obey ethical principles so as to win the heart and minds of the public backup and having faith in the research. the public needs to be able to trust research, its methods and results, hold it in high esteem for the potential that it will contribute to take appropriate policy on the particular problems of the general people. the appropriate policy on any problem is contributing factor for effective planning and thus affect development. impact of research on policy: in contrast to the academic perspective of research impact, practitioners hold a very different view. for example, young claims that for research to have any impact, the results must inform and shape policies and programs and be adopted into practice26. researchers wishing to maximize the impact of their work have to attract the interest of policymakers and practitioners and then convince them that a new policy or different approach is valuable and then foster the behavioral changes that are necessary to put them into practice (ibid). according to fig. -2: model on impact of research bangladesh journal of bioethics 2020; 11 (1): 40-50 50 sumner et al. impact is multilayered and refers to use i.e. consideration or actual outcome of social change27. it can be visible or invisible, progressive or regressive, intended or unintended and immediate or long term. the research council of the uk acknowledges academic impact as the demonstrable contribution that excellent research makes to academic advances but it also emphasizes the need for economic and societal impacts as the demonstrable contribution that excellent research makes to society and the economy by, among other things, increasing the effectiveness of public services and policy. impact of research on planning: planning is very important for successfulness and the effective performance of an organization. it is not only for organizations but also for individuals. it is the most basic of all the managerial functions. it involves selecting missions and objectives and the actions to achieve them. therefore, every organization or individual gives a greater emphasis on planning. without research, it is not possible for pragmatic planning on any issue either at the individual or family or community or organizational or societal level. on the other hand, ethical consideration is important to get authentic result of the research for formulation of effective planning. because planning as a process involves the determination of future course of action, that is why an action, what action, how to take action, and when to take action. these are related with different aspects of planning process. impact of research on development the term research and development is widely linked to find out truth or to investigate the fact that may contribute to take appropriate decision to solve problems. under the circumstances, ethics may contribute to find out the required results through proper investigation that also helps to development to reach goals. research also helps for innovation both in the corporate and government world or the public and private sectors. research findings on any issue are prerequisite for development. research result allows a company to stay on top of its competition. without research an organization or a company may not survive on its own and may have to rely on other ways to innovate such as engaging in mergers and acquisitions or partnerships. through research, companies can design new concluding remarks: ethics ensure that the research produces knowledge by ensuring that research is not being repetitive. every research must produce some new knowledge, promote truth and minimize error. research ethics create some prohibitions to behaviors such as falsifying data, incorrect reporting and misrepresentation of data. ethical behavior is similarly essential for cooperative work since it inspires an atmosphere of trust, answerability and reciprocal admiration amongst researchers28. this is important particularly when bearing in mind matters linked to data allotment, joint-authorship, exclusive rights, guiding principle, confidentiality, privacy, reduction of harm, benefits and rewards, vulnerable groups and so on. ethics, research, policy, planning and development are inter-locked each other in writing this paper. without ethics, it is very difficult to get authentic and reliable data as well as findings or results of the research. if the results are not reliable then it creates impediment to take an appropriate policy as well as it affects to chalk out meaningful bangladesh journal of bioethics 2020; 11 (1): 40-50 51 planning and all together create problem for development. references: 1.sarker, profulla c. qualitative research in multidisciplinary perspective. dhaka: mother’s publications. (2018). 2. johnstone, m. bio-ethics: a nursing perspective. churchil livingstone: elsevier publications. 2009. 3.oddi l.f. and cassidy, v.r. nursing research in the united states: the protection of human subjects. international journal of nursing studies 1990.;27(1): 21-34. 4.david, b. and resnik, d.b. (2015).what is ethics in research and why is it important? new york: national institute of environmental health sciences. 5. welman, c., kruger, f. and mitchell, b. (2005). research methodology. south africa: oxford university press. 6. flick 2009).? 7.makore-rukuni, m.n. (2001). introduction to research methods in counselling. harare: zimbabwe open university. 8 kumar, r. (2011). research methodology: a stepby-step guide for beginners. london:sage publications. 9. birch, m., miller, t., mauthner, m. and jessop, j. (2002). introduction ethics in qualitative research. london: sage. 10. horn, p. (1999). clinical ethics case book. belmont, california: wadsworth. 11. (kurtz and burr, 2008:251).??? 13. stevens, m. (2013). ethical issues in qualitative research. king’s college london: social care workforce research unit 14. israel, m. and hay, i. (2006). research ethics for social sciences. california: sage publications. 15. brown, s. (2016). making choices: a framework for making ethical decision. new york: mcmillilan publications. 16.beauchamp, t. and childress, j. (2001). principles of biomedical ethics. new york: oxford university press. 17.motsoaledi, m.p. (2015). ethics in health research: principles, processes and structures. republic of south africa: department of health. 18.hogan, s. (2008). voluntary participation: research methods. new york:: sage publications. 19. shamoo, a. and resnik, d. (2015). responsible conduct of research, new york: oxford university press. 20. hammersley, m. and traianou, a. 2012. ethics in qualitative research: controversies and contexts. london: sage publications ltd. 21.de vos, a.s. (2002). research at grass roots: for the social sciences and human services professions. van schaick: sage publications 22.howard (2004: 413),? 23. hesse-biber, s. n. (2016). the practice of qualitative research: engaging students in the research process. california: sage publications. 24.hickson. m. (2008). research handbook for health care professionals. united kingdom: blackwell publishing. 25. kirk, s. (2007). “methodological and ethical issues in conducting qualitative research with children and young people. a literature review”. international journal of nursing studies , 44 (7): 1250-1260. 26.young, j. (2008). impact of research on policy and practice. research, policy and practice, capacity, (35): 4–7. 27. sumner, a., ishmael-perkins, n., & lindstrom, j. (2009). making science of influencing: assessing the impact of development research (ids working paper 335). brighton: ids. 28.grady, c. (2010). “do irbs protect human research participants?” jama: the journal of the american medical association, 304 (10):45-51. author contribution: 1st author profulla c. sarker guided the conception of the idea, the manuscript writing process, and checked the manuscript meticulously. 2nd author uttam kumar das conceived the idea, did the literature review and wrote the manuscript. conflict of interests: the authors declare that there is no conflict of interest in this study. invitation-19.cdr registration: 9:00. be seated by 9:20 please. session 1: 9:30-11:00 inauguration welcome address : md. nurul amin, secretary, planning division, ministry of planning. progress of bbs : prof shamima parvin lasker, secretary general, bangladesh bioethics society & vice president, aba address from aba : prof darryl macer, secretary, asian bioethics association. address from bbs : prof taslima monsoor, president, bangladesh bioethics society special guest : prof dr abul kalam azad, dg, directorate general of health services, ministry of health & family welfare. special guest : dr. md. murad hassan mp, honorable state minister, ministry of information, government of the people's republic of bangladesh. chief guest : m. a. mannan mp, honorable minister, ministry of planning, government of the people's republic of bangladesh. award hand over photo session vote of thanks : dr uttam kumar das, director, social science research council, planning division 11.00 -11.15 : morning refreshment dear sir/madam you are cordially invited to attend the inaugural session of 20th asian bioethics conference organized by bangladesh bioethics society in cooperation with ssrc, planing division; pmr, dghs, ministry of health & family welfare, bmrc, aba and eubios ethics institute on friday, 22 nov, 2019 at nec auditorium, planning ministry, agargoan, dhaka. m. a. mannan mp, honorable minister, ministry of planning, government of the people's republic of bangladesh has kindly consented to grace the occasion as the chief guest. dr. md. murad hassan mp, honorable state minister, ministry of information, government of the people's republic of bangladesh; md. nurul amin, secretary, planning division, ministry of planning; prof dr abul kalam azad, dg, directorate general of health services, ministry of health & family welfare (moh&fw) will present as special guests. we would appreciate your presence in the programme. prof dr taslima monsoor prof. shamima parvin lasker phd president & vice president, aba secretary general bangladesh bioethics society bangladesh bioethics society friday, 22 november, 2019 nec auditorium, ministry of planning, agargoan, dhaka programme th20th20 asian bioethics conference 22-24 november 2019 theme: bioethics for humanity, dignity and solidarity page 1 justice and non-human animals bangladesh journal of bioethics 2017; 8(1): 44-57 44 original article justice and non-human animals robin attfield 1 and rebekah humphreys 2 1. emeritus professor of philosophy, cardiff university, email: attfieldr@cardiff.ac.uk 2. lecturer in philosophy, trinity st. david’s university, email: r.humphreys@tsd.uwtsd.ac.uk part 2 abstract: it is widely held that moral obligations to non-human beings do not involve considerations of justice. for such a view, nonhuman interests are always prone to be trumped by human interests. rawlsian contractarianism comprises an example of such a view. through analysis of such theories, this essay highlights the problem of reconciling the claim that humans have obligations to non-humans with the claim that our treatment of the latter is not a matter of justice. we argue that if it is granted that the basic interests of nonhuman beings sometimes count for more than the peripheral interests of humans, then our understandings of obligation and of justice must be aligned, so that what we say about obligation is not countered by assumptions about the invariable priority of humans in matters of justice. we further consider whether such a conclusion can be endorsed by those who adopt certain alternative theories to contractarianism. we conclude that adherents of a range of theories including sentientism and biocentrism must accept that human interests can sometimes be superseded by animal interests, and that this applies not least in matters of justice. keywords: justice, contractarianism, animal interests, moral theory, rawls, moral agency note: part 1 of this article has been published in the previous issue of the bangladesh journal of bioethics (volume 7, issue 3, 2016). animals and moral agency: as we have remarked, it might be thought possible to respond to the objection (regarding the incoherence of rawls’s exclusion of animals) with the claim that it is far from clear that no animals have the capacity for moral agency 23 24 . indeed, work by ethologists shows that some mammals demonstrate behaviours that strongly suggest that they have cognitive and emotional capabilities which form part of the bedrock of human morality including, for example, the capacity to sympathise and empathise, as well as the capacity for reciprocal altruism 25 26 . recent work by frans de waal and colleagues indicates that a sense of fairness is not uniquely human 27 28 and has a ‘long evolutionary history’ 29 . further, some philosophers too have presented arguments that, at first glance, seem to go against the traditional, widely held view that animals are not moral agents. for example, stephen clark has claimed that ‘beasts, let us say, are ethical: that is, they respond to aspects of a situation and to features of their kindred, that a good man also respects’ 30 , and david degrazia argues that animals are capable of moral agency and of a sense of fairness, albeit a mailto:attfieldr@cardiff.ac.uk mailto:r.humphreys@tsd.uwtsd.ac.uk bangladesh journal of bioethics 2017; 8(1): 44-57 45 limited sense 31 . that said, few ethologists or philosophers would readily claim that animals are moral agents in a strict sense. thus degrazia says: there is a sense of moral agency according to which perhaps no, or at any rate very few, nonhumans are moral agents. in this sense, one is a moral agent only if one is capable of (1) deliberating on the basis of what one takes to be moral reasons, (2) acting on the basis of such deliberation, and (3) justifying one’s decisions with an explicit argument appealing to moral reasons (taking animal seriously, p. 203). it is clear that there are few non-human animals that could be characterised as moral agents on the above sense of moral agency. and whether or not we agree with degrazia’s definition of agency here, there is a sense of moral agency that requires much more than displaying appropriate behaviours; for example, it requires deliberating about possible courses of action and about what makes actions right or wrong, in a way that is capable of being independent of our desires and feelings, and that requires a process of justification. as clark notes ‘[animals] are not moral: for they do not, as far as we can see, construct intellectual systems to accommodate their immediate responses’ (the nature of the beast, p. 107). and whilst the ethologist de waal recognises that there are many animals which possess cognitive capacities and emotional abilities found in our own species, at the same time he stresses his reluctance to claim that animals are full moral agents: ‘to communicate intentions and feelings is one thing: to clarify what is right, and why, and what is wrong, and why is quite something else… i hesitate to call the members of any other species than our own ‘moral beings’ (good natured , pp. 209-10). moreover, in relation to their research involving studying the response of certain non-human beings to the inequitable distribution of rewards, sarah brosnan and de waal claim that ‘it is the evolution of this response that allowed the development of a complete sense of fairness in humans, which aims not at equality for its own sake but for the sake of continued cooperation’, where a full sense of fairness involves distributing benefits even when such distribution results in a negative payoff for oneself. while there is some evidence of such a sense of fairness in chimpanzees, they state that ‘[t]here is less evidence that nonhuman species seek to equalize outcomes to their own detriment’ 32 . but there is another reason for being wary about calling animals moral agents. moral agency, of course, is intimately tied to issues concerning responsibility and to the concept of culpability; agents are commonly held accountable for their choices, their acts, and their omissions. but few would accept that animals are fully fledged moral agents in the sense of being accountable for what they do, and with good reason. it is one thing to say that some animals have cognitive capacities that enable them to have what we might call ‘moral sentiments’, and that they are capable of behaviours that could be interpreted as moral, but quite another to jump from such claims to saying that animals are moral agents in a strict sense; a sense which depends upon being able to reflect upon one’s thoughts and actions in a way that can make one culpable for what one does. as mark rowlands argues: bangladesh journal of bioethics 2017; 8(1): 44-57 46 if animals are moral agents, they are responsible for what they do and so can be praised or blamed for this. at one time, courts of law… set up to try… animals for perceived crimes were not uncommon (see, e.g., evans, 1906; dinzelbacher, 2002). i assume that few would wish for a return to this practice. at the core of this unwillingness is the thought that animals are not responsible—and so cannot be blamed—for what they do. if this is correct, then their characterization in terms of moral agency should be resisted’ (rowlands, ‘animals and moral motivation’, p. 18) 33 34 35 . we should then be sceptical of the claim that animals are moral agents, at least in a sense relevant to the capacity to make deliberations in matters of justice. as martha nussbaum relatedly claims, ‘insofar as there is reciprocity between humans and some nonhuman animals, it is not the type of reciprocity described in rawls’s theory, based on the possession of reflexive rational and moral capacities’ 36 . nussbaum, while strongly influenced by rawls, does not accept the kantian commitment to rationality as a necessary condition for being a recipient of justice: that animals suffer pain and indignity at the hands of humans has often been conceded to be an ethical issue; it has more rarely been acknowledged to be an issue of social justice. if we do so acknowledge it… this new problem will require theoretical change. images of social cooperation and reciprocity that require rationality in all parties… will need to be reexamined (frontiers of justice, p. 2). nussbaum then rejects those aspects of rawls’s theory that exclude animals from being capable of being recipients of justice on the ground that they lack rationality, a necessary characteristic for the possession of moral agency. for nussbaum, such claims depreciate the intelligence of many animals (p. 327), and fail to recognise that animals have a range of capabilities and species-specific ‘entitlements based upon justice’ (p. 392), which latter include ‘opportunities for nutrition and physical activity; freedom from pain, squalor, and cruelty; freedom to act in ways that are characteristic of the species… freedom from fear and opportunities for rewarding interactions with other creatures… and to enjoy the light and air in tranquility’ (p. 326). denying animals such freedoms is a matter of justice, for such freedoms are essential to animals’ flourishing, and enable them to fulfill their capabilities, thus constituting needs. that said, even if we accept (for argument’s sake) that some animals are indeed capable of moral agency, or of the rationality required for being (or becoming) a moral agent, recognition of the cognitive and emotional capacities or abilities of animals, such as the capacity for altruistic reciprocity, and the ability to sympathise and / or empathise, does not provide a sufficient reason for including animals in contract theories as recipients of justice. indeed, nussbaum argues that ‘it seems doubtful… that we can include animals sufficiently in a rawlsian theory simply by acknowledging these facts… [t]he capacity for reciprocity is present only in some animals; and yet issues of unfair and cruel treatment extend very bangladesh journal of bioethics 2017; 8(1): 44-57 47 broadly. if there is reciprocity between humans and dogs or apes, it is not clear that there is reciprocity between humans and birds and lions. and yet, our treatment of all these animals appears to raise questions of justice’ (p. 333). accordingly, the theory that obligations of justice are restricted to those obligations which focus on parties able to enter into contracts and capable of a sense of justice is implausible in any case, not least because there are many human beings which are neither able to enter into contracts nor currently capable of a sense of justice, but which are nevertheless capable of being harmed and benefited by our moral deliberations and thus capable of being recipients of distributive justice. here we should add that many sentient non-human animals have needs comparable to these and to other human beings, and are thus capable of being recipients of distributive justice as well. rawls persisted in arguing to the contrary in his later writings, claiming that ‘the status of the natural world and our proper relation to it is not a constitutional essential or basic question of justice’ (political liberalism, p. 246); but such claims serve to underline why we should hesitate to give unqualified assent to rawlsian theories of justice. and this general conclusion also has a bearing on theories of justice of this general kind, which, because of being based on contracts, whether real or hypothetical, will foreseeably be unduly restrictive and narrow, excluding not just non-human beings, but also many humans who are unable to enter into contracts (or to experience a sense of justice) for various reasons. contractarianism revised: in relation to contractarianism, there have of course been attempts to extend or modify the contract doctrine so as to include animals as recipients of justice, most notably on the part of mark rowlands, who notes that the rational beings in the contract choose rules by imagining what they would want those rules to be if they did not have certain properties 37 . being in the original position is about being able to restrict one’s reasoning about oneself and morality: this process of reasoning looks something like this: ‘as a matter of fact, i have property p. but what if i did not have property p? what principles of morality would i want adopted if i didn’t have p?’... [b]eing in the original position is… simply a matter of allowing one’s reasoning about morality to be guided by the above sorts of restrictions (animal rights, p. 136). when rowlands talks of a ‘property’ here, we take him to mean not only particular characteristics (like colour of eyes or hair), but also more general ones, including sex, race, and class. the rational beings in the contract choose rules by imagining what they would want those rules to be if they did not have certain properties. in this way those in the original position are not only debarred from knowledge of their individual characteristics, but also (or so rowlands suggests) from any knowledge of their species. rowlands applies his view of contractarianism to the ethics of factory farming and animal experimentation. the consequences humans would have to endure if they were to become vegetarians and animal research were phased out can be compared with the consequences animals have to endure from the practices of intensive rearing and animal research. in comparison to the suffering animals endure in these practices, humans would suffer very little by becoming vegetarians bangladesh journal of bioethics 2017; 8(1): 44-57 48 and by a phasing out of animal experiments. given that the individuals in the contract make choices behind a veil of ignorance, they would not know which species they were a member of. (it may be that they are non-human, rather than human.) and given that animals suffer enormously in these practices compared to what humans would suffer if they were abolished, the most rational choice would be a world where widespread vegetarianism was put into practice and animal experiments were phased out (animal rights, pp. 149-50). however, rowlands’s would-be rescue of contractarianism and attempt to include animals in the contract as deserving recipients of justice is creditable but unconvincing, as the notion of rational choosers of indeterminate species is barely coherent. for, given that the choosers do not know to which species they belong, or as what they are choosing, the very concept of choosing is eroded to such an extent that it cannot be relied upon to operate as it normally does. besides, choosers who have no idea what their own good consists in can hardly be understood as capable of rational choice at all. (for further problems, see garner, theory of justice for animals, pp.34-36.). can other contractualist theories which present a concept of justice as impartiality protect the interests of animals in a more convincing manner? more recently, robert garner has provided a revealing and an informative analysis of brian barry’s contractarian stance in relation to animals and justice (theory of justice for animals, pp. 36-42). barry’s approach originates in scanlon’s contractualist theory according to which judgments about morality are ‘judgments about what would be permitted by principles that could not reasonably be rejected, by people who were moved to find principles for the general regulation of behaviour that others, similarly motivated, could not reasonably reject’ (what we owe to each other, p. 4). relatedly, principles of justice then, as garner notes, ‘come about as a result of bargaining and negotiation within the original position… only those principles that cannot be reasonably rejected by others pass the test and can be included as principles of justice’ (theory of justice for animals, p. 37: here garner cites works of brian barry) 38 39 . in the light of barry’s stance, ‘the inclusion of animal protection principles within justice as impartiality would require that they be principles that cannot be reasonably rejected’ (theory of justice for animals, p. 37). that said, garner plausibly argues that it is unlikely such a requirement would afford genuine or sufficient protection for animals. justice is still owed directly to moral agents only, and since animals lack moral agency their interests are excluded from being given direct consideration. in other words, it is not the interests of the animals themselves that are to be considered in matters of justice; rather ‘the interests of animals can only be considered indirectly by those humans who regard it as a good they wish to promote’ (theory of justice for animals, p. 38). relatedly and importantly, ‘in barry’s scanlonian version of the contract, the participants know they are humans and know what their particular, narrow, self-interests are’ (theory of justice for animals, p. 38). as such, while those deliberating about justice might find it reasonable to accept a principle that outlaws, say, using animals for entertainment in ways that cause them to experience pain and distress, nevertheless in the light of the fact that many people have a vested interest in maintaining the status quo with regards to our use of animals (including a vested interest in ensuring the continuance of practices that exploit animals and cause them considerable suffering), many would not find it bangladesh journal of bioethics 2017; 8(1): 44-57 49 reasonable to accept a principle that ‘impacts negatively upon their conception of the good’ such as one involving fundamental economic interest. this conclusion is heightened by the fact that all that is required for a proposed principle of justice to be rejected is an individual veto’ (theory of justice for animals, p. 38). thus we arrive at the problem highlighted earlier in this essay; contractualist theories appear susceptible to the claim that they cannot sufficiently protect the interests of animals, even vital ones. (while they may condemn much factory-farming on social and environmental grounds, it remains a problem that they would not protect the animal interests at stake in the absence of these grounds.) indeed, they do not appear to be able to take sufficiently into account what animals are owed, according to philosophers such as nussbaum and garner, as a matter of justice. with regards to barry’s attempt to include animals, then, we have seen that the tension between protecting animals and liberalism’s emphasis on rejecting principles that conflict with one’s conception of the good raises its head again. in relation to rowlands’s attempt, given that those in the original position do not know to which species they belong, the concept of choice becomes so eroded that it is it is difficult to fathom how those in the original position, making ‘choices’ behind a veil of ignorance, are to make rational choices at all. this is a problem integral to the rawlsian framework itself as the matrix for principles of justice—the framework on which decisions of justice are made. as such, the problems arising from rawlsian contractarianism (particularly problems related to the charge of inconsistency in respect of its exclusion of animals and to the claim that it cannot sufficiently protect animals’ weighty interests from being unjustifiably overridden by less weighty humans ones) cannot be resolved by merely trying to modify or revise the contract so as to include animals. relatedly, the framework is based on a conception of justice which itself is rooted in a certain conception of rationality: rationality requires somehow abstracting one’s self from the particulars in order to obtain a disinterested and an impartial viewpoint. in seyla benhabib’s words, such a self is ‘disembodied and disembedded’ from concrete reality 40 . indeed, it is far removed from having any knowledge of the differences between individuals, and yet differences would need to be taken into account should the rational choosers be able to make choices which attempt to make those disadvantaged in society better off: such differences would, for benhabib, include gender differences, but to these one should add species differences. thus it is difficult to imagine how the rawlsian goal of equality could be attained by disembodied choosers, ignorant of the particulars (and, in relation to considering animals’ interests as a matter of justice, ignorant of species-specific differences). non-anthropocentrism, justice and animals: in the light of the above concerns regarding anthropocentric conceptions of justice and regarding contractarianism, it is now time to consider what can be said about justice towards non-human animals by people who reject anthropocentrism (even if they are not adherents of animals rights) and who accept an alternative moral framework. for even alternative moral theories that adopt a nonanthropocentric stance tend to exclude animals from the sphere of justice, and yet, as we have seen, doing so means that animals’ interests are likely to be unfairly overridden by stricter obligations of justice with regards to human interests. but if advocates of such theories wish bangladesh journal of bioethics 2017; 8(1): 44-57 50 to provide a framework which can genuinely take the interests of animals into account, then their theory of obligation with regards to animals needs to be brought into line with their claims about whether animals are entitled to justice. however, if such theories encounter problems with including non-human animals as recipients of justice (as contractarianism does) then they may be seen to undermine themselves as non-anthropocentric moral theories. the kind of anthropocentrism that is relevant here is not metaphysical or teleological anthropocentrism, the claim that everything exists for the sake of humanity, but the normative or ethical kind, which claims that human interests are the only interests that matter in morality, and that human beings alone have moral standing. most ethicists these days reject this kind of anthropocentrism, partly because they can do so without adopting any stance in metaphysics, but for a range of good reasons besides. however, it should be said at the outset that rejecting normative anthropocentrism need not involve acceptance of obligations to animals, as it is compatible with holding that non-human animals warrant moral consideration but have relatively slight moral significance. (for the distinction between moral considerability and moral significance, see goodpaster, ‘on being morally considerable’ (note 20). nevertheless, the usual grounds for rejecting normative anthropocentrism take us much further. the usual grounds include the wrongness of inflicting pain and suffering on non-human animals without a good justification, and these grounds imply that animal suffering is morally significant enough to be weighed against human interests, and to be found more serious than trivial ones, but perhaps less serious than vital interests. but this in turn suggests that, besides non-human animals having moral standing, their well-being has quite considerable moral significance, and enough to support obligations in their regard, and obligations of justice at that. certainly there are other grounds that can be advanced for rejecting anthropocentrism, and so the reasoning just rehearsed does not apply of itself to all those who share in this rejection. yet for many of the grounds for rejecting it, there will be arguments that are counterparts of the one just advanced, capable of sustaining the same conclusion. for example, biocentrists standardly hold not only that all living creatures have moral standing, but also that their good or flourishing has intrinsic value. this view is compatible with the relevant degree of intrinsic value being slight. but when living creatures in their millions are at risk, as when a forest is threatened, this very approach implies that a very high degree of intrinsic value is in question, and therefore that agents who can prevent the forest being destroyed have an obligation to prevent it happening and to preserve the forest. besides, the argument just presented has an interesting spin-off, for many would agree that intrinsic value is what we have obligations to promote. let us adopt this assumption for present purposes. on this basis, both sentientists (who recognise negative intrinsic value in animal suffering) and biocentrists (who recognise positive intrinsic value in the well-being of non-human living creatures in general) have to accept that whenever the well-being of the creatures whose moral standing they recognise is at stake, obligations are incurred, other things being equal. moral agents, in other words, have obligations with regard to (at least) bangladesh journal of bioethics 2017; 8(1): 44-57 51 sentient animals, and possibly with regard to non-human creatures in general, where there are no other moral considerations, or where other considerations exist but cancel each other out. but this conclusion has a bearing on our theory of justice; for a theory of justice which purports to set aside recognised obligations as insignificant cannot be accepted. if so, and even if we still hesitate to affirm animal rights, our theory of justice must sometimes prioritise non-human interests over some human interests 41 42 . so far in this section, it has been suggested that traditional theories of justice are likely to need to be modified by those who accept either sentientism or biocentrism. but what of other normative stances? the view that animals can be the focus of obligations can be supported by virtue ethicists, for some of the virtues can be construed as upholding kindness, mercy and loyalty towards non-humans, despite costs to the human agent concerned, and thus as supporting not only acts of supererogation but also sometimes obligatory ones. there can undoubtedly be obligations of loyalty, and plausibly there can sometimes be obligations to be kind or to be merciful too. virtue ethicists are not obliged to accept this, but their virtueethical stance permits and enables them to accept it. further, once obligations are recognised, then once again our understanding of justice needs to be modified accordingly. virtue ethics, then, is compatible with obligations of justice being owed to animals. this can all likewise be accepted by non-anthropocentric consequentialists, who relate our obligations to promoting states of value, and include among these states valuable states of non-human animals; for this was implicit in the earlier reasoning. (many sentientists, after all, are also consequentialists, as are some biocentrists.) it could also be accepted by those deontologists who hold that one of our duties is not to harm existing creatures. for this duty could well be interpreted as a requirement of justice, and as sometimes taking priority over some duties to human beings. while neither consequentialists nor deontologists are required as such to accept that justice is owed to animals, their generic normative stances certainly allow of this conclusion (just as virtue ethics does). rawlsian and other contractarians, however, can hardly accept this view about animals and justice, since non-human animals cannot enter into contracts, and almost certainly lack the capacity for a sense of justice. certainly, for rawls, only humans can be recipients of justice, humans being the only species capable of a sense of justice and of moral agency. conclusions: if we hold that animal ethics is just a matter of moral obligations not grounded in justice, plus compassion, then it is understandable that it is often side-lined before issues such as the relief of human poverty and the upholding of human rights, for the latter are certainly regarded as matters of justice. however, since the vital interests of animals turn out to be more significant than the trivial or peripheral interests of humans, or, in other words, the treatment of animals is a matter of justice, then there are obligations to prevent avoidable and unnecessary animal suffering, and good grounds to regard this as a matter not just of compassion but also one of justice and of fairness, just as there are also good grounds to relieve human poverty and to uphold human rights. bangladesh journal of bioethics 2017; 8(1): 44-57 52 it has been found that rawls’s contractarianism and related revisionist positions encounter problems with regards to this conclusion: particularly problems related to the charge of inconsistency, but also to the claim that contractarianism cannot sufficiently protect animals’ weighty interests from being overridden by less weighty human ones. in relation to the latter claim, there appears to be a tension in liberal attempts to provide sufficient protection for animals; a tension that arises from liberalism’s emphasis on the freedom of individuals to pursue their own conception of the good as long as doing so does not interfere with the good of others. in relation to the former charge, one could try to overcome the inconsistency of excluding animals from the contract by, for example, either including those animals which are at least as cognitively developed as babies and infants, or by excluding marginal humans along with animals. but such an attempt raises a number of further issues. one issue is that comparison of the mental capacities of different beings would not be an easy task, not least because different capacities will manifest themselves in different ways, and will be possessed by beings (whether of the same or of different species) in varying degrees. but such a comparison would be necessary in order to determine which beings should be included in the contract and which excluded. as such, it would become incredibly difficult to determine which beings should be recipients of justice. besides, a theory that restricts obligations to those who are capable to entering into contracts and / or to those who possess certain rational capacities is implausible, not least because there are many beings (humans and non-human animals included) which are unable to enter into contracts and which would not meet the conditions deemed necessary for the possession of rationality, but which are nevertheless capable of being harmed and benefited by our moral deliberations and thus capable of being recipients of distributive justice. another issue concerns rowlands’s revised contractarian position more specifically; we have seen that the notion of choice in rowlands’s theory becomes so eroded as to make it impossible to see how choosers could make decisions concerning justice. in any case, it has been found that the issues arising from rawlsian contractarianism cannot be resolved by merely trying to modify the contract, for there is a problem regarding the very framework from which obligations are derived. yet unless rawlsian contractarianism and its framework can be drastically revised so as to overcome the various problems mentioned above, it is to be concluded that it must be rejected because of its failure to include animals in the sphere of justice. overall, contractarianism’s exclusion of animals from the sphere of justice has serious implications, for it follows that animals’ basic needs and interests could easily be overridden by less weighty human interests. to overcome this, animals need to be included in the sphere of justice, and this would involve overcoming the disparity between our understanding of our obligations to animals and our understanding of what is owed to animals as a matter of justice; in other words, what we say about obligations and about justice with regards to animals need to be aligned, so that animals’ interests are not unjustifiably countered and bangladesh journal of bioethics 2017; 8(1): 44-57 53 disregarded by traditionalist assumptions about the priority of humans in matters of justice. while even some non-anthropocentric theories (such as sentientism and biocentrism) have (like contractarianism) excluded animals from considerations of justice, it has been found that they (unlike contractarianism) have the resources to overcome this disparity, and include animals as recipients of justice. while it may not always be easy to motivate acceptance of such non-anthropocentric theories, as opposed to, for example, contractualism, our capacities for sympathy and for respect for non-human lives as well as for human beings mean that this is far from an insuperable obstacle to the acceptance of one or another of these theoretical stances. it should be re-affirmed that no appeal to animal rights is required of those who endorse these conclusions; these obligations hold good even for those who reject such considerations, and the same holds for inter-species issues of justice. it is possible to have obligations (for example, to relieve poverty, or to reduce the suffering of animals used in the practices of animal experimentation and factory-farming) without the individuals of the class towards which the obligations are targeted having rights to that treatment. correspondingly an acceptance of obligations towards non-human animals need not imply a matching recognition that those animals have matching rights, although taking seriously such obligations plausibly requires that we grant animals some appropriate legal rights, if only so that their interests can be properly protected and promoted (whether or not we recognise them as having moral rights) 43 . the inclusion of non-human animals within the scope of justice makes the language of animal rights less inappropriate than it might appear from traditionalist perspectives, but does not mandate those who recognise this inclusion to endorse animal rights as well. whether or not we are happy with language of this kind, we can and should recognise that there are obligations of justice towards animals; such, at any rate, is the central conclusion of this essay. authors’ contributions: the first author presented a related paper at a conference, and the second author expanded the argument of that paper significantly in the light of the recent literature. both authors then contributed revisions, and the first author adjusted the references in line with the journal’s requirements and added responses to the comments of an anonymous referee. conflict of interests: no conflict of interests arises in connection with this essay. acknowledgement: the authors would like to acknowledge the helpful academic advice of simon robertson, jan deckers and an anonymous referee of bangladesh journal of bioethics, and the practical assistance and encouragement of david lockwood and of steven goundrey. bangladesh journal of bioethics 2017; 8(1): 44-57 54 references 23 see clement, g. ‘animals and moral agency: the recent debate and its implications’, journal of animal ethics 3, 1 (2013): 1-14. 24 see also rowlands, m. ‘animals and moral motivation: a response to clement’, journal of animal ethics 3, 1 (2013): 15-24. 25 bekoff, m. and pierce, j. wild justice: the moral lives of animals (chicago and london: university of chicago press, 2009). 26 de waal, f. good natured: the origins of right and wrong in humans and other animals (cambridge, ma and london: harvard university press, 1996). 27 see brosnan, s.f. and de waal, f.b.m. ‘monkeys reject unequal pay’, nature 425 (2003): 297-299. 28 brosnan, s. f. ‘justice and fairness related behaviors in non-human primates’, proceedings of the national academy of sciences 110 (2013): 10416-10423. 29 proctor, d., williamson, r.a., de waal, f.b.m. and brosnan, s.f. ‘chimpanzees play the ultimatum game’, proceedings of the national academy of sciences 110 (2013): 2070– 2075. 30 clark, s.r.l. the nature of the beast: are animals moral? (oxford and new york: oxford university press, 1984), p. 107. 31 degrazia, d. taking animal seriously: mental life and moral status (cambridge: cambridge university press, 1996), p. 203. 32 brosnan, s.f. and de waal, f.b.m. ‘evolution of responses to (un)fairness’, science 346, 6207 (2014). 33 evans, e.p., the criminal prosecution and capital punishment of animals (london: heinemann, 1906); cited rowlands, m.(see note 24) 34 dinzelbacher, p., ‘animal trials: a multidisciplinary approach’, journal of interdisciplinary history 32 (2002): 405-21; cited rowlands, m. (see note 24) 35 see further rowlands, m., can animals be moral? (new york: oxford university press, 2012), pp. 85-86. 36 nussbaum, m.c., frontiers of justice: disability, nationality, species membership (cambridge, ma: the belknap press of harvard university, 2006), p. 333. 37 rowlands, m. animal rights: a philosophical defence (london: macmillan press, 1998), pp. 120-58. 38 barry, b. justice as impartiality (oxford: clarendon press, 1995), p. 65, cited by garner (see note 10). 39 barry, b. theories of justice (hemel hempstead: harvester-wheatsheaf, 1989), p. 8, cited by garner (see note 10). 40 benhabib, s. situating the self: gender, community and postmodernism in contemporary ethics (oxford: blackwell, 1992), p. 152. 41 see further attfield, r. ethics: an overview (london and new york: continuum/bloomsbury, 2012). 42 problems for endorsing animal rights are ably presented in rainer ebert and tibor r. machan, ‘innocent threats and the problem of carnivorous animals’, journal of applied philosophy, 29.1, 2012, 146-159. bangladesh journal of bioethics 2017; 8(1): 44-57 55 43 see hare, r.m. moral thinking: its levels, method, and point (oxford: clarendon press, 1981), pp. 150-57. alphabetical list of references (both parts) abbey, ruth (2007), ‘rawlsian resources for animal ethics’, ethics and the environment 12, 1: 1-22 attfield, robin (1987), a theory of value and obligation (london, new york and sydney: croom helm) attfield, robin (1995), value, obligation and meta-ethics, value inquiry book series, vol.30 (amsterdam and atlanta, ga: editions rodopi) attfield, robin (2012), ethics: an overview (london and new york: continuum/bloomsbury) barry, brian (1989), theories of justice (hemel hempstead: harvester-wheatsheaf barry, barry (1995), justice as impartiality (oxford: clarendon press) barry, brian (1999), ‘sustainability and intergenerational justice’, in andrew dobson (ed.), fairness and futurity: essays on environmental sustainability and social justice, (oxford: oxford university press) bekoff, mark and pierce, jessica (2009), wild justice: the moral lives of animals (chicago and london: the university of chicago press benhabib, seyla (1992), situating the self: gender, community and postmodernism in contemporary ethics (oxford: blackwell bentham, jeremy (1843), ‘anarchical fallacies’, in the works of jeremy bentham, volume 2 (edinburgh: w. tait) brosnan, sarah f. and de waal, frans b. m. (2003), ‘monkeys reject unequal pay’, nature 425 (2003): 297-299 brosnan, sarah f. (2013), ‘justice and fairness related behaviors in non-human primates’, proceedings of the national academy of sciences 110: 10416-10423 brosnan, sarah f. and de waal, frans b. m. (2014), ‘evolution of responses to (un)fairness’, science 346, 6207 clark, stephen r.l. (1984), the nature of the beast: are animals moral? (oxford and new york: oxford university press) clement, grace (2013), ‘animals and moral agency: the recent debate and its implications’, journal of animal ethics 3, 1: 1-14 degrazia, david (1996), taking animal seriously: mental life and moral status (cambridge: cambridge university press) de waal, frans (1996), good natured: the origins of right and wrong in humans and other animals (cambridge, ma, and london: harvard university press) dinzelbacher, p. (2002), ‘animal trials: a multidisciplinary approach’, journal of interdisciplinary history 32: 405-2 ebert, rainer and machan, tibor r., ‘innocent threats and the moral problem of carnivorous animals’, journal of applied philosophy, 29.1, 2012, 146-159 bangladesh journal of bioethics 2017; 8(1): 44-57 56 evans, e. p. (1906), the criminal prosecution and capital punishment of animals (london: heinemann) frey, r. g. (1980), interests and rights: the case against animals (oxford: clarendon press) gaita, raymond (2002), the philosopher’s dog (london: routledge) garner, robert (2002), ‘political ideology and the legal status of animals’, animal law 8, 77: 77-91 garner, robert (2012), ‘rawls, animals and justice: new literature, same response’, res publica 18, 2: 159-172 garner, robert (2013), a theory of justice for animals: animal rights in a nonideal world (new york: oxford university press) goodpaster, kenneth (1978), ‘on being morally considerable’, journal of philosophy 75: 308-325 hare, r. m. (1981), moral thinking: its levels, method, and point (oxford: clarendon press) humphreys, rebekah (2008), ‘contractarianism: on the incoherence of the exclusion of non-human beings, percipi 2: 28-38 humphreys, rebekah (2011), ‘animal rights, interests and moral standing: a critical examination of the dialogue between regan and frey’, in manish vyas (ed.), issues in ethics and animal rights, (delhi: regency publications) midgley, mary (1983), animals and why they matter (harmondsworth, uk: penguin) möllendorf, darrel (2002), cosmopolitan justice (boulder, co: westview press) möllendorf, darrel (2011) ‘cosmopolitan and compatriot duties’, the monist 94, 4: 535-54 nussbaum, martha c. (2006), frontiers of justice: disability, nationality, species membership (cambridge, ma: the belknap press of harvard university) proctor, darby, williamson, rebecca a., de waal, frans b. m. and brosnan, sarah f. (2013), ‘chimpanzees play the ultimatum game’, proceedings of the national academy of sciences 110: 2070–2075 rawls, john (1993), political liberalism (new york and chichester, uk: columbia university press) rawls, john (1999) a theory of justice, revised edition (oxford: oxford university press) [originally published 1971] rowlands, mark (1998), animal rights: a philosophical defence (london: macmillan press) rowlands, mark (2012), can animals be moral? (new york: oxford university press) rowlands, mark (2013), ‘animals and moral motivation: a response to clement’, journal of animal ethics 3, 1: 15-24 scanlon, t. m. (1998), what we owe to each other (cambridge, ma, and london: the belknap press of harvard university press) singer, peter (1995), animal liberation, second edition with a new preface by the author (london: pimlico) warnock, g. j. (1971), the object of morality (new york: methuen) bangladesh journal of bioethics 2017; 8(1): 44-57 57 wissenburg, marcel (1993), ‘the idea of nature and the nature of distributive justice’, in the politics of nature: explorations in green political thought, eds. a. dobson and p. lucardie (london: routledge) microsoft word 4 cpf bangladesh journal of bioethics 2018; 9 (3): 28-44 28 levels and determinants of complementary feeding pattern exclusive of minimum meal frequency and dietary diversity among children of 6 to 23 months in bangladesh naznin pervin1, darryl macer2, shamima p. lasker3 1. bds, msc, mhe, mph, consultant dental surgeon, salauddin specialized hospital ltd , email: nazneenmowshumy@gmail.com 2.mph, ph.d., hon.d., ausn president; provost; ausn professor of bioethics and biomedicine; director, eubios ethics institute (chair),email: provost@ausn.info 3.phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd); professor & head of anatomy, shahbuddin medical college, dhaka, bangladesh. visiting professor of clinical anatomy & bioethics, american university of sovereign nation, usa. founding chairman & sectary general, bangladesh bioethics society, treasurer, world association of medical editors (wame), chairperson, ethics & publication, asian pacific association of medical editors (apame), email: splasker04@yahoo.com orcid id: https://orcid.org/0000-0002-3484-9526 abstract: objective: to estimate the level of complementary feeding pattern (cfp) among children aged between 6 to 23 months and to identify the determinants in individual, household and community level in bangladesh. methods: from secondary data of bangladesh demographic health survey (bdhs) 2011 was used in this study. a total of 2,373 children aged between 6 to 23 months were selected. to estimate the level of cfp dimension index and the “score of the index” was used as dependent variables. statistical analyses and tests were guided by the nature of the variables. multivariable logistic regression analyses were performed to identify the significant determinants of cfp. results: the overall level of cfp among children aged between 6 to 23 months was low. more than 95% of the children experienced inadequate (92.7%) cfp level. the mean levels of cfp as well as percentages of no or inadequate (94.1%) cfp were significantly lower among children of the youngest age group (06 months), uneducated parents, unemployed/laborer fathers, socio-economically poor families, food insecure families and rural areas. however, only few variables remained significant for adequate cfp in the multivariable logistic regression analysis. adequate cfp was significantly lower among the children aged between 6 to 23 months (or: 0.22, 95% ci: 0.10-0.47), children of illiterate fathers (or: 0.32, 95% ci: 0.11-0.95) and socio-economically middle-class families (or: 0.28, 95% ci: 0.09-0.86) as compared to their reference categories. conclusion: inappropriate and inadequate cfp may cause serious health hazards among children of 6 to 23 months in bangladesh. it is ethical to take effective interventions and strategies by the government and other concerned stakeholders to improve the overall situation of cfp in bangladesh. key words: cfp, children, individual, household, community, bangladesh, complementary feeding, minimum meal frequency, dietary diversity. introduction: malnutrition is the largest risk factor in the world for disability and premature mortality among young children, especially in developing countries. although the condition is entirely bangladesh journal of bioethics 2018; 9 (3): 28-44 29 preventable. malnutrition is a significant underlying factor in more than half of the deaths of young children in these countries1. recent analyses have found a decrease in child deaths under 5 years of age to 8.795 million in 2008 worldwide 2. and 7.7 million in 2010 3 , yet malnutrition remains one of the key factors associated with global loss of life in young children2,4,5. the objective of millennium development goals (mdgs) of united nations (un) focused on reducing poverty, and extreme hunger, and improving education by 2015 6. one of the objectives of mdg was to decrease the prevalence of underweight children under 5 years of age (under-5 children) as the primary measure of malnutrition by 2015 6. in ethiopia, 47%, 11% and 38% of children under five years of age were stunted, wasted and underweight, respectively7. an ethiopian child is 30 times more likely to die by his or her fifth birthday than a child in western europe and the most common cause of child death is the interacting combination of malnutrition and infection 8. proper feeding practices during infancy and early childhood are fundamental for normal growth, development, and survival of infants and children, particularly in developing countries 9,10,11. south asian countries including bangladesh reveal the highest burden of childhood undernutrition due to unimproved feeding of children that causes faltered growth and development, and illness, such as, respiratory infections, diarrheal diseases etc 9,12. according to the various studies, 6-23 months of age of a child is a “critical window” for the transition of body and cognitive development 9,13. after 6 months of age, children need complementary food because breast milk or infant formula alone is no longer sufficient to maintain the child’s growth 9,13. at this stage, children should be fed small quantities of nutritional solid and semisolid foods in addition to breastfeeding 13. the world health organization (who) and the united nations international children’s emergency fund (unicef) have articulated a global strategy and formulated guidelines for complementary feeding of the breastfed child 14. although appropriate complementary feeding pattern (cfp) among children aged between 6 to 23 months brings numerous health benefits 9, inappropriate and inadequate introduction of cfp may increase the risk of malnutrition among under-five children 7,15,16. the levels of cfp are affected by numerous individual, household and community level factors 9,16. the undernourished children are more likely to develop severe health hazards that impede body’s metabolism and retard utilization of immunity resulting from deficiencies in immune competence 17,18. although bangladesh has made magnificent progress in health and human development since its independence in 1971 19,10, this country shows limited success in beating the odds of child malnutrition. for instance, the prevalence bangladesh journal of bioethics 2018; 9 (3): 28-44 30 of under-five child malnutrition in bangladesh is nearly 40%, which causes nearly 60% of under-five deaths 21. inappropriate feeding practice could be one of the profound causes of high under-five mortality in this country 22. considering the limited number of studies in bangladesh, this study aimed to estimate the levels of cfp among children of 6 to 23 months using composite dimension index and then to identify the determinants of cfp focusing on individual, household and community level factors. to our knowledge, none of the previous studies used composite dimension index to measure the levels of cfp in bangladesh. although dimension index is originally developed and used to calculate human development index by the united nations development programme (undp), it is also applied to address other issues 23,24. ethical implication: in this study secondary data was used. hence irb approval was not necessary. however, verbal consent was taken from bdhs. since studies based on dimension index to interpret cfp are still scarce, further reports to provide universally accepted cut off points to define different groups of cfp would be immensely useful for the purposes of comparison, monitoring, evaluation and advocacy. the primary causes of malnutrition include a lack of quality food, poor infant and child feeding and care practices such as suboptimal breastfeeding, deficiency of micronutrients such as vitamin a or zinc, and recurrent attack of infections, often intensified by intestinal parasites 25 in this perspective, this research is very important in this area to address the child feeding practice. objectives: general objectives: there is limited research on cfp and minimum meal frequency and dietary diversity among children of 6 to 23 months in bangladesh. therefor this study has been undertaken to estimate the levels of cfp among children of 6 to 23 months using composite dimension index and then to identify the determinants of cfp focusing on individual, household and community level factors. specific objectives: 1. to find out the levels of cfp among children aged 6 to 23 months. 2. to find out the prevalence of practice of cfp based on multilevel factors. 3. to identify the determinants of cfp methodology: this retrospective study was performed by analysis of surveys conducted by bangladesh demographic and health survey (bdhs) in 2011 which was a nationally representative crosssectional survey, during august to november, 2015 for the master thesis of american university of sovereign nations (ausn). bangladesh journal of bioethics 2018; 9 (3): 28-44 31 inclusion and exclusion criteria: a total of 8,761 under-five children (unweighted) born after january 2006 or later, were considered for anthropometric measurements, of which data (anthropometric and age) were completed for 7,647 children (around 88%). among them 2,373 children aged between 6 to 23 months were considered as final sample (figure 1). (all the under-five children outside the range of 6-23 months were excluded from the analysis. from the total of 2,405 children aged 6-23 months, 32 children were excluded due to missing information. therefore, the final sample for analysis was 2,373 children aged 6-23 months). measuring levels of cfp and outcomes: to measure the level of cfp among children, 20 frequently asked questions (indicators) had been included for eligible mothers of households (figure 2).they were: complementary food items namely, 1. plain water. 2. noodles, bread and others made from grains. 3. other solid, semisolid. 4. potato, cassava and other tubers. 5. fish or shellfish. 6. any dark green leafy vegetable. 7. eggs. 8. tinned, powdered or fresh milk. 9. any other fruits. 10. other liquid other than juice. 11. juice. 12. meat. 13. pumpkin, carrot, squash. 14. mangoes, papayas, other vitamin a fruits. 15. baby formula. 16. foods made from beans, peas, lentils, nuts. 17. fortified baby food. 18. yogurt 19. liver, heart, other organs. 20. cheese, dessert, other milk products. for each question, responses were coded binary as 1= yes (practice) and 0 = no (not practice). thereafter, the formula of “dimension index” (given below) was used in accordance with the construction method of the human development index (hdi) to estimate the level of cfp 26. firstly, cronbach’s alpha coefficient was used to evaluate the internal reliability of the 20 indicators. according to our analysis, the cronbach’s alpha estimate was 0.701, suggesting a high internal consistency. the index was then constructed using the sums of weighted binary input variables where maximum and minimum values were also chosen for underlying dimension. performance of the dimension index was expressed into a unit-free index between 0 and 1 26 .the index is defined as: dimension index = actual value − minimum value maximum value − minimum value the actual value here indicates the sum score of 20 binary indicators for each respondent and the maximum and minimum values were 20 and 0, respectively. the individual score of cfp (based on dimension index) was converted into percentage by multiplying 100. these scores were then divided into two categories. 1. individuals with dimension score of exactly 0 % belonged to the “no cfp” group. 2. individuals with other scores ranging from 1-100 % belonged to the “cfp” group (20). the cfp scores were bangladesh journal of bioethics 2018; 9 (3): 28-44 29 figure 1: sample size selection figure 2: percentage of complementary foods received by children (bdhs 2011) a total of 8,550 children under 5 years of age were eligible for anthropometric measurements 8,435 children have complete and credible anthropometric data height and weight data are missing for 115 7,647 children have complete and credible anthropometric and age data age data are missing for 790 children 5,242 children age less than 6 months and greater than 23 months were excluded 2,405 children have complete and credible anthropometric, nutrition and age data mothers of 32 children who respond “do not know” for cfp were excluded 2,373 children deemed eligible for the present study (final data) 32 bangladesh journal of bioethics 2018; 9 (3): 28-44 28 again divided into three categories: no cfp (0 %), inadequate cfp (1-49%) and adequate cfp ( 50.0%). both variables with two and three categories were used as dependent variables in multivariable analyses. covariates: covariates were classified into three level characteristics: individual, household, and community characteristics. individual level characteristics were: age of child (6-11 months, 12-17 months, 18-23 months); sex of child (male, female); mother’s education (illiterate, literate); father’s education (illiterate, literate); father’s employment status (currently unemployed composed of unemployed persons and students, laborers composed of farmer, agricultural worker, fisherman and rickshaw etc.; service holders composed of doctor, lawyer, accountant, teacher and so on; businessman). household socioeconomic status based on wealth index (poor, middle, rich), mass media exposure through television, radio and newspaper/magazine (yes: all medias exposed to at least once a week, no); food insecurity (yes, no) were considered as the household level characteristics. the wealth index was constructed using household asset data via principal components analysis 27. household socio-economic status was considered as the household-level characteristics. household socioeconomic status, namely the wealth index was constructed from data on household assets, including ownership of durable goods factors with cfp. statistical significance (analyses were carried out using spss software (version 20.0). such as televisions and bicycles) and dwelling characteristics (such as source of drinking water, sanitation facilities, and construction materials). principal components analyses were used to assign individual household wealth scores. these weighted values were then summed and rescaled to range from 0-1, and each household was assigned into quintiles: the first quintile: poorest, the second quintile: poorer, the third quintile: middle class, the fourth quintile: richer and the fifth quintile: richest 27. five household food security indicators were selected using the household food insecurity access scale. community level characteristics were represented by the place of residence (urban, rural) and region of residence (south, south-east, central, mid-west, northwest, and east). statistical analysis: the continuous score of cfp based on dimension index were tested using anova-test and t-test. these tests tested the differences of cfp among various categories of each independent variable. contingency analysis was used to test the bivariable associations between the cfp (with three categories) and selected factors by applying the chi-square (  2) test. multivariable binary/multinomial logistic regressions (binary for cfp scores with two categories and multinomial for cfp scores with three categories) were 3333 bangladesh journal of bioethics 2018; 9 (3): 28-44 29 used to examine the associations of selected was accepted at p < 0.05. statistical study limitations: this study is not free from limitations. due to unavailability of recent data, 27. data was used in this study that does not present the current nutritional status. the cross-sectional nature of the study limits us to assess the cause and effect relationships between selected factors and cfp. most of the food items were given to the children in last 24-hours preceding the survey time, however, the children could occasionally receive some other foods but simply did not the previous day. all food items were treated equally may limit this study. another limitation could be information bias, which may result from collecting information of self-reporting age, education, occupation, household assets as well as nutritional indicators. result: the mean level of cfp was 24.2, which was significantly lower among the children aged 6-11 months (19.1%), illiterate mother (18.8%), illiterate father (19.8%) and also among children of currently unemployed families (22.6%) (table 4.1). children belonging to the poorest socio-economic group (19.6%), no exposure to television (20.7%) and newspapers (22.9%), food insecurity (22.2%) and rural area (20.70%) also revealed significantly lower scores of cfp. moreover, the mean level of cfp varied significantly among various geographical regions with the lowest level in southeastern region. the overall level of cfp experienced by children aged between 6 to 23 months in bangladesh could be described as a catastrophe. poor level of cfp was measured significantly using multilevel factors, such as, age, parental education, father’s employment status, socioeconomic status, mass media exposure, food insecurity, pace of residence and region of residence. interclass variations of the percentages, based on multilevel factors (e. g. individual, household and community levels), of the children among the various level of cfp (e.g. no cfp, inadequate cfp and adequate cfp) were observed using chi-square test. according to the categories of dimension index, more than 90% children received inadequate complementary food. children age, mother’s education, father’s education, father’s employment status, socioeconomic status, mass media exposures (television and newspaper/magazine), food insecurity and place of residence were significantly associated with cfp categories (table 4.2). for instance, the percentage of adequate cfp was significantly lower among younger group of children (2.5%), among children of illiterate mother (1.8%), illiterate father (1.0%). similarly, the percentage of adequate cfp was significantly lower among the children of those families, who belonged to the groups of socio economically poor (1.6%), no mass media 34 bangladesh journal of bioethics 2018; 9 (3): 28-44 28 table 4.1 mean level of complementary feeding practice variables mean ( sd) (%) standard error (se) (%) p values children age (months) 6-11 19.1 ( 11.7) 0.40 12-17 26.2 ( 11.8) 0.42 <0.001a 18-23 28.0 ( 12.2) 0.45 sex of child male 23.9 ( 12.4) 0.36 0.332b female 24.5 ( 12.5) 0.36 mother’s education illiterate 18.8 ( 9.97) 0.51 <0.001b literate 25.2 ( 12.7) 0.28 father’s education illiterate 19.8( 10.7) 0.43 <0.001b literate 25.7 ( 12.7) 0.30 father’s employment status currently unemployed 22.6 ( 13.9) 1.91 labours 23.3 ( 11.8) 0.29 <0.001a service holders 26.1 ( 13.2) 0.59 businessmen 28.8 ( 14.5) 1.20 socioeconomic status poor 19.6 ( 10.6) 0.47 <0.001a middle 21.4 ( 11.1) 0.52 rich 26.7 ( 12.8) 0.34 watch television weekly no 20.7 ( 11.1) 0.36 <0.001b yes 26.5 ( 12.8) 0.34 listen to radio weekly no 24.1 ( 12.5) 0.27 0.179 yes 25.3 ( 12.8) 0.89 read newspapers/magazine weekly no 22.9 ( 11.8) 0.27 <0.001b yes 30.4 ( 13.7) 0.68 food insecurity no 25.3 ( 12.9) 0.33 <0.001b yes 22.2 ( 11.3) 0.40 place of residence urban 27.4 ( 13.4) 0.49 <0.001b rural 22.8 ( 11.8) 0.29 region of residence southern 23.7 ( 12.5) 0.76 southeastern 22.3 ( 12.9) 0.58 central 23.6 ( 12.7) 0.66 western 28.8 ( 11.4) 0.69 <0.001a mid-western 26.2 ( 11.8) 0.67 northwestern 25.9 ( 11.2) 0.65 eastern 21.1 ( 12.6) 0.67 total 24.2 ( 12.5) 0.26 sd, standard deviation; se, standard error; a = anova test; b = t-test 35 bangladesh journal of bioethics 2018; 9 (3): 28-44 28 exposure (2.0% for television and 3.0% newspaper/magazine), food insecurity (2.6%) and rural area (3.0%). in contrast, the percentage of inadequate cfp was significantly higher among younger the children aged 12-17 months (94.1%), among children of illiterate mother (95.3%), illiterate father (95.9%), the children of those families, who belonged to the groups of socio-economically poor (95.4%), no mass media exposure (94.6% for television and 94.0% newspaper/magazine), food insecurity (94.7%) and rural area (93.7%). only 4.4% children were found to receive adequate cfp. all multilevel factors other than sex of child, listening to radio and region of residence were significantly associated with cfp. multivariable association of cfp with multilevel independent variables: multivariable logistic regression (binary/multinomial) analysis have been performed to identify the determinants of cfp or to observe the effects of several socio-demographic factors based on individual, household and community level factors. the results of binary logistic regression were presented first under the dichotomous dependent variable “any cfp”. according to these results (table 4.3.), children aged between 6 to 23 of age were less likely to receive any cfp (or: 0.55, 95% ci: 0.32-0.96) as compared to the group of 18-23 months. in contrast, children of 12-17 months of age were more likely to receive any cfp (or: 2.63, 95% ci: 1.14-6.07). other variables were not significantly associated with the dependent variable “any feeding practice”. according to the results of multinomial logistic regression analysis (presented under the categories of inadequate and adequate take ‘no cfp’ as a reference in table 4.3), children of illiterate fathers had significantly less likelihood of having adequate cfp (or: 0.32, 95% ci: 0.110.95). children from the socioeconomically middle class families were less likely to receive adequate cfp (or: 0.28, 95% ci: 0.09-0.86) as compared to rich children. children of families with no exposure to newspaper/magazine also revealed significantly less likelihood of receiving adequate cfp (or: 0.38, 95% ci: 0.160.92) than reference category. place of residence had somewhat significant effect (p=0.09) on adequate cfp. most of the socio-demographic variables were not significantly associated with cfp. some factors, such as, children age, father’s education, socioeconomic status and frequency of reading newspaper/magazine had significant effects on adequate cfp. table 4.4 highlights the association between child underweight and cfp. cfp was significantly (p=0.005) associated with underweight. more than 30% children received inadequate complementary foods were underweight. other factors, such as, children age, mother’s education, father’s education, father’s occupational status, 36 bangladesh journal of bioethics 2018; 9 (3): 28-44 29 socio-economic status, watch television weekly, read newspapers/magazine weekly, food insecurity, place of residence and region of residence were significantly associated with child underweight. binary logistic regression analysis showed that cfp had significant effect on child underweight. children who were fed inadequate food had more chance to be underweight than those who did not receive any complementary food. other factors, such as, children age, socio-economic status, watch television weekly, read newspapers/magazine weekly, food insecurity, place of residence and region of residence had significant impact on child underweight. discussion: the study reveals a low level of cfp (composed of no cfp or low cfp) among children aged between 6 to 23 months in bangladesh. the higher prevalence of under-nutritious complementary foods during the early mentioned “critical window” period of growth for children. our findings are consistent with the findings of a study in bangladesh 28. and other south asian countries such as india, pakistan, sri lanka and nepal 9,29,30. lack of knowledge and awareness regarding appropriate cfp may influence the poor nutritional supplements among children 31. according to my knowledge, no previous studies have addressed the level of cfp through dimension index based on 20 complementary food items. we found significant interclass variations of cfp for different individual, household and community level variables. for instance, receiving complementary foods were significantly lower among children of the younger age group (6-11 months) than among those in the older age group (18-23 months). several studies reported that percentages of infants receiving complementary foods increases with age but did not show any significant variations 32,33,34 . cfp was also found significantly lower among children of illiterate parents, children of fathers who were labourers, socioeconomically poor families, children of families never exposed to mass media, food insecure families and rural settlement. these findings were consistent with another study conducted in nepal 34. the united nations children’s fund (unicef) reported that in bangladesh over 33 million children under 18 years of old, which accounts for around 56% of the child population, are currently living below the international poverty line and around 57% are deprived of adequate nutrition 27. bangladesh is one of the south asian countries where female children experience higher mortality than males 35. in this country, more attention is paid to male children in intra-family food distribution and healthcare. such kinds of discrimination against female children can aggravate the situation of under-nutrition and other health 37 bangladesh journal of bioethics 2018; 9 (3): 28-44 28 table 4.2 associations between multilevel factors and complementary feeding pattern variables complementary feeding pattern p values no inadequate cfp adequate cfp children age (months) 6-11 41 (4.8%) 791 (92.7%) 21 (2.5%) <0.001 12-17 8 (1.0%) 753 (94.1%) 39 (4.9%) 18-23 19 (2.6%) 656 (91.1%) 45 (6.2%) sex of child male 36 (3.0%) 1109 (92.5%) 54 (4.5%) 0.903 female 32 (2.7%) 1091 (92.9%) 51 (4.3%) mother’s education illiterate 11 (2.9%) 362 (95.3%) 7 (1.8%) 0.028 literate 57 (2.9%) 1838 (92.2%) 98 (4.9%) father’s education illiterate 19 (3.1%) 580 (95.9%) 6 (1.0%) <0.001 literate 49 (2.8%) 1620 (91.6%) 99 (5.6%) father’s employment status currently unemployed 3 (5.7%) 48 (90.6%) 2 (3.8%) labours 45 (2.7%) 1568 (94.2%) 52 (3.1%) <0.001 service holders 17 (3.3%) 457 (89.8%) 35 (6.9%) businessmen 3 (2.1%) 127 (87.0%) 16 (11.0%) socioeconomic status poor 15 (3.0%) 474 (95.4%) 8 (1.6%) <0.001 middle 17 (3.7%) 433 (95.0%) 6 (1.3%) rich 36 (2.5%) 1293 (91.1%) 91 (6.4%) watch television weekly no 31 (3.3%) 880 (94.6%) 19 (2.0%) <0.001 yes 37 (2.6%) 1320 (91.5%) 86 (6.0%) listen radio weekly no 61 (2.8%) 2013 (92.9%) 94 (4.3%) 0.691 yes 7 (3.4%) 187 (91.2%) 11 (5.4%) read newspapers/magazine weekly no 59 (3.0%) 1850 (94.0%) 60 (3.0%) <0.001 yes 9 (2.2%) 350 (86.6%) 45 (11.1%) food insecurity no 45 (2.9%) 1421 (91.7%) 84 (5.4%) 0.005 yes 23 (2.8%) 779 (94.7%) 21 (2.6%) place of residence urban 14 (1.9%) 660 (90.5%) 55 (7.5%) <0.001 rural 54 (3.3%) 1540 (93.7%) 50 (3.0%) region of residence southern 4 (1.5%) 252 (94.7%) 10 (3.8%) southeastern 22 (4.4%) 451 (90.4%) 26 (5.2%) central 7 (1.9%) 354 (93.7%) 17 (4.5%) 0.398 western 6 (2.2%) 248 (92.2%) 15 (5.6%) mid-western 8 (2.6%) 285 (92.5%) 15 (4.9%) northwestern 9 (3.0%) 278 (93.0%) 12 (4.0%) eastern 12 (3.4%) 332 (93.8%) 10 (2.8%) total 68 (2.9%) 2200 (92.7%) 105 (4.4%) 38 bangladesh journal of bioethics 2018; 9 (3): 28-44 29 table 4.3 results of multivariable logistic regression analysis variables complementary feeding pattern any cfp (yes/no) inadequate cfp adequate cfp adjusted or (95% ci) p values adjusted or (95% ci) p values adjusted or (95% ci) p values children age (months) 6-11 0.55 (0.32-0.96) <0.001 0.57 (0.33-1.00) 0.050 0.22 (0.10-0.47) <0.001 12-17 2.63 (1.14-6.07) 0.037 2.68 (1.16-6.19) 0.021 1.84 (0.72-4.71) 0.206 18-23 (ref.) 1.00 1.00 1.00 sex of child male 0.92 (0.56-1.49) 0.725 0.91 (0.56-1.50) 0.719 1.01 (0.54-1.89) 0.978 female (ref.) 1.00 1.00 1.00 mother’s education illiterate 1.11 (0.52-2.37) 0.779 1.11 (0.52-2.35) 0.792 1.48 (0.46-4.69) 0.509 literate (ref.) 1.00 1.00 1.00 father’s education illiterate 1.01 (0.54-1.89) 0.981 1.03 (0.55-1.92) 0.934 0.32 (0.11-0.95) 0.040 literate (ref.) 1.00 1.00 1.00 father’s employment status currently unemployed 0.42 (0.08-2.25) 0.313 0.44 (0.08-2.36) 0.341 0.23 (0.02-2.12) 0.193 labours 0.94 (0.28-3.20) 0.918 0.98 (0.29-3.35) 0.976 0.49 (0.13-1.89) 0.297 service holders 0.68 (0.19-2.40) 0.551 0.70 (0.20-2.48) 0.584 0.50 (0.13-2.01) 0.330 businessman (ref.) 1.00 1.00 1.00 socioeconomic status poor 0.85 (0.39-1.84) 0.539 0.86 (0.40-1.86) 0.704 0.55 (0.18-1.70) 0.299 middle 0.69 (0.35-1.34) 0.687 0.70 (0.36-1.37) 0.297 0.28 (0.09-0.86) 0.025 rich (ref.) 1.00 1.00 1.00 watch television weekly no 0.89 (0.51-1.57) 0.695 0.90 (0.51-1.58) 0.712 0.68 (0.31-1.49) 0.336 yes (ref.) 1.00 1.00 1.00 listen radio weekly no 1.24 (0.55-2.81) 0.607 1.24 (0.55-2.81) 0.608 1.21 (0.42-3.44) 0.722 yes (ref.) 1.00 1.00 1.00 read newspapers/magazine weekly no 0.82 (0.38-1.77) 0.602 0.86 (0.40-1.85) 0.702 0.38 (0.16-0.92) 0.032 yes (ref.) 1.00 1.00 1.00 food insecurity no 0.83 (0.47-1.46) 0.526 0.83 (0.47-1.46) 0.518 0.90 (0.42-1.95) 0.796 yes (ref.) 1.00 1.00 1.00 place of residence urban 1.43 (0.75-2.70) 0.275 1.40 (0.74-2.65) 0.300 1.93 (0.90-4.13) 0.090 rural (ref.) 1.00 1.00 1.00 region of residence southern 2.40 (0.75-7.70) 0.276 2.40 (0.75-7.68) 0.141 2.84 (0.65-12.38) 0.164 southeastern 0.72 (0.34-1.49) 0.140 0.71 (0.34-1.47) 0.357 1.26 (0.44-3.58) 0.663 central 1.67 (0.64-4.34) 0.380 1.65 (0.65-4.30) 0.304 2.42 (0.69-8.45) 0.165 western 1.34 (0.49-3.73) 0.294 1.32 (0.48-3.66) 0.592 2.44 (0.66-9.01) 0.182 mid-western 1.19 (0.47-3.01) 0.570 1.17 (0.47-2.97) 0.735 2.03 (0.59-6.99) 0.263 northwestern 1.19 (0.48-2.92) 0.711 1.17 (0.48-2.88) 0.733 2.04 (0.58-7.13) 0.263 eastern (ref.) 1.00 1.00 1.00 ci, 95% confidence interval 39 39 bangladesh journal of bioethics 2018; 9 (3): 28-44 30 table 4.4 association between underweight and child feeding practice variables under weight (n=2227) underweight (no/yes) (binary logistic regression results) prevalence p values (chi square) b s.e. p values ors 95.0% c.i. lower upper child feeding pattern no (ref) 13 (20.6%) 1.00 inadequate 675 (32.6%) 0.005 0.60 0.33 0.041 1.82 0.95 3.48 adequate 18 (19.6%) 0.23 0.49 0.585 1.26 0.54 2.93 children age (months) 6-11 (ref) 197 (24.6%) 1.00 12-17 246 (32.5%) <0.001 0.50 0.11 <0.001 1.65 1.31 2.09 18-23 263 (39.4%) 0.76 0.12 <0.001 2.13 1.68 2.70 sex of child male (ref) 357 (31.8%) 0.905 1.00 female 349 (31.6%) -0.01 0.09 0.900 0.98 0.81 1.19 mother’s education illiterate (ref) 160 (45.8%) <0.001 1.00 literate 546 (29.1%) -0.08 0.14 0.573 0.92 0.69 1.22 father’s education illiterate (ref) 239 (42.4%) <0.001 1.00 literate 467 (28.1%) -0.10 0.12 0.392 0.90 0.70 1.14 father’s employment status currently unemployed (ref) 11 (22.9%) 0.444 1.00 labours 546 (34.9%) <0.001 0.53 0.36 0.142 1.70 0.83 3.47 service holders 119 (24.9%) 0.43 0.37 0.250 1.53 0.73 3.20 businessmen 30 (21.9%) 0.43 0.41 0.296 1.54 0.68 3.50 socioeconomic status poor (ref) 225 (49.1%) 1.00 middle 167 (38.7%) <0.001 -0.32 0.14 0.023 0.72 0.54 0.95 rich 314 (23.5%) -0.76 0.14 <0.001 0.46 0.35 0.61 watch television weekly no (ref) 365 (41.9%) <0.001 1.00 yes 341 (25.1%) -0.28 0.11 0.010 0.75 0.60 0.93 listen radio weekly no (ref) 649 (31.9%) 0.498 1.00 yes 57 (29.5%) -0.01 0.17 0.975 0.99 0.70 1.40 read newspapers/magazine weekly no (ref) 632 (34.1%) <0.001 1.00 yes 74 (19.7%) -0.25 0.15 0.090 0.77 0.57 1.04 food insecurity no (ref) 394 (27.0%) <0.001 1.00 yes 312 (40.5%) 0.28 0.10 0.007 1.33 1.08 1.64 place of residence urban (ref) 167 (24.1%) <0.001 1.00 rural 539 (35.1%) 0.14 0.11 0.229 1.15 0.91 1.44 region of residence southern (ref) 84 (33.3%) 1.00 southeastern 152 (32.8%) 0.09 0.17 0.580 1.10 0.78 1.55 central 110 (30.7%) -0.11 0.18 0.534 0.89 0.61 1.28 western 57 (22.1%) <0.001 -0.46 0.21 0.027 0.62 0.41 0.94 mid-western 80 (28.1%) -0.26 0.19 0.184 0.76 0.52 1.13 northwestern 85 (30.6%) -0.28 0.19 0.151 0.75 0.51 1.10 eastern 138 (41.6%) 0.35 0.18 0.061 1.42 0.98 2.05 40 bangladesh journal of bioethics 2018; 9 (3): 28-44 31 hazards among female children compared to male 36. . regional variation also has been observed in terms of cfp. variations in cfp may conceal important intra-regional differences due to diverse cultural norms and needs more investigation. conclusion: the overall level of cfp among children is still low in bangladesh and needs further improvement. the levels of cfp are found to be strongly associated with several individual, household and community factors. some of these factors namely children’s age, father’s education, socioeconomic status, mass media exposure and place of residence are justified to be considered while developing strategies or interventions to address the issue of child cfp in bangladesh. more studies are needed to assess the level of cfp in bangladesh. recommendations: although numerous policies and strategies have been issued in bangladesh to improve the iycfp, some challenges such as insufficient resources and lack of coordination among stakeholders are impeding their implementation and enforcement. 1. strengthening of the existing strategies such as eradication of poverty through marginalized and vulnerable group development, empowering women to practice decision making autonomy and minimizing rural urban differential through planning and providing modern facilities are urgently necessary to improve the situation of cfp in bangladesh. 2. proper cfp can also be ensured by undertaking social safety net program and community-based nutritional interventions, for example, food for education, food for work for slum dwellers and so on 28. 3. the feeding practice of home-based foods with various textures should be encouraged 37. 4. health promotion program through crosscollaboration among various organizations are needed to ensure proper cfp. 5. behavioral change communication through nutritional education, particularly in slum and rural areas, which support and educate mothers, need to be developed for improving appropriate feeding practice to children 38,39. in addition, more efforts should be given to review existing nutritional interventions that target the iycfp in bangladesh. 6. longitudinal studies are recommended to determine the cause-effect relationships between plausible factors and cfp in bangladesh. 40 bangladesh journal of bioethics 2018; 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3:382-6. 37. liubai li, sujun li, ali m, ushijima h. feeding practice of infants and their correlates in urban areas of beijing, china. pediatrics international 2003; 45: 400-406. 38. garg a, chadha r. index for measuring the quality of complementary feeding practices in rural india. j health popul nutr 2009; 27(6):763-771 39. faber m, benade ajs. nutritional status and dietary practices of 4–24-month-old children from a rural south african community. public health nutrition 1998; 2(2), 179–185. author contributions: 1st author naznin pervin was involved in concept and design of the paper; 2nd and 3rd authors darryl macer and shamima p. lasker were equally involved in the literature search, review, compilation, manuscript writing and revision respectively. conflict of interest: there is no conflict of interest relevant to this paper to disclose43 44 bangladesh journal of bioethics 2018; 9 (3): 28-44 28 microsoft word bjb-2019-nurunnabi et al bangladesh journal of bioethics 2019; 10(2): 7-13 7 societal concerns with biotechnology and necessity of regulations abu sadat mohammad nurunnabi1, miliva mozaffor2, mariya tabassum3, taohidur rahman saikat4, nahid kabir5, mohammad akram hossain6 1. research assistant, bridgepoint collaboratory for research and innovation, bridgepoint active healthcare, toronto, on, canada. email: abu.nurunnabi@sinaihealthsystem.ca (corresponding author) 2. clinician researcher, biomedical research foundation (brf), dhaka, & laboratory consultant and lecturer, department of biochemistry, medical college for women & hospital, uttara, dhaka-1230, bangladesh. email: miliva17@yahoo.com 3. lecturer, department of biochemistry, mugda medical college, dhaka-1214, bangladesh. email: drmariyatabassum@gmail.com 4. bsc (hons.) student, department of biochemistry and molecular biology, tejgaon college, dhaka-1215, bangladesh. email: taohidurrahman9@gmail.com 5. msc student, school of environment and life sciences, independent university, bangladesh, bashundhara, dhaka-1212, bangladesh. email: nahidkabir@gmail.com 6. professor and head, department of microbiology and mycology, national institute of preventive and social medicine (nipsom), dhaka-1212, bangladesh. email: akram.prof@gmail.com doi: doi: https://doi.org/10.3329/bioethics.v10i2.50660 abstract: biotechnology is the use of living systems and organisms to develop or make products, or any technological application that uses biological systems, living organisms or derivatives to make or modify products or processes for specific use. biotechnology is a constantly evolving field of modern science. new tools and products developed by biotechnologists are useful in research, agriculture, industry and healthcare. although it has many benefits including lowering our environmental footprint, and helping in diagnosis and treatment of diseases, it comes with its all-possible disadvantages. the four main societal concerns revolve around are ethical, safety, bioterrorism and environmental issues. this paper aims to describe those societal concerns raised by applications of biotechnology and possible regulations related to biotech innovations and policy implementation. key words: biotechnology, societal concerns, ethical issues, laboratory safety, bioterrorism, environmental protection. introduction: people have been harnessing biological processes to improve their quality of life for some 10,000 years, beginning with the first agricultural communities. approximately 6,000 years ago, humans began to tap the biological processes of microorganisms in order to make bread, alcoholic beverages, and cheese and to preserve dairy products1. such processes are not what is meant today by biotechnology. moreover, today’s biotechnologies vary in application and complexity. the term ‘biotechnology’ first widely applied to the molecular and cellular technologies that was emerging in the 1960s and ’70s. genentech, a pharmaceutical company established in 1976 by swanson and boyer to commercialize the recombinant dna bangladesh journal of bioethics 2019; 10(2): 7-13 8 technology, as pioneered by boyer, berg, and cohen1. early companies such as genentech, amgen, biogen, cetus, and genex began by manufacturing genetically engineered substances primarily for medical and environmental uses1. biotechnology is the use of living systems and organisms to develop or make products, or any technological application that uses biological systems, living organisms or derivatives to make or modify products or processes for specific use2. new tools and products developed by biotechnologists are useful in research, agriculture, industry and healthcare. innovations through biotechnology using organisms or their parts or products provide valuable substances or processes that have become essential in our day-to-day life. for example, production of human insulin in bacteria to treat type i diabetes mellitus without causing allergic reactions is a more modern example of biotechnology. two widely used biotechnologies that manipulate genes are recombinant dna technology, which endows single-celled organisms with novel characteristics using genes from other organisms, and transgenic technology, which creates multicellular organisms that bear genes from other types of organisms2. very recent innovations are genetically modified (gm) fruits and vegetables, such as a type of corn that manufactures a bacterial insecticide, are termed as “transgenic plants”3. thus, biotechnology use knowledge of biological sciences and advanced technologies to generate new and useful products and processes for the benefit of society. living standards have risen alongside biotech innovation and economic growth in so many countries. even when it comes to developing countries, biotechnologies and innovative solutions are helping to combat issues such as disease, hunger and poverty3. although it has many benefits including lowering our environmental footprint, and helping in diagnosis and treatment of diseases, it comes with its all possible disadvantages4. several ethical concerns such as informed consent, confidentiality, wellbeing of the subjects for research, equal access to the benefits of research, intellectual property rights, costs have come into the focus4-9. human and laboratory safety issues are crucial as it is assumed that in future insects and plantdestroying bacteria or diseases may continue to evolve to give rise to superpests or ‘superbugs’10-12. moreover, there might be chances of outbreak of epidemics, due to faulty or erroneous handling of microorganisms or chemicals in the biotech laboratories12.13. relating this issue, major emphasis is on how to control bioterrorism using genetically engineered super pathogens, drugs or chemicals4,14-17. environmental issues have also come to the forefront as gmos are thought to be the organisms actually put the entire food supply at risk through the homogenization of plant life and the death of biodiversity18-21. therefore, bioethics community stands for the safe regulation of potential benefits of innovations in biotechnology and for welfare of mankind as well as our environment, which has become crucial at the moment. this paper aims to describe those societal concerns raised by applications of biotechnology and possible safeguards related to biotech innovations and policy implementation. bangladesh journal of bioethics 2019; 10(2): 7-13 9 societal concerns: today’s social challenges are numerous, complex, and urgent, from ageing societies, climate change, to energy efficiency and security3,4. there is a wide consensus that the disconnection between economic growth and wellbeing is increasing. at the same time research and innovation have become one of the main engines of growth4. however, these two overarching trends have not yet been reconciled: there is a clear lack of exploitation of innovative solutions to address these social challenges4. besides, biotechnology developments are often controversial because of the societal issues they raise. they frequently become the subject of public debate that presents different viewpoints. regarding modern biotech innovations, we are going to discuss four main societal concerns revolve around – ethical, public and laboratory safety, bioterrorism and environmental issues. 1) ethical issues: uncovering the human genome was a tremendous step forward for science, but the discovery created a series of new concerns4. researchers have been able to use the information from the human genome project to develop the new science of pharmacogentics, how an individual’s genes affect his or her body’s ability to metabolize or react to a drug. modern pharmacogentics aims to eliminate adverse drug events (ade) and side effects by tailoring drugs specific to a patient’s genome. while the new personalized medications can eliminate side effects, the use of genetic information to create medicine contributes to the rising cost of drugs, and shifts attention away from designing affordable drugs available for mass population4,5. another burning issue is stem cell research. supporters argue the embryos used to generate stem cell lines were going to be destroyed, and using them for research has the capacity to save untold numbers of lives. in contrast, opponents believe creating new lines from embryonic stem cells is akin to abortion, and the destruction of any embryo for research purposes is an ethical violation5. however, both sides have come to a partial agreement on the use of adult stem cells over embryonic cells, but functionally the adult cells offer far fewer options and less promising research4-6. besides the age-old debate over whether cloning genes is sacrilegious, innumerable ethical questions arise over the appropriateness of licensing genetic inventions and other intellectual property issues5,7,8. in addition, it will most certainly go against the ethics of a significant number of science and professional societies as well existing laws of different countries. there are also other ethical concerns including when scientists use humans as clinical trial subjects – informed consent, confidentiality, wellbeing of the subjects, equal access to the benefits of research, compensation – have come into the table of discussion for decades4,5,7-9. last but not the least, the concept of gm foods, its efficacy, acceptance and associated consumer rights, right to food, cost also have been debated4,5. 2) public or laboratory safety or biosafety issues: maintenance of laboratory safety or biosafety is a crucial point to ensure public safety. human and laboratory safety issues are crucial as it is assumed that insects and plant-destroying bacteria or diseases will continue to evolve with the gmos, resulting in superpests and superdiseases that are bangladesh journal of bioethics 2019; 10(2): 7-13 10 untreatable. similar may happen with overconsumption of antibiotics, which are also gm products, and loss of their ability to fight off disease will result in rise of ‘superbugs’10-12. some new technologies, usually non-biologicals such as nanoparticles, make commercial production lines before they have been sufficiently tested for safety12. there is also concern about technician safety in laboratories even under secure conditions when working with organisms of unknown virulence. the public health danger posed by potentially pandemiccausing viruses or bacteria escaping from laboratories has become the subject of considerable discussion in public health sphere12,13. the goal of biotech experiments, as researchers manipulate already-dangerous pathogens, is to produce vaccine or other remedies. however, outbreak of epidemics have already been experienced in course of history, due to faulty or erroneous handling of micro-organisms or chemicals12.13. 3) bioterrorism: biological weapons is not a myth anymore. in the recent past, the threat of a global bioterrorist attack has increased dramatically. in addition to the already existing microorganisms and techniques, the recent explosion in biotechnology has considerably added to the arsenal of the bioterrorist4,14. molecular biotechnologies are now much available which can be used by committed bioterrorist groups to manipulate and modify microorganisms and to make them increasingly infectious, virulent or treatment resistant for causing maximum casualties14-17,. apart from that, research involving biological or chemical weapons necessarily involve exposures to toxic agents and levels of risk higher than those that exist in most research4,17. such research would seem to compromise the core tenet of medical ethics that studies should not knowingly do harm. indeed, the environmental protection agency of the u.s. now refuses to accept toxicity tests done on human subjects to determine “safe levels”4,17. 4) environmental issues: environmental integrity remains a moral concern for environmentalists as they have predicted that biotechnology will promote the replacement of the natural environment with a purely artificial world and cause deprivation of healthy contact of human beings with nature18,19. recent controversies about genetically engineered crops have highlighted the need for experimental evidence and sound scientific judgment to assess the risks versus benefits. this concern is perhaps the most widely cited by those opposed to genetically modified organisms (gmos). it is very difficult to predict what will happen in an ecosystem where a new organism has been introduced whether genetically modified or not. for example, if farmers introduce any herbicide-resistant marker into a plant, there is the possibility those traits may be transferred to a weed, making it resistant to herbicides as well19. the backlash against gmos has been strong and is growing day by day. opponents of gmos claim the organisms actually put the entire food supply at risk through the homogenization of plant life and the death of biodiversity18-21. they also argue that insects and plant-destroying bacteria or diseases will continue to evolve with the gmos, resulting in superpests and superdiseases that are untreatable by modern methods18,19,21. similarly, physicians, microbiologists, bangladesh journal of bioethics 2019; 10(2): 7-13 11 environmental scientists argue that gmos include antibiotics that make their way into the human body. overconsumption of antibiotics is harmful, as because those drugs lose their ability to fight off disease19. regulations of biotechnology and public policy: societal issues are inevitably associated with regulation and public policy22. regulations and public policies are always fashioned in accordance with background assumptions or politically negotiated consensus about moral questions like “what is the public good? or who should make decisions and control events? or what are the fundamental purposes of government and society?”5 even when tradition or consensus rules that individuals are to have complete discretion in exercising moral judgement (as is the case with respect to religious duties in most parts)5. the purpose of public policies is to find a balance between safety regulation and innovation22. the two are not necessarily at odds: innovation has the potential to enhance safety, e.g. by replacing high-risk products with newer, safer products. moreover, regulatory frameworks that are suitably designed and implemented have the potential to foster innovation; for example, fuel economy standards have improved the average fuel economy of e.u. and u.s. vehicles23. thus, it is incorrect to assume that regulation inevitably creates barriers to innovation. however, one valid area of concern is that regulations have the potential to impede or delay the introduction of innovative products to the market, if the regulations add substantial up-front costs and delays to the process of developing and marketing a new product23. hence, the regulatory process for the use of any biotech product should take into account both the risks and benefits of implementing that technology as well as the consequences of non-implementation and the viability of alternative technologies. as new biotechnology discoveries are made, many western governments develop regulations, legislation and guidelines to minimise risks to people and the environment23-27. many governments have created environmental risk management bodies that regulates and manages risk concerning new products or organisms23-27. conclusion: biotech innovations are inevitable for upcoming days. if properly developed, biotechnology represents an opportunity for developing countries to realize tangible health and nutritional benefits, sustainable agriculture, green energy and other possibilities to eliminate hunger and poverty. the regulatory agencies must carry out regulatory functions to protect public health, ensure biosafety, prevent bioterrorism and environmental harms. however, the intent of the regulatory guidelines should be providing mechanisms to assess the safety of biotechnology products while simultaneously offering a framework for advancing innovation and increasing transparency, coordination, efficiency, and predictability. many countries are actively developing this technology, and their support for biotechnology may turn the tide in global public acceptance in near future. references: bangladesh journal of bioethics 2019; 10(2): 7-13 12 1. encyclopaedia britannica. biotechnology. available from: https://www.britannica.com/technology/biotechn ology (accessed december 17, 2017). 2. verma as, agrahari s, rastogi s, singh a. biotechnology in the realm of history. j pharm bioallied sci. 2011;3(3):321-3. 3. dasilva e, baydoun e, badran a. biotechnology and the developing world. electronic j biotechnol. 2002;5(1):64-92. 4. silverman e. the 5 most pressing ethical issues in biotech medicine. biotechnol healthc. 2004;1(6):41-6. 5. macer drj. biotechnology and bioethics: what is ethical biotechnology? in: brauer d. ed. modern biotechnology: legal, economic and social dimensions. biotechnology. vol.12. weinheim: vch; 1995. 6. nurunnabi asm. prospects and problems of stem cell research in bangladesh: can equity and justice be maintained in the context of public health demand? eubios j asian int bioethics: ejaib. 2016;26(3):117-24. 7. shapiro ht. ethical and policy issues of human cloning. science. 1997;277(5323):195-6. 8. la montagne jr. biotechnology and research: promise and problems. lancet. 2001;358(9294):1723-4. 9. kumar s. biosafety and biosecurity issues in biotechnology research. biosafety. 2015;4(1):e153. 10. frommer w, krämer p. safety aspects in biotechnology classifications and safety precautions for handling of biological agents. arzneimittelforschung. 1990;40(7):837-42. 11. gupta v, sengupta m, prakash j, tripathy bc. biosafety and bioethics. basic and applied aspects of biotechnology. 2016;503-20. 12. pike rm. past and present hazards of working with infectious agents. arch pathol lab med. 1978;102(7):333-6. 13. coelho ac, díez jg. biological risks and laboratory-acquired infections: a reality that cannot be ignored in health biotechnology. front bioeng biotechnol.2015;3:e56. 14. moorchung n, sharma ak, mehta sr. bioshock: biotechnology and bioterrorism. med j armed forces india. 2009;65(4):359-62. 15. noah dl, huebner kd, darling rg, waeckerle jf. the history and threat of biological warfare and terrorism. emerg med clin north am 2002;20:255-71. 16. zilinskas ra. recombinant dna research and biological warfare. in: zilinskas ra, zimmerman bk, eds. the gene splicing wars: reflections on the recombinant dna controversy. new york: macmilian publishers; 1986;167-203. 17. caplan al, sankar p. human subjects in weapons research. science. 2002;298(5595):923. 18. mclean mr. the future of food: an introduction to the ethical issues in genetically modified foods. in: khan as. ed. nanotechnology: ethical and social implications. london: crc press; 2012. 19. maghari bm, ardekani am. genetically modified foods and social concerns. avicenna j med biotechnol. 2011;3(3):109-17. 20. heydari b, razmkhah n. intellectual property right of transgenic crops and right to work: bioethical challenges in rural communities. bangladesh j bioethics. 2014;5(2):49-60. 21. singh ov, ghai s, paul d, jain rk. genetically modified crops: success, safety assessment, and public concern. appl microbiol biotechnol. 2006 a;71(5):598-607. 22. fogleman v. regulating science: an evaluation of the regulation of biotechnology research. environmental law. 1987;17(2):183-273. 23. national academies of sciences, engineering, and medicine (nasem). the current biotechnology regulatory system. in: preparing for future products of biotechnology. washington dc: national academies press (us); 2017. 24. health canada. health canada's role in the regulation of products from biotechnology. 2008. available from: https://www.canada.ca/content/dam/hcsc/migration/hc-sc/sr-sr/alt_formats/hpfbdgpsa/pdf/pubs/reg_bio_mod-eng.pdf (accessed december 30, 2017). 25. government new zealand. ministry for the environment. genetic modification in new zealand. 2016. available from: https://www.mfe.govt.nz/publications/hazards/g bangladesh journal of bioethics 2019; 10(2): 7-13 13 m-nz-approach-jun04/genetic-modification-newzealand (accessed december 28, 2017). 26. european food safety authority (efsa). gmo applications: regulations and guidance. available from: https://www.efsa.europa.eu/en/applications/gmo/ regulationsandguidance (accessed december 30, 2017). 27. uk government. health and safety executive. the genetically modified organisms (contained use) regulations 2014. available from: https://www.hse.gov.uk/pubns/priced/l29.pdf (accessed december 29, 2017). authors’ contribution: asm nurunnabi and m mozaffor were involved in concept and design of the paper; asm nurunnabi, m mozaffor, m tabassum, tr saikat, n kabir and ma hossain were equally involved in the literature search, review, compilation, manuscript writing and revision. conflict of interest: the authors report no conflicts of interest in this work. microsoft word tanvir ahmedpaper submission for bangladesh journal of bioethics 1 bangladesh journal of bioethics 2021;12 (1):14-24 14 the case of doctor-patient relationship in bangladesh: an application of relational model of autonomy tanvir ahmed ma in philosophy jahangirnagar university, savar, dhaka-1342, bangladesh. email: tanvir92ju@gmail.com doi: https://doi.org/10.3329/bioethics.v12i1.51900 abstract: the objective of this article is to establish an alternative doctor-patient relationship model and describe its importance in the case of the doctor-patient relationship in bangladesh. there is a lot of diversity in the religious beliefs, social norms and values in bangladesh. likewise, the development of biological science as well as medical technology, the allocation of healthcare resources must be considered as an important issue. that is why the autonomy of both doctor and patient is a relational factor here. besides, the four traditional doctor-patient relationship models offered by ezekiel j. emanuel and linda l. emanuel are not beyond criticism. so, we need an ideal doctor-patient relationship model for bangladesh to protect every patient’s autonomy which will give freedom to the patient in choosing their own treatment as well as which will not conflict with the patient’s social or cultural values. in this article, i have selected the relational model of autonomy as the method of alternative doctor-patient relationship model. hopefully, this alternative model will work better since it considers care first concerning a patient’s autonomy. besides, doctors would treat their patients as a ‘care seeker’ rather than ‘client’ or ‘customer’, and simultaneously, patients would perceive their physicians as ‘caregivers’. but, applying the relational model of autonomy in the case of doctor-patient relationship is more challenging in bangladesh due to some obstacles like large numbers of population, illiteracy, insufficiency of skilled doctors and hospitals, corruption in medical sectors, social prejudices and so on. but, if we can overcome these problems, the relational model of autonomy will be considered as a suitable doctor-patient relationship model in bangladesh. key words: care ethics, doctor-patient relationship, relational autonomy, religious and social values, medical ethics, bangladesh. (some part of this article was presented at 20th asian bioethics conference, dhaka, bangladesh as poster presentation). introduction: the doctor-patient relationship is an important issue in medical ethics. since ancient times, all medical codes and guidelines were concerned to identify the basic principles of an ideal doctor-patient relationship. but there is no ideal model that is applicable to all cultures and all societies. the development of biological as well as medical sciences, medical technology, moral thinking, and social values, should be taken into consideration when we analyze any such relationship. in the last century, scholars have proposed various models for the doctor-patient relationship. the most accepted model is offered by ezekiel j. emanuel and linda l. emanuel. they mentioned four models of doctor-patient relationship in their article “four models of the physician-patient relationship”1. bangladesh journal of bioethics 2021;12 (1):14-24 15 according to emanuel and emanuel, these four models are: i. the paternalistic model, ii. the informative model, iii. the interpretive model and iv. the deliberative model. emanuel and emanuel’s views are accepted and used in western well-ordered societies or developed countries2. but, these models are not suitable for all countries of the world due to social, cultural, religious and economic differences. all of these models, any single model is not appropriate for the bangladeshi context. paternalistic model exists in our practices of medical ethics2 though it has some merits too during emergency treatment1. but, we reject it because this model violates the patient’s freedom, respect as well as autonomy. we can consider informed consent as a better model than paternalism. but it is not applicable because of the number of illiterate patients, insufficiency of trained doctors. besides, in the interpretive model, the relationship of doctor-patient is maintained in a value hierarchy which contains two rival agents: superior and inferior. in that model, a doctor has got a superior position where the patient is treated as inferior. thus, we consider the interpretive model as inappropriate for bangladesh. finally, the deliberative model is also inappropriate because this model would not be compatible with the socioeconomic and cultural pattern of bangladesh. therefore, we need an alternative practice of medical ethics in bangladesh that will be suitable for our society and culture. as bangladesh has a large population with different cultures and beliefs, it is difficult to ensure every patient’s autonomy. the conception of autonomy in bangladeshi people’s beliefs and culture is relational. so, i argue for a richer conception of autonomy, especially ‘relational autonomy’ for the practices of medical ethics in bangladesh. the next section will introduce us to relational autonomy shortly. relational autonomy: relational accounts of autonomy have been substantially developed by feminist philosophers. this conception comes from the idea of care ethics where the caring issue is regarded as more important in medical ethics as well as in bioethics. to give a clear notion about relational autonomy, we need to know the characteristics of care ethics. the care ethics esteems ‘care’ as the prime basis of morality and rejects the thought of ‘fairness’ in moral thinking. care ethicists feature some human characteristics, for example, care, sympathy, empathy, compassion, relations, which are more familiar with the feminine gender. the care ethics begins from the feminist approach of morality. carol gilligan first worked on the development of care ethics in her book in a different voice (1982). later, this conception of care ethics is expanded by some other feminist philosophers like nel noddings and van den hoven. gilligan’s works give us a positive interpretation by reconstructing traditional negative understanding of care related to women and acknowledge care as an ethically important thought. in gilligan’s view, women are more caring to maintain relationships whereas men are concerned about “moral rules and justice”3. the term ‘relational autonomy’ does not refer to a single synthesized conception of autonomy but is rather an umbrella term, designating a range of related viewpoints4. it refers to an idea of autonomy grounded bangladesh journal of bioethics 2021;12 (1):14-24 16 on the social nature of people’s lives. from these perspectives, people are intrinsically connected with a social environment marked by economics, politics, ethnicity, gender, culture, and so on. besides, their profile is framed and formed by their social environment, just as their experience of embodiment, associations with others, and opportunities for a decent life. the supporters of ‘relational autonomy’ specifically have contended that people’s identities, needs, interests, and indeed autonomy are in every case additionally molded by their relations to other people. not independence, but interdependence, is the core of the relational idea of autonomy. social environmental factors and connections enable us to flourish and develop a robust capacity for selfdetermination and identity formation5. relational autonomy can be considered as a conception of autonomy that puts the person in a socially inserted organization of others. relationships (with family, community and society), responsibility, care and interdependence are the key components of relational autonomy. individuals build up their self-appreciation and form capacities and life plans through the connections they develop on a day and long-term basis. therefore, relational autonomy states that social surroundings and relationships are essential for developing autonomy, and encourages us to act in manners guided by an ethic of trust and care6. in medical ethics, the relational model of autonomy is the most popular model to protect a patient’s autonomy nowadays. in health care, respect for autonomy emphasizes in particular the patient’s freedom of choice, specifically over what happens to his/her body. in medical issues, all patients are fundamentally connected with a social environment marked by economics, religion, politics, ethnicity, gender, culture, and so on. that is why every patient’s autonomy is different. so, a patient’s autonomy can be protected by applying relational model of autonomy in the case of medical ethics such as patientcentered care, doctor-patient relationship and so on. suitability of relational autonomy in doctor-patient relationship in bangladesh: there are so many reasons why the relational model of autonomy is suitable for a developing country like bangladesh. i will figure out some reasons and argue that relational autonomy is more suitable than any other doctor-patient relationship model. some reasons are given below: bangladesh is a poor country with a huge population. the financial position of each person is different. everyone’s type of autonomy is not the same. people of different levels of society have different sorts of autonomy. if we give the same medical care to everyone, then it will not be able to protect everyone’s autonomy. the autonomy of people of the upper level of the society is not applicable to the lower level people of the society. many people are involved in many issues such as individual belief, ritual, religion, culture, etc. in the field of autonomy. the doctors of our country do not treat all patients in the same way. the attitude of doctors is paternalistic. this paternalistic behavior of doctors is most commonly seen in the treatment of poor patients. relational models of autonomy can be shown in different ways bangladesh journal of bioethics 2021;12 (1):14-24 17 to treat all patients from different economic classes and protect everyone’s autonomy. constraint factors: religious belief and social values: an important aspect of bangladesh is that people of different religions live here. most of the population is muslim (88%) while a considerable number of citizens are hindus (10%), christians (1%), and buddhists (1%). here also live various ethnic entities and those who have different cultures and beliefs. every person from every religion has different rituals and beliefs. in medical treatment, doctors should consider that. if the treatment policy contradicts the patient’s religious beliefs, that will violate the patient’s autonomy. some cases like abortion, organ transportation, receiving blood from others and so on may create some critical conditions. for instance, one of the most popular cases in bangladesh is the abortion case. although abortion is legally prohibited in bangladesh, abortion may be justified if there is a risk of death for the newborn and the pregnant mother. besides, most muslims does not support abortion because of their belief. conservative muslims never support abortion because it is prohibited in islam. according to islam, every life is sacred and as a fetus is a living entity, we have no right to kill a fetus and ruin its sanctity. but in recent times some liberal muslims support abortion. islam has a different view of the life of a pregnant woman is threatened. for example, if a woman is at risk of cancer or any other incurable disease due to pregnancy, or if there is a risk of death in childbirth, and if the matter is directed by a neutral and experienced doctor, then abortion before the age of four months is legal according to islam7. conversely, sometimes abortion becomes urgent to save the mother’s life but the muslim mother does not want it as she believes her religion. in that situation, abortion will not be supported. so, in these cases, doctors should know the patient’s opinion to support the patient’s freedom as well as to protect the patient’s autonomy. sometimes, many muslim families do not support abortion but the woman who is pregnant supports it. so, in this case, the woman’s opinion should get priority. now let us come to the context of hindus. traditional religions have different beliefs about abortion, rules and regulations that hindus follow. abortion is not supported in any way in the traditional hindu scriptures. according to the hindu religion, killing a fetus through abortion is equivalent to killing a priest. even a woman who kills a fetus through abortion seems to destroy her offspring8. that is, in hindu religious culture, abortion has been identified as an extremely reprehensible act. the rigveda says, “vishnu himself is the guardian of the future newborn” (rigveda 6, 36: 9). that is, vishnu himself has taken the responsibility for the life and death of the fetus. in that case, killing the fetus during pregnancy would be a great sin. again, in the shatapatha brahmana, it is said, “the woman who has removed the fetus from her body has undoubtedly committed a great sin” (shatapatha brahmana 3: 1.2.2.1). an analysis of these scriptural statements shows that abortion is not supported in any way in the traditional hindu scriptures. liberal hindu scholars, however, support abortion in the interest of saving the lives of pregnant mothers and newborns. christianity also opposes abortion. to christians, human life is sacred and a gift bangladesh journal of bioethics 2021;12 (1):14-24 18 from god that is said to be respected and protected. this teaching is called the holiness of life. the bible teaches that man was created in the image of god and also teaches that killing is forbidden. jesus reminded his followers that every living thing is precious to god. considering that, the killing of fetuses is also prohibited. in the case of a woman’s pregnancy, the first fetal performance according to christianity is a time when the mother feels the movement of the first fetus. according to ancient catholic theology, the soul is received during the first fetus. according to christian doctrine, the ‘soul’ is a boundary that separates non-human beings from human beings9. so it is wrong to kill an embryo in the womb. however, some liberal christian theologians believe that abortion can be supported if the pregnant mother and child are at risk of death. thus, there are differences of opinion among christians regarding abortion, which also applies to the christian citizens of bangladesh. the moral problem of abortion is also created in buddhism. buddhism does not support ‘killing living beings’ like abortion. buddhists believe that no life should be neglected or deliberately killed. buddhism does not support abortion because life is deliberately killed here. however, there is a crisis in buddhism when pregnant mothers and children are at risk of death. because, if abortion is to be accomplished to save a pregnant woman, it will conflict with buddhism. therefore, in such a crisis, different decisions may have to be taken. another topic that is currently being discussed in the medical field of bangladesh is organ transplantation which involves social and religious issues also. for example, most muslims believe that islam forbids organ donation. muslims who oppose organ donation believe that since the qur’an does not directly mention organ donation, organ donation is not acceptable in islam. according to islamic custom, the body of a dead person is to be buried as soon as possible after death. therefore, the preservation of organs from the body of a dead person cannot be supported. liberal islamic thinkers, however, advocate saving lives through organ transplants because protecting human life is a virtuous act in islam. likewise, organ transplantation is supported in hinduism. organ donation is supported in hindu scriptures because it saves the life of another human being and simultaneously, selfless donations (daan) are considered as a pious act. in hinduism, charity is the third of the ten virtuous deeds. besides, the death afterlife is an ongoing process of rebirth in hindu belief. this concept is seen as a positive reflection in organ donation and transplantation10. the main branches of christianity, both catholic and protestant, support and encourage transplantation. christians consider organ donation to be an act of love and a way to follow jesus' example11. again, organ donation and transplantation are not supported in buddhism. according to buddhist culture, corpses have to be kept intact with respect to nature and ancestors. therefore, it is not justifiable to remove an organ from the body of a dead person before cremation after death12. there are some additional cases like some buddhists deny taking vaccines for bacterial diseases. because they believe that germs are also living entities and bangladesh journal of bioethics 2021;12 (1):14-24 19 according to their religious belief, killing a living entity is a sin. they give priority to the other living entity rather than their own life. in these cases, heavenly salvation is more important than saving one’s own life. so, the doctor should keep this in mind when he gives treatment to a buddhist patient. some gender-related issues are also involved in the medical policy of bangladesh. there are many differences in diseases between men and women, and their treatment is different. but, in a maledominated society like bangladesh, it is not considered properly. most of the time, our society does not require the necessary attention to women, especially pregnant women. an adult girl needs special care and nutrition during her period. but, because of some prejudices, most of the time we are not concerned. in our society, after the marriage of a girl, she has to live with her husband, accommodating the new culture and ritual of her father in law’s house. so, in bangladesh, girls are facing many obstacles where the men do not have to go through such problems. for that reason, the autonomy of man and woman is not the same in bangladesh and the medical treatment is not the same, rather relational. in doctor-patient relationships, these sorts of gender-related issues should be considered. that is why relational autonomy is important to protect men’s and women’s different autonomy. from that discussion, we understand that in the case of doctor-patient relationship in bangladesh, considering every patient’s religious beliefs and social issues are very important. because, in maximum cases, the patient’s value and the doctor’s value may not be the same. doctor value may be saving a patient’s life; conversely, a patient’s value may be heavenly salvation following his/her own religious or cultural beliefs. doctors have no right to hit a patient’s belief and social value. everything is a related issue in treatment. when a patient’s religious beliefs and social values are considered, then the patient’s autonomy will be protected. thus, we may claim that relational models of autonomy can play a vital role in bangladesh content. constraint factors: patient’s economic and geographical differences: bangladesh is a very poor country and people are engaged in different occupations. all classes of people including the rich, middle class, and poor people are here. so it is not possible to afford the treatment costs of all people equally. so, everyone’s autonomy is not the same here. for example, in the case of high-cost medical treatment, rich or middle-class patients can sustain it but poor patients cannot. sometimes, for the poor patient, running the family cost is more important than their medical treatment. in such cases, doctors should inform patients about their treatment costs. also, there are differences between the physical condition and treatment of urban people and rural people. the eating habits of people in all the districts of our country are not the same. there is also a difference between the food and nutrition of the people of the different regions. in those districts where natural disasters are high, people of these areas suffer from malnutrition and diseases. it is especially seen in the northern districts of bangladesh. most of the northern districts of bangladesh are poor and the children are deprived of necessary vaccinations after birth. most of the children in the village grow up in an unsavory environment. so, bangladesh journal of bioethics 2021;12 (1):14-24 20 the medical services of the people of the city will not be the same as the medical services of those rural area people. here, geo-cultural identity is an important part that must be considered in medical policy. considering the geographical, economic and environmental aspects of different people in each region of bangladesh, healthcare will be equally balanced. so, we may say that economic and geographical issues should be considered as a relational issue in medical policy like doctor-patient relationship in bangladesh. here, the relational model of autonomy can ensure the autonomy of people by treating people in one area with their medical needs. the benefits of relational autonomy in doctor-patient relationship: when we get benefits from the applications of relational autonomy, then we will realize why the relational model of autonomy is so important for bangladesh in the context of doctor-patient relationship. now, this section will emphasize the benefits of relational autonomy. the benefits that will be the most in doctor-patient relationship in bangladesh are given below: firstly, the paternalistic approach will be reduced. the patients will get the freedom to express their own opinion about diseases and the doctors cannot impose any treatment on the patients. therefore, the patient will be informed about their medical treatment and hence the patient’s autonomy will be protected. secondly, a patient’s religious beliefs and social values are not violated. in the relational model of autonomy, a particular patient’s religious beliefs and social values are considered by the doctor. thirdly, there will be no class discrimination between doctor and patient where paternalistic model builds class discrimination between doctor and patient creating superior position for the doctor and treats the patient as inferior. in the paternalistic model, patients are dominated by the doctor whence in relational model of autonomy, patients get proper freedom. fourthly, there will be a strong relationship constructed between the doctor and the patient. in relational model of autonomy, patients are informed about their own diseases. for this reason, patients get an idea about their diseases and treatment. hence, the patient gets the confidence of the doctor’s advice. because, next time, the patients will be more careful about their health and diseases. consequently, this built up a positive relationship between doctor and patient. fifthly, the apprehensiveness of the patient may get relieved and the confidence will be reached. patients will be psychologically strong when they will be informed about their health condition and get the freedom to choose their own treatment which is suitable. sixthly, corruption in medical treatment will be reduced. corruption in the medical field is a common instance in bangladesh. paternalistic approach cannot remove this corruption because patients are treated here as a client or a customer. but, the relational model of autonomy will consider all patients as a care seeker and make the doctor a caregiver. as a result, care ethics will be established instead of professional attitudes and there will be no corruption here. bangladesh journal of bioethics 2021;12 (1):14-24 21 seventhly, people in bangladesh will rely on the medical services of the country. because maximum people have no reliance on the treatment policy of bangladesh. paternalistic approach is one of the reasons for this attitude. thereby, people go to inexperienced doctors and take the wrong treatment. relational model of autonomy can increase the reliance on bangladeshi medical treatment policy. challenges of applying relational autonomy: when we apply the relational model of autonomy in the case of doctorpatient relationship in bangladesh, it will be very challenging. we have to face many types of obstacles. this section will focus on the challenges of applying relational autonomy. firstly, population is the first major obstacle. bangladesh is a small country with a large number of populations. according to the report of bangladesh statistics 2019, there are 85,633 registered physicians, 8,130 registered dental surgeons and 48,001 registered diploma nurses in bangladesh for the whole population of 164.6 million13. as indicated by these statistics on physicians who were registered with bmdc (bangladesh medical and dental council), there is only one physician per 1,847 people14. necessarily, these data show a very poor doctor-patient ratio and have a significant impact on the doctor-patient relationship. for this reason, the doctor-patient relationship is rather complex in bangladesh because doctors claim that it is not possible to maintain an ideal relationship with patients since they have to provide services for a gigantic populace inside a restricted period. managing an excessive number of patients and the pervasiveness of conflict of interest have serious negative outcomes. in some cases, one can even doubt whether a doctorpatient relationship is actually present in treatment decisions. now, the question may be raised about where the patient does not receive medical treatment properly, and then how we can protect everyone’s autonomy. secondly, illiteracy plays as a major obstacle in establishing relational autonomy. most of the people of our country are illiterate and they have no idea about medical treatment. thus, discussing about their diseases and treatments is quite impossible. at the same time, each patient should be aware of their respective religious beliefs and social values which they will share with the doctors. in most cases, many patients are not aware of their own religion. in these cases, the guardians of patients assist in giving informed consent. but, this process does not establish the patient’s own autonomy and this may turn into another form of paternalism. if the patient is illiterate, communication between the doctor and the patient is interrupted and the doctor is obliged to provide medical care which s/he thinks better. so, in this case, autonomy will not be established, and as a result, it will turn into paternalism. so, the main factor is that if we establish relational autonomy in doctor-patient relationships to ensure every patient’s autonomy, everyone must be educated at least. thirdly, language is an important medium to establish relational autonomy successfully in doctor-patient relationships. if the doctor and the patient do not understand each other’s language, then proper communication between them is not bangladesh journal of bioethics 2021;12 (1):14-24 22 possible. doctors have to study in english and the language of medical science is very complex which patients cannot understand properly. the doctor also needs to understand the language that the patient will speak. as most of the people of bangladesh are illiterate, the lack of proper use of language will be a big obstacle in establishing relational autonomy. the people of most districts of bangladesh speak regional languages and they name various diseases in regional terms that may be unknown to the doctor. as a result, the doctors will not comprehend the patient’s religious and social values properly and the kind of medical care they provide to the patient may not be properly reported to the patient. then the patient’s autonomy in the medical service will not be established securely. so, in these types of cases, doctors should know the use of people’s language in different regions. then relational autonomy will only get success. fourthly, doctors should be highly educated and have to be experts on various diseases. the skilled and specialist doctors who are in bangladesh are mainly providing medical services to the capital dhaka and divisional cities. in rural areas, there are few experts and skilled doctors. there are also many quack and fake doctors in the country. so people of all classes will not get equal treatment when they go to different classes of doctors. besides, if the doctors want to understand the religious and social values of their patients, then they will have to study it. in addition to medical science, doctors should keep in mind the notion of different branches of knowledge like history, religion, anthropology, social science and so on. but sometimes the doctors do not have the proper skills in these areas. therefore, to ensure patient’s autonomy, the doctor has to be proficient in his own field. fifthly, another major obstacle is the insufficiency of the allocation of healthcare resources. the allocation of healthcare resources includes distributing healthrelated materials and services among various uses and people. the medical resources that are used in the dhaka city hospital are not available in the hospitals of other districts outside dhaka. as a result, discrimination creates in providing services to patients in different areas of hospitals. consequently, both medical treatment and the autonomy of the patient are hampered. so, ensuring the allocation of healthcare resources in every hospital in bangladesh is very important to establish relational autonomy in doctor-patient relationships in bangladesh. sixthly, in emergencies when the patients are about to die or in a coma, this is impossible to get information about the patient. in these situations, a patient’s life is more important than protecting the patient’s autonomy to the doctors. for example, there are many road accidents that occur in bangladesh every day where the identity of the victims is unknown. in this situation, doctors should give priority to protect patient’s lives. here, the doctor’s value is protecting the patient’s life and the doctor will decide what sort of treatment will be best for the emergency patients. in this case, paternalism is more acceptable than relational autonomy. so, we have to keep these points in mind. seventhly, the doctor’s role in bangladesh is multidimensional. a senior doctor simultaneously is an instructor in clinical school and a chief of the hospital as well as bangladesh journal of bioethics 2021;12 (1):14-24 23 a private consultant. most of the doctors work as a clinical officer and private practitioner. besides, doctors work in diagnostic centers or get commissions from them, subsequently, they have contending interests. obliquely, doctors help pharmaceutical companies to market their medicine prescribing their medicine to the patients and get some percentage of the expense from the companies15,16. these types of issues impact the patient-physician relationship and this indiscipline in the medical sector will also create problems to establish relational autonomy. above the discussion, we found that a lot of obstacles will be faced to establish relational autonomy in the case of doctorpatient relationship in bangladesh. it is a very challenging issue. but, with a view to accepting these challenges, we need to develop some issues to tackle these obstacles. the steps that will be taken in this regard are discussed below: first of all, we need to give proper training to the doctors and the number of doctors has to be increased. the huge population may seem to be a big obstacle to us but this will not be a big obstacle for us if we can make adequate skilled and specialist doctors. in implementing this, the government will have to increase the budget in the medical sector. at the same time, adequate hospitals and health complexes should be built in the city and village areas. besides, the allocation of healthcare resources should be ensured in every hospital. in bangladesh, the rate of education should be increased and everyone must have correct ideas about their social and religious values. at the same time, the doctors also have the correct ideas about the religious and social issues of the people living in bangladesh. besides, the government will have to pay attention to the corruption in the medical field. the relational model of autonomy in doctor-patient relationships will never be established unless corruption is suppressed in the medical sectors. because, if the relational model of autonomy is established and simultaneously, the medical sector is corrupted, the medical policy will be paternalistic again. conclusion: this article shows how to reduce paternalistic approach in the medical sector in bangladesh and build up an appropriate doctor-patient relationship model that may protect every patient’s autonomy considering all religious, cultural, economic and geographical circumstances. this alternative model will give freedom to the patient in choosing their own treatment as well as which will not conflict with the patient’s social or cultural values. for this purpose, i have used the relational model of autonomy in this article as a suitable model in the case of doctor-patient relationship. in this regard, i have discussed different religious, social, cultural values which exist in the belief of people living in bangladesh. most of the people in our country are muslims. we found that various medical issues such as abortion, organ transplantation etc. exist here. sometimes, islamic religious values contradict medical policy. the same happens to hindus, christians and buddhists. if a doctor’s values contradict a patient’s social or cultural values, the patient’s autonomy will be violated. because, sometimes a patient’s heavenly salvation is more important while for a doctor, saving a patient’s life is more important. as we found that relational bangladesh journal of bioethics 2021;12 (1):14-24 24 autonomy considers a patient’s cultural and social value, it is more appropriate for bangladesh in the case of doctor-patient relationship. but, applying relational model in doctor-patient relationship is more challenging in bangladesh due to some obstacles like large numbers of population, illiteracy, insufficiency of skilled doctors and hospitals, corruption in medical sectors, social prejudices and so on. but, if we can overcome these problems, relational model of autonomy will be considered as a suitable doctor-patient relationship model in bangladesh. acknowledgments: this paper is the part of my master’s thesis. i deeply acknowledge the suggestions that i received from my master’s thesis supervisor, a s m anwarullah bhuiyan, phd professor, department of philosophy, jahangirnagar university. i am very much thankful to him. references: 1. emanuel ej, emanuel ll. four models of the physician-patient relationship. the journal of the american medical association. 1992;267(16):22212226. doi: 10.1001/jama.267.16.2221 2. talukder mmh. on patient-physician relationships: a bangladesh perspective. asian bioethics review. 2011;3(2):65-84. doi: 10.1353/asb.2011.0010 3. hoven mvd. a claim for reasonable morality. commonsense morality in the debate on the limits of morality. quaestiones infinitae. utrecht: utrecht university. 2006; lii:93. 4. mackenzie c, stoljar n, editors. relational autonomy: feminist perspectives on autonomy, agency, and the social self. new york: oxford university press; 2000. 4 p. 5. dove es, kelly se, lucivero f, machirori m, dheensa s, prainsack b. beyond individualism: is there a place for relational autonomy in clinical practice and research?. clinical ethics. 2017;12(3):150-165. https://doi.org/10.1177/1477750917704156 6. baylis f, kenny np, sherwin s. a relational account of public health ethics. public health ethics. 2008;1(3):196–209. https://doi.org/10.1093/phe/phn025 7. abortion of women: the end of a controversy [internet]. 2020. available from: https://lawpark.blogspot.com/2017/11/blogpost_14.html?m=1 (access on 26 december 2020). 8. hinduism and abortion [internet]. 2009. available from: http://www.bbc.co.uk/religion/religions/hinduism/h induethics/abortion (access on 28 august 2020). 9. singer p. practical ethics. 3rd ed. cambridge: cambridge university press; 2011. 128 p. 10. a hindu perspective on organ donation [internet]. 2020. available from: https://www.organdonation.nhs.uk/helping-you-todecide/your-faith-and-beliefs/hinduism/ (access on 28 august 2020). 11. robson n, dublin n, razack ah. organ transplants: ethical, social, and religious issues in a multicultural society. asia-pacific journal of public health. 2010;22(3):1-16. https://doi.org/10.1177/1010539509357446. 12. sugunasiri sh. the buddhist view concerning the dead body. transplantation proceedings. 1990;22(3):947-9. 13. ministry of planning, bangladesh bureau of statistics (bbs), statistics and informatics division (sid). bangladesh statistics 2019. 2019. 46 p. available from: https://bbs.portal.gov.bd/sites/default/files/files/bbs .portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff 80a4ff82e/2020-05-15-09-25dccb5193f34eb8e9ed1780511e55c2cf.pdf (access on 8 november 2020). 14. bangladesh has one doctor for every 1847 people. the financial express [internet]. 2018 february 20. available from: https://thefinancialexpress.com.bd/health/banglades h-has-one-doctor-for-every-1847-people1519053209 (access on 8 november 2020). 15. knox c. dealing with sectoral corruption in bangladesh: developing citizen involvement. public administration and development. 2009;29:117–32. 16. transparency international bangladesh. national household survey 2007 on corruption in bangladesh. 2008. 67 p. available from: https://www.tibangladesh.org/research/hhsurvey07full180608% 5b2%5d.pdf (access on 26 december 2020). author contribution: i conceived the idea, did the literature review, wrote the manuscript and checked the manuscript meticulously. conflict of interests: there is no conflict of interest. microsoft word bjb-2019-shaorin et al bangladesh journal of bioethics 2019; 10(2): 1-6 1 sexual and reproductive health and rights of women: a rights-based approach shaorin tanira1, raihana amin2, sanchita adhikary3, khadiza sultana4, rashida khatun5 1. graduate student, school of rehabilitation therapy, faculty of health sciences, queen's university, kingston, on, canada. email: shaorin.tanira@queensu.ca (corresponding author) 2. junior consultant (gynaecology), geriatric hospital, bangladesh association for the aged and institute of geriatric medicine (baaigm), agargaon, dhaka-1207, bangladesh. email: raihanaamin205@gmail.com 3. junior consultant (obstetrics & gynaecology), jessore sadar hospital, jessore-7400, bangladesh. email: drsadhikary@gmail.com 4. medical coordinator, bangladesh women’s health coalition (bwhc), adabor, dhaka-1207, bangladesh. email: chhonda17@gmail.com 5. graduate student, department of population sciences, university of dhaka, dhaka-1000, bangladesh. email: rashidakhatun6135@gmail.com doi: https://doi.org/10.3329/bioethics.v10i2.50667 abstract: violations of women’s sexual and reproductive health and rights are frequent all over the world. women’s sexual and reproductive health is related to multiple human rights. the term ‘rights-based’ has become increasingly linked to the concept of a more comprehensive approach to sexual and reproductive rights of women around the globe. the rights-based perspective is derived from the treaties, pacts and other international commitments that recognize and reinforce human rights, including the sexual and reproductive rights of women. we conducted an extensive review of the guidelines, frameworks, research reports and published articles that have been cited as informing the rights-based approach. the findings of the review highlights what is meant by sexual and reproductive health and rights by the stakeholders, why this matter is important, and what can be done. it demands more partnerships with human rights, women’s and other civil society organizations, increased number of successful national policies, initiatives and/or legislative changes, increased budget and other resources at national and/or local community level, mass communication and engagement of men to promote and advance women’s sexual and reproductive health and rights. achievement of gender equality is very crucial, because it is a human right that advances women’s empowerment; and is interlinked with sexual and reproductive health and rights. key words: sexual and reproductive health and rights, gender equality, women empowerment, women’s rights. introduction: access to comprehensive sexual and reproductive health and rights is a basic human right. however, violations of women’s sexual and reproductive health rights are frequent all over the world1. the international conference on population and development (icpd) programme of action recognizes that realizing the right to reproductive health is a critical element of guaranteeing reproductive rights1. the icpd programme of action broadly defines reproductive health as “a state of complete bangladesh journal of bioethics 2019; 10(2): 1-6 2 physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes”2. moreover, according to the icpd programme of action, sexual and reproductive rights “rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health”2 and also include the right "to make decisions concerning sexuality and reproduction free of discrimination, coercion and violence, as expressed in human rights documents"2. the rights-based perspective is derived from the “treaties, pacts and other international commitments that recognize and reinforce human rights”3, including the sexual and reproductive rights of women. this paper is the outcome of an extensive review of the guidelines, frameworks, research reports and published articles that have been cited as informing the rights-based approach to women’s sexual and reproductive health and rights. current situation and challenges: maternal mortality, gender-based violence, lack of access to appropriate health care and an absence of family planning services drive violations of reproductive rights across the world4. an estimated 287,000 maternal deaths occurred worldwide in 2010; most of them were preventable. however, the aggregate data masks gross inequalities both within and between countries. for instance, the risk of dying during pregnancy, and when giving birth, for a woman in a developing region is 15 times higher than in developed regions. in total, 99% of maternal deaths occur in the developing world, mainly in africa and south asia5. in addition, more than 200 million women annually are estimated to experience life-threatening complications in connection with pregnancy, often leading to serious disability6. 3 million babies die in the first week of life and even more are stillborn every year7. the main reason behind the large number of preventable maternal and infant mortality, underpinning the disparities between and within the world’s regions, is a lack of quality health care8. despite an increased focus on voluntary family planning, among other interventions, there are still large gaps in the availability of contraceptive services, especially in sub-saharan africa and other developing countries where unmet need is near about 25%, while the global average is around 11%9. it has been estimated that more than 120 million women have unmet needs for family planning services9. those women hardly decide freely on whether to have children and the number and timing of child bearing, and are more vulnerable to contracting sexually transmitted infections (stis), including hiv/aids4,8. lack of access to family planning services also increases the rate of abortions, including unsafe abortions – an estimated yearly 80 million unwanted or unintended pregnancies each year and an estimated 45 million are terminated. of those, 19 million are unsafe with almost 40% done on women below 25 years of age. about 68,000 women die each year from complications of unsafe abortion6. lack of formal education (especially primary bangladesh journal of bioethics 2019; 10(2): 1-6 3 and secondary) for girls not only reflects insufficient access to health education (especially sexual health and family planning), but also illustrates the behind the scene facts: a world in which adolescent girls are forced or otherwise coerced into sex and/or marriage4,9. child, early and forced marriages (and early unions without marriage) are among the many harmful practices affecting young girls, primarily in the developing world9. these violations of reproductive rights – childbirth before physical and mental readiness – a common consequence of early marriages, can lead to obstetric fistula and other detrimental health consequences for both babies and mothers. additionally, evidence shows that adolescent mothers are much less likely to have access to formal and health education than adolescent girls not affected by motherhood11. moreover, patriarchal concepts of women’s roles within the family mean that women are often valued based on their ability to reproduce10. women are also often blamed for infertility. besides, early marriage and pregnancy, or repeated pregnancies spaced too closely together, often as the result of efforts to produce male offspring because of the preference for sons, has a devastating impact on women’s health with sometimes fatal consequences9-11. therefore, international community has acknowledged that maternal mortality and other associated vulnerabilities are primarily a human rights challenge and a social justice issue12. rights-based approach: the term ‘rightsbased’ has become increasingly linked to the concept of a more comprehensive approach to sexual and reproductive rights of women around the globe. reproductive rights are a constellation of freedoms and entitlements that are already recognized in national laws, international human rights instruments and other consensus documents. reproductive rights refer to a diversity of civil, political, economic, social and cultural rights affecting the sexual and reproductive life of individuals and couples2. the universal declaration of human rights (udhr) is a milestone document in the history of human rights. drafted by representatives with different legal and cultural backgrounds from all regions of the world, the declaration was proclaimed by the united nations general assembly in 1948, as a common standard of achievements for all peoples and all nations13. it has been further shaped by major united nations conferences of the 1990s that focused on human rights, gender equality, sexual and reproductive health, and hiv and aids, as well as by the most important document, the 1994 international conference on population and development (icpd), which was adopted by consensus and later endorsed by the united nations general assembly2. another important document, also adopted by consensus and endorsed by the united nations general assembly, is the beijing declaration and platform for action, adopted in 1995 at the fourth world conference on women14. furthermore, the 2005 world summit outcome, adopted by the united nations general assembly in 2005,15 and the commitment to both sexual and reproductive health in the outcome document of the 2010 united nations summit on the millennium development goals, adopted by the united nations bangladesh journal of bioethics 2019; 10(2): 1-6 4 general assembly in 2010,16 further confirmed the commitment to reproductive health. in june 2012, the united nations reaffirmed its commitment to reproductive rights in the united nations conference on sustainable development, rio+20.17 women’s sexual and reproductive health is related to multiple human rights, including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination1,10,18. achievement of gender equality is very crucial, because it is a human right; advances women’s empowerment; and is interlinked with sexual and reproductive health and rights19,20. effectively addressing reproductive health problems calls for an integrated, rights-based approach that draws on the fields of health, ethics, law and human rights. this approach can provide analytical tools to identify root causes and inequities, shape humane and effective programmes and policies, and pressure governments into working proactively18. implementation mechanisms: while hardwon gains for sexual and reproductive health and rights often face backlash and set-backs, several organizations around the globe, together with un agencies, are determined and fighting to change the status quo19. gender equality, the concept that all individuals should be treated in a way that ensures equal opportunities and outcomes, is a human right. the highest attainable standard of sexual and reproductive health is not possible without gender equality5 and this has been recognized at the level of international policy. for example, the sustainable development goals (sdgs) recognize that sustainable development cannot be achieved without gender equality21. not only is gender equality a goal in itself i.e. goal 5, but there is a specific target within this goal on universal access to srh (target 5.6), in addition to a target on srh in the health goal (target 3.7)21. hence, addressing gender inequality is a prerequisite for respecting, protecting and fulfilling the right to sexual and reproductive health. it demands more partnerships with human rights, women’s and other civil society organizations, increased number of successful national policies, initiatives and/or legislative changes, increased budget and other resources at national and/or local community level, mass communication and engagement of men to promote and advance women’s sexual and reproductive health and rights1. the provision of reproductive health services must conform to the international human rights framework comprising the right to health such as the standards guaranteeing availability, accessibility, acceptability, and quality of health facilities, goods, and services22. these are regarded as core components of the right to sexual and reproductive health. a) availability: states must ensure that there are an adequate number of functioning health care facilities, services, goods and programs to serve the population, including essential medicines such as contraception and emergency contraception. b) accessibility: states must ensure that health facilities and services are accessible bangladesh journal of bioethics 2019; 10(2): 1-6 5 both physical and economically to their populations without any discrimination. information also must be accessible so that individuals and groups must be able to seek, receive, and disseminate information and ideas on health issues. c) acceptability: health facilities, services, and goods must be culturally appropriate and should take into account the interests and needs of minorities, indigenous populations, and different genders and age groups. d) quality: reproductive health care must be of good quality, meaning that it is scientifically and medically appropriate and that service providers receive adequate training. to summarize the above discussions, we may say that through all those treaties, meetings and conferences, three points of focus forged a new consensus on reproductive rights16 – i) individuals have the right to control their sexual and reproductive lives without interference, while governments must ensure equal access to health care, including comprehensive reproductive health services; ii) a rights-based approach can provide health practitioners with an ethical framework and understanding of societal factors. it can improve the effectiveness of interventions and empower clients; and iii) international human rights treaty obligations can increase pressure on governments, as well as raise the visibility of sexual and reproductive health problems. conclusion: all the above discussions can be summarized as violations of the major human rights concepts of liberty (incorporating autonomy), social justice, and equality around the globe, while we talk on sexual and reproductive health and rights of women. moreover, the discourse of human rights cannot provide readymade answers to the problems and dilemmas that arise in any given context. however, where several measures present themselves as comparably effective, the preference should be for the alternative that is the least detrimental to the enjoyment of human rights. struggles over women's rights to sexual and reproductive health have also been crucial in advancement of women's rights movement. for decades, women's rights advocates have drawn attention to the ways in which the status of women is fundamentally linked with their sexuality and reduction. this sort of approach means trusting women as autonomous beings who can actively exercise control over their sexual and reproductive lives and to make decisions on these matters on the basis of access to adequate information. to conclude, improvement of reproductive and sexual health and rights directly affects equitable and sustainable development, the attainment of various millennium development goals (mdgs). references: 1. united nations population fund (unfpa) center for reproductive rights (crr). icpd and human rights: 20 years of advancing reproductive rights through un treaty bodies and legal reform. 2017. available from: https://www.unfpa.org/sites/default/files/pubpdf/icpd_and_human_rights_20_years.pdf (accessed august 27, 2017). 2. united nations. report of the international conference on population and development (icpd), cairo, 1994. 1995. available from: https://www.un.org/development/desa/pd/sites/w bangladesh journal of bioethics 2019; 10(2): 1-6 6 ww.un.org.development.desa.pd/files/icpd_en.pd f (accessed june 29, 2017). 3. berglas nf, constantine na, ozer ej. a rightsbased approach to sexuality education: conceptualization, clarification and challenges. perspect sex reprod health. 2014;46(2):63-72. 4. temmerman m, khosla r, say l. sexual and reproductive health and rights: a global development, health, and human rights priority. lancet. 2014;384(9941):e30-1. 5. world health organization (who), world bank, united nations population fund & united nations children's fund (unicef). trends in maternal mortality: 1990 to 2010: who, unicef, unfpa and the world bank estimates. geneva: who; 2012. 6. glasier a, gülmezoglu am, schmid gp, moreno cg, van look pf. sexual and reproductive health: a matter of life and death. lancet. 2006;368(9547):1595-607. 7. world health organization. world health organization fact sheet. making pregnancy safer. saudi med j. 2004;25(8):1133-5. 8. rosenfield a, min cj, freedman lp. making motherhood safe in developing countries. n engl j med. 2007;356(14):1395-7. 9. united nations population fund (unfpa). how universal is access to reproductive health? a review of the evidence. new york: unfpa; 2010. 10. united nations population fund (unfpa). sexual and reproductive health for all: reducing poverty, advancing development and protecting human rights. new york: unfpa; 2010. 11. united nations population fund (unfpa). giving girls today and tomorrow, breaking the cycle of adolescent pregnancy. new york: unfpa; 2007. 12. united nations human rights. office of the high commissioner. reproductive rights are human rights: a handbook for national human rights institutions. 2014. available from: https://www.ohchr.org/documents/publications/n hrihandbook.pdf (accessed june 17, 2017). 13. united nations. universal declaration of human rights. paris, 1948. 1948. available from: https://www.un.org/en/universal-declarationhuman-rights/ (accessed june 18, 2017). 14. un women. fourth world conference on women. beijing, 1995. 1995. available from: https://www.un.org/womenwatch/daw/beijing/pl atform/ (accessed july 10, 2017). 15. united nations. 2005 world summit outcome. 2005. available from: https://www.un.org/en/development/desa/populat ion/migration/generalassembly/docs/globalcomp act/a_res_60_1.pdf (accessed july 11, 2017). 16. united nations. united nations conference on sustainable development, rio+20. rio de janeiro, 2012. 2012. available from: https://sustainabledevelopment.un.org/rio20 (accessed july 11, 2017). 17. united nations. millennium development goals report, 2011. available from: https://www.un.org/millenniumgoals/11_mdg% 20report_en.pdf (accessed july 17, 2017). 18. kols a. a rights-based approach to reproductive health. unfpa/programme for appropriate technology in health. new york: unfpa; 2003. 19. miller am, kismödi e, cottingham j, gruskin s. sexual rights as human rights: a guide to authoritative sources and principles for applying human rights to sexuality and sexual health. reprod health matters. 2015;23(46):16-30. 20. international planned parenthood federation (ippf). gender equality strategy and implementation plan. 2010. available from: https://www.ippf.org/sites/default/files/201804/ippf%202017%20gender%20equality%20st rategy%20-%20english.pdf (accessed july 15, 2017). 21. united nations. open working group session on promoting equality, including social equity, gender equality and women's empowerment. joint statement to the open working group on the sustainable development goals (sdgs). 2014. available from: http://sustainabledevelopment.un.org/content/doc uments/6405argentina.pdf (accessed august 19, 2017). 22. kumar j. how does quality of care relate to a rights-based approach to family planning programs? new york: population council; 2015. available from: https://www.popcouncil.org/uploads/pdfs/2015r h_qoc-rightsbasedfp_wp1.pdf (accessed august 9, 2017). authors’ contribution: s tanira was involved in conception of the paper; s tanira, r amin, s adhikary, k sultana and r khatun were equally involved in the literature search, manuscript writing and revision. conflict of interest: none to disclose. microsoft word macchiarini bangladesh journal of bioethics 2018; 9(1):1-12 1 macchiarinigate: the fall from grace of stem cell healer, paolo macchiarini, and clues and concerns from the early literature that cast ethical doubts jaime a. teixeira da silva p. o. box 7, miki-cho post office, ikenobe 3011-2, kagawa-ken, 761-0799, japan; jaimetex@yahoo.com abstract: after a long and successful career in tracheal surgery and lung cancer, paolo macchiarini became very famous in 2008 with the transplantation of a trachea from a cadaver that then apparently used the patient’s own stem cells to supposedly regenerate new trachea, i.e., tissue-engineered tracheae. among the nine patients that received this revolutionary treatment, using biological or artificial tracheae, under macchiarini’s supervision, six have reportedly died. although several critics had expressed concerns with the procedures, allegations of misconduct against macchiarini first arose in august of 2014 by four karolinska institutet (ki) colleagues, and an independent investigation was called for by ki based on claims made in seven published papers. among the claims were the fact that the procedure constituted a high risk, information on the patients was incomplete and that there was no or incomplete ethical approval, thus constituting misconduct. his cv was also shown to contain inaccuracies. by september 10, 2016, most of these claims have now proved to be true, and macchiarini was found guilty of misconduct by ki. this paper looks primarily at earlier published papers by macchiarini and his collaborators in a search for clues to better understand the evolution of altruism, or narcissism. an assessment of the controversial papers, and of letters written by critics and skeptics like pierre r. delaere, indicate that insufficient experimental evidence was presented for several case studies, and that claims made about the success of the procedures exceeded what was shown by the evidence. a domino effect of personal and professional tragedies ensued, in rapid succession, between 2014 and 2016. the effect on the field of stem cell research has been chilling, and the side-effects have taken their toll, with several high-profile resignations, primarily at ki, within the swedish education system and in the nobel committee. this case has mesmerized the bioethics and biomedical communities for years. key words: ethics in medicine; karolinska institutet; legend; science; stem cell; tracheae paolo macchiarini’s experience and rationale: clues from the early literature: to understand how it is that a famed thoracic surgeon, paolo macchiarini, born in basil, switzerland, in 1958, and the child of italian parents1, has become the center of one of the world’s greatest stem cell research scandals, a look at the individual’s publishing history could reveal clues as to how ideas and objectives may have evolved over time. most stories that have more recently grabbed headlines over the past four years, from 2014-2018, either in the mainstream media, or on blogs, tended to focus on a very specific set of papers that later became the subject of an ethics investigation and a complex series of events that would eventually lead to the current downfallen status of macchiarini. most of those bangladesh journal of bioethics 2018; 9(1):1-12 2 stories, however, do not appear to have examined the early macchiarini literature in detail, in a search for clues that could allow the public and stem cell community to better understand how macchiarini and colleagues could have reached this state of fall from grace. in this first section, i seek to find clues in earlier papers and the wider macchiarini literature, in a bid to understand how things began to fall apart. it is important to maintain this scandal in mind, because it may afflict any stem cell scientist that is left with their guard down, who has been careless, who has cut corners in an attempt to gain fame or reputation using less than accepted methods, or who has dappled in misconduct. a search for paolo macchiarini on pubmed – the world’s leading medical science data-base – revealed, until 2016, 193 papers related primarily to thoracic surgery, lung cancer, and xenotransplantation, the latter which involves the transplantation of non-human cells, tissues or organs into humans. macchiarini in 1998 described himself, in a three-person correspondence to nature, while working at the department of thoracic and vascular surgery, hôpital marie-lannelongue, paris-sud university in france, as “a clinician involved in clinical allotransplantation and experimental xenotransplantation (heart-lung and lung)”2. that 1998 letter to the editor, which was in fact a rebuttal to butler et al., also published in the same year3, revealed some fundamental aspects of this thoracic surgeon that might later have led to his unravelling and consequent downfall. the butler et al. paper in fact sounded an alarm on xenotransplantation, highlighting the risks involved, and claiming that there was insufficient scientific evidence to allay such fears, especially in the light of evolving regulation, particularly in the us where, at that time, the us food and drug administration (fda) had placed a moratorium on porcine transplants in the light of the fact that endogenous retroviruses found in pigs could infect human cells in vitro, a revelation made by le tissier et al. in 19974, researchers at british institutes, of the so-called “trojan pig”. butler et al. further injected fear into the unregulated use of xenotransplantation in surgeries in “xeno-havens”, where experimental surgeries using xenotransplants and stem cells could take place under a business model that was waiting to explode to deal with surgeries dying to find solutions. in 1998, macchiarini countered these concerns and fears by stating, in a direct personal jab at butler et al.1: “although you have published quite a lot on this subject, as far as i know none of the authors has been at the bedside of a patient”, suggesting that the emotive and subjective perspective took precedence over objective, evidence-based science. further widening the rift with the stance by butler et al., by claiming to understand the pain and struggle of patients, macchiarini stated: “they [referring to butler et al.] cannot feel the frustration of patients who die while waiting for an organ nor the wonderful sensation of being able once more to breathe or to move without effort. what about the parents seeking a therapeutic solution for children with terminal diseases? as a clinician, is it really ethical for me to have no solution or should i be more concerned with infection and social arguments?” this fascinating emotive appeal to patients’ struggles – even if implicitly ignoring the scientific evidence or red flags – may have served as the apparently altruistic factor that would spur ensuing research into xenotransplantation and thoracic surgery by macchiarini. in the same letter, macchiarini describes the successful use of a “nude mouse to bangladesh journal of bioethics 2018; 9(1):1-12 3 host a human trachea derived from human embryonic cells.” several months later, 10 cm3 of that human trachea was transplanted “into piglets to test whether the process might be used in human babies as an alternative to their death.” claiming success with this procedure, macchiarini then challenged butler et al.: “do i have the right to propose this technique to the parents? i think i do and we are in the process of asking for permission to do it.” with this seminal statement that challenged conservative protocol, macchiarini positioned himself as being a surgeon with an altruistic objective aimed at aiding dying patients with life-saving remedies in the form of xenotransplants, even if these went against popular or cautionary rationale, or scientific evidence (e.g.4). planting his exploratory flag into unchartered territory, macchiarini ended his commentary by emphatically stating “the time has come for clinicians rather than basic researchers to give their opinions on clinical xenotransplantation”, projecting thus himself and his research group, as a key solution to dying patients. why did macchiarini make such bold and confident assertions when his own published findings of a pig-to-human xenograft, in which pig lungs were perfused with human blood, showed “an early and violent hyperacute rejection that results in irreversible pulmonary dysfunction and failure within approximately 150 minutes of reperfusion”5? such failed xenografts, and other failed tracheal and tracheoesophageal allotransplantation experiments, which were made by the paris-sud university lung transplantation group6,7, should have served as humbling experiences to indicate that the risks – both violent and fatal – supported the concerns and warnings made by butler et al. and should have served as risk-limiting factors in the search for supernatural solutions to human medical deficiencies. close examination of the 1997 macchiarini et al. paper5 reveals that other than broad statements related to animal care and informed patient consent to use blood, no other ethical guidelines or approvals were indicated. admittedly, at that time, it is likely that international committee of medical journal editors (icmje)-style requirements for animal-based tests or human trials – which have only in recent years become detailed and stringent for biomedical results to be published in biomedical journals – did not yet exist. failed procedures were no stranger to macchiarini, as was shown by a paper detailing a failed tracheal allograft replacement8, a product of his phd thesis. however, the attention to scientific discovery as the guiding force to find medical solutions to treatment and surgery seemed to have predominated macchiarini’s earlier work on lung cancer, for example in 19919, apparently driven by sound scientific principles and patient-related ethics. so, at what point did macchiarini deviate off the ethical path, or was it a gradual progression in a passionate desire to find a cure for respiratory ailments, but brought down by an incredible growth in power and global fame, and a concomitant increase in funding by european and russian agencies? examination of macchiarini’s cv (http://www.circare.org/info/pm/cv_eng.pdf) published by his (until recently) swedish employer, the karolinska institutet (ki), in sweden, indicates some facts worthy of pointing out, as a background to the evolution of research in xenotransplantation that will support this evolution in stances and practice by macchiarini that eventually led to his downfall. this cv, which was used to guarantee bangladesh journal of bioethics 2018; 9(1):1-12 4 macchiarini’s position at ki, specifically at the karolinska university hospital, was shown by ki on september 9, 2016 to carry inaccuracies. statements made in 2004 by macchiarini10 suggest macchiarini’s frustration with the progress of science in finding innovative solutions to tracheal grafts or replacements, alluded to in the title as “déjà vu all over again”, noting that “an ideal graft must have some prerequisites: lateral rigidity and longitudinal flexibility, complete air tightness, biocompatibility, nonimmunogenicity, nontoxicity, resistance to bacterial colonization, freedom from the need for immunosuppression, permanent construction, ease of implantation, and the ability to provide a platform of ciliated respiratory epithelium resurfacing.” with this statement, the mental blue-print for how he would achieve his revolutionary xenotransplantation surgeries were set in stone. the rise of paolo macchiarini to legendary status: macchiarini’s bold objectives appeared to thus have been set in stone by 2004, at which point he moved from hannover medical school in germany (1999-2004) to the university of barcelona in spain (2005-2009). the work conducted in germany with the hannover interdisciplinary intrathoracic tumor task force group and in spain, together with his collaborators, would ultimately propel macchiarini to legendary status. was an invitation to speak on “surgical management of the subglottic airway” at the royal bristol infirmary, university of bristol, uk, in november 12, 2001, as documents his ki cv, the stepping stone and start of what would be a highly productive and fame-inducing collaboration with the martin birchall group at the division of surgery, department of clinical medicine, university of bristol? from 2009-2012, macchiarini was an honorary professor of surgery at university college london, suggesting that the birchall alliance was rewarding. independent of what the driving forces were that led to this powerful germany-spain-uk experience, by the time macchiarini reached ki in sweden, he had already clocked several dozen publications in some of the most respected and leading medical journals related primarily to xenotransplantation and surgery, including – but to name a few – the british journal of surgery11 of jif2015 = 5.596, multiple papers in the journal of thoracic and cardiovascular surgery of jif2015 = 3.494, annals of thoracic surgery of jif2015 = 0.658, biomaterials of jif2015 = 8.387, new england journal of medicine of jif2015 = 59.55812, and the lancet of jif2015 = 44.00213. in fact, macchiarini was no stranger to publishing prowess, scoring a paper in the lancet in 1992 from work with his italian collaborators at the university of pisa on neovascularisation and metastasis in lung cancer14. of importance to the realization of macchiarini’s altruistic dreams, and to finally solidify his proof of success, serving as a counter-argument to the disagreements with butler et al.3 that surfaced a decade earlier, several of those papers projected the stem cell-based tissue-engineering theory into practice, including with human trials, such as in five papers13, 15, 16, 17, 18. the macchiarini turning point, or was the only way up? emboldened by increasingly challenging research, larger research groups, bigger funding and higher profile publications in leading medical journals, both as original research and reviews, macchiarini was on track to global fame with tracheal transplants, until a rock was hit on the road bangladesh journal of bioethics 2018; 9(1):1-12 5 to fame, a classic case of a boom-to-bust career caused by uncontrollable public scandal18. that rock, which may now be considered as one of several fatal boulders, refers to the 2008 paper in the lancet2. from that paper, a 2009 erratum emerged in which it was found that the affiliations of three of the authors were incorrect. in november 2008, while praising the experiment in the 2008 paper2, sato and nakamura19 also expressed reservations about the mechanism underlying its success, stating that “macchiarini and colleagues did not use any specific measures to aid revascularisation in the graft. nevertheless, they observed rapid recovery of blood flow and luminal mucosal appearance. the seeded epithelial cells and chondrocytes in the biological prosthesis before the implantation may have induced early revascularisation. however, as the investigators mention, it is unclear whether the seeded cells regenerated the tissue, including the cartilage and mucosa. until the functions of the seeded cells are more clearly elucidated, some doubt remains about whether their results should be regarded as a fully tissue-engineered replacement or an allotransplantation of the trachea.” despite this, almost mesmerized by the almost magical discovery, a reporter from a british newspaper, the independent (http://www.independent.co.uk/us), jeremy laurance, wrote a commentary for the lancet using hyperbolic praises, such as: “every superlative in the book from an “astonishing milestone” to “the start of a new era in medicine” has been used to describe the first successful windpipe transplant”, “unquestionably a major development”, “on a scientific level, the procedure has proved that it is possible to grow organs using a patient’s own stem cells, eliminating the problems of rejection that have always plagued transplants. stem-cell research, which has promised so much in the laboratory, has at last delivered a genuine clinical advance”20. the macchiarini-birchall alliance, which started in 1997, and everyone in between, had finally received dividends from its investments, a medical discovery almost too good to be true. the lancet page indicates that, to date, that paper had been cited 778 times on scopus until the end of 2016. institutional review board and ethics permissions: yet, statements made by birchall in the laurance piece may have proved to be the fateful blow and the beginning of the end to macchiarini’s rise to fame: “ethical permission was obtained — which would not have been possible in the time in the uk, according to birchall — and the team got the go-ahead. a donor trachea was obtained and stripped of its living cells using a process developed at the university of padua. stem cells from castillo’s bone marrow and airway were taken to the faculty of clinical medicine and dentistry, university of bristol, and grown following a protocol developed by anthony hollander. there was even a moment when the project teetered on the verge of disaster as easyjet refused to allow the cells on board its flight. then a medical student remembered a german physician with a plane who agreed to fly the cells to barcelona, where they were placed with the trachea in a bioreactor developed in milan and, 4 days later, the seeded trachea was transplanted.” this paragraph, even to non-medical scientists, reeks of questionable ethics: if it was impossible to obtain ethical permission for such a procedure in the uk at the time, then how was it possible to complete the procedure at the university of bristol in the uk? clues to this question later emerged in a 2012 paper by lowdell et al.21, as bangladesh journal of bioethics 2018; 9(1):1-12 6 described later. why did easyjet refuse to carry these cells? who was this elusive german physician who transported the cells? and most importantly, was there proof at all, from any of the researchers’ research institutes, of ethical approval for this procedure? ironically, birchall stated to laurance: “we, paolo and i, took the biggest personal risk. we could have been in serious trouble if things had gone wrong—fingers would have been pointed.” these issues remain unclarified, and an investigation into birchall’s decisions and level of responsibility in the macchiarini-birchall alliance have yet to be explored and resolved. global criticism of the macchiarini et al. (2008) paper: coincidentally, or not, three letters to the lancet were published in february 2009, by wu et al., of the school of stomatology, fourth military medical university, xi’an, in china, by delaere and hermans, of the department of otolaryngology head & neck surgery and the department of radiology, respectively of the university hospital, catholic university of leuven, belgium, and by zhang et al., collectively from the department of orthopaedics, second affiliated hospital of zhejiang university school of medicine, in hangzhou, china, and the tissue engineering centre, shanghai 9th people’s hospital, shanghai jiaotong university school of medicine, in shanghai, china. the most pertinent criticisms made of the 2008 macchiarini et al. paper, and whose process is described by wu et al.22 as “macchiarini and colleagues then used this tubular matrix [referring to “a nature-derived tracheal matrix from donor tracheal tissues”] as a scaffold on which to engineer native tracheal tissues by seeding autologous epithelial cells and mesenchymal stem cells.”, by these three groups were: “macchiarini and colleagues do not indicate whether this tracheal matrix would eventually be replaced by newly formed cartilage tissues. such a decellularised matrix would degrade completely in vivo, and would lose its original supporting role, which would lead to the collapse of the airway. we suggest detailed follow-up of morphological changes to the patient’s trachea”22. “macchiarini and colleagues seeded cells with a density of 1.0×106/ml onto the surface of the scaffold. for cartilage tissue engineering, the preferred cell density is 5.0×107/ml, because of chondrocytes’ limited proliferate and migrating ability in vivo. in this study, how many cells could penetrate into the pores of the scaffold, and could the above cell density provide sufficient cells for further tissue formation? perhaps such data could be presented in in-vitro specimens” 22. “although revascularisation has been noticed in the inner surface of the graft, we think it will be difficult for the seeded epithelial cells to survive and form mucosal tissue at this site, because of the length of time full revascularisation will take and of the very limited nutritional perfusion from surrounding tissues. we suggest that macchiarini and colleagues could collect the patient’s sputum postoperatively and analyse the cells in it so that we can ascertain whether the seeded epithelial cells have been chipped out and discharged” 22. “the main drawback of the proposed reconstruction is the lack of an intrinsic blood supply”23. “histological analysis of the full thickness of the cartilaginous and membranous tracheal construct at bangladesh journal of bioethics 2018; 9(1):1-12 7 the time of implantation would have allowed for a comparison of the transplant histology with that of the normal tracheal wall. the paper’s illustrations show only isolated and non-organised clusters of epithelial and cartilage cells, and do not allow for histological comparisons”23. “the volume-rendered ct images and virtual bronchoscopic images … provide no clear information about the reconstructive value of the tissue-engineered tracheal transplant.” 23 “the reconstructive value of the avascular tissue-engineered transplant remains unclear in the absence of information about preimplantation histology and postreconstruction morphology”23. “one point was not discussed”; “what would macchiarini and colleagues have done if, having prepared the tissue-engineered graft, the patient’s condition was found to be unsuitable for transplantation at that time?”; “although macchiarini and colleagues’ result is very exciting, perfection of graft preservation might ultimately do more to further the clinical application of tissue-engineered products”24. almost ironically, what had given the appearance of a magical, perfect treatment to treat trachea-bronchial problems, suddenly appeared to have a series of defects and insufficient proof to support the stated claims. in their 2009 response, macchiarini et al.25 rebutted all three sets of readers’ concerns, while stating: “although there are many important scientific questions to be addressed, including those raised by our correspondents, we argue that clinical outcomes are far more important in assessing the value of the technique than pre implantation histology.” what was curious about the authors’ response was that it was co-authored by only five of the 15 original authors. were the remaining 10 co-authors consulted, and had they approved this response on their behalf? no public explanation exists for this discrepancy in authorship. refutation of criticism by macchiarini and colleagues: the patient in the 2008 paper13 is still alive, a fact that macchiarini et al. could use to argue the fact that their experiment was a success. in 2011, jungebluth et al.26, with macchiarini as the last, senior author, and who was already associated with ki in sweden at that time, a new case was presented as part of this collaboration between sweden, iceland, germany and the uk. the authors reported, in a 36-year-old male patient, a “clinical transplantation of the tracheobronchial airway in a patient with recurrent primary trachea cancer, with use of a tailor-made artificial scaffold reseeded ex vivo with mononuclear cells (mncs) and a growth factor-induced endogenous stem cells mobilisation.” the deviation of the technique from the 2008 paper was rationalized and explained as follows: “in 2008, we reported the first fully tissue-engineered tracheal transplantation with a non-immunogenic decellularised human donor trachea reseeded with bone-marrow-derived mesenchymal stem cells (mscs) and respiratory cells. however, this approach is limited by the shortage of donor organs of an appropriate size and has other disadvantages ... as a result, an alternative, tailor-made synthetic tracheal scaffold is an urgent clinical need.” soon after, a study published in the lancet by birchall in a uk-exclusive collaborative effort, and excluding macchiarini, reported on the “replacement of an adult airway using stem cells on a biological scaffold”, i.e., a stem-cell-based organ transplant, in a 12-year-old boy27. the study concluded by stating: bangladesh journal of bioethics 2018; 9(1):1-12 8 “at 2 years follow-up, he had a functional airway and had returned to school.” at first sight, three successful studies, with three the lancet publications and a massive spike in research funding would spell apparent glorious success. yet, this was not to be. in an interview with david holmes1 regarding the jungebluth et al. study26, which holmes described as “the world's first transplant of a trachea made entirely from a synthetic nano-composite scaffold, seeded with the recipient's own stem cells”, macchiarini stated “i'm like a wild animal that does not need to be in a cage, i need to express my convictions that i can help a patient with innovative things.” he also stated that “only those who risk going too far can possibly find out how far one can go.” in the same interview with holmes, philipp jungebluth, who at that time already had an 11-year relationship with macchiarini, noted: “crossing frontiers is the only way to develop medicine and research further. paolo crossed them already and changed medicine, and he will keep on going.” this was also a fateful prediction. teaming up with a team of heavy hitters in the world of medicine in the us, macchiarini indicate that “biological scaffolds made of allogeneic or xenogeneic extracellular matrix derived from nonautologous sources. these scaffolds can act as an inductive template for functional tissue and organ reconstruction after recellularisation with autologous stem cells or differentiated cells.” and that, when “guided by appropriate scientific and ethical oversight, could serve as a platform for the engineering of whole organs and other tissues”28. in a personal email to the author in september 2016, badylak would come to distance himself from macchiarini. in a 2013 paper29 that includes an interview with macchiarini and birchall, as well as the opinions of critics such as delaere, vogel stated that in addition to the 2008 case, another 14 patients had received bioengineered tracheas, by either the macchiarini or the birchall group. raising great concerns in that piece, vogel stated that “the researchers have mentioned other patients in passing in several papers, but no formal reports have been published about their health, and science has not been able to independently verify the current status of all the patients.” in the vogel paper, it became evident that at least two of the patients had died, but a 2016 report indicated that 6 out of 9 patients had deceased30 while the reporting by a science watchdog31, leonid schneider, indicates that many more patients exist, although their deceased status is unclear32. it is unclear if there are other patients. birchall claimed that one of the children died of the cancer while macchiarini indicated that “another adult patient also died of the cancer that had damaged the trachea.” consistent with other criticisms of the macchiarini and birchall findings, delaere affirmed that “if they claim something miraculous, they have to show corresponding data. they don’t do that.” almost coincidentally, gonfiotti et al.33 showed how the 2008 patient, despite requiring repeated endoluminal stenting, was able to sustain a relatively normal social and working lifestyle, five years after the original transplant. in 2013, birchall et al.34, excluding macchiarini, offered a rebuttal, indicating that all three projects were different, independent, but “congruent”, and as an “evolution in thought”. stressing that clinical trials are need to support their one-off case reports, birchall et al. further defended their studies by indicating that the treatments differed for different bangladesh journal of bioethics 2018; 9(1):1-12 9 patients, but that all were “treated under compassionate use-licences”, referring to the use of a highly controversial approach in which “advanced therapy medicinal products (atmps) are substantially modified human or animal cells or cell-device combinations” used to treat patients outside of a clinical trial21. birchall et al. close their rebuttal by stating that “there will probably always be a need for the compassionate use of evolving techniques. such uses provide not only hope for an individual, but useful clues to inform the necessary laboratory science.” in essence, the macchiarini et al.25 and birchall et al.34 rebuttals failed to offer concrete responses to scientific concerns, preferring instead to offer broad excuses, the “evolving” and “compassionate” arguments, and little substance to explain the observed medical shortcomings. until mid-2014, it would have felt that macchiarini and colleagues were still on track to increased fame, until tragedy after tragedy struck. the saga as continues to unfold from 2014-2018, is summarized by kremer30, retraction watch35, with alternative perspectives by schneider36, who is being sued by macchiarini. a formal report issued to ki on september 23, 201637, sheds new light on possible ethical figure-related issues with macchiarini-related papers. this will surely not be the last we hear of macchiarinigate. conclusions and take-home message: the last few years has seen first large praise towards the macchiarini (and to a less extent birchall) successes with transplantations. those studies were astonishing at the time, in a positive way, because they offered the hope and promise of real solutions to near-dying patients. yet, it took so many years for specialists and scientists to notice the warning signs, many of which had even been fairly clear in published papers and editorials. apart from a handful or less of outspoken critics, undoubtedly delaere being the most vocal, the astonishing aspect of macchiarinigate is how many elite journals, their editor boards, including editors-in-chief, and hundreds of scientists who cited these papers, failed to notice any irregularities. there was clearly a culture of suppressed opinion at ki, as several co-authors of a 2011 jungebluth et al. paper38 only requested to be removed as co-authors in march and april 2016 after several ethical investigations had been initiated, two ethical reports had been issued and several negatively revealing documentaries were aired on swedish television. macchiarinigate shows that hyperbolic claims of magnificent and almost miraculous results should always be assessed with great caution and additional scrutiny. there is no doubt that the desire to publish a revolutionary medical finding may have also prompted insufficient scrutiny by the lancet and other top level leading medical journals, as they sought the top publishing prize for bringing these “revolutionary” results to the medical and stem cell research communities. although it is still unclear if macchiarini himself is in charge of all of the ethical mishaps underlying these cases, two salient points remain: a) regarding the published papers, all authors assume collective responsibility when something is published, so they receive glory when the papers were lauded, but they must also assume collective responsibility should those papers be felled due to ethical oversight or misconduct; b) amidst the multiple co-authors, many young surgeons, medical practitioners and researchers will undoubtedly be – where in fact misconduct has taken place – be the innocent victims of another person’s lack of respect of research and publishing bangladesh journal of bioethics 2018; 9(1):1-12 10 protocol and ethics. this case must therefore serve to fortify current checks and balances in research laboratories, with oversight by research institutional ethics committees, or even national independent ethical boards, greater scrutiny and a desire to slow down the publishing process to ensure more quality control and checks. as shown by the obokata stap stem cell scandal and now macchiarinigate, there are risks to one’s career, and even to human life, as one seeks for research objectives with grand solutions. these aspects, together with six core ethical issues (1. ethical guidelines and laws for high-risk ethical procedures, transplantation and clinical trials; 2. the value and weight of “ethical guidelines”; 3. plagiarism, self-plagiarism and professional victimization; 4. ethical inconsistencies by the editor-in-chief of elsevier’s the lancet’s richard horton; 5. the need to show ethical consent forms as part of the open data debate; 6. the ethics of a factually inaccurate and outdated cv) discussed elsewhere39 merit greater open discussion by the biomedical community. six macchiarini papers are destined for retraction following an investigation by the central ethics review board40. finally, the issue of brand protection in the macchiarini case41, despite wide-spread evidence over many years, is a new issue worthy of debate in biomedical ethics. references: 1. holmes d. paolo macchiarini: crossing frontiers. the lancet 2012; 379(9819): 886. 2. macchiarini p. xenotransplants: proceed with caution. nature 1998; 392: 11-12. 3. butler d, wadman m, lehrman s, schiermeier q. last chance to stop and think on risks of xenotransplants. nature 1998; 391: 320-324. 4. le tissier p, stoye jp, takeuchi y, patience c, weiss ra. two sets of human-tropic pig retrovirus. nature 1997; 389: 681-682. 5. macchiarini p, mazmanian gm, oriol r, de montpreville v, dulmet e, fattal s, libert jm, doubine s, nochy d, rieben r, dartevelle p. ex vivo lung model of pig-to-human hyperacute xenograft rejection. journal of thoracic and cardiovascular surgery 1997; 114(3): 315-325. 6. macchiarini p, mazmanian gm, de montpréville vt, dulmet em, chapelier al, dartevelle pg. maximal preservation time of tracheal allografts. the paris-sud university lung transplantation group. annals of thoracic surgery 1995; 60(6): 1597-1604. 7. macchiarini p, mazmanian gm, de montpréville vt, dulmet em, chapelier al, dartevelle pg. experimental tracheal and tracheoesophageal allotransplantation. journal of thoracic and cardiovascular surgery 1995; 110 (4, part 1): 1037-1046. 8. lenot b, macchiarini p, dulmet e, weiss m, dartevelle p. tracheal allograft replacement: an unsuccessful method. european journal of cardio-thoracic surgery 1993; 7:648-652. 9. macchiarini p, hardin m, basolo f, bruno j, chella a, angeletti ca. surgery plus adjuvant chemotherapy for t1-3n0m0 small-cell lung cancer. rationale for current approach. american journal of clinical oncology 1991; 14(3): 218-224. 10. macchiarini p. trachea-guided generation: déjà vu all over again? the journal of thoracic and cardiovascular surgery 2004; 128(1): 14-16. 11. birchall ma, bailey m, barker em, rothkotter hj, otto k, macchiarini p. model for experimental revascularized laryngeal allotransplantation. british journal of surgery 2002; 89: 1470-1476. 12. lotz j, macchiarini p. double aortich arch: diagnosis by mri. new england journal of medicine 2004; 25:351(22): e20. bangladesh journal of bioethics 2018; 9(1):1-12 11 13. macchiarini p, jungebluth p, go t, asnaghi ma, rees le, cogan ta, dodson a, martorell j, bellini s, parnigotto pp, dickinson sc, hollander ap, mantero s, conconi mt, birchall ma. clinical transplantation of a tissue-engineered airway. the lancet 2008; 372(9655): 2023-2030. erratum: the lancet 2008; 373(9662): 462. 14. macchiarini p, fontanini g, squartini f, angeletti ca, hardin mj. relation of neovascularisation to metastasis of non-small-cell lung cancer. the lancet 1992; 340(8812): 145-146. 15. asnaghi ma, jungebluth p, raimondi mt, dickinson sc, rees le, go t, cogan ta, dodson a, parnigotto pp, hollander ap, birchall ma, conconi mt, macchiarini p, mantero s. a double-chamber rotating bioreactor for the development of tissue-engineered hollow organs: from concept to clinical trial. biomaterials 2009; 29: 5260-5269. 16. baiguera s, jungebluth p, burns a, mavilia c, de coppi p, macchiarini p. tissue engineered human tracheas for in vivo implantation. biomaterials 2010; 31: 8931-8938. 17. baiguera s, gonfiotti a, jaus m, comin c, paglierani m, del gaudio c, bianco a, ribatti d, macchiarini p. development of a bioengineered human larynx. biomaterials 2011; 32(19): 4433-4442. 18. teixeira da silva ja, dobránszki j, al-khatib a. legends in science: from boom to bust. publishing research quarterly 2016; 32(4): 313-318. 19. sato t, nakamura n. tissue-engineered airway replacement. the lancet 2008; 372(9655): 2003-2004. 20. laurance j. martin birchall: using stem cells to help make transplant history. the lancet 2008; 372(9656): 2104. 21. lowdell mw, birchall m, thrasher aj. use of compassionate-case atmp in preclinical data for clinical trial applications. the lancet 2012; 379(9834): 2341. 22. wu w, liu y-p, zhao y-m. clinical transplantation of a tissue-engineered airway. the lancet 2009; 373(9665): 717. 23. delaere pr, hermans r. clinical transplantation of a tissue-engineered airway. the lancet 2009; 373(9665): 717-718. 24. zhang p, luo x-s, wang h-j. clinical transplantation of a tissue-engineered airway. the lancet 2009; 373(9665): 718. 25. macchiarini p, birchall ma, hollander ap, mantero s, conconi mt. clinical transplantation of a tissue-engineered airway – authors’ reply. the lancet 2009; 373(9665): 718-719. 26. jungebluth p, alici e, baiguera s, blomberg p, bozóky b, crowley c, einarsson o, gudbjartsson t, le guyader s, henriksson g, hermanson o, juto je, leidner b, lilja t, liska j, luedde t, lundin v, moll g, roderburg c, strömblad s, sutlu t, watz e, seifalian a, macchiarini p. tracheobronchial transplantation with a stem-cell-seeded bioartificial nanocomposite: a proof-of-concept study. the lancet 2011; 378(9808): 1997-2004. erratum: the lancet 2016 mar 5; 387(10022): 944, removing karl-henrik grinnemo. erratum: the lancet 2016 mar 26; 387(10025): 1276. erratum: the lancet 2016 apr 2; 387(10026): 1376, removing bo nilsson, katarina le blanc, and ana isabel teixeira. expression of concern: the lancet 2016 april 2; 387(10026): 1359. 27. elliott mj, de coppi p, speggiorin s, roebuck d, butler cr, samuel e, crowley c, mclaren c, fierens a, vondrys d, cochrane l, jephson c, janes s, beaumont nj, cogan t, bader a, seifalian am, hsuan jj, lowdell mw, birchall ma. stem-cell-based, tissue engineered tracheal replacement in a child: a 2-year follow-up study. the lancet 2012; 380(9846): 994-1000. 28. badylak sf, weiss dj, caplan a, macchiarini p. engineered whole organs and complex tissues. the lancet 2012; 379(9819): 943-952. 29. vogel g. trachea transplants test the limits. science 2013; 340(6130): 266-268. bangladesh journal of bioethics 2018; 9(1):1-12 12 30. kremer w. paolo macchiarini: a surgeon’s downfall. http://www.bbc.com/news/magazine-37311038 (2016; last accessed: june 21, 2018) 31. teixeira da silva ja. science watchdogs. academic journal of interdisciplinary studies 2016; 5(3): 13-15. 32. schneider l. macchiarini’s trachea transplant patients: the full list. https://forbetterscience.com/2017/06/16/macchiarinis-trac hea-transplant-patients-the-full-list/ (2017; last accessed: june 21, 2018) 33. gonfiotti a, jaus mo, barale d, baiguera s, comin c, lavorini f, fontana g, sibila o, rombolà g, jungebluth p, macchiarini p. the first tissue-engineered airway transplantation: 5-year follow-up results. the lancet 2014; 383(9913): 238-44. 34. birchall ma, elliott mj, lowdell m, de coppi p. stem-cell-based, tissue-engineered tracheal replacement in a child authors' reply. the lancet 2013; 381(9861): 113. 35. retraction watch. paolo macchiarini. http://retractionwatch.com/category/by-author/paolo-macc hiarini/ (last accessed: june 21, 2018) 36. schneider l. macchiarini. https://forbetterscience.wordpress.com/?s=macchiarini (last accessed: june 21, 2018) 37. teixeira da silva, j.a. (2016) report #1 (18 cases) on paolo macchiarini-related papers and request for ethical investigation by karolinska institutet and swedish authorities. self-published 39 pages. https://www.researchgate.net/publication/308475863 (last accessed: june 21, 2018) 38. jungebluth p, luedde m, ferrer e, luedde t, vucur m, peinado vi, go t, schreiber c, richthofen mv, bader a, haag j, darsow kh, bartel sj, lange ha, furlani d, steinhoff g, macchiarini p. mesenchymal stem cells restore lung function by recruiting resident and non-resident proteins. cell transplantation 2011; 20(10): 1561-1574. 39. teixeira da silva ja. ethical perspectives and ramifications to the paolo macchiarini case. indian journal of medical ethics 2017; 2(4): 270-275. 40. schneider l. swedish central ethics review board finds macchiarini guilty of misconduct, requests retraction of 6 papers. https://forbetterscience.com/2017/10/30/swedish-centralethics-review-board-finds-macchiarini-guilty-of-misconduc t-requests-retraction-of-6-papers/ (last accessed: june 21, 2018) 41. berggren c, karabag sf. scientific misconduct at an elite medical institute: the role of competing institutional logics and fragmented control. research policy 2018 (in press) https://doi.org/10.1016/j.respol.2018.03.020 author contribution statement: the author researched, wrote, and edited all versions of the manuscript. conflicts of interest and disclaimer: the author declares no conflicts of interest, financial or other. this research was conducted in the absence of any financial funding. the author has been in contact with prof. macchiarini and his co-authors, the journal editors and the swedish authorities (ki and other), as well as media representatives, primarily between september 12 and 23, 2016, to deliver the reports indicated in 201637. none of these contacts has influenced the content or outcome of the perspectives outlined in this commentary, which was submitted prior to the first contacts. microsoft word dasaolu homosexuality bangladesh journal of bioethics 2018; 9(2):26-37 26 on efficient causation for homosexual behaviours among traditional africans: an exploration of the traditional yoruba model dasaolu, babajide olugbenga department of philosophy, olabisi onabanjo university, ogun state, nigeria. email: dasaolu.babajide@yahoomail.com abstract: in the face of the recent backlashes against homosexual persons in africa, on the ground that the phenomenon is un-african and/or threat to procreation and marital values, it is pertinent to review the discourse in the light of how ancient africans perceived the reality. this is imperative given the lack of consensus on the part of scientists to disinter a conclusive finding on what causes homosexual behaviours among humans. in this research, i employ traditional yorùbá philosophy to provide a plausible justification for homosexuality among the people. in the face of this justification via yorùbá folklore, i find that there is no documented evidence among the ancient yorùbá that is suggestive of discrimination and stigmatization of homosexuals and inter-sex persons. as homosexual persons were respected but not criminalized, this study recommends the regurgitation of this outlook in the contemporaneous dealings with homosexual persons, beginning with the repealing of the same-sex marriage prohibition act of 2014 in nigeria, which is inconsistent with african values and outlooks on the subject. keywords: homosexuality; philosophy; causal factor; yorùbá folklore; africa introduction: what causes homosexual behaviours among humans? is there any conclusive scientific evidence for homosexual orientations? these are the questions that initiated this research in the first place. upon a critical scrutiny of some of the foremost claims on the causative factors for homosexual behaviours, it is unfortunate that there is nothing conclusive or suggestive of clinical validation. the matter is unfortunate because homosexual persons have been perceived as less than normal humans. in some countries, they are even persecuted for being who they are. but must this continue? if there are no scientific validations, the cause of homosexual behaviours, is it possible to employ a traditional african outlook to examine the phenomenon for solace? how relevant and penetrating, the african position on the cause of homosexual behaviours? furthermore, were homosexual persons in traditional africa criminalized and stigmatized? these are the questions that i seek to explore within the pages that follow. i will end the inquiry with some thoughtful bangladesh journal of bioethics 2018; 9(2):26-37 27 recommendations on how to deal with homosexuals in contemporaneous times. the quest for efficient causation for homosexuality in the sciences: the search for the cause of homosexual behaviours has put psychologists, genetic scientists, psychiatrists and even philosophers to work. for those who are affiliated to the study of genes, biologism has been put forward as an approach. biologism is “…the view that human behavior and social situations can be causally explained by an appeal to the physical mechanisms at play in the organic biological processes of the human body.”1 the understanding here is that homosexuals have been determined by the genes and hormones in their bodies to have sexual orientations or affiliations as they do. in other words, they have been programed by genetics to be thus. natalie angier2; christopher daly3; curt suplee4 are few minds who have used media as a medium to publish these scientific findings. however, this perspective has come under scrutiny. the works of stanton l. jones and don e. workman5 and richard c. friedman and jenifer downey6 have served sharply to show that there is no conclusive scientific judgment “that homosexual orientation or attraction (much less behaviour) is biologically fixed or immutable.”7 in a related development, psychiatrists richard c. friedman and jenifer downey observe that: “at clinical conferences one often hears discussants commenting that “homosexuality is genetic” and, therefore, that homosexual orientation is fixed and unmodifiable. neither assertion is true…the assertion that homosexuality is genetic is so reductionistic that it must be dismissed out of hand as a general principle of psychology.”8 other renowned minds that have made profound efforts to seek the what science claims to be the cause(s) of homosexual orientations in humans are: simon levay9; william byne and bruce parsons10; simon burton.11 the widespread accentuated but unfortunate outcome is that there is no proper scientific evidence to serve as effective causation for homosexual orientation in humans. perhaps one may think that the lack of consensus among scientists, as it pertains to the causal factor of homosexual behaviours may be responsible for the malicious treatment and estrangement of homosexuals in several places in africa, such an outlook lacks basis, especially when considers the scientific verdict on race and the endless discrimination on the basis skin colour. after several years of stigmatization and discrimination against africans and people with black skin, the scientific community has come to the conclusion that human genetic diversity cannot be captured by race. in the 21st century, francis collins and craig venter, after extensive and rigorous bangladesh journal of bioethics 2018; 9(2):26-37 28 laboratory efforts, conclude that human genetic diversity cannot be captured by the concept of race. they revealed as well that all humans have genome sequences that are 99.9% identical.12 for venter, the concept of race has no genetic or scientific basis.13 in the same vein, collins and mansoura chronicle: “those who wish to draw precise racial boundaries around certain groups will not be able to use science as a legitimate justification.”14 it is the case that even when most of these scientific validations on race arrived at the turn of the millennium, there has been the continuous interest on segregation on the yardstick of skin colour. when one applies this sense of reasoning to homosexuality, the analogy will be too glaring to require further elaborations. as a result, homosexuals will likely continue to suffer stigmatization in the face of scientific explanation (assuming there is at least, one). furthermore, the presence or absence of a causative factor by scientists has not improved the situation of lgbqt in africa since there has been the emphasis, mostly by african heads of government that homosexuality is “un-african, a disease of the morally corrupt west.”15 it is therefore pertinent, at this juncture to explore the popular response within africa – rejection and stigmatization of homosexuals. homosexuality from the mainstream and dominant african perspective: my task here is to explore and attempt a reconstruction of the vehemence against homosexual behaviours in africa from the hands of her heads of government and scholars versed with the african past. despite the moral bankruptcy that has generally characterized leadership in africa, it is interesting to note that most african leaders have denounced homosexuality as evil, unnatural and incongruent to african culture and psyche. a brief survey of some of their views is revealing: president robert mugabe of zimbabwe compared homosexuality to bestiality and has ordered the police to raid the offices of gays and lesbians.16 in fact, mugabe claimed that homosexuals were “worse than pigs and dogs.”17 namibian president, san nujoma, was more antagonistic and vitriolic in his attack of the homosexuals. he declared that “the republic of namibia does not allow homosexuality or lesbianism here. police are ordered to arrest you, deport you and imprison you.”18 nujoma sees homosexuality as against god’s will and act that shows that the devil is at work. indeed, namibia’s home affairs minister, jerry ekandjo urged the police officers to eliminate gays and lesbians from the face of namibia.19 there are others beside those in the leadership cadre who feel that homosexuality is totally un-african and that it negates all the cherished values of a typical african. thus the reactions of africans may take the following forms: that homosexuality should not be accepted, it is bangladesh journal of bioethics 2018; 9(2):26-37 29 not the plan of god…it is completely bad and it does not originate from africa, it is satanic and controlled by the evil spirits. john ernest is of the view that homosexuals should be disenfranchised in africa; they have no rights to be respected. ernest opined that “homosexuality is a curse and that god should punish those who are engaged in the act, just as god reacted to the people of sodom and gomorrah.”20 john ernest continues that “africa has no right to respect gays according to african tradition and even the bible. in fact, the act of gay is immoral and should be condemned by all civilized nations of the world.”21 yet there are those who feel that africa would be throwing away its culture and ethics to the western culture and principles and thus playing the fool if it should respect the right of the homosexuals. that is why there has been a strong reaction to the gay activist group’s effort to stall a bill seeking to ban same sex marriages in nigeria.22 though there has been a few dissenting voices, the general consensus in the african milieu is that homosexuality should not be allowed to take root in africa. it is foreign to african culture and religion. thus, its manifestation should be treated as an aberration rather than a socially acceptable behavioural pattern. but is this in line with how traditional africans viewed it? ebun oduwole, an erudite of great influence on traditional african bioethics disaffirms. this is a view some other minds such as laurent magesa, placid tempels may also share with oduwole. in spite of her admission that there were instances of homosexual and inter-sex persons among the traditional yoruba, ebun oduwole argues that it was generally frowned upon. in her words, oduwole affirms: “…homosexuality is not as alien to traditional african societies as some people would want us to believe. however, it is equally clear that while there were traces of the phenomenon in indigenous yoruba society, for example, it was generally considered to be unacceptable. hence, the same-sex marriage prohibition act of 2014 in nigeria is consistent with our cultural values” (emphasis mine).23 oduwole makes two seemingly valid but erroneous claims in the above. i will summarily tend to these as i simultaneously pull the erroneous and misleading implications of her rendition. her evidence that homosexuality “…was generally considered to be unacceptable…”24, in indigenous yorùbá society derives from ódù otúrá gorì-ìrete, one of the many verses of the ifá corpus whose rendition in the english is thus: two men are copulating two men are copulating two women are copulating, two women are mating bangladesh journal of bioethics 2018; 9(2):26-37 30 why don't we take a man? and then take a woman why don't we take a man? and then take a woman therein lies enjoyment and fulfilment divination was cast for erifobogbile the (primordial) head's diviner divined for it too when head was to site a domicile head was told to offer a sacrifice may i trade and make profits my (primordial) head, may i have two thousand children may i trade and make profits oduwole is assured that this ódù “gives a vivid account of homosexuality and points to it as an exercise in futility.”25 however, it is strange how her perception that homosexual affair is an exercise in futility is enshrined in that ódù. even if we admit for the sake of argument, oduwole’s conviction that homosexuality is an exercise in futility perhaps because procreation does not ensue, then oduwole must be willing to shun heterosexual women with mullerian agenesis from sexual intercourse since that too will be an exercise in futility. medically certified barren women and women past menopause who are heterosexuals, will on the showing of oduwole be performing exercises in futility. her reasoning may even imply that they need not make love again. in retrospection, oduwole may say that the ódù reveals that a man-woman sexual intercourse is more enjoyable and fulfilling than a homosexual intercourse. she may use the yorùbá saying that “his eyes are like the eyes of one who has anal sex” to justify this seeming lack of enjoyment. however, this reasoning too is flawed. as a result, homosexuals engaged in anal sex have not come out to say that they lack enjoyment and fulfillment. to feed this proposition into their sexual orientation and then criticize same clearly indicates the strawman fallacy. analogically, there are reported cases of vaginal intercourse where the woman complains of discomfort and pains, sometimes accompanied with bleeding. whither pleasure and fulfillment? obviously, enjoyment and fulfillment in sexual intercourse is an argument that may be deployed to both homosexuals and heterosexuals. it is not a yardstick to relegate or denounce the former and be mute regarding the latter. i find recourse to the ifá corpus as a basis for the rejection of homosexual practices in traditional yorùbá societies as inefficient. i will amplify this position in the next section. for the moment, i concern with oduwole’s second erroneous and misleading claim. oduwole stresses that “the same-sex marriage prohibition act of 2014 in nigeria is consistent with our cultural values.”26 here, she assumes that nigeria is a homogenous political entity, where what holds in a predominantly christian south bangladesh journal of bioethics 2018; 9(2):26-37 31 with diverse ethnic groups obtains in a predominantly muslim north where the sharia operates. moreover, i beg to differ from oduwole to show that the same-sex marriage prohibition act of 2014 is not consistent with african cultural values. some instance will suffice here! among the traditional hausa in present day northern nigeria and the lango people of northern uganda, there were men identified as yan duada and makudo dako respectively. in the words of mathew paige yan duada “… were effeminate men and were considered an option for other men to marry. other traditions were found in the nilotico lango. there was the third gender makudo dako, which were people of the male sex who dressed as women, and treated as women. marriage between men and makudo dako was a common practice.”27 similarly, among the traditional yorùbá the terms adofùrọ̀ and lakíríboto, are suggestive of gay and inter-sex persons respectively. there were no strict penal codes against these humans. they were respected and accorded their own rights as human beings. there were neither sharia laws that made them death row candidates nor imprisonments of a decade and four years. to then insist as oduwole does that that “same-sex marriage prohibition act of 2014 in nigeria is consistent with our cultural values”28 is not anywhere close to the truth, unless of course she means our cultural values diluted with euro-christian and arab-islamic orientations. at this juncture, a critic may demand whether or not dressing is a sufficient determinant of the nature of humans to be classified into the popular binary sexual orientation of malefemale. this study ripostes that this may be necessary; it is not a sufficient condition. there are many straight males who dress as female just as gay males persist and dress like females. dressing is not a sufficient yardstick granted that it is necessary to differentiate the two popular sexes. thus far, i have been able to establish two crucial aims here. the first is that the african heads of government who tinker that homosexuality was alien to africa are not enlightened enough regarding africa’s history of sexuality. the second is the erroneous rendition by oduwole and her disciples that in spite of the traces of homosexual, the reality was perceived as a threat to heterosexual marital institutions and procreation. personally, i find these outlooks premised on the lack of proper scientific basis for homosexuality. in the remainder of this inquiry, i seek to unclad a more plausible trado-yorùbá explanation for the existence and persistence of homosexuality among humans and why these persons were not discriminated against back then. the trado-yorùbá discourse on the efficient causation of homosexual persons: in this section, i offer a causative explanation for homosexuality using yorùbá bangladesh journal of bioethics 2018; 9(2):26-37 32 myth as cue. however before disclosing this affair, it is important to offer that homosexual behaviours have received minimal causal explanation vis-à-vis realities like kleptomaniac. whereas the kleptomaniac has an inherent genetic disposition to acquire by crook, what does not belong to them, the homosexual is on the defensive. the latter has no genetic explanation from research authorities of the mainstream and dominant scientific enterprise and also face stigmatization and persecution more than the kleptomaniac. the question there is: how have traditional africans engaged and speculated on homosexuality, i use the traditional yorùbá folklore as a cue. before the advent of colonialism and the enchanted of the african mind with arabic and western values, cultures and religions, there were allegories used to explain why things are the way that they are. these allegories or myths have served as a way of understanding the world, for social cohesion and mutual coexistence. a critique may at this junction refuse to bat an eye, over my choice for myths as a basis even when it is the case that had already ceded that there is no scientific consensus on homosexuality. hence, i need to provide an explanatory justification before exploring the indigenous yorùbá creation myth as a plausible reason why there were no homophobic acts in precolonial times. while speaking on the role that myths play in the development of scientific theories, renowned erudite sir karl raimund popper leaks: “i realize that such myths may be developed, and become testable; that historically speaking all – or very nearly all – scientific theories originate from myths and that a myth may contain important anticipations of scientific theories. examples are empedocles’ theory of evolution by trial and error or parmenides’ myth of the unchanging block universe, in which nothing ever happens and which if we add another dimension becomes einstein’s block universe...”29 obviously, several factors militating against the development of african science will have made the development of african myths into testable scientific theories impossible. factors as poor understanding or complete ignorance of indigenous cultures and tradition, the aftermath of arab-islamic and euro-christian values, education, religions, culture and traditions are foremost. but my contention is not to engage with these. my point is that the yorùbá creation myth is pregnant with some testable truths which render homophobic ideas obsolete. i will now concern with the myth of the creation of humans as holds among the traditional yorùbá. if there is any truth in the role that sexual selection play in reproduction, it is minimal. this claim is incontestable if one recalls that there are several cases of sexual relations that do not yield into conception, pregnancy, bangladesh journal of bioethics 2018; 9(2):26-37 33 gestation and then finally delivery. in the words of olanrewaju shitta-bey “it is a scientific fact that sexual intercourse does not necessarily result into pregnancy even when the spermatozoa of a man and the ovum of his female counterpart are medically proven to be satisfactorily active.”30 it is therefore not uncommon to have many sterile personalities among species in the plant and animal kingdoms. contrary to the claim of charles darwin31, the traditional yorùbá contests that sexual selection plays minimal role as the impact of other factors have not been take into consideration. in plain language, sexual intercourse as an aftermath of the evolutionary theory of sexual selection does not guarantee reproduction and ultimately the preservation of the species. if the yorùbá evolutionary theory and the role of olódùmarè (higher god) and the òrìṣàs (divinities) are used to assess this reality, it becomes clear that even traditional yorùbá has more consistency over darwin’s theory of evolution through natural and sexual selection. at this juncture, a re-interpretation is needed to for the yorùbá human creation account in order to put in the proper perspective, the role of olódùmarè and the òrìṣàs in the affairs of the universe. it is not to be contested that the saying: “olódùmarè ní ó n fún énìyàn ni ọmọ” (olódùmarè, the higher god is the giver of children) is permeating among the traditional yorùbá. it is this additional condition that the traditional yorùbá adds to the role of natural and sexual selection. this condition is the role played by olódùmarè and the òrìṣàs during and after sexual intercourse. it is from this truth that when olódùmarè and the òrìṣàs bless the union of a man’s sperm cell and a woman’s egg cell after sexual intercourse or manipulation over a petri dish (if it is a biotechnological process), that the yorùbá may utter: “o ti fẹrakù” (conception has occurred in her/it). this is seen by the yorùbá as a sign that olódùmarè and the òrìṣàs have granted their request toward procreation. one point must be noted here though! there is a large gulf between “o ti fẹrakù” (conception has occurred in her/it) and “o ti l’oyun” (pregnancy has occurred in her/it) for the traditional yorùbá. this is “because the stages/processes involved between the moment of conception and the delivery of the baby (for instance, orisha nla may or may not carry the function of molding the ara of the human person)”32 a proper and detailed account of the evolution of the foetus has been documented by olanrewaju shitta-bey. i will not pursue that case further to avoid digression from the aim of this research. hence, i concern with the primordial deity called òrìṣàńlá. who is òrìṣàńlá? how important is this entity toward the creation of a human? it is agreed that ọbàtálá or òrìṣàńlá (one of the primordial divinities in the yorùbá world-view (fond of drinking palm wine) fashions a human body (ara) out of clay or sand. meanwhile, olódùmarè (higher god) bangladesh journal of bioethics 2018; 9(2):26-37 34 gives life-force or soul (èṃí) to the ‘craft’ of òrìṣàńlá. the animated ara then proceeds to àjàlá’s abode (another primordial divinity who makes orí) to make a choice of destiny, orí. granted, òrìṣàńlá is the primordial divinity that casts a human body, it is very likely that he may cast inter-sex persons. he may omit the genitals of a woman, thereby creating confusion of the sex of the person.33 assuming a critic interposes at this juncture that òrìṣàńlá has the capacity to cast a kleptomaniac. would this not justify the stealing on the part of the human entity? on first showing, this observation is correct. a deeper reflection will however reveal to the critic that the condition of the kleptomaniac has genetic and scientific explanations. homosexuality is however futile in explanation, hence the recourse to traditional yorùbá folklore. secondly, there are no recorded cases of kleptomaniac among traditional and even the contemporary yorùbá. such an act as kleptomaniac has no existence in the history and tradition of the people. it will therefore be a form of conceptual superimposition on the part of the critic, demanding that kleptomaniac be given causal validation as homosexuality from yorùbá folklore. extemporaneously, “òrìṣàńlá could mould a woman with stronger bones and muscles that will make her more masculine. he may also mould women without womb.”34 furthermore, and in the most severe cases, he “may not carry the function of molding the ara of the human person,”35 and this could lead to miscarriage for the gestating woman. these are perhaps some of the ideas that inform the traditional yorùbá position on sexuality. it therefore does not strike one that traditional yorùbá sexuality is one that recognizes that aside the male and female sexes, there could be other sexes that emanate from the craft of òrìṣàńlá. this is precisely why in the yorùbá language, there is not gender-specific pronoun for the male and female sexes.36 in addition, “biological anatomy is not a limitation to social status as that of husband, wives, mothers, or fathers among the yoruba. in addition, the yoruba language provides no pronoun for sexual distinction. the notion of gender among the yoruba is complex and multidimensional.”37 the climax of this study have served to reveal that among the indigenous yorùbá, there is a likely understanding of homosexual and inter-sex persons as the crafts of òrìṣàńlá, in a similar way that albinos too. there was no jail terms for these peoples neither were they restricted from social life. clearly, traditional yorùbá society is not a homophobic one. it was a kind of society where sex and gender are flexible and amenable. some recommendations: in the light of the arguments that i have put forward in the last section, it is the case that there is an established but unfair exposition by scholars regarding ancient yorùbá explanation for the cause of homosexuality and the general bangladesh journal of bioethics 2018; 9(2):26-37 35 acceptance back then. hence, it is the recommendation of the study that since homosexuality was not frowned upon by african progenitors it is fallacious, to put this as a justification for the criminalization of homosexuals. it is for this reason that i propose for the repeal of the same-sex marriage prohibition act of 2014, which is not consistent with african cultural values. hence, similar laws in other parts of africa should similarly be repealed. in addition to the foregoing, homosexual persons who have contributed to the development of the society through their efforts in various spheres of life should be celebrated and not be discriminated against. through this, homosexuals may be seen beyond their sexuality but just like any other human. thirdly, there is need for sexuality orientation for people who discriminate against homosexuals in social and work places. information centers should be made available for citizens to get adequate resources on what homosexuality is about. furthermore, they must be made to realize that the causative factor through the teaching of traditional african folklores. here, schools should educate young people especially about it such that it does not come strange as they get older. conclusion: this essay has explored the characterization and extent of three claims on homosexuality. first, that there is no scientific consensus regarding the cause of homosexuality. that there is no scientific evidence for homosexuality does not strengthen the case of most african leaders who condemn the reality. ‘western’ science does not have the final answer to all things. these leaders are therefore left with the option of perusing indigenous african cultures for answers. it is however the case that the influence wielded by christianity and islam over the minds of contemporary african leaders is an impasse to the natural admission of homosexuality among the african forbearers. second, that african leaders and scholars who have upheld the anti-same sex marriage either understanding of african culture or are just homophobes who do not wish to have any interaction with homosexuals. these persons have also used the glorious past of africa to gird their resolve that homosexuality is un-african. third, that the traditional yorùbá community like many other pre-colonial areas in africa was not against homosexuals since there is no evidence revealing that homosexuals were punished, discriminated and persecuted as they are in recent times. impliedly, my contention is that homosexuality is not foreign to africa and for the traditional yorùbá, it is òrìṣàńlá that stands as efficient cause for their being. it is therefore the recommendation of this work to revive this idea that it is òrìṣàńlá that made the homosexual thus. unless we do this, there is clear evidence that we in the 21st century are vicious but not virtuous, bangladesh journal of bioethics 2018; 9(2):26-37 36 lettered but not fully educated, in our dealings with ‘fellow humans’ whose places we may be, had òrìṣàńlá taken an overdose of his favourite, the palm wine. homosexuality by its very nature is neither a vice nor a virtue. it is a reality that relies on the context. the serial rapist, kleptomaniac, racists are deemed virtuous or otherwise within contexts and the science of their conditions. the kleptomaniac is clinically validated and the judge will be lenient. a serial rapist may in very rare cases get leniency since he could be medically validated to have mental disorders vis-à-vis the ‘one-off-rapist.’ bias as to what constitute rape and mental state may also come to play. however, the homosexual is bogged down by prejudices and perceived as a threat to family values irrespective of context. homosexuality is neither virtue nor vice. it needs to be contextualized before this disjunction can work. strictly speaking the whole gamut of this inquiry has been dedicated to this. author contribution: author developed the conceptual idea and wrote the manuscript. conflict of interest: declared none. acknowledgements: i wish to acknowledge the intellectual exploration of bioethics within the african purview as laid out in the reflections of professor ebun oduwole, one of the prominent sages of the ogun school of philosophy, olabisi onabanjo university, ago-iwoye, nigeria. more so, i desire to use this medium to relay my profound gratitude to a former student, emmanuel ofuasia whose critical comments, conceptual clarifications and accentuation on clarity of arguments has added value to this research. i thank him immensely. references: 1k.a. rodier. “biologism and simone de beauvoir: a phenomenological re-reading of “the givens of biology””. m.phil thesis submitted to department of philosophy, university of sasketchewan, saskatoon, canada 2007 , p. 10 2see natalie angier. “study suggests genes sway lesbian’s sexual orientation”. new york times. march 1993a 12; natalie angier. “report suggests homosexuality is linked to genes”. new york times. july 1993b, 16. 3christopher daly. “study of twins suggest lesbianism has a genetic component”. washington post. march 1993 15. 4curt suplee. “study provides new evidence of “gay gene””. washington post. october 1995 31 5stanton l. jones and don e. workman. “homosexuality: the behavioural sciences and the church”. journal of psychology and theology. 1989 213. 6richard c. friedman and jenifer downey. sexual orientation and psychoanalysis: sexual science and clinical practice. (new york: columbia university press 2002) 7l.d. wardle. “the biological causes and consequences of homosexual behavioural and their relevance for family law policies”. depaul law review. 56(3): 997-1034 8op. cit., friedman and downey, p. 39 9simon levay . “a difference in hypothalamic structure between heteroseuxal and homosexual men”. science. 1991 1034. 10william byne and bruce parsons. “human sexual orientations: the biological theories reappraised”. archives of general psychiatry 1993 228. bangladesh journal of bioethics 2018; 9(2):26-37 37 11simon burton. the causes of homosexuality: what science tells us. (cambridge: jubilee centre 2006) 12michael yudell. “a short history of the concept of race.” in s. krimsky & j. sloan (eds). race and genetic revolution: science, myth and culture. pp. 13-30. (new york: columbia university press 2011), p. 22 13rick wiess & justin gillis. “teams finish mapping human dna.” washington post. 2000 14f.s. collins, m.k. mansoura. “the human genome project: revealing the shared inheritance of all humankind.” cancer. 2001, vol. 92, p. s224 15op. cit., kahn-fogel, p. 316 `16k. boykin “homosexuality in africa.” http://www.keithboykin.com/author/ africa.html. posted january 11, 2001. retrieved on the 11th april, 2018. 17john ernst. “bbc africa live”. http://www.mask.org.za/article.php?cat=ajd=74. retrieved on the 15th august, 2018. 18op cit., boykin 19op cit., obasola, p. 84 20op cit., ernst 21ibid 22op. cit., obasola, p. 83 23ebun oduwole. philosophy and the challenge of relevance in african society. 79th inaugural lecture. olabisi onabanjo university, agoiwoye, ogun state. 20th february, 2018., p. 15 24ibid, p. 15 25ibid., p. 14 26ibid., p. 15 27op. cit., paige 28op. cit., oduwole, p. 15 29karl r. popper. conjectures and refutations. (london: routledge & kegan paul 1963), p. 36 30olanrewaju. a shitta-bey. “the humanity of the foetus: a yorùbá perspective.” african journal of history and culture. 2015 7 (2), p. 54 31charles darwin. on the origin of species by means of natural selection, or the preservation of favoured species in the struggle for life. (new york: modern library edition 1949). 32op. cit., shitta-bey, p. 54 33babajide olugbenga dasaolu. “òrìṣàńlá made me thus: arguing for homosexuality using the yorùbá thought system as paradigm.” lasu journal of philosophy. 2018 vol. 1 (2), p. 201 34ibid, p. 201 35 op. cit, shitta bey p. 54 36see o. oyewunmi. the invention of women: making an african sense of western gender discourses. (minneapolis: university of minnesota press 1997) 37o. olajubu. “seeing through a woman’s eye: yorùbá religious tradition and gender relations.” journal of feminist studies in religion. 2004 20 (1), p. 42 microsoft word mala mitu 1st 1 bangladesh journal of bioethics 2019; 10 (3) 14-18 14 youth action against moral deterioration mehedi mala mitu master student of clinical pharmacy and pharmacology north south university, dhaka email: mitumala043@gmail.com doi: https://doi.org/10.3329/bioethics.v10i2.50653 abstract: in past, chinese traveler fa-hien (14th century) to ibn batuta (14th century) or from nicola kanti (15th century) to queen elizabeth (20th century), every travelers and scholars are attracted by the charms and fame of bangladesh. ibn batuta described bengal as “a hell full of bounties” and “wealthiest” land of the world”. but now a day, along this progress anxiety has proportionately increased. in this present age, science and technology are the easily available to common people. the world has come to a handful but yet people are still not so happy. as if the demand is insatiable. so, anxiety, apathy, intolerance, fear and panic are increased. morality is deemed declining. why immorality among young increased is a concern? mark twain said, “always do what is right, it will gratify half of mankind”. what is right? a vantage point is needed to know. our moral values which guide us and aids us in our conscious mobility in life. this article tries to find out the cause root of immorality among young generation and how to protect young generation from this moral deterioration. key words: youth, new generation, morality, moral deterioration (some part of this article presented at the 20th asian bioethics conference, 22-25 november 2019, dhaka, bangladesh). introduction: the word “mortality” came from a latin word “moralis” means “character, manner or proper behavior”. according to the merriamwebster dictionary the definition of the word moral is “concerning or relating to what is right and wrong in human behavior”. morality is generally regarded as a standard or ideal criterion which is based on the social tradition, culture, religion etc. the literal meaning of the word “moral decay” is deterioration of the moral value like patience, generosity, courtesy etc. inspector general of bangladesh police a.k.m. shohidul haque said, according to psychologists sigmund freud’s theory, three tendencies are innate in every human being as for example id, ego and superego. the id satisfy certain basic needs, such as food, sex, power, etc. under the influence of ego, a person can balance everything. superego can bestow superhuman qualities of a person and a person can become an inhuman and he does not hesitate to commit any crime or heinous act with increase in id’s influence. he does not even have the sense of laws, sins and guilt also transformed into a person of unscrupulous and perverted taste. in this type of superego is seen bangladesh. despite immediate legal action against a gang rape accused in subarnachar, bangladesh, a mother of six children was raped within three months of this legal action. bangladesh journal of bioethics 2019; 10 (3) 14-18 15 actually, good education, self-education and the practice of civility are needed to increase ego’s influence by suppressing id. at the same time, it is essential to provide exemplary speedy punishment to the perpetrators of such perverted tastes through strict enforcement of law including socially boycott them. therefore, this article this article has been written to find out the cause of deterioration among young generation and what are the action need to increase ego’s influence by suppressing id. cause of moral deterioration: there are certain reasons behind the moral decay of a society, some notable reasons are discussed below: lack of proper education: education is the backbone of a nation. the relationship between education and development of a nation is proportional. education is the first guidance for the world humanity. because only by acquiring knowledge, people can understand the difference between truth and falsehood, justice and injustice. but nowadays most of the education is certificate based. students are falling behind in their moral education rather run after to pursuit a good result that leading to increasing in moral decay. drug availability: intoxication seems to be in the vein of many youth in bangladesh. the number of drug addicts were 1.7 million in 2001 and in 2019 it is 7.5 million. drug addicts are involved in various crime to collect their money to buy drugs. oishee, a drug addicted young girl killed her parents by sharp blade. is one of the most unprecedented immoral acts in bangladesh. terror on campus: the campus is a sacred place where students will acquire knowledge. but unfortunately, terrorism has been developed in the student’s politics which disrupting the learning environment of the university and facing ordinary students suffering from insecurity. terrorism on campus is becoming the foothold of moral deterioration. the youth must join in a healthy politics. only an honest politician can remove corruption from the country. an honest political leader can motivate a hundred young people to defend their morals and values. corruption can be eradicated from the society by relying on ethics. the effect of unemployment: at present, per capita income of bangladesh is about 1,909 us dollars. despite the increase in per capita income, bangladesh has the highest unemployment rate among south asian countries. this rate was doubled in the past 6 years. poverty is increasing due to the impact of unemployment. although the number of higher degrees is increased, but the number of qualified job opportunities for them is not increased. according to international labor organization (ilo), 56% bangladeshi involved in workforce feel that they are not paid a fair rate. so, some of them get involved in various types of immoral activities like bribery to fulfill their basic needs. internet access: every part of the world there are 4g, 5g. it takes a second to bring everything including pornography in front of eyes of young people of bangladesh like other part of the world. easy access and inappropriate use of internet is also responsible for moral deterioration. some young people are fascinated by western culture and watch inappropriate subjects. as a result, number of rape case is increased than before. the number of rapes in 2001 was 622. in 2019, for first 6 month it was 731 for women and 496 for children respectively. bangladesh journal of bioethics 2019; 10 (3) 14-18 16 age between 6-month-old girl to a 60-yearold lady seems to not be getting rid from rape. so, at present times, moral decadence is like an alarming disease to us. breaking down the traditional system: there was a time when children used to greet elders and elders used to love children. the elders used to rule when someone in the family did wrong. but in the evolution of time, these are very rare nowadays. urbanization is taking place by breaking down the traditional systems. the rule and discipline are being loosened specially in city system, causing of erosion of moral values. lack of religious education: religion has a great impact on daily life of any human being. in islam it is said that, “the teaching of morality is the greatest asset for the children”. not only in islam but also in all religions, moral education has given the priority. children learn good things of religion and refrain from bad things. lack of religious education may be one of the causes of increase moral deterioration. the intrusion of corruption: currently, corruption seems rampage in our society. corruption enter into education, food, medicine etc. what will the students learn from a corrupted teacher? one of the examples of moral decay in education is leaking of questions paper of exam. some medical students are taught in “education and service”. therefore, some doctors only run after money. because of less importance has been given on medical ethics education while they were student. so, there is a lack of moral value among them. role of youth society in preventing moral decay: young society is the most important population of a country. they have endless vitality than children or older society. they are the present and future of bangladesh. it is the youth who brings color to this aging world. it is the youth who gives hope to the hopeless, who brings changes to a society. their efforts can lead a nation to thrive and live-in harmony. from generation to generation the youth have been the main shield to protect this country. from the language movement in 1952 to the liberation war in 1971 or from the chaotic situation in 1990 to the protest for safe road in 2018, the young society have kept the soil of the country tight. but at present, because of the broken family, availability of drug, misuse of internet, some young generation is on the verge of collapse today. some are creating gang culture in different places and getting involved in robbery only because of moral decay. they forget to practice moral values rather than give more importance to enjoyment and domination attitude. a book named youth and development says, “the descendant of the youth is due to the environmental reflection bad effects of science and technology, state’s apathy and above all, family’s indifference.” this deviance of the youth is a threat to the country. young people are the future doctors, engineers, pharmacists, ministers that means the main infrastructure of the country is in their hands. so, if they take morality as the standard of their ideology, it will then be the sustainable development for a country. young society is the state asset and they are the main driving force of a country. only the youth can suppress the current anarchy in the country. although we as human beings have reached the pinnacle of civilization and the pinnacle of humanity. but sadly, we have come down further in terms of human beings. bangladesh journal of bioethics 2019; 10 (3) 14-18 17 love and respect are almost become zero. when an animal is born, it’s already an animal but when a human child is born, he needs to be a human with time by learning and transforming moral values. moral education comes from the family. children are given with moral education by family that raise them as the future leaders of our society. when a child comes out family boundary, society also has responsibilities to create morality among the children. it is possible to create values among the children by organizing various social awareness programs, discussion meetings and cultural programs. action against moral deterioration: student club: generally, the university students are attached with many club activities. they can open a club with the need for moral education and values. the main purpose of this club should be educated morally to school children and college teenagers. college students need to pay special attention in this case because during this period of time teenagers are more prone to crime. therefore, they can organize various seminars and rallies routinely. they can organize mobile library so that every age of people can borrow books from them as books keep people away from immoral acts. moral education in institution: educational institutions are the best place to create morality inside a person. when a child leaves the family boundary, they enter educational institutions first. but it is a pity that at present, only science, technical, professional subjects are given more emphasis rather moral education. as a result, nation is getting doctors, engineers but there is no ethics in them. so, some doctors become butchers and some engineers become corrupted. so moral education is essential in institution. university authority should come forward to show interest in incorporating morality in the syllabus. avoid internet addiction: young society must always choose the true path. they should use internet accurately. always accept things those are good and they should not spend too much time on social media rather concentrate on reading various types of constructive literature and books in internet. young generation can make small messages on moral values and its importance and send it to others. however, they can make short stories or drama to raise awareness about moral decay by posting it on social media. create employment: unemployment is the cause of moral decay for most young men and women. they are suffering from depression as they are not getting jobs even after getting higher education. out of that frustration, they are engaging in various immoral activities. so, they have to build themselves as successful entrepreneurs from their respective places and not just rely on the administration. those who are successful entrepreneurs can make people aware by organizing seminars or discussion meetings. this will reduce unemployment as well as moral decaying. sports: the youth has to be playful. they have to involve themselves in all kinds of sports like cricket, football, volleyball, badminton. because playing keeps both mind and body fresh. for entertainment they should not rely on smartphone rather they can play various types of sports. religion: the essence of every religion is discipline and values. religion is one of the tool for creating moral education. by bangladesh journal of bioethics 2019; 10 (3) 14-18 18 practicing religion properly, the youth will be able to protect them from moral decaying. conclusion: today's young woman is the bearer of the next generation. napoleon said, “give me an educated mother and i will give you an educated nation”. so, it is very important for young woman to have moral education. a child who learns morality from an early age cannot do anything bad thing in the future. it is not possible to prevent from this moral decay overnight. this requires long-term planning. who doesn't want a country where there will be no violence, no food adulteration, have security for girls, no corruption, no fear of death on the streets? who doesn't want such a country? it is true that the country became independent in 1971, but in order to ensure the true independence of all citizens, the youth must come forward to resort morality. youth have to stand by the side of this endangered humanity and all the moral decaying of the society with the strong wind of their youth. how fire purifies gold from impurities, moral values do the same to us. moral values are as important as the air we breathe, moral values are as important as the water we drink. moral values make us human. moral values are what makes life worth-living for ourselves and for others. moral education may increase ego’s influence by suppressing id. acknowledgement: i would like to thank prof shamima lasker, professor & head of anatomy, shahabuddin medical college for her feedback on various versions of this paper. i express my gratitude to her for giving me opportunity to publish this article. i also thanks to dr sharmin islam for encouraging me to write this article. references: 1. angelo valenti, always do what is right. it will gratify half of mankind and astound the other. – mark twain. 2018. https://www.linkedin.com/pulse/always-do-whatright-gratify-half-mankind-astound-other-valenti (accessed nov 2019) 2.definition of moral. https://www.merriamwebster.com/dictionary/moral (accessed nov 2019) 3.drug addiction bangladesh. dhaka tribune, 27th february, 2019 4.inspector general of bangladesh police a.k.m. shohidul haque . daily news kaler kantho, 16 april, 2019, dhaka, bangladesh. 5.per capita income of banglades. daily news prothom alo, 19th march, 2019, dhaka, bangladesh. 6.rape cases in bangladesh. bangladesh. daily news protidin, 20th april, 2019 7.shamima lasker and arif hossain. teaching of bioethics in medical schools in bangladesh. eubios journal of asian and international bioethics 2008; 18(6): 180-81. 8.shamima lasker and arif hossain. introduction of bioethics and its necessity in bangladesh bangladesh journal of bioethics 2010; 1(1):2. 9.utah state board of education career and technical education. causes of crime. 2016. https://www.uen.org/lawenfstudent/downloads/le_ch 3.pdf (accessed october 2019) authors’ contribution: author conceived the idea of the paper. she involved in the literature search, manuscript writing and revision. conflict of interest: none to disclose untitled-1 bangladesh bioethics society education minister, nurul islam nahid, mp unesco ethics workshop in march 2009 mahbubey alam, attorney general unesco ethics workshop in march 2009 malama meleisa director, unesco dhaka at unesco ethics workshop 2009 darryl macer, regional advisor, unesco, stbangkok at 1 international conf conference 2010 prof aams arefin siddique,vc, du at st1 international conference, march 2010 architect yeafesh osman, state minister, s&ict at a month long bioethics course, august 2010 prof dr syed modasser ali, health advisor at seminar of bioethics, may 2011 benazir ahmed bpm (bar),commissioner, dmp at road safety programme, june 2013 obaidul quader, minister of communication road safety programme, june 2013 hasanul haq inu, minister of information at award ceremony, june 2014 selina hossain, bengali writer, at human rights training programme september, 2011 bioethics phd & master holders from bbs prof nazrul islam, chairman, ugc, at a month long bioethics course, june 2010. bioethics course of nih, usa conducted by bbs through video conference international bioethics seminar at national heart foundation in 2018 research methodology training course of bbs human rights & boiethics training course of bbs for undergraduate students ethics review committee of bbs over view under auspices of regional unit for social and human science in asia and the pacific (rushsap), unesco, bangkok and unesco dhaka, bangladesh bioethics society (bbs) was founded in 2009. due to gradual development of science and technology, citizens of bangladesh are stepping forward with many positive hopes and dreams. the country is rapidly turning from the agro-based rural society to urban society. due to lack of proper education along with these developments, people are somewhat confused about what is wrong and what is right. moreover, for the advancement of sciences and technology people are facing dilemma for ethical issues arising from medicine, biotechnology, environment and social life as a whole. in consideration of these, the country demands an urgent need for implementation of bioethics principles for social development. therefore, bbs was established with the initiative of prof. shamima p lasker and dr arif hossain launched by he nurul islam nahid, minister for education and primary & mass education, people republic of bangladesh to create awareness, promote knowledge and skills of bioethics in personal and social life, and encourage teaching and research in bioethics. bbs is a non profit, non political, multi-disciplinary and voluntary organization. it is the first and only society in bioethics in bangladesh. vision moral upbringing of citizens for sustainable development of bangladesh. mission to bring community people to think rationally about the critical issues and balance the risks & benefits in their choices and decisions for peace, human rights, tolerance and democratic governance. goals ethically enlightened citizen in all strata of society regardless to poor rich, cast and creed. objectives 1. uphold the value of free, open and reasoned discussion of issues in bioethics; 2. disseminate the ideas and results of bioethics research through popular lectures, public awareness programme and publications; 3. teach bioethics in bangladesh at all level; 4. promote and organize lectures, seminars, workshops and national & international conferences in bioethics; 5. establish network with regional and global organization of bioethics 6. facilitate the government policy in bioethics. journal bangladesh journal of bioethics (bjb) is an official journal of bangladesh bioethics society. journal published quarterly. bjb promotes multi-cultural and multi-disciplinary study in the field of ethics in medicine, science, social science, law, education and policy studies. journal is indexed by ncbi, usa bangljol of inasp, uk; doaj; islamic world scientific citation, isc, iran; index medicus for south-east asia region imsear, who and drij. it is regularly published by hinary, geneva foundation for medical education and research (who/oms), global ethics.net, georgetown university law library, world medical journal editors (wame), udl thesis & bangljol affiliations l unesco asia-pacific school of ethics l global ethics observatory (geobs), paris l bioethics research library at georgetown university, a part of the kennedy institute of ethics, usa. l international society of bioethics (sibi), spain. l global ethics.net collaborators of bbs government of bangladesh: l university grants commission, bangladesh l national commission for unesco (bncu), ministry of education l directorate general of health services (dghs), ministry of health & family welfare l national heart foundation hospital & research institute l national institute of cardiovascular disease (nicvd) l social science research council, ministry of planning l national academy for education management (naem), ministry of education l department of epidemiology, nipsom, mohakhali, dhaka l bangladesh police (highway range) l bangladesh road transport corporation (brtc) l bangladesh bureau of statistics l press institute of bangladesh foreign organizations: l unesco dhaka l regional unit of social and human science in asia and the pacific (rushsap), unesco bangkok, thailand l national institute of health (nih), usa l american university of sovereign nations (ausn) activities l mou with american university of the sovereign nations, usa to send members of bbs for master's of bioethics & global public health (mbgph) and master's of public health (mph) with scholarship. l collaboration with nhi, usa for 3 months course on ethical and regulatory aspects of clinical research. l short course on research with human. l send members regularly in different international conferences abroad from 2009 to develop human resource e.g. usa, thailand, china, singapore, iran. nepal, taiwan, japan, philippines, turkey, india etc. l organize courses/seminars/workshops to familiarize the idea of bioethics & research methodology l encourage research on bioethics issues in bangladesh since 2009. l youth leadership training workshop for undergraduate students to uphold human rights. l art/picture competition on bioethics for undergraduate & post graduate students. l involvement in government policy e.g. education policy. l road safety programme. l ethics review committee. membership membership benefits: l leadership opportunities: hold position in executive committee / subcommittee of bbs. l voting right: right to vote in bbs election. l be listed in and access online bbs members directory. l networking: access to attend bioethical meetings/ conferences/ seminars/workshops in county and abroad. l access to attend in research / training in bioethics. l access to attend annual general meeting l free journal subscription. l receive the societies newsletters and society's activities news. membership fees: life member : tk 5,000 general member : tk 500 per year student member : tk 300 per year international life member : us$ 100 international general member : us$ 10 subscription option: membership fees are payable at any time in the year by cash to treasurer of bbs or by tt at bangladesh bioethics society janata bank ltd. dhaka sheraton hotel & corporate branch dhaka, bangladesh ac/no: 0100005693904 swift: janbbddh prof. dr. md. humayun kabir talukder publicity secretary, bangladesh bioethics society hktalukder@yahoo.comemail: cell: 01711534774 prof shamima parvin lasker secretary general,bbs 1085/1 malibagh chowdhury para, dhaka-1219 mobile: 01712522627, email: splasker04@yahoo.com website: www.bioethics.org.bd contact page 1 page 2 microsoft word justice for children-16.11.20 bangladesh journal of bioethics 2020; 11 (1): 35-43 35 justice for children in bangladesh: legal and ethical issues nahid ferdousi professor of law, school of social sciences, humanities and languages bangladesh open university, bangladesh email: ferdousi329@gmail.comm doi: https://doi.org/10.3329/bioethics.v11i1.49268 abstract: reform of the child justice system has started with the enactment of the children act 2013 in bangladesh. the act adopted a number of institutional setups for child-friendly justice i.e. child help desks in the police station, separate children’s court, child development centres, national child welfare board etc. these all are interlinked and the responsibilities of concerned authorities have been focused on the law. in practice, most of the children are deprived of their fair justice in different phases i.e. police arrest, prosecution, court hearing, and correctional treatment as there is a lack of professional ethics of concerned personnel. ethical approach, skill, and knowledge of personnel are major challenges for the treatment of offender children. thus, code of ethics is important for professionals to provide value-based justice for the best interest of the children. the study focuses on the legal and ethical responsibility towards the child justice system in the country to protect child rights and their childhood. keywords: children, justice, law, ethics, responsibility. introduction: law, ethics, morality and values form an integral part of society. their combination is required for the protection and justice for the children. the consciousness is reflected in the international legal instruments as well as in the constitution of bangladesh to protect children against neglect, cruelty, exploitation and to provide equal opportunities for development. as per the international instruments, the rights for children are the right to be treated with dignity1,the right to life 2 , the right to be presumed innocent 3 , prohibition of torture and ill-treatment of children. accordingly, the government of bangladesh has been enacted a new legal framework with the commencement of the children act 2013 replacing the old children act 19744 to create a more effective justice for the children best interest. child justice is a key component of child rights in terms of upholding their best interests when they involved with crime. the fundamental purpose of children law and child justice system is to control crime, to rehabilitate the children, and establish a fair justice. the children act 2013 paves the way for child welfare boards, child-specialized police officers, separate children’s court, child development centres, probation officers for the protection and welfare of the children. the age of the children has increased from 16 to 18 in the law. many of the justice aspects dealt with in the statute are interrelated so the judiciary, law-enforcing agents and other dealing authorities must be sensitized to the provisions of the children’s laws. in the justice system, all authorities of the justice system are bound by ethical rules in professional practice. absence of a separate bangladesh journal of bioethics 2020; 11 (1): 35-43 36 code of ethics, the children did not get improved social services from the judges, prosecutors, investigators and the other related authorities. the requirements of the concerned agency’s ethics and professional responsibilities assist in fair justice for the children. lack of coordination among related ministries, absence of institutional accountability and regular monitoring system are major barriers to implementing the children act, 2013 rightly and also these are hindering the existing legal system. through many reforms in children’s law, children have many different paths of rehabilitation instead of just prison or jail time. but there are many children in the country who are detained for alleged wrongdoing without the protection they are entitled to. throughout the country, children are charged and sentenced for actions as adults. most of the law enforcement officials tend to mistreat underage individuals during cases while working through the lens of an adult. unfair punishments are still handed down domestically, which is definitely a violation of law as well as ethics. it is ethical to allow courts dealing with child offenders to punish them for taking part in illegal activities. the latest change in children’s law attempts to expunge the children’s court system. ever since the establishment of children courts, there has been controversy on the subject of how they should be run and what rules should be applied. as well with more children being tried as adults it weeds out the worst cases; therefore, making the children courts appear more effective. many children get involved in unsafe activities and it is important that their actions are corrected. laws regarding children’s justice modified many times to assist courts in the rehabilitation of offender children. it is ethical to allow courts to rehabilitate children from unsafe lifestyles5. the ethical and responsible professionals must strive to obey the law and safeguard the best interests of the children, while delivering competent services as a part of the justice system. professionals like police officers, judges, probation officers and social workers must be committed with requisite skills, knowledge and ethical approach towards the child-oriented treatment of children. however, they must never simply assume this to be an ordinary case. it is the professional's duty to know and understand the legal obligations and responsibilities that apply when children in conflict with the law. although there is no such code of ethics about treatment toward a child offender, they must treat the children offenders regarding their individual ethical values. an understanding of children's evolving capacities to make decisions, coupled with knowledge about emotional and social development, is critical to such work. in this context, ethics, values and morality have been playing a phenomenal role in nourishing and building good relations among concerned agencies. an ethical approach is important for all concerned to ensure the fulfillment of children’s rights. the study focuses on the legal and ethical issues towards the attitude of dealing authorities for improving the values basis justice system where children can enjoy their basic human rights. bangladesh journal of bioethics 2020; 11 (1): 35-43 37 method: the study was mainly qualitative in nature. it is designed mainly based on the existing laws relating to child protection and justice in bangladesh. necessary data are collected from secondary sources. secondary data have been collected from different sources such as reading materials, journals, research articles, the internet, leading cases, international conventions, government statistics and so on. legal framework for child protection: bangladesh has separate children laws that are applicable to establish different types of care and protection services for the offender children. the children act provides safeguards for the protection of children who come to contact with it as victims, witnesses, and offenders and focuses specialized system with a child’s dignity, age, gender, incapacities, maturity and so on. the concerned ministries are drafting the different laws on victim-witness protection, children’s rules and children’s policy for further activation of the justice system. it requires to mention here that after the ratification of the uncrc 1989, the laws regarding children’s justice were not consolidated in bangladesh. most of the children are deprived from proper protection of their rights under the laws and usually they received the same treatment as the adults in the criminal justice proceedings. consequently, children lost their childhood as they suffered adversely in the criminal justice system. major changes of the law: in bangladesh, the act 2013 defines a child as anyone up to the age of 18 years while the age of children was 16 years in the act 1974 and only for age disparity with international norms children did not get access to fair justice6. as per international instruments children are entitled the exclusive rights to get justice on the basis of their age, maturity into essential circumstances and needs. however, the act 2013 introduces a new provision regarding children age, specialized children courts, certified correctional institutions, probation service, diversion and alternative sentencing. bangladesh introduced the right-based approach by the act 2013 for the protection and wellbeing of the children. the law prohibits to arrest the children under the age of 9 years. if any child above age 9 is arrested, the use of handcuff and ropes are completely forbidden in the law. moreover, the law covers many aspects of children’s vulnerability in detention stages such as, the new provisions regarding the child affairs police officer who maintains separate treatment of the offender children 7 . it prescribes the duties of the police officer such as contacting probation officer, informing parents and family members, and exploring appropriate diversion programs for justice involved children upon instruction from the children court8. looking at the concept of children court, three juvenile courts were established under the act 1974 in bangladesh but the act 2013 requires that at least one children court be established in each district headquarter and metropolitan areas, which has the exclusive jurisdiction to deal with juvenile offenders9. the children court has the responsibility for the assessment and determination of age of bangladesh journal of bioethics 2020; 11 (1): 35-43 38 the delinquent children 10 . the law strictly prohibits the joint trial and the trail shall be completed within 360 days from the day of the child’s first appearance before the court. another angle of institutional service in the country, the act2013 provides more comprehensive outlines for the establishment of certification and operational producers of child development centers as correctional institutions11. the three correctional centers along with juvenile court has been established under the act 1974. later, the act 2013prescribes to establish and maintain a necessary number of child development centers or certified institutions for both male and female children12. additionally, the act 2013 elaborately focuses the provision of probation officer with the appointment, responsibilities and duties for ensuring probation service in the centers13 . as per the law probation officer has important responsibilities in the time of arrest, trial and field inquiry of the children case 14 . the officer prepares and preserve a separate file for each detained child to follow the procedure for alternative care15. to extent the wellbeing services, the act2013 includes the provision of a child welfare board for monitoring the child development centers and certified institutes. the law prescribes the appointments, roles and activities of the board in detail. the main responsibilities of the board are to supervise and evaluate the activities of child development centers, provide guidelines for rehabilitation and reintegration, and review the development and implementation of all programs related to offender children. the board with the probation officer is responsible for finding out suitable alternative care and ensuring the children’s best interest16. the national level board are only entitled to provide guidance and instruction. other district and city level boards can enforce the supervisory power and it would be played an important role for reducing delinquency17. regarding the punishment of children, the act 2013 moderated the punishment system of the offender children in line with international conventions in bangladesh. as per the law children shall not be sentenced to death or imprisonment for life. the duration of the penalty of the children would not exceed the maximum period rather children can be detained in child development centers instead of jail until the age of 18. the law strongly is forbidden to detain children with adults in prison 18 . so, the law allows the imprisonment of the children for extreme cases is really uniformity with the international standards. the concepts of diversion and any types of alternative measures were not recognized in the 1974 act, so the act 2013 introduced the provision for a diversion program, family conferencing, restorative justice and alternative dispute resolution 19 . the department of social service is mandated to design and implement diversion programs and cannot be used as legal document in court proceedings 20 . both probation and police officer are assigned to take necessary steps to arrange this program for reformation of the detained children21. bangladesh journal of bioethics 2020; 11 (1): 35-43 39 a drawback of the legal issues on child justice absence of children rule: the act 2013 recognizes some administrative authorities and mentions their responsibilities for establishing a child-oriented justice system22. at present lack of children rules 23 these provisions of the act 2013 yet to be implemented fully with child-friendly police desk, adequate number of probation officers, and child welfare boards. the child welfare board or the probation officer shall determine the most suitable alternative care for the child, taking into consideration for the best interest of the delinquent children 24 . the district or sub-district child welfare board shall review the information received and shall make recommendations to the concerned authority for the overall welfare of the child25. but there is no specific guideline or definite rule that how the methods would be applied or how alternative interventions would be conducted in the ground. however, district and sub-district level boards do not have any functions dealing directly with offender children, despite having a mandate to inspect prisons, making their role in regard to these children unclear26. this is completely an ethical issue to deal with children welfare. in this context, establishment of child affairs police desk, child welfare board, family conferencing and other diversion programs seem to be most challenging tasks27. insufficient supportive key actors:the most significant components of child justice are the child affairs police officers and child development centres (cdcs) with adequate probation officers. the act 2013 requires every police station to maintain a child affairs desk and to have a capo28 in that desk, till adequate child affairs desk has been set up. rather it is often published in newspapers that children below the age of accruing criminal responsibility are being arrested by the police officers and detained with the adults. additionally, child development centres (cdcs) is clearly inadequate and as a result the child offenders therein do not have regular communication with their parents. there are at present only three cdcs and no other cdcs or rehabilitation center for the development of child offenders in the country. lack of cdcs, the rights of the children is continuously being violated once they are kept in prisons 29 . it is clear that reformed act 2013 has been in effect in bangladesh for almost eight years now, key actors in charge of child justice (i.e., police officers, probation officers and judges) still lack clear understanding of child rights laws. since there are only three specialized institutes for children correction under the act1974and there are no child development centers established under the act 2013yet. the law prescribes the provision relating probation officers 30 who are prepare and preserve, a separate file for each child in child development centers and follow the procedure for alternative care of offender children 31 . the probation officer is also responsible to submit the social enquiry report about the offender children in the court as prescribed by the children rules 32 . the main problem is that there is no children rules and updated probation offenders’ law in the country rather the service has been executed bangladesh journal of bioethics 2020; 11 (1): 35-43 40 by the probation of offenders ordinance 1960. limited children court: presently, except the three special children courts, there are no separate children courts which could ensure that children are separated and treated differently from the adults at all stages of the criminal proceedings33. as per the act 2013, the children court will arrange for proper seating arrangements for the child and will provide special arrangements for challenged child, where necessary 34 . from 2014, the additional session judge court is performing responsibilities and working as a children’s court in each district and metropolitan area in the country. although, the additional sessions judges have been empowered as the children’s court within their own respective jurisdictions, but the additional session judge court are arguably the busiest criminal courts in the country and therefore, either a children’s court exclusively dealing with child offenders should be established or a less busy should be empowered as children’s court for ensuring children justice. although the act2013 has brought a massive change in the field of child justice the childoriented specialized justice units have not been established in bangladesh. due to the functional structure and resource constraints, law enforcement agencies, courts, and child development centers are not able to provide adequate services that reflect the interests of the juvenile. the law documented the functioning of specific children courts as one in each district but except for three children courts in the centers, the separate children courts have not been established yet. thereafter, the ministry law justice and parliamentary affairs determined by a gazette notification that the additional session judges court will be empowered as a children court35. it requires note that the act 2013, further has been amended in 2018 to expand the children’s courts. the act2018 (amended) contains the provision of establishing the children tribunals in each district. at present all tribunals of the women and children repression prevention are working as children tribunals for the operating trail procedure of children offenses. the majority of the children cases are tried by the criminal courts where no special procedure is followed which are mentioned in the act 2013. even the modernized judicial process is not nearby due to not having separate courts and specialized child-friendly courtroom 36 . in this regard, either the criminal court environment should be changed or the trial should be held in these separate courts which are made especially for juveniles. after reforms of child justice law, lack of proper implementation of the act 2013, creates many limitations among key actors in the justice administration. consequently, most of the children are not getting proper services from the dealing authorities. there are not enough resources in cdcs to develop into meaningful service for protecting the rights of a child offender. that's why protecting the rights of offender children is a major challenge in bangladesh 37 . consequently, a large number of children are subjected to physical, verbal, humiliating, and threatening by the concerned agencies. bangladesh journal of bioethics 2020; 11 (1): 35-43 41 the underlying factors influencing offender children include low family income, social insecurity, inadequate awareness and reluctance of the duty bearers, poor institutional capacities for child protection. however, the above situations demand a national code of ethics regarding core values of authorities in child justice system. however, to reduce the detained children the child affairs police desk should be launched in all police stations. when new concepts are fully in place, fewer children cases will need to go to court. in the meantime, these desks have been already set up in some police stations in divisional levels and more are in the process. additionally, independent national child welfare boards should be set up in each district for monitoring the condition of the physical, social, and mental development of the detained children. these institutions all together are able to implement the provisions of alternative care and diversions of the children. however, there are no children rules on how methods of diversions would be practiced in the ground. thus, bangladesh should act proactively to make the necessary children rules in line with international guidelines38. ethical issues of concerned authorities: child justice system comprises the set of laws, policies, regulations, and services needed across all social sectors especially social welfare, education, health, security, and justice to support prevention and response to protection-related risks 39 in this context, ethical guideline is important part to build social relations and growth of society especially in the justice for children 40 . it is obligatory for all dealing authorities to be at least familiar with and preferably conversant with the ethical guidelines. identifying responsibilities in laws is essential to address most of the children rights issues as they directly deal with children and the societies, they live in. it is crucial to protect children's rights, active participation from the individual, family, community and society as a whole along with the processes of law41. often lack of professional ethics of police officers shows their rough attitude when they arrest offender children. most of the children do not receive a child-friendly approach from child development centres. moreover, the session court's environment and the trial procedure are not appropriate for the children dealing. within the children justice system, ethics is relevant to most management and policy decisions relating to punishment. hence, the part of the justice system that addresses the provision of protection of children should include ethics systems. in bangladesh, a set of national standards for the protection of children has been developed to set the framework for the administration of child justice. ethical standards are highly important for the country to provide valuebased treatment of child offenders in all stages of justice. equally, the development of the code of ethics in the legal system is most needed and for that there is no other alternative but raising the knowledge of professional responsibility, legal accountability, and judicial professionals with regard to ethics42. in practice, child justice authorities are facing variety of dilemmas in the course of their career. some will be personal, some will be social, and others will be legal. none of these bangladesh journal of bioethics 2020; 11 (1): 35-43 42 is necessarily an ethical dilemma. a child welfare authority should remember that they are accountable for their actions to the law and court. many of the duties of concerned authorities are imposed either by law or by court order. one should certainly consider that one has a responsibility to follow those duties. however, not everything legal is necessarily ethical 43 . the persons who are working with offender children have a responsibility for providing fair service to the children in their care and protection. they have also some responsibilities towards their immediate colleagues and other professionals with whom they need to collaborate in the interests. in this situation, child justice authorities draw on their knowledge, values, and skills to help children in need and to address social problems. they act honestly and responsibly to promote ethical practices on the part of the organizations with which they are affiliated. code of ethics should spell out why children and meeting their needs are important, strengthening the motivation of childcare workers to carry out their work effectively and reinforcing their professional values, such as respect, care and concern for the children and families with whom they work. therefore, ethics is crucial in decisions concerning discretion, force, and due process, because juvenile justice professionals can be tempted to abuse their powers44. conclusion: children are the most vulnerable who need special care and protection, especially in their justice system. over the years, the justice system of the children has gradually improved in bangladesh but still has a lot to do in this area. while comprehensive laws dealing with issues such as procedures and correctional systems for child offenders are being called by new circumstances. governmental commitment to fulfill protection rights includes social welfare policies, adequate budgets, public acknowledgment and ratification of international instruments. the stakeholders, the court, the family, the detention facilities and programs, and the community are responsible for the adoption of the new change. a sound child justice system fundamentally requires improved social services, specialized assistance, childcentered initiatives and committed personnel with requisite skills, knowledge and values. finally, it is highly important to introduce some alternative measures such as, bail, conditional discharge, suspension of sentence, probation, community service, compensation. modern rehabilitation programs with living guidance can be introduced for the children especially for trauma victims, psychological cases, drug and alcohol addicts to restore the delinquent back to normal living and to develop their personality. it is also important to train up the people associated with the child justice system so that proper implementation of the children act 2013 can be ensured. it is highly important for the country to have complete structured rules and regulations on the basis of international principles to provide valuebased treatment of the destitute children in all stages of justice. in terms of child protection and justice, the policymakers, the executives, the academicians, and the civil society should bangladesh journal of bioethics 2020; 11 (1): 35-43 43 put their all effort for an effective juvenile justice system. references: 1. the un standard minimum rules for the administration of juvenile justice (the beijing rules) 1985; rule 13. 2. the un convention on the rights of the child (uncrc) 1989; article 6. 3. the un rules for the protection of juveniles deprived of their liberty1990; rule 17. 4. the children act 2013 (act no. 26 of 2013). 5. ferdousi, nahid, the establishment of children’s courts in bangladesh: from principle to practice, oxford university commonwealth law journal. 2015; 15 (2): 211. 6. the children act 2013, sec 4. 7. ibid.sec 14. 8. ibid.sec 52(4). 9. ibid. sec 19. 10. ibid., sec 21 (4). 11. ibid. sec 59-69. 12. ibid. sec 63. 13. ibid. sec 5. 14. ibid. sec 6. 15. ibid. sec 84. 16. ibid.sec 8. 17. ibid. sec 9. 18. ibid. sec 33. 19. ibid. sec 48. 20. ali, m imman,the children act 2013: a commentary by justice imman ali. dhaka: penal reform international and bangladesh legal aid and services trust; 2013: 63. 21. the children act 2013, sec 37, 38. 22. ferdousi, nahid, the children act, 2013: a milestone of child protection in bangladesh, the daily star. 24 september 2013: 12. 23. the children act, 2013 has authorized the government to frame rules for attaining the objectives of the act. 24. ibid. sec 86. 25. ibid. sec 93. 26. ibid. sec 7. 27. islam m. r. & sikder, m. a. effectiveness of legal and institutional framework for juvenile justice in bangladesh: a critical analysis,social research reports. 2014(26): 66-81. 28. the children act 2013, sec 13. 29. hoque, m enamul, best interest of the children, academic press and publishers library, dhaka. 2009: 18. 30. the children act 2013, sec 5. 31. ibid. sec 84. 32. ibid. sec 31. 33. borhan uddin khan & muhammad mahbubur rahman, protection of children in conflict with the law in bangladesh, dhaka: save the children uk 2008: 66-67. 34. the children act 2013, sec17 (4). 35. bangladesh government official gazette notifications under the ministry law justice and parliamentary affairs, 24 april 2014. 36. hossain, md. zakir. legal analysis towards justice for children, the daily sun, 17th march, 2020. 37. ferdousi, nahid. the establishment of children’s courts in bangladesh: from principle to practice, oxford university commonwealth law journal, 2015; 15 (2): 197. 38. ibid. 199. 39. ali, m. imman, towards a justice delivery system for children in bangladesh: a guide and case law on children in conflict with the law, unicef bangladesh. 2010: 26. 40. ferdousi, nahid. “the children act, 2013: a milestone of child protection in bangladesh”, the daily star, 24 september; 2013: 12. 41. muncie,john.the united nations children’s rights and juvenile justice, youth justice handbook: theory, policy and practice, cullompton: willan; 2009: 20–21. 42. ferdousi, nahid, legislative action for protection of juvenile offenders in malaysia and bangladesh: an overview, journal of malaysian and comparative law.2014; 41(1): 125 140. 43. miah, md. abdul kader, akter, mahmuda & kamruzzaman md. the effectiveness of restorative justice practice in bangladesh: an analysis, humanities and social sciences. 2017; 5 (5): 176-183. 44. islam, m. rezaul and sikder, md. anwarul islam. effectiveness of legal and institutional framework for juvenile justice in bangladesh: a critical analysis. social research reports. 2014;26: 66-81. author contributions: authorconceived the idea, literature review and wrote the manuscript. she checked the manuscript meticulously. conflict of interests: the authors declare no conflict of interest in this study. bangladesh journal of bioethics 2020; 11 (1): 35-43 35 microsoft word organ donation bangladesh article correction 1 bangladesh journal of bioethics 2021; 12 (1): 1-13 1 religious, cultural and legal barriers to organ donation: the case of bangladesh md shaikh farid, ph.d.1, tahrima binta naim mou2 1. associate professor, department of world religions and culture, dhaka university, dhaka1000, bangladesh, email: sfarid@du.ac.bd 2. adjunct lecturer, sonargaon university (su), and m.phil. researcher, department of world religions and culture, dhaka university, e-mail: tahrima_mou@yahoo.com doi: https://doi.org/10.3329/bioethics.v12i1.50654 abstract: there is a substantial shortage of organs available for transplantation in bangladesh. this has resulted in the commodification of organs. this study analyzes the religious, cultural, and legal barriers to organ donation in bangladesh. it is based on the examination of available literature and primary sources i.e. religious decrees and opinions of religious leaders of faith traditions, and the bangladesh organ donation act, 1999. the literature was retrieved from databases, such as pubmed, biomed, and google scholar using the key words: organ donation in islam, organ donation in bangladesh, organ donation and religions. the study found that although many islamic scholars accept organ donation, both living and cadaveric, under some conditions, some bangladeshi muslim clerics oppose donation. they argue that organ retrieval violates the sanctity of the human body and retrieval of organs may harm a living donor or lead to death, and organ donation may encourage the commercialization of body parts. both commercialization and harming oneself are considered sins. thus, the divergent views of muslim clerics are a major barrier to organ donation among the bangladeshi muslims. cultural and social factors also have a negative impact. most people desire to be buried with their bodies intact. although the bangladesh government promulgated the bangladesh organ donation act, 1999, and amended it in 2018, it restricted donors and recipients to members of the extended family, which also reduced the donor pool. this study argues that the muslim orthodox clerics’ stand against organ donation and other cultural and legal issues are the major obstacles to organ donation in bangladesh. key words: organ donation, organ transplantation, cadaveric donation, islamic bioethics introduction: organ donation is one of the major developments of medical sciences in the 21st century. organ transplantation is a life-saving process for people who are suffering from organ failures. although organ donation and transplantation can be a new hope to dying patients, the attitude and acceptability of organ donation and transplantation vary according to religious, cultural, and legal issues. these diversities in legal, cultural, religious, and traditional concepts regarding organ donation and transplantation restrain its acceptability and create a lack of willingness to organ donation among the people of bangladesh. therefore, comparing to other countries, bangladesh lacks behind in organ donation and transplantation. although organ donation is bangladesh journal of bioethics 2021; 12 (1): 1-13 2 increasing steadily in bangladesh, still this medical practice is stuck in its primary stage of development 1. thus, the question arises what are the reasons behind this situation even after knowing that saving a life is a virtuous act? do people know the importance of organ donation? for what reasons bangladeshi people are not willing to donate organs even to their family members? why is the percentage of organ donation in the country very low? is this because of religions or religious beliefs, cultural issues, educational, social prejudices, mistrust of medical professionals or hospitals? what are the opinions of religious leaders and religious scholars of the country regarding organ donation? how do the medical authority and the government act on this very crucial issue? in this paper, we discussed only religious, cultural, and legal barriers to organ donation in bangladesh. methodology and methods: this study discusses and analyzes the religious, cultural, and legal barriers to organ donation in bangladesh. thus, the article is descriptive and analytical. this article discusses the issue from four major religious perspectives, such as islam, hinduism, buddhism, and christianity in the context of bangladesh. the article is based on examining available literature and primary sources i.e. religious decrees and opinion of religious leaders of faith traditions, and the bangladesh organ donation act (1999). the literature was retrieved from databases, such as pubmed, biomed, and google scholar using the key words: organ donation in islam, organ donation in bangladesh, organ donation in religious scriptures. organ donation scenario in bangladesh and around the world: both living and cadaveric organ donation and transplantation are very common medical practices worldwide. however, in bangladesh, these life-saving medical procedures are not well established yet. even, there are no actual estimates regarding life-threatening diseases and the need for organ transplantation. it is estimated that around 20 million people are suffering from kidney diseases which are about 9 percent of the country's total population, and half a million people are suffering from corneal diseases. more than 35,000 people die because of kidney failure. the yearly need for kidney transplantation is estimated at roughly 5000 2. however, only around 100 people can have kidney transplants with kidneys donated from their relatives 2, 3. in 1982, the first-ever successful kidney transplantation was conducted at bangabandhu sheikh mujib medical university (then institute of postgraduate medicine & research). after that, on a limited scale, regular kidney transplantations have been continued as kidney donation continues to come from living donors, who are believed to be close relatives of kidney recipients 1. the initiative of cornea transplantation began in 1974 and the successful cornea transplantation was conducted in 1984 4. to promote cornea donation challenging false perceptions and fear of donation in the society, a public awareness campaign had been extended over three decades. this has resulted in more cornea donations and transplantations in recent years 2. bangladesh journal of bioethics 2021; 12 (1): 1-13 3 concerning liver disease, one in three bangladeshi suffers from liver disease. compare to kidney transplants, liver transplants are a recent development and are rare. the first-ever successful liver transplantation of the country was conducted in 2010 at birdem hospital 1. although liver transplantation was started in 2010, it happens rarely because of a shortage of donations and a lack of trust of people in medical and transplant procedures. there are ten transplant centers both in the public and private sectors. some private hospitals and charity centers such as kidney foundation and centre for kidney disease and urology hospital, square and evercare hospital conduct transplantation from living donors. however, mainly, in public hospitals, transplantations are performed. these centers mainly implant kidney and cornea, and bone marrow that has been introduced recently 5. this picture shows the capacity of organ donation and transplantation in the country. because of the shortage of organ donation and capacity for organ transplantation, each year thousands of bangladeshis die while waiting for an organ donor and possible transplantation. this is because of an acute imbalance between the number of people waiting for transplantation and the number of organs donated. the unavailability of potential donors makes the situation worse. although the need for organ transplantation is growing over time, the practice of organ donation is not enough in the country. in bangladesh, laws regarding organ donation and transplantation are still confined to close family members 6. although the cadaveric transplantation is permitted in the amended bangladesh organ donation act (1999), the donation and transplantation are limited to living donors only 7. this has resulted also in the commodification of organs 8. compare to bangladesh, organ transplantation has become a normal and familiar strategy for treating organ failure largely in developed countries. in 1984, the united states constituted the national organ transplant act (nota) which forms a legitimate structure for organ transplantation. it assures the organ procurement and transplantation network (optn) as a private, non-benefit organization under government supervision, which keeps up an automated review of potential organ donors and recipients. these organ banks are formed to obtain organs and supply them for transplantation when it is needed 5. in developed countries, such as the uk, a healthy adult citizen can donate organs at his or her consent at any age. in the usa, a healthy person aged between 18-70 years can donate a kidney. in canada, a healthy person can donate a kidney, a lobe of the lungs, and a part of his or her liver if he or she wishes. concerning neighboring countries, such as india a relative donor can donate an organ to the patient whenever it is required. a nonrelative donor can donate organs by informing the state authorization committee at least 24 hours before. in sri lanka, any healthy person can donate an organ to the patient with the consent of the ethical committee of the health ministry 9. in pakistan, if the required organ cannot be collected from the first-degree relative, an organ can be collected from a cadaveric or living non-relative donor with the approval of bangladesh journal of bioethics 2021; 12 (1): 1-13 4 the human organ transplant authority under the observation of the national monitoring authority 10. many muslim countries have formulated and enacted laws and regulations on organ donation from living and cadaveric donors. for example, egypt is the only muslim country where no objection is recorded from islamic scholars regarding organ donation and transplantation 11. in saudi arabia, both living and cadaveric donation are allowed for organ transplantation 12. among the muslim middle east countries, iran has the best model for organ donation and transplantation as there is no prohibition of relative and nonrelative, and living and cadaveric donors 13. moreover, any healthy nonrelative organ donor is rewarded with a special monetary award. that’s why there is no waiting list for kidney transplantation in iran 14. religious issues of organ donation in bangladesh: we discussed the issue from four major religious perspectives, such as islam, hinduism, christianity, and buddhism in the context of bangladesh. organ donation in bangladesh: an islamic perspective: for organ donation and transplantation, religions and religious sentiments play an important role throughout the world including bangladesh 15. no religion formally forbids organ donation and transplantation both from living and cadaveric, except some orthodox jews rabbis, some muslims and christian scholars 16. many muslim countries, such as saudi arabia, malaysia, indonesia, turkey, oman, egypt declared religious decrees (fatwas) permitting organ donations from both living and cadaveric donors 17. these countries have brain death laws and organ transplant acts, and most importantly, in these countries, the concept of brain death and organ donations are supported and approved by islamic scholars and religious leaders of different faith traditions 18. however, some south asia muslim clerics (scholars) and muftis (jurists) oppose organ donation — living and cadaveric — because according to them, the human body is an “amanat” (trusteeship) from allah and it must not be dissected 19. similar to other south asian countries, there are opinions for and against organ donation among the islamic scholars in bangladesh. the cultural and social norms are blended with islamic religious tradition in bangladesh. therefore, it is difficult to make the bangladeshi muslims understand religious issues and any other issues which are not directly discussed in the quran and the sunnah (the traditions of the prophet). the problem arises because, despite many religious decrees (fatwas) from religious scholars around the world supporting organ donation and transplantation, there is a lack of agreement among muslim scholars concerning whether organ donation is compatible with islam 20. the literature on organ donation and transplantation also demonstrates that muslims are more likely than people of other religions to have a negative view on organ donation 19. studies also demonstrate two main concerns: first; muslims are often uncertain whether organ donation is permissible or forbidden in islam, and second; even in cases where muslims believe organ donation is permissible in bangladesh journal of bioethics 2021; 12 (1): 1-13 5 islam, this attitude does not often lead them to organ donation through actions, such as having donor cards 21. those who don’t believe that organ donation is permissible they argue that human beings are not the owner of their bodies rather they are the caretaker only 20. referring to the quran they argue that after being buried, human bodies will decay, but during the process of resurrection, human bodies will be resurrected with all their memories and deeds. human organs and skin will thus bear witness against one’s actions on the day of judgment 22. the qur’an prescribes, “and you did not veil yourselves lest your ears, your eyes, and your skin should bear witness against you, but you thought that allah did not know most of what you did” (qur’an, 41:22). thus, they argue that donation or transplantation of organs is not allowed in islam as it is considered an alteration to allah’s creation 22. it is also stated in the quran that “verily we have honored the children of adam. we carry them on the land and the sea, and have made provision of good things for them, and have preferred them above many of those whom we created with a marked preferment” (qur’an, 17:70). they also argue referring to a statement of prophet muhammad (pbuh), where he stated, “breaking the bone of a dead person is like breaking it alive”. therefore, human bodies should be preserved as much as possible because the sanctity of the human body is very much important in islam 14, 23. thus, muslims must bury dead bodies as soon as possible. moreover, they argue that modern medical facilities, equipment, and treatments are not available to transplant patients in many muslim countries including bangladesh. therefore, they are critics of the western biomedical practices. they believe that the main purpose of the western biomedical practices is nothing but another way of money-making 22. that’s why muslim scholars are against organ donation and transplantation. these divergent views create a dilemma among muslims who wish to donate their organs for transplantation and medical researches. while some scholars deny the importance of organ donation and transplantation, many islamic scholars welcome it wholeheartedly. there are different interpretations by different religious leaders, ‘and ‘ulemas’(scholars), but many of them support living organ donations under the following conditions 24: 1. donation should not cause a major loss to the donor’s health. 2. a person receiving an organ should be beneficial for his/her health. 3. donation should not be for money. scholars argue that if any question is not directly answered in the quran and hadith, muslims should look for an answer in ijma (consensus) and qiyas (analogy). as there is no direct statement regarding organ donation in islam, therefore, muslims should follow secondary and subsidiary sources of islamic shariah. regarding the enhancement of public welfare and the common good bangladesh journal of bioethics 2021; 12 (1): 1-13 6 (maslahah), it is asserted by one of the significant rules of the shariah that despite islam forbidding the violation of the human body, necessity makes prohibited things permissible 18, 24. thus, they argue that organ donation and transplantation are permissible based on the principle of the necessity and welfare of the community or human beings. even, there is evidence that prophet mohammed (pbuh) himself replanted the eye of qatada ibn noman, the arm of muawith ibn afra, and the hand of habib ibn yasaf which were amputated in the battle of ohood 12, 24. regarding blood transfusions, the principle of necessity allows blood transfusions from non-muslims according to the hanafi, shafi, and hanbali schools, while the maliki school allows it if a muslim donor is not available 22. similarly, a verse from the quran can be cited in support of this position. the quran says, “he has explained to you in detail what is forbidden to you, except under compulsion or necessity” (qur’an, 16:89). this implies that ‘necessity overrides prohibition’. in islam, it is argued that one can treat oneself legally without doing any harm to human dignity and honor. that is why every legal treatment and life-saving method is permissible in islam. the concept of altruism is encouraged in islam. to save one’s life or do well to others selflessly is always appreciated in islam 25. in the quran, it is stated that “whosoever saves the life of one person it would be as if he saved the life of all mankind” (quran 5:32). in 1992, during the third international congress of the middle east society on organ transplantation, the grand mufti of the republic of tunisia, shaikh m. m. sellami said, “according to islam a human being is not the owner of a part of his body or the whole body. in any case, organs should not be traded, but donated” and later, he added on, “i am afraid that these drug gangs could use their network overseas to start trading in human organs” 16. maulana abdullah al-maruf, a bangladeshi islamic scholar, referred to the decision of the oic's islamic council which declared that one can donate his or her organs before or after his or her death for the welfare of the mankind. he stated that “a man, however, cannot sell his organs according to islamic principles but he can donate…this is because human organs are highly precious in the eyes of islam and they cannot be regarded as commercially tradable objects” 26. these positive views on organ donation by muslims scholars are not reflected in an actual donation, because many bangladeshi muslims are still reluctant and hesitant to organ donation. therefore, compared to bangladesh with other muslim countries, such as saudi arabia, turkey, iran, lebanon, and kuwait have more organ donation and transplant 27. moreover, the percentage of living kidney and liver donors in bangladesh is less than any other neighboring country. the reasons behind these are nothing but lack of knowledge about organ donation, its process, misinterpretations of religious decrees (fatwas) of islamic scholars by local religious leaders (imams). moreover, this divergent view of islamic scholars regarding organ donation is creating a dilemma among the bangladeshi muslims who wish to donate their organs. bangladesh journal of bioethics 2021; 12 (1): 1-13 7 organ donation in bangladesh: a hindu, buddhist and christian perspectives: hinduism supports organ donation and transplantation. the concept of daan or selfless activities has always been appreciated in hinduism. there are many verses found in hindu scriptures that indirectly support organ donation (18). the bhagavad gita notes, “...it is said that the soul is invisible...knowing this you should not grieve for the body” (chapter 2:25). similarly, the manusmruti says, “of all the things that it is possible to donate, to donate your own body is infinitely more worthwhile”. interestingly, the practice of organ donation is also found in hindu mythology. the xenotransplantation of head and neck on hindu god ganesha, lord shiva's consort, is considered a classic example of organ donation 18. although ganesha's elephanthead may be a mythological figure, still it makes for an intuitive concept, considering the period when shiva purana was inked. moreover, in puranic hindu texts, dating back to 2500-3000 b.c., a vivid description of the reconstruction of mutilated noses using skin homograft is also found 28. therefore, many hindu scholars have publicly supported organ donation for the benefits of other people. organ donation is regarded as an integral part of living 18. in buddhism, the process of death is considered a very important time and is treated with the utmost care and respect 19. however, preserving the physical integrity of a dead body is not considered important in buddhism. according to some buddhist scholars, the concept of brain death is seen to be problematic. in tibetan buddhism, it is believed that spiritual consciousness can stay in the body even after one’s death. the departure of this spiritual consciousness is regarded as the actual moment of one’s death and till then the body must be kept undisturbed. as buddhism believes in rebirth, therefore, if any disturbance occurred to the dead body, the next rebirth can face adverse effects 19, 29. however, this concept creates conflicts with the concept of generosity (daana) or selfless giving which is one of the core beliefs in buddhism. thus, in this dilemma, buddhist scholars have different opinions on organ donation. some scholars entirely oppose cadaveric donation while others leave it to individual choices 18. in other words, in buddhism, the donation is viewed as a matter of individual choices 30. those who support organ donation consider it a valuable opportunity of generosity on several levels. first, to donate one’s body or body parts for research or organ transplantation is a unique way to detachment to one’s own body. second, to give priority to another person’s welfare above one’s interest is an excellent expression of the bodhisattva ethics of compassion or love. third, to donate one’s organs with an intention to benefit others will bring huge benefits in future lives, enabling one to obtain a blessed rebirth and future opportunities for dharma practice; if donations are dedicated to the enlightenment of all living beings, the merits are immeasurable 31. christianity generally supports organ donation and transplantation. most anglican, bangladesh journal of bioethics 2021; 12 (1): 1-13 8 catholic, and protestant scholars find organ donation as an act of selflessness, thus, they approve organ donation and transplantation 29. in the new testament, several instances of homologous transplantation are found that go back to the 1st century a.d.. for example, jesus christ restored a servant's ear which was severed by simon peter's sword in a battle. besides, it is also mentioned in the new testament that tortured and mutilated saint agatha’s breast had been implanted again by saint peter, and saint mark had fixed a soldier’s battle-amputated hand 28. pope john paul ii also supports organ donation publicly 18. former pope benedict xvi always carried his donor card. regarding organ donation, pope benedict xvi viewed that an organ donation is an act of compassion that is morally permissible if it is free and voluntary. he also said that organ transplantation is ethically acceptable with the consent of the donor and without undue risk of the donor. for cadaveric donation, the death of the donor must be fully confirmed 16. he noted: i offer my organs to help whoever is in need; it is simply an act of love. but, above all, it means i repeat to carry out an act of love toward someone in need, toward a brother in difficulty. it is a free act of love, of availability, that every person of goodwill can do at any time and for any brother. that is all. in my capacity, i do not allow myself to judge the law of any state. i do not judge laws. i only say that to give one’s organs spontaneously for transplants, in full awareness and full knowledge means to give expression to a true, deep act of love for one’s neighbor. 16 organ donation in bangladesh: social and cultural barriers: the shortage of organs for transplantation makes it important to understand why some people are reluctant to donate their organs. there are many causes why certain groups are less likely to give consent to organ donation. among these causes, both social and cultural issues play an important role, especially in developing and least developed countries, such as bangladesh 32. there are some social obstacles and prejudices among the bangladeshi regarding organ donation, which hamper organ donation. firstly, most bangladeshi desire to be buried with their bodies intact, thus they are not willing to donate organs posthumously. this belief is partly associated with religious conviction as they believe that their bodies belong to allah, therefore, they cannot support to dissect human bodies 3. secondly, most people fear that they may die during surgeries or after surgeries if they go under surgery for organ retrieval for donation as they lack knowledge on the process of organ donation 3. thirdly, fear of mutilation is another misconception concerning organ donation as they believe that if a person wants to donate an organ, other organs might also be taken. this misconception can be corrected by informing donors or relatives of cadaveric donors that only organs identified for donation will be retrieved from donors 29. fourth, family pressure plays a negative impact on the donation, particularly on its bangladesh journal of bioethics 2021; 12 (1): 1-13 9 earning members. in most cases, families do not allow an earning member of a family for donations because they are afraid that the person might not be able to earn livelihood if he or she donates an organ 33. also, married women are always discouraged by in-law’s families to donate organs to members of their paternal families. fifth, they fear that organs will be sold or used by rich people if they donate organs. studies claim that the system of organ allocation to waiting list patients is not fair all the time. wealthy patients are moved up the waiting list faster than poor patients during the transplantation of organs 34. sixth, organ trafficking is another fear that forbids people from organ donation as it includes unethical doctors, medical staff, and the rich people of bangladesh. seventh, commercial dealings with organs are also a major barrier to organ donation 8. eighth, people’s mistrust of hospitals and health care professionals play also a negative role in donation especially when it comes to overseeing sick patients in hospitals, and declaring brain death in bangladesh. ninth, the cost of the transplantation process and medicines is so high therefore poor people cannot afford it. as the whole process is very costly, that is why most of the families avoid organ transplantation in the country. lastly, there is also a scarcity of transplantation centers with minimal cost and modern facilities in bangladesh, which is another major barrier to organ donation 1. the problem of biopiracy, a form of bioviolence where developed countries collect cells or tissues illegally from the marginalized populations or developing countries without any consent or fair compensation or agreement, is another major barrier to organ donation. these illegal acts are done for many scientific research studies, such as aids, polio, cancer, gene mapping and so on, and bangladesh is a good market place in this regard 8. these social and cultural barriers and prejudices and the shortage of modern transplant technologies are causing damage to this life-saving procedure in bangladesh. therefore, the percentage of living organ donation, and cadaveric donation, which is yet to start in bangladesh, is very low compare to many other muslim countries and its neighboring countries. organ donation in bangladesh: legal issues: bangladesh organ donation act, the first laws on organ donation and transplantation, was passed in 1999 where the government of bangladesh ensured legal procedures for the collection, preservation, and legal use of human organs and transplantation. although this act allows two types of donors, living and cadaveric, the cadaveric donation was not in practice in all these years. besides, the donor lists in 1999’s act were confined only to legal successors, such as husband, wife, father, mother, sister, brother, adult son, daughter and blood-related uncle, aunt as prospective donors 7, 35. however, in 2018, the amendment of this act allowed grandparents, grandchildren, and first cousins as potential donors. in this amendment, a national cadaveric panel is proposed to be established to monitor the transplantation process along with providing facilities to doctors for the transplantation process. if any accusation is found regarding bangladesh journal of bioethics 2021; 12 (1): 1-13 10 organ donors and recipients, then the individual will be punished with two years of detainment or a taka of 5 lakh fine or both. if any specialist is found to be involved with the damage of the law his or her enlistment will be dismissed from the bangladesh medical and dental council. again, if any institution is found denying the law, its registration of the transplantation center will be canceled by the authority and will be fined 7. this amendment is truly welcomed and also is praised by the medical authority of bangladesh 5. however, the act of 1999 is amended in 2018, its scope is still limited. the age limit is decided from 65-70 years both for donors and recipients, although the average life expectancy in bangladesh is higher than this age limit 5. although the volunteer donors are allowed for kidney transplantation, for other transplantations, the donor list is still restricted within a family and close relatives 7. therefore, in 2019, the high court of bangladesh gave a verdict regarding this issue where volunteer donors, who are not relatives to patients, are permitted to organ donation. the verdict was announced by the high court of bangladesh when a petition is filed regarding kidney transplantation where it clearly said not only the proposed 28 members from the patient’s family but also voluntary donors, non-relatives of patients, can also donate his or her kidney willingly for transplantation. it also added that a thorough check-up of both the physical and mental health of the volunteer is required before donation. regarding the verdict, the petitioner’s counsel, barrister rashna imam said that sometimes family members do not want to be a donor and sometimes they unmatched with the patient and in that situation, a volunteer donor is a must for saving one’s life, under a monitoring process 36. however, for cornea, skin, tissue, and bone marrow donation close relatives are not required. the law allows the donation and retrieval of major transplantable organs. the infrastructure of the icu, brain death committee, transplant coordinator, and the national committee for cadaveric organ transplantation are well defined in the law. however, there is no central monetary transaction rules and no clear guidelines on organ allocation system according to the law. voluntary donation during one’s lifetime (opt-in) has also not been discussed in the law. organ procurement organization and audit system for transplantation are not mentioned. moreover, there is no system for compulsory referral of all possible cases of brain death in hospitals 7. besides, it is needed to introduce presumed consent which has been effective in many countries including some muslim countries 5. as the act is still very restrictive, therefore, when close relatives are not found for donation, the rich people buy organs from the poor donors introducing them as close relatives. and most of them often go to the neighboring countries for treatments and transplantations which are also a financial loss to the economy of bangladesh 8. in an interview regarding the issue, gonoshasthaya kendra trustee, dr. zafrullah chowdhury, bangladesh journal of bioethics 2021; 12 (1): 1-13 11 said that in iran and canada, only regulatory bodies decide whether donors should donate organs to a patient or not. he also added that rich people were getting kidney transplanted in india, sri lanka, singapore, and the us; thus, the bangladesh government is losing foreign currencies worth of taka 8,000 crore every year 37. therefore, it is recommended that the government of bangladesh should allow voluntary donation so that organ trafficking and organ commercialization can be restricted. however, it is argued that allowing nonrelative donors into the donor pool may cause more harm than benefits and it would be an unethical practice while more than 20% of people still live below the poverty line. allowing unrelated donors to organ donation in bangladesh will coerce the poor people into selling their organs to rich patients 6. however, the illegal commercialization of body parts is being practiced around the world, therefore the government must stop the commodification of organs by enforcing laws and introducing stern punishments 38. organ donation in bangladesh: a way forward: although bangladesh has experienced significant improvement in cornea donation, the donation of other organs is still lacking. the following measures might be taken to increase organ donation and transplantation: 1. there should be a comprehensive awareness program regarding the importance of organ donation. the government, non-government organizations, media, public representations, religious scholars, doctors, nurses, all stakeholders should work together to make the awareness campaign a success. 2. a ‘national coordination committee’ should be introduced by the government comprising all concerned stakeholders to monitor organ donation and transplantation. 3. enactment of law against illegal organ trafficking. 4. transplant facilities should also be prioritized in government hospitals so that poor people can get the benefit of organ donation. 5. manpower training, subsidy for the organ donors for ensuring postoperative care and needy recipients for transplantation, establishing a central organ registration system, introducing a “donor card” could be introduced. 6. an organized training program is needed to prepare manpower for organ retrieval and transplantation. 7. there should be a scope of organ donation by all healthy relatives or nonrelatives like those in developed countries. the age limit for healthy donors and sick recipients should be raised to a standard level. 8. all organ donors should be given fixed compensation and proper treatment and other facilities on a priority basis if necessary. 9. physicians involved in organ donation and transplantation should be safeguarded, and if any physician does not make medical negligence in bangladesh journal of bioethics 2021; 12 (1): 1-13 12 transplantation procedure should be not discharged. 10. there should be required doctors, nurses, and technical supports for the smooth functioning of organ transplantation. conclusion: organ donation and transplantation are major parameters to the development of the health care system of a nation. most nations are making progress in practices of organ donation and transplantation and are offering hope of new lives and survival benefits to their people. as bangladesh cannot afford to lag in organ donation and transplantation, all the concern stakeholders, particularly the government, physicians, community, and religious leaders should take organ donation and transplant positively, and treat religious, cultural, and legal issues from positive perspectives for a life-saving opportunity and the betterment of human beings. moreover, it is not people who do not want to donate their organs but lack of mechanisms to facilitate donation are major barriers to organ donation in bangladesh. therefore, the practice of organ donation in bangladesh should be increased under proper guidelines and surveillance as soon as possible. references 1. ali m. organ transplantation in bangladeshchallenges and opportunities. ibrahim medical college journal. 2012;6(1):i-ii. 2. rahman m, mahmood s. status of organ donation and transplantation in bangladesh. transplantation. 2017;101:s30. 3. billah mm, farzana h, latif a, mitra p, chowdhury ta, rahim ma, et al. knowledge and attitude of bangladeshi physicians towards organ donation and transplantation. bangladesh critical care journal. 2016;4(1):23-7. 4. haider s. the quest for corneas. star weekend magazine, . 2007. 5. sardar nn. the analysis of the perceptions of health professionals toward organ donation and transplantation in bangladesh. 2018. 6. siraj ms. why is family-oriented organ transplantation policy and practice necessary for bangladesh? bangladesh journal of bioethics. 2020;11(1):1-9. 7. bangladesh organ donation act. in: law mo, editor. dhaka: the government of bangladesh; 1999. 8. moniruzzaman m. “living cadavers” in bangladesh: bioviolence in the human organ bazaar. medical anthropology quarterly. 2012;26(1):69-91. 9. chowdhury z, karim t. limitations and remedies amended the human organ transplantation act. dhaka: bangladesh. . the business standard. 2019. 10. moazam f, jafarey a. pakistan's experience with kidney transplantation and trade: a call for international solidarity. indian journal of medical ethics. 2014;11(3):156-62. 11. budiani d. facilitating organ transplants in egypt: an analysis of doctors' discourse. body & society. 2007;13(3):125-49. 12. albar m. organ transplantation: a sunni islamic perspective. saudi journal of kidney diseases and transplantation. 2012;23(4):817. 13. ghotbi n. the ethics of organ transplantation in the islamic republic of iran. eubios journal of asian and international bioethics. 2013;23:190. 14. alkhawari fs, stimson gv, warrens an. attitudes toward transplantation in uk muslim indo‐asians in west london. american journal of transplantation. 2005;5(6):1326-31. 15. daar as. ethics of xenotransplantation: animal issues, consent, and likely transformation of transplant ethics. world journal of surgery. 1997;21(9):975-82. bangladesh journal of bioethics 2021; 12 (1): 1-13 13 16. bruzzone p, editor religious aspects of organ transplantation. transplantation proceedings; 2008: elsevier. 17. ghods aj. current status of organ transplant in islamic countries. exp clin transplant. 2015;13(1):13-7. 18. oliver m, woywodt a, ahmed a, saif i. organ donation, transplantation and religion. oxford university press; 2011. 19. lo c-m. deceased donation in asia: challenges and opportunities. liver transplantation: official publication of the american association for the study of liver diseases and the international liver transplantation society. 2012;18:s5-7. 20. sharif a. organ donation and islam— challenges and opportunities. transplantation. 2012;94(5):442-6. 21. rasheed sa, padela ai. the interplay between religious leaders and organ donation among muslims. zygon®. 2013;48(3):63554. 22. siraj ms. organ donation for transplantation in bangladesh: policy, practice and ethics: city university of hong kong; 2016. 23. mousavi sr. ethical considerations related to organ transplantation and islamic law. international journal of surgery. 2006;4(2):91-3. 24. albar m. islamic ethics of organ transplantation and brain death. saudi journal of kidney diseases and transplantation. 1996;7(2):109. 25. ebrahim afm. organ transplantation: contemporary sunni muslim legal and ethical perspectives. bioethics. 1995;9(3):291-302. 26. transplant of kidney from brain-dead to begin soon. the daily star. 2019. 27. shaheen f, souqiyyeh m, editors. increasing organ donation rates from muslim donors: lessons from a successful model. transplantation proceedings; 2004: elsevier. 28. chawla as, chandra r, agarwal y. tissue and organ transplantation: myths, miracles, and triumphs. astrocyte. 2014;1(2):144. 29. robson nzmh, razack ah, dublin n. organ transplants: ethical, social, and religious issues in a multicultural society. asia pacific journal of public health. 2010;22(3):271-8. 30. keown d. buddhism, brain death, and organ transplantation. journal of buddhist ethics. 2010;17:1-34. 31. tsomo kl. into the jaws of yama, lord of death: buddhism, bioethics, and death: suny press; 2012. 32. jafarey a, nagral s. towards deceased organ donation in asia: negotiating the challenges. indian j med ethics. 2014;11:137-8. 33. irving mj, tong a, jan s, cass a, rose j, chadban s, et al. factors that influence the decision to be an organ donor: a systematic review of the qualitative literature. nephrology dialysis transplantation. 2012;27(6):2526-33. 34. d'alessandro a, peltier j, dahl a. the impact of social, cognitive and attitudinal dimensions on college students' support for organ donation. american journal of transplantation. 2012;12(1):152-61. 35. rahman k, osman m, mahmud s, rahman m. the legal guideline for organ transplantation and therapeutic tissue removal. journal of dhaka medical college. 2009;18(2):174-7. 36. rahman m. kidney donation outside close relatives for emotional reason valid. dhaka tribune. 2019. 37. hc allows organ donation also to known people. new age. 2019. 38. board s. ethical incentives—not payment— for organ donation. n engl j med. 2002;346(25). author contributions: the 1st author conceived the idea and wrote the manuscript and checked the manuscript meticulously. the 2nd author did the literature review, wrote a part of the manuscript. conflict of interests: the authors declare that there is no conflict of interest in this study. microsoft word why is family-oriented organ transplantation policy and practice necessary for bangladesh bangladesh journal of bioethics 2020; 11 (1): 1-8 1 why is family-oriented organ transplantation policy and practice necessary for bangladesh? md. sanwar siraj, ph.d. assistant professor, department of government and politics, jahangirnagar university, savar, dhaka-1342, bangladesh, email: siraj_sanwar@juniv.edu doi: https://doi.org/10.3329/bioethics.v11i1.49191 abstract : in the west, in countries such as the us and uk, people are equally encouraged to donate organs both to their relatives and nonrelatives. in practice, although family is the priority in the us and uk, anybody can donate organs to anyone else lawfully. contrastingly, in bangladesh, people are only legally allowed to donate organs for transplantation to close relatives. bangladesh’s living organ transplantation policy and practice is in stark contrast with the western secular biomedical perspective. in this artcile, i address that the notion of individual freedom and liberty in regard to the donation of organs for transplantation in the west is consistent with secular culture and biomedical perspectives, but such biomedical policy and practice is at odds with the bangladeshi muslim culture, socio-economic reality and biomedical perspective. as bangladesh is a family-oriented collective society, the kinship relation and strong familial bonds may encourage relatives into donating organs to a patient. more than 20% of people still live below the poverty line, and the covid-19 pandemic has pushed poor people into extreme poverty. the practice of allowing unrelated altruistic donors as is done in the west and iran, or even in the special circumstance in paksitan, the act of donating organs will comprehensievly increase organ trade in bangladesh, which in turn will cause more harms than benefits. this study conludes that the government should uphold family-oriented biomedical policy and practice in bangladesh until poverty is eliminated. it implies that patients who do not have close relatives, or whose poetntial relative donors are medically unsuitable for transplantations should wait for deceased organs for transplantation. key words: family, organ transplantation, policy, bangladesh introduction: the first sucecssul organ transplantation between close relatives was performed in bangladesh in 1982, and the practice became more regular from 19881. untill the legislation of 1999, there was no legal provision in relation to organ donation for transplantation in bangladesh. the human organ transplantation act (hota) was first approved in 1999. the act allowed organ donations from both living donors and brain dead donors for transplantation. for living donations, a number of close family relatives were lawfully allowed to donate organs for transplantation. the act was then revised in 2018 that added a number of extended family relatives as potential donors to the existing donor list. the revised act upholds the family-oriented nature of biomedical policy. despite the transplantation of corneas from brain dead donors having commenced in bangladesh, the transplantation of vital organs (e.g., kidney, liver, heart and pancreas etc.) has not yet been introduced2. the government of bangladesh recently attempted to initiate a program of transplantation of vital organs from brain dead donors. conversely, in the west, in countries such as the us and uk, people are equally encouraged to donate organs both to their bangladesh journal of bioethics 2020; 11 (1): 1-8 2 relatives and non-relatives2,4. in practice, although family is the priority in the us and uk anyone can lawfully donate organs to anyone else. unrelated altruistic donors are legally allowed to donate organs in the islamic republic of iran if a patient is unable to find a potential donor from inside their own family, and also donation from the deceased is permitted 58. in the islamic republic of pakistan, if a related donor is not avilable, or if such potential donors are incompatible with the patient, an unrelated donor can donate organs on the condition that the evaluation committee (ec) is satisfied that such a doantion is “coercion-free” and “voluntary”9. a small group of libertarian bangldaeshis recently put pressure on the governement of bangladesh so as to extend the biomedical policy and practice beyond just relatives as is done in the west, arguing on the grounds of individual liberty and freedom that public policy does not prohibit someone from donating organs. some even urge to the government to extend biomedical policy and practice, likley as using the model of iranian practice. some threfore urge the governement to allow unrelated altruistric donations conditionally in special circumstances as in pakistan. they view that extending bioemdical policy and practice to beyond relatives in bangladesh will save the lives of many patients, and will cause greater benefits than harms. i contend that the government should uphold the family-oriented character of bioemdical policy and practice of living organ donation for transplantation in bangladesh until poverty is eliminated. the practice of allowing unrelated altruistic donors to donate organs lawfully will force poor people into selling their organs to alleviate poverty. stipulations of the policy and practice of living organ donation for transplantation in bangladesh: the human organ transplantation act (hota) was first passed by the bangladesh parliament in 1999, allowing both brain dead donors, and living related donor transplantations. according to the 1999 act, the first degree blood relatives such as the father and mother, adult sons and daughers, adult sisters and brothers, and second-degree relatives by blood are the uncles and aunts both from paternal and maternal sides, and emotional relatives such as husbands and wives are the only people who can legally donate organs for transplantation (section 1: 4). the existing act that was revised in january 8, 2018 and came into force officially on january 28, adds a number of extended family relatives to the existing donor list. the act redefines the term ‘close relatives’ and adds a number of third-degree blood relatives, namely grandparents, grandchildren and first cousins (section 1: 4). apart from these family relatives, unrelated donors are not legally allowed to donate organs for transplantation in bangladesh. the stipulation of the new act also adds that anybody can donate skin, tissues, bone marrow and corneas to anyone else (section 3:1), but that vital organs (e.g., kdiney, liver, and pancreas etc.) are to be donated only among these relatives listed in the act. the act does not allow the selling of organs or receiving of financial benefits for donating organs. it also completely prohibits advertisements for the purpose of selling organs (section 9). thus the policy and practice of living organ transplantation in bangladesh has bangladesh journal of bioethics 2020; 11 (1): 1-8 3 remained family-oriented because unrelated altruistic donors are not lawfully allowed to donate organs for transplantation. stipulations of the policy and practice of living organ donation for transplantation in the west: in the us and uk, people are equally encouraged to donate organs both to their relatives and non-relatives3,4. in practice, depite family members being the priority in the us and uk, anyone can lawfully donate organs to anyone else. in the uk, for example, a living donations can be classified consequently as a directed altruistic donation, non-directed altruistic donation, paired/pooled donation or non-directed altruistic donor chain donations. the first category of donation, directed altruistic donation, is where an individual can donate an organ to a family member, partner or good friend. donating organs to someone with whom donors have no genetic or pre-existing emotional relationship with is called a non-directed altruistic donation. if a donor is not medically suitable for someone whom they wish to donate to, they may join a joint scheme and be matched with another donor recipient pair in the same situation, so that more than two people in need of a transplant are able to exchange compatible organs. in the final category, the nondirected altruistic donor can donate their organ into a paired/pooled scheme. by matching two or more potential donors and recipients, a chain of operations can be carried out. at the end of the chain, the remaining organ is then donated to the best-matched patient on the basis of a national waiting list3. i contend that as bangladesh is a family-oriented collective society1, introducing the uk biomedical policy and practice of living organ transplantation into a non-western country is culturally and socio-economically at odds, and such policy and practice would encourage poor bangladeshis to sell their organs to to non-blood relatives to alleviate poverty. why is western living organ transplantation policy and practice inappropriate with bangladeshi indigenous culture, socio-economic situation and biomedical perspectives? as mentioned earlier, people in the west such as the us or uk are equally encouraged to donate organs both to their relatives and nonrelatives. in practice, although family is the priority in the us or uk anyone can lawfully donate organs to anyone else. this article argues that westerners are free, autonomous, independent and rational individuals and this gives individuals the right to make their own decisions regarding organ donation for transplantation. western secular values stipulate that humans should be treated equally, that individual autonomy should be the basis of all national activities, and that biomedical laws and practices should be guided by the western emphasis on individual autonomy, equality and freedom of choices10. westerners hold the view that as long as people abstain from doing harm, they should be permitted to donate to anyone they choose. as westerners also believe that organ donation is an altruistic activity as a gift of life, so, these charitable and altruistic activities should not be limited to relatives only. conversely, i contend that traditional family bonds and relations in the west are not strong enough, but have become broken and strained 11, secularminded, freely-motivated western people bangladesh journal of bioethics 2020; 11 (1): 1-8 4 are not obliged to only donate to family members. thus, modern secular biomedical policies and practices allow anybody in the west to donate freely to anyone they wish. i argue that the bangladesh governemnt ought not to establish the western approach of individual freedom, equality and free choice in biomedical policy that legalises donations to both family members and unrelated patients. despite the difference of the survival rate between unrelated and related donor-recipient pairs not being statistically significant, i contend that western individual free choice is inappropriate for a non-western country whose cultural ties are strongly connected with the community such as the family. the application of such secular western values to biomedical decisions are contrary to the islamic emphasis on religious dignity and the muslim tradition of collective decision-making12, which prioritizes non-individualist values. establishment of the western biomedical approach in the muslim society of bangladesh would thereby cause enormous societal, economic and familial problems. if the government established western secular biomedical policy in bangladesh, it may encourage donors to donate both to families and unrelated patients, and as such will increase the organ trade in bangladesh. in the name of altruistic motivation, poor bangladeshis may easily sell their organs to alleviate their poverty. i argue that if bangladesh’s governemnt endorses western biomedical policy, such as that of the uk, it will cause more organ business in bangladesh. i argue that extending biomedical policy beyond family relatives would make bangladeshi families more vulnerable and perilous. in the name of respecting individual freedoms, as in western cultures, or saving the lives of vulnerable patients, the extension of biomedical policy to unrelated donors would place poor bangladeshis into markets as daily commodities. organ selling is an immoral practice 13-22, because potential donors and recipients involve bargaining position for organs what sellers and buyers do in markets for a commodity exchange1. these immoral practices should not be allowed in bangladesh. despite individuals being seen as possessing the human right to donate organs to anyone else altruistically, i argue that allowing unrelated altruistic donors to donate organs legally on the grounds of individual rights, social justice or equity would be unrealistic and unjustified for bangladeshis. as bangladesh is a familyoriented collective society and almost all bangladeshis are born, raised and live in the familial structure, the kinship relation and familial bond may encourage bangladeshis to donate organs to their ill patients1. as the government has already extended the donor list to include thirddegree blood relatives, bangladeshi patients may find potential donors from inside their own families. allowing a western-style free donation system may create social burdens for bangladeshis. allowing unrelated donors to donate organs legally will compromise the strengh and integrity of the family. if unrelated patients are lawfully allowed to receive organs, rich patients will easily buy organs from the poor, and bangladeshi families may no longer be able to find donors inside their own familiess in their time of bangladesh journal of bioethics 2020; 11 (1): 1-8 5 need1. almighty surely has defined limits for the use of the body. scholars permit muslims to donate organs to their relatives even though it may risk one’s life to save another, this belief prohibits muslims from donating organs to unrelated patients 13,14 also, saving the life of a relative by donating organs is more valued in islam as the qur’an states “and give to the near of kin his due and [to] the needy and the wayfarer, and do not squander wastefully” (qur’an, 17:26). some argue that how could bangladeshi practice save the life of an orphan who does not have any relatives? the view that as organ donation for transplantation is a charitable and humanitarian activity, the public policy does not and can not prohibit individuals from donating their organs to anyone else, because the aim of public policy is to ensure benefits rather than harms for all members in the society. i contend that as these cases are very few, allowing unrelated altruistic donors to donate organs legally in order to save the lives of a few orphans may create many social problems in bangladesh that would outweigh the total benefits. allowing unrelated donors to donate organs to save the lives of orphans may encourage poor people to sell organs. if orphans do not have relatives, they should wait for deceased donation for transplantation. as the government is recently trying to establish transplantation of vital organs (e.g., kidney, liver, heart, and pancreas etc.) from brain dead donors, the successful immediately introduction of a program allowing deceased organ donation for transplantation would be a good solution for saving the lives of orphans and other patients. otherwise, permitting unrelated donors to save the lives of few orphans may severely increase organ trade in bangladesh, causing more harm than good. stipulations of the policy and practice of living organ donation for transplantation in iran and paksitan: some refer to the policy and practice of living organ transplantation in the perspective of iran where unrelated donors can donate organs for transplantation. let me berifly discuss the policy of living organ transplantation in iran. once a patient is identified, medical professsionals search for a medically-suitable living related donor for transplantation. in doing so, physicians advise the patient to find a potential donor within their family 23. if a patient does not have any related potential donors, or a potential relative donor is not willing to donate, then the recipient is referred to the dialysis and transplant patients association (datpa) to find an organ from a deceased donor (dd), waiting in the queue for a maximum of six months 8. if the patient does not find an organ from a dds the datpa searches for suitable organs from living unrelated donors (lud)8. luds receive a fixed amount of compensation (10 million iranian rials), one year post-operative medical insurance, medicines at subsidized costs, and waived hospital fees from the government or charities after transplantation7. luds also receive extra financial compensation from recipients for their donation7. if such unrelated donation is adopted in bangladesh, the poor will easily sell their organs to rich patients to get out poverty, in line with what happens in iran 24,25. this biomedical policy and practice should not be introduced in bangladesh, as the harm it causes will outweigh benefits. bangladesh journal of bioethics 2020; 11 (1): 1-8 6 some even refer to the biomedical perspective of paksitan where unrelated altruistic donors are conditionally allowed to donate organs for transplantation in special circumstances. let me briefly discuss the stipulations of the policy and practice of living organ donation for transplantation in pakistan. an unrelated altruistic donor is allowed to donate organs only in the situation when close relative donors such as parents, adult progeny, adult siblings, and spouses are not available and/or such potential relative donors are medically unsuitable for transplantation. in the case of unavailability of such close relatives, the law prescribes that the ec may permit donation by unrelated donors only after satisfying the ec that such a donation is fully “voluntary” and “coercion-free” 9. some bangladeshis argue that if pakistan, being a south asian muslim society, can allow unrelated altruistic donors to donate organs for transplantation in special conditional circumstances, the bangladesh governemnt should also allow the same practice. i contend that bangladesh’s biomedical policy already allows a wider number of relatives (e.g., parents, adults progeny, adult siblings, spouses, paternal and maternal uncles and aunts, grandparents and grandchildren, and first cousins) to donate organs for transplantation, while in pakistan the number of potential donors is fewer (i.e., parents, adult sons and daughters, sisters and brothers, and spouses). bangladeshi patients are thus more likely to find a potential donor from inside their family. to cite the view of moniruzzaman (2010); extending biomedical policy to beyond relatives is a concession of a few rich patients who might want to avoid harming the body of their own relatives, and instead try to obtain an organ donation from a poor person2. despite the bangladesh governemnt having extended its biomedical policy to third-degree blood relatives, i agree with the view of moniruzzaman (2010) that it is the corrupt intention of a few rich patients to buy an organ from a poor person instead of obtaining it from their relative 2. as more than 20% of people still live below the poverty line26, and the covid-19 pandemic pushes poor people into extreme poverty and makes others economically vulnerable (27), allowing unrelated donors to donate organs even in special cases will severely increase the organ selling problem in the country. in the name of altruistic donations, poor people will easily sell their organs to rich patients to get away from poverty, thereby outweighing possible benefits. in addition to the poor socio-economic conditions of people in bangladesh, i also argue that allowing unrelated donors to donate organs lawfully will severely increase organ trading in bangladesh, where there is no effective accountability mechanism, and corruption has been a burden for many years 28. for instance, in 2012, ti ranked bangladesh as the thirteenth most-corrupted country in the world29. in 2015, the national household survey on corruption in the service sectors of bangladesh estimates the cost of bribery in regard to unauthorised and informal payments annually to be 8,822 crore bdt, which equals 0.6% of the gross domestic product (gdp)30. in this reality, allowing unrelated donors to donate organs lawfully will comprehenssively increase the organ trade in bangladesh, which may negatively bangladesh journal of bioethics 2020; 11 (1): 1-8 7 affect the health of larger sections of the population. the vested interest groups such as rich patients and brokers will be the only beneficiaries of such an extension to bioemdical policy and parctice. concluding remark: the policy and parctice of living organ donation for transplantation in bangladesh should be family-oriented until poverty is eliminated. otherwise, allowing unrelated donors to donate organs to anyone else or in special circumstances will encourage poor bangladeshis to sell their organs to get away from poverty. the successful implementation of a program for deceased organ donation for trasnplantation may save the lives of many patients, especially those whose who do not have potential relative donors avilable, or if they do, are medically incompatible with their relatives. bangladeshi policy makers, health professionals, legal experts, transplant communities and bioethicists should consider this with the utmost attention. acknowledgments and funding information:i deeply acknowledge the suggestions that i received from my ph.d. supervisor, professor ruiping fan. i am also thankful to dr. rebecca dewey, university of nottingham for providing me with meticulous editing work on the manuscript. a part of this study was supported by the research activities fund (grant number: 000669), university grants committee (ugc) of hong kong. references: 1. siraj ms. organ donation for transplantation in bangladesh: policy, practice and ethics. phd thesis: city university of hong kong, hksar; 2016. 2. moniruzzaman md. “living cadavers” in bangladesh: ethics of human organ bazar. phd thesis, university of toronto, canada; 2010. 3. human tissue authority. types of living organ donation [internet]. human tissue authority. 2018 [cited 2020 aug 27]. available from: https://www.hta.gov.uk/guidan ce-public/living-organ-donation/types-living-organdonation.accessed on 1 april 2019 4. nathan hm, conrad sl, held pj, mccullough kp, pietroski re, siminoff la, et al. organ donation in the united states. am j transplant. 2003 apr;3(s4):29–40. 5. ghods aj. the history of organ donation and transplantation in iran. exp clin transplant. 2014;12(suppl. 1):38–41. 6. ghotbi n. the ethics of organ transplantation in the islamic republic of iran. eubios j asian int bioeth. 2013;23(november):190–3. 7. mahdavi-mazdeh m. the iranian model of living renal transplantation. kidney int. 2012;82(6):625–6. 8. hammond s. how iran solved its kidney shortage, and we can too. washington, d.c.; 2018. [cited 2020 aug 26]. available from https://www.niskanencenter.org /how-iran-solved-its-kidney-shortage-and-we-cantoo/ accessed on 1 february 2019 9. the transplantation of human organs and tissues act of pakistan. pakistan; 2010. [cited 2020 aug 26]. available from http://punjablaws.gov.pk/laws/2428 a.html. 10. childress jf, beauchamp tl. principles of biomedical ethics. 7th ed. new york: oxford university press; 2009. 1–455 p. 11. cherry mj. individually directed informed consent and the decline of the family in the west. in: fan r, editor. family-oriented infromed consent: east asian and american perspectives. springer, dordrecht; 2015. p. 43–62. 12. siraj ms. beyond western conservatives and progressive liberals: a moderate islamic view. int j chin comp philos med. 2014;12(2):16, 135–9. 13. moazam f. bioethics & organ transplantation in a muslim society: a study in culture, ethnography and religion. usa: indiana university press; 2006. 1–264 p. 14. moazam f. sharia law and organ transplantation: through the lens of muslim jurists. asian bioeth rev. 2011;3:316–32. bangladesh journal of bioethics 2020; 11 (1): 1-8 8 15. ismail sy, massey ek, luchtenburg ae, claassens l, zuidema wc, busschbach jj v, et al. religious attitudes towards living kidney donation among dutch renal patients. med health care philos. 2012;15(2):221–7. 16. rizvi ahs, naqvi asa, zafar nm, ahmed e. regulated compensated donation in pakistan and iran. curr opin organ transplant. 2009;14(2):124–8. 17. naqvi saa, ali b, mazhar f, zafar mn, rizvi sah. a socioeconomic survey of kidney vendors in pakistan. transpl int. 2007;20(11):934– 9. 18. alkhawari fs, stimson g v., warrens an. attitudes toward transplantation in u.k. muslim indo-asians in west london. am j transplant. 2005;5(6):1326–31. 19. efrat a. the politics of combating the organ trade: lessons from the israeli and pakistani experience. am j transplant. 2013;13(7):1650–4. 20. el-shahat yim. islamic viewpoint of organ transplantation. transplant proc. 1999;31(8):3271–4. 21. phadke kd, anandh u. ethics of paid organ donation. pediatr nephrol berl ger. 2002;17(5):309–11. 22. natour a, fishman s. islamic sunni mainstream opinions on compensation to unrelated live organ donors. rambam maimonides med j. 2011;2(2):1–7. 23. ghods aj. dialysis and transplantation news renal transplantation in iran. nephrol dial transpl. 2002;17:222–8. 24. zargooshi j. iranian kidney donors: motivations and relations with recipients. j urol. 2001;165(2):386–92. 25. koplin j. assessing the likely harms to kidney vendors in regulated organ markets. am j bioethicsournal bioeth. 2014;14(10):7–18. 26. asian development bank. poverty data: bangladesh [internet]. bangladesh and adb. 2020 [cited 2020 may 13]. available from: https://www.adb.org/countries/bangladesh/poverty. 27. ovi ih. covid-19 fallout: income drops to create 16.4m new poor this year. dhaka tribune. 2020 jun 24. [cited 2020 aug 25]. available from https://www.dhakatribune. com/business/economy/2020/06/24/bangladesh-tohave-16-4m-new-poor-in-2020. 28. naher n, hoque r, hassan ms, balabanova d, adams am, ahmed sm. the influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east asia. bmc public health. 2020;20(1):1082. 29. ti. ti corruption perceptions index. berlin: transparency international [internet]. ti. 2012 [cited 2020 aug 26]. available from: https://www.transparency.org/en/cp i/2012# accessed on 1 april 2019 30. tib. corruption in service sectors: national household survey 2015 [internet]. tib. 2016 [cited 2020 aug 26]. available from: https://www.tibangladesh.org/beta3 /images/2016/es_nhhs_16_en.pdf accessed on 10 march2019 author contribution: author conceived the idea, did the literature review, wrote the manuscript and checked the manuscript meticulously. conflict of interest: the author declares that there is no conflict of interest in this study. microsoft word clinical bioethemistry miliva et al corrected bangladesh journal of bioethics 2019; 10(3): 5-10 5 ethical considerations in clinical biochemistry and laboratory medicine: a discussion based on ‘the belmont report’ miliva mozaffor1, mariya tabassum2, mohammad tipu sultan3, shamima parvin4 1. clinician researcher, biomedical research foundation (brf), dhaka & laboratory consultant and head, department of biochemistry, ashiyan medical college hospital, dhaka-1229, bangladesh. email: miliva17@yahoo.com (corresponding author) 2. assistant professor, department of biochemistry, pabna medical college, pabna-6600, bangladesh. 3. postgraduate student, department of forensic medicine & toxicology, dhaka medical college, dhaka-1000, bangladesh. 4. professor and head, department of biochemistry & vice-principal, mugda medical college, dhaka-1214, bangladesh. abstract: with technical sophistication and innovation in the field of medical science, a considerable proportion of medical diagnosis now rely on laboratory analyses, which emphasises the crucial role of laboratory physicians in patient care. sustaining high ethical standards remains crucial in both clinical biochemistry and laboratory medicine, and several ethical dilemmas are faced by laboratory physicians in day-to-day practice. in a low-resource country like bangladesh, formal ethics education or ethical framework in laboratory practice is still absent; ethics has not received that much attention it this field. this paper has considered ethical issues encountered during the daily routine work of laboratory physicians and specially focused on the ethical issues encountered during the pre-analytical, analytical and post-analytical phases of laboratory medicine practice and discuss those issues in light of ‘the belmont report’ (1978) perspective. it is not intended to be a comprehensive one, rather it aims to complement existing guidelines and documents that are available in some institutions and to offer a framework for addressing ethical issues encountered in the practice of clinical biochemistry and laboratory medicine in bangladesh. key words: the belmont report, ethics, clinical biochemistry, laboratory medicine, bangladesh. introduction: with technical sophistication and innovation in the field of medical science, a considerable proportion of medical diagnosis now rely on laboratory analyses, which emphasises the crucial role of laboratory physicians in patient care1. in laboratory medicine, there is usually no direct or minimal contact with patients; however, the laboratory physicians’ first and foremost duty is to act in the best interests of the patient who is often “just a number” (as coded)2. although personal knowledge of the patient is often lacking, the laboratory physician does have intimate knowledge of at least a part of the patient – “the labelled specimen” – and an unusual but traditional three-way contract is made between clinician, laboratory physician and patient2,3. this is the case in particular where a life-altering event may occur on the basis of the definitive decision of a laboratory physician and the act of faith with which this is accepted by the patients1-3. the evolution of medical ethics over the years is well documented and evolved bangladesh journal of bioethics 2019; 10(3): 5-10 6 through the nuremberg code from 19474, the declaration of geneva from september 1948, with its continual amendment until october 20175, the declaration of helsinki from june 1964, with its continual amendment until october 20136 and ‘the belmont report’ from 19787. while many of these documents focus on medical research, concepts in the declaration of geneva and the belmont report are also applicable to the practice of clinical medicine to date. moreover, ‘the belmont report’ remains one of the key milestones concerning ethics in biomedical research. created in 1978 by the national commission for the protection of human subjects of biomedical and behavioral research of the united states, it outlines ethical principles and guidelines for the protection of human subjects. it identifies three core principles; those are as follows:7 a) respect for persons: to ensure autonomy of the subjects/patients as well as to protect autonomy of those with diminished capacity to consent and make decision by themselves. b) beneficence: acting in the best interests of patients or study subjects as well as maximize benefits and minimize harm. it is also termed as non-maleficence. c) justice: moral obligation to treat all the patients equally disregarding age, sex, and race, and to ensure fair allocation of resources, e.g. treatment facilities and medications/vaccines, what is rightly due in terms of benefits, risks and cost. as practicing physicians in the field, we have felt that sustaining high ethical standards remains crucial in both clinical biochemistry and laboratory medicine, and several ethical dilemmas are faced by laboratory physicians in day-to-day practice2. the importance of ethics in clinical biochemistry and laboratory medicine can never be ignored; however, there is variability in ethics education worldwide, focusing on the ethics in the laboratory procedure and practice. in a lowresource country like bangladesh, formal ethics education or ethical framework in laboratory is still absent; ethics has not received that much attention it this field. as we have stated earlier, the three basic principles of ‘the belmont report’ can be applied to both research and clinical settings. in this paper, these three principles will mostly be highlighted to clarify the ethics in clinical biochemistry and laboratory medicine. this paper aims to focus on the ethical issues encountered during daily routine work of laboratory physicians and will consider the pre-analytical, analytical and post-analytical phases in laboratory medicine and discuss those in ‘the belmont report’ perspective. ethical issues in the pre-analytical phase: usually it is assumed that the referring clinician has ordered the appropriate tests to support his/her provisional diagnosis, not for any financial gain, discussed the risks and benefits of the tests to the patients, referred testing to an appropriate laboratory (one that is that is properly certified and approved by the corresponding authority and in which the referring individual has no financial interest) and practiced those three ethical principles to the best of his/her ability. the maintenance of ethical standards in the pre-analytical phase is the collaborative responsibility of the laboratory, the health care provider, bangladesh journal of bioethics 2019; 10(3): 5-10 7 researcher, phlebotomist, nurse, or whoever collects the specimen8. in pre-analytical phase, their roles include proper identification of the patient, collection of the appropriate sample using the appropriate technique, accurate identification and labeling of the sample so that the right tests are performed, and proper handling of the specimen until testing is performed8,9. in this stage, the application of those three principles is as follows: a) respect for persons: consent should be obtained prior to sample collection, preferably a written one, and this consent should be informed (the patient knows what testing is being performed and why)10-12. however, the consent may be implied when a patient provides a requisition from the clinician and willingly sits in a collection chair and allows a sample to be taken. however, implied consent is nuanced as a patient who is sitting to have blood collected may have been told what to do and may not actually understand that they had a choice8. informed consent may pose an ethical problem if the patient is incompetent to make any decision due to age, mental status, or critical illness10-12. however, who may be allowed to give consent on behalf of the patient may vary among regions, may be influenced by different cultural practices12. besides, the patient’s right to refuse to be tested or the methods of collection of samples, should be respected7. however, there are certain situations in which patient autonomy is not absolute. for example, a patient may be deemed incompetent to make a decision about his/her health, as when the patient is unconscious, mentally ill, or under the influence of drugs11,12. children are generally considered as incompetent in decision-making for themselves until and unless they are legally emancipated from their parents; however, the status of children and adolescents under 18 years of age remains an area of controversy and is viewed differently in different parts of the world12. there are cases of compulsory testing in certain groups such as intravenous drug users and prisoners. in these exceptional cases, healthcare professionals have an obligation to consult the guidelines provided by the institution in which they practice, and they must weigh the risks of loss of a patient’s autonomy versus the benefits of the testing11. confidential information about patient demographics, the visit of a patient to a testing facility, which tests were ordered, and the reasons for those tests, should be given only to appropriate persons8,9,13. confidentiality is a must at every step of the process – specimen transportation, data entry and report delivery13. b) beneficence: all tests should benefit the patient based on the best medical evidence. in addition, sample collection should not cause harm. examples of harm in the preanalytical phase include infection or pain from the collection process (e.g. inadvertent puncture of an artery and other adverse events). therefore, standard operating procedures and trained personnel should be in place8,9. besides, the collection procedure should be carried out using universal precautions to protect both the patient and healthcare worker. additional specimens shall not be collected for research procedures without bangladesh journal of bioethics 2019; 10(3): 5-10 8 informed consent from the patient and approval from the appropriate ethics board14. c) justice: the clinical laboratory should, as far as it is able, provide access to a wide variety of laboratory tests at reasonable cost. there should be no preference given to individuals to facilitate or expedite the collection process at the expense of other patients8-10. ethical issues in the analytical phase: confidentiality, quality assurance and competence are vital for all laboratories and settings. in the analytical phase, confidentiality may be maintained through automation that uses automated bar code readers, automated analysis, and autoverification, as the patient names are deemed by codes15. nevertheless, challenges of ensuring confidentiality are often greater in small laboratories with low-resources that perform manual testing and in operations that conduct near-patient (point-of-care) testing. now we look at those three principles: a) respect for persons: patient have the right to decline to have their specimens analyzed even after the specimens have been collected and processed8,9. confidentially should be respected and maintained13,15. however, in point-of-care settings, it is really difficult because testing is often conducted in a common room with access by trained and non-trained personnel8. b) beneficence: the aim of the laboratory in the analytical phase is to provide the best possible analytical result. this is achieved through good laboratory practice and maintenance of professional standards. good laboratory practice should involve the establishment of a rigorous quality assurance program encompassing quality control testing, proficiency testing and laboratory accreditation8,9,15. the maxim “a wrong result is worse than no result” is a guiding principle in this regard8,15,16. good laboratory practice includes refusal to analyze or report a result when there is evidence of poor sample integrity, incorrect or poor labeling or other deficiencies that may compromise the test result8,9,17. laboratories should maintain proper certification and only qualified, properly trained personnel should perform point-ofcare testing2,8. c) justice: discrimination in the analysis of patient samples based on gender, age or racial origin is an injustice17. laboratories should develop appropriate operating procedures for each type of testing. it is expected that all specimens are analyzed accurately and in a timely manner8,9,17. ethical issues in the post analytical phase: the post analytical phase includes reporting and interpretation of results, residual specimen storage, and access to data. laboratories should have a policy for specimen storage and data protection8,9. archiving of results in either electronic or hard copy format is an important aspect of good laboratory practice15. now we will discuss those three principles here: a) respect for persons: there are substantial differences in the world regarding the confidentiality of results. in some areas, the patient and the referring clinician are the sole legitimate recipients of laboratory data11. exceptions are made if the patient is a juvenile or is incapable of receiving or understanding laboratory results. however, bangladesh journal of bioethics 2019; 10(3): 5-10 9 in other areas, the patient's family is regarded as legitimate recipients of a patient's laboratory results12. in addition, the patient should be allowed to give consent for access by others (such as family members) as required12,13. respect for local customs as to legitimate recipients of laboratory data should be taken into account as laboratories develop a policy on dissemination of results13. in some areas, there may be exceptions regarding who may access results; access is affected by legal requirements and government regulations, especially in forensic cases12,13. patients have a reasonable expectation that their samples will be used solely for the laboratory testing requested by the clinician. individuals have the right to decide when and if their records or specimens shall be used outside the normal medical care to which they have consented12,14. further testing of residual samples (except for method validation or in cases where samples are completely anonymized) should be approved by a local ethics committee or board, and patient consent may be required14. b) beneficence: misinterpretation of results can lead to patient harm; to minimize this harm, only qualified personnel should interpret reports15,16. it is expected that results should include an appropriate name for the test performed, an appropriate reference interval, which may be age and gender specific, the unit of measurement and, when possible, a designation that the test is within or above the reference interval. timely access to results is important; withholding of results because of non-payment might lead to harming the patient especially in emergency situations17. delays in reporting should be avoided. it is very crucial that ordering clinicians should be notified of errors as soon as those are identified, and test results should be corrected as soon as possible16. c) justice: the reporting of results should be consistent for all patients. rapid reporting may be required for some results, such as for "critical" and "significant-risk" results;8 however, the rules for rapid reporting must apply regardless of the source of the sample and the patient’s ability to pay17. sometimes residual samples are often used without the patient’s knowledge, which is quite unethical. however, there are many discussions and debates on who owns patient specimens and whether patients should share in profits, if financial gains are derived from leftover samples18,19. rules and practices vary by region and institution. in current discussion, bio-banking of leftover specimens and the ethical issues associated with it are beyond its scope. conclusion: this paper is not intended to be a comprehensive one; however, we have tried to complement existing guidelines and documents that are available in some institutions and to offer a framework for addressing ethical issues encountered in the practice of clinical biochemistry and laboratory medicine in bangladesh. as laboratory-based physicians, it is our utmost duty to uphold the standards of professionalism, be honest in all professional endeavors, and maintain a high level of personal integrity as well as maintain the existing professional code of ethics. we should also maintain a high level of quality in the product(s) of our professional endeavors, including validity and reliability of laboratory test results, interpretive opinions, bangladesh journal of bioethics 2019; 10(3): 5-10 10 scientific research, publication of data, and different forms of knowledge dissemination. moreover, we should ensure promotion of safety and welfare of patients, employees, coworkers, colleagues, the public, and the environment. references: 1. taylor jr, thompson pj, genzen jr, hickner j, marques mb. opportunities to enhance laboratory professionals' role on the diagnostic team. lab med. 2017;48(1):97-103. 2. wijeratne n, benatar sr. ethical issues in laboratory medicine. j clin pathol. 2010;63(2):97-98. 3. arora dr, arora b. ethics in laboratory medicine. indian j med microbiol. 2007;25(3):179-180. 4. the nuremberg code (1947). bmj 1996;313:1448. 5. anonymous. world medical association declaration of geneva. afr health sci. 2017;17(4):1203. 6. world medical association. world medical association declaration of helsinki: ethical principles for medical research involving human subjects. jama. 2013;310(20):2191-2194. 7. department of health, education, and welfare; national commission for the protection of human subjects of biomedical and behavioral research. the belmont report: ethical principles and guidelines for the protection of human subjects of research. j am coll dent. 2014;81(3):4-13. 8. sekadde-kigondu cb, higgins t, bruns de, gronowski am, ethical considerations in clinical chemistry and laboratory medicine. (available at: http://www.ifcc.org/media/446404/ifcc_tf_et hics_in_lab_medicine.pdf) (accessed on august 25, 2019). 9. canadian society for medical laboratory science (csmls). csmls code of ethics. (available at: https://www.csmls.org/about-us/ourmembers/code-of-ethics.aspx) (accessed on august 26, 2019). 10. nyrhinen t, leino-kilpi h. ethics in the laboratory examination of patients. j med ethics. 2000;26(1):54-60. 11. leino-kilpi h, nyrhinen t, katajisto j. patients' rights in laboratory examinations: do they realize? nurs ethics. 1997;4:451-464. 12. jefford m, moore r. improvement of informed consent and the quality of consent documents. lancet oncol. 2008;9:485-493. 13. watwe jm. disclosure of confidential medical information. issues med ethics. 1998;6(2):56-57. 14. borovecki a, mlinaric a, horvat m, supak smolcic v. informed consent and ethics committee approval in laboratory medicine. biochem med (zagreb). 2018;28(3):030201. 15. plebani m. the detection and prevention of errors in laboratory medicine. ann clin biochem. 2010;47(pt 2):101-110. 16. heher yk, dintzis sm. disclosure of harmful medical error to patients: a review with recommendations for pathologists. adv anat pathol. 2018;25(2):124-130. 17. stempsey we. the virtuous pathologist – an ethical basis for laboratory medicine. am j clin pathol. 1989;91(6):730-738. 18. caenazzo l, tozzo p, pegoraro r. biobanking research on oncological residual material: a framework between the rights of the individual and the interest of society. bmc med ethics. 2013;14:17. 19. medical research council, uk. human tissue and biological samples for use in research: operational and ethical guidelines. 2014. (available at: https://mrc.ukri.org/publications/browse/humantissue-and-biological-samples-for-use-inresearch/) (accessed on august 31, 2019). authors’ contribution: m mozaffor and s parvin were involved in conception of the paper; m mozaffor, m tabassum, mt sultan and s parvin were equally involved in the literature search, manuscript writing and revision. conflict of interest: none to disclose. microsoft word faiqua's research for abc 20(2) edited bangladesh journal of bioethics 2020; 11 (3): 21-32 21 drug abuse and drug addiction among students of university of rajshahi faiqua tahjiba llb (hons.) 2nd year student university of rajshahi, bangladesh e-mail: tfaiqua18@gmail.com doi: https://doi.org/10.3329/bioethics.v11i3.50595 abstract: objectives: the aim of this study was to investigate the actual condition of the students of university of rajshahi (ru) regarding drug abuse and addiction. using case study method the research was conducted with four objectives: (a) to find out how respondents began drug abuse; (b) to discover the causes of their drug addiction; (c) to understand the process of their drug abuse; and (d) to find out the economic, social and health effects of drug abuse. methods: case study method was used in this research. through snowball sampling 18 drugaddicted students of ru were selected as respondents. in-depth interview with a schedule was used to collect data from the respondents in january 2019. results: findings of the study show that the causes of drug addiction included curiosity, frustration, friends’ request, neglect from family and friends etc. the drugs which they usually abused were yaba, phensydyle, ganja (weed), chuani etc. their average monthly expenditure for collecting drugs was in between taka 8,000-10,000. they collected those drugs from rickshaw pullers at different points within the campus and from mizaner mor, budhpara slum and other places outside the campus. the respondents opined that drugs were available if sufficient money could be spent. the respondents had senior and junior fellow students and local boys as companions while taking drugs. most of them faced physical problems after taking drugs, and some of them tried to get rid of this curse of drug addiction. conclusion: the findings of this research show that the rate of drug addiction among the students of ru was quite alarming. therefore, all stakeholders including the students, guardians, teachers, university authority, the law makers and law enforcing agencies, researchers, civil society, ngo’s and the state must come forward together to combat this formidable foe. key words: drug, drug abuse, drug addiction, university of rajshahi, awareness (some part of this article presented at the 20th asian bioethics conference, 22-25 november 2019, dhaka, bangladesh). background: addiction is a disease that affects brain and behavior of a person. when people become addicted to drugs, they cannot resist the urge to use them, no matter how much harm the drugs may cause. drug abuse occurs when a person uses legal or illegal substances in the ways he shouldn't. addiction refers to that stage when he cannot stop taking those substances. students who are addicted to drugs and abuse those substances cause great harm to themselves and also to the society. bangladesh journal of bioethics 2020; 11 (3): 21-32 22 there are some specific acts passed in bangladesh in order to control the abuse of drugs. the drugs act, 1940 is one of those. the main objective of this act is to regulate the import, export, manufacture, distribution and sale of drugs1. according to section 37 of this act, any person who does not sell the patent or proprietary medicines or pharmaceutical specialties according to this act and sell drugs in public street etc. shall be punishable with imprisonment which may extend to two years, or with fine, or with both. the drugs (control) ordinance, 1982 is an ordinance, which was declared in order to control, manufacture, import, distribution and sale of drugs2. recently, narcotics control bill, 2018 has been passed in parliament. this bill has been passed with a provision of death sentence or life imprisonment as punishment for producing, trading and using 200 grams or more ‘yaba’ or more than 25 grams of ‘heroin’ and ‘cocaine’. if a person carries, trades, stores or processes ‘yaba’ weighing less than five grams, he or she could be sentenced to five years in jail and fined. one could be sentenced to death for carrying, trading, storing or processing ‘yaba’ weighing over five grams according to this bill. people in possession of less than 25 grams of ‘heroin’ and ‘cocaine’ could be punished with two to ten years’ imprisonment. if they have more than 25 grams, the punishment could be death or life imprisonment. in the existing law, there is no provision for death sentence or life imprisonment for offences related to heroin and cocaine. the maximum punishment is 15 years3. in spite of these acts and the punishments for the offence of drug abuse, the threat of drug addiction is spreading all over the country day by day. peace and tranquility of the society is hampering greatly by the curse of drug. students, as well as people of ages and classes are facing the adverse situation. this research tried to find out drug abuse and drug addiction among the students of rajshahi university. definition of terms: drug: drug is a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body. the drugs act,1940 gives the definition of drug. in this act, unless there is anything repugnant in the subject or context (a) “the board” means the drugs technical advisory board constituted under section 5; (b) “drug” includes-(i) all medicines for internal or external use of human beings or animals, and all substances intended to be used for or in the treatment, mitigation or prevention of diseases in human beings or animals, not being medicines and substances exclusively used or prepared for use in accordance with the ayurvedic, unani, homoeopathic or biochemical system of medicine, (ii) diagnostic, abortive and contraceptive substances, surgical ligatures, sutures, bandages, absorbent cotton, bacteriophages, adhesive plasters, gelatin capsules and antiseptic solutions, (iii) such substances (other than food) intended to affect the structure or any function of the human body or intended to be used for the destruction of varmints or insects which cause disease in human beings or animals, bangladesh journal of bioethics 2020; 11 (3): 21-32 23 (iv) any substance, mentioned as monograph in any of the editions of the british pharmacopoeia or the british pharmaceutical codex or the united states pharmacopoeia or the national formulary of the united states or the international pharmacopoeia, whether alone or in combination with any substance exclusively used in the unani, ayurvedic, homoeopathic or biochemical system of medicine and intended to be used for any of the purposes mentioned in sub clauses (i), (ii) and (iii), and (v) any other substance which the government may, by notification in the official gazette, declare to be a “drug” for the purposes of this act. drug abuse: drug abuse refers to the use of certain chemicals for the purpose of creating pleasurable effects on the brain.4 drug addiction: addiction is defined as a chronic relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. it is considered as a brain disorder because it involves functional changes to brain circuits involved in reward, stress and self-control and those changes may last a long time after a person has stopped taking drugs5. review of literature: as far as i have gone through, there has not been any research conducted specifically relating to drug addiction and its abuses at university of rajshahi. however, findings of the studies that i have found to be concerned with the present study in one way or another are summarized below: the smoking and tobacco products usage (control) act, 2005, as amended by the smoking and tobacco products usage (control) (amendment) act, 2013, is the principal law governing tobacco control in bangladesh. the act is comprehensive and covers smoke free policies; tobacco advertising, promotion and sponsorship; and packaging and labeling of tobacco products, among other areas. the smoking and tobacco products usage (control) rules, 2015 are the implementing rules of the act and provide further details regarding many provisions of the law6. chloe c.y. wong, jonathan mill and cathy fernandes in their article “drugs and addiction: an introduction to epigenetics” defined addiction as a deliberating psychiatric disorder, with a complex etiology involving the interaction of inherited predispositions and environmental factors. in this article the authors discussed various drugs of abuse7. in her book like a diamond in the sky, explored the reasons for which the youth in bangladesh are feeling alienated. she also tried to find out the factors that led to their addiction and drew a picture of how they were constantly blamed by the government, parents and friends, which make the addicted person more frustrated8. in the book of anxiolytic drugs: dependence, addiction and abuse, showed the abuse of benzodiazepined and flunitrazepam as drugs in the uk. he showed that the main cause of taking those drugs regularly in high doses was physical dependence as manifested by a withdrawal syndrome on discontinuation of the drug9. bangladesh journal of bioethics 2020; 11 (3): 21-32 24 harris isbell and hf frazer pointed out the causes of drug addiction, such as, personality disorder, frustration, curiosity and crave for pleasurable feeling in mind. he also noted that physical dependence is not entirely due to the changes in the autonomic nervous system10. mark a.r. kleiman, jonathan p. caulkins and angela hawke in their book drugs and drug policy: what everyone need to know pointed out the relationship between drugs and crimes. according to the authors drugs lead people to commit crime because: 1. drug use makes them act irrationally; 2. they need money to buy drugs; and 3. because they get involved in the violence that surrounds the business of producing and dealing in drugs.11 marina barnard in her book titled drug addiction and families records the effects of drug use on family dynamics and relationship including possible social and emotional costs. its impact on the physical and mental health is also discussed12. robert t. ammerman, peggy j. ott, ralph e. torter in the book prevention and societal impact of drug and alcohol abuse brought substance use and abuse at the forefront of the social problems. they also paid attention to the progress that has been made in explicating the impact and consequences of the substance use and abuse13. m. hepburn in “drugs of addiction” identified the increase of drug addiction among young women in britain. he also highlighted the problem of drug abuse during pregnancy14. l. kovatsi, d. et al. in the article ‘drugs of abuse: epigenetic and mechanisms in toxicity and addiction’ discussed the abuse of substances such as ethanol, cocaine, heroin, and the toxic effects of these drugs on almost every system of the organism. they also identified the lacking remaining in the strategies to decrease the toxicity of these drugs on human body15. the edited book titled drugs and youth: the challenge of today by ernest harms took note of the increase in the use of drugs by teenagers during the 1950s. he unearthed some unknown facts on the issue and considering its magnitude proposed to call it an ‘epidemic’16. research gap: from the review of literature by the researcher, it is found that the concept of the actual condition of drug addiction among the students of rajshahi university is missing. the researcher found out this gap and tried to explore the cause of drug addiction of the students of ru, the percentage of the addicted students, their level of addiction and also the awareness of the administration or ru in this regard. mainly, the limited information on the addicted students of ru is the research gap in this study. research questions: 1. how do the students become drug addicts? 2. what are the causes of their drug addiction? 3. who are the suppliers? are they students of ru or not? bangladesh journal of bioethics 2020; 11 (3): 21-32 25 4. what are the harmful effects they are facing after becoming drug addicts? 5. is the administration of ru concerned enough about drug abuse? objectives 1. to find out how the respondents began drug abuse; 2. to discover the causes of their drug addiction; 3. to understand the process of drug abuse; 4. to find out the economic, social and health effects of drug abuse. methodology: case study was the method used for this study. the study locale was the university of rajshahi (ru). the students of ru were the population of this research. the total number of the students studying at ru is around 37,000. among them 18 drug addicted students, who agreed to participate in this study were selected as respondents. case study method was used in this research. through snowball sampling 18 drug addicted students of ru were selected as respondents. all of the respondents were male. the researcher was not able to find any female drug addicted student who agreed to take part in the study as a respondent. type of the research: the research is qualitative in nature. data have been collected from 18 drug addicted students through in-depth interview. sources of data: the sources from which data have been collected can be classified into two types-primary and secondary. primary sources: the data and information about the abuses of drug in ru, directly collected from respondents are the primary data used in this research. secondary sources: the data and information which were collected from books, articles, study reports etc. are the secondary data collected for this research. the researcher used various information provided in many books articles, records etc. sampling design: it is not easy to reach drug addicted students and to convince them to participate as a respondent in a research. snowball sampling was used to select the respondents for this study. in snowball sampling the researcher gathers information the information given by the first few respondents the researcher succeeded in collecting data from 18 drug addicted students of university of rajshahi. she took information from only those who were willing to be respondents for this research. in this manner the researcher was able to collect data from 18 students. data collection method: in-depth interview using a schedule was employed to collect data from the respondents in january 2019. data processing and analysis: the data were processed manually and simple statistics e.g. frequency distributions and percentages were used to analyze data. research findings: in this section data collected from the students of ru are presented using simple statistical tools e.g., bangladesh journal of bioethics 2020; 11 (3): 21-32 26 frequency distribution and measures of central tendency. information presented in this section has been collected from the addicted students, who were 18 in number. most of the respondents had a single earning member in their families (n=8, 44%). thirty three per cent of the respondents had 2 earning family members while 17 per cent of them had 3 earning members in their families. only 5 per cent of the respondents had more than 3 earning members in their families (table 3.1). table 3.1: number of earning members of family number of earning members no. of respondents percent 1 8 44 2 6 33 3 3 17 more than 3 1 5 total 18 100 table 3.2: whether the respondents have their own earnings or not whether the respondents have their own earnings or not no. of respondents percent yes 5 28 no 13 72 total 18 100 among the respondents, 72% didn’t have any source of income of their own. twenty-eight percent of them had their own sources of income (table 3.2). most of the respondents (78%) opined that the earning of their family members was enough to meet up their necessities. but 22% of them told that the earning of their family members was not enough to satisfy their needs (table 3.3). table 3.3: whether the earning of the family members of the respondents is enough to meet up their needs whether the earning of the family members of the respondents is enough to meet up their needs no. of respondents percent yes 14 78 no 4 22 total 18 100 table 3.4: satisfaction of the respondents regarding their academic results satisfied or not no. of respondents percent yes 6 33 no 12 67 total 18 100 thirty-three percent of the respondents were satisfied with their academic results. but most of them, about 67% were not satisfied with it (table 3.4). table 3.5: opportunities for sufficient recreation gets enough opportunity for recreation no. of respondents percent yes 5 28 bangladesh journal of bioethics 2020; 11 (3): 21-32 27 no 13 72 total 18 100 most of the students opined that they did not get proper opportunities for recreation (72%). twenty-two percent of them said that they got enough scope for recreation (table 3.5). the respondents consumed different types of drugs. all of them consumed ganja. yaba was consumed by 15 (83%) drug users. they also consumed local liquor which was also called as ‘chuani’ (n=14, 78%) and phensydyle (n=16, 89%) as drugs. eleven percent of the respondents used other drugs (table 3.6). of the respondents, 67% collected their drug materials within ru campus and 89% of them collected those from outside of the campus(3.7). table 3.6: names of drugs consumed by respondents names of drugs no. of respondents percent yaba 15 83 ganja 18 100 local liquor (chuani) 14 78 phensydyle 16 89 others 02 11 (multiple response) table 3.7: place of collecting/buying drugs places no. of respondents percent within ru campus 12 67 outside ru campus 16 89 (multiple response) among the respondents, 67% bought drugs from other drug addicted students. fifty percent of them collected drug from the tea and cigarette sellers. eighty three percent of the respondents bought drugs from rickshaw pullers and 89% of them managed the drugs from the outsiders (table 3.8). table 3.8: drug selling agents agents no. of respondents percent drug addicted students 12 67 tea and cigarette sellers 09 50 rickshaw puller 15 83 outsiders 16 89 (multiple response) table 3.9: availability of drugs availability of drugs no. of respondents percent yes 14 78 no 3 17 no response 1 6 total 18 100 among the respondents, 78% thought that drugs which are consumed by them were sufficiently available. seventeen percent of them opined that those were not always bangladesh journal of bioethics 2020; 11 (3): 21-32 28 available. six percent of the respondents did not answer this question (table 3.9). of the 100 respondents, 5% opined that their monthly expenditure of money for drugs was less than 5000 taka. fifty percent of them told that the amount was around 5000-10000 taka on their part. forty four percent of the respondents answered that their expenditure was more than 10000 taka per month for the purpose of drugs (table 3.10). table 3.10: amount of money spent for drug consumption (per month) amount of money (taka) no. of respondents percent <5000 1 5 500010000 9 50 >10000 8 44 total 18 100 table 3.11: availability of drugs at residential halls for students availability of drugs at students’ halls no. of respondents percent easily available 8 44 more or less available 6 33 scarcely available 4 22 total 18 100 among the respondents, 44% thought that drugs were ‘easily available’ at the students’ halls of ru. thirty three percent of the respondents thought that the drugs were ‘more or less’ available at the halls. twenty two percent of the respondents opined that drugs are ‘scarcely’ available at the halls (table 3.11). table 3.12: whether wants to come out of drug addiction whether wants to come out of drug addiction no. of respondents percent yes 15 83 no 3 17 no response 00 00 total 18 100 among the respondents, 83% expressed their willingness to come out of drug addiction. seventeen percent of them were not willing to come out from this curse (table 3.12). on the question whether the respondents took drugs alone or in a group, 25% stated that they took drugs alone. fifty three percent of the respondents opined that they maintained groups while taking drugs. twenty two percent of them remained silent. as regards the question about the group members of the addicted students, 58% answered that they were their university friends, 33% said that the group members were their roommates, 18% opined that they were their seniors of the university. in the opinion of 7% of the respondents, their companions were their juniors and 24% bangladesh journal of bioethics 2020; 11 (3): 21-32 29 expressed that the group members were their local friends. while answering the question on their sources of earning which they used for collecting drugs, 28% opined that they earned that money by themselves and 72% said that the money came from their family or other sources. of the 18 respondents, 56% opined that they faced physical complicacy after being addicted to drugs. twenty two percent of them said that they did not face any physical difficulties and another 22% of the respondents remained silent in this regard. among the respondents, 36% informed that they were involved in other illegal activities after becoming addicted to drugs. sixty four percent of the respondents responded that they were not involved in any such activities. among the respondents, 15% informed that their families were informed about their addiction to drugs. sixty seven percent of them said that their families were not informed about this and 18% of them did not answer this question. on the question, whether the respondents have taken any steps to come out from drug addiction, 27% replied in the affirmative, 51% replied in the negative and 22% of them remained silent. case studies: this section presents five cases of drug addiction using pseudonyms of respondents. the researcher interviewed in an in-depth manner 5 addicted respondents to obtain the case studies from the 18 addicted respondents. this interview deeply focused on the beginning of their drug addiction, reasons behind their addiction, the drugs which they usually take, whether there is specific reasons on their choosing these drugs or not, the places from where they collected these drugs, their monthly expenditure for the purpose of drugs, their opinions about the percentage of addicted students in ru and whether they tried to come out from the curse of drug or not. case 1: rakib hasan (pseudonym), a 4th year student of university of rajshahi, is addicted to drugs since the last 3 years. he started to take drugs through his friends and finally became fully addicted. he is addicted to more or less all kinds of drugs. but, most of the time, he takes yaba and phensydyle. he has some specific reasons for choosing these drugs. he opined that, ‘yaba’ makes the body and mind energetic and it makes the mind more attentive. the body feels light after taking ‘phensydyle’. he collects drugs from some rickshaw pullers, who pull rickshaw around the ru campus, the bank of the river padma, various slums including the slum of ‘budhpara”. his expenditure in drugs is not the same every month. he gets this money from his family and other sources. his level of taking drug depends on his financial situation. rakib thinks that at least 15% of the student of ru are related to drugs through taking or dealing in those drugs. he didn’t ever try to get rid of drugs. case 2: nafis ahmed (pseudonym), a 3rd year student of ru, has been addicted to drugs since last 4 years. he is involved in bangladesh journal of bioethics 2020; 11 (3): 21-32 30 politics and his starting of taking drugs was through his political colleagues. it became extensive after he was admitted to ru. now he takes drugs regularly. he is a chain smoker and he takes more or less all sorts of popular drugs including yaba, phensydyle and ganja. he thinks that drugs have different effects on human body and mind. and when he felt these types of effects by taking drugs, he became addicted and wanted to feel that same feeling again and again. he mainly collected drugs from the political personnel who came from outside the campus. he also said that drugs were available in ‘budhpara’ and ‘mijaner mor’. he spent about 20,000 taka every month for the purpose of consuming drugs. he earns some money through his political activities and in maximum cases those activities were illegal. he took money from his family by telling lies. he used this money for the purpose of drugs. he thought that at least 8%-10% of the students of ru were addicted to drugs. he never tried to get rid of this curse of addiction. but he wants to recover from it. he already had to drop a year for the adverse effect of drug addiction. so, he thinks that he should leave this addiction as soon as possible. case 3: mahin (pseudonym), a 4th year student of ru became addicted to drugs after he got admitted to the university of rajshahi. he belongs to an upper class family. he didn’t take any drugs before. but, now he is fully addicted to drugs. he is also addicted to gambling. when he wins in gambling , he uses that money for the purpose of buying drugs. when he is defeated in gambling, he manages the money for drugs at any cost. he usually takes ‘yaba’ and ‘ganja’ as drugs. together with his friends, he takes ‘phensydyle’ and ‘chuani’. he takes these drugs to get the pleasant feeling derived from taking those. he collected these drugs from the other gamblers and drug addict students. he could easily get these drugs from them. his expenditure for the purpose of drug consumption was about 20000--25000 taka per month. he has no specific idea about the percentage of addicted students in ru. mahin never tried to get rid of the curse of this addiction. but he wanted to come out of it, though he thinks that he has to face various problems if he tries to do that. case 4: sakib (pseudonym) is a student of 3rd year in ru. he was a smoker from class 9. after being admitted to college, he started taking ganja. his addicted life started mainly after his entrance to the university. there was none to make him refrain from such activities. he started to take ‘yaba’ and ‘ganja’. he mainly started taking drugs to satisfy his curiosity. now he was used to with ‘ganja’, ‘yaba’, ‘phensydyle’ and ‘chuani’. he mentioned some specific reasons for his choosing these drugs. after taking cigarette, when one takes ganja, he feels energetic. yaba brings a pleasant feeling in body and it increases the sexual excitement of a person. phensydyle makes a person more attentive to his works. so, sakib has chosen these drugs. he collects the drugs from ‘budhpara’, ‘mijaner mor’ and various places of ru. his monthly expense for drugs is about 1000015000 taka. he takes this money from his family by telling lies and sometimes he gets involved in ‘seat business’ in the halls of ru to earn money. he thought that about 10-12% students of ru were addicted to drugs. bangladesh journal of bioethics 2020; 11 (3): 21-32 31 sometimes, he feels that he should leave his addiction but he never tried to get rid of it. case 5: ashik (pseudonym), a 2nd year student of ru, became addicted to drugs after admitting to ru. he is involved in politics. he was influenced to take drugs by his friends. he mainly consumed ‘ganja’ and ‘yaba’. besides, he took ‘phensydyle’ and ‘chuani’. he thought ganja makes the body feel light. yaba makes mind and body refreshed and it increases attraction to the people of opposite sex. and so, he has to involve in more illegal activities. he collects these drugs from various places of ru and the rickshaw pullers help him a lot in finding those drugs. he does not have any specific rate of expense for the purpose of drugs. he himself was involved in dealing drugs. he collected drugs from drug peddlers he was acquainted to at a low price and sold those to the students at a high rate. and thus, he earned a lot of money. he used this money to buy drugs for himself. he did not have any specific idea about the percentage of the addicted students in ru. he never tried to come out of this curse of drug addiction. discussion: in this research, the researcher found out the answers to some important questions about drug addiction through the respondents. from the information collected from students in general (both drug addicted and non-addicted) the researcher found that most respondents (36%) knew more than 30 drug addicted students at ru. in response to the question on whether the respondents were smokers or not, the researcher found that, 47% respondents were addicted to cigarette. though smoking is not normally treated as a form of drug addiction, still it works as a gateway to the addicted life of the students. from the survey it is found that, 18% of the respondents were addicted to drugs. this is quite an alarming situation. most of the addicted students took yaba, ganja, phensydyle and “chuani” as drugs. in maximum cases, university friends and local friends of the respondents played the significant role in their drug addiction. the main reasons for their drug addiction were frustration, not being satisfied with their academic results, family problems etc. here, the researcher found that most of the drug addicted students collected drugs from the other drug addicted students of ru, rickshaw pullers around ru and the outsiders. most of the students opined that drugs were ‘more or less’ available at the halls of ru. in case of monthly expenditure for drugs, most addicted students informed that the amount was within 3000-7000 taka. drug addiction has brought about a severe harmful effect on the economic, social, physical and mental condition of the students. conclusion: findings of this research clearly show that drug abuse has already immerged as a threat among the students of ru. the researcher found that, drugs were quite easily available to the students at ru. if students have enough money, they can easily buy drugs. this availability of drugs increased the rate of drug addiction among the students. the rickshaw pullers, who pull rickshaw within ru campus were considered as a great source of drugs. they supplied drugs to the students of ru and gave them information about drugs. sometimes, students become drugs dealers. they collected drugs from their known peddlers at a low rate and sold bangladesh journal of bioethics 2020; 11 (3): 21-32 32 those to the other addicted students at a high price. thus, they earned a lot of money by drug dealing and used that money for collecting drugs for themselves. an alarming information found from the research is that drugs were quite easily available in the halls of ru. so, it is clear that the students and other staffs of the halls were involved in drug dealing. this caused high risk to the nonaddicted students, because there is every chance for them to become addicted. there are some specific places, where the addicted students gathered together for taking drugs. they chose the field of “iblish chattar”, roof top of “shiraji vaban”, charukala, ru rail line area etc. as the perfect place for their consumption of drugs. students in general faced awkward situations by the activities of the addicted students. the availability of drugs in ru is increasing addiction day by day among the students. it is undoubtedly a risky condition for the safety of the students as well as the peaceful environment of the university. drugs are being abused indiscriminately, therefore, all stakeholders including the students, guardians, teachers, university authority, the law makers and law enforcing agencies, researchers, civil society, ngo’s and the state must come forward together to combat this formidable foe. references: 1. the drugs act, 1940 (act no. xxiii of 1940). 2. the drugs (control) ordinance, 1982. 3. death penalty for yaba offenders, the daily star, october 9, 2018. 4. mandal ananya. what is drug abuse. 2018. doi: https://www.news-medical.net/health/what-is-drugabuse.aspx (access on july 2019). 5. luscher c, ungless ma. the mechanistic classification of addictive drugs. plos med 2006, 3(11): e437. 6. thesmoking and tobacco products usage (control) act, 2005. 7. wong, chloe c. y., mill, jonathan and fernandes, cathy. drugs and addiction: an introduction to epigenetics. 2010. doi: http://doi.org/10.1111/j.1360-0443.2010.03321. 8. omar, shazia. like a diamond in the sky. zubaan publishers. bangladesh; 2009. 9. lander, malcolm. anxiolytic drugs: dependence, addiction and abuse. elselvier inc. london; 1993. 10. isbel, harris and frazer, h. f. (1950). addiction to analgestics and barbiturates. published online (issn: 1521-0081): american society for pharmacology and experimental therapeutics. 11. kleiman, mark a.r., caulkins, jonathan p. and hawken, angela. drugs and drug policy: what everyone need to know. oxford university press. new york; 2011. 12. barnard, marina. drug addiction and families. jessica kingsley publishers, london; 1999. 13. ammerman, robert t., ott, peggy j.torter, ralph e. prevention and societal impact of drug and alcohol abuse. lawrence elbaum associates publishers, london; 1999. 14. hepburn, m. (1996). “drugs of addiction” in advances in prenatal medicine. forrester cokburn (ed.). the pathenan publishing group, pp. 120-123. new york; 1996. 15. kovatsi, l., fragou, d., samanidou, v.njau, s. and kouidou, s. drugs of abuse: epigenetic mechanisms in toxicity and addiction.2011 bentham science publishers, doi: https://doi.org//10.2174/092986711795496836. 16. harms, e. drugs and youth: the challenge of toda. paragon press, ltd, canada.1964 author contribution: the author conceived the idea, did the literature review and wrote the manuscript. she also checked the manuscript meticulously. conflict of interests: no conflict of interest in this study to declare. microsoft word ravi bangladesh journal of bioethics 2020; 11 (2): 1-9 1 environmental ethics through value-based education ravichandran moorthy1, gabriel tyoyila akwen 2 1. associate professor, universiti kebangsaan malaysia, asian bioethics association, email: drravi@ukm.edu.my 2. department of political science, federal university gashua, yobe, nigeria email: akwengab123@gmail.com , akwengabriel@fugashua.edu.ng doi: https://doi.org/10.3329/bioethics.v11i2.49257 abstract: environmental ethics is the subject in philosophy that examines the moral relationship of human beings to the environment and its non-human species. it concerns human’s ethical relationship with the natural environment. the central question concerning environmental ethics is essentially – what is human being’s moral obligation concerning the natural environment? the paper will firstly provide a review of the ethical relations of humans and the environment, secondly examine how value-based education can assist in inculcating environmental ethics among learners. keywords: environment ethics, value-based educations, values, ethics, moral obligations introduction: mother earth is in great perils. human activities and the demand for resources have created enormous pressure and stress on the sustainability of earth. resource depletion and environmental devastation have plagued the world in the last several decades, creating havoc to the environment and the life of species inhabiting it, which includes the humans. human neglect, due to over development, has created many environmental issues, such as excessive pollution in land, water and air, overpopulation, poor management of industrial and household waste, climate change and global warming, deforestation and others, have impacted mother earth severely. these impacts are already clearly visible – the impacts on human health, the melting of the ice-cap and rise in sea levels, extinction of certain species, irreversible pollution of the water sources, unhealthy air levels and many more. despite being the most intelligent species, humans, due to their greed and consumption patterns, have willingly allowed for the ruin of the environment. in the past decade many initiatives are being carried out at all levels of society to create environmental awareness and invoke actions to mitigate environmental degradations and climate change issues. the authors posit that mitigation efforts should start in the school systems. besides imparting knowledge and skills, values education should be imparted with greater emphasis. values, norms and principles of nature should also be taught at an early age, so that children start to appreciate and value nature and the environment since childhood. only through the inculcation of ethics for the love, preservation and protection of the environment that long term solutions have be envisioned. while some of the damages to the environment are natural, a host of others are manmade. “man with his domestic bangladesh journal of bioethics 2020; 11 (2): 1-9 2 animals his domestic animals, cultivation and fire can induce changes, similar to those produced by a reduction in the long term average precipitation, in a very much shorter time” 1. the environment could be saved from both natural and human disasters through environmental ethics value-based education. this would enhance man’s understanding, attitudes, and skills on how to relate in the environment. besides, disaster mitigation strategies could be acquired through such education. in most cases, fields trips that are environmental based have proven to change the students’ perception of the environment. importance of environmental ethics: ethics are shared values of the society that are not static, they can be changed or revised, due to prevailing circumstances in the society. other features of ethics include belief and attitudes. environmental ethics is a body of knowledge that deals with an understanding of the moral association between man and the natural environment, including the nonhuman creatures that inhabit and constitute the environment2. environmental ethics encompasses developing a fitting grasp of the human-nature association, noting the goods and principles that emerge from the relationship, determining the rules that those goods and principles substantiate, and employing those norms to make regulations on environmental concerns and interactions3. studies on environmental ethics began during the post-modern thinking era. this was after the technological civilization (increase use of pesticides, deforestation and industry) brought about a new culture that sees human beings as the master of the environment4, 5. the new culture came with problems like air and water pollution, the exhaustion of environmental resources, depletion of the ozone layer, forfeiture of biodiversity, destruction of ecosystems, and worldwide climate change6 .the aforementioned constitute ethical discussions and subsequently influence the human ability to solve environmental problems. although there are rising concerns about environmental issues in nearly all aspects of human lives, the ethical environmental values and norm have not been very well emphasized in policies relating to the environment. fundamental ethical questions should be openly debated, to provide the required clarity of thought on the goals the policy expect to achieve. "should we only protect the environment to the extent that we have an interest in it? what is it that is worth protecting: species, individuals, ecosystems? what does the notion of sustainability means7?". thinking about these questions are essential as it allows the policymaker to reflect on the ethical principles that these policies will anchor on. yet, in reality, maybe due to ethical ignorance, "questions like these often remained unanswered and sometimes even unasked, in the formulation and implementation of environmental policies and actions"8 .it is by asking and answering the above-raised questions that the relevance of environmental ethics would be felt. an education that is environmental ethics based would assist man to delineate his moral and ethical responsibilities to the environment, even in the face of a threat to man's survival. for instance, in developing countries, people living in the rural areas bangladesh journal of bioethics 2020; 11 (2): 1-9 3 depend on firewood for their cooking, but cutting down of trees for this purpose is disastrous to the environment from the perspective of those living in developed societies. actions such as this and many more that are motivated by survival instincts are morally rejected in some quarters because of their negative impact on the environment. through the discipline of environmental ethics, man has come to strike a balance on how to utilize environmental resources without causing much harm. this is done through the teaching of ethical decisions, for example, the poor in most rural poor communities are encouraged to plant two trees when they cut one down. environmental ethics is useful for pointing out that if conscious efforts are not taken the next generations will not afford to meet their needs from the environment. it further advocates for the avoidance of bad environmental behaviour9. on the part of organisations, environmental ethics is an essential inner resource that permits firms to utilize a value-creating approach for augmenting environmental performance. in this context, environmental performance denotes an organization's behaviour concerning the natural environment. this has to do with how the organization taps accessible resources with a resilient obligation to check activities that can harm the environment. through environmental ethics, many firms have developed the natural inclination to build synergy among their internal resources to improve their environmental performance as a strategy of outclassing their competitors10. to this end, business environmental ethics of organizations stimulate proactive environmental activities and improves environmental performance. this is why environmental education (training) to employees has become a sine qua non and more relevant11 because of its ability to boost the organization's environmental performance and competitiveness. employee's environmental morals, motivations and behaviour in terms of knowledge and utilization of ideas in line with green products and resources recycling12 are important components that enhance environmental performance and competitiveness of firms. in another dimension, compared to a few decades past where only a handful of people realized that man's activities were altering the world's environment, with the emergence of environmental ethics, more people are informed about how human impunity actions are rapidly destroying the global environment. therefore, new information and improved understanding now characterize the human relationship with the environment. in this regards human beings have realized that they have a moral duty to leave the environment in good condition for the future generation. more so, that we are not at liberty to exploit environmental resources to the level of exhaustion. most importantly that other species have rights to co-live with human beings in the environment as well13 .this new knowledge demonstrates the relevance and dire need for environmental ethics. with environmental ethics culture, humancentered standpoints can be changed into eco-centred views and human perceptions about the environment and environmental bangladesh journal of bioethics 2020; 11 (2): 1-9 4 principles can be transformed positively. environmental ethics education can reveal the path and strategies of inculcating positive environmental values in students. particularly at the universities as important places in people's scientific and social development, young people taking both vocational and environmental ethics education will not be the source of environmental problems but part of the solution when they begin their professional career. in this theoretical study, the importance of environmental ethics education for university students will be emphasized14. environmental ethics plays an important role in man's quest to preserve the earth and manage the natural resources to meet the needs of the geometric increasing human population. this cannot be achieved with man's inadequate perception of environmental ethics. through education in environmental ethics, man has come to understand that there many environmental ethics that we need to practice as we carry out our day-to-day activities to maintain the sustainability of the. environmental ethics principles: generally, the debate on environmental ethics falls into four wide-ranging aspects; “firstly it reflects on human beings' ethical relationship with the natural environment; secondly, it concerns human beings' responsibility in safeguarding and preserving the natural environment; thirdly it concerns human beings' in providing leadership in safeguarding and preserving the natural environment and fourthly it concerns human beings' in ensuring earth's resources remains adequate for future generations” 15. these dimensions need to be guided by environmental ethics principles for success to be achieved. there are numerous principles to establish how humans should treasure the environment. the vastness of the field of environmental ethics makes it challenging for one principle to be applied. several theories have been propounded since the inception of the discipline of environmental ethics, and they have highlighted countless principles of environmental ethics. more so, due to differences in environmental problems and human needs of different societies, there are no universally accepted principles of environmental ethics. be that as it may, some of the principles that are predominantly found in the existing theories are discussed below. anthropocentrism is one of the principles of environmental ethics. etymologically, the concept of anthropocentrism is derived from a combination of two greek wordś "ανθρωπoς (anthropos, or human being) and κ́εντρoν (kentron, or centre)" 16. in environmental ethics, anthropocentrism connotes "the belief that value is humancentred and that all other beings are means to human ends"17. by this, it means that only human beings are worthy of moral contemplations.18 the word anthropocentrism is a global held perspective that accord privileges to the improvement of man's welfare at the detriment of other aspirations. anthropocentrism could be viewed as the love of one's species, and, secondly, as intolerance for other species19. this principle contents that man is the most bangladesh journal of bioethics 2020; 11 (2): 1-9 5 essential being, all other living creatures are just fixtures designed to support man's survival and development. there are two strands of anthropocentrism-the weak and strong anthropocentrism. whereas weak anthropocentrism thinks that human beings are the hub because it is only via the human standpoint that environmental conditions are understood. strong anthropocentrism, on the other hand, believes that human beings are the focus because they justly deserve to be there20. non-anthropocentrism is another known principles of environmental ethic. in contrast to anthropocentrism, the principle of nonanthropocentrism offers value to every object, every animal dwelling in an environment. this principle believes in everything that sustains itself in nature. from the lens of non-anthropocentrism, the world is not seen based on its utility but its intrinsic worth. hence, the stance that man is not superior to members of all species.21 this principle believes that the non-human world also possesses an essential value in itself and broadens moral standing to non-human species. among the adherents of this principle, some expand morality only to species that can react to pleasure and pain, for instance, humans and animals, others, to all living beings, plants and trees inclusive, and some to the degree of including the land, rocks, soil, ecosystem, etc22. the nonanthropocentrism principle is perceived as an abstraction given the level of urbanization and technological advancements that characterized the contemporary world23. there are many variants of nonanthropocentrism, sometimes they are treated as separate principles of environmental ethics. while at some instance the concept "ecocentrism" is counted as a principle of environmental ethics, in this context it is seen as one variety of non-anthropocentric principle. others include hierarchical biocentrism, psychocentrism, and egalitarian biocentrism24. widyaningtyas, et al25 identify three principles of environmental ethics "(1) compassion for nature bearing, (2) respect for nature bearing, and (3) life in harmony with nature bearing", which they posit are derived from biocentric and eco-centricity theory. from their first principle it can be deduced that as humans progressively love and care for the environment, a mutual and strong relationship would be established between individuals and nature. to this extent, nature is viewed to be alive in a physical, spiritual and mental sense. the second principle is founded on the theory ecological community, which asserts that the environment is a moral community and humans as community members have a moral responsibility to respect other members of the community. the third principle stresses that the quality of a good life is not determined by facilities, wealth or material values. life in harmony with nature bearing as a principle states that human beings need to see themselves as a part of nature, therefore, should make use of nature appropriately. this can be achieved through obedience to natural law, which entails moderate utilization of nature and avoidance of overexploitation26. from the african standpoint, ibanga27 pinpoints five principles of environmental ethics, which are taken from the broad corpus of african environmental ethics. one of the bangladesh journal of bioethics 2020; 11 (2): 1-9 6 principles is that of accommodation. it portrays that nonhuman presence and care for future generation should be contemplated and accommodated in humans' day-to-day resolves and dealings. next is the principle of gratitude. under this principle, man is expected to act towards the environment in such a manner that reflects appreciation towards other species. because even the nonhumans contribute and support man's existence in the environment. the third is the principle of restoration. it admonishes human beings to always restore to nature the loss they have caused it. for instance, re-planting two trees after one is deliberately cut down. the succeeding is the principle of control. here man is encouraged to act in a fashion that he would be able to control and prevent his actions from creating too many undesirable externalities. the last is the principle of necessity. man is expected to act only on choices and actions that are extremely necessary. all the above-discussed principles of environmental ethics are precepts proposed to guide peoples' actions in the environment. most of the principles call for control and caution to man's decisions and actions, so that his lifestyle and dealings would prevent depletion of resources and reduce damages that his lifestyle can cause other beings and their communities. put differently, these principles serve as a framework to foresee before acting. value-based education: what is valuebased education? value-based education is a philosophy and approach to education that emphasizes the inculcation of principles, values and ethics to the learners. it is an innovative way of thinking about education, where learners are introduced to values holistically by assimilating these values as principles that will guide behavior and actions28. the next question is why there is a need for value-based education? the rat-race to acquire for academic and professional qualifications have undoubtedly pushed value education on the sideline. material success, competitions and consumptions have become the new-age mantras in society – contributing the degradation of human values, their behaviours and negative impacts to the environment. therefore, to address these harms, the authors believe that the education philosophy and education systems requires a thorough reexamining and revision. a more robust and significant value-based education curriculum need to incorporate into the school syllabus that will invoke the desired human values and ethics. “philosophers, educationists, and other stakeholders can be the catalyst to create awareness among the public and policy makers on the necessity to relook and revamp the education system, across the board” 29. what are desired values in value-based education? there many moral and ethical values and norms that regulates human behaviours in societies. the values are cultural and society-specific, one society may place a greater importance of a specific set of values compared to another society. societies may have different levels priority and acceptance of values and norms in society. however, the universal values such as respect, tolerance, peace, care, compassion and love manifest in all societies. through value-based education, learners have the bangladesh journal of bioethics 2020; 11 (2): 1-9 7 opportunity to learn, deliberate and reflect their actions based on these values. the school syllabus of some countries have incorporated moral or civic classes as part of their curriculum, where values are specifically taught. nonetheless, value education may be carried out in any type of lessons, but the values can be drawn out in the activities. for instance, “in a geography lesson regarding water resources, learners can be exposed to the principle of water for all (water equity or sharing), the right for access to clean water (human rights), as well as responsibility to use water in a sustainable way (environmental ethics)”.30 through this geography lesson, learners have the opportunity to internalize the values of sharing, respect for the rights of all, and responsibility to the environment. through these activities, teachers or instructors can initiate discussion in class and encourage the learners to reflect of these values. studies show that value-based education tend to produce learners with more self-confidence and take greater responsibility for their actions and behaviours. subsequently, when learners start thinking about these values and reflect it within their lives, it becomes a normative set of values for that individual. this allow them to be more reflective and self-aware, with regards to their actions and behaviours. when learners start to internalize and model the values in their lives, they become ethically intelligent. it refers to the consequence of thought process on an ethical vocabulary, that may encompass value-loaded words such as love, compassion, peace, respect, justice, fairness etc. when learners start thinking about the gist of these vocabulary, and incorporate those expressions into their lives, they became ethically intelligent. weinstein31 asserts that individually who are ethically intelligent know how to employ this awareness the immediately. nevertheless, being ethically intelligent is not only about knowing what is right, but having the resolve to do what is deemed right. ethical intelligence is most valuable, and it manifest through five principles – do no harm, make things better, respect others, be fair, and be loving. these principles are the buildingblock of communities, societies and nations, it binds individuals together, as persons of faith and in all relationship individuals have or are likely to have32. the authors believe that environmental ethics and its awareness can be inculcate more efficiently through value-based curriculum and teaching. as explained in the previous paragraphs, values, norms and ethics that allows for the safeguard and appreciation of the environment should inculcate early in the schooling process. the experiential learning that takes place in value-based systems will improve learners’ relational trust and become more engaged in value-based environmental discourses. individuals need to feel responsible and empowered to be a guardian for the environment. they will feel compelled, not only to constantly acts in an sustainable way, but also have the moral standing to speak up against actions by others that are environmentally unsustainable. conclusion: the importance of value-based education in the school curriculums have been largely neglected or even ignored. moral and civic classes in schools are usually bangladesh journal of bioethics 2020; 11 (2): 1-9 8 non-exam lessons, and are often regarded not important by the schools and parents. the school systems and even the parents often place great emphasis on subjects and exams that will secure their children jobs and further educational opportunities. this is an incorrect postulation, while job seeking skills and knowledge are important, value and ethics education is crucial for characterbuilding of individuals. for example, indian thinkers claimed that ‘the end of education is character’, which denotes to the mental and moral qualities distinctive to an individual33. for mahatma gandhi, education is the development of human personality, which reveals in the body, mind, heart and spirit of humans. through education, the spiritual, intellectual and physical strength of the individual is aroused. subsequently, it also arouses the notions of sympathy, fellowship and deep feelings of love. “it also nurtures conflict resolution behavior among individuals – that is to manage differences through dialogue, tolerance, friendship, reconciliation and confident building among individuals” 34. therefore, the purpose of education is to produce individuals who endowed with values and norms, and understand one’s responsibilities in the world in which one lives35. references: 1. campbell, a. & graham, c. the impact of man on the environment of botswana. botswana notes and records 1971: 91-110. 2. akpan, b. s., & leonard, n. environmental ethics: from philosophy to movement. bulletin social-economic and humanitarian research, 2018; (2). https://cyberleninka.ru /article/n/environmental-ethics-fromphilosophy-to-movement [14 august 2020]. 3. sandler, r. l. “environmental virtue ethics. international encyclopedia of ethics. 2013. 4. pai, t.y., wang, s.c., lo, h.m., chen, l., wan, t.j., lin, m.r., lin, c.y., yang, p.y., lai, w.j., wang, y. h. & lu, t.h. “a simulation of sewer bio deterioration by analysis of different environmental ethics and literacy 875components with a model approach”, international bio deterioration and biodegradation. 2017; (125): 37-44. https://doi.org /10.1016/j.ibiod.2017.08.003 [14 august 2020]. 5. liu, q., cheng, z., & chen, m. effects of environmental education on environmental ethics and literacy based on virtual reality technology. the electronic library. 2019; 37(5) 860-877 6. environmental ethics and principles of implementation. 2020. https://www.academia./ 38498608/ environmentalethicsandprincipleofimpleme ntation [15 august 2020] 7. ten have, h.a.m.j. environmental ethics and international policy. 1st edn, unesco: paris, 2006 8. ibid 9. temel, s. prospective teachers' understanding of environmental ethics approach: a qualitative study. in shs web of conferences. 2019; (66): 01-10. 10. singh, s. k., chen, j., del giudice, m., & elkassar, a. n. environmental ethics, environmental performance, and competitive advantage: role of environmental training. technological forecasting and social change, 2019; (146): 203-211. 11. singh, s.k. & el-kassar, a.n. role of big data analytics in developing sustainable capabilities. j. clean. prod, 2019; (213): 1264–1273. 12. sarkis, j. the role of employees' leadership perceptions, values, and motivation in employees' provenvironmental behaviors. j. clean. prod. 2018; (196): 576–587. 13. verma, a. k. environmental ethics: need to rethink. international journal on environmental sciences. 2017; 8(1): 7-9. 14. karataş a. the importance of environmental ethics education at universities. 8th international technology, education and bangladesh journal of bioethics 2020; 11 (2): 1-9 9 development conference valencia, spain. 10-12 march, 2014. publisher: iated; 2014. 15. moorthy, r. & jeyabalan, g. environmental ethics in river water management american journal of environmental sciences 2011; 7(4): 370-376 16. kopnina, h. "anthropocentrism and post‐ humanism." the international encyclopedia of anthropology 2018: 1-8. 17. kopnina, h, et al. anthropocentrism: more than just a misunderstood problem. journal of agricultural and environmental ethics. 2018; 31(1): 109-127. 18. callicott, j. b. “conservation values and ethics.” in principles of conservation biology, edited by martha j. groom, gary k. meffe, & c. ronald carroll, 111–35. sunderland, ma:sinauer; 2006. 19. hayward, t. anthropocentrism: a misunderstood problem. environmental values. 1997; 6(1): 49–63. 20. kukreja, r. what are environmental ethics? 2020 https://www.conserve-energy-future .com/environmental-ethics.php. [14 august 2020] 21. jagat, p. “sterba on reconciling anthropocentric with non-anthropocentric ethics”, indian philosophical quarterly, 2003; 33(3): 443. 22. carrie, w. the role of philosophy in environmental debates. http://www.helium. com/items/1436902-ethics-environmental [19 august 2020]. 23. weston, a. non-anthropocentrism in a thoroughly anthropocentrized world. the trumpeter 1991; 8 (3):1-9 24. kortetmäki, t. anthropocentrism versus ecocentrism revisited: theoretical confusions and practical conclusions. sats. 2013; 14 (1) 21-37. 25. widyaningtyas, p. & else liliani. principles of environmental ethics in indonesian newspaper short stories: an ecocriticism study. 1st international conference on language, literature, and arts education (icllae 2019). atlantis press, 2020. 26. ibid 27. ibanga, d. concept, principles and research methods of african environmental ethics. 2018; 11(7): 123-142 28. moorthy, r. & sivapalan, s. some ethical thoughts from the indian traditions. eubios, j. asian, int. bioethics. 2010; (20): 180-183. 29. moorthy, r. 2019. value-based education to overcome hatred & divide. in macer, d.r.j (ed). legacies of love, peace and hope: how education can overcome hatred and divide. christchurch, n.z.: eubios ethics institute. pp.87-92 30. ibid 31. weinstein, b. 2011. ethical intelligence: five principles for untangling your toughest problems at work and beyond. california: new world library. 32. ibid 33. chandrasekar, v. conflict resolution through value-based education and its impact: the indian model. in moorthy, r. and panneerselvam, s. (eds.). conflict resolution: perspectives from indian philosophy and traditions. ukm press: bangi, 2018. 34. moorthy, r. indian civilization, philosophy and conflict resolutions. in moorthy, r. and panneerselvam, s. (eds.). conflict resolution: perspectives from indian philosophy and traditions. ukm press: bangi, 2018. 35. devi, a. h. ‘gandhi's concept of education and its ethical perspectives for the development of peace.’ 2019. https://www.mkgandhi.org/articles/g_edu.ht m [1 august 2019]. author contributions: the 1st author ravichandran moorthy conceived the idea, did the literature review and wrote the manuscript. the 2nd author gabriel tyoyila akwen guided the conception of the idea, the manuscript writing, and checked the manuscript meticulously. conflict of interests: the authors declare that there is no conflict of interest in this study microsoft word 3. partner violence bangladesh journal of bioethics 2018; 9 (3): 16-27 16 intimate partner violence in bangladesh: a scoping review jhantu bakchi1*, satyajit kundu2, subarna ghosh3, sumaiya akter4 1. department of public health, north south university, dhaka, bangladesh, email: jbakchi.nfs.pstu@gmail.com orcid: https://orcid.org/0000-0001-5599-9884 (*corresponding author). 2.department of biochemistry and food analysis, patuakhali science and technology university, dumki, patuakhali-8602, bangladesh, email: satyajitnfs@gmail.com orcid:https://orcid.org/0000-0001-9610-1479 3. lecturer, department of public health nutrition, primeasia university, bangladesh, email: subarnaghosh.pstu@gmail.com 4. department of food microbiology, patuakhali science and technology university, dumki, patuakhali-8602, bangladesh, email: sumaiya.nst@gmail.com abstract: introduction: intimate partner violence (ipv) has unfavorable consequences for women as well as for newborn babies, which is very serious and preventable public health problem. it is believed to have an excessive occurrence in lives of women in south asia. the objective of this study is to describe the prevalence, risk factors and consequences of ipv in bangladesh. methods: a scoping review was carried out based on the past 12 years of posted and gray literature about ipv in bangladesh using arksey and o’malley’s framework. only the literature addressing abuses or violence in households or outside including physical, sexual or mental violence on the married woman in bangladesh were taken into consideration for the study. results: the overall prevalence of ipv in bangladesh, the latest reviews of rates ranging from 15.5-82.7%.most of the ipv in bangladesh was based totally on the experience of legally married women. the main risk factors of ipv in bangladesh were women being younger, from lower socioeconomic reputation, from lower academic attainment and lower education of husband, dowry, child marriage, perceived disobedience of wives, family conflict, children had recently been ill, and incapability of to furnish sexual satisfaction. maternal depressive symptoms, signs of stress, anxiety and constraint to the better health of young children are the main consequences of ipv in bangladesh. besides, ipv causes unwanted pregnancy, pregnancy loss in the form of miscarriage, induced abortion, or stillbirth and termination of pregnancy in bangladesh. conclusions: woman’s empowerment may reduce ipv and understanding attitudes towards ipv in cultural context could be crucial for developing interventions to reduce ipv and its consequences. keywords: intimate partner violence, health consequence, scoping review, bangladesh introduction: the occurrence of intimate partner violence (ipv), a gross violation of human rights, is one of the most prevalent abuses throughout the world and common varieties of violence towards women such as physical, sexual, and emotional abuse and controlling behaviors via an intimate companion, low and middle-income nations have the greater incidence1. intimate partner bangladesh journal of bioethics 2018; 9 (3): 16-27 17 violence is really common in all fields like socioeconomic, spiritual, and cultural groups. basically, women are reported as being victims of ipv. intimate partner violence (ipv) is one of the most common forms of violence against women worldwide2.a large number of research work documents the prevalence, determinants, and consequences of men’s violence against their wives and female partners. a review of population-based surveys from around the world identified that between 10% and 69% of women in various settings had been physically assaulted at least once by an intimate male partner3. while domestic violence is a universal problem, it is a problem of extreme magnitude in less developed countries such as bangladesh4. in bangladesh, several studies identified a number of risk factors for ipv. for example, studies have identified that the risk of experiencing violence was significantly higher among younger women5,6, less educated women7,8, women with less educated husbands7, women living in poor households7, and women who believed their husbands were justified in beating them in certain circumstances9.evaluation of dhs information from 10 countries also reported that physical or sexual ipv ever stated by presently married women ranged from 17% in the dominican republic to 75% in bangladesh in 200810. a hospitalbased survey in bangladesh indicated that 43% of females experience physical ipv in their lifetime, 35.5% of them experienced sexual ipv, and 32.5% experienced each physical and sexualipv11.an estimated three in every five ladies in bangladesh experience violence along with physical or sexualviolence12. one of the most frequent forms of violence towards females globally is abuse through the husband or partner3.a study conducted in bangladesh reported that more 94% of women had experienced physical, sexual, or psychological violence at some point in their marriage or intimate relationship4. several consequences have been identified due to ipv, for example, there is a negative consequence of ipv on maternal, physical, and mental health13–15.this negative consequence of ipv on women may also affect their children’s health directly and indirectly16,17. relevant information about ipv, the elements which generate the underlying causes where women experience ipv in these settings, with also to pick out the determinants of ipv and above all have to recognize its alarming incidence rates in bangladesh as well as in south asia. bangladeshis are presently transitioning from low to middle-income nations rapidly but still, women are faced with undesirable violence from their partners, and thus ipv in bangladesh is not only a human right issue but also a public health issue. hence, this study is aimed to evaluate literature about ipv in bangladesh to describe the prevalence, risk factors and consequences of ipv. methods: arksey and o'malley’s (2005) five stages for scoping literature reviews were followed (see figure 1). stage 1: defining the research question: the research question was defined in collaboration with all researchers of the team with the identification of some bangladesh journal of bioethics 2018; 9 (3): 16-27 18 abuse/form which may lead to ipv. three major factors were considered which are known as potential forms of ipv in bangladesh and which guided the review. figure 1: arksey and o’malley’s framework stages for conducting a scoping review operational definition domestic violenceany abusive, violent, coercive, forceful or threatening act or word inflicted by one member of a family or household on another can constitute domestic violence. it includes everything from saying unkind or demeaning words to grabbing a person’s arm, to hitting, kicking, choking or even murdering. sexual harassment/abuseis unwanted sexual activity, with perpetrators using force making threats or taking advantage of victims not able to give consent. gender-based violence-gender-based violence is a phenomenon deeply rooted in gender inequality and continues to be one of the most notable human right violation within all societies. gender-based violence is violence directed against a person because of their gender. both men and women experience gender-based violence but the majority of victims are women and girls. stage 2: identifying relevant studies: the inclusion and exclusion criteria and search strategy were developed and implemented with the input of the research team and focusing on the objective of the study. the inclusion and exclusion criteria are detailed below (see table 1). our search strategy included: electronic databases, grey literature and reports on newspapers. the following databases were searched for spouse abuse/beating/ battering, home violence, intimate companion violence, spousal abuse, accomplice abuse, gender-based violence, and bangladesh. most of the articles were searched in pubmed, research gate, embase and only open access articles were collected from them. the search was conducted on march 10, 2019, and updated up to 15 december 2019 including papers from 2007 (12 years prior to the initial search). reference lists of included citations, key reports, organizational and other websites were hand-searched. stage 3: study selection: two researchers separately reviewed assigned titles and abstracts for relevance. articles that were identified as relevant by either reviewer were considered for full-text review. two researchers again separately examined full texts for their assigned papers for relevance; another two researchers were also appointed for resolving disagreements. stage 4: charting the data: data were abstracted by one reviewer and checked by another reviewer including: year of publication; purpose; participants/ population involved; type of nurse bangladesh journal of bioethics 2018; 9 (3): 16-27 19 addressed; study design; research site(s); trends; outcomes and recommendations related to ipv. stage 5: collating, summarizing and reporting the results: stage 5 involved collating, summarizing and reporting results. results and discussion: the search retrieved 70 citations, with 55 potential papers after dispelling duplications. figure 2 presents a flowchart of literature retrieved levels of screening and included studies. this review included 22 distinct studies. table 2 presents studies by study design/paper type. the findings are in the following sections, which center of attention on the occurrence of ipv, health consequences of ipv, danger elements for ipv, women’s responses to ipv, health system responses to ipv, and elements affecting women’s care-seeking behavior in bangladesh. prevalence of ipv in bangladesh: by using statistics from the chosen city and rural areas of bangladesh the who multicountry study revealed out women’s fitness and home violence (lifetime ipv incidence over 50%) & this extremely excessive lifetime occurrence rate is steady18. together, the literature suggested that an average of 15.5-48%of women in various places in bangladesh have experienced ipv11,19–25. the highest prevalence rate used to be stated by women residing in rural areas in the peripheral zones backyard of dhaka city (82.7%), which included 77 villages in bangladesh and the lowest prevalence rate was seen as 15.5%21,26.some of the findings are not going to replicate the present rates of ipv in bangladesh because of these incidence rates from the research were calculated 5-8 years ago. about 52-64% of women in a number of areas of bangladesh experienced physical ipv and about the same for sexual ipv (11-65%) which was stated by current community-based surveys23,24. the prevalence rate was also very high (4363.8%) in hospital-based studies where respondents described some bad consequences of ipv alongside physical and mental tortures11,27. recently a study conducted in one of the slums of dhaka city showed that ipv rate is the same as other communities which indicates that ipv may not vary on economic status22.besides, non-muslim females and girls who watched mass media usually were less probable to be bodily abused through their husbands than muslims and females who did not watch mass media at all19.the excessive occurrence of ipv experienced females in this study is steady with that mentioned in different research inbangladesh28–30.for females, in all levels of life, such as adolescents, pregnant women, older adults experiences of ipv had been documented, and the kinds of ipv experienced consisting of physical, sexual, emotional, and verbal abuse and a variety of controlling behavior in varying frequencies19,25–27. additionally, sexual abuse was one of the predominant stated varieties of ipv in bangladesh, with rates ranging from 6.2% to 65% but the majority of research mainly stated bodily violence as ipv11,21,23,24,26,31. a study also reported that three out of four (75.6%) bangladeshi women experience violence from husbands32. bangladesh journal of bioethics 2018; 9 (3): 16-27 20 different types of ipv in bangladesh: for females, in all levels of life, such as adolescents, pregnant women, older adults experiences of ipv had been documented, and the kinds of ipv experienced consisting of physical, sexual, emotional, and verbal abuse and a variety of controlling behavior in varying frequencies19,25–27. in addition, the partner’s anger primarily based on jealousy, whenever, in search of health care for herself, it is the most frequent trouble being predicted to ask the partner’s permission thus 84% of the female stated emotional violence through their intimate partner24. teasing (khota, tishara), demonstration of anger, verbal abuse (galigalaj), threat of abandonment or divorce and remarriage were the major kinds of emotional abuse.the most frequent form of physical ipv ever perpetrated used to be having slapped or thrown something at their partner, followed through having pushed or shoved their partner, hit their companion with a fist or something else, kicked, dragged, beaten, choked or burned their partner, and having threatened or used a gun or knife on their partner33. risk factors of ipv in bangladesh: a woman’s younger age, low socioeconomic reputation and low academic attainment, low education of husband, dowry, perceived disobedience of wives, family conflict and children had recently been ill are the wide variety of individual risk elements for ipv in bangladesh which was recognized by many research22,23,26,27,34.in bangladesh, dowry is associated with violence seems to be less frequent in contrast with different south asian settings35,36.a study has found an association between early marriage and ipv and stated that the incidence rate used to be modestly in villages which are (44.1%) with the reasonable occurrence of early child marriage (15–25%), and was the best (51.8%) in villages with the highest incidence of very early child marriage (>25 %)31.the lack of ability to work or to work properly, the incapability to furnish sexual satisfaction, and verbal conflict had been the major reason behind such abuse37.a study claimed that each physical and sexual ipv occurrence rate is greater amongst these respondents whose pregnancies were unintended and females belonging to the poorest category of relative family wealth19.several studies showed that early reproductive women are more vulnerable to ipv who are in the range of 15-31 years22,25–27.muslim women are at greater risk of ipv in bangladesh32.in addition, men who witnessed father-to-mother violence are more likely to perpetrate ipv, suggesting an intergenerational transmission of violence38.moreover, ownership of jewellery/large household assets by woman, substance abuse by husband and his involvement in extramarital sex, and education of woman more than the husband increased the likelihood of ipv in bangladesh39. a randomized controlled trial study reported that women who were allocated to receive interactive messages about contraception were more likely to report physical ipv compared with the control group receiving usual care40.in bangladesh, junior men are at heightened risks of perpetrating ipv and thus reducing the perpetration of ipv by them men is very critical41. bangladesh journal of bioethics 2018; 9 (3): 16-27 21 health outcomes and other consequences of ipv in bangladesh: a current survey carried out in 2019 mentioned that one of every six female met the criteria for major depressive episode (mde) because of ipv; psychological factor was most common, accompanied through sexual and physical. previous studies have revealed that the strong predictors of long-term bad intellectual health consequences amongst mothers are physical and sexual ipv, consisting of signs of stress, depression, and anxiety18,42,43.sexual violence turned into maternal depressive symptoms after 68 months of childbirth and has a stimulation on under-nutrition among under-5 children and thus different studies showed the ipv as a constraint to the better health of young children24,26. accidents, small cut, physical pain, broken bone or tooth, abrasions, bruise-swelling, and burns are the kinds of physical fitness consequences of ipv in bangladesh21,22,27,44. while a variety of research had been carried out in rural settings and reported that physical accidents were greater than different consequences ofipv21,22. ipv in bangladesh during pregnancy and it’s consequences: nearly15.5-65% of females experienced ipv at some stage in pregnancy, ensuing in pregnancy and labor problems and different detrimental outcomes for themselves and their newborns, it is possible to know that previous researches were investigated ipv on the time of pregnant and lactating period11,19,24–26,44. another study indicated that ipv during pregnancy prohibited getting proper antenatal care (anc) and the extreme physical ipv and low utilization of adequate anc have an enormous association between them. the study also found that, due to the low use of medically trained providers for assistance with delivery, mothers experience physical ipv and sexual ipv19.there’s another association between maternal physical ipv experiences and the low use of anc which was found by data from a statewide survey in india45 and clinic-based research in developed settings46,47. in the preceding studies, it is displayed that there’s a recognized association of ipv with lower anc checkup and medically educated personnel who helped in delivery supply a crucial context for the extended rates of bad pregnancy effects and signs of gynecologic morbidity32,48,49. besides, based on obtaining delivery care from a medical professional and visiting a professional anc provider, it had been seen that women who have experienced each physical and sexual ipv are substantially less possibly to obtain or visit, which is shown in the findings of a study19. in another study, it was observed that over 25% of females looking for abortion care, experience ipv in the previous year; in turn, this was related to different achievable constraints to reproductive autonomy and reproductive healthoutcomes25. ipv can bring a reverse consequence on child health whose mother experienced ipv during pregnancy or lactating period. maternal ride of any physical or sexual ipv used to be related to an elevated chance of stunting and underweight of their children26.females who ever experienced physical and sexual ipv have a greater proportion of low birth weight11. however, other findings from bangladesh journal of bioethics 2018; 9 (3): 16-27 22 bangladesh also stated that the risk of illness is increasing in children aged 5 years and below whose mothers met the ari and diarrhea criteria and who have experienced ipv in the preceding 12 months50.women in bangladesh experiencing violence from husbands were more likely to report both unwanted pregnancy and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth32. besides, physical ipv is significantly associated with the termination of pregnancy51. acceptance of ipv and seeking assistance: besides, some studies mentioned that bangladeshi women can also proceed with their life while staying in abusive relationships, in some instances for as long as many years even they do no longer expose ipv22,25. another study found that whenever those physically abused women attempt to find help by disclosing their experience (only 21%) and they get help according to their depicts (19%). the possible reasons for no longer searching for help could be excessive stage of violence acceptance, worries about bringing an awful title to the family, lack of self-belief that this would be beneficial and shame/embarrassment/fear of getting blamed. lack of facts concerning formal sources of assist hindered about 14% of the abused female from looking for help. those who sought assistance did so ordinarily when they were unable to undergo violence anymore. physically abused ladies most regularly are trying to find assistance from casual sources, such as relatives from their very own aspect and neighbors and very few females sought help from pretty formal sources such as nearby leaders/clubs and legal provider providers22. the probability of disclosure and help-seeking is improving according to severe and prevalent physical abuse. the severity of violence regulating disclosure and help-seeking behavior29,52,53along with the age of the blamed women29,54, woman’s incomeearning status54, and education55. seeking help also depends on the presence of children in a violent relationship56. due to lack of understanding of violence, many women in bangladesh cannot seek help57.violence against women in bangladesh has both structural and systemic dimensions. the response of different women’s groups and their strategies to counter violence is now an emerging trend in bangladesh58. a study claimed that empowerment may be protective against ipv in the aggregate59.moreover, understanding attitudes towards ipv in cultural context is important for developing interventions to reduce ipv and its consequences60. conclusions: women being younger, from low socioeconomic reputation, from low academic attainment and low education of husband, dowry, child marriage, perceived disobedience of wives, family conflict, children had recently been ill, and incapability of to furnish sexual satisfaction were the wide variety of individual risk elements for ipv in bangladesh. after all, ipv is no longer seen as a personal matter, it also helps to encouraged many women to search for outdoor services, if there seems to be an effective alternative in the understanding of ipv in bangladesh. however, in moving forward, because of consisting of bangladesh journal of bioethics 2018; 9 (3): 16-27 23 restrictive policies and practices that lower the reputation of women relative to men within the context of intimate relationships as well as their role in society, and many of the obstacles that stop female from in search of legal redress and recourse from ipv which is need to address. table 1: inclusion and exclusion criteria populations exposure/situation outcomes study design inclusion married women, men, adult girls and boys any abuses or violence in household or outside include sexual, mental or physical assault. all outcome relevant to the three sort of violence all study designs including published and gray literature, primary studies, newspaper reports exclusion teenager, widow, widower unidentified rape case or causalities between two different household conference abstract, commentaries and editorials table 2: type of evidence included in the review (n=22) method description references quantitative (n=18; 81.8%) cross sectional (n=6) 24, 39, 23, 22, 44, 51 hospital based (n=1) 11 secondary analysis (n=9) 25, 41, 32, 19, 21, 26, 34, 38, 32 randomized control trial (n=1) 40 not specified (n=1) 31 qualitative (n=3; 13.6%) not specified (n=2) 37, 60 case studies (n=1) 59 mixed method (n=1; 4.5%) 58 bangladesh journal of bioethics 2018; 9 (3): 16-27 17 references 1. who. understanding and addressing violence against women: intimate partner 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violence and symptoms of gynecologic morbidity among women in north india. int fam plan perspect. 2006:201-208. 49. jasinski jl. pregnancy and domestic violence: a review of the literature. trauma, violence, & abuse. trauma, violence, abus. 2004;5(1):47-64. 50. silverman jg, decker mr, gupta j, kapur n, raj a, naved rt. maternal experiences of intimate partner violence and child morbidity in bangladesh: evidence from a national bangladeshi sampleshort title: maternal ipv and child morbidity. jama pediatr. 2009;163(8):700-705. 51. rahman m. intimate partner violence and termination of pregnancy: a cross-sectional study of married bangladeshi women. reprod health. 2015;12(1):102. 52. ansara dl, hindin mj. formal and informal help-seeking associated with women’s and men’s experiences of intimate partner violence in canada. soc sci med. 2010;70(7):1011-1018. 53. ellsberg mc, winkvist a, peña r, stenlund h. women’s strategic responses to violence in nicaragua. j epidemiol community heal. 2001;55(8):547-555. 54. hyman i, forte t, du mont j, romans s, cohen mm. help-seeking behavior for intimate partner violence among racial minority women in canada. women’s heal issues. 2009;19(2):101-108. 55. coker al, derrick c, lumpkin jl, aldrich te, oldendick r. help-seeking for intimate partner violence and forced sex in south carolina. am j prev med. 2000;19(4):316-320. 56. meyer s. seeking help to protect the children?: the influence of children on women’s decisions to seek help when experiencing intimate partner violence. j fam violence. 2010;25(8):713-725. 57. morrison ke, luchok kj, richter dl, parra-medina d. factors influencing helpseeking from informal networks among african american victims of intimate partner violence. j interpers violence. 2006;21(11):1493-1511. 58. zaman h. violence against women in bangladesh: issues and responses. in: women’s studies international forum. vol 26 bangladesh journal of bioethics 2018; 9 (3): 16-27 20 22. elsevier; 1999:37-48. 59. schuler sr, lenzi r, badal sh, bates lm. women’s empowerment as a protective factor against intimate partner violence in bangladesh: a qualitative exploration of the process and limitations of its influence. violence against women. 2017;23(9):1100-1121. 60. schuler sr, yount km, lenzi r. justification of wife beating in rural bangladesh: a qualitative analysis of gender differences in responses to survey questions. violence against women. 2012;18(10):1177-1191. doi:10.1177/1077801212465152 author contributions: 1st author developed the concept and design of the paper; 2nd, 3rd and 4th were equally involved in the literature search, review, compilation, manuscript writing and revision. . conflicts of interests: the authors are declaring that they have no conflicts of interest. 27 microsoft word shamima article authorship bangladesh journal of bioethics 2021; 12 (1): 25-34 25 understanding of authorship by the post graduate medical students at a center in bangladesh shamima parvin lasker 1, muslema begum 2, arif hossain3, md abdul matin 4, saiful islam 5, darryl macer 6 1. phd (usa), mph (usa), emmb (europe), mphil (bd), msc (bd), professor & head of anatomy, shahabuddin medical college, dhaka, bangladesh; secretary general, bangladesh bioethics society. email: splasker04@yahoo.com (corresponding author) research id: https://orcid.org/0000-0002-3484-9526 2. md, fcps, assistant professor, depatment of anaesthesia & intensive care medicine dhaka medical college, bangladesh. email: muslemabeg@yahoo.com 3. phd, professor & course co-ordinator, etrat university, iran; vice president, bangladesh bioethics society. email: ahossainbbs@yahoo.com 4. phd, assistant director, (research & planning), dghs; bangladesh. email: drmatin1963@gmail.com 5. mph, mbbs, medical officer, dghs, bangladesh. email: drsaifulislam@gmail.com 6. ph.d., hon.d., president, american university of sovereign nations, usa. email: provost@ausn.info doi: https://doi.org/10.3329/bioethics.v12i1.51970 abstract: education on authorship was delivered and evaluated by pre test and post test questionnairen on 30 post graduate medical students at the department of anestheology, dhaka medical college, bangladesh between january and june 2019 to understand the knowledge, skill and attitude of post graduate medical students on authorship. result: before intervention, majority (60%) of the students felt that who perform the research work should be the author of the article. but 40% students were divided and felt that who advised the design of the research (20%), who provided the grants (10%) and chief/head of the division (10%) should be the author of the article respectively. maximum (70%) respondents did not know the order of authorship. of 40% respondent felt that the pi should be always the first author and 40% don’t know the answer. half of the students (50%) felt that keeping honorary author increased the opportunity of acceptance of publication. of 36.7% and 13.3% of students felt that keeping honorary author increased the article’s value and made good relation to them to get some extra facility from them respectively. of 20% participants were pressurized by lab head/head of department for inclusion of their name as an author. half of the (56.7 %) respondents felt that the author’s contribution should be stated in the article. only few 4 (13.3%) respondents said that their institute had guideline for authorship. however, after education 100% of students felt that who perform the research work should be only the author of the article. all (100%) respondents understood the order of authorship. most of the students (86%) felt that pi should be always the first author. of 100% respondent felt supervisor of the research should be the last author. all students (100%) felt author’s contribution should be mentioned in the article. all (100%) students did not want to include as author those who help in research design and secured grant; and they did not like to keep honorary author in their article. all (100%) students expressed that their institute had no guideline for authorship. after intervention, three groups of students were asked to write one page of article on anesthesiology. interestingly, they did not include any name in the author by line who were not participate or had any contribution in the writing. conclusion: the comparative data between preand post-text have highlighted a general lack of understanding of the basic concept of authorship ethics which significantly improved after bangladesh journal of bioethics 2021; 12 (1): 25-34 26 the intervention. the results also indicate that the education on authorship improved the awareness of postgraduate medical students in a particular centre. key word: authorship, medical student, publication ethics, bangladesh introduction: authorship is a basis of success for a researcher. but authorship process needs integrity. violation of ethics, authors dispute arises during pre and post publications of the article. this may decrease the trust of reader toward academic society. in the ancient times, articles generally had no authorship1. from middle ages, individuals started to feel the senses of authority, ownership and concern with plagiarism over their writing1. it is the printing press made the development of the concept of authorship as intellectual property rights in 1440 1. however, in 1978, a group of medical journal editors in vancouver, british columbia established publication guidelines for authors and editors. they developed international committee of medical journal editors (icmje), who designed the uniform requirements for manuscripts submission to help the authors and editors of the biomedical science to promote integrity in authorship 2. currently, most of the journals of biomedical, science, social science and other journals follow the icmje definition of authorship2. according to icmje, the authors are those who have substantial contribution in research and can take responsibility for a specific section of the research during any allegation. single contribution is not satisfied the authorship principles universally e.g. procurement of funding, providing technical services, suppling research materials or chemicals, administration of a research group, data collection and analysis; writing or editing manuscript etc2. but a research found that more than half of the articles did not satisfy icmje criteria of authorship 3. another study also reported that 40% article among 6,686 manuscript published in lancet did not meet the icjme criteria of authorship 4. however, there are some authors who neither do work for the research, nor met the authorship criteria have been attributed as honorary authors or gift authors or guest authors 5. honorary authorship is widely condemned and in the extreme is considered as misconduct 6. from above literature, it is obvious that there is gap in basic knowledge of authorship ethics especially in early career academics. no date has yet been available regarding the knowledge, skill and attitude of post graduate medical students on authorship in bangladesh. there is no systematic education on authorship for the post graduate medical students in bangladesh as well. therefore, this research has been undertaken to aware the post graduate medical students about the norms and regulation of authorships principles to avoid inadvertent violations of ethics in writing. this research will generate evidence of first time about the knowledge, skill and attitude on authorship. the evidence of the research may assist in policy decisions regarding authorship in medical curriculum in bangladesh. bangladesh journal of bioethics 2021; 12 (1): 25 28 materials and methods: a cross-sectional study was done on 30 post graduate medical students at the department of anestheology, dhaka medical college, dhaka, using 30 self-administered questionnaires between january to june 2019. education was given on authorship in a 4 hours long workshop starting from 8 am to 12 pm. survey was done by pretest and post-test questionnaire to evaluate the current knowledge of authorship principles among students. at the end of the post-test, all students were divided into three groups. they were given a writing task in group to understand their skill. it was a pilot study. sample were taken purposively according to the selection criteria. during workshop, in a class room setting, lectures and video demonstration on authorship were delivered. students took approximately 15 minutes to complete the questionnaire. questionnaire was validated by applying feedback form three post-graduate students. questionnaire consisted of two parts: the first part concentrated on demographic data about the age, sex, and educational qualification of participants; number of the publications, course or training on publication ethics. the second part was dedicated to a selfassessment questions to evaluate the knowledge by multiple choice questions. skill was assessed by 3 level of likert scale by 'yes', 'no or 'not sure' questions. ethical clearance was obtained from bangladesh medical research council (bmrc). all the participants were given an explanation about the objectives of the study, risk/ benefit of the study and right to withdrawal of their participation from the study. those who provided their written consent could participate in this study only. participants received a copy of ic form for their own reference. confidential were maintained properly and results were anonymous. questionnaire and ic form were kept in a sealed envelope and were stored in a locked and secured place for the period of three years. after three year, all the survey forms will be destroyed by burning. statistical basis of the sampling technique was estimated by raosoft, where marginal error-5%, ci-95%, response distribution100%. data were analyzed using spss version 22.0 software and ms-excel 2007. demographic and other variables were analyzed by frequency and percentage distribution. the knowledge on authorship before and after was compared by using a chi-square test. a p< 0.05 was considered statistically significant. no questionnaire was included for analysis when it was not properly filled out. results and discussion: a pilot study was done by pre-test and post-test questionnaire to understand the awareness of post graduate medical students on authorship by judging their knowledge, attitude and skill. demography: the mean±sd age of the respondents was 32.52 ±3.37, range between 28-42 yeas. there were 17 (56.70%) male and 13 (43.30%) females among 30 students. all the respondents were at thesis part of their post graduate study. they did not have any previous course or training on principles of authorship. there was also no provision for systematic education on authorships ethics by the institution. majority (93.3%) of 27 bangladesh journal of bioethics 2021; 12 (1): 25 28 respondents learn authorships ethics from their teachers/friends during post graduate course. authorship criteria: in our study, before education students were asked whether they know the authorship criteria. majority students 23 (76.87%) said that they did not know the authorship criteria. but after education all the respondents (100%) felt that they understood the authorship criteria (table 1). the difference was significant. in another question, before intervention, students were asked what could be the criteria for authorships. majority (60%) of the respondents felt that who perform the research work should be the author of the article. but other (40%) were divided before education. some felt that who design the research 6 (20%), who provide grants 3 (10%), and chief/head of the division 3 (10%) should be the author of the article respectively. but after education all the respondents (100%) felt that who perform the work should be the author of the article (table 1). no similar interventional research has been found to compare our research. however, research regarding the authorships criteria on different academics were seen. a research said that 21% of the first authors and 34% of last authors did not meet icmje criteria for authorship. whereas, 50% of the authors in between in the author by-line did not meet the criteria for authorship 3. at a question to corresponding author whether the name was mentioned in acknowledgement who had not make substantial contribution to the work. of 54% of the corresponding authors said that this statement was not applicable to their manuscript and 12 corresponding authors did not answer this question 3. in a statement vesna et al said that who did not fulfil authorship criteria are more prone to commit other types of scientific misconduct 3. order of author: in our study, before education, respondents were asked about the order of authorship. more than half of the respondent 18 (60%) felt that they did not know the answer. but only 2 (6.7) felt they knew the order of authorship. but after education all respondents (100%) felt that they understood the order of authorship (figure 1, table 1). at another question, students were asked about the sequence of authorship. majority 21 (70 %) felt that according to contribution authorship should be awarded. but 8 (26%) felt it should be depended on chief of the research team. only one (3.3%) felt sequence of the authors should be write according to seniority. but after education all respondents (100%) felt that sequence of authorship should awarded according to contribution authorship (table 1). balaji thought that researchers with less than six years of research experience found authorship decisions more difficult than more experienced researchers (48% vs 30%). more experienced researchers found decisions on authorships and order of authors easier than less experienced researchers 7. in our research, when we asked whether pi should be always the first author. students were divided in their opinion in this question before education. of 12 (40%), 5 (16.7%) bangladesh journal of bioethics 2021; 12 (1): 25 28 table 1: comparisons on questions of authorship between before and after education on authorship ethics delivered (n=50). before education after education p<0.05*** question yes no don’t know yes no don’t know do you know authorship criteria? 23.33% 76,67% 100% 0.008*** do you understand the meaning of the order of authors? 6.7% 60% 18 % 100% 0.000*** should a principal investigator always be a 1st author on papers? 58% 12% 30% 86% 14% 0.000*** are you keep honorary authors/ guest practices in your article? 20% 20% 60% 100% 0.030*** are you pressurized by lab head/ head of department for include their name as an author? 20% 20% 60% 20% 80% 0.006*** do you like to accept authorships when you didn't deserve it? 3.3% 70% 26.7% 100% 0.006*** did you do reciprocal agreement with colleague/friends to exchange authorship to increase the number of publications? 3.3% 73.3% 23.3% 100% 0.000*** should authors contribution be required to state in the article? 56.7 % 20% 23.3% 100% 0.000*** are there guidelines to determine who should be listed as an author in your institute/ country? 20% 10% 70% 80% 10% 2% 0.000*** are there guidelines who should be listed in the acknowledgments section in your institute/ country 13.3%% 23.3% 63.3% 100% 0.009*** and 12 (40%) felt yes, no, don’t respectively. but after education most of the respondents (86%) felt that pi should be always the first author and 14% felt that pi should not be always the first author (table 1). before education, at a question of who should be the last author? of 15 (50%), 7 (23.3%), 26 (26.7) felt supervisor, who supervise overall research and assistant of research could be the last author respectively (table 1). 29 bangladesh journal of bioethics 2021; 12 (1): 25 28 figure 1 shows the response of a question of whether students know the order of authorship author credit when not deserve it: at a question of whether they were offered an author credit when they didn't deserve it. of 27 (90%) respondents felt that they had never been offered an author credit when they didn't deserve it. it may happen because of they were post graduate level students and they had not had any publication yet. but one respondent (3.3%) expressed that he got the request. but after education all the respondents (100%) felt that they should not offered an author credit when they didn't deserve it (table 1). at another question whether they were maintained request for unauthorized authorship. majority 21(70%) respondents felt they did not maintain request for unauthorized authorship. but 1 (3.3) respondent felt that he maintained the request for unauthorized authorships. of 8 (26.7) said that they don’t know answer. but after education most of the respondents (100%) felt that they should not accept undeserved authorship (table 1). one respondent who expressed that he got a undeserve request and he maintained the unauthorized authorship; we did not know why he latter denied. our figure 2 shows that what respondents felt in case of question of reciprocal agreement with colleagues to exchange authorship to increase the publication (n=30). study protocol did not permit us to go for indepth interview of that particular student. reciprocal agreement: in case of question of reciprocal agreement with colleagues to exchange authorship to increase the number of publications, of 22 (73.3%) respondents felt they did not do this whereas 7(23.3%) were not sure on this question. but only one person (3.3%) felt he did reciprocal authorship (figure 2). but after education all respondents (100%) felt that they did not do the reciprocal agreement with college to exchange authorship to increase the publication, (table 1). honorary authors: in our study, regarding the honorary authors, we found that almost half 13 (43.3%) of respondents felt that honorary author should be the most experience person in their field. other felt that the chief of the davison 6 (20%); who give permission to use lab or materials 7(23.3%); internationally known persons 4 (13.3%) were the honorary author respectively (figure 3). 30 bangladesh journal of bioethics 2021; 12 (1): 25 figure 3 shows the response of a question of students whether they know the meaning of honorary authorship (n=30). at a question of why did you like to keep honorary author? half of respondents 15 (50%) felt that keeping honorary author opportunity would increase the number of publications. of 11 (36.7%) and 4 (13.3%) felt that keeping honorary author, article value would increase and make good relation to get some extra facility for them respectively (figure 4). but after education, all respondents (100%) felt that they did not like to keep honorary author (table 1). almost similar result has been found. vesna pointed out that 18% of authors were honorary authorship in their study and 55% were icmje-defined honorary authorship3. another survey reported that the prevalence of guest/honorary authorship varies up to 60%. articles with more than five authors have more gift or honorary authors than articles with three authors. if excludes the honorary / guest and gift author number would decline into two8. in our study 20% participants were pressurized by lab head/head of department for inclusion of their name as an author. no similar researched had not been found to compare our research. but research from balaji found that preclinical teachers (basic science) experienced more (46%) pressure to include undeserved authors in their papers than in paraclinical (community medicine) (25%)7. in our study, half of the (56.7 %) respondents felt that the author’s contribution should be stated in the article. but after intervention all students (100%) felt author’s contribution should be mentioned in the article. figure 4 shows the reasons to keep honorary authorship (n=30). the causes of misconduct in authorships are poorly understood. actually, academic promotion systems put substantial pressure on researches to produce numerous research publications9 that may include undeserve authorships. the judgment systems for funding also considers quantity rather than quality of publications 6,10. in addition, pressure to publish with lack of time, tight deadlines and other competing pressures may be the case of misconduct in authorship11. publish or perish is the today's competitive world’s maxim. therefore, it is tremendous pressure of researchers to publish significant number of articles per year to ensure 31 bangladesh journal of bioethics 2021; 12 (1): 25 continuity in academia, funding, and fulfill the expectations of institution. this is another leading cause of increase inappropriate authorships 12. lacanian emphasizes that the individuals involved in misconduct in face of more fundamental and devastating forms of crisis, which fail researcher to abide by codes and guidelines13. according to freudianpsychoanalytical perspective, when scientific research emerges as an impossible profession and challenged and frustrated to succeed by the researchers (the scientific super-ego) that conflicting imperatives and may easily become tormented the subjects 13. some researchers believe that research is a group work. where some arrange to work part by part such as thesis writing or manuscript writing or publication (author tasks), others conduct out research in allocation by part or data collection or data analysis of (non-author tasks) to give more effort and time in individual section to achieve scientific goal and considers each author should be listed in author byline. however, this arguments of “passive contribution” are not accepted by the most of the journals 8. how can a junior handle in an unethical request of seniors in authorships who do not have any substantial contribution? daniel k sokol suggested that it will not be wise to refuse senior to say using words such as honesty, trust, fairness, professionalism, or academic integrity rather it is better to say that the journal requires to sign an authorship form from all authors to satisfy authorship criteria. it may make the senior to feel morally attacked by highlighting the inappropriateness of the request14. in this way, the junior can be able to avoid participating in an unethical practice. in addition, medical journals should adopt various measures to discourage the practice of inappropriate authorship 14. in our study, majority 25 (83.3%) respondents did not know whether they had faced any type of problem yet. where one 1 (3.3%) student faced the situation that they did not include a name who was author mistakenly. two (6.7%) included a person without his permission and 2 (6.7%) included a person but he/she did not do any research. at another question of who would be the responsible during authorships dispute? half of the respondents 15 (50%) felt chief researcher would be the responsible during authorships dispute. other 4 (13.3) , 4(13.3), 4(13.3) and 3 (10%) respondents felt senior of the research team, chief of the division, grant institution and journal would be the responsible during authorship dispute respectively (figure 5). our study population were postgraduate students, most of them had yet no publication. but it is interesting to compare study of balaji that 29% respondents had been denied authorship they believed they deserved it. only 41.5% responders were aware of ghost authorship. a gift or guest authorship was offered to 10.7 % study participants whereas 14.35% had been ghost author7. actually, university set criterion on number of publications for researcher's career evaluation is the main cause of inappropriate authorships7. however, disputes cases regarding authorships were the most frequent scientific misconduct in the nordic countries15. 32 bangladesh journal of bioethics 2021; 12 (1): 25 guidelines: before education, respondents were asked whether their institute had any guideline for authorship. more than figure 5 shows that response of at a question of who would be the responsible during authorship dispute (n=30) half 19 (63.3%) respondents did not know whether their institute had any guideline for authorship criteria. some 7 (23.3%) said their institute had no guideline for authorship and few 4 (13.3%) said that their institute had guideline for authorship. but after intervention, majority respondents (80%) felt that their institute had no guideline for authorship (table 1). a study among 100 countries on authorship education result showed that 67% countries had received some publication ethics training, 41% country had received no course and only a small proportion rated training received as excellent9. writing to the students: after post-test on authorships ethics, all medical students were asked to divide into 3 groups. each group contained 10 students. after group discussion, students were asked to write one page of article on anesthesiology. writings were checked. it is interesting to note down that no name was included in the author by line who were not participate or had any contribution in the writing. it could be concluded that their skill on authorships were increased by intervention. limitation of survey: there were certain limitations in the present survey. this was a questionnaire-based survey and hence the results rely upon the replies that were received. however, as this was a first and pilot study from bangladesh, an effort to capture the existing situation of the level of knowledge, attitude, and skill in authorships ethical in scientific writing in the bangladesh. hence it needs to be validated through further study by undertaking with large number of participants and more duration of time for training/workshop in the near future. the sample size of this study was limited. it may not represent the national scenario. conclusions: an interventional study was done on 30 post graduate medical students at the department of anestheology, dhaka medical college, dhaka, between january to june 2019. survey was done by pretest and posttest questionnaires questionnaire to understand the current knowledge, attitude and skill of the postgraduate students on authorships ethics. the comparative data between preand post-text had highlighted a general lack of understanding of the basic concept authorships which improved after the intervention. knowledge of students were significantly increased by the workshop on authorship. more workshops with large sample large number of students are needed on authorships to finally conclude substantial remark of success of the intervention. recommendations: we sanctioned four recommendations, e.g. 1. supervisors should 33 bangladesh journal of bioethics 2021; 12 (1): 25 recommend authorships principles, so that research students can be competence enough and can handle the issue of inappropriateness when it arises. 2. institutions, universities should encourage in authorships ethics education. 3. editors and publishers should endorse a policy on authorship to prevent wrongness with scientific medical writings. 4. government should take policy to incorporate authorships ethics in post graduate curriculum at university level. acknowledgement: we express our sincere indebtedness and heartfelt thanks to director general of health services (dghs), ministry of healthy, people republic of bangladesh under health, population and nutrition sector development programme [hpnsp] for their support to complete this research. it was impossible to finish this novel research without their kind support. we express our thanks and deepest regards to all the participants of this research for their co-operation and collaboration. references: 1.lisa e. the concept of authorship: an historical perspective. annual meeting of the national council of teachers of english 1985. 2.icmje (international committee for medical journal editors) recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals 2015;1-17. www.icmje.org http://www.icmje.org/recommendations/browse/roles-andresponsibilities/defining-the-role-of-authors-andcontributors.html (access on july 2018) 3. vesna šs, ana m, dragana a, martina h, jelena o, anamaria š. icmje authorship criteria are not met in a substantial proportion of manuscripts submitted to biochemia medica. biochem med j 2015;25(3):324–334. 4. seog hee park, md kyu ho choi, md young ha park, md researcher contributions and fulfillment of icmje authorship criteria: analysis of author contribution lists in research articles with multiple authors published in radiology 2003; 226; 1:16-23 5. cse (council science editors). cse’s white paper on promoting integrity in scientific journal publications. editorial policy committee. 2012. www.councilscienceeditors.org (access on feb 2019). 6. molly tl, elbert dg, robert jmcd. publication ethics: an examination of authorship practices. am j health behav 2005 ; 29(6): 579-587. 7. balaji dm , anju bm, harsh js. knowledge, attitudes and practices of medical researchers toward authorship in scientific journals. int j basic clin pharmacol. 2020;9(4):582-589. 8. sandeep bb. 2012. authorship issues.lung india. 2012 jan-mar; 29(1): 76–80. 9. sara s, jason r, elizabeth l, donald bp, sarah m, timothy th. biomedical authors’ awareness of publication ethics: an international survey. bmj open 2018; 8:e021282:1-14. 10. psooy k. 2010. underserved authorship: too much of a good thing. canadian urology association j, 4:391–2. 11 sharma bb and singh v 2011. ethics in writing: learning to stay away from plagiarism and scientific misconduct lung india. 28(2): 148–150. 12.baethge c. 2008. publish together or perish: the increasing number of authors per article in academic journals is the consequence of a changing scientific culture: some researchers define authorship quite loosely. dtsch arztebl int 105;20:380-383. 13. zwart h. 2017. tales of research misconduct. a lacanian diagnostics of integrity challenges in science novels. springer opens, nijmegen, netherlands. 14. daniel ks. 2008. the dilemma of authorship. bmj. 1; 336 (7642): 478. 15.magne nf, peter k. authorship: attitudes and practice among norwegian researchers. bmc medical ethics 2014, 15:53 author contributions: 1st author shamima lasker conceived the idea, planed the research design, did the literature review and wrote the 1st draft. 2nd author muslema begum did the research design, conducted the workshop, gathered the data and done the statistics wrote the manuscript and checked the manuscript meticulously. 3rd author arif hossain, 4th author md abdul matin and 5th author saiful islam conducted the workshop, planed the research design, guided the research and checked the manuscript meticulously. last author darryl macer guided the conception of the idea, the manuscript writing process, and checked the manuscript meticulously. conflict of interests: the authors declared that there is no conflict of interest in this study. 34 microsoft word impaired dicision bangladesh journal of bioethics 2016;7(1):17-26 17 ethics of clinical research involving adults with impaired decision-making capacity tonmoy biswas 5th year, mbbs, faridpur medical college, bangladesh email: tshekhor@yahoo.com abstract: background: proper decision making capacity, adequate disclosure and voluntary decisions are basic constituents of informed consent which is required in surgical procedures, any interventions, any tissue collection, or any research involving the human participants. but, it becomes more hectic if the participants or patients are physically or mentally impaired for proper understanding or rational decision making. time has gone by assembling or regulating effective laws for research involving persons with impaired decision making capacity. still, question arises, is it ethical to enroll an incompetent person who is not physically or mentally fit to make a decision in risky research or interventional trials? if it is, how the informed consent and ethical measures can be taken? method: extensive literature review was done in google scholar, pubmed and national or institutional websites with the corresponding keywords to summarize the cases of impaired decision making and regulation of informed consent and ethical measures in those cases. results: decision making capacity requires three level of capacities and four levels of abilities. if a person has factual understanding, implies a certain level of rational belief, knows to manipulate information to arrive at a choice and remains stable on the choice, is known to be capacitated in decision making. impaired decision making capacity is more common in alzheimer’s disease and schizophrenia research. although a definite line between decisional capacity and incapacity is still in question, many assessment tools are available to conclude it. moreover, decisional incapacity has been found as a significant ratio in general or psychiatric hospitals and nursing homes regarding psychological disorders or critically ill conditions. but, these conditions should not prevent anyone from understanding, choosing, or accepting any intervention as sometimes they may have some preserved abilities too. as per accepted ethics, respect for persons incorporates at least two ethical convictions. first, the individual should be treated as an autonomous agent and second, the person with diminished autonomy is entitled to protection. that’s why, in case of severe psychiatric diseases and alzheimer’s diseases, surrogate consent is recommended. but surrogacy should be reviewed by the institutional review board (irb). multimedia consent process, advanced consent directives, rational consent waiver and many other processes are practiced in case of ethical research involving decisional incapacitate persons which are discussed in the paper. conclusion: it should be clarified by the irb whether involvement of impaired subjects has beneficial scientific aim or not. capacity assessment system should be in an organized and systemic way. threshold for capacity and recognition of persons able to conduct this process should be fixed. role of surrogacy and involvement of irb to align it in a proper manner is always a matter of concern. consideration of risk management, subjects’ autonomy and assent-dissent issues should be clarified in research. key words: research ethics; incapacity; research ethics committee; informed consent; bangladesh bangladesh journal of bioethics 2016;7(1):17-26 18 introduction: ethical issues are often emphasized in research involving human participants as mandatory. informed consent, as the most essential aspect of medical research, owes its origin to the father of medicine, hippocrates. currently, ethical principles and the consent have been shown to have great implications in clinical research, randomized control trial, medical intervention, treatment, and surgery. informed consent is based on three model; information sharing, decisional capacity and volunteerism and requires four types of abilities for proper decision making. but, if the participants are adults (excluding pediatric and emergency patients) and suffering from some mental disorders, schizophrenia, alzheimer disease, and critical illness or other handicapped condition, their decisional capacity is mostly impaired 1, 2 .what is the way of consent in those cases? what are the problems specifically arise concerning this issue? what is the ethical solution to those problems? this paper will review answers to the mentioned questions and specific measures. method: this research was done during the three month course of national institute of health (nih), usa on ethical and regulatory aspects of clinical research conducted by bangladesh bioethics society in 2014. through the literature review from google scholar, pubmed and national or institutional websites, it has been wanted to focus on history and consequence of research involving decisionally incompetent persons with highlighting ethics implemented in different research and practical studies. research principles involving patients of alzheimer’s disease, schizophrenia, patients of intensive care unit, of various psychological disorders, and with other decisional incapacities have been emphasized and reviewed by corresponding key-words. pediatric research and emergency research is to be excluded in this research article. decisional capacity and incapacity: decisional capacity defines a person’s abilities to realize, appreciate, reason, and make a selection3. it comprises evaluating a patient in a clinical care or subject in a research whether he/she is psychologically or legally skillful of adequate decisionmaking or not4. specifically, four levels of abilities counting as understanding, appreciating, reasoning, and communicating a stable choice are required to evaluate a person as decisionally capacitate. clinically, decisional capacity is closely related to competence that means the ability to consent for a care, management, and treatment or ability to refuse those 5. however, it is task based process, that is, a person has or lacks capacity for a particular decision at a particular time and under particular situations. on the other hand, defining decisional incapacity is not measured by definite objective standards, but on the cautious judgment of those who are closely related to that person and have a proper understanding about him/her6. therefore, a patient or subject has the deficient capacity related to a matter, if at specific time he cannot make a decision for himself related to that matter as a result of an impairment or functional trouble of the mind or brain7. thus, healthcare providers or clinical researchers should be observant to hints of decisional incapacity during assumption. it should be kept in mind that disagreement with the clinician’s treatment or recommendation is not itself only a clue to reduced capacity anyway. in various bangladesh journal of bioethics 2016;7(1):17-26 19 conditions, a person can be incompetent in decision making, such as alzheimer disease, schizophrenia, some mental and psychiatric disorders, neurological disorders, or some other medical conditions 4, 6. additionally, a person can be decisional incapacitate due to over-staying in intensive care unit, post-operative state, medical effects, persistent distracting pain, and loos, grief, or devastating news etc6. the principle of autonomy involves a physician’s consideration of the authority of a patient to decide, even if the decisions seem to be unwise. therefore, an individual must have decisionmaking capacity for making an autonomous decision or giving an informed consent to any medical treatment or research participation4. problem historical scenario: though the autonomy of a patient was first talked about in 1767, the idea of informed consent was in an ambiguous manner for many years8. in 1898, albert neisser, discoverer of the gonococcus was first questioned about ethical issues and informed consent when he injected cell free serum from syphilitic patients to non-syphilitic patients. though, according to albert moll, about 600 cases of unethical research without informed consent were reported, the case of neisser could trigger a firing debate in public society in that time. in 1900, prussian parliament issued an ethical regulation for bio-medical research which was the first interference in the open research involving human participants9. regarding a case in 1914, a judge in new york ruled to take patients’ consent before surgery although he withdrawn the necessity of consent in emergency cases and in cases of unconscious patients as an exception. consequently, after some more debates and events, german law addressed the ethical matter of therapeutic and non-therapeutic research in 1931. this was the first authorized regulation before the nuremberg code in 1947 and declaration of helsinki in 1964. however, from 1950 to 1970s different courts reshaped the ideas of informed consent and constructed it into a modern manner later on8, 9. informed consent was taken into concern in different times in the history in different places due to debated cases in 1971, 1972, 1973, 1974, 1976, 1978, 1980, 1984, 1986 and later years10. alzheimer disease: alzheimer disease (ad) is a neurological disorder which progressively abolishes memory and other mental functions caused by brain atrophy and spontaneous nerve tissue degeneration. it usually starts with forgetfulness and confusion and progress into losing all types of memory with disorientation, 11mood swing, changes in sleep, mis-identification, agitation, depression, delusion, 12, 13impaired speaking and writing, diminished thinking, reasoning, and decisional capacity11. as this condition lacks decisional capacity, it has been taken into a great concern to obtain informed consent. one study in united states showed 84% impairment of at least one of the four abilities of decision making among the alzheimer patients14. another study in california showed worse performance of these patients in decision making even than schizophrenia and diabetes patients15. about 60% of the alzheimer disease (ad) patient was incompetent in decision making as reported in another research 16 . likewise, in another study, 40% of the patients with ad were incapable to give consent in clinical trials and that is obviously bangladesh journal of bioethics 2016;7(1):17-26 20 significant in any basis17. all the data from research about ability of decision making among ad patients clearly states that in this condition, most of the patients don’t have the sufficient acceptable understanding, appreciating, reasoning, and communicating capacity which is required for agreement with any informed consent for any intervention, treatment or clinical trial. schizophrenia: schizophrenia is a chronic mental condition characterized by hallucination, illusion, delusion and impaired decision making18 caused by unclear genetic malfunction and environmental factors19. some other features of schizophrenia include disorganized motor functions and thinking18. decision making in the schizophrenia is significantly worse than other healthy participants due to lack of working memory in all age groups,20 even in the early stages of adolescence19. a study showed that 52% of their schizophrenia patient was impaired in decision making where it was only 12% in angina patients and 4% in non-psychiatric patients22. also, in a study, 18-20% schizophrenia patients had extreme low understanding and reasoning level.23 schizophrenia in younger patients can result fewer years of education than non-psychiatric young patients24. even, their decisional capacity was found lower than the hiv patients25. so, it is certain that during treatment or management of a schizophrenia patient or in case of any clinical trial, informed consent is a matter of unease due to decisional incapacity of most of the patients. other incapacities: depending upon the affected area, stroke patients are sometimes incapable of proper decision making and informed consent26. roughly, about 20 to 25% of the psychiatric patients are in lack of at least one component of decisional capacity27. one research among the medical patients in hospital showed 48% incapacity for informed consent among variety of medical conditions which signifies the ethical matter to involve them in any research or clinical trial28. another study in a nursing center showed about 30% incompetency among different medical situations29. in a study among the parkinson disease patients with impaired cognition, most were not capable to give informed consent: only 13% were capable in that drug trial30. patient of intensive care unit most of the times remain unconscious and cannot give any consent mostly31. although chief conditions have been discussed, there can be many other causes of decisional incapacity for informed consent in adult as discussed before. finally, informed consent and other ethical matters become greatly unstable in medical treatment, surgery, clinical trial, and research studies involving human participants if they are incapable of understanding, reasoning, appreciating and communicating, concisely of decision making. capacity evaluation procedure: basically, there are three vital steps for capacity assessment of adult participant: first, to detect the information related to the decision by examining the decision that needs to be anticipated, as well as the characteristics of substitute rational decisions with the pros and cons of them; second, to assess the cognitive ability for evaluating capability of understanding the information, decision making, and volunteerism; third, to assess the factors acting behind one’s capacity like delusions, hallucinations, depression, manic illnesses, and lack of maturity32. macarthur competence assessment tools for clinical research and treatment bangladesh journal of bioethics 2016;7(1):17-26 21 (maccat-cr and maccat-t) is widely used for capacity assessment. moreover, competency to consent to treatment inventory (ccti), and mini-mental state examination (mmse) are also necessary tools in research involving adult participants33. other tools include aid to capacity evaluation (ace), the hopkins competency assessment test (hcat), and the understanding treatment disclosure (utd) etc34. although, there are some debates and counter-opinions based on of evaluation of the assessment measures and tools35, this paper will not discuss that issue. preserved abilities: in a previous research, it was reported that 38% of those judged incapable of consenting to drug randomized control trial (rct) and 55% of those judged incompetent of consenting to neurosurgical rct are still capable of appointing a proxy36. if this the scenario, then participants should be first asked to appoint an individual as surrogate themselves before further deterioration of their cognitive thinking and rational capacity. ethical approaches to the problems: ethical approaches regarding informed consent in decisional incapacitated adults are still in mirage; no exact policy addressed this problem. alzheimer disease ethics: in any study involving alzheimer disease patient, it is better to check for decisional capacity properly, as some cases may have intact decisional capacity as exception. if the capacity is found diminished, it is recommended to check for the preserved abilities to appoint a family member or known person as a surrogate himself. but, in the matter of research interventions, it is better to make a proxy surrogate at the early stage of disease progression before full loss of capacity37. this type of research protocol is highly screened by institutional review boards (irbs) and they accept surrogate consent most of the cases. but, the acceptance of person working as proxy varies. a study in usa showed that most of irb were affirmative in appointment of authorized representatives, spouses, parents, adult children, and adult siblings as a surrogate but negative in case of adult grandchildren, other adult families, and friends. but, in case of this kind of research, assessment of direct benefits from the expected results and probable risks are measured and evaluated effectively. most review boards permit the research if it has minimal tolerable risks, otherwise don’t38. ethics in schizophrenia: the approaches in a case of schizophrenia also include the initial step of alzheimer disease that is the proper assessment of decisional capacity and calculation of preserved abilities. however, in schizophrenia, informed consent can be theorized as comprising three basic elements: information sharing, decisional capacity and capacity for voluntarism39. the first one is information sharing; all the information regarding the trial or study should be disclosed to the patient including study aims, possible risks and advantages of participation, options of participation, and related study plan like using a placebo40. to address the cognitive impairment, multimedia presentation and computerized information with spontaneous feedback showed significant increase in decisional capacity in these patients41. but, problem arises with the second element which is decisional capacity and as we discussed, schizophrenia patients often lack of it. bangladesh journal of bioethics 2016;7(1):17-26 22 to solve this matter, we can use surrogate consent like alzheimer but, most schizophrenia patient prefer autonomous decision making rather than proxy consent42. so, surrogacy should always be the last option. to deal with their cognitive impairment, advanced research directives can be the preference. it is actually a written prior document that provides clear consent about the all upcoming possibilities. it will indicate the entire possible scenario that may arise during the course of research, involving risks and benefits of each step. this is advanced strategy to preserve the autonomy of the schizophrenic patients in decision making despite having some limitations43. in case of its limitations, surrogate can be chosen as an option. finally comes the third element of informed consent, voluntarism which is more important but less understood. voluntarism is always in question when the physician treating the individual is himself an investigator because the individual depends upon the clinician for continuous well-being. but, this problem can be solved by involving the researchers who are not related to the patient’s treatment44. another useful strategy is to encourage schizophrenia community in research procedure and to involve them in reviewing the study plan. web based tool to enhance the informed consent process in schizophrenia is also a newly appreciated theory45, 46. ethics in other psychiatric conditions: in psychiatric conditions, research undergoes more ethical evaluation. as there are two types of research, therapeutic and non-therapeutic; nontherapeutic has fewer risks. so, it can be permitted after proper assessment, but the therapeutic study requires more concern47. in case of proper direct beneficial study, irb can determine the legally authorized surrogate. if the risk is more than the minimal, the consent of the team involved in patient treatment must be obtained 48. it is recommended to have some core safeguards in psychiatric research; irb risk-benefit assessment, consent assessment, necessity requirement, sufficient evidences with proxy decision makers, assent-dissent issues, and independent monitoring. more ethical emphasize should be given on blood draw, two pet (positron emission tomography) scans with arterial line, drug withdrawal, and phase-ii drug trial49. however, consent waivers sometimes can also be considered in psychiatric research based on some criteria in certain cases but those should be appropriately judged by the irb50. ethics of consent in critically ill or intensive care unit (icu) patients: in the critically ill patients, informed consent also requires its basic three components as mentioned above. but, it is predictive that most participants are not capable to fulfill the criteria of informed consent at this stage. however, information sharing, decisional capacity and capacity for voluntarism can be addressed consciously before progression of alignment. if it is not possible, surrogate consent is often practiced51. but study showed that surrogates were more inaccurate regarding similarities with the patient choice52. so, researcher also looked for other measures. sometimes, the specific informed consent was not obtained53. some regulations also suggested waiver of consent in emergency cases as an exception. in some cases like septic shock, waiver of informed consent did not have negative effect upon the progression of research. in recent years, some ethical regulations have been agreed to become positive in waiving consent procedure of clinical trial for critical bangladesh journal of bioethics 2016;7(1):17-26 23 patients in intensive care units. but for that case, proper assessment of risks by irbs is mandatory54. conclusion: informed consent of the incapacitate adults in decision-making is an emerging ethical issue in health research. at first we have to determine a definite line between decisional capacity and incapacity and estimate the capabilities of the participant with the established assessment tool with proper observation of the preserved abilities. according to the statistical data, alzheimer patients, schizophrenia patients, psychiatric patients, and critically ill patients are invariably unable to understand ethical matters of treatment or research and unable to give informed consent. we should acquire data from them by the methods described above. established guidelines are needed to be followed to maintain participants’ autonomy and beneficence. after that purpose of the research can be served ethically. revision of national medical ethics policies by the experts regarding this issue is mandatory. further, health professionals should be informed about the serious ethical matter. however, appropriate ethical approaches to the decisional incapacitate adults is solely obligatory to heighten the practicability of research involving human participants. references: 1. koch hans-georg. reiter-theilstella, helmchen hanfried. informed consent in psychiatry: european perspectives of ethics, law and clinical practice, ist ed. badenbaden: nomos verl-ges.germany, 1996. 2. wood susan y, friedland barbara a, mcgrory c. elizabeth. informed consent: from good intentions to sound practices a report of a seminar. population council new york 2001; www. popcouncil.org [ref list] 3. appelbaum ps, grisso t. macarthur competence assessment tool 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"clinicians' judgement of capacity of nursing home patients to give informed consent." psychiatric services (washington, dc) 47, no. 9 (1996): 956-960. 30. karlawish, j., cary, m., moelter, s. t., siderowf, a., sullo, e., xie, s., & weintraub, d. (2013). cognitive impairment and pd patients’ capacity to consent to research. neurology, 81(9), 801–807. doi:10.1212/wnl.0b013e3182a05ba5 31. booth, m., doherty, p., fairgrieve, r., & kinsella, j. (2004). relatives’ knowledge of decision making in intensive care. journal of medical ethics, 30(5), 459–461. doi:10.1136/jme.2002.000802 32. amer, a. b. (2013). informed consent in adult psychiatry. oman medical journal, 28(4), 228–231. doi:10.5001/omj.2013.67 33. dunn, l. b., & misra, s. (2009). research ethics issues in geriatric psychiatry. the psychiatric clinics of north america, 32(2), 395–411. doi:10.1016/j.psc.2009.03.007 34. laura l. sessums, jd, md ; assessing medical decision-making capacity; physician’s weekly; feature article may 8, 2012; http://www.physiciansweekly.com/medical-decisionmaking-capacity/; last accessed: december 15, 2014 35. kim, scott yh. evaluation of capacity to consent to treatment and research. oxford university press, 2009. 36. kim, scott yh, jason h. karlawish, h. myra kim, ian f. wall, andrea c. bozoki, and paul s. appelbaum. "preservation of the capacity to appoint a proxy decision maker: implications for dementia research." archives of general psychiatry 68, no. 2 (2011): 214219. 37. kim, s. y. h. (2011). the ethics of informed consent in alzheimer disease research. nature reviews. neurology, 7(7), 410–414. doi:10.1038/nrneurol.2011.76 38. gong, m. n., winkel, g., rhodes, r., richardson, l. d., & silverstein, j. h. (2010). surrogate consent for research involving adults with impaired decision making: survey of institutional review board practices. critical care medicine, 38(11), 2146–2154. doi:10.1097/ccm.0b013e3181f26fe6 bangladesh journal of bioethics 2016;7(1):17-26 26 39. roberts l w. ethics and mental illness research. psychiatr clin north am 2002. 25525– 545.545 40. macklin r. understanding informed consent. acta oncol 1999. 3883–87.87 41. dunn l b, lindamer l a, palmer b w. et al improving understanding of research consent in middle‐aged and elderly patients with psychotic disorders. am j geriatr psychiatry 2002. 10142–150.150 42. roberts l w, warner t d, brody j l. perspectives of patients with schizophrenia and psychiatrists regarding ethically important aspects of research participation. am j psychiatry 2000. 15767–74.74 43. arboleda‐florez j, weisstub d n. ethical research with the mentally disordered. can j psychiatry 1997. 42485–491.491 44. levine r j. consent issues in human research. in: emanuel ej, crouch ra, arras jd, et al eds. ethical and regulatory aspects of clinical research: readings and commentary. baltimore, md: johns hopkins university press, 2003. 197–201.201 45. macaulay a c, commanda l e, freeman w l. et al participatory research maximises community and lay involvement. bmj 1999. 319774–778.778 46. harmell, a. l., palmer, b. w., & jeste, d. v. (2012). preliminary study of a web-based tool for enhancing the informed consent process in schizophrenia research. schizophrenia research, 141(2-3), 247–250. doi:10.1016/j.schres.2012.08.001 47. welie sp & berghmans rl: inclusion of patients with severe mental illness in clinical trials: issues and recommendations surrounding informed consent. cns drugs 2006; 20:67-83. 48. s. j. delano, j. l. zucker et al. protecting mental health research subjects without prohibiting progress. hosp community psychiatry. 1994 june; 45(6): 601–603. 49. wendler d, prasad k. core safeguards for clinical research with adults who are unable to consent. ann intern med. 2001;135:514-523. doi:10.7326/0003-4819-135-7200110020-00011 50. rosoff aj. informed consent (a guide for health care providers). rockville, maryland: aspen publications; 1981;p14. 51. davis n, pohlman a, gehlbach b, et al. improving the process of informed consent in the critically ill. jama. 2003;289(15):1963-1968. doi:10.1001/jama.289.15.1963. 52. coppolino, michael, and lynn ackerson. "do surrogate decision makers provide accurate consent for intensive care research?." chest journal 119, no. 2 (2001): 603-612. 53. chenaud, c., merlani, p., luyasu, s., & ricou, b. (2006). informed consent for research obtained during the intensive care unit stay. critical care, 10(6), r170. doi:10.1186/cc5120 54. chenaud, c., merlani, p., & ricou, b. (2007). research in critically ill patients: standards of informed consent. critical care, 11(1), 110. doi:10.1186/cc5678 author declared no conflict of interest. microsoft word child marriage in bangladespolicy and ethics bangladesh journal of bioethics 2020; 11 (1): 24-34 23 child marriage in bangladesh: policy and ethics ahnaf tahmid arnab1 md. sanwar siraj, ph.d.2 1. undergraduate student, department of government and politics, jahangirnagar university, savar, dhaka1342, bangladesh, email: ahnaf.bracket@gmail.com 2. assistant professor, department of government and politics, jahangirnagar university, savar, dhaka-1342, bangladesh. siraj_sanwar@juniv.edu (corresponding author) doi: https://doi.org/10.3329/bioethics.v11i1.49193 abstract: bangladesh is a muslim-majority society with more than 163 million people. most bangladeshis hold the ideals of islamic norms and values which is manifest in all sorts of sociocultural behaviour. in reference to such values, the tradition of legitimizing child marriage in bangladesh is the issue that needs to be addressed in a holistic yet rigorous approach. currently bangladesh ranks 4th in the world and 1st in asia in terms of child marriage. recently the child marriage restraint act 1929 has been abolished and it has been replaced by the act of 2017 preserving article 2 of the previous statute, the legal age for marriage for a boy 21 and for a girl 18. this act adds article 19 which legalizes minors (below 18 years of age) to be married off with the consent of the parents/guardians at the presence of a magistrate under “special circumstances” deemed with securing the best interest for them. the law artfully coincides with the muslim marriage law which allows participants of 15 years and above to get legally married and as such contradicts the international law and the act of 2017 itself. in the west intimate relationships including extra-marital cohabitation before reaching 18 years of age are culturally accepted. in contrast, such extra-marital and intimate relationships are strictly prohibited in muslim-majority societies, which are dearly adhered in bangladeshi muslim culture. this study examines how the religious cultural and socioeconomic realities influence child marriage practice in bangladesh. along with secondary documents, we interviewed 22 individuals including the deputy commissioner, the district women and children affairs officer, elected union parishad chairman and members, social workers, married couples and their parents/guardians at manikganj district. in addition, we also conducted a mass survey with 62 randomly selected participants, and a voluntary online survey where the opinion of another 53 young students were collected to find broad opinion. we also collected stories of how marriages take place at the rural, urban and sub-urban areas in bangladesh. the study has revealed that bangladeshis does not support marriage at early ages but socio-economic reality often pushes poor into getting their children married at early ages. many view that the special provision may encourage child marriage in the country. this study suggests that the government of bangladesh should redefine public policy in regard to finding a middle ground between islamic ethics and international values by exploring isomorphic mimicry and other socio-culturally accepted measures with a view to abolishing child marriage successfully. key-words: child marriage, muslim, culture, bangladesh. introduction: bangladesh is a south asian muslimmajority society where 90% of the inhabitants are muslims, 9% hindus and the rest 1% belong to christianity, buddhism and other religious groups1. thus, it is obvious that muslim values and ethics occupy the largest share in mainstream bangladeshi culture. it is a breeding zone for multiple socio-political paradoxes. such an alarming issue in the bangladesh journal of bioethics 2020; 11 (1): 24-34 24 0 20 40 60 80 niger central african republic chad bangladesh mali south sudan burkina faso guinea mozambique india chart 1: top 10 countries with chart 1: top 10 countries with chart 1: top 10 countries with chart 1: top 10 countries with highest rates in child marriagehighest rates in child marriagehighest rates in child marriagehighest rates in child marriage statecraft is its policies regarding early marriage, and how instead of reducing cases of child marriage for which the policies were designed in the first place, it is being subtly encouraged. the legal practice of child marriage has been prevalent in bangladesh since the child marriage restraint act adopted in 1929. section 2 of this act states that the legal age for marriage for a boy is 21 and for a girl 18. the present child marriage rate in bangladesh is the highest in asia, with 52 percent of girls getting married before 18 years of age, and 18 percent married before turning 152. it ranks 4th in the world, second only to india in numbers, the three other countries where the child marriage rate is higher than bangladesh are backward african countries3. studies have rooted out the eminent causes of child marriage in bangladesh, which primarily include poverty, lack of education and social barriers, such asthe thought of ensuring the protection of the daughter by getting her married off at a young age4. a 2018 report5 shows various socio-economic reasons which provoke the practice of child marriage. these include safety issues, perceived lower value of the girl child, unequal education and livelihood opportunities, gendered norms and harmful practices, and heightened vulnerabilities due to natural disasters. according to a 2017 unicef report6, among the countries with the highest rates of child marriage before age 18 (counted among women now 20 to 24), bangladesh ranks 4th globally. its position remains just behind that of 3 african countries, namelychad, central african republic and niger (see chart 1). lately, the 1929 act has been abolished and a new law called the child marriage restraint act 2017 has been passed keeping article 2 of the 1929 act, which contains the legal age for marriage in bangladesh, unchanged. the new law adds a new provision in article 19 that describes: “…under such special circumstances as may be prescribed by rules in the best interests of the minor, at the directions of the court and with consent of the parents or the guardian of the minor, as the case may be, it shall not be deemed to be an offence under this act”. this means that adolescents at any age can get married legally by taking the consent from their parents/guardians and seeking permission from the courts under “special circumstances” for securing the best interests of the bride and the groom. but the provision does not specifically explain the term “special circumstance” or what chart 1 shows the position of bangladesh among the countries with the highest rates in child marriage. bangladesh journal of bioethics 2020; 11 (1): 24-34 25 kind of “interests” it would serve for the participants. so, a set of question relevantly arises including who will get benefitted from the law? and how could it help in decreasing current child marriage rate in the country? the muslim law keeps the minimum age for marriage at 15 years or the age when puberty begins, since islam encourages early marriage to prevent extra-marital relationships. in the case for formal marriages, the muslim law differs to a great extent from the international law which is currently being followed in the state. the internationally recognized laws state that the minimum age for a person to get married is 18 years. unicef deems the act of marrying off a person before 18, or a minor, to be a violation of human rights. it states that “…marriage before the age of 18 is a fundamental violation of human rights. many factors interact to place a child at risk of marriage, including poverty, the perception that marriage will provide ‘protection’, family honor, social norms, customary or religious laws that condone the practice, an inadequate legislative framework and the state of a country’s civil registration system. while the practice is more common among girls than boys, it is a violation of rights regardless of sex”7. the reason for selecting 18 as the ‘age of adulthood’ does not have a particular scientific basis. rather it is linked mostly to the age of universal suffrage or voting rights. this universal bar of 18 years is therefore championed by the developed western societies, without paying heed to the geographic, psychological or sociocultural attributes of distinctive nations. research works are yet being conducted to find out the age at which the psychological growth of a human being attains a minimum threshold. the age of maturity and the minimum age for marriage are not to be entangled here, since there is a lack of proper scientific documentation in determining either of the two. the western communities have fixed 18 years as the age of maturity for consent. but one can easily find infinite cases of premarital sexual contacts, pregnancies and live-in relationships (where the partners cohabitate without formal wedding procedures) globally, before the participants turn 18. and these practices are taking place with the consent of the people involved. so, is consent only required when two people want to be formally engaged in a marital relationship? since it is an established fact that when a person reaches puberty, s/he develops sexual cravings and thus stepping towards the path of fulfilling those desires is very natural and evidential. this biological fact is thoroughly reflected in the culture of the west, which is different from the muslim culture. the important thing is that the western secular culture, upon which the international laws regarding marriage and human rights are based on, approves premarital sexual relationships and cohabitation. besides, only in recent years, the neurobiological underpinnings of “maturity” are being researched for legal institutions – where primarily the growth of the “frontal cortex” of human brains are argued as signs of maturity8. like other majority muslim societies such as bangladesh, an act which is called “zina” or fornication, is considered outrageous, extra-religious, and is strictly prohibited. there are two fundamental sources in muslim laws – the holy qur’an (the verbatim words of almighty allah) and bangladesh journal of bioethics 2020; 11 (1): 24-34 26 the hadith (the sayings, actions and practices of prophet muhammad and his companions). these offer references for the prohibition of extra-marital relationships as follows: “do not go near adultery, surely it is an indecency, and an evil way [of fulfilling sexual urge]” (qur’an, 17:32); "the believers are... those who protect their sexual organs except from their spouses... therefore, whosoever seeks more beyond that [in sexual gratification], then they are the transgressors" (qur’an, 23:5-6). the hadith also states “receive teaching from me, receive teaching from me. allah has ordained a way for those women. when an unmarried male commits adultery with an unmarried female, they should receive one hundred lashes and banishment for one year. and in case of married male committing adultery with a married female, they shall receive one hundred lashes and be stoned to death” (sahih muslim, 17:4191). muslims in bangladesh often see it as their religious duty to have their children married off before reaching puberty as it may ensure psychological and physical wellbeing of their children. however, socio-economic realities often push poor people towards child marriage in order to ensure their social security and lift themselves out of poverty. as bangladesh is a poverty-ridden society in which more than 20% people still live below the poverty line9. millions of people cannot afford healthy food, shelter, clean water, medication and energy. millions more live in the streets. a large chunk of 60% of the population live in the rural areas10, and are accustomed to social superstitions, such as “dowry system”. in order to avoid the burden of giving higher dowry rates, the poor, illiterate and unaware parents/guardians often marry their daughters off at comparatively younger age. henceforth, these are the people who may certainly take advantage of the existing laws and ultimately instead of decreasing, child marriage will inevitably increase. it will adversely affect the health of the under-age married children, and will hinder the socioeconomic development of the country. in iran, the legal age for marriage at 18 according to the “convention on the rights of the child” (1994). but it still reserves some ambiguity in situations where the law may contradict the shariah law. it allows girls below 13 and boys below 15 to get married, since the “age of majority” is calculated based on lunar years11. turkey became a signatory to the convention on the elimination of all forms of discrimination against women (cedaw) in 1985 and set its legal age for marriage at 18 according to the convention on the rights of the child,12 yet its directorate of religious affairs suggested in 2018 that children as young as 9 could marry under islamic law13. in pakistan, for example, the traditions of swara (marrying off girls to resolve conflict), addo baddo (marriage within families or tribes), watta satta (exchange of wives) or pait likkhi (getting girls married often before their birth) – are still in practice14. pakistan still follows the child marriage restraint act of 1929, setting the legal age for marriage of boys at 18 and girls at 16 – which bangladesh abolished in its reformed act of 2017. on the contrary, in malaysia for example, although the state laws require for women to be 18 to marry, yet through consent or shariah courts, a woman can marry off if she reaches 16 years of age15. thus, we bangladesh journal of bioethics 2020; 11 (1): 24-34 27 can see that, although there is a narrow deviation from international standards, yet the age-limit is specified: not below 16, unlike that in the “special provision” (section 19, child marriage restraint act 2017) in bangladesh. in the case for bangladesh, similar actions can be undertaken through the neo-institutionalist approach called isomorphic mimicry, which implies: “different organisms evolving to look similar without actually being related. in particular, isomorphic mimicry is the process by which one organism mimics another to gain an evolutionary advantage”16. hence, the notion of isomorphic-mimicry is to transfer the “plausible infrastructural bases” from a socio-culturally similar society and ‘improvise’ it accordingly in order to practically use it in the host society. in bangladesh, such a strategy could possibly put a greater impact on the early marriage issue, by defining the core pillars of marriage clearly and altering the social institutions in a controlled manner through proper statutory laws and their implementation. moreover, this study addresses the following relevant policy and ethical questions: (1) should bangladeshis follow western secular and autonomy-oriented marriage law in regard to child marriage? (2) how have the islamic cultural factors and socio-economic realities shaped the marriage law in bangladesh? (3) what extent of policy reform is necessary for such cases? and (4) how should public policies be ethically and socially justified in the country? by analysing the views and perceptions of the interviewees, this study attempts to explore the necessary reforms which are ethically sound, morally defensible and socio-economically adjustable in the context of bangladesh, and which may help in decreasing child marriage that will ensure better outcome for the country. research methodology: in addition to the review of secondary literature, we collected the primary data in two phases. in the first phase, we purposively interviewed 22 individuals including the deputy commissioner, the district women and children affairs officer, elected union parishad chairman and members, social workers, married couples and their parents/guardians at manikganj district in march 2017. we asked interviewees the following questions: what are the causes of child marriage in bangladesh? how could bangladeshis refrain from the practice of child marriage? do you consider that the current law can abolish child marriage rate bangladesh? is it ethically permissible to allow adolescents into getting legally married at any age, under ‘special circumstances’? we also collected stories from parents/guardians of married couples regarding how marriages take place in the rural and urban areas of bangladesh. the views and perceptions were collected in bengali as bangladeshis love to express themselves in their native language, bengali. the data were then transcribed into english. we coded and analyzed them using content and thematic analysis. in the second phase, we also conducted a mass survey with randomly selected 62 participants in urban areas of dhaka and sub-urban regions of chittagong to find broad opinion. the majority of the respondents are male because the survey was conducted in the streets of the respective districts and people do not usually want to allow unknown people bangladesh journal of bioethics 2020; 11 (1): 24-34 28 inside home due to security reasons. the sample represents are the public and private service holders, academics, businessmen, students, farmers and daylaborers. in order to capture the thoughts of the young adults, we have also conducted a voluntary online survey where the opinion of another 53 respondents was recorded in early december 2019. this sample mostly involves the students of public and private universities. some of the major questions asked to the respondents of both the surveys were: do you know about the child marriage restraint act 2017? do you support the ‘special provision’ in article 19 of the act? do you think the current child marriage restraint policy will increase rather decrease child marriage in bangladesh? findings from the field: traditionally, bangladesh is a collective society with a patriarchal structure in which a father/guardian is always positioned at the center of stage and is always respected by all the family members. although decisions are usually made by the family members discussing together in families but the father/guardian plays important role in making decisions, especially decisions regarding the marriage of their daughters. in bangladesh, daughters born in poorer households are often considered as a burden by their families. marrying the daughter off to a man at an early age is therefore considered as a survival strategy for many bangladeshi families, especially the poor ones. as bangladesh is a ruralbased society, people who live in rural areas are prone to poverty and poor people are somehow forced to get their daughters married at early ages. a parent, rahman whose age was 55, said that “i was married at the age of 22 and my wife was 14. i am a fisherman and live in the jamuna riverside. every day, i catch fish in jamuna river and sell them out in local markets. the money i earn by selling fish in markets is generally used to bear the expenses of our daily lives. we have three daughters and two of them were married off at early ages. i went to the union parishad office and was issued age certificates of my daughters and got them married at their early ages as because i was unable to secure the life of my daughters socially and even unable to feed them regularly. i searched for husbands for my daughters so as to the girls can depend”. a social service worker also said that the local representative is often convinced by poor parents and issues 18+ age certificate that is required for the legal marriage systems. the representative is sympathized and issues age certificates when they see that the poor parents live in vulnerable conditions with many of their daughters. the poverty is the underpinning factor that makes poor people more vulnerable in living their daily lives. it pushes poor families towards making decisions into getting their daughters married at early ages. a vast majority people in bangladesh still live in rural areas and the prevalence rate of child marriage in the rural people tends always to be higher than the urban people. a question was asked to interviewees regarding the causes and consequences of early marriages in bangladesh. for example, an elected union parishad chairman who took few minutes and replied that “rural people feel happy when they see that they can get married their daughters at early ages. because marrying off daughters at early ages ensures financial and social security. these bangladesh journal of bioethics 2020; 11 (1): 24-34 29 securities are manifested as follows: firstly, parents don’t need to pay much dowry if their daughters get married at early ages. what i see is that a young girl is mostly liked by the potential brides, which surmounts to lesser dowry. secondly, poor people, especially rural, are prone to have more children as poverty drives them to produce more children, for economic and awareness issues”. an elected union parishad member added a few lines with a view that “poor parents who have more daughters are always eager to get their daughters married at early ages as they feel secure socially. because marrying off daughters at early ages is beneficial for poor parents/guardians who usually have more daughters”. parents/guardian always want to get their daughters married at early ages when they see that they are unable to secure their daughters, unable to provide the cost of their basic necessities i.e. food, shelter, cloth, education and healthcare. these reasons gear to increase the prevalence rate of child marriage higher in rural areas, as unicef reports.(17) a social worker, who works for the development issues, said that the consequences are mostly negative as many whose daughters are marrying off at early ages. he opined that “girls who are married at early ages often tend to bear children and manage household activities. as a result, they have to quit their education at early ages. it is not only associated with poor social outcomes but also it is adversely affected on adolescent’s physical health”. he also added that “adolescents who have pregnancies at early ages usually have an increased risk of death during childbirth and malaria, and have poor child health outcomes such as the incensement of infant mortality rates, loss of weights and diarrhea diseases”. studies found that pregnancies as a result of early marriages cause negative health outcomes for girls and her offspring’s18. most bangladeshis get their children married at early ages as because it helps them to prevent doing their daughters premarital physical relationships. parents who have unmarried adolescent daughters at home are worrying about the fear of their daughters getting involved in pre-marital sexual relationships. thus, parents want to have their adolescent daughters get married at their early ages. a father of a newly married adolescent girl narrated his opinion in a line that “as we are muslims, we have to follow the rules and instructions offered by the quran and hadith. pre-marital-physical relationships are strictly prohibited in islam and we must have to get our daughters married when they are at the stage of their puberty. if our daughters do wrong things with others, we have to be punished for our wrong deeds in the day of the final judgment. for this reason, i got my daughter married before she turned 16. as i am a muslim, i believe that marrying off my daughter at early age ensures my daughters physical safety and it also protects my family prestige and honor.” muslim marriage law sharply contradicts with the internationally accepted law that is prescribed by the bangladesh government. as pre-marital relationship is socio-culturally prohibited in bangladesh, the contradiction between the muslim marriage law and statutory law often encourages muslims into getting their children married at early ages in order to preserve sexual and family honor. bangladesh journal of bioethics 2020; 11 (1): 24-34 30 0% 20% 40% 60% 80% 100% question 1 question 2 question 3 question 4 question 5 question 6 question 7 chart 2: opinion from mass survey, n=62 yes no the following chart 2 and chart 3 reveal the answers to seven of the major questions asked from the questionnaire to the respondents in the mass survey and the online survey. the questions are: 1) do you think it is appropriate for a minor (>18) to get married? 2) are you aware of the child marriage restraint act 2017? 3) do you support article 19 of the child marriage restraint act 2017? 4) do you think females are more victims of child marriage than males? 5) is it appropriate for a child to get married at 15 or less as per the muslim marriage law? 6) do you think the current act will encourage not decrease child marriage in bangladesh? 7) should the act be further revised? majority (60%) of the randomly surveyed people was against getting their children married off at early ages; nearly 40% people and 60% of young adults are aware about the child marriage restraint act. although their view was supportive to the special provisions in relation to child marriage but vast majority of them such as 80% and 90% opined that such provisions chart 2 is a representation of the mass survey (n=62) based on the questions 1-7. will negatively affect in the rate of child marriage in the country. randomly surveyed people, adult and young, were supportive in regard to adding special provision in the act since they mostly believed that the law tacitly legalizes marriage at early an age. pertaining to a strong sense of religious duty, the respondents, both in offline and online surveys, opted in support for a child to get married before 15 if their religion permits it. however, about 95% and 83% (questions 7 in chart 2 & 3) of the respondents believed that the act of 2017 chart 3 is a representation of the online survey (n=53) based on the questions 2, 3, 4, 5, 7. needs to be further revised. furthermore, more than 70% of the respondents in the field survey opined that this special provision would rather increase child marriage in the country instead of decreasing it. this ambiguity in the responses may have lead from the inclusion of the special provision and the inability of the act to find a balance between the religious sentiments 0% 50% 100% question 7 question 5 question 4 question 3 question 2 chart 3: opinion from online survey, n=53 yes no bangladesh journal of bioethics 2020; 11 (1): 24-34 31 and socio-ethical boundaries of the people of bangladesh. apart from the special circumstances provision, the current state law of bangladesh strictly prohibits early marriages in the country as it is prescribed as illegal before turning the age of a girl 18 and a boy 21. a dc whom we consulted said that “although poor people want to get their daughters married at early ages but the administration always follows the stipulations of the child marriage restraint act, 2017. once we are informed that an early marriage has taken place anywhere at my administrative areas, i promptly recommend my officials to stop such a marriage, and a vast number of such illegal marriages have been postponed with the help of local representatives and mass people”. a dwao at the ministry of women and children affairs (mowca) also added that as bangladesh socioeconomically develops and people are aware about the negative consequence of early marriage, the rate of child marriage decreases day by day. she also said that the administration is stricter than that of previous days to stop early marriage in the country. many viewed that the special provision added in the new law (child marriage restraint act, 2017) in article 19 will help increasing, not decreasingchild/early marriage in the country. a guardian of a newly married girl said that “as the current act does not specifically define about the provision 19 titled as special circumstances, poor people will easily take the benefits in getting their adolescent children legally married at early ages. thus, child marriage will be increased in the country. critics and experts have opined that as nothing is defined in this provision, it will surely increase the prevalence of child marriage rate in the country and this provision will necessarily be used for many people for gaining their unethical benefits19. in terms of punishment for violating the injunctions specified in the act of 2017, there are notable differences with the preceding act of 1929. the latter is stricter in terms of imprisonment and fines, but at certain places there are rooms for going easy on the violator, through certain legal loopholes. mostly, the tenure of imprisonment (for the parent/guardian/conductor) has been increased, for example, from 3 months (1929) with or without fines to 2 years (not less than 6 months) or a fine of tk. 50,000, or both (2017). failure to pay the fines may also result in 3 months of extended imprisonment, as of 2017. the new law has also added a provision to penalize the marriage registrar convicted of registering a case of child marriage with similar punishment as mentioned earlier. it has also added a counter-intuitive provision of exemption from accusation, which would dismiss the charges against a violator (initiator, before the crime has taken place) if s/he submits an affidavit or bond stating to refrain from such activities in the future. in terms of the ethical issues, child marriage is globally declared as an unethical practice. it is condemned in advanced societies, in spite of some inclinations in the poorer countries. the practice is not deliberately promoted in religious scripture, but the ambiguity in the verses often lead religious spokespersons to the path of misinterpretation. the foremost issue, as mentioned earlier, is bangladesh journal of bioethics 2020; 11 (1): 24-34 32 neurological and physiological. the effects of child marriage can lead a child towards premature death or economic inefficiencies. overall, the ethical implications can fuel socio-economic turbulence within families and societies and often cause obstructions in establishing international parameters, such as sustainable development goals [goal 5.3], the convention on the elimination of all forms of discrimination against women (cedaw) and other antidiscriminatory and progressive global regulations. concluding remark: we have deduced that socio-economic factors such as poverty act as a prime mover in increasing the rate of child marriage in bangladesh. the study has found that the poor people are always more prone to get their children married off at early their ages. in addition, the special provision added in the article 19 of 2017 child marriage restraint act will encourage not decrease child marriage in bangladesh. the study has discovered that poor people will tacitly take the opportunity of the article 19 as defines as ‘special provision’ which legalizes minors to be married off with the consent of the parents/guardians at the presence of a magistrate. since there is no definition for identifying those who will be included under the ‘special provision’, the study has revealed that poor people will mostly take such opportunity in the name of poverty. as more than 20% bangladeshis still remain below the poverty line9. it will encourage child marriage throughout the country. we conclude that the government should revise the current child marriage restraint act to find a plausible middleground between the ‘religious’ perspective and the ‘international’ code of ethics. besides the legal age for marriage for a boy and a girl being 21 and 18 respectively, the government should define article special provision and set the minimum age for marriage that is both morally permissible and justifiable in the socio-cultural environment of bangladeshi. recommendations: if the following recommendations are considered it will help the government decreasing child marriage rate in bangladesh: 1. according to the child marriage restraint act 2017, section 2 states that the legal age for marriage for a boy is 21 and for a girl it is 18. the law adds a new provision in article 19 that describes that adolescents at any age can get married legally by taking the consent from their parents/guardians and seeking permission from the courts under “special circumstances” for securing the best interests of the bride and the groom. but the provision does not specifically explain the term “special circumstances” or what kind of “interests” it would serve for the participants. this study recommends that the legal age for marriage for a boy (21) and a girl (18) should always be encouraged but the article 19 that adds ‘special provision’ must be clearly defined. the people who may be included under the ‘special provision’ and the procedure through which they will be included – should also be clearly defined. otherwise, bad people will get the benefits getting their children married off at early ages. bangladesh journal of bioethics 2020; 11 (1): 24-34 33 2. the government should also undertake the comprehensive policy strategies to reduce poverty among the people of the country. as the covid-19 pandemic hits the economy worldwide, people in the low-and middle-income countries would be especially more vulnerable in that situation. without taking appropriate policy strategy, it would be impossible for the government to reduce the rate of child marriage for the country. 3. the government should properly implement the stipulations of the child marriage restraint act. proper implementation of this act may decrease child marriage in the country. accountability and transparency mechanisms should also be properly ensured to implement this act. references 1. south asia :: bangladesh — the world factbook central intelligence agency [internet]. [cited 2020 feb 7]. available from: https://www.cia.gov/library/publications/theworld-factbook/geos/bg.html accessed on 7 march 2020 2. bangladesh: legalizing child marriage threatens girls’ safety | human rights watch [internet]. [cited 2020 feb 7]. available from: https://www.hrw.org/news/2017/03/02/bangla desh-legalizing-child-marriage-threatens-girlssafety accessed on 7 march 2020 3. child marriage increases in bangladesh: unicef [internet]. prothom alo. [cited 2020 feb 7]. available from: https://en.prothomalo.com/bangladesh/news/1 72370/child-marriage-increases-inbangladesh-unicef accessed on 17 april 2020 4. nahid f. child marriage in bangladesh: socio-legal analysis. int j sociol anthropol. 2014 jan 31;6(1):1–7. 2 p. 5. a scoping analysis of budget allocations for ending child marriage in bangladesh [internet]. [cited 2020 feb 7]. available from: https://socialprotection.org/discover/publicatio ns/scoping-analysis-budget-allocationsending-child-marriage-bangladesh accessed on 7 march 2020 6. untying the knot: 10 worst places for child marriage | world vision [internet]. [cited 2020 feb 7]. available from: https://www.worldvision.org/child-protectionnews-stories/10-worst-places-child-marriage accessed on 8 may 2020 7. child marriage [internet]. unicef data. [cited 2020 feb 7]. available from: https://data.unicef.org/topic/childprotection/child-marriage/ accessed on 8 may 2020 8. sapolsky r. behave: the biology of humans at our best and worst. vintage; 2017. 790 p. 9. bangladesh | data [internet]. [cited 2020 feb 7]. available from: https://data.worldbank.org/country/bangladesh 10. bangladesh rural population 1960-2018 data | 2020 forecast [internet]. [cited 2020 feb 7]. available from: https://tradingeconomics.com/bangladesh/rural -population-percent-of-total-population-wbdata.html accessed on 8 may 2020 11. brides gn. iran child marriage around the world. girls not brides [internet]. girls not brides. [cited 2020 jun 10]. available from: https://www.girlsnotbrides.org/childmarriage/iran/ accessed on 8 may 2020 12. ohchr | convention on the rights of the child [internet]. [cited 2020 jun 10]. available from: https://www.ohchr.org/en/professionalinteres t/pages/crc.aspx accessed on 16 june 2020 13. turkey’s highest religious body suggests children as young as nine could marry under islamic law | the independent [internet]. [cited 2020 jun 10]. available from: https://www.independent.co.uk/news/world/eu rope/turkey-children-marry-age-nine-islamiclaw-diyanet-government-chp-mpinvestigation-muslim-a8142131.html accessed on 16 june 2020 14. nasrullah m, muazzam s, bhutta za, raj a. girl child marriage and its effect on fertility in pakistan: findings from pakistan demographic and health survey, 2006–2007. matern child health j. 2014 apr 1;18(3):534– 43. 15. child, early and forced marriage legislation in 37 asia-pacific countries [internet]. koninklijke brill nv; [cited 2020 feb 7]. available from: https://primarysources.brillonline.com/browse/ human-rights-documents-online/child-earlyand-forced-marriage-legislation-in-37asiapacific-countries;hrdhrd10212016001 accessed on 16 sept 2020 16. krause p. of institutions and butterflies: is isomorphism in developing countries necessarily a bad thing? :4. bangladesh journal of bioethics 2020; 11 (1): 24-34 34 17. unicef. early marriage. new york: unicef; 2005. 18. finlay je, özaltin e, canning d. the association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 lowand middle-income countries. bmj open [internet]. 2011 jan 1 [cited 2020 feb 7]; 1(2). 21 p. available from: https://bmjopen.bmj.com/content/1/2/e000226 accessed on 16 sept 2020 19. debate on law on child marriage prevention (02-03-2017) [internet]. [cited 2020 feb 7]. available from: https://www.youtube.com/watch?v=1vwesen qd24 accessed on 16 sept 2020 author contributions: 1st author ahnaf tahmid arnab conceived the idea, did the literature review and wrote the manuscript. 2nd author md. sanwar siraj guided the conception of the idea, the manuscript writing process, and checked the manuscript meticulously. conflict of interests: the authors declare that there is no conflict of interest in this study. microsoft word knowledge, attitude and perception of nigerian physiotherapists regarding the ethics of professional practice bangladesh journal of bioethics 2018; 10 (1): 11-20 11 knowledge, attitude and perception of nigerian physiotherapists regarding the ethics of professional practice samuel o bolarinde 1 henry e. mba 2 1. phd ibadan, physiotherapy department, federal medical centre, owo, ondo state. nigeria. email: sobolarinde@yahoo.co.uk (corresponding author) 2. bmr.pt. ife, physiotherapy department, federal medical centre, owo, ondo state. nigeria. email: henryfresh14@gmail.com abstract: background of the study: physiotherapists in nigeria renewed their practicing license annually through the regulatory body and are provided with the professional code of ethics, which stipulate the appropriate conduct, behavior to guide and regulate the practice of their profession; however, the level of knowledge, attitude and perception of the ethical guidelines by nigerian physiotherapists need to be investigated. aim of study: this study assessed the knowledge, attitude and perception of nigerian physiotherapists about the ethics of their professional practice. methodology: the cross-sectional study recruited 117 licenced physiotherapists working in various health institutions in nigeria. they were recruited for the study during the 2018 annual scientific conference of clinical and academic physiotherapists in nigeria. data on demographic, work experience, knowledge, attitude and perception of ethics of professional practice were obtained using a self-administered questionnaire. data were summarized using descriptive statistics of percentage and frequency distribution. results: all the participants 117 (100%) had copies of the code of ethics and oath of professional practice. 74.6% of participants had good knowledge of the code of professional ethics while 25.39% had poor knowledge. only 40.8% (48) of the respondents demonstrated good attitudes toward the code of professional ethics. similarly, only 43.4% (51) of the respondents demonstrated a good attitude towards the oath of professional practice. 57.0 % of the respondents have heard about ethical misconduct among colleagues while only 13.60% have been involved in ethical misconduct concerning colleagues or patients. a greater proportion of the respondents (78.2%) considered ethics in physiotherapy as very important while 43.4% supported the introduction of physiotherapy ethics as a course to physiotherapy students in year three of their undergraduate training. conclusion: the majority of nigerian physiotherapists have good knowledge of the professional code of ethics and oath of professional practice; however, their attitudes towards periodic updating their knowledge on the code of ethics and professional oath remain poor. clinical implication and recommendation: ethical matter are very important to the practice of physiotherapy; however, the poor attitudes of physiotherapy toward updating their knowledge on ethical matters call for the need for the regulatory body and the professional association to organise seminars and workshops on ethics in physiotherapy and introduce pre-renewal test on ethics before annual licence renewal. keywords: physiotherapy, knowledge, ethics, oath, practice bangladesh journal of bioethics 2018; 10 (1): 11-20 12 introduction: health ethics is a set of moral principles, beliefs and values that guide health care professionals in making choices about medical care.1 health care professionals sometimes face difficult decisions about medical treatments that involve moral principles, religious beliefs, or professional guidelines therefore health ethics provide the health care practitioners with a thoughtful exploration of how to act well and make morally good choices, based on beliefs and values about life and health.1 the practice of medical ethics globally has been established upon the four moral principles of autonomy, beneficence, nonmaleficence, and justice.2 health care providers are; therefore, expected to not only have the skills and knowledge relevant to their field of professional practice but also possess adequate knowledge of ethical moral principles and legal expectations that arise out of the standard practices.3 the global trends in medico-legal issues and the growing public concern regarding the ethical conduct of healthcare professional demands a high level of professionalism among health care practitioners.4 physiotherapy as a profession in health care system provides services that develop, maintain, and restore maximum movement and functional ability throughout the lifespan of patients.5 physiotherapists constitute part of the multidisciplinary team in the management of the sick and mobility impaired persons, offering services in various settings (inpatient, outpatient, hospice, home) in order to alleviate the physical and functional aspects of the patient’s suffering.6 physiotherapists make decisions that involve ethical judgment in the course of practice; however, such decision-making is not limited to the point of care, it often extends beyond treatment options. a conflict could arise if a physiotherapist’s/ individual’s conviction conflicts with his/her concepts of the requirement of his professional role while some decisions may directly or indirectly be influenced by the web of his/her relationship with other health disciplines or the society.7 dilemmas may arise when the attitude, values, and goals of the profession conflict with those of another, and if the ethos of the profession and that of the society in which the professional functions are in conflict.8 therefore, the possession of adequate knowledge of ethical moral principles and legal expectations will be of great benefit. the profession of physiotherapy like other health professionals has a regulatory body that regulates and controls the professional practice of her registrants. the code of practice as written in the medical rehabilitation therapists board of nigeria’s (mrtb) core standard of proficiency for registrants of medical rehabilitation therapists (physiotherapy inclusive) stipulate appropriate conduct and behavior expectation for professionals in medical rehabilitation9; hence, physiotherapists decisions that involve ethical judgment in the course of practice should be guided by the code of professional behavior. the recent increase in the number of court cases against health care professionals in nigeria may indicate a low level of awareness and inadequate basic knowledge bangladesh journal of bioethics 2018; 10 (1): 11-20 13 of medical ethics. all health care workers are provided by the professional code of ethics to regulate the practice of their profession. physiotherapists in nigeria renewed their practicing license annually and are provided with the professional code of ethics/practice in addition to the renewed license; however, do nigerian physiotherapists actually read, understand and apply the professional code of ethics in their daily clinical practice? this background forms the basis of the present study with an attempt to evaluate the knowledge, attitude and perception of nigerian physiotherapists in relation to the ethics of professional practice. methods: the study utilized a descriptive, cross sectional research design of registered physiotherapists working in both private and public institutions in nigeria. the study protocol was approved by the health research ethics committee of federal medical centre, owo (fmc/ow/380/lxx1v/192). the rationale behind the study was explained to all participants and informed consent was granted from them before their participation. the survey instrument for the study was a four sectioned self-administered questionnaire. section a obtained information on demographic characteristics and job history, section b on knowledge of ethics and the role of the regulatory body among physiotherapists, section c was on physiotherapist attitude towards ethics and oaths of physiotherapy practice while section d obtained data on the perception of professional ethics among physiotherapists. data were summarized using the statistical package for social science (spss) version 20.0 software. descriptive statistics of means, percentages and frequency tables were used to describe the result. result: a total number of 117 licensed physiotherapists participated in the study. eighty-one (68.9%) were males while 36 (31.1%) were females. the highest percentage in the age distribution was in the range 21 -30 (56.2%) followed by 31-30 age group (28.1%), while 51-60 age group had the least percentage (2.6%). in terms of work experience, 1-5 years of working experience had the highest percentage (63.8%) among the respondents, while 1620 years was the year of experience with the lowest percentage (4.3%). the result also shows that the professional cadre with the highest percentage was a basic grade physiotherapist (58.7%), while the least was a chief physiotherapist and assistant director of physiotherapy services (5.1% each). the socio-demographic characteristics of participants is as shown in table 1 table 1: demographic characteristics of participants. n=117 variables n % (percentage) gender male (m) female(f) 81 36 68.9 31.2 age 21 30 31 40 41 50 1 60 66 33 15 3 56.2 28.1 12.8 2.6 work experience 1-5 6-10 11-15 1620 20 and above 75 15 10 5 12 63.8 12.8 8.5 4.3 10.2 designation physiotherapist (pt) senior physiotherapist(spt) principal physiotherapist(ppt) chief physiotherapist (cpt) assistant director (ad) deputy director/ director 69 16 11 6 6 9 58.7 13.6 9.4 5.1 5.1 7.7 bangladesh journal of bioethics 2018; 10 (1): 11-20 14 table 2 shows the knowledge level of physiotherapy regarding the ethics of physiotherapy and the role of the regulatory body. on the self-rated scale, 18 (15.3%) of the respondents had excellent knowledge of ethics of physiotherapy practice, 36 (30.6%) good knowledge and 11(9.4%) fair knowledge. table 2 : knowledge of ethics and role of regulatory body among physiotherapists questions and response by physiotherapists n percentage (%) 1. 1. how do you rate your knowledge of ethics in physiotherapy from 1 to 5 (1 being the lowest score and 5 the highest)? 1 = poor 2 = fair 3 = good 4 = very good 5 = excellent 1 11 36 51 18 0.9 9.4 30.6 43.4 15.3 2. does the mrtb regulate the relationships between physiotherapists and nurses, doctors and other professionals? yes no 9 108 7.7 91.8 3. are physiotherapists, doctors, nurses and other health professionals subject to the mrtb? yes no 5 112 4.3 95.2 4. is the mrtb punitive? yes no 40 77 34.0 65.5 5. does the mrtb deal directly with professional confidentiality? yes no 49 68 41.7 57.8 6. does the mrtb deal directly with physiotherapist’ strikes? yes no 10 107 8.5 91.0 7. can physiotherapists prescribe treatment without prior medical consultation? yes no 91 26 77.4 22.1 8. does the mrtb deal directly with physiotherapy fees? yes no 33 84 28.1 71.4 9. when prescribing an exercise or completing a medical record form illegibly, does the physiotherapist hurt an article of the mrtb? yes no 52 65 44.2 55.3 10. can physiotherapists consult or prescribe physiotherapy treatment without a face-to-face consultation? yes no overall adequate knowledge 74.6% overall inadequate knowledge 25.4% 78 39 66.3 33.2 bangladesh journal of bioethics 2018; 10 (1): 11-20 15 regarding the regulatory role of the medical rehabilitation therapist boardthe regulatory body of the physiotherapy profession. nine (7.7%) agreed that the relationship between physiotherapists and nurses, doctors and other health professionals are regulated by the board, professionals are regulated by the board, while 108 (91.8%) disagreed. 40 (34.0%) of respondents perceived the board as a punitive body while 77 (95.2%) disagreed. 49 (41.7%) agreed that the board deals directly with professional’s confidentiality while 68 (57.8%) disagreed. the overall average knowledge shows that 74.6% of respondents have adequate knowledge of the regulatory role of the medical rehabilitation therapist board, while 25.4% have inadequate knowledge. table 3 shows the participants’ attitudes towards the ethics of physiotherapy practice. the result shows that all the participants 117 table 3: physiotherapists attitude towards ethics and oath of physiotherapy practice questions and response by physiotherapists n percentage (%) 1. do you have a copy of mrtb code of ethics? yes no 2. have you read the mrtb code of ethics in the last three years? yes, entirely yes but partially no 117 0 48 54 15 100 0 40.8 45.9 12.8 3. how often do you update yourself regarding the subject? once in a month once in 6 months once in a year no update 10 21 48 38 8.5 17.9 40.8 32.3 4. have you read the oath of your physiotherapy practice in the last three years? yes , entirely yes but partially no 51 23 43 43.4 19.6 36.6 5. how often do you update yourself by reading through the oath of physiotherapy practice? once in a month once in 6 months once in a year no update 5 22 34 56 4.3 18.7 28.9 47.6 bangladesh journal of bioethics 2018; 10 (1): 11-20 16 table 4: perception of professional ethics among physiotherapists questions and response by physiotherapist n percentage (%) 1. do you think that professional attitudes involving ethics are determined exclusively by the character and personality of the individual? yes exclusively by character and personality no, but influenced by character and personality no, character and personality are of no concerns 2. regarding your peers, have you heard of or experienced any examples of what would be considered ethical misconduct on their part? yes, i have experienced it yes, i have heard of it no 43 65 9 31 67 19 36.6 55.3 7.7 26.4 57.0 16.2 3. have you ever done anything that could be considered ethical misconduct with respect to colleagues or patients? yes no 16 101 13.6 85.9 4. how important do you think is ethics in physiotherapy for your training as a physiotherapist? (1 being the lowest score and 5 the highest). not important less important important very important 0 3 22 92 0.0 2.6 19.6 78.2 5. at what time do you think the teaching of ethics in physiotherapy should be included / addressed in the undergraduate curriculum? year 1 year 2 year 3 year 4 year 5 all year 1 24 51 15 1 25 0.9 20.4 43.4 12.8 0.9 21.3 bangladesh journal of bioethics 2018; 10 (1): 11-20 17 (100.0%) have a copy of the code of professional ethics. 48 (40.8%) have read the entire copy while 15 (12.8%) have never read in their last 3 years. only 10 (8.5%) of the respondents update their knowledge on ethics of physiotherapy practice once in every month, 21(17.9%) once in 6 months, while 38(32.3%) never updated themselves. the result also shows that; 51(43.4%) have read the oaths of physiotherapy practice entirely, while 43(36.5%) have never read the oath of practice in their entire years of practice. 5(4.3%) update themselves by reading the oaths of physiotherapy practice once in a month, 56 (47.6%) never updated themselves by reading the oath of physiotherapy practice. table 4 shows the perception of the respondent on professional ethics among physiotherapists. the result showed that 43(36.6%) are of the opinion that professional attitudes involving ethics are determined exclusively by character and personality of individuals, while 9(7.65%) saw no role or involvement of character and personality in determining professional attitude towards ethics. 31 (26.4%) have experienced ethical misconduct in their practice, 67 (60.0%) have only heard, and 19 (16.15%) have neither heard nor experienced ethical misconduct. 16(13.6%) have been involved in ethical misconduct with respect to patients / colleagues while 101 (85.85%) have not. 92 (78.2%) viewed ethics as very important in their training as physiotherapists while only 3(2.6%) saw ethics as less important to their training. a greater proportion of respondents agreed that teaching of ethics should be introduced in the undergraduate curriculum at year three of their training, while 25(21.3%) suggested all the five years of training discussion: the study revealed that the majority of the respondents had very good knowledge of ethics of professional practice and good knowledge of the regulatory roles of the medical rehabilitation therapist boardthe regulatory body for the profession of physiotherapy. this finding is consistent with the findings by barnie et al 4; atila et al 10 and arati and bhagawati 11 that reported good knowledge of professional ethics among health workers, physiotherapists and nurses respectively. findings from this study show that all the respondents have a copy of the code of professional ethics. this could be attributed to the annual distribution of the code to all physiotherapists on the annual renewal of practicing licence by the regulatory body. the proportion of respondents that have entirely read the code of professional ethics in the last three years was: however, less than half of the population while a greater proportion has only read partially. this finding corroborates the research of vieira and neves 12 and almeida et al 13 in which a greater proportion of health professionals claim to have partially read the code of ethics of their profession. regarding the oath of physiotherapy practice, the findings of this study indicated that less than half of the respondents have read the oath of physiotherapy practice once and entirely in the past three years, while only a negligible proportion of the respondents keep updating their knowledge about the oath monthly and biannually. it is bangladesh journal of bioethics 2018; 10 (1): 11-20 18 worrisome: however, to observe from the findings of this study that a greater proportion of the respondents did not update their knowledge by reading through the oath of physiotherapy practice in the last three years. contending with ethical dilemmas in clinical practice is a daily occurrence in almost all health institutions worldwide.14,15 the poor attitude demonstrated by the respondents toward the update of knowledge on ethical issues remains serious professional negligence which could lead to unpleasant conflicts between the health care practitioners, patients and patients relatives which sometimes end in legal suits and litigations. the study shows that a greater proportion of the respondents (55.3%) perceived that professional attitudes involving ethics are not solely determined by a knowledge of ethics but are influenced by the character and personality of the professionals. these findings supported the findings of coelho 16 on ethics in physiotherapy and atila et al10 on perception, interest and knowledge of physiotherapy faculty regarding professional ethics. the two authors concluded that character and personality of the professionals have a higher level of influence over professional attitudes involving ethics than knowledge of ethics. ethical misconduct among health care professionals may therefore be attributed to the professionals’ character and personality rather than poor or inadequate knowledge of professional ethics. the findings of the study show that 60% of the respondents have heard about professional misconduct among physiotherapists, 26.4% have experienced ethical misconduct while 16.2% have been involved in ethical misconduct involving patients or colleagues. this result indicated that the respondents are aware of ethical misconduct in clinical practise. these findings are similar to the findings of atila et al 10 that reported 61% as the proportion of physiotherapists who had experienced some form of ethical misconduct by their colleagues. this finding could be attributed to a low level of update of knowledge on ethics of professional practice among physiotherapists. a greater proportion of respondents (92%) viewed professional ethics as very important to the training of physiotherapists. this result corroborated the findings of atila et al, 10 arati and bhagawati11 who reported 78% and 90% level of importance among physiotherapists and nurses respectively. in this study, all the respondents agreed that ethics should be introduced as a course in the undergraduate curriculum of a university’s education. these findings supported the findings of atila et al10 and coelho et al16 which reported that the majority of respondents agreed to the introduction of ethics as a course in the undergraduate curriculum of physiotherapy training. furthermore, nearly 44.0% of the respondent in the present study preferred the introduction of ethics in the third year of training, 20.4% in year two while 21.4% preferred all the five academic sessions of university’s training. the reasons for higher preference for the third year of university training could be attributed to the fact that students begin clinical postings in the hospital where they have more contact not only with their classmates and lecturers; but mainly with patients. bangladesh journal of bioethics 2018; 10 (1): 11-20 19 conclusions: the majority of nigerian physiotherapists have good knowledge of the professional code of ethics and oath of professional practice. they however, opined that professional attitudes involving ethics are not solely determined by a knowledge of ethics but are influenced by the character and personality of the professionals. in addition, nigerian physiotherapists have a positive perception of ethics of professional practice; however, their attitudes towards periodic updating their knowledge on the code of ethics and professional oath remain poor. ethical matters are very important to the practise of physiotherapy; therefore, courses on ethics, improving professional character and personality should be included in the university training curriculum and be introduced before the clinical year of training. the observed poor attitudes of physiotherapists toward the periodic update of knowledge on ethical matters call for the need for the regulatory body and the professional association to organise seminars and workshops on ethics in physiotherapy and the possible introduction of pre-renewal test on ethics before annual licence renewal. acknowledgement: the authors acknowledge the technical support received from the staff of the physiotherapy department, federal medical centre, owo, ondo -state, nigeria references: 1. opoku, j.k and peter addai-mensah an assessment of perceptions and knowledge of health care ethical principles among health care practitioners in the kumasi metropolis. global journal of arts humanities and social sciences 2014 vol.2(6) pp.77-92. 2. beauchamp tl, childress jf. principles of biomedical ethics 5th edition, oxford university; oxford: 2001. beauchamp, tom l, and james f. childress. principles of biomedical ethics. new york, n.y: oxford university press, 2001. 3 unnikrishnan b, kanchan t, kulkarni v, et al., perceptions and practices of medical practitioners towards ethics in medical practice a study from coastal south india. j forensic leg med. 2014; 22:51-6 4 barnie ba, forson pk, opare-addo mna, appiah-poku j, rhule gp, et al. knowledge and perceptions of health workers’ training on ethics, confidentiality and medico-legal issues. j clinic res bioeth 2015.6: 205. doi:10.4172/2155-9627.1000205 5 world confederation for physical therapy. london: world confederation for physical therapy; c2014. available from: http://www.wcpt.org/policy/ 6 kumar sp, jim a. physical therapy in palliative care: from symptom control to quality of life: a critical review. indian j palliat care 2010;16:138‑46. 7 westra ae, willems dl, smit bj. communicating with muslim parents: ‘the four principles’ are not as culturally neutral as suggested. eur j pediatr 2009; 168(11):1383 1387. 8 oyeyemi a. ethics and contextual framework for professional behaviour and code of practice for physiotherapists in nigeria. journal of the nigeria society of physiotherapy, 2011.(18 and 19) 9. the medical rehabilitation therapists board of nigeria. professional code of ethics: core standards for proficiency for registrants of medical rehabilitation therapists board of nigeria. revised edition mrtb; 2018. 10. atila barros magalhães , monique natálle silva pereira , bruno nonato pedroso nascimento, mardson danilo sousa de lima, rafaela okano gimenes, renato da costa teixeira: perception, interest and knowledge of physiotherapy faculty regarding professional ethics . rev. bioét. (impr.). 2016; 24 (2): 32231 http://dx.doi.org/10.1590/198380422016242133 11. arati timilsina; bhagawati kc. level of knowledge and practice of patient care ethics among nurses in pokhara janapriya. journal of interdisciplinary studies, 2017. (6) pp 17-28 12. vieira pspg, neves nmbc. ética médica e bioética no curso médico sob o olhar dos bangladesh journal of bioethics 2018; 10 (1): 11-20 20 docentes e discentes. o mundo da saúde. 2009;33(1):21-5. 13. almeida am, bitencourt agv, neves nmbc, neves fbcs, lordelo mr, lemos km, et al. conhecimento e interesse em ética médica e bioética na graduação médica. rev bras educ med. 2008;32(4):437-44 14. goldie j. review of ethics curricula in undergraduate medical education. med educ , 2000.34: 108-119. 15. eckles re, meslin em, gaffney m, helft pr medical ethics education: where are we? where should we be going? a review. acad med, 2005. 80: 1143-1152. 16. coelho phs. ética em fisioterapia: interesse, percepção e níveis de conhecimento entre alunos do curso de fisioterapia em uma universidade no interior da amazônia brasileira [tcc]. santarém: universidade do estado do pará; 2014. authors' contributions: samuel o bolarinde coordinated the study, conceived the study, and participated in its design and data analysis, interpretation and revised the manuscript. henry e. mba participated in data management and analysis, drafting of the manuscript and revised the manuscript. all authors read and approved the final manuscript. conflicts of interests: the author(s) declare no conflicts of interests microsoft word implementation of nagoya protocol 1 bangladesh journal of bioethics 2020; 11 (2): 35-41 35 implementation of nagoya protocol – the case study of indonesia endang sukara1, safendrri komara ragamustar 2, ernawati sinaga 3 1.professor, study center for environmental ethics, universitas nasional jakarta, pejaten campus 12520, jakarta, indonesia & indonesian academy of sciences (aipi), gambir, 10110, jakarta indonesia (corresponding author). email: endangsukara@gmail.com 2. universitas nasional jakarta, pejaten campus 12520, jakarta, indonesia. email: ersinaga2003@yahoo.com.sg 3. school of government public policy, sentul, 16810, bogor, west java, indonesia. email: s.ragamustari@gmail.com doi: https://doi.org/10.3329/bioethics.v11i2.49262 abstract: indonesia consists of more than 17,000 islands separated for hundreds of thousands of years, which consequently results in biodiversity and cultural diversity richness. strong connection between people and biodiversity form a vast array of traditional knowledges which are related to the conservation and the use of biological diversity. during the last 3 decades, tremendous advancement in science and technology has been able to uncover the intrinsic value of biodiversity. many lead chemical compounds have been isolated and identified from, and have opened up huge opportunities in developing new businesses based on biodiversity. the consciousness of the intrinsic value of biodiversity is, however, only being understood by countries with high science and technology capacity. the intrinsic value of biodiversity remains abstract to most of the people in the developing and less developed nations. the convention on biological diversity (un-cbd), cartagena and nagoya protocol are legal documents to ensure conservation, sustainable use and sharing of the benefits from the utilization of biodiversity and its components. nagoya protocol dealing with access and benefit sharing from the utilization of biological materials has open new and better opportunities for the developed nations to study the potential use of biological resources exist in developing and less develop nations. the implementation nagoya protocol on access, fair and equitable sharing of the benefit from the utilization of biodiversity very complex and full with ethical dilemmas. basic principles stipulated in the universal declaration on human rights and bioethics unesco 2005 e.g. consent, persons without the capacity to consent, equality, justice and equity, respect for cultural diversity and pluralism, solidarity and cooperation, sharing of benefits, protecting future generations, protection of the environment, the biosphere and biodiversity may be applied in addressing ethical issues. (some part of this article was presented at 20th asian bioethics conference, dhaka, bangladesh). introduction: biodiversity is the variety of life on earth. it is the most complex feature of our planet and it is the most vital. without biodiversity, there is no future for humanity. biodiversity is important to support life systems and to keep our planet green and healthy. there is no record of the number of species on earth, but it is estimated to be around 10 million. the total number of species used by human civilization for food, health and energy is very limited. the majority of species are remained untapped 1,2. it is believed that biodiversity has an enormous value as genetic resources. biodiversity plays an important role in nutrient cycle, soil formation. plant resources and photosynthetic organisms have a tremendous vehicle as an active carbon sink and controlling the climate. the presence of biodiversity is also an important bangladesh journal of bioethics 2020; 11 (2): 35-41 36 element in controlling diseases, natural disaster protection, and erosion control. biodiversity has a spiritual value, source of education and knowledge, recreation and esthetical values3. during the last 2 decades, the advancement of science and technology, biotechnology growing rapidly and influence mankind understanding on the important of biodiversity related to food, health, and energy. biodiversity is now becoming an important asset for bioeconomy. indonesia is a maritime country with more than 17,000 islands across the equator, laying between asia and australia. the islands are separated from each other for hundreds of thousands of years. it is no doubt that species exist in the islands undergone a long period of isolation and adaptation creating species endemicity of both flora and fauna. komodo for example is only found in komodo island while a single horn rhino is only found in west coast of java and maleo bird is endemic to sulawesi island. indonesia is also blessed with over 42 terrestrial ecosystem types and more than 5 ocean ecosystems from ice landscapes and alpine mountains, to spectacular coral reefs, sea grass beds and deep weber seas4. it is obvious that indonesia is known as a mega bio-diversity country source? there are about 1.500 species of algae, 80.000 species of cryptogrames, 595 species of lichenes, 2.197 species of fern, 30.000 to 40.000 species of plants, 8.157 species of animal (mammal, birds, herpetofauna, and fish) and 1.900 butterfly species 5. among them, 270 species of mammals, 386 species of birds, 328 species of reptiles, 204 species of amphibian, and 280 species of fishes are endemic5. in indonesian context, the connection between people, cultures, traditions and biodiversity is strong. the vast array of traditional knowledge accumulated and being embodied in daily life for hundreds of thousands of years. traditionally, biodiversity used as food, source for medicine, fiber for clothing, coloring agent, source of energy. the way of using biodiversity is quite diverse depending on the tribes in the country. in relation to food, indonesians consume around 100 plant species as carbohydrate sources, 100 legume plants, 450 species of fruits and 250 species of vegetables, diverse species of animals, both terrestrial and aquatic, mushroom, fungi and microbes 6. study in an area of 1 ha of the low land forest in sumatera, there are more than 300 species of plant observed. evaluation using ethnobotanical analysis, the total number of 51 plants species are used as source of fruit, 21 species as source of vegetable, 6 species for spices, 77 species as source for traditional medicine, 2 plants species containing poison, and 45 species as a source of energy (firewood), 65 species as raw material for craft and art, 157 species for construction and 27 species are suitable for future pulp, paper and plywood industry 7. related to health, the use of diverse plant species is already embedded to the culture of javanese tribes. the mixer of plant species is blend and sell to the market as traditional medicine, jamu. around 75 percent of indonesians consume jamu on a regular basis, either to prevent or treat diseases jamu has been an integral part of indonesia’s socio-cultural identity 8. the use of diverse plants species as medicine is already exist since ancient time in indonesia. bangladesh journal of bioethics 2020; 11 (2): 35-41 37 advancement of science and technology in utilizing biodiversity: the advancement of science and technology has opened our understanding on the value of biodiversity unexpectedly. deep study on around 200 plant species extracts native to indonesia by the indonesian institute of sciences (lipi) cooperated with cosmetic industry, shiseido in 2007, the total of 30 lead molecules found and may be patented. advancement of science and technology may unlock the intrinsic value of the indonesian plant biodiversity and open opportunities to bring this research output to commercial. another example is scorodocarpus borneensis (baill) becc, a family of oleaceae traditionally, the seed and bark are used as vegetable, root and fruit as medicine and ritual ceremony 9. this species is one among 200 rare plant species to indonesia 10. using sophisticated equipment, lc-ms and nmr, supported by dept techniques, this species containing scorocarpine b which is leukemia cell inhibitor11. in addition, during the last 3 decades, tremendous advancement of science and technology has been able to continuously uncover the intrinsic value of biodiversity. in the near future, many lead chemical compounds may also be isolated and identified from microbial genetic resources. pseudobotyris terrestris from wallacea region is a fungal species reported by uchida 12 and fraga 13 has an ability to produce enzymes for lipid digestion which may important for treating obesity and atherosclerosis in the future. diverse actinomycetes and actinomycetes non streptomycetes are successfully being isolated from the regions. the potential value of non-actinomycetes non streptomycetes are tremendous for degrading polylactate resin and plastics, as a raw material for developing anticholesterol, antibiotics, anti-viral. antitumor, anti-neoplastic, stabilizer for medicine, food, cosmetics, for the production of industrial enzymes, diagnostics, food colorant, and novel paints coatings 14. the expedition to foya membramo, papua – indonesia, discovered many new species of reptiles, fishes, birds, and mammals. it is not only important for taxonomists, but also as materials in drugs discovery project. frog from genera of xenopus, silurana, hymenochirus, and pseudhymenochirus in the family pipidae containing gene responsible for the synthesis of small aphifilic peptide collapsing ion-gradients and lethal to many microbial pathogens. frogs skin are a rich source of genes important in producing peptides with varying degrees of antimicrobial activities and cytotoxicities to mammalian cells. magainin, peptide glycine-leucine-amide (pgla), caerulein-precursor fragment (cpf), and xenopsin-precursor fragment (xpf) peptides have been isolated from norepinephrine-stimulated skin secretions from several species of xenopus and silurana. analogs of the magainins, cpf peptides and hymenochirin-1b with increased antimicrobial potencies and low cytotoxicities have been developed that are active (mic < 5 μm) against multidrugresistant clinical isolates of staphylococcus aureus, escherichia coli, acinetobacter baumannii, stenotrophomonas maltophilia and klebsiella pneumoniae. despite this, genes having therapeutic potential in frog skin as an anti-infective agents for anticancer, anti-viral, anti-diabetic, or immunomodulatory drugs 15. another great achievement is in pain therapy. a chemical compound called ziconotide, which is also known as snxbangladesh journal of bioethics 2020; 11 (2): 35-41 38 111, is a novel non-opioid analgesic drug. ziconotide is actually a synthetic version of ω-conotoxin mviia (ω-mviia), which is a peptide that is found in the venom of the fish-eating marine snail, conus magus 16. there are more than 600 different species of cone snails exist. it belongs to the phylum of mollusca and the genus conus. most of the species inhabit the warm water of tropical reefs. the venom of each species of cone snail contains its own unique mixture of chemicals. this increases the likelihood that some of the chemicals may be useful to humans in the future. ziconotide itself could be up to 1,000 times more effective than morphine at relieving pain and has the added advantage of not being addictive. in addition, it doesn't cause the development of tolerance in the patient. tolerance is a state in which a medication that was once effective no longer works. ziconotide is used after other analgesics have been tried and have failed to work. it is prescribed only for people who are suffering from intense and prolonged pain, such as the pain that may be experienced by people with certain types of cancer or for people experiencing neuropathic pain. ziconotide is sold under the brand name of prialt. santa cruz biotech news mentioned that ziconotide is sold as a selective antagonist of n-type voltage sensitive calcium channels (vscc) with a current price of us$ 6.500.000 per gram 17. currently, data of entire genome sequences of organisms can be extracted and saved as electronic files. the genomic data has the potential to be used to develop production systems for fine chemicals without the need to grow or cultivate the source organism, known as synthetic biology. thus, through synthetic biology, genetic resources, genes can be utilized readily for economic benefit. an example of the production of chemical compounds using synthetic biology is done by evolva, a switzerland-based company. the company produces vanillin through synthetic biology. genes in the vanillin biosynthetic pathway were inserted in yeast, and are being used to convert sugar into vanillin. the fluctuating production and price of natural vanillin due to climate change and other factors will most likely make synthetic biology-vanillin a viable option in the future. with those examples, biodiversity could be used as a good starting point for establishing bio-based industry including synthetic biology. biodiversity is an important asset in developing a blue-print to establish production pathways of highvalue chemical compounds using genetic data from biodiversity which could boost economic development while increasing science capacity. access to biodiversity is mandatory. legally binding protocol, nagoya protocol, is in place. the implementation of this protocol will not be always easy and need to concider bioethics principles. how to proceed: the implementation nagoya protocol on access, fair and equitable sharing of the benefit from the utilization of biodiversity is very complex and full with ethical dilemmas. basic principles stipulated in the universal declaration on human rights and bioethics unesco 2005 such as consent (persons without the capacity to consent), equality, justice and equity, respect for cultural diversity and pluralism, solidarity and cooperation, sharing of benefits, protecting future generations, protection of the environment, the biosphere and biodiversity may be applied in addressing ethical issues may help to smoothen its implementation. bangladesh journal of bioethics 2020; 11 (2): 35-41 39 the consent of most people in developing countries and less developed nations on the intrinsic value of biodiversity is lacking. for this reason, before access to biological resources, the capacity to consent the people in the developing country and less developed nation own biodiversity should first be improved. with an appropriate knowledge on the intrinsic value of biodiversity, the equality, justice and equity may be developed through continues dialog. respect on cultural and traditional knowledge should become an instrument for access to biodiversity. in the implementation of nagoya protocol, solidarity and cooperation, sharing of benefits are an important part which should be understood by all parties involved. the developed country who owns the technology need an access to biodiversity, basic principles of bioethics should be incorporated in the mechanism of access to ensure fair and equitable sharing of the benefit from the utilization of biodiversity and its components. when access granted, another basic principle of bioethics, protecting future generations, protection of the environment, the biosphere and biodiversity is mandatory. over exploitation should be prevented to ensure that biodiversity is conserved, used sustainably while creating the prosperity for all. trust between countries rich in biodiversity and countries having high science and technology capacity at all levels is becoming a crucial factor. greater transparency and recognition on comprehensive rights of people providing biodiversity is a key element in maintaining trust. global community has signed three legally binding protocol namely the convention on biological diversity (un-cbd) signed at the earth summit in rio de janeiro, brazil, in 1992 and entered into force on 29 december 1993, cartagena protocol on biosafety adopted on 29 january 2000 and entered into force on 11 september 2003 and nagoya protocol on access to genetic resources and the fair and equitable sharing of benefits arising from their utilization to the convention on biological diversity which entered into force on 12 october 2014. those three legal documents should be used to properly manage biodiversity to ensure conservation, sustainable use and sharing of the benefit from the utilization of biodiversity and its components. those three legally binding protocols are now ratified by indonesian by releasing national legislation namely act no. 5 th 1994, act no. 21 th 2004 and act no. 11 th 2013. the cbd, cartagena and nagoya protocol are in line with the indonesian constitution, which clearly states that all-natural resources belong to the state and are to be used for the utmost welfare/benefit of the people of indonesia. in the preamble of the convention on biological diversity, it is mandatory for each contracting party conscious the intrinsic value of biological diversity and of the ecological, genetic, social, economic, scientific, educational, cultural, recreational and aesthetic values of biological diversity and its components and on the importance of biological diversity for evolution and for maintaining life sustaining systems of the biosphere. conservation of biological diversity must be a common concern of humankind, and each contracting party is responsible for conserving their biological diversity and for using their biological bangladesh journal of bioethics 2020; 11 (2): 35-41 40 resources in a sustainable manner. each contracting party is also fully aware that the conservation and sustainable use of biological diversity is of critical importance for meeting the food, health and other needs of the growing world population, for which purpose access to and sharing of both genetic resources and technologies are essential. the implementation of such protocol can not solely depend of rule and regulation but need ethics/bioethics considerations. trust between countries rich in biodiversity and countries having high science and technology is the most crucial factor in implementing convention on biological diversity including cartagena and nagoya protocol. there is also a need for greater transparency on the possible future value of biodiversity through research and development. access to biodiversity is subject to negotiation while respecting a comprehensive right of the local peoples, their needs and aspirations for sustainable development and poverty alleviation. a rights-based approach would be important to promote people's knowledge about the existence of their rights and to develop political strategies to make people’s rights become reality. statement from australian national health and medical research council is fundamental: the responsibility for maintaining trust and ethical standards cannot depend solely on rules or guidelines. ethical consideration should be an integral part in the implementation of such rules and guidelines. in developing products of both research and researchers should involve people transparently and honestly especially when dealing with values and principles. the elimination of 'difference blindness' and a subtlety of judgement is required to eliminate prejudice and maintain respect. model legislation should be developed to provide a comprehensive scheme for ensuring conservation and sustainable use of biological resources and to support for the ‘inalienable rights of local communities over their biological resources, knowledge and technologies’. access to biological resources subject to prior informed consent of local communities, fair and equitable sharing of benefits, effective participation of local communities and appropriate institutional mechanisms to ensure effective implementation of nagoya protocol on access and benefit sharing. conclusion and recommendation: nagoya protocol on access and benefit sharing from the utilization of biological resources is an important step to get most benefit from biological resources. the protocol could be a vehicle for strategic partnership between country rich in biodiversity and country with greater capacity in science and technology. due to the nature of biodiversity where the intrinsic value of the resources is uncertain and can only be elucidated by advance science and technology, the implementation of nagoya protocol full of ethical dilemmas. rule and regulations is not sufficient in implementing access and benefit sharing properly. ethics/bioethical consideration is of importance. basic principle stipulated in the universal declaration on human right and bioethics unesco may incorporated to ensure smooth implementation of the protocol. acknowledgements: greatly acknowledge the universitas nasional and the indonesian academy bangladesh journal of bioethics 2020; 11 (2): 35-41 41 of sciences for giving me an opportunity to participate in the 20th asian bioethics in dhaka, bangladesh. acknowledgement also directed to the organizing committee for inviting me to join this symposium. references: 1. sukara, e. the 4th international conference on sustainable future for human security (sustain) 2013, clock tower centennial hall, kyoto university, japan, kyoto, october 2013; 18-21, 2013 2. sukara, e. biodiversity a common wealth for a crowded planet. the 2nd gss leading expert seminar – graduate school programme for sustainable development and survivable societies, kyoto university – japan december 19, 2013. 3. sukara, e. tropical forest biodiversity to provide food, health, and energy solution of the rapid growth of modern society. procedia environment sciences 2014; 20: 803 – 808. 4. sukara, e. 2019. capacity building as mutual benefit in life sciences research collaborations. national workshop: evaluation of capacity building measure as impacts of research permits. indonesian ministry for research and higher education, jakarta. 5. widjaja, e. a., y. rahayuningsih, j. s. rahajoe, r. ubaidillah, i. maryanto, e. b. walujo dan g. semiadi. kekinian keanekaragaman hayati. 2014, lipi press, jakarta: indonesia. 6. walujo, e. b. keanekaragaman hayati untuk pangan. konggres ilmu pengetahuan nasional x jakarta, 8 – 10 nopember 2011. 7. rahayu, m., s. susianrti and y. purwanto. kajian pemanfaatan tumbuhan hutan non kayu oleh masyarakat local di kawasan konservasi pt wira karya sakti sungai tapa – jambi. jurnal biodiversitas 2007; 8(1): 73 –78. 8. ragamustari, k. rleveraging jamu heritage using science and technology. the jakarta post, jakarta / mon, april 8, 2019 / 03:04 pm. 9. siagian, m.h., m. rahayu dan u. hapid. telaah pemanfaatan tumbuhan “bawa hutan” (scorodocarpus borneensis) di daerah kenohan – kalimantan timur. prosiding seminar nasional etnobotani iii. dsnpasar – bali, hal” 2000, 270-273. 10. mogea, j.p.m., d. gandawidjaja, h. wiriadinata, r.e. nasution dan irawati. tumbuhan langka indonesia. buku seri panduan lapangan. pusat penelitian dan pengembangan biologi – lipi. balai penelitian botani, herbarium bogoriense. bogor, indonesia, 2001. 11. kartika, r., t. barus, r. surbakti, and p. simanjuntak. structure characterization of alkaloid scorodocarpines derivative from fruits of scorodocarpus borneensis becc (olacaceae). asian journal of chemistry. 2014; 26 (18): 6047-6049. http://dx.doi.org/10.14233/ajchem.2014.16562. (updated on september 23, 2019). 12. uchida, r., y. pil kim, i namatame, h. tomoda and s omura. sespendole, new inhibitor of lipid droplet synthesis in macrophages, procuced by pseudobotrytis terrestis fka 25. the journal of antibiotics 2006; 59 (2): 93–97. 13. fraga, b. m. natural sesquiterpenoids. natural product report, stanford university, stanford, usa,2007. 14. sukara e, p. lisdiyanti, h. yamamura, j-y. park, y. kurihara, n. sukarno, w. sjamsuridzal, k. ando, and y. widyastuti. potentials of the wallacea biodiversity in bioprospecting. berita iptek 2009; 47 (1): 918. 15. conlon, j. m. and m. mechkarska. host-defense peptides with therapeutic potential from skin secretions of frogs from the family pipidae. pharmaceuticals 2014, 7, 58-77; doi:10.3390/ph7010058. 16. mcgivern, j. g. ziconotide: a review of its pharmacology and use in the treatment of pain. neuropsychiatric disease and treatment 2007; 3(1): 69–85. 17. crampton, l. cone snail venom facts and potential medical benefits. 2019. https://owlcation.com/stem/cone-snailsdangerous-venom-with-medicinal-uses (updated on september 23, 2019). author contribution: 1st author endang sukara conceived the idea, designed of the manuscript, performed the literature search, wrote the initial draft, checked the manuscript meticulously and gave final approval of the manuscript for submission. 2nd author safendrri komara ragamustari did the critical revision of the article, performed the literature search and gave the final approval of the manuscript for submission. 3rd author ernawati sinaga performed the literature search, revised the article critically and checked the manuscript meticulously and gave final approval of the manuscript for submission. conflict of interests: no conflict of interest in this study to declare. microsoft word fina revised saima article 21.11.2020 1 bangladesh journal of bioethics 2020; 11 (2): 21-34 21 detrimental consequences of unethical anthropogenic interventions upon the ecosystem of teknaf peninsula, chattogram, bangladesh saima ahmad associate professor, geography & environment bangladesh open university, gazipur email: saima.ahmad68@gmail.com doi: https://doi.org/10.3329/bioethics.v11i2.49261 abstract: the eastern coastal zone of bangladesh is endowed with dynamic terrestrial ecosystem. the wide river estuaries, the uninterrupted teknaf coast, and the rich biodiversity of the study area provide ample opportunities for socio-economic development. nevertheless, the terrestrial ecosystem of the east coast has been deteriorating in an accelerated rate owing to unethical anthropogenic interventions. few studies regarding ethical attitudes of local communities to conserve the coast were conducted earlier. the main theme of the study was to identify the detrimental consequences of unethical anthropogenic intervention upon the terrestrial ecosystem of teknaf peninsula, chattogram. the objectives were (i) to measure the heavy metal concentration and (ii) the physio-chemical quality of soil, and (iii) to analyze the depletion of vegetation coverage at the study area. five heavy metals likecadmium, copper, iron, lead, and zinc; and three physio-chemical parameters such as, the ph, electrical conductivity, and temperature of sample soil were measured. the average concentration of pb in soil (0.25 mg/g) is 10 times higher than world average (0.03 mg/g), while the concentration of fe at himchari area (s 03) soil is 1.54 mg/g more than world average (3.4 mg/g). the physiochemical parameters are within standard range. unethical discharge of toxic effluents from shrimp hatcheries, and municipal garbage dumping are main sources of pollution, which ensue into degradation of the terrestrial and coastal and marine ecosystems. further, the vegetation coverage has depleted manifolds. hence, the department of environment (doe), bangladesh 1 declared the area as an ‘ecologically critical area’ (eca). the concerned stakeholders, likecpp volunteers and officials, forest division, fisheries research institute, bangladesh water development board, union chairman and journalists of cox’s bazar recommended insertion of moral ethics among local stakeholders through trainings, motivational lectures, demonstrations and dramas, as well as, incorporation of lessons about consequences of unethical and unscrupulous activities upon geoenvironment into text books. though least practice has been found regarding the practice of moral values and ethics during the survey, the present research advocates in developing ‘knowledge pool’ about coastal environment, creating awareness, and developing moral ethics among the local, regional and national stakeholders. keywords: bio-diversity, ecologically critical area, ethics, knowledge pool, moral values, terrestrial ecosystem. introduction: the teknaf coast, one of the significant ‘ecologically critical areas’ (eca) of the country was selected as the study area. the coast lies within the ‘bio-ecological zone 8a’, which consists of the i) coastal plain, and iii) sandy beach/sand dunes 2 (map 1). the study focuses upon the detrimental consequences of unethical anthropogenic intervention upon the terrestrial ecosystem of the study bangladesh journal of bioethics 2020; 11 (2): 21-34 22 area. three indicators, such as (i) the concentration of heavy metals and (iii) physio-chemical quality of soil and (iii) vegetation coverage of the study areas were selected to measure the detrimental impacts of unethical anthropogenic activities upon the study area. collected soil samples were measured to find out the concentration of five heavy metals and quality of four physio-chemical parameters. the literatures regarding the heavy metal concentration in soil revealed the seasonal distribution of heavy metal (cd, pb, zn, cu, mn and fe) concentration in the littoral sediments of the bay of bengal coast3. the study mentioned the river, industrial region, and uncontrolled domestic wastewater discharge areas as the hotspots of pollution. the researchers stated that, the concentration of cd, pb, zn and fe were high at matamuhuri, moheshkhali and bakkhali rivers and had affected the aquatic ecosystem. according to the doe (2014) declared that, the cox’s bazar municipality received around twelve tones of household wastes into the water bodies daily of which more than half of them end up in the bakkhali river. the level of dissolved oxygen (do), total dissolved solids (tds) and biological oxygen demand (bod) in the cox’s bazar municipality area varied greatly in comparison to the standard values. further, the doe declared that, in 2013 the level of tds was 9,110 ppm (standard value below 2,100 ppm) in the river’s middle wharf area, which accentuates the gradual contamination of the river water 4. rashid and his colleagues focused on the adverse effects of toxicity due to the escalation heavy metal concentration in saline sea water, sea sediment, sea shells, and on oyster along the east coast of the bay of bengal5. raknuzzaman and coauthors aimed to provide baseline information on the toxic trace metal concentration in different coastal environment of bangladesh6. seven trace metal concentration, such as, cr, ni, cu, zn, as, cd and pb was determined in water and sediment samples collected from four coastal sites of bangladesh, namely bakkhali river estuary, cox’s bazar, karnaphuli river, chattogram, meghna estuary and sunderbans. the study confirmed that, a wide range of metal concentration was observed among the sampling sites. the soil of the no.6 fishery ghat at bakkhali river was detected as the main source point of pollution. the heavy metal contamination in sediment in recent years along karnaphuli river estuary by measuring the depthdistribution of core sediment composition, grain-size parameters, toc content and pb radioactivity of the karnaphuli river estuary sediment7. the variations of all core sediment properties showed an abnormal sediment layer (8–20 cm) below the surface and the surface sediment of karnaphuli river estuary was contaminated with cr and pb. further, the researchers stated that, the catastrophic events, such as, landslides, cyclones, and heavy rainfall, between 2007 and 2008, led to the changes in source materials and depositional environment of estuary, and bangladesh journal of bioethics 2020; 11 (2): 21-34 23 thus altered metal accumulation in sediments. the heavy metal increase at karnaphuli river estuary sediment was associated with accelerated urban and industrial growth in recent 30 years, including catastrophic events in the area. the surface sediments along the bay of bengal coast has high concentrations of major (si, al, ca, fe, and k) and minor (cd, mn, ni, pb, u, zn, co, cr, as, cu, rb, sr, and zr) heavy metals8. the mangrove for the future (mff) is a regional initiative which promotes investment in coastal ecosystem conservation for sustainable development. bangladesh is one of the countries where mff focuses on healthy and well managed ecosystems to ensure ecosystem based resilience coastal communities9. the ‘coastal vegetation improvement for community resilience in sabrang union of teknaf peninsula’ (2016-2017) is one of the mff projects, which aimed to improve lives and livelihoods of community people by reducing poverty and to ensure sustainable management in the sabrang union of teknaf. the project distributed 33,000 saplings and 150 bondhu chulas with a aim to reduce use of fire wood by the community. the project achieved success in reduced rate of tree cutting for domestic and other uses, increased plantation at homesteads and refrain from cutting down the road side trees 10. the mangroves as highly productive wetlands and vital coastal resource for the socio-economic development11. the researchers mentioned productivity and physical structure of the mangroves as two key variables, which provides suitable habitat for nursery, growth, and migration of floral and faunal species by recycling wastes and nutrients at the coastal areas. the study also mentioned that, 13 mangrove user communities are highly dependent upon the mangroves. for instance, the small-scale fishing, like the catch of fin fishes, shrimps and prawns, crabs, mollusks are done from the mangrove areas along the coastal areas. realizing the importance of the mangroves, about 1,469 ha of euryhaline mangroves were reported to be planted by different management regimes11. though the literatures investigated into the concentration of heavy metals at the coastal area sediments, there were lesser studies regarding the heavy metal concentration at the source points of pollution in the soil of the teknaf peninsula. hence, the study selected the major point sources of pollution along the study area as the sample areas and collected soil samples from the most polluted soil of the sample areas. moreover, little has been studied regarding the pattern of vegetation coverage of the study area, though the vegetation coverage of the area has been declining in a rapid pace. main theme and objectives: the main theme of the study was to identify the detrimental consequences of unethical anthropogenic intervention upon the terrestrial ecosystem of teknaf peninsula, chattogram. to achieve the theme, three objectives were selected, such as (i) detection of heavy metal concentration level in soil, (ii) identify the physiochemical quality of soil, and (iii) analyze bangladesh journal of bioethics 2020; 11 (2): 21-34 24 the vegetation coverage status of the teknaf coast. justification: lack of awareness, knowledge and ethical values of the local stakeholders are the vital driving forces causing detrimental changes and destruction of the terrestrial ecosystem of the coastal zone in bangladesh. the most vital component of terrestrial ecosystem is the soil, while vegetation functions as the ‘producer’ of the ecosystem food chain. hence, the study focused upon anthropogenic invention induced soil quality deterioration, which ensue depletion of floral bio-diversity of the teknaf coast. the present research found that, creating awareness about the impacts of unscrupulous activities of local and national stakeholders at the east coast ecosystems must be ensured through proper in-depth knowledge about diverse sectors of the coastal zone. methodology: selection of study area and sample areas: the study area was selected after a reconnaissance survey, as well as thorough literature survey and analysis of the satellite imageries of the last twenty-five (1990-2015) years. the sample areas were selected on the basis of presence of three distinct environmental features, such as the (i) source points of heavy metal concentration, (ii) areas of significant vegetation coverage depletion, and (iii) areas of substantial ecological criticality. selection of environmental indicators: the cd, cr, cu, hg, ni, pb, and zn are the eight most common pollutant heavy metals 12 a,b. among these, the present study measured the concentration of four heavy metals such as the cd, cu, pb, and zn; and the concentration of heavy metal fe was measured for its significance as a nutrient for the terrestrial organisms13. further, three physio-chemical parameters, such as the ph, temperature, and electric conductivity (ec) were selected as the physio-chemical parameters to measure the soil quality and thus, identify the state of terrestrial ecosystem of the teknaf coast. map 1: bio-ecological zone of the study area 2 research approach: the research was conducted in both quantitative and qualitative research approach. primary sources of data: (i) the soil samples were collected from the point sources of pollution to measure the heavy metal concentration and physio-chemical quality of soil and (ii) the vegetation coverage was derived from the analysis of the six temporal landsat images (19902015). secondary sources of data: (i) national and international reports, and (ii) published and unpublished academic journals and books. bangladesh journal of bioethics 2020; 11 (2): 21-34 25 sample collection: the soil samples were collected by ‘point sampling’ method from three source points of pollution at the study area. toxic water drained directly from the shrimp hatcheries and fish processing industries into the beach soil at the sonarpara and himchari shrimp hatchery area; and the polluted beach soil due to garbage disposal by the tourist markets, hotels and visitors at the inani beach ‘tourist spot’ area were collected. methods of sample analysis: the level of concentration of five major heavy metals in the soil samples were analyzed in the environment laboratories of the department of geography and environment, department of soil, water and environment, and cars, d.u. the soil samples were collected during the dry weather (pre-monsoon), from 16th -20th march, 2016. (i) analysis of heavy metal concentration in soil samples: the heavy metals were analyzed to measure the concentration level in soil samples by ‘atomic absorption spectroscopy (aas-7000)’ method. the soil samples were collected from a depth of six to eight inches at the point sources of pollution by ‘point sampling’ method. the samples were grinded and digested by ‘nitrichydrochloric acid digestion’ method and then filtered into clear bottles. the digested samples were submitted at the centre for advanced research in science (cars), university of dhaka to measure the concentration level of the analytes likeiron, zinc, copper, lead, and cadmium in soil samples. the sample had to be diluted many folds to keep the results in the analytical range. (ii) analysis of non-metal or nutrient concentration in soil samples: the content of the two major non-metals or nutrients, such as phosphorous and sulphur was measured by hno3 digestion method (combination of nitric-perchloric acids). (iii) analysis of physio-chemical parameters in soil samples. three physiochemical parameters, such as the ph, electric conductivity (ec), and temperature of soil was measured with the ph meter, calibrated by ph 7.0 buffer solution (distilled water) to analyze the environmental quality of the study area. the samples were measured and analyzed in the environmental laboratories of the department of geography and environment and the department of soil, water and environment, university of dhaka. (iv) analysis of landsat images for vegetation coverage:six ‘radiometrically corrected temporal landsat images’ were analyzed and maps were created with arc/gis and erdas imagine software to measure the ‘vegetation coverage’. the ‘normalized difference vegetation index (ndvi)’ method was used to reveal the vegetation coverage pattern in the study area (map 2). the scale of ndvi ranges from -1.0 to + 1.014. the ndvi index separates green vegetation from other surfaces as the chlorophyll of green vegetation absorbs red light for photosynthesis and reflects the nearinfrared (nir) wavelengths. hence, the areas with strong infra-red wave length reflectance show healthy green dense vegetation, which is represented with index value from 0.6 to +1 15. further, the index value from 0.2 to 0.4 indicates bangladesh journal of bioethics 2020; 11 (2): 21-34 26 sparse vegetation, and values from 0.4 to 0.6 indicate moderate vegetation. on the other hand, the index value below 0.2 represents water bodies and areas without vegetation, while bare soil, rocks, water bodies, snow, and clouds have around zero reflectance15. table 1.1 illustrates the pattern of physiographic features within the ndvi range. table 1.1: ndvi classification ranges ref no data presentation: the attributed data were presented with tables, graphs, and maps. results of the study: heavy metal concentration in soil: the concentration of five heavy metals in soil samples, such as cadmium (cd), copper (cu), iron (fe), lead (pb), and zinc (zn) of three sample areas of the teknaf coast has been shown in table 1.2. cd concentration in the soil: the cd concentration of the soil samples at three source points of the study area is below detection level (bdl) (table 1.1). cu concentration in soil: the concentration of cu ranges from 0.08 mg/g to 0.15 mg/g, while the average (n=3) was 0.12 mg/g (table 1.1, fig. 1.1) in the study area. the soil sample, collected from a drain pouring toxic waste water directly to the soil and water from several hatcheries had the highest content of cu (s 02). the cu content of the sample areas were quite lower than the world average (0.9 mg/g). fe concentration in soil: the fe concentration ranges from 2.09 mg/g to 4.94 mg/g, with an average (n=3) of 4.20 mg/g (table 1.1, fig.1.2). the highest content of fe is at himchari shrimp hatchery area (s 03), which is 1.54 mg/g more than the world average (3.4 mg/g). pb concentration in soil: the pb concentration of s 01 and s 02 is 0.24 mg/g and 0.26 mg/g, while the average (n=2) is 0.25 mg/g (table 1.1, fig. 1.3). the pb concentration of s 03 is below detection level (bdl). however, the average concentration of pb in the soil of sample areas is 10 times higher than the world standard average concentration (0.03 mg/g). zn concentration in soil: the zn concentration ranges from 0.71 mg/g to 0.86 mg/g, while the average (n=3) was 0.78 mg/g (table 1.1, fig. 1.4). the highest content of zn is at himchari shrimp hatchery area (s 03).the concentration of zn in the soil of the sample areas is quite lower than the world average concentration (5.0 mg/g). physio-chemical quality of soil: three (ph), (ii) electric conductivity (ec), and (iii) temperature was taken to measure the physio-chemical quality of soil (table 1.3). (i) potential of hydrogen (ph) of soil: the ph level of the three source points of the teknaf coast varies from 5.8 to 7.6. this shows that, the soil of both s 02 and s 03 ndvi range feature -1 0 bare soil, rock, water, snow, cloud 0 0.2 barren land / built up /rock 0.2 0.4 sparse vegetation 0.4 0.6 moderate vegetation bangladesh journal of bioethics 2020; 11 (2): 21-34 18 table 1.2: heavy metal concentration in soil of teknaf coast fig. 1.1: concentration of cu in soil fig. 1.2: concentration of fe in soil fig. 1.3: concentration of pb in soil fig. 1.4: concentration of zn in soil. sample id c d -co n ten t w o rld s ta n d a rd o f c d c u -co n ten t w o rld s ta n d a rd o f c u f e-co n ten t w o rld s ta n d a rd o f f e p b -co n ten t w o rld s ta n d a rd o f p b z n co n ten t w o rld s ta n d a rd o f z n soil sample mg/g mg/g mg/g mg/g mg/g mg/g mg/g mg/g mg/g mg/g sample 01 inani beach, marine drive bdl 0.11 0.13 0.9 2.58 3.4 0.24 0.03 0.77 5.0 sample 02 sonarpara, marine drive bdl 0.11 0.15 0.9 2.09 3.4 0.26 0.03 0.71 5.0 sample 03 himchari, marine drive bdl 0.11 0.08 0.9 4.94 3.4 bdl 0.03 0.86 5.0 average -- 0.12 3.20 0.25 0.78 27 bangladesh journal of bioethics 2020; 11 (2): 21-34 19 were ‘slightly alkaline’ type. the soil quality at inani beach tourist spot area (s 01), as well as, the average soil condition of the sample areas is ‘moderately acidic’ in nature (table 1.3, fig.1.5). (ii)electrical conductivity of soil: the ec of the soil ranges from 1.22 ms/cm to 6.37 ms/cm in the sample areas, with an average ec of 4.21 ms/cm (table 1.3, fig.1.6). (iii)the temperature of soil: the temperature of the sample area varies from 26.4 to 26.5 °c, and the average temperature was 26.5°c (table 1.3, fig.1.7). findings and discussion: the east coast of bangladesh is a dynamic coast with diverse opportunities and vulnerabilities. the longest uninterrupted coast of the world –the cox’s bazar coast, the wide river estuaries serving as the breeding ground and nursery of diverse flora and fauna, the rich terrestrial ecosystem endowed with the mangrove and many other indigenous trees, the largest tourist spots of the country like the cox’s bazar and inani beach, the hills bordered by the narrow coastal plains, the wide and shallow continental shelf offers diverse physiographic and socio-economic opportunities of sustainable development. nevertheless, all these opportunities have been facing deterioration owing to unethical and unscrupulous anthropogenic interventions like illegal land grabbing leading to coastline accretion and/ or erosion, destruction of the floral and faunal diversity, soil and water pollution due to huge discharge of untreated toxic heavy metals from the industries and water vehicles, excessive logging of indigenous trees for accommodating land for housing, shrimp cultivation, salt farming, agriculture, mixed and misuse of land properties. realizing the situation, the present study attempted to analyze the state of major two components of terrestrial ecosystem-the soil and the vegetation coverage of the east coast. hence, the heavy metal concentration and physio-chemical quality of the soil and the vegetation coverage depletion of the study area were identified in the study. the main sources of heavy metal pollution in soil were the urban traffics, and agrochemical products used in the agricultural land16. from the data acquired, the concentration of the heavy metal fe in soil was detected as the highest (3.2 mg/g), followed by the zn (0.78 mg/g), pb (0.35 mg/g), and cu (0.12 mg/g) concentration (table 1.1). however, the average concentration of pb in soil (0.25 mg/g) was 10 times higher than world average (0.03 mg/g). the lead (pb) as an extremely stable heavy metal which is a dangerous neurotoxin to human and other animals17. though natural presence of 15 to 40 ppm of lead per kg (mg/kg) of soil is considered as natural, pollution might increase the level to several thousand ppm. the densely populated and industrial areas where weathering, chipping, scraping, sanding, and sand –blasting of structures bearing lead-based paints generally are the major sources of high pb concentration. the concentration of fe at himchari area (s 03) soil was 0.54 mg/g more than world average (3.4 mg/g). the fe is an essential plant micronutrient occurring naturally. deficiency of fe in plants lessens the chlorophyll of the leaves18. however, fe itself is not toxic, but this heavy metal interacts with other toxic 28 bangladesh journal of bioethics 2020; 11 (2): 21-34 18 soil sample ph ec (ms/centimeter) temperature (°c) sample area 01 (inani beach, marine drive) 5.8 6.37 26.5 sample area 02 (sonarpara, marine drive) 7.6 2.04 26.5 sample area 03 (himchari, marine drive) 7.6 1.22 26.4 average 7.0 3.21 26.5 table 1.3: physio-chemical quality of soil. source: present study, field survey, march, 2016 fig. 1.5: potential of hydrogen (ph) of soil fig. 1.5: potential of hydrogen (ph) of soil fig. 1.6: electrical conductivity of soil fig. 1.7: temperatures of soil 29 bangladesh journal of bioethics 2020; 11 (2): 21-34 19 metals. the anthropogenic sources, such as airborne dust during copper metallurgy are a major source of cu, pb and cd18. copper (cu) is an essential heavy metal for plant growth available in soil19. wide and continuous use of fertilizers in agricultural sector causes cu contamination. a wide variety of copper products produced in bangladesh, such as copper foil, bars and rods, sheets and plates, tubes and pipes, wire, unwrought, and many other products20. the concentration of pb in the chattogram city area was around 7.33 mg/kg, while the concentration of cd was around 2.43 mg/kg during the summer season. the municipal wastes from rapidly growing urbanized areas, industrial effluents, chemical fertilizers or agricultural land, and as the major causes of metal and metalloid pollution in bangladesh which has been posing substantial threat to the local people21. the agricultural land and vegetables in sewage-irrigated areas are highly contaminated with cd, pb, and chromium (cr). cd might cause serious deleterious effects both in plants and mammalian consumers22. the main source of cd in soil is the emissions from industries. according the researchers, cd has high phytoaccumulation mobility from soil to plant and hence, might enter the food chain. the zn concentration at s 01 (0.13 mg/g) and s 02 (0.15 mg/g) exceeded the world average (0.9mg/g). the shrimp hatchery areas at cox’s bazar contain the highest levels of zn, cu and pb due to huge discharge of different salts and chemicals from hatcheries to the beach soil23. the soil remediation consists of actions such as removal, control, containment, or reduction of contaminants in soil to a safe level for biological entities24. the paper mentioned that, the remediation of copper contaminated soil can be done by the phytoremediation process as this method is economical and eco-friendly. the soils naturally contain 2 to 100 ppm (average 30 ppm) of cu which is essential for plant growth. on the other hand, excessive cu concentration might cause toxicity leading to decrease in plant growth and seed germination. the physio-chemical parameters, such as the ph, ec and temperature of the soil samples were measured (table 1.1 and 1.2). the ph in the soil of s 02 and s 03 (ph 7.6) contained higher ph than the neutral ph level (ph 7.0). excess presence of ph in soil change the slightly alkaline soil into moderately alkaline; and decrease of per unit of ph increases the zn fivefold in soil25. the soil ec is an indicator of salinity of soil, which indicates the nutrient availability and loss, soil texture, and available water capacity26a. hence the crop yields and activity of soil microorganisms, such as emission of greenhouse gases are regulated by the ec 26b. the soil ec in the sample areas ranged from 1.22 to 6.37 ms/cm in the study area. the average was 3.21 ms/cm, while the highest ec was at s 01 (6.37ms/cm). the soil temperature plays a vital role in the physical, hydrological, and biological processes27. the soil temperature regulates the transformation and uptakes of nutrients by plant roots and agricultural crops28. 30 bangladesh journal of bioethics 2020; 11 (2): 21-34 20 the soil might show high spatio-temporal variability29. vegetation coverage: the vegetation coverage at the teknaf coast has depleted at a great extent, showing a decline in index value from + 0.21 (1990) to + 0.02 (2015) (fig.1.8, map 2 a & b). according to the vegetation ranges, the study area has ‘sparse vegetation’14 & 15. in 1990, the value of the vegetation index at the study area ranged from -0.18 to 0.95, which might be categorized as ‘sparsely vegetated area’ (map 2 a). however, in 2015 the value in the vegetation index ranged from 0.007 to 0.56, which indicates acute decline in vegetation coverage in the study area (map 2 b). the study observed that, besides the physiographic cause, such as shoreline erosion, excessive cutting down of trees for domestic fire woods, logging and other purposes were the major causes of vegetation depletion. the cd has high phytoaccumulation mobility from soil to plant and hence, might enter the food chain29. hence, higher concentration of cd in plants might cause toxicity leading to decreasing nutrient uptake, inhibiting photosynthesis, and plant growth. the declined vegetation coverage of the study area ensued enhanced soil erosion and causing massive shoreline erosion30.moreover, the climate change induced hazards like cyclone and storm surge, tidal inundation, and wave cut erosion has increased in the study area due to decreasing vegetation coverage. conclusion and recommendations: the deterioration of the terrestrial ecosystem of the east coast is the consequence of municipal garbage dumping, industrial waste discharge, plantation of exotic and map a map b map 2 (a & b): vegetation coverage of teknaf peninsula, cox’s bazar: 1990 & 2015 non-native plant species, lack of public awareness and knowledge about the ecosystem conservation, conflict of multiple, as well as unplanned land use, illegal and unscrupulous land 31 bangladesh journal of bioethics 2020; 11 (2): 21-34 21 encroachment by local stakeholders, shrimp cultivation, and over exploitation of floral and faunal species for consuming and trading. the present research advocates to minimize the discharge of toxic industrial and municipal effluents from the point sources by implementing advanced ‘waste treatment plant’ and ensuring close regular monitoring. nevertheless, besides the application of modern waste treatment mechanisms, strong emphasis has to be given upon creating awareness at local and national level through developing knowledge pool regarding the conservation, as well as protection of the coastal zone terrestrial ecosystem. regular trainings, demonstrations, rallies, and dramas should be held among the national and local stakeholders about the detrimental impacts of anthropogenic interventions in the terrestrial ecosystem of the east coast of bangladesh. national level initiatives have to be taken for incorporating knowledge about the sustainable management of the coastal terrestrial ecosystem into the text books of all levels. proper and adequate knowledge about the terrestrial ecosystem, awareness enriched with trainings, moral values and ethics regarding the conservation of the terrestrial ecosystem management has to be ensured for achieving the sustainable development goal. limitations: 1) the management of the shrimp hatcheries and fish processing factories were not available for kiis, 2) the local stakeholders were unaware and ignorant about the detrimental impacts of deterioration of ecosystems, 3) the government stakeholders mentioned about lack of proper and fullyfunctional infrastructural and law enforcing procedures to protect the terrestrial and coastal and marine ecosystems of the east coast, and 4) majority of the tourists were unaware and uninformed about their unscrupulous activities like throwing garbage at the coastal beach. acknowledgements: the author wishes to express her appreciation to the ministry of science and technology, gob (national science and technology fellowship: 2015-2018 (for ph. d degree) for their financial support. the author would also like to extend her acknowledgements to the department of geography & environment, department of soil, water and environment, and centre for advanced research in sciences (cars), university of dhaka for providing laboratory facilities and other logistic supports while conducting this research. references 1. government of bangladesh. the bangladesh environment conservation act 1995. act no.1. bangladesh gazette, extra-ordinary issue of 16-21995 and amended by act nos. 12 of 2000 and 9 of 2002. 2. nishat, a., huq, s.m., imamul, barua, s.p., reza, ali. a.h.m.khan, moniruzzaman, a.s. 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(ed.) phytoremediation of copper-contaminated soil. in book: phytoremediation: management of environmental contaminants. chapter: 12. 2015; ann 33 bangladesh journal of bioethics 2020; 11 (2): 21-34 23 karczewska, andrzej mocek, piotr goliński, mirosław mleczek. springer international publishing. available from: doi: 10.1007/978-3319-10969-5_12 19. apori, e. o.s. hanyabui,j. asiamah. remediation technology for copper contaminated soil: a review. asian soil research journal. 2015; 1(3): 1-7. article no. asrj.45322. available from: doi: 10.9734/asrj/2018/4532 20. market research.com. copper market in bangladesh to 2020 market size, development, and forecasts. global research & data services oy. 2016 [cited 2020 nov 19]. available from: www.marketresearch.com/global-research-dataservices-v3891/copper-bangladesh-sizedevelopment-forecasts-10332154/ (accessed on 11.10.2019) 21. m. mominul islam, md. rezaul karim, xin zheng and xiaofang li. heavy metal and metalloid pollution of soil, water and foods in bangladesh: a critical review international journal of environmental research and public health — open access journal. 2018; [cited 2020 nov 19];issn 1660-4601.file. available from: www///e:/bangladesh%20bioethic%20society/he avy%20metal%20and%20metalloid%20pollution.p df (accessed on 12.10.2019) . 22.shahid m.,dumat c.,khalid s.,niazi n.k., antunes p.m.c. cadmium bioavailability, uptake, toxicity and detoxification in soil-plant system. in: gunther f.a., de voogt p. (eds). reviews of environmental contamination and toxicology. 2016; vol.241. (continuation of residue reviews). springer, cham. 73-137. available from: https://doi.org/10.1007/398_2016_8 (accessed on 12.10.2019). 23.raknuzzaman,md.,kawser,m.a.,saiful,i.,.m., mamun,a.h.,tokumura,masahiro.sekine, makoto, masunaga, shigeki. assessment of trace metals in surface water and sediment collected from polluted coastal areas of bangladesh. journal of water and environment technology. 2016; 14(4): 247-259. available from: https:// doi. org/10.2965/jwet.15-038(accessed on 12.10.2019) 24. apori, e. o.s. hanyabui,j. asiamah . remediation technology for copper contaminated soil: a review. asian soil research journal. 2018; 1(3): 1-7. article no. asrj.45322. available from: doi: 10.9734/asrj/2018/4532 25. mertens j., smolders e. zinc. in: alloway b. (eds). heavy metals in soils. environmental pollution. 2013; vol. 22. springer, dordrecht. doi.org/10.1007/978-94-007-4470-7_17 26. (a,b) united state department of agriculture (usda). soil electrical conductivity. natural resources conservation (nrc) services. 2014 [cited 2020 nov 19]; available from: https://cropwatch.unl.edu/documents/usda_ nrcs _ ec_guide.pdf (accessed on 12.10.2019). 27. hailong he, miles f. dyck, robert horton, min li, huijun jin, bingcheng s. advances in agronomy. chapter five distributed temperature sensing for soil physical measurements and its similarity to heat pulse method. 2018; vol.148, elsevier.173-230. available from: https:// doi.org/10.1016 /bs.agron. 2017.11.003 28. haishui yang, jiajia zhou, jinxia feng, silong zhai, weiping chen,jian liu, xinmin bian.chapter five ditch-buried straw return: a novel tillage practice combined with tillage rotation and deep ploughing in rice-wheat rotation systems. advances in agronomy. 2018; 154.257-290. available from: https://doi.org/10.1016/bs.agron.2018.11.004 29. hailong he, miles f.dyck, robert horton, min li, huijun jin, bingcheng si.advances in agronomy. chapter five distributed temperature sensing for soil physical measurements and its similarity to heat pulse method.vol.148, elsevier . 2018; 173-230. available from: doi.org/10.1016 /bs. agron. 2017.11.003 29. shahid m., dumat c., khalid s., niazi n.k., antunes p.m.c. cadmium bioavailability, uptake, toxicity and detoxification in soil-plant system. in: gunther f.a., de voogt p. (eds). reviews of environmental contamination and toxicology. 2016;vol.241:73-137. (continuation of residue reviews), vol. 241. springer 2016. cham. available from: https://doi.org/10.1007/398_2016_8 30. ahmad, saima. analysis of geo-environmental indicators for coastal zone management of east coast of the bay of bengal along bangladesh. unpublished ph.d. thesis. department of geography & environment. 2018; university of dhaka. dhaka -1202 author contributions: author conceived the idea, did the literature review and wrote the manuscript. conflict of interest: the author declares that there is no conflict of interest. 34 microsoft word editorial bangladesh journal of bioethics 2020; 11 (3) 1 editorial vol 11 no 3 (bioethics and educational institutes) in the past few years, bioethics, the branch of applied ethics, has been widely established as a discipline, as a value framework, a framework of principles, a tool, as a medium for practical skill development to help individuals understand complex moral, social, legal, environmental issues in medicine, clinical and health research. as a discipline, bioethics invite interdisciplinary deliberation and draws people from all sectors of society to engage in discussion. bioethics also serves as the potential medium for greater community engagement and participation involving both professionals and non-professionals. as a branch of applied ethics, bioethics, have dealt with the complex ethical issues such as animal experiments, biological enhancements, organ donation, surrogacy, gene technologies, reproductive technologies, the beginning and end of life care, public health, health policy and planning. though the list is not exhaustive, the pressing need of incorporation of bioethics within the educational curriculum, at different levels, was to make rational and autonomous humans capable to undertake informed decisions in complex situations of life. with the evolution of the branch, bioethics education has rapidly developed over the last few decades. it has been extended to be a part of academic curriculum with the purpose to help students develop the critical thinking skills in dealing with complicated ethical issues; to develop the skill of rational argumentation, reasoned responses. the papers in this issue on bioethics and educational institutes emphasize the need and practical implications of incorporation of bioethics in the academic curriculum across the globe. the first paper entitled a survey on the attitude of college students to the right to privacy as opposed to the right to know by nader ghotbi highlights the importance of informed decisions to balance the two conflicting human rightsthe right to know and the right to ‘privacy and confidentiality’. conducting the survey on 222 bioethics students at an international university in japan, the paper had used a case study method to study the students’ perception and attitude towards this conflict of rights. the study concludes with findings that majority of students have stated the importance of both these rights in a democratic society. the study also reveals the need of case-based decisions on specific circumstances and careful consideration of the consequence of such decisions. additionally, the paper establishes the limitation of the legal boundaries and the need of ethical, rather bioethical analysis, in resolving debates in many instances. the second paper on awareness and perceptions on bioethical issues among pre-service science teachers by zulfeki daud, zainab ari, and noorahfizah daud investigates the awareness and perception level of bioethical issues among pre-service science teachers in a malaysian education institution. using a questionnaire-based survey and using spss version 22, the paper indicates that pre-service science teachers were aware of the existence of bioethical issues. however, there exists statistically significant difference of perception of the bangladesh journal of bioethics 2020; 11 (3) 2 bioethical issues according to religion and course. male, muslim and science major course preservice teachers are more aware of the issues to be bioethical. while majority of the pre-service teachers are aware of cloning, other bioethical issues such as organ donation, genetic modification, stem cells, abortion, gene therapy, gene screening and euthanasia seemed to require more awareness. the paper concludes with the recommendation of wider discussion of the bioethical issues and incorporation of the bioethical issues in science curriculum among preservice science teachers. the third paper on drug abuse and drug addiction among students of university of rajshahi (ru) by faiqua tahjiba emphasizes the need of more comprehensive approach to deal with drug abuse in the educational setting. investigating the actual condition of the students of the university regarding drug abuse and addiction and using case study method, the paper, finds that there are different social and economic causes intricately related to the drug addiction among the university students. these include curiosity, frustration, friends’ request, neglect from family and friends etc. additionally, the study reveals that there is a tendency to use specific drugs such as yaba, phensydyle, ganja (weed), chuani etc. stating the average monthly expenditure for collecting drugs by these students, the paper concludes that the rate of drug addiction among the students of ru is quite alarming. therefore, all stakeholders including the students, guardians, teachers, university authority, the law makers and law enforcing agencies, researchers, civil society, ngo’s and the state must come forward together to address the issue. the fourth paper on legacies of love, peace and hope: how bioethics education can overcome hatred and divide by darryl r.j. macer narrates a strive for peaceful and harmonious coexistence even to undertake bioethical decisions. the author mentions in the pursuit of a good life (eubios), both individuals and societies, need to educate themselves on the pursuit of love of life in all domains, self-love, love of others, loving good and love of life. reflecting on his own journey, the author underlines that for the sake of bioethics education, nurturing good decisions is important and nurturing of good decisions imply an enhanced peaceful and harmonius coexistence in the world. for, bioethics, need to be used as the empowering tool to enable individuals and population to make right choices, to undertake right decisions at right time and place. the fifth paper on ethics after darwin: completing the revolution by rainer ebert demonstrates a big-picture of the discussion of the important implication of darwinism for ethics. the author argues that there is a misfit between scientific view of the natural world and the view, still dominant in academic philosophy and wider society alike, that there is a discrete hierarchy of moral status among conscious beings. the author suggests that the clear line of traditional morality – between human beings and other animals – is a remnant of an obsolete moral outlook. he argues that the phenomenal consciousness might have occurred in evolution from one generation of animals to the next, and can be considered to be the plausible and nonarbitrary cut-off point, separating “someones” from “somethings.” concluding with the open note and highlighting that there is a far greater implication such as non-consumption of bangladesh journal of bioethics 2020; 11 (3) 3 “conscious animals” if the community of moral equals in fact coincides with the community of conscious beings, the paper, exemplifies how theoretical bioethics can be used as the tool in argument development at the individual and population level. in sum, the papers in this issue, had demonstrated how and why bioethics need to be part of the academic curriculum and how exactly it can be used for enhanced knowledge, attitude, and practice of the issues. as the guest editor of the issue, i thank all the authors for selecting the journal and adding value to the journal through their intellectual and philosophical contributions. i do, specifically, thank each author for contributing to the issue with the emphasis on the need of the bioethical discussions in different domains of academics. i convey my heartfelt gratitude to all the reviewers for giving your precious time to review the papers of the issue and also in providing valuable insights and comments for the contributors to improve. i am also grateful to professor shamima parvin lasker and ms. tahera ahmed for giving the opportunity to edit this issue. finally, i hope readers will be benefitted in their thoughts about bioethics education and bioethics will find a definite place in the curriculums, at all levels, across the globe. thank you, dr. rhyddhi chakraborty fhea (programme leader (hnd-health care practice), global banking school, london, uk visiting faculty (philosophy & global health), ausn, usa senior associate member, royal society of medicine, london, uk) guest editor, bangladesh journal of bioethics, vol-11, issue 3 references: chadwick, ruth felicity. 2019. bioethics. encyclopædia britannica. https://www.britannica.com/topic/bioethics. last accessed january 09, 2021 ike, c.g., anderson, n. 2018. a proposal for teaching bioethics in high schools using appropriate visual education tools. philos ethics humanit med 13, 11 https://doi.org/10.1186/s13010-018-0064-1. last accessed january 08, 2021 ten have h.a.m.j. 2014. bioethics education. in: ten have h., gordijn b. (eds) handbook of global bioethics. springer, dordrecht. https://doi.org/10.1007/978-94-007-2512-6_96. last accessed january 09, 2021 wilmott, chris. 2004. ethics and bioethics. bioethics briefing. available at ethicsbrief1.pdf (le.ac.uk). last accessed january 10, 2021 microsoft word police ethics (2) bangladesh journal of bioethics 2020; 11 (1): 9-23 10 policing ethics: context bangladesh md.sharifur rahman adil lecturer of philsophy, feni south east degree college. bangladesh email: adil.doc.info@gmail.com doi: https://doi.org/10.3329/bioethics.v11i1.49192 abstract: the police are one of the most powerful and important forces for any country. the main task of the police is to install a sense of security in the ordinary citizens and to protect their life and property when they are in danger. bangladeshi police have a glorious past with tremendous achievement. especially in our great liberation war in 1971, they played an important role in achieving our liberation. eliminating terrorism & militancy and others several operation that leads with the risk of their life. but there are still a lot of accusations against the police force. likeabusing of power, misconducting with the people, committing crossfire defying the high-court order, wearing white dress when they move to detain criminals, arresting without warrant, and many other including bribery, extortion, trading drug and yaba, playing partisan role, keeping bad association, filing case against deceased man, charging sheet against the infant who has not been born yet, enforcing disappearance, suppressing the freedom of express, violating human rights, doing anti-social activities such as rape, forcible extortion, drinking alcohol, etc. are the real scenario of bangladesh police. policing ethics or related unethical behaviors, in particular, are shaped by both societal perceptions and organizational socialization of the police personnel on how authority should be exercised, as well as the latter's relationship with the socio-political and economic structures overtime. this paper proposes to explain the role of police as the main law enforcement agency in any democratic country. an attempt has been made to bring different perspectives of ethics which comprises views of aristotle, machiavelli, immanuel kant, j s mill and john rawls. the paper focuses on police ethics. police ethics’ reflects the society and the regulations that shape the policing system. this paper also discuss the results and analysis of the consequences of moral degradation caused by the police. this article explore the police brutality because of the lack of ethics and highlight the public's attitude towards police as well. the ethical standards and the code of conduct of police practitioners should actually abide by is an ongoing debate. key word: ethics, applied ethics, police, policing ethics introduction: the police are one of the most omnipresent organizations of the country. the police are expected to be the most accessible, interactive and dynamic organization of any society. their roles, functions and duties in the society are natural to be varied and multifarious on the one ihand; and complicated, knotty and complex on the other hand. broadly speaking the twin roles, the police are expected to play in a society are maintenance of law and order. to establish a conflict free society, in any type of governance, the law enforcing agencies, especially the institution of police play a vital role in the implementation of the law and order dicta as envisioned either by the constitution, executive, legislature or judiciary. once, the slogan of the police was – `service is the religion of police’. but now the police slogan is `people are police, police are people ‘.the duty of the police is bangladesh journal of bioethics 2020; 11 (1): 9-23 11 to install a sense of security in the ordinary citizens, and to protect the life and property of the citizens when they are in danger. if the police fail to perform this duty, they are held accountable as per the law of the country. but the scenario of bangladeshi police is totally different. now we often hear about police involving various unethical, illegal, unsocial, muscle power, abuse of power and immoral activities in order to provide the security1. ethics can play a vital role to prevent such unethical and immoral activities of police. it’s time to shout for policing ethics. because we know that – every man is equal in the eye of law and no one can remain above law. so, the police are no exception. as a main law enforcement agency police should be morally sound. methodology: the methodology adopted for the study is doctrinal and non doctrinal. the doctrinal research which is based on primary and secondary sources, like books, journals, magazines, newspapers, articles and websites. non doctrinal research includes the data collection through the questionnaire, interview question, and observation method. applied ethics: police ethics is a branch of applied ethics. the most well-known branches of applied ethics are medical and business ethics. applied ethics is the field that holds ethical theory accountable to practice and professional practice accountable to theory. therefore, the philosophers should not dictate to professionals the norms that are supposed to govern their professional practice, without a very thorough knowledge of that practice. on the other hand, the professionals have to under-stand that their experience and intuition are insufficient for defensible judgment, and that all their constraints do not exempt their decisions from ethical scrutiny2. ethics: policing ethics consist of two separate words policing and ethics. first i will discuss ethics and then i will discuss the police. however, ethics is a branch of philosophy. ethics involves systematizing, defending, and recommending concepts of right and wrong conduct3. ethics derives from the ancient greek word ἠθικός ethikos, which is derived from the word ἦθος ethos (habit, “custom”) the ancient greek adjective êthikos is itself derived from another greek word, the noun êthos meaning “character, disposition4. as a branch of philosophy, ethics investigates the questions “what is the best way for people to live?" and “what actions are right or wrong in particular circumstances?" in practice, ethics seeks to resolve questions of human morality, by defining concepts such as good and evil, right and wrong, virtue and vice, justice and crime. bioethicist larry churchill has written: “ethics, understood as the capacity to think critically about moral values and direct our actions in terms of such values, is a generic human capacity”5. “joe has strange ethics.” the english word ethics is derived from an ancient greek word êthikos, which means “relating to one’s character”. the ancient greek adjective êthikos is itself derived from another greek word, the noun êthos meaning “character, disposition”. finally, we can say ethics" is a system or code of conduct based on universal moral duties and obligations that indicate how one should behave. lillie an author said about nature of ethics-“we may define ethics as a normative science of the conduct of human beings living in societiesa science which judges this conduct to be right or wrong, to be good or bad, or in same similar way”6. bangladesh journal of bioethics 2020; 11 (1): 9-23 12 police: the police are those who are the members of a government organization which is responsible for enforcing law and maintaining peace and order, prevention and detection of crime. the police are one of the major components of the criminal justice system. police officers are well aware of rules and regulations. however, some officers do not pay respect to all the rules and regulations, with some being ignored while some are strictly adhered too. some rules are treated as advisory, whilst others are treated as binding. policing ethics: a pragmatic exploration of police ethics is necessary to effectively inculcate the values in the decision making processes of police officers. this does not mean that philosophical issues should be ignored but that they are placed in a utilitarian perspective7. according to schmalleger, police ethics is the special responsibility for adhering to moral duty and obligation that is inherent in police work8. in the 1700s immanuel kant, a german philosopher developed the idea of the categorical imperative. here ‘categorical ’means unconditional. according to him, one should develop such principles that will hold good both for himself and society at large. kant’s ideas have been used in the development of policing ethics. police maintain the law and order and protect the life and property of the citizens know can be regarded as universal principles j.s. mill, an english philosopher of the 1800s called it “greatest happiness principle, ethical behavior according to him is that which is useful to the society at large. for utilitarianism, aristotle’s golden mean and machiavelli’s end justifies means stands right only if those principles promote the greatest good of the greatest number of people. the utilitarian principle holds good in the light of happiness and bad in course of its reverse. rawl’s, a modern american philosopher opines that everybody must be treated equally without any regard for economic and social status. he needs to treat the rich the same way as the poor, the famous person the same way as the layman on the street. these philosophical considerations would help us to understand the concept of ‘policing ethics.’ duty of police: every organization must have specific purposes, commitments, aims, and goals. these are included in the mission statement of the organization. the mission of the police is as follows: 1. prevention and detection of crime 2. protection of life and property of the citizens through enforcement of law 3. preservation of peace, order, and safety 4. enforcement of laws and ordinances 5. safeguarding of constitutional guarantees 6. investigating problems and incidents 7. enhancement of the quality of life of the citizens by fostering a sense of security in communities and individuals the mission of the police cannot be achieved without the involvement of the community in the policy agenda. community policing ensures the involvement of the community and promotes the culture among the police and community to work together robert peel set forth the following principles on which the police force should be based: 1. the duty of the police is to prevent crime and disorder. 2. the power of the police to fulfill their duties is dependent on public approval and on their ability to secure and maintain public respect. 3. public respect and approval also mean the willing cooperation of the public. bangladesh journal of bioethics 2020; 11 (1): 9-23 13 4. the police must seek and preserve public favor not by pursuing but by demonstrating impartial service to the people and the law. the police should strive to maintain a relationship with the public that gives the belief that the police are the public and the public are the police. the test of police efficiency is the absence of crime and disorder, not the visible appearance of police9. peel’s principles emphasized the interdependency of the police and the public in controlling and preventing crime and disorder. peel also opined that the police could only be successful at their jobs when they got public approval and assistance in their actions without resorting to force or severity of the law. it is true now that police cannot control crime and disorder without the support and voluntary co-operation of the people10. what do the law and ethics say and what police done? police have to perform the most significant role in making the criminal justice system a success in doing so police have to be ethically sound, socially acceptable, and morally just and sympathetic. often allegations are heard about brutality and corruption of the police. the police are given power by law, for example, to use force to carry arms, to arrest and detain people, to search for people, vehicles, and belongings. likewise other state organs, the police may be the reason for the violation of human rights during performing their duties. policemen often use force at the time of arresting somebody empowered by the cpc (the code of criminal procedure) for example how to secure arrest by using force ( section 46)/ breaking door, window to escape at the time of arrest ( section. 48) / breaking door, window to escape at the time of arrest (section.49)excessive use of force is forbidden at the time of arrest(sec 50) power of body search ( section.51,52)/ power of arms seize (section.53) arrest without warrant (section 54) arrest of vagabonds by o/c (section.55) / pursuit of offenders into other justification (sec.58)/ police to report apprehensions (sec. 62) / and so on forth. however, the role of police regarding immoral activities is a matter of question within the national frontiers. various aspects of interpersonal relations are governed according to the constitution adopted by the country. in bangladesh, the constitution has taken due care to protect rights of the citizen and to that extent adopted various articles, in clauses 27,31,32,33,34,35,37and 43 right to live, right to work, right to own property, freedom of speech, equal treatment before the law, right to be defended in a criminal proceeding, right to be produced before the court. when arrested within twenty-four hours etc have been incorporated. the state has assured a guarantee to all those legal rights to its citizens through various organizations and mechanisms. the police regulation of bengal (prb), 1943 rule no 280, 102,103,163,166 of the code of criminal procedure (crpc), 1898 also protects the right of the public and in section 24 of the evidence act, 1872.section 24 of the said act states that a confession of an accused person shall be irrelevant if it was made by inducement or threat. let's see what the perception of the public about police is. the research was conducted by the researcher himself. this survey was conducted in the years 2019. the target group of the study was the 15 to a 79year-old population except for the district of noakhali, barishal, feni, dhaka & chittagong. about 1000 people were interviewed for the study. the sample was formed by quota sampling, the quotas being bangladesh journal of bioethics 2020; 11 (1): 9-23 14 the target group’s age, sex, regional and municipal distribution. the interviews were conducted in 25 localities in bangladesh as face-to-face interviews, using the computeraided personal interview system (capi). the interviews were conducted during the period 19 october 8 november 2019. the mean margin of error of the overall results on a 95% confidence level is ±2.5 percentage units. forty -five unique studies covering 251 cases met inclusion criteria. data reported in 21 studies indicated that 65% of people seem that police brutality happens lack of morality and police harass innocent people in an unethical way. data from 75 studies indicated that police do not perform their duty properly. if the police are moral, the crime will be reduced by 75 percent from the country. 52 % of people considered that the police are influenced by political parties. data reported in 13 studies indicated that 8 of 100 police are ethical and a survey across a wide range of bd and transport/ sectors reported that 82% of drivers have to pay exhortation to police per week/ monthly, otherwise the police harassed them in several ways. the image crisis of the police force has been seen among the people due to immoral behavior by some police officers though they lead several operations with the risk of their life. yet people's perceptions of the police are not positive. there are many reasons. the main reason for this negative perception is the conduct of illegal, biased, and amateur activities. however, police have taken place many immoral, unsocial & amateur activities due to lack of morality. some of these facts we can learn which are published in several newspapers and some of the facts remain hidden. from the published news we can assume how biased and immoral the police are in the absence of morality! for example, transparency international stated that police are the most corrupted organization in bangladesh. voice of america reports bangladesh police to have a long history of allegations and police in bangladesh have long been accused of abduction, enforced disappearance, extrajudicial killing, and other abuses12. bangla daily newspaper jaijaidin reports with the source of bbc that ‘there is no crime that the police are not involved’13. below i present some of the immoral activities of the police by taken help from several reports that published the daily newspapers of bangladesh. in 2019, nusrat murder was a burning issue across the country, it was proved that the then oc of sonagazi moazzem hossain was the fuel in this murder. the daily sun reports that allegations against oc moazzem proved in the investigation. in detail they report former sonagazi model police station oc was sued for spreading a video on social media after recording a statement from nusrat at sonagazi model police station. during an interrogation, moazzem asked nusrat offensive and unpleasant questions over the incident. later, he spread the video on social media. on april 6, nusrat was set afire at an examination center allegedly by people loyal to the principal of her madrasa after he was arrested and subsequently suspended as she had accused him of sexually harassing her in sonagazi upazila of feni district14. the daily protham alo on 12th june reports that the police submit a charge sheet in the name of the deceased person. surprised by the incident, the court judge said, "this is not a big deal in all possible countries"15. in the daily jugantor published with the headlines name `grab the money’ that covers a lot of accusation against the police bangladesh journal of bioethics 2020; 11 (1): 9-23 15 on 24th august 2014, they enclose a lot of incident below i just mention one of them. on january 3, sub inspector (si) mashiur rahman was arrested saudi arabia resident badal khan, while he talking to a friend on the road in south bishal of darussalam police station. badal first complained si mashiur demanded money from him after his arrest. if you do not pay the money, yaba and the money laundering case threatens to get caught. seven policemen, including two officers-incharge of two police stations in chattogram, were sued yesterday for taking tk 23 lakh from a businessperson by "threatening to kill him in crossfire".yasin, 55, owner of m/s yasin enterprise in chattogram city, filed a case with the court of additional chief metropolitan magistrate mohiuddin murad16. bangladeshi’s best english newspaper the daily star published reports where they told that a video showing on-duty policemen harassing a young woman at a checkpoint in the capital has triggered outrage on social media on 24th october-18. at least two policemen were seen in the footage stopping a three-wheeler auto-rickshaw carrying the woman, who was traveling alone and seeking to check her handbag. as the cops started using offensive language, an altercation broke out between the woman and the policemen. the law enforcers were heard hinting that she was a prostitute (you just came out of a hotel) as she was traveling late at night. as the cops constantly shone a torch in her face, she asked them to take it off and check her handbag. the policemen still kept on intimidating her. as the woman protested their indecent behavior, one of the cops threatened that they would take her away’17. the same newspaper reports another immoral activities of police officers where they reportofficer-in-charge of paltan police station mahmudul haque has been suspended following allegations of rape. he allegedly raped a woman after promising to marry her and give her a decent job18. another english daily the new age reports like same that is -` a police constable was beaten up by local people allegedly for sexually harassing a19. five railway policemen allegedly raped the woman after arresting her on allegations of stealing a mobile phone. police produced her before a court the following day showing her arrested with five bottles of contraband phensidyl syrup20. i can present more data similar to the above as evidence of the police’s unethical and illegal activates.such as abu bakkar siddique, 45, an accused in a case filed under the digital security act, died in the custody of tejgaon industrial area police station21. police filed a case against a 10-month-old child22. highway police are regularly taking bribery and extortion every day in the name of intimidation of the case and viewing of papers23. extortion allegation against police 24. million taka extortion of police on 102 bar and club in the capital 25. intimidating the case police are accused of embezzling merchant money26. a police member threw a schoolgirl at a ventilator after the rape27. 'police shoot with broken legs, i'm crippled now'28. charge sheet against a child!29, a private car has been broken by a man who is in abroad 30. a police constable was beaten up by local people allegedly for sexually harassing a woman in on 30th august-19 31. from these news we are clear that how immoral and biased the police is. in protham alo published a piece of interesting news about bangladesh journal of bioethics 2020; 11 (1): 9-23 16 the police and their partisan role. they reported on september 6, 2014, that bnp’s convenor abdul azizullah died on may 27. but after 20 months of his death chawakbazar thana police have accused him of a case. he allegedly threw bricks at the police in the old central jail area of dhaka on september 6. and police alleged that he also exploded cocktail with other leaders of opposition party bnp32. i can present more examples about police immorality by taken news from newspapers such as 12 members of police including sp was accused of selling a million pieces of yaba in cox's bazar. the investigation of a committee constituted by the police headquarters also confirmed the incident. however, the police administration did not take any action against them33, police threat for crossfire34. accused of arranging a crossfire drama after the teenager's death in police torture35. crossfire fearing threat is to earn money36. oc, si among 4 sued for extortion using ‘crossfire’ threat37. with the silent support of the police, the center seized the ballot and set fire to it38. blackmail showing nude pictures of a housewife in thakurgaon. police did not take charge of the police station39. police officer tried to blackmail bangladesh bank official threatening yaba taint40. police did not take any action rabbi's case against si masud 41. in some cases, people have been “picked up” from homes or streets by members of the security forces who subsequently denied knowledge of their whereabouts to family members. this may amount to enforced disappearance. in some cases, family members witnessed their loved ones being taken away by security forces only to be found later in the morgues. in the media, some reports repeat official narratives of “gunfights” with security forces – such as the police, the rapid action battalions (rab), or unknown armed persons leading to deaths of suspected drug dealers42. police did not take action even though there were casinos in dhaka43. charge sheet has been submitting at the court against the 13 peoples’ including 13 police members where nasim khan, khalishpur (khulna) thana officer is accused of upholding the eyes of small businessmen. in a statement of the case, they mention that the police uphold the eyes of shah jamal accusation of robber when they did not get the money that they demand44. however, police authorities are receiving a lot of complaints against their members every day from across the country. some of these include bribery, harassment, torture of women, and extortion. apart from that, policemen are also being accused of threatening to kill people. these allegations are pouring in at the ‘igp complain monitoring cell’. on average, this cell receives more than 3000 complaints per month through e-mails, text messages, or calls45. the daily star wrote another column on the editorial page about police immorality on 24 january 2019. they enclose some data about police abuse of power. they reported that it is quite ludicrous that a physically challenged man whose right arm has been deformed since birth has been made one of the 52 people accused of violently attacking the police using sharp instruments like machetes46. another english daily the daily new age published about police immature action with veteran peoples’ on 5th february-2019, the reports was as 70-yearold karamat ali, visually-challenged came to the high court division on monday, seeking anticipatory bail in a ‘gayebi mamla’ (false case) filed against him by police before the december 30 general election. bangladesh journal of bioethics 2020; 11 (1): 9-23 17 the case accused karamat ali and 39 others of committing subversive activities and rioting by setting fire to a motorbike at village banda goaliya, kheruadani union, muktagaccha, mymensingh district on december 22, just eight days before the parliament elections. karamat ali came to the high court along with the 39 accused in the case filed with the muktagaccha police station on december 24. karamat ali, was wearing black goggles and roaming the supreme court premises with the support of a bamboo stick, drew the attention of bystanders at noon when he was seen gossiping with other accused besides the sc’s sculpture. there is none to take care of karamat as his wife and two sons died many years ago. karamat is unable to move without the support and he makes his life on alms from the well-off47. monday 25th april 2018, a case was filed by the police against a young man for carrying yaba pills in chittagong. in a dramatic turn of events, a counter case was filed by the accused’s mother against seven police officers, claiming that it was a sort of sued. according to meherunessa, her son mehedi hasan was picked up from the street by the police and the police demanded money worth bdt three lacs. “at his refusal, the police put 40 yaba tablets in his pocket and charged him for carrying them”, claimed by meherunnessa. such an instance, however, is not new. reports of similar occurrences from the leading dailies are mentioned below. on the 31st of january 2016, a female student was sexually harassed and alleged to carry 200 yaba pills. this was after she was brought down from her rickshaw by the subinspector of mohammadpur area and taken to a shop in the name of the search. according to the woman, the policemen searched her bag for an hour and asked her to take off her jacket with indecent language. the si was later suspended48. in february of the same year, a barisal police officer was suspended for extortion and harassing two businessmen. the subinspector forcefully took the businessmen to a hotel in natun bazar bus terminal area and demanded tk 50,000 from them, according to a complaint by the businessmen. later, the si put yaba tablets inside one of their pockets and threatened to arrest them if they do not give him the sum of money, the businessmen alleged49. in late october of 2016, a sub-inspector of chowgacha police station kept yaba pills via a source at a store owned by mr. rabon kumar. the pills were found by the si after the source came out. after other traders in the market stood up for rabon, the si and his source fled the scene50. in december 2016, two chittagong metropolitan police constables were suspended for deliberately putting yaba pills in a journalist’s pocket. mr. mostafa was brought down from his bus and taken to the police box. he alleged that the constable tried to trap him when he found nothing after searching his pocket 51 . in 2018, three incidents of a similar pattern took place in jessore. on 11th june, an si got into trouble as he tried to put a packet of opium into a young man’s pocket in the baily road area. on 15th june, an si of the kotwali police station of benapole was barred for trying to make a college teacher accused in a drug peddling case. a source of the si tried to arrest the teacher after inserting some yaba pills into his pocket, triggering chaos52.two days after this incident, a police constable of jessore faced bangladesh journal of bioethics 2020; 11 (1): 9-23 18 mob beating for allegedly putting yaba in the pocket of a businessman named pikul. in the way of conversation, the constable tried to put 3-4 pieces of yaba tablets wrapped in a polythene packet into pikul’s pocket. upon pikul’s screaming, a mob gathered and beat the police constable as they found yaba tablets in his hands53. incidents like these are rampant in dhaka city. on june 27, 2018, a journalist named ashik was stopped by patrol police and put on a police van. he was beaten and told that he would be set free if he paid tk. 100,000/. after the journalist said that he could only pay tk. 5,000, the police charged him with possession of yaba, according to a report of bdnews24.com54. of late we find there is a decline in police standards. various reasons can be attributed to this, firstly, bangladesh has long been under colonial rule. most of the rules and regulations of the police were enacted at that time. with that regime, there is a huge difference between the current regime and the people's perspective. therefore, the rules and regulations imposed during the time of building harmony between both the police and the people are the main obstacles. secondly, lack of training given to police personnel is another cause of concern, because along with a degree, the skill also contributes to the personality development of police officers. thirdly, the immoral and biased attitude of the police cannot be stopped as there is no stick punishment for the police. on the other hand, some members of the police are punished for the crime. often, crime is terrible but punishment is negligible. it is alleged that there were serious allegations against many officers of the rank of sub-inspector, inspector, assistant police commissioner or additional police commissioner, but no strict penalty or action was taken against them. as the initial allegations were proved, the action was taken against the accused police personnel by the government employees (discipline and appeal) rule-1. necessary steps should be taken to enforce the penal code under government employees (discipline and appeals) rule-1. fourthly, the police personnel’s often regulated in politics if the government continues to do so, it will be unable to regulate police; on the other hand, will become dependent on them and people will continue to suffer at the hands of their protector. fifthly, insufficient salary – allowance for police, sixthly, anxiety and boar is another cause of police because, police officers and constables work 13-18 hours a day, which is almost double the working hours of the government employees of other professions. on an average officer in charge of a metropolitan police station works 18 hours a day, an officer in charge in district and thana levels works 15 hours. in all the police stations sub-inspectors, assistant sub inspectors and constables work 13-16 hours a day. as professional service requires sufficient rest and refreshment. as advocated by national police commission a chief of police of a state should be given a fixed tenure of the office to encourage functional independence. it has been commonplace in bangladesh for transfers and postings of officers to be used as a kind of reward and punishment, as a result of which, many chiefs of police have had allegiances to political parties. also, the selection of police chief could be entrusted to an expert committee. the committee may be given a pre-specified number of candidates, decided based on seniority, to choose from. strict supervision and monitoring, tough punishment, and the will bangladesh journal of bioethics 2020; 11 (1): 9-23 19 to put an end to the culture of impunity can only stop the involvement of the police force in extortion and serious crimes. furthermore, we expect departmental action to be taken against all corrupt police officials, not just a few ocs and cops who are sued on extortion allegations. the police department should display a serious zero tolerance towards all police crimes. this is very fundamental. a civilized society based on the rule of law cannot be built unless we have an honest police force. it is expected the people at the top echelon of police and their authority, the home ministry, should realize this. neyroud and beckley emphasize the significance of ethics for the police in particular, because: they have the discretion to make decisions which affect the life, liberty, and property of other citizens, they have the power to use intrusive, covert and deceptive methods, they have to enforce the law, they have to protect the rights of citizens, they have a crucial role in protecting hardto-reach minority groups, they are public servants and, therefore, as the appointed guardians of the public’s interests, they must show high standards of integrity (a commitment to moral life), they are the gatekeepers of citizenship and respectability, the integrity of the police worldwide has suffered a series of shocks, whether it be as a result of corruption, incompetence, or racism55 the main goal of policing ethics is to maintain neutrality when taking any action. maintaining integrity in decision making, they don’t be partisan. the tremendous power that police have over people’s lives requires ethics in exercise. people expect that police should always represent well over evil. to achieve and maintain public trust, police must be persons of good character who hold foremost the ideals of fairness and justice. how police use their discretion to enforce the law and solve problems determines whether the public views the police with ethics or having ethical behavior. overall policing ethics is uphold the law, norms, and ethical guidelines in all official operations and private life. respect the general citizen and serve them as an example to others and show bias to no-one. the law is the same for all. be reliable and above bribery. this is what the police are all about.” in below some maxim for policing ethics given by nurul huda, former igp of bangladesh 56. 1) police must not evade the registration of a crime as that means committing a breach of law under the penal code. such evasions embolden the criminal, to say the least; 2) police must not misbehave with the citizens; 3) police must not implicate innocent persons in criminal cases and must not fabricate evidence to secure a conviction; 4) police must not resort to third-degree methods in the investigation of cases. such practices only tend to alienate the police from the public, and are not permitted by the law either; 5) police must not extort confessions from the accused by adopting tortuous methods of investigation; 6) police must be apolitical in their professional capacity and impartial in their application of the law; 7) the police shall not indulge in excesses like a violation of the principle of the minimum use of force; and 8) police officials must not show any proclivity to please the political bosses for their personal and professional gains. in short, the philosophy of ethical policing is to be fair in making a decision, neutral in bangladesh journal of bioethics 2020; 11 (1): 9-23 20 action, sober to people, habituated in doing the right thing, and avoiding wrong things. ethical behavior by individual officers and by the department as a whole is indispensable to effective police-community partnerships57. police will provide personal services to the individuals based on their needs and the function of the police is to be based on need assessment giving due regards to local norms and values. instead of sitting in the office to receive a complaint or patrolling by car, the officers are to get out from their office and vehicles and initiate positive interactions with the citizens in their area of responsibility to have public views and suggestion about ongoing policing, local problems and changes in policing, if required58 . the police have to realize that they are public servants and accountable to the public. they are meant to ensure public security within the limits prescribed by law. if the community assists police, the investigation of crimes would be effective and efficient resulting in the overall improvement of law and order situation. conclusion: police are the most important and essential force of any nation. we cannot think of peaceful sustenance without an efficient and responsible police force. not every person needs to always need the assistance of the police in his day to day life. however, in the absence of police total anarchy will let lose upon us. if we aim to make quality policing a way of life, then the existing police setup has to be replaced with one that is more “customer & ethics-friendly”. there has to be a clear, shared sense of mission accompanied by clearly understood organizational goals. the citizens have to be a part of the policy decision-making process. the police command and control structure has to fully rest with the police chiefs. police leadership has to be empowered to effectively control their erring subordinates. there have to be credible and effective mechanisms for policing the police. and finally, the police act 1861 has to be replaced with new legislation that embraces all the essential elements of reinvention, based on the best models available in the world. people’s faith in the police should be restored. police do not have the license to kill even a killer and they have to protect the right to life and personal liberty of an arrested person in their custody and state should rein in their agents and bring them to justice those are abridging the fundamental human rights of arrestees and subjecting them to fortune, physical harassment and custodial violence. efforts should be made to restore the faith of the people in the police given that law enforcement agencies are integral for maintaining law and order in the country and their contribution to the society cannot be undermined. police ethics provides a compass to both police officers and police managers, by specifying the core imperatives, values, and virtues of policing, by delineating the process of moral reasoning and decision-making, by setting the standards of ethical conduct, and by defining the means and the content of police ethics education and training. police scholars and practitioners have to cooperate in developing police ethics. this is not an easy task for either of them. developing and implementing police ethics invokes changes in the police organization. police organizations and police officers, as we know, are very resistant to change. those police scholars and practitioners entrusted with developing police ethics must, therefore, themselves be persons of high integrity. in developing and implementing police ethics, a lot of people will have to be told the things they most definitely do not want to hear. bangladesh journal of bioethics 2020; 11 (1): 9-23 21 reference [1] the daily inquilab (2016) harum– scarum behaviors of police 17th january 2016, available on https://www.dailyinqilab.com/article/132/%e0%a6 %aa%e0%a7%81%e0%a6%b2%e0%a6%bf%e0%a6 %b6%e0%a7%87%e0%a6%b0%e0%a6%ac%e0%a7%87%e0%a6%aa%e0%a6%b0 %e0%a7%8b%e0%a7%9f%e0%a6%be%e0%a6%86%e0%a6%9a%e0%a6%b0%e0%a6%a3 retrieved on 01,02,2020 [2] the daily protham alo, 14th february,2015 [3] collected from internet, newton [4] internet encyclopedia of philosophy “ethics” [5] an intermediate greek-english lexicon. 1889.s [6] “are we professionals? a critical look at the social role of bioethicists.” daedal us. 1999. pp. 253–274 [7] william lillie, an introduction to ethics, 1964. pp. 1-2 [8] carter, d l.. the police and the community. (7th ed.) upper saddle river: prentice hall. 2002 p94 [9] schmalleger, f. criminal justice today. 6th ed. new jersey: prentice hall. 2001.p-224 [10] ibid, pp-21 [11] www.newwestpolice.org/peel.html retrieved on 01,02,2020 [12] voa (2019), bangladesh police accused of harassment with fake cases on 13th march 2019, available on https://www.voanews.com/southcentral-asia/bangladesh-police-accused-harassmentfake-cases retrieved on 01,02,20 [13] the daily jaijaidin (2019) trans. there is no crime that the police are not involved, 2nd october 2019, available on https://www.jaijaidinbd.com/todays-paper/firstpage/69271/ be retrieved on 01,02,20 [14] the daily sun (2019), allegations against oc moazzem proved in investigation on 26th may 2019 available on https://www.dailysun.com/post/395316/2019/05/26/allegationsagainst-oc-moazzem-proved-in-investigation:-pbi retrieved on 01,02,20 [12] the daily protham alo( 2013) case charge sheet against deceased man ,12th june,2013, available on http://archive.prothom-alo.com/detail/date/201306-12/news/359750 retrieved at 01,02,20 [13] https://www.jugantor.com/old/firstpage/2014/08/24/138620 retrieved at 02,02,20 [14] the daily star( 2018) woman harassed police checkpoint in dhaka, 24th october,2018 available on https://www.thedailystar.net/backpage/womanharassed-police-checkpoint-in-dhaka-1651165 retrieved on 01,02,20 [15] the daily star (2019) dhaka poltan oc suspended over rape allegation, 1st october 2019,available on https://www.thedailystar.net/backpage/dhaka-paltanoc-suspended-over-rape-allegation-1807801 retrieved on 02,02,2020 [16] the daily star (2020) crossfire threat: 7 cops sued for extorting money from businessman 20th february 2020, available on https://www.thedailystar.net/city/news/7-cops-suedextortion-using-threat-crossfire-1870594 retrieved on 02,02,2020 [17] the daily new age (2019), 5 khulna railway cops sued, 24th september 2019, available on https://www.newagebd.net/article/85521/5-khulnarailway-cops-sued retrieved on 02,02,20 [18] the daily new age( 2020) police can’t avoid responsibility for custodial death, 20 january 2020 available on https://www.newagebd.net/article/97184/police-cantavoid-responsibility-for-custodial-death-dmp-chief retrieved on 02,02,20 [19] bbc (2017) police have charged a 10-month-old baby in a fight and theft case in bangladesh (trans) 9th may 2017 available on https://www.bbc.com/bengali/news-39859558 retrieved on 02,02,20 [20] the bangladesh today https://www.bangladeshtoday.net/%e0%a6%ae%e0% a6%b9%e0%a6%be%e0%a6%b8%e0%a7%9c%e0% a6%95%e0%a7%87%e0%a6%97%e0%a6%be%e0%a6%a1%e0%a6%bc %e0%a6%bf%e0%a6%a5%e0%a6%be%e0%a6%ae%e0%a6%bf %e0%a6%af%e0%a6%bc%e0%a7%87%e0%a6%aa%e0%a7%8d/ retrieved on 02,02,20 [21] the independent (2017) extortion allegation against police, 13rd june 2017, available on http://www.theindependentbd.com/arcprint/details/99 085/2017-06-13 retrieved on 02,02,20 [22] the daily janakantha (2017) police take from 102 bar and club in the capital 01st may 2017, available on http://web.dailyjanakantha.com/details/article/265478 / retrieved on 02,02,20 bangladesh journal of bioethics 2020; 11 (1): 9-23 22 [23] the daily potham alo (2018) police extorted money by showing fear of crossfire 7th january 2018 ,available on https://www.prothomalo.com/bangladesh/crime/%e0 %a6%95%e0%a7%8d%e0%a6%b0%e0%a6%b 8%e0%a6%ab%e0%a6%be%e0%a7%9f%e0% a6%be%e0%a6%b0%e0%a7%87%e0%a6%b0%e0%a6%ad%e0%a7%9f%e0%a6%a6%e0%a7%87%e0%a6%96%e0%a 6%bf%e0%a7%9f%e0%a7%87%e0%a6%9f%e0%a6%be%e0%a6%95%e0%a 6%be%e0%a6%86%e0%a6%a6%e0%a6%be%e0%a 7%9f-2 retrieved on 02,02,20 [24] jagonews2.com (2019) after the rape, the police threw the schoolgirl with a ventilator 20th may 2019, available on https://www.jagonews24.com/country/news/501375 retrieved on 02,02,20 [25] the daily protham alo (2018), police shot in my leg now i’m paralyzed , 25th november 2018, available on https://www.prothomalo.com/bangladesh/article/156 6554 retrieved at 02,02,20 [26] the daily star (2017) charge sheet against a child,11th may 2017, available on https://www.thedailystar.net/editorial/charge-sheetagainst-child-1403692 retrieved on 02,02,20 [27] the daily protham alo (2018) lives in abrade ,car broken in gazipur! 12th sepetember 2018 available on https://www.prothomalo.com/bangladesh/article/155 7205 retrieved on 02,02,20 [28] the new age http://www.newagebd.net/article/83017/policethrashed-for-sexual-harassment retrieved on 02,02,2020 [29] the daily protham alo police saw the dead man throwing cocktails! 9th sepetember 2018 available on https://www.prothomalo.com/bangladesh/article/155 6797 retrieved on 02,02,20 [30] the daily jugantor (2018) the police are involved in the crime as there is no severe punishment 17th sepetember 2018 available on https://www.jugantor.com/todays-paper/lastpage/91200/ rtrieved on 02,02,20 [31] the daily deshrupantor (2019) police threat of crossfire! 26th september 2019 available on https://www.deshrupantor.com/lastpage/2019/09/26/170186 retrieved at 02,02,20 [32] the daily samakal (2019) allegedly arranging crossfire dramas after the teenager's death in police torture 11th april 2018 available on https://samakal.com/bangladesh/article/1804675/h retrieved on 02,02,20 [33] the daily protham alo https://www.prothomalo.com/bangladesh/article/742 144/%e retrieved at 02,02,2020 [34] banglanews 24 https://www.banglanews24.com/articles/59818/p [35] the daily sangram (2015) ballot seals, fires occupying the center with the silent cooperation of the police 28th april 2015 available on http://www.dailysangram.com/post/185828 retrieved on 02,02,20 [36] the daily kalerkantho (2016) the police did not file a case and released the accused 16th september 2019, available on https://www.kalerkantho.com/print-edition/lastpage/2019/09/16/815141 retrieved at 02,02,20 [37] bdnews24.com (2016) police officer tried to blackmail bangladesh bank official threatening yaba tint, 11th january 2016 available https://bdnews24.com/bangladesh/2016/01/11/policeofficer-tried-to-blackmail-bangladesh-bank-officialthreatening-yaba-taint retrieved on 02,02,20 [38] bangla tribune (2016) police did not take rabbi's case against si masud ,19th january 2016 available on https://www.banglatribune.com/national/news/70921/ retrieved on 02,02,20 [39] the daily protham alo(2018) knowing about casino in dhaka, the police did not take action 22nd september 2019, available on https://www.prothomalo.com/bangladesh/article/161 5525/ retrieved at 02,02,20 [40] deshebideshe (2018) police took out two eyes for not getting money! available on https://www.deshebideshe.com/home/printnews/1138 26 retrieved on 02,02,20 [41] dhaka tribune https://www.dhakatribune.com/bangladesh/crime/201 8/02/17/allegations-police-involve-harassmentthreats/ retrieved at 02,02,2020 [42] the daily star (2019) disabled man charged with attacking policeman,24th january 2019, available on https://www.thedailystar.net/editorial/news/disabledman-charged-attacking-policemen-1691968 retrieved on 02,02,20 [43] the daily new age (2019) 70 years old visually challenged karamat in hc in ‘gayebi mamla’ 5th february 2019 available on http://www.newagebd.net/article/63865/70-year-oldvisually-challenged-karamat-in-hc-in-gayebi-mamla retrieved on 02,02,20 bangladesh journal of bioethics 2020; 11 (1): 9-23 23 [44] the independent (2016), ‘adabor police si harassed female student’ [published on 11th february 2016, available on http://www.theindependentbd.com/arcprint/details/33 604/2016-02-11] retrieved on 07,02,20 [45] http://www.thedailystar.net/country/barisal-citycop-suspended-‘extortion’-211861] retrieved at 02,02,20 [46] dhaka tribune {2016), ‘police si lays yaba trap but flees after mob beating’ [published on 26th oct. 2016, available on http://www.dhakatribune.com/bangladesh/2016/10/2 7/police-si-lays-yaba-trap-flees-mob-beating/ retrieved on 04,02,20 [47] daily sun newspaper (2016), ‘two cops closed for harassing journalist’, [published on 7th dec. 2016, available on http://www.dailysun.com/arcprint/details/190053/two-cops-closedfor-harassingjournalist/2016-12-07] retrieved at 02,02,20 [48] the independent (2016), ‘adabor police si harassed female student’ [published on 11th february 2016, available on http://www.theindependentbd.com/arcprint/details/33 604/2016-02-11] retrieved at 02,02,20 [49] http://www.thedailystar.net/country/barisal-citycop-suspended-‘extortion’-211861] retrieved on 02,02,20 [50] dhaka tribune {2016), ‘police si lays yaba trap but flees after mob beating’ [published on 26th oct. 2016, available on http://www.dhakatribune.com/bangladesh/2016/10/2 7/police-si-lays-yaba-trap-flees-mob-beating/ retrieved on 03,02,20 [51] daily sun newspaper (2016), ‘two cops closed for harassing journalist’, [published on 7th dec. 2016, available on http://www.dailysun.com/arcprint/details/190053/two-cops-closedfor-harassingjournalist/2016-12-07] retrieved on 02,02,20 [52] ntv online (2017) ‘cops closed for putting yaba pills into teacher’s pocket’ [published on 16th june 2017, available on http://en.ntvbd.com/bangladesh/59543/cops-closedfor-putting-yaba-pills-into-teacher’s-pocket] [53] bangla news 24 (2017) ‘police constable lynched in jessore’ [published on 18th june, available on http://www.banglanews24.com/english/national/articl e/61758/police-constable-lynched-in-jessore] retrieved on 02,02,20 [54] bdnews24.com (2017), ‘journalists demonstrate over photojournalist’s arrest for yaba possession’ [published on 8th july 2017, available on https://bdnews24.com/bangladesh/2017/07/08/journal ists-demonstrate-over-photojournalists-arrest-foryaba-possession] retrieved on 02,02,20 [55] , neyroud, p & beckley, a. 2001. policing, ethics and human rights. devon: willan. p222 [56] nurul huda, a citizens’ expectation from the police, published at the daily star on 4th february2019 [57] a k m shahidul haque, police community with concept of community policing, 2016,dhaka, pp. 80 [58] ibid, pp-20 author contributions: author conceived the idea, did the literature review and wrote the manuscript. and checked the manuscript meticulously. conflict of interests: the authors declare that there is no conflict of interest in this study. microsoft word macerabc20paperrevised bangladesh journal of bioethics 2020; 11 (3): 33-42 33 legacies of love, peace and hope: how bioethics education can overcome hatred and divide darryl r.j. macer ph.d., hon. d., mph, president, american university of sovereign nations (ausn), usa; director, eubios ethics institute, new zealand, japan and thailand; secreary, asian bioethics association email: darryl@eubios.info web: www.eubios.info doi: https://doi.org/10.3329/bioethics.v11i3.51220 abstract: in our pursuit of a good life (eubios), both individuals and societies, need to educate themselves on the pursuit of love of life in all domains, self-love, love of others, loving good and love of life. in this paper i reflect on my own journey through growing up in christchurch, and experiences around the world, that are the basis for that conclusion. in our efforts to pursuit bioethics education we can enhance peaceful and harmonius coexistence in our world, through nurturing good decisions that we should all make. key words: bioethics, peace, bioethics education, eubios, introduction: in the past three decades a systematic program of bioethics education has been implemented through eubios ethics institute. this project aims to increase the love of life across the world. the main products so far have been: 1) production of cross cultural materials. improvement via expert meetings. adapted and translated in different languages to teach school and university classes about bioethics. increasing the amount of free on-line teaching materials for bioethics education in different countries. 2) a network of teachers in different countries that have tried the materials, and created bioethics curricula for their local school, bioethics clubs and other endeavours. 3) a network of bioethics experts, in national and regional associations (including the asian bioethics association, all india bioethics association, bangladesh bioethics society, and so on). 4) development of statements (e.g. eubios declaration of bioethics, 2002; joint action plan with unesco, 2006, and so on) 5) testing of evaluation methods. 6) sharing of museum displays and teacher training strategies. 7) moral games and participatory methods 8) teacher training workshops and government support. 9) curriculum review and development. 10) launch of dedicated degree programs (e.g. masters and phd degree programs in bioethics). 11) strengthening research-policy linkages 1. pursuit of a good life (eubios): in our pursuit of a good life (eubios), both individuals and societies, need to educate themselves on the pursuit of love of life in all bangladesh journal of bioethics 2020; 11 (3): 33-42 34 domains, self-love, love of others, loving good and love of life. i coined the term eubios from greek language as a response to the then commonly used terms “euthanasia” (good death) and “eugenics” (good genes) because i think life ethics should be a more positive and holistic approach then what i had seen in much of the writings about these issues until then. i have provided more of my background that led me to this conclusion in a paper published in the book, legacies of hope, peace and love1 where i reflect on my own journey through growing up in christchurch, and experiences around the world, that are the basis for the conclusions expressed in the title of this paper. in our efforts to pursuit bioethics education we can enhance peaceful and harmonious coexistence in our world, through nurturing good decisions that we should all make. 2. a good life (eubios) demands the culture of peace: it seems like almost every day the news brings us pictures of violence, heartache, broken relationships, secular violence and so much more evidence that it is hatred which is the guiding principle of human interrelationships. yet this was not what human beings were made to do according to the foundations of theories of human creation made in god’s image. all human beings simply would like a good life (eu-bios), and the universal declaration of human rights declares it as an intrinsic right and obligation. legacies of hope is a project involving people of all ages, all religions, and many positive education and social systems, who argue that this much violence is enough.1 it is claimed that the culture of peace started in august 1945 when the hiroshima and nagasaki atomic bombs showed that world wars were no longer survival strategies2. how much further can we sit by and claim that this hatred is someone else’s problem, when we still see the constant wars, terrorist attacks, and other acts of hate? 3. commonalities of all peoples: we are all born into the world, and we all die. we have a conscience and make moral decisions. some of our ethics is linked to the group that we belong to, or claim to stem from. how do we define our affiliations? it’s easy for a church or a mosque to disown a person who commits an act of hate or so-called hate crime and say then that the person is not one of us because they committed a criminal act to kill. this is one of the challenges that all religions face, how do deal with the violence that religion sometimes promotes. you may say it’s not true that religion promotes hatred or the feeling of separation from those who are not the same faith. i would immediately reply it is one of my experiences inside many religious places of worship that the followers separate people into believers and the nonbelievers, and society in generally has the expression to talk about us and them. what makes a welcoming community, is when we do not feel that we are a moral stranger when we enter into a place together with others. over time people have been told that jews, brahmans, christians and muslims, and so on, are all the chosen race and chosen faith. many indigenous people for millennia have been told that they are god’s chosen people. bangladesh journal of bioethics 2020; 11 (3): 33-42 35 people of many religions have been told to be exclusive, they may exclude options of marrying people from outside the faith, outside the village, or of going to a different country. these are ways that we exclude people from us. these other people become “them”. these “them” are already distinguished as somehow foreign to us. in some countries such as the united states, foreign people are called “aliens”. fortunately, this is a word which japan has dropped in the past decades for those who come from other places in the same planet. the racism and religious hatred are ways that people often use to avoid to associate with the “other”. so we can say that people should dispense with labels for others, beyond a personal name. this is why i implore others to simply call me darryl. we need to expand the boundaries of who we consider to be moral agents in bioethics education,3 and there is a clear trend to do this over time.4 environmental ethics education also includes peace education5. this does not mean that we need to create some new label so that all are equal in the eyes of each other, such as man or woman. distrust grows because we are often in a different place of worship, a place of peace and reflection. we should not call the people who are not members of the same faith, aliens. even worse maybe “evil aliens” because the stranger killed somebody at some time in the past or present. so-called “primitive” societies had rituals of revenge where in the sad case of the death of somebody they would exchange life for a life, through a proportional method of execution so that the evil actions would be discouraged. but in the world of 21st first century we are trying to build a commonality for people with a sustainable vision of universal human rights of love and legacy of inclusive education for everybody, and not be focused on the exclusion. the legacies project is ongoing and open, so after reading the papers, poetry, and/or watching the videos please feel free to be inspired and contribute your own thinking to this project. the bioethics education projects continue, along with the focus provided by the legacies project. eubios ethics institute, means good-life ethics institute, and as a nongovernment organization formed in christchurch, new zealand we feel it is our duty and obligation to work for a better world than the one which we do not see ourselves to be in. having had the privilege to grow up in an innocent and quiet, yet exciting town of christchurch, it is a legacy for us to share this to those around as well as to try to replicate and share the experiences we have with other people. 4. bioethics education and cross cultural materials: in the past three decades a systematic program of bioethics education has been implemented through eubios ethics institute. i wanted to make information on bioethics openly available to all, through the web, and low cost publications, because people in developing countries could not afford to purchase books or journals on this subject, and teachers did not have access to many materials. this project aims to increase the love of life bangladesh journal of bioethics 2020; 11 (3): 33-42 36 across the world. the rest of this paper will discuss the main products so far. the first was the production of cross cultural bioethics materials. these were improved via expert meetings and school trials. the materials were adapted and translated in different languages to teach school and university classes about bioethics3,6. the balancing of principles that people use in moral decision making, such as self-love (autonomy), love of others (justice), loving life (do no harm) and loving good (beneficence) can provide us with a vehicle to express our values according to the desire to love life.4 human beings are spiritual beings, sharing emotions such as love and hate, greed and generosity. any system which fails to acknowledge this is destined to fail. we all may agree love is dominant in our mind, but how do we extend an emotion, to a system to analyze our decisions? issues like justice, abortion, euthanasia, and stewardship of nature have been debated for millennia. we need to consider this diverse heritage when building a universal ethics. differences in approaches are clear from early historical discussions of these issues, for example, there have always been people supporting and opposing euthanasia or abortion. there are debates in every country over questions such as whether to build roads or preserve biodiversity. these differences and similarities are seen within any group of people within every society. the social environment that people grow up in, and the education strategies, are being more similar with time suggesting that a universal approach is even more possible now than it was a century ago. the more possibilities that we have, the more decisions that we need to make. fortunately, standards of education are increasing, but this is no guarantee that the right decisions will be made even in democracies. people need to be taught more on how to make decisions, and the education system should accommodate this need of modern life, with a legal system that allows development of this capacity. the textbooks of bioethics were developed firstly in english and japanese in the 1990s, and then expanded as more authors contributed materials. the support of the ministry of education, culture and welfare in japan, and the sasakawa peace foundation allowed trials of materials in many countries in the years 2001-20063. the materials continue to be available on-line for free download in editable form from eubios ethics institute, and they were also made available on unesco website while i was serving as unesco regional adviser for social and human sciences in asia and the pacific from 2004-2013. 5. bioethics education networks and bioethics associations: at the same time that materials are being tested, networks of teachers in different countries who have tried the materials, and created bioethics curricula for their local school, bioethics clubs and other endeavours, were developed. the first bioethics education network that i developed was in japan among teachers in 19967. the eubios international bioethics education network was initiated in 2004 and it is also linked to the international association of bioethics (iab) international bioethics bangladesh journal of bioethics 2020; 11 (3): 33-42 37 education network. these networks still exist, but many more persons around the world share experiences of bioethics education with each other at conferences, through publications, and the efforts are selfsustaining. we could incorporate these goals of ethics education and (education) development of critical thinking through the inclusion of a global call for bioethics education by all states when they unanimously signed the 1997 universal declaration on the human genome and human rights, in article 20: “20. states should take appropriate measures to promote the principles set out in the declaration, through education and relevant means, inter alia through the conduct of research and training in interdisciplinary fields and through the promotion of education in bioethics, at all levels, in particular for those responsible for science policies”8. freedom of expression could be given more emphasis as a principle of bioethics. article 19 of the 1948 universal declaration of human rights, upholds the “freedom to hold opinions without interference.” article 21 of universal declaration on the human genome and human rights 1997 “states should … also undertake to facilitate on this subject an open international discussion, ensuring the free expression of various sociocultural, religious and philosophical opinions.” in all societies there is a transition from paternalism to informed consent to informed choice. network of bioethics experts have been supported through holding many roundtable workshops, in tsukuba, kumamoto, bangkok and other places. these networks also led to the establishment of national and regional associations, including the asian bioethics association, all india bioethics association, bangladesh bioethics society, and so on. 6. development of statements of purpose and the goals of bioethics education: all sectors of society are faced with ethical issues in the pursuit of their duties. critical to building the capacity of society for this open reflection on the goals of bioethics are educators. to ensure public participation and making wise decisions about their and their children’s future, providing bioethics education at all levels is necessary. however how do we define the goals? the task of an educator includes empowering their students/learners to develop their maturity as individuals as well as being able to be cooperative members of changing societies. learners, as we all should be, need to be prepared so they are able to apply knowledge to make good decisions during their life. how can we train educators and sustain their motivation to take upon this task? how can we create communities that are able to consider all sides of ethical debates? research has shown that there are a number of goals of bioethics education, as discussed in the regional action plan for bioethics education that emerged from the unesco asia-pacific conference on bioethics education (2006), including: a) knowledge: development of transdisciplinary content knowledge. bangladesh journal of bioethics 2020; 11 (3): 33-42 38 understanding the advanced biological concepts. being able to integrate the use of scientific knowledge, facts and ethical principles and argumentation in discussing cases involving moral dilemmas. understanding the breadth of questions that are posed by advanced science and technology. understanding of cultural values. b) skills: (capacity building in skill acquiring should be multi-faceted or many sided, and the goals include): balancing benefits and risks of science and technology. being able to undertake a risk/benefit analysis. develop critical thinking and decision-making skills and reflective processes. develop creative thinking skills. develop foresight ability to evade possible risks of science and technology. skills for developing “informed choice”the required skills to detect bias in scientific method, interpretation and presentation of research results. c) personal moral development: understanding better the diversity of views of different persons. increasing respect for all forms of life. elicit a sense of moral obligation and values including honesty and responsibility. being able to take different viewpoints to issues including both biocentric and ecocentric worldviews rather than only anthropocentric perspectives. increasing respect for different people and culture, and their values. developing scientific attitudes, reflective processes, and an ability for holistic appraisal, while not ignoring the value for reductionist analysis. knowledge about bias in the interpretation and presentation of research results, benefits and risks of technology and bioethical issues, and how to detect bias. exploration of morals/values (values clarification). values analysis and value based utilization of our scarce natural resources. there are many other elements of the action plan, and it built on the eubios declaration of bioethics (2002). to further mainstream bioethics, government adoption was necessary. so we could convene again with unesco. the unesco regional highlevel meeting on the teaching of philosophy in asia and the pacific, held in manila, philippines, 25-26 may 2009, an action plan called “thinking for the future: an action plan for the promotion of philosophy teaching in asia and the pacific” was agreed which set its first set of goals for philosophy education as the search for wisdom. the goals are broader than those for bioethics education, namely: the outcomes of philosophy education include: a) understanding and a search for wisdom. to this end we encourage: development of trans-disciplinary knowledge clarification of concepts enhancement of the ability to integrate knowledge, principles and argumentation in rational discussion understanding the power of questions broadening intellectual horizons knowledge of cultural values in different communities search for meanings living a better life bangladesh journal of bioethics 2020; 11 (3): 33-42 39 b) development of capacities for: quality thinking and reflective processes wise judgment and decision-making skills formulating appropriate questions creative thinking foresight reasoned choice interpretation, construction and communication of knowledge respect for reasons and evidence better understanding of reality c) development of a disposition to: use knowledge and skills for good increasing respect for all forms of life take into account the interests of others and the environment in the spirit of solidarity have empathy and compassion be tolerant, inclusive, and reasonable understand better the diversity of views of different persons (listen to others) respect different points of view, people and culture, and their values reflect upon values consider alternative possibilities and world-views build and improve other virtues the action plan also concluded on curriculum that: “philosophy curricula based on research needs to be developed, adapted to local needs and integrated across all levels of education. cooperation between different academic disciplines to encourage thinking and development of a transdisciplinary curriculum that achieves the above aims. curriculum development workshops for in service and pre service teachers and for all levels of education needs to be organized.”i 7) testing of evaluation methods and pedagogical development: the task of a teacher includes empowering their students to develop their maturity as individuals as well as being able to be cooperative members of changing societies. students need to be prepared so they are able to apply knowledge to make good decisions during their life. this begs the question of what is knowledge. how can we evaluate that students have learnt something useful? knowledge is much more than the latest trends in science and technology, or the latest political ideals. the wisdom from traditions of one’s own, and many other communities are essential to the resources that our minds call “wisdom”. how can we train teachers and sustain their motivation to take upon this vocation of sharing wisdom? how can we create communities that support these goals? there are various roles and challenges for teachers and educational institutions, and those who develop curriculum. depending on the goals of the educational systems a variety of training strategies and methods will be used. how can we empower teachers to make a special contribution in the wider context of constructing a mature society? mature means a person, or a society that can balance the benefits and risks of alternative options, and make well-considered decisions, and talk about it. evaluation of bioethics education was tested in many country trials in the eubios ethics institute teaching trials9. bangladesh journal of bioethics 2020; 11 (3): 33-42 40 the common social goal to respect the moral choices of others has developed hand in hand with the emergence of increased media attention in pluralistic democracies to display the divergent views on many topics. these dialogues can show us that local wisdom from our corner of the world is similar to local wisdom from others on the other side of the globe, so that they now also join to “us” to construct a larger “us”. these lessons also assist us in the development of a globally accessible multicultural and multidisciplinary curriculum that offers cases from many local wisdoms that can be shared. some particular projects have also been supported such as sharing of museum displays and teacher training strategies. the background theory and many examples of games and methods to use in teaching are in moral games for teaching bioethics. this book describes the use of moral games and participatory methods was published in association with the unesco chair of bioethics at haifa.10 a persons’ identity and ethic is developed based on their own and other people’s opinions that grows as we face various dilemmas through our life. to have a balanced opinion from the community, it is important to hear from persons in a range of positions with different occupations. interactive ethics education allows the classroom to be a place for moral exploration and clarification of values. 8) curriculum review and development: what can we teach in a curriculum that will influence the way that people make moral choices? can a curriculum shape the future of our society to remove extremism, racism and hatred? can we develop a global set of wisdom that covers many localities and includes local wisdoms? consensus is possible after recognition of the individual yet connected history of relationships between different persons and communities, to try to preserve social harmony. this consensus building is seen even in countries that have structured paternalism affecting the relationships between persons. we also assisted in the development of the unesco bioethics core curriculum, which sets out to introduce the bioethical principles that countries of the world agreed to in the 2005 universal declaration on bioethics and human rights. unesco developed a bioethics core curriculum in 2009, based on the universal declaration on bioethics and human rights (2005). in 2006 a second edition of teaching materials was developed by eubios ethics institute in cooperation with unesco bangkok, published for bioethics education trials in asia-pacific under the title, a cross cultural introduction to bioethics (ccib).3 each of those materials has learning objectives. in addition, in 2010 case studies were developed by my team in unesco bangkok, linked specifically to the bioethics core curriculum. in 2019 a sdg curriculum, linked to the 17 sustainable development goals (sdg) was also developed, a project which is also ongoing to provide open access resources for educators around the world on eubios ethics institute website. a review of the curriculum in 47 asia-pacific countries found that critical thinking is bangladesh journal of bioethics 2020; 11 (3): 33-42 41 valued highly in all countries.11 critical thinking capacity is essential for empowering persons to cope with changing times. how do we promote the creation of ideas, and individuality in an era of globalization? the rapid progress of technology has led to challenges in the way that we live. the systems and patterns that are seen in the relationships between patients, families, health professionals, and the society in general changed. appropriate education requires teachers to apply methods and resources appropriately and to develop the decision-making ability in students, teachers and policy-makers so our society can evolve with the demands of the times. there is also linkage to different goals of education through teaching guides. a teaching guide is available for ccib to follow the organization of the bioethics core curriculum and the case studies3. the teaching guide is structured that in each section it first introduces the ccib chapter, than the case study. these teaching materials and teaching guide are all open to further additions, and feedback is welcomed. eubios ethics institute provides many teaching materials that may be also used as teaching materials, and these are available also in word format. 9) launch of dedicated degree programs: establishment of a new independent university, american university of sovereign nations (ausn) in 2013 on native american land in the united states, and of a new global accreditation commission, accredited universities of sovereign nations, in 2018. ausn is organized as a 501(c)(3) non-profit entity, are providing opportunities to build up the capacity of trainers through offering masters and doctoral degree programmes. recruitment of one hundred professors around the world to provide their time and skills to ausn as allowed the emergence of a global bioethics’ education program. establishment of the first ph.d. program on federally recognized. native american reservations in the united states (doctorate in bioethics, sustainability and global public health – offering specializations in bioethics and global public health, and sustainability, peace and global development) has led to wider provision of trained faculty. establishment of seven master degree programs also provides wide levels of training. signing over 30 international collaborative agreements with universities and other institutions around the world allows people to develop bioethics as a profession, and there is also an integrated master of science in sustainability, peace and development from ausn. the course on global public health and peace is mandatory in all bioethics degree programs. 10) strengthening research-policy linkages and conclusions: the creation of networks linking research into policy is a cornerstone of efforts in all levels, from local to regional. list serves function in english for educators and students, and persons from a wide range of countries have tried these resources, and contributed to this project over the past years. we can see that there is a willingness to bangladesh journal of bioethics 2020; 11 (3): 33-42 42 develop values education stimulated by recent reemergence of ethics education and philosophy education to equip all citizens to be better able to respond to the challenges of contemporary society. the precise way that we apply applied ethics to full transdisciplinary curricula across universities in higher learning for the good of society relies on local wisdom, but we can see that there are many common threads and all can benefit from this dialogue between civilizations and between persons to construct empowered individuals more capable of making moral judgments. references 1. macer drj. ed., legacies of love, peace and hope: how education can overcome hatred. christchurch, n.z.: eubios ethics institute; 2019. 2. fuchinoue h. what has the a-bomb dome symbolized over time? in drj macer (ed.). asian-arab philosophical dialogues on culture of peace and human dignity. bangkok: unesco; 2011. 56-71. 3. macer drj. cross cultural introduction to bioethics. christchurch, n.z.: eubios ethics institute; 2006. available from https://www.eubios.info/publications_links 4. macer drj. bioethics is love of life. christchurch, n.z.: eubios ethics institute; 1998. available from https://www.eubios.info/publications_links 5. baker m, grundy m, junmookda k, macer drj, manzanero li, reyes d, ngo tt, waller a. environmental ethics education. christchurch, n.z.: eubios ethics institute; 2019. author contributions: the author conceived the idea, wrote the manuscript and checked the manuscript meticulously. conflict of interests: no conflict of interest in this study to declare. 6. macer, drj. bioethics education for informed citizens across cultures. school science review 86 (december 2004), 83-86. 7. asada y, akiyama s, tsuzuki m, macer ny, macer drj high school teaching of bioethics in new zealand, australia, and japan. journal of moral education, 1996; 25: 401-420. 8. unesco. universal declaration on the human genome and human rights. paris: unesco, 1997. 9. macer drj. (ed.). asia-pacific perspectives on bioethics education. bangkok: unesco; 2008. 10. macer drj. moral games for teaching bioethics haifa: unesco chair for bioethics; 2008. available from https://www.eubios.info/publications_links 11. wolf a, macer, drj. conceptual maps of the goals of teaching philosophy and human dignity in drj macer (ed.). asian-arab philosophical dialogues on culture of peace and human dignity. bangkok: unesco; 2011, 104-110. further information: while it is desirable to find culturally appropriate terms to refer to philosophy, such as thinking for the future, at each level of education these goals apply to broader goals of education and development of thinking in general. further information on specific training programs for postgraduate certificates, masters, and doctoral degrees in these subjects are offered through american university of sovereign nations and may be found at https://www.ausovereignnations.org education listserve <http://groups.yahoo.com/group/bioethicseducation/ > student listserve http://groups.yahoo.com/group/ bioethics_for_students/ microsoft word rainer ebert ethics after darwin bangladesh journal of bioethics final dec 18, 2020 bangladesh journal of bioethics 2020; 11 (3): 43-48 43 ethics after darwin: completing the revolution rainer ebert phd. visiting research fellow centre de recherche en éthique 2910 boulevard édouard-montpetit montréal, qc h3t 1j7, canada email: rainerebert@gmail.com web: www.rainerebert.com doi: https://doi.org/10.3329/bioethics.v11i3.51221 abstract: this is a big-picture discussion of an important implication of darwinism for ethics. i argue that there is a misfit between our scientific view of the natural world and the view, still dominant in academic philosophy and wider society alike, that there is a discrete hierarchy of moral status among conscious beings. i will suggest that the clear line of traditional morality – between human beings and other animals – is a remnant of an obsolete moral outlook, not least because it has no counterpart in empirical reality, and i will invite the reader to think, with me, about tenable alternatives. keywords: evolution, speciesism, human dignity, moral status, moral equality introduction: there is a great deal of disagreement about matters of morality across social, cultural, and religious boundaries. and yet, there are some moral beliefs that are shared by a great majority of people in most societies and cultures, and across religious traditions. one such belief, perhaps the most consequential of all, is the belief that there is something morally special about being human. the fact that someone is a human being, rather than a dog or a cow or a rat, is thought to make a big difference in how he or she may be treated. people of faith sometimes say that human lives, and human lives only, are sacred, as humans, and humans only, are created in the image and likeness of god.1 the german philosopher immanuel kant expressed a similar idea in secular terms. he argued that humans, but no other animals, have an intrinsic worth – “dignity” – which makes them valuable “above all price.”2 in stark contrast, he held that nonhuman animals are valuable only insofar as they are useful in advancing human interests. they “exist only as means, and not for their own sakes […], whereas man is the end.”3 this type of thinking defines much of our current relationship with nonhuman animals, and has grave practical implications. if human life is priceless, humans may not be killed, even if doing so would promote the greater good, whereas other animals, having a much lesser moral status, can be sacrificed for minor and sometimes even the most trivial human pleasures. in particular, people generally believe that we are justified in killing nonhuman animals simply because we prefer the taste of their bodies over plant-based alternatives, yet would be horrified at the idea of killing an innocent human being for the same purpose, or even if necessary to achieve something as important as saving the lives of other humans. for convenience of expression, i will subsume under the term “traditional bangladesh journal of bioethics 2020; 11 (3): 43-48 44 morality” a spectrum of diverse moral worldviews that have the idea of equal human worth or dignity at their core, and i will sketch an evolutionary argument that casts serious doubt on all of them. i will focus on the big picture, at the expense of some of the rigor that is ordinarily expected from a philosophy paper. my hope is to spark your curiosity, enough to read my lengthier publications in which i develop the argument in more detail. discussion: if all humans are to count the same, and more than other animals, that must be true in virtue of some feature that all humans have in common, but other animals lack. a philosophical defense of traditional morality must identify that feature. an obvious candidate, of course, is species membership. we are all biologically humans, members of the species homo sapiens, and other animals are not. if we in fact deserve special treatment, could that be the reason why? james rachels calls the view that grounds our full moral status in the fact that we are members of the human species “unqualified speciesism.” according to unqualified speciesism, “mere species alone is morally important. […] [t]he bare fact that an individual is a member of a certain species, unsupplemented by any other consideration, is enough to make a difference in how that individual should be treated.”4 as quickly as our membership in the human species comes to mind as a candidate for the ground of our supposed superiority, as implausible it seems after just a moment’s reflection. imagine we came across a hitherto undiscovered species on a remote island in the pacific. the members of that species are intelligent. they have institutions of government and learning very much like we do, and rich emotional and cultural lives. they have been aware of our existence for a while, and they have studied our societies and languages from afar, but they chose not to reveal themselves, seeking to avoid possible conflict. we can converse about science and philosophy with them, and agree with them to engage in joint projects. surely, if one of us were to injure or kill one of them for a small personal gain, as we do in the case of non-human animals without much thought or hesitation, the rest of us would be morally outraged – and rightly so. just because they belong to a species that is not our own does not make it acceptable to treat them as if they were less than us. otherwise, how could we credibly object to someone who treats people of different races or the opposite sex as inferior? there is no reason to believe that species membership, in itself, is more relevant to morality than race or sex, which is why unqualified speciesism is deeply implausible and philosophers who defend it are few and far between. a much more promising variety of speciesism is qualified speciesism. “on this view, species alone is not regarded as morally significant. however, speciesmembership is correlated with other differences that are significant.”5 within qualified speciesism, i think it is helpful to distinguish between views that are committed to moral individualism and views that instead appeal to kind membership. views of the first sort hold that there is an intrinsic feature, typically a potential or genetic disposition for some specific kind of mental life, that is necessary for membership in the human species and at the same time sufficient for bangladesh journal of bioethics 2020; 11 (3): 43-48 45 full moral status.6 in contrast, views of the second sort hold that, rather than each having an intrinsic feature that confers full moral status, humans are special because they belong to a kind that is characterized by the fact that its members normally, albeit not universally, have certain intrinsic features, such as the advanced cognitive capacities we have in common with the intelligent beings on the newly-discovered pacific island in our thought experiment.7 traditional morality, regardless of which of these two forms of qualified speciesism it takes, fits well with the aristotelian idea of a hierarchy of being, according to which each species is a static group of organisms with a distinct essence. the philosophical line of traditional morality that morally distinguishes humans from other animals finds its match in the empirical line that aristotle thought distinguishes the human species from other animal species.8 since the publication of charles darwin’s the origin of species in 1859, however, we know that there is no such line on the empirical side of things.9 we now understand that all life is interrelated, and that biological characteristics come in degree and continually evolve as a result of natural selection. that is particularly true for the psychological capacities that are commonly associated with the special moral status of human beings, such as autonomy, rationality, self-consciousness, language ability, and moral agency. as the principle of evolutionary continuity informs us, any differences between species are differences in degree, and not in kind, and i will argue that this change in scientific perspective has important moral implications. before presenting my argument, however, i should make a disclaimer. in the decades after the publication of the origin of species, there was considerable debate over what, if anything, darwinism can tell us about issues in moral philosophy, and much of that debate has to do with the old philosophical question of the relation between fact and value, the so-called isought problem. henry sidgwick wrote in 1876 that the theory of evolution “has little or no bearing upon ethics,”10 and ludwig wittgenstein similarly remarked in the 1920s that the “darwinian theory has no more to do with philosophy than has any other hypothesis of natural science.”11 in a sense, they are right. the connection between darwinism and moral philosophy is more subtle than straightforward logical implication. what i will argue then, to put it more carefully, is that darwinism undermines traditional morality, chipping away at its credibility, rather than outright disproving it. that being said, let us get back to our comparison between the aristotelian and the darwinian perspective on nature. darwin has replaced the aristotelian picture of life on earth as an assortment of neatly separated boxes, one for each species, with what we now know to be the real picture, that of a vast and complex tree of life, with branches so numerous that most are likely still unknown to us. according to traditional morality, only a small number of the individuals represented in that tree, us, have a special moral status, and constitute the community of moral equals, from which all non-human life is excluded. if that is to be true, we should be able to draw a line between us and them. but where should we draw that line? there is no recognizable discontinuity in the bangladesh journal of bioethics 2020; 11 (3): 43-48 46 spectra of degrees of capacity, potential, or genetic disposition for the psychological capacities that are commonly associated with the special moral status of humans. being autonomous, rational, selfconscious, able to use language, and so on all are scalar properties – i.e., they come in degrees –, which makes line-drawing problematic, for at least two reasons. first, wherever we choose to draw the line, our choice will be arbitrary, at least to some degree. for the moral individualist, who as we recall ties full moral status to having the potential or genetic disposition for a certain degree of mental capacity, drawing the line is tantamount to specifying that degree, and how could there be a principled reason to pick one degree over another that is only slightly different from it? the qualified speciesist arguing from kind membership too must specify a degree of mental capacity that must be normal for a kind in order for the members of that kind to qualify for full moral status, and he or she must further explain what it takes for a capacity to become the norm for a given kind. again, there seems to be no principled way to do that. second, even if we somehow find a nonarbitrary way to draw the line, doing so implausibly opens a moral gulf between individuals whose difference from one another in terms of empirical reality is entirely unremarkable. wherever we cut through the tree of evolution, those facing each other along the cut will be strikingly similar in their bodily and mental nature, yet traditional morality would have us treat them in fundamentally different ways. to further illustrate my argument, i am borrowing a thought experiment from english evolutionary biologist richard dawkins: imagine you take “a picture of yourself. now take a picture of your father and place it on top. then find a picture of his father, your grandfather. then place on top of that a picture of your grandfather’s father, your great-grandfather. […] now do the same thing with his father, your great-greatgrandfather. and just carry on piling the pictures on top of each other, going back through more and more and more great-great-greats. […] how many greats do we need for our thought experiment? oh, a mere 185 million or so will do nicely! […] it isn’t easy to imagine a pile of 185 million pictures. how high would it be? well, if each picture was printed as a normal picture postcard, 185 million pictures would form a tower about 220,000 feet high: that’s more than 180 new york skyscrapers standing on top of each other. […] what did [your 185-million-greatsgrandfather] look like? an old man with wispy hair and white sidewhiskers? a caveman in a leopard skin? forget any such thought. […] your 185-million-greatsgrandfather was a fish. so was your 185-million-greats-grandmother, which is just as well or they couldn’t have mated with each other and you wouldn’t be here.”12 if traditional morality is to be believed and there is to be a community of moral equals, one of your great-great-greats must have been the first to be a member of that bangladesh journal of bioethics 2020; 11 (3): 43-48 47 community. let us call him adam. which picture in the pile shows adam? it is hard to tell! in fact, there seems to be no principled way to determine who among your ancestors was adam. note that this is not an innocuous case of vagueness, as in the case of the concept of baldness, but a serious shortcoming, as much depends, in terms of morality, on where we draw the line that separates equals from unequals. it makes a great difference in the way your (great)n+1-grandfather would have deserved to be treated whether we decide that he is adam, or instead decide that your (great)ngrandfather gets to be adam, and yet there seems to be no more or less reason to go one way rather than the other. for example, who among the two gets to be adam matters greatly for the morality of killing them. it is much more seriously wrong to kill someone with full moral status than it is to kill someone with a lesser moral status, and it is implausible, and moreover morally unacceptable, that there could be individuals for whom it depends on an arbitrary, unprincipled choice whether they are entitled to the protection enjoyed by moral equals. further, whichever picture we pick, the intrinsic difference between the individual on that picture, adam, and his father will be unnoticeable. if the two of them were to stand in front of us today, we would most likely not be able to tell who among them is more similar to us in terms of autonomy, rationality, self-consciousness, language ability, and all the other capacities we commonly associate with our heightened moral status. in stark contrast to whatever minor differences in biological reality there may be, the way traditional morality would have us treat adam, who has full moral status, is radically different from the way it would have us treat his father, who does not have full moral status. that is implausible. it is implausible that a small difference in genetics or capacity makes a momentous difference in terms of moral status. conclusion: what can we take away from all this? we have seen that there is a tension between the biological fact that all life is interrelated, through evolution, and biological characteristics come in degree and the philosophical idea of a discrete hierarchy of moral status. consequently, traditional morality seems to be in serious trouble. it simply does not fit our modern scientific view of the natural world. the line posited by traditional morality, between humans and other animals, turns out to be a remnant of an obsolete moral outlook, with no counterpart in empirical reality. as i see it, there are two ways we can go from here. we can abandon the idea that there is a special class of morally considerable beings who have an equal moral status higher than that of all others, and instead endorse some sort of consequentialism, or perhaps a deontological moral theory that accommodates gradual moral status. or we can attempt to find an alternative basis for full and equal moral status, which would have to be a non-threshold property that is both binary and ethically relevant, hence allowing us to carve out of the natural world of organisms the community of moral equals along a non-arbitrary line that carries empirical significance. if you, like me, believe that human equality is a great achievement that we should not give up easily, i hope you will agree that it is well worth to try to go the second way. in my doctoral dissertation13 and recent papers in social theory and practice14 and philosophia,15 i hint at an alternative to bangladesh journal of bioethics 2020; 11 (3): 43-48 48 traditional morality that upholds the ideal of equality, and provide a more detailed version of the argument sketched in this article. in a nutshell, i argue that phenomenal consciousness, a deeply mysterious phenomenon that scientists and philosophers have hardly begun to understand, might have occurred in evolution from one generation of animals to the next, and hence can serve as a plausible and non-arbitrary cut-off point – separating “someones” from “somethings.” if the community of moral equals in fact coincides with the community of conscious beings, the implications for our way of life would be far-reaching. most importantly, we would be under a moral obligation to references 1 cf., for example, richard harries, norman solomon & timothy winter, abraham's children: jews, christians and muslims in conversation (london/new york: t&t clark, 2006), part ii, chapter 5. 2 immanuel kant, groundwork of the metaphysics of morals, transl. and ed. by mary gregor (cambridge: cambridge university press, 1997), p. 42, 4:434. 3 immanuel kant, lectures on ethics, ed. by p. heath & j. b. schneewind, transl. by p. heath (cambridge: cambridge university press, 1997), p. 212, 27:458-459. 4 james rachels, created from animals: the moral implications of darwinism (oxford: oxford university press, 1990), p. 183. 5 rachels 1990, p. 184. 6 for recent examples of such views, see massimo reichlin, “the argument from potential: a reappraisal,” bioethics 11 (1997), pp. 1-23, patrick lee & robert p. george, “the nature and basis of human dignity,” ratio juris 21 (2008), pp. 173-193, and s. matthew liao, “the basis of human moral status,” journal of moral philosophy 7 (2010), pp. 159-179. 7 examples are carl cohen, “the case for the use of animals in biomedical research,” new england journal of medicine 315 (1986), pp. 865-870, and michael allen fox, the case for animal experimentation: an evolutionary and ethical perspective (berkeley: university of california press, 1986). move away from consuming conscious animals and towards a plant-based diet. acknowledgments: i would like to thank françois jaquet, c. e. abbate, and audiences at lagos state university, the twentieth asian bioethics conference in bangladesh, the university of nairobi, the university of dar es salaam, jagannath university, and rice university for helpful feedback on various versions of this paper. author contribution: the author developed the conceptual idea and wrote the manuscript. conflict of interest: the author declares no conflict of interest. 8 cf. marc ereshefsky, “species,” the stanford encyclopedia of philosophy (fall 2017 edition), ed. by edward n. zalta, url = <https://plato.stanford.edu/archives/fall2017/ent ries/species/>. 9 a line from a later book by darwin usefully illustrates the departure from aristotle’s claim that humans are separate in kind from other animals in virtue of their rationality, and is often quoted in the animal ethics literature: “the difference in mind between man and the higher animals, great as it is, certainly is one of degree and not of kind” (charles darwin, the descent of man, part one (new york: american home library, 1902), p. 170). 10 henry sidgwick, essays on ethics and method (oxford: oxford university press, 2000), p. 11. 11 ludwig wittgenstein, tractatus logicophilosophicus (new york: harcourt, brace, and company, 1922), p. 77, 4.1122. 12 richard dawkins, the illustrated magic of reality (new york: free press, 2012), pp. 3840. 13 rainer ebert, “the wrongness of killing,” phd dissertation, rice university (2016), url = <http://hdl.handle.net/1911/96270>. 14 rainer ebert, “mental-threshold egalitarianism: how not to ground full moral status,” social theory and practice 44 (2018), pp. 75-93. 15 rainer ebert, “are humans more equal than other animals? an evolutionary argument against exclusively human dignity,” philosophia 48 (2020), pp. 1807-1823. microsoft word disability discrimination 1 bangladesh journal of bioethics 2021; 12 (1): 54-60 54 why a new ethical framework is needed to eliminate disability discrimination? a new learning from the pandemic. gausul azam ranju1 and tania serice2 1. physiotherapist & in-charge, physiotherapy department, bgc trust medical college & hospital (bgctmch), chittagong, bangladesh and founder of ethics policy & inclusion (epni), rowsonhat, nasir building, chittagong, bangladesh. email: physioranju@gmail.com. orcid: https://orcid.org/0000-0002-62618557 (corresponding author). 2. senior staff nurse, ministry of health and family welfare, bangladesh. doi: https://doi.org/10.3329/bioethics.v12i1.51902 abstract: discrimination between disabled and non-disabled people is still an issue of fairness and justice. in this covid-19 pandemic time, this issue highlighted in a significant way. in hospital, the disabled persons to face today issues while triage like whether they have the right to get the ventilator first when there is limited ventilation support or their vulnerability could be the cause for being neglect or they do not have to have a quality of life. there are lots of ethical dilemmas that we face today and these are not solvable overnight by the existing framework or policies. the existing paternalism, utilitarianism, or even ableism can not ensure making people living with disabilities (plwd) rights equal. it is very clear that the professional expertise, policy or framework have so many loop holes that we are still struggling to take steps to effective and ethical decision making. this paper focuses the emergency of ethics based research, policy directions, and frameworks to eliminate those discriminations. keywords: disability ethics, pandemic ethics, covid-19, healthcare policy, people living with disabilities (plwd), disability discrimination. introduction: the world bank reported that one billion (15% of the world's population), experience some form of disability where 110 million to 190 million people experience significant disabilities1. if we think there are two categories of people on this earth disabled and nondisabled, do we wrong to categories human beings? or, if we think that how could we decide “who’s life is worth living” among them, do we wrong? we will see some reallife examples of those circumstances in this paper below. if we start our practice depending on these answers how could we maintain all the healthcare principles & ethics like autonomy, nonmaleficence, beneficence, and justice? the 3 ethical duties in this corona crisis for the healthcare leaders, proposed by the eminent bioethics institute hasting center, are i) the duty to safeguard; iii) the duty to plan and iii) the duty to guide2. when we have a lot of problems and dilemmas on our existing ethical frameworks and policies, then how could we maintain our duties to manage the principles? if we skip to give the concern on that point and treat the disabled as normal people, then it creates unfairness. because a normal person can use the stairs, but the wheelchair-needed disable person can’t. on the other hand, if bangladesh journal of bioethics 2021; 12 (1): 54-60 55 we think they are different from the ablebodied people, then equality, equity & rights are questioned. this issue also creates a false binary to think about which one is normal and which one is abnormal2. on the other hand when a senior disabled patient and a junior disabled patient come at the same time for the same treatment, who should get the priority? the issue of ableism (discrimination in favor of ablebodied people) and ageism (discrimination on the basis of age) creates a conflict on these points termed as structural discrimination2. if we are so strict to follow the duties and legislature that we have the concept of utilitarianism and deontology raises a myriad of ethical dilemmas which again make questions on the basic moral principles. if the policies and frameworks only considered the able-bodied then it is to deny the statement of the 2030 agenda for sustainable development, where it is clearly stated that the “disability cannot be a reason or criteria for lack of access to development, programming and realization of human rights”1. besides this utility and duty-based ethics (utilitarianism & deontology), there is another issue about medical paternalism that could hamper the doctor-patient relationship. instead of getting the solution, it is defined as a problem indeed. according to the encyclopedia of applied ethics (2012) “paternalism is a problem, however, when interference with clients goes beyond what is absolutely necessary or is used as camouflage for actions that are motivated by other interests”3. today, it is very clear that the professional expertise, policy, or framework have so many loopholes that we are still struggling to take steps to effective and ethical decision making. this paper focuses on the emergency of ethics based research, policy directions, and frameworks to eliminate these discriminations. our aim is to understand why we need to develop our existing ethical framework and infrastructure and focus on the emergency of ethics based research, policy directions, and frameworks to eliminate these disparities. methodology: this is a current controversy or short communication-based paper related to the covid-19 pandemic crisis. it is not a biostatistical based study but an ethical based case study and investigation. it does not collect any data from the patients or any other respondents, and that's why informed consent is not necessarily important for this account. in this article, two patients' names are mentioned directlly as “michael hickson” and “22-year-old ginny” in the case section number [2] and [4] below, where their info’s we just collected from the authentic press/media reports that we already cited in our article. we did not use any scale but we make arguments based on the very established bioethical theories like utilitarianism, paternalism, and ableism. to make the citations & bibliography we use mendeley software. ethical dilemmas: [case 1]: covid-19 pandemic raises a myriad of ethical dilemmas. among these dilemmas, bramble 2020 mentioned 8 major ethical questions (1) question on lockdown, (2) who is morally blame to bangladesh journal of bioethics 2021; 12 (1): 54-60 56 covid-19, (3) question about immunity passport, (4) question on mask, (5) question on moral duties, (6) question on vaccine trial, (7) triage question & (8) question on living the life4. from these important questions, number seven (7) is very relevant to think about the rights and facilities for pandemic healthcare. he asked if all of the life-saving resources (e.g ventilator, icu bed, etc) of the hospital have to run out, who should get their first use? if it could be the issue of disability then this problem faces a major challenge to eliminate discrimination. now it is clear that this triage problem increases the disability discrimination instead of elimination and even if the solution is asked to the bioethicist how would we be satisfied in this disability triage critics, they have no easy answer yet5. [case 2]: michael hickson, a quadriplegic patient tested positive for covid-19 in early june in austin, texas. he was admitted to the st. david’s south austin medical center from a nursing home. eventually, the hospital stopped treating him. cause? the doctor said the man has no “quality of life”. a recorded conversation explains that doctor asked “will it (treatment) affect his quality, will it (treatment) improve his quality of life? and the answer is no”. the patient already died. the patient’s wife asked does it mean that he’s paralyzed with a brain injury, so he doesn’t have the quality of life? the doctor said “correct”6.so, there is another ethical question on that perspective and that is if someone is disabled (paralyzed), does it mean that he does not have a quality of life? [case 3]: in nepal, a wheelchair user disable was died after he was suspected as covid positive in the southern chitwan district. when he was admitted into a local hospital, there were no wheelchair-friendly healthcare facilities which may cause his death as stated by the german public international broadcaster deutsche welle7. the lack of adequate facilities makes them vulnerable and if it is, then could we say that this vulnerability is intentionally manmade? [case 4]: as stated by the bbc, 22-year-old ginny was a wheelchair needed girl who needed a supporter or assistant to conduct her daily life. if her assistant became covid positive in any case, it would be a very complicated situation for her. she had a ventilated tracheotomy and she was very anxious due to the lockdown for “zero guidance” if her assistant became ill or isolated. as a people living with disability (plwd), ginny has 11 times more likely to die than her peers due to this covid pandemic8. what should we do to eliminate this discrimination here? [case 5]: study says people with intellectual and developmental disabilities (idd) has a high risk of sever outcomes from covid-199. according to fair health study, people with intellectual disabilities and developmental disorders are 3 times more likely to die if they have covid-19, compared with others. it does not end, people with related conditions like down syndrome and other chromosomal anomalies and congenital conditions like microcephaly have also the risk. director of medical ethics at the new york university grossman school of medicine, arthur caplan commented “there is no bangladesh journal of bioethics 2021; 12 (1): 54-60 57 question….these people are high risk and must be given priority for vaccination”10. but who here? and who cares? when, we have a gap into our guidelines and policy making for immunization11. this is the point to raise the question how could we distribute vaccines for the greatest good for the greatest number? argumentation: there are more than 1 billion disabled people in the world. in only the uk two-third of covid, deaths have occurred within the disabled community, stated by the bbc8. now it is very common and we all know by heart that washing hands frequently and maintaining 6 feet of physical distance prevents sars-cov-2 contamination, but is it disable friendly? hand washing and physical distancing are not always possible or sometimes impossible for the peoples living with disabilities12. when we need to take immediate response for an immediate situation we are not ready to create disable friendly policy and infrastructure compared to the non-disabled. we may notice now, in the civilized world people living with disability (plwd) are faced with a lot of discrimination like the upper [1], [2], [3], [4] and [5] cases. when a pandemic has a great risk and it is more dangerous, the inequalities in the healthcare sector acts as a mediator to enhance public health discrimination. people living with disabilities (plwd) faced discrimination and some of them also faced unfairness by medical professionals13. to achieve universal health coverage when it is important to maintain global health commitment, 80% of people living with disabilities (plwd) from the low-income and middle-income countries faced a limited capacity to respond with the covid-19. and in this way, the risk of increased mobility and mortality is growing up. in a recently published paper in the lancet public health, richard armitage from university of nottingham stated that three issues make plwd more vulnerable: (1) inequities to access public health messaging, (2) disruption of the physical distancing, and self-isolation, and (3) increasing risk of covid-19, and the additional barrier to get healthcare facilities14. the debate also have raised a few dilemmas between people with chronic conditions and disabilities. a burning question about the triage process is who particularly will be treated as more vulnerable to get emergency healthcare (e.g. ventilator) first and and why. covid-19 pandemic has now untold suffering among all aspects of human lives. disabled people are 42% more likely to have poor health and, therefore, they are extremely vulnerable to the virus. according to the who, people with disabilities have a high risk due to their difficulty to enter the hospital or clinics, difficulty to maintain social distance, problem to gather updated information, and for the problem to touch anything15. hence, it is difficult and sensitive to measure who will get the healthcare first. according to the equality act 2010, it is unfair to create discrimination with the people living with disabilities (plwd)16. though the disability rights movement, the disability discrimination legislation, and the un convention on the rights of persons with disabilities change the perception of the disability, there is another perception between the difference of disability rights and human rights. and now the healthcare bangladesh journal of bioethics 2021; 12 (1): 54-60 58 priority is seemingly an issue about rights. according to the un convention, the disability right is not so specific an issue or different than the human right. they all are the citizens and have a similar right as human rights e.grehabilitation, healthcare, live into the community, and the right to have a say about their own healthcare facilities. like every human being, people living with disabilities also need the same healthcare and treatments17. so when the disability comes in front, why this question arises who will get the healthcare (e.g ventilator) first? to eliminate these disparities the concept of the “medical model” or later the “social model” legitimate medical paternalism17. but is it suitable to make this answer ethical? on the other hand, for the fair distribution of all facilities, there are still several dilemmas to decide what we should do in terms of best interest of the patient, scarce hospital resources and most perceived benefit of the society. based on the 40 years of philosophical and academic observations by the scholars in the field of disability, reynolds stated that the 3 core insights from disability theory: “assumptions about the quality of life, the problem of ableism, and the distinction between disability, disease, and illness”18. when medical rationing and disability justice is an essential element, ableism is one of the major causes of discrimination, unfair costing, and affect to determine the good health of people with disabilities today19. “this form of systemic oppression leads to people and society determining who is valuable or worthy based on people’s appearance and/or their ability to satisfactorily produce, excel and behave”. as stated by talila a. lewis20. so to make the proper framework, to decrease the devaluation of the peoples living with disabilities, “ableism” has a question mark and the question is whether it is really working. thirdly among the three philosophical approaches (utilitarianism, liberalism & communitarianism) utilitarianism is the most important public health discourse and a standard among the policymakers and the practitioners. according to beauchamp and childress utilitarianism is one of the ethical theories also that help to make a final decision based on their ultimate ends and consequences and it is the best-known ofted used theories for the medical and nursing ethics21. so, could it be confirmed to eliminate the discrimination of the public health issues of the disabilities? all of these models or frameworks have proved their effectiveness in different settings and context; however, the issue of argument is based on the fact that still discrimination is happening in situ. medical paternalism is like a tendency of a physician that determines patients' wishes or choices should not be honored. so it makes a patient surrogate-decision-maker and disvalues their autonomy22. however, according to bassford, “ … … medical paternalism is only considered when utilitarian considerations apply and don't violate any personal rights”23. unfortunately, roger severino, the director of the office for civil rights at the u.s. department of health and human services warned that “ … … medical providers must not engage in “ruthless utilitarianism” in deciding who gets life-saving treatment for the coronavirus”24. he claimed by the name of utilitarianism, disables and old people bangladesh journal of bioethics 2021; 12 (1): 54-60 59 should not be put at the end of the line for healthcare facilities in this pandemic emergency24. hence, if we think or judge paternalism or utilitarianism or anything other else is an appropriate medical or social model or framework to eliminate the discrimination, then how can we overcome from being ableism? as stated by leah smith,“ableism is a set of beliefs or practices that devalue and discriminate against people with physical, intellectual, or psychiatric disabilities and often rests on the assumption that disabled people need to be ‘fixed’ in one form or the other. ableism is intertwined in our culture, due to many limiting beliefs about what disability does or does not mean, how able-bodied people learn to treat people with disabilities and how we are often not included at the table for key decisions”25. leah smith says that to de-root this ableism it is essential to set up and fix that there is always a seat at the table for both of you and those who are not like you, and it is also considered to judge our treating procedure when a person with disabilities once seated at the table. therefore, ableism raises the assumption that the able bodies are more superior than the non-able or abnormal bodies. oppositely the other issue of injustice could occur if disabilities are over medicalized17. conclusion: though there are lots of frameworks are available to date, the rising ethical issues as discussed in this paper can not be solved. to eliminate the disparities, we recommend further ethics based research, policy directions, and ethical framework to decrease the health inequalities for individuals with disabilities, which will also help to strengthen health and human service, its workforce capacity and ensure inclusive environment for people living with disability for future pandemic and economy of the country. references: 1. world bank. disability inclusion overview [internet]. 2020 [cited 2020 dec 26]. available from: https://www.worldbank.org/en/topic/disability(acc essed on 26 dec. 2020). 2. singh s. disability ethics in the coronavirus crisis. j fam med prim care [internet]. 2020;9(5):2167. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc73 80818/ (accessed on 26 dec. 2020). 3. graumann s. social services ethics, overview. in: chadwick rbt-e of ae (second e, editor. san diego: academic press; 2012. p. 175–81. available from: http://www.sciencedirect.com/science/article/pii/b 9780123739322003987 (accessed on 26 dec. 2020). 4. bramble b. pandemic ethics: 8 big questions of covid-19. bartleby books; 2020. 5. stramondo j. covid-19 triage and disability: what not to do | bioethics.net [internet]. 2020 [cited 2020 sep 15]. available from: http://www.bioethics.net/2020/03/covid-19-triageand-disability-what-not-to-do/ (accessed on 15 sep. 2020). 6. streicher b. quadriplegic patient dies of covid-19 after austin hospital, guardian decide against life-saving treatment | wfaa.com [internet]. 2020 [cited 2020 sep 15]. available from: https://www.wfaa.com/article/news/investigations/ quadriplegic-covid-19-patient-dies-after-austinhospital-stops-treatment/269-6ffe3515-97b1-4962beca-a3f9e0499a34 (accessed on 15 sep. 2020). 7. pandey l. coronavirus in nepal a double threat for disabled people [internet]. 2020 [cited 2020 sep 20]. available from: https://p.dw.com/p/3ho8b (accessed on 20 sep. 2020). 8. webster l. coronavirus: why disabled people are calling for a covid-19 inquiry bbc news [internet]. 2020 [cited 2020 sep 17]. available from: https://www.bbc.com/news/uk-53221435 (accessed on 17 sep. 2020). bangladesh journal of bioethics 2021; 12 (1): 54-60 60 9. landes sd, turk ma, formica mk, mcdonald ke, stevens jd. covid-19 outcomes among people with intellectual and developmental disability living in residential group homes in new york state. disabil health j [internet]. 2020;13(4):100969. available from: http://www.sciencedirect.com/science/article/pii/s1 93665742030100x (accessed on 17 sep. 2020). 10. rabin rc. developmental disabilities heighten risk of covid death the new york times [internet]. 2020 [cited 2020 dec 29]. available from: https://www.nytimes.com/2020/11/10/health/coviddevelopmental-disabilities.html (accessed on 29 dec. 2020). 11. who | catch-up vaccination. who [internet]. 2020 [cited 2020 dec 29]; available from: http://www.who.int/immunization/programmes_sys tems/policies_strategies/catch-up_vaccination/en/ (accessed on 29 dec. 2020). 12. hartman m. an unequal response: covid-19 and disability covid-19 johns hopkins bloomberg school of public health [internet]. 2020 [cited 2020 dec 29]. available from: https://www.jhsph.edu/covid-19/articles/anunequal-response-covid-19-and-disability.html (accessed on 29 dec. 2020). 13. johnson e. disability, medicine, and ethics. ama j ethics. 2016;18(4):355–8. 14. armitage r, nellums lb. the covid-19 response must be disability inclusive. lancet public heal. 2020;5(5):e257. 15. who emro | considerations for people with disability during covid-19 in who’s eastern mediterranean region | violence-infocus | violence, injuries and disabilities [internet]. [cited 2020 dec 30]. available from: http://www.emro.who.int/violence-injuriesdisabilities/violence-infocus/considerations-forpeople-with-disability-during-covid-19.html (accessed on 30 dec. 2020). 16. equality act 2010. 17. shakespeare t, iezzoni li, groce ne. disability and the training of health professionals. lancet. 2009;374(9704):1815–6. 18. reynolds jm. three things clinicians should know about disability [internet]. vol. 20, ama journal of ethics. american medical association; 2018 [cited 2020 sep 12]. p. e1181–7. available from: www.amajournalofethics.org (accessed on 12 sep. 2020). 19. andrews ee, ayers kb, brown ks, dunn ds, pilarski cr. no body is expendable: medical rationing and disability justice during the covid19 pandemic. am psychol. 2020; 20. savin k, guidry-grimes l. confronting disability discrimination during the pandemic. hast cent [internet]. 2020; available from: https://www.thehastingscenter.org/confrontingdisability-discrimination-during-thepandemic/?fbclid=iwar2ssy8avhxj5284pri9s2w qzum3vzvtszjgq6dex4cb_fhqmz7vov90msk (accessed on 12 sep. 2020). 21. melia km. ethics for nursing and healthcare practice [internet]. sage; 2013. available from: https://books.google.com.bd/books?hl=en&lr=&id =1ddpagaaqbaj&oi=fnd&pg=pp2&dq=melia, +k.+m.+(2013).+ethics+for+nursing+and+healthc are+practice.+sage.&ots=g11m3w6yuh&sig=vzma nrke5yk7bnypl841dyq8eeo&redir_esc=y#v=o nepage&q=melia%2c k. m. (2013). ethics for nu (accessed on 12 sep. 2020). 22. brennan ta. just doctoring: medical ethics in the liberal state [internet]. univ of california press; 1991. available from: http://ark.cdlib.org/ark:/13030/ft9w1009qr/ accessed on 12 sep. 2020). 23. bassford ha. the justification of medical paternalism. soc sci med. 1982;16(6):731–9. 24. fink s. u.s. civil rights office rejects rationing medical care based on disability, age [internet]. 2020 [cited 2020 sep 13]. available from: https://www.nytimes.com/2020/03/28/us/coronavir us-disabilities-rationing-ventilators-triage.html (accessed on 13 sep. 2020). 25. smith l. #ableism – center for disability rights [internet]. [cited 2020 sep 13]. available from: http://cdrnys.org/blog/uncategorized/ableism/ (accessed on 13 sep. 2020) author contribution: 1st author gausul azam ranju conceived the idea, designed of the manuscript, performed the literature search, wrote the initial draft, checked the manuscript meticulously and gave final approval of the manuscript for submission. 2nd author tania serice did the critical revision of the article, performed the literature search and gave the final approval of the manuscript for submission. conflict of interests: no conflict of interest in this study to declare. microsoft word bjb biomedical ethics_systemic review in nigeria final 1 bangladesh journal of bioethics 2021; 12 (1):35-48 35 ethical issues in biomedical research in nigeria: a systematic review chinaza richard ikeagwulonu1, chigozie jesse uneke2 , obeta mark uchejeso3 1. senior medical laboratory scientist, department of medical laboratory science, alex ekwueme federal university teaching hospital, abakaliki, nigeria and member, african institute for health policy and health systems, ebonyi state university, abakaliki, nigeria. email: rikeagwulonu@gmail.com, 2. deputy vice chancellor, academics ebonyi state university, abakaliki and founder/director, african institute for health policy and health systems, ebonyi state university, abakaliki, nigeria. email:unekecj@yahoo.com 3. head of department / chief medical laboratory scientist, department of medical laboratory management, federal school of medical laboratory science, jos, nigeria. (corresponding author): email: uchejesoobeta@gmail.com doi: https://doi.org/10.3329/bioethics.v12i1.51904 abstract: the use of human subjects in research comes with lots of ethical challenges. the purpose of this review is to assess the various ethical issues that have been associated with biomedical research in nigeria. this article also find out the possible ways of improvement of this scenario. pubmed/medline, google scholar, jstor, and ajol search were the possible search engine for literature from 2000 to 2020. key words were used including ethics, ethical issues, biomedical research and nigeria. of the 113 publications were found. a total of 18(15.9%) fulfilled the study inclusion criteria and were included in this review. twelve ethical issues were highlighted including informed consent (12 studies), autonomy and voluntariness (8 studies), beneficence (8 studies), counseling (5 studies), compensation (4 studies), professional behavior and attitudes (2 studies), confidentiality (2 studies), social, cultural and religious practices (2 studies), scientific integrity (1 study), communitarianism (1 study), equity (1 study), and trust (1 study). most of the studies were cross sectional and carried out in southern nigeria. we found that there are ethical issues in biomedical research in nigeria of which informed consent is most widely studied. also, participants had varying degree of understanding of their rights as research subjects. as a result, there is need to enhance the capacity of investigators to better understand these issues and also increase their explanatory skill to help participants achieve complete understanding of their various rights and process. keywords: ethics, ethical issues, biomedical research (br), research, systematic review introduction: ethical issues in biomedical research involving human subjects have received a growing concern since the promulgation of nuremberg code as far back as 1947 1. ever since then, adhering to ethical principles has helped to protect the dignity, rights and welfare of research participants and reduce to barest minimum moral doubts that can arise when carrying out any biomedical research involving human subjects. “ethics” in simple terms is defined as “norms for conduct” that distinguishes between acceptable and unacceptable behavior 2 and in a very common sense, honesty; social responsibility and integrity are considered the basic ethical norms. any deviations from these norms result to research misconduct comprising of “fabrication, falsification, or plagiarism (ffp). “the ethical justification of biomedical research involving human subjects is the prospect of discovering new ways of benefiting people’s health” 3 and to achieve this, many countries and institutions 2,3,4,5 had developed codes and regulations that set out guidelines. these codes must be followed to conduct any biomedical research involving human subjects. despite these codes, issues of ethics have continued to pose a challenge to biomedical research in developing countries like nigeria. nonetheless, deficits in infrastructures, bangladesh journal of bioethics 2021; 12 (1):35-48 36 paucity of funds and poor human research capacities has resulted in most research in nigeria. these hinder to take rigor and often timely research compared to developed and western countries. although biomedical studies carried out in these developed countries are not totally free from misconduct and also battles with issues associated with ethics 6, the trovan study conducted by pfizer in kano, nigeria in 1996 8 was a wakeup call to nigeria to led development of the nigerian code of health research ethics (nchre) by the national health research ethics committee in nigeria in 2007 9. this nchre guide all researchers involved in human subjects’ researches in nigeria. interestingly, biomedical researchers in nigeria have identified some of the ethical issues confronting them in the course of their research, however; there has been no effort to review these ethical issues for proper understanding. the growing call for these reviews necessitated the present study to give a general overview of what these ethical challenges are at a glance. method: a systematic review of literature on ethical issues in the context of biomedical research in nigeria was conducted between august 2017 and may 2020 with articles published in the last 20 years (2000 and 2020) using pubmed/medline, google scholar, jstor, and ajol(african journal online). key words included a combination of the following: ethics, ethical issues, biomedical research and nigeria. we included only studies reported in english. full text original research articles of studies involving human subjects, addressing issue of ethics in biomedical research, and research done in nigeria. all review articles, case reports, letters, brief reports, communications, retrospective chart reviews, news articles, articles published before 2000 and articles written in other language were excluded from this study. all publications were retrieved online, and data search ended 2nd may 2020. data extraction was carried out for each paper highlighting the following: name of first author and year of publication, study design, study location, subject, main study population, journal name, and ethical issue(s) studied/identified. the search strategy and results are provided in figure 1. the authors are aware the elements of an informed consent including voluntarism, information disclosure (counseling), and decision-making capacity (autonomy) 7; however, we decided to present them individually for clarity and for better understanding of this study. results: a total of 113 articles were found following a thorough search of databases listed above criteria. out of which 18 (15.9%) articles (8 -23) met the inclusion criteria. out of the 18 articles 10 (55.1%) were carried out in the southern part of nigeria, while 2(11.1%) where carried out in northern part of the country. two of the studies (11.1%) were multi-country in nature, whereas 2(11.1%) where done both in northern and southern part of the country. among the studies conducted in southern nigeria, the southwest leads with 10(60%) followed by the south east 3(30%). in terms of study design, 17(94.4%) of all the studies were cross sectional in nature with just 1(5.6%) cohort study design. clinical practice represents the highest area of biomedical research identified with about 8 (44.4%) studies, followed by genetics/genomics 5(27.8%). clinical trials and non specific studies were 2(1.1%). most of the studies as shown in table 1 were conducted in 2014 (22.2%) followed by 2018 (16.7%). almost all the studies were adult based. a total of twelve (12) ethical issues associated with biomedical research where identified in this review and presented in table2; they include: informed consent (11 studies), autonomy and voluntariness (8 studies), beneficence (8 studies), counseling (5 studies), bangladesh journal of bioethics 2021; 12 (1):35-48 37 compensation (4 studies), professional behavior and attitudes (2 studies), confidentiality (2 studies), social, cultural and religious practices (2 studies), trust (2 studies), scientific integrity (1 study), communitarianism (1 studies), and equity (1 study). fig. 1. flow diagram for the selection of studies on ethical issues in biomedical research in nigeria informed consent (ic) : a total of eleven studies (61.1% )(table 2) investigated the ethical issue of obtaining an informed consent in the research. in their reports, ic was not being observed before treatment 20, respondents were not asked if they wanted to join the study 10, research participants either did not understand that the information given to them were adequate 2,4. four studies (36.4%) reported poor understanding of the key elements of the ic process, e.g. the rights of the participants and invitation to joining the research 9,10,14,20. participants in four studies reported that they were told the purpose of the study during the informed consent discussion 8,18,21,22. one study (9.6%) which was based on obtaining assent in children, reported that the health care researchers fail to obtain assent from children during research, but reported obtaining consent directly from their parents 16. poor communication, poverty, illiteracy, therapeutic misconception and confusion about the dual roles of the researchers and the health professionals were factors compromising understanding of ic 3,4, bangladesh journal of bioethics 2021; 12 (1):35-48 38 whereas retrospectives, belief that consent from parents are enough and assent was unnecessary 16. some researchers opined that medico legal reasons, hospital/unit policy, informing patients about benefits, risks and alternatives and to take decisions about the planned clinical procedures were reasons for obtaining consent before going ahead to carry out any clinical procedure 11. participants were divided if they could change their minds after signing a consent form, considers the form a legal document and insist their consent should be sought before enrolling them in any research/trial respectively 14. as identified in three studies, some subjects only give their consent to participate in research depending on what they are to benefit directly11,16,19. therapeutic options, special ways of minimizing risks of operation and detailed explanation about diagnoses are more frequently asked questions during ic process in clinical practice, whereas taking a course in bioethics and compulsory communication skills are ways of improving ic process generally 11. satisfying consent from the patients’ perspective is associated with better recall of consent information for clinical procedures 22. in situations the participants fail to provide ic, they will not likely be threatened 11. researchers and participant’s practice of ic is independent of their social demographic variables 16; however educational level 14 and age 9 were seen to play significant role in other studies. autonomy and voluntariness: eight studies (44.4%) were identified which investigated autonomy and voluntariness in biomedical research (table 2). respondents from three of the studies clearly reported being told the research they were invited to partake in research voluntarily availed themselves without being pressured 8,18,21. five studies reported that decision to participate in the research was a collectively on their husbands 8,12,18,19,21. married women were most likely to discuss enrollment decision with someone else before making a decision 8,12,19. significant association was seen between women having decision to participate in clinical procedures and obtaining her husband’s permission as well as 21. voluntary participation in research is a factor of the benefits accruable from such research 10,12,19,23. from four studies, respondents acknowledge knowing their right to either participate or withdraw from the studies at any time 8,9,10,18. two of these studies equally reported low understanding of these rights among few research participants 9,10. one study reported consequences of withdrawing from research after giving consent to include losing all benefits, being seen as an ungrateful person, and seen to be unwise withdrawing while still ill of the same disease of which the research could have helped provide treatment 9. counselling: five studies (27.8%) reported the ethical issue of providing adequate information and counsel to study participants during biomedical research. three of these studies (60.0%) reported that the study participants were not adequately counseled and are not being well armed with enough information concerning the research they were involved in 9,20,25. two studies (40.0%) however, opined that respondents were adequately counseled for the benefits and risks associated with the study they were involved in 18,21. significant association was found between having a clinical procedure done on client and having counseled clients on benefits and risks of the procedure 21. one study also reported that most times counseling was geared toward giving patients an exaggerated hope of success 25. beneficence: eight studies (44.4) documented the issue of beneficence in biomedical research. four of these eight studies (50%) reported appropriate bangladesh journal of bioethics 2021; 12 (1):35-48 39 knowledge of benefit associated with participating in research among the respondents 9,12,18,21. there were three studies (37.5%) that identified poor knowledge and poor understanding of risks associated with participating in biomedical research among respondents 8,10,18. however, there was one study (12.5%) reported that the poor knowledge of benefits 10 and good knowledge of risks 22 among research subjects. one study reported immediate benefit as one major reason respondents considers before deciding whether or not to participate in the research 23. five studies (62.5%) enumerated some of the benefits in participating in research to include obtaining free medical tests, free checkup (to know their oral health, sugar, cholesterol and blood pressure level as well as their genotype), improved knowledge of their health conditions as well as improvement in health delivery of their communities 9,10,12,19,23. one study (12.5%) identified risk in biomedical research participation to include: diminishing of the immune system, general drug side effects, death on discontinuation and inefficacy of the drug and compliance issues 9. confidentiality: two studies (11.1%) reported the issue of confidentiality in biomedical research. in one of the studies respondents were satisfied on how their information was handled by the researchers 20 whereas in the second study respondents are not aware of how their records would be kept 10. communitarianism: one study (5.6%) reported communitarianism as an issue in biomedical research. proper engagement of the community where the research was carried out or where the participants were recruited in research. in this study individual autonomy becomes inappropriate in the face of communitarianism as participants stressed respect for the decision of the community elders, community leadership approval and opinions with compliance with traditional practices and norms, recognition of the influence of the existing societal authority structures in decision makings over research participation to protect the community from harm and exploitation 23. scientific integrity: one study reported (5.6%) issue of integrity in biomedical research. in this study, chance of getting caught and penalties for scientific misconduct was reported to be low 13. knowledge gaps in research ethics and pressure to publish enough papers for promotion are common predisposing factors to misconducts among biomedical researchers, resulting in research fabrication, falsification, and plagiarism 13. professional behaviour and attitudes: two studies (11.1%) reported issue of professional behavior and attitudes in biomedical research. in one of the study (50%) professionals observed professional boundaries with patients during treatment 20 and the other explained respondents were not being pressured to garner consent during treatment 21. compensation: four studies (22.2%) reported compensation as an issue of ethics in biomedical research. while three studies (75%) highlighted need to compensate research participants and even pay those with higher value than others more money 15, 17, 25, one study (25%) reported not giving any incentives 21. in some instances, private firms like clinics indicated willingness to work with research teams if they would be allowed to distribute the study stipend to referred participants 17. cultural, social and religious practices: in two studies (11.1%) the issue of culture, bangladesh journal of bioethics 2021; 12 (1):35-48 40 table 1: general characteristics of the studies reviewed author year of publication study location study design subject main study populations journal name 8 2006 multicountry usa nigeria cross sectional genetic adult african enrolled in genetic studies of hypertension am j public health 9 2007 nigeria cross sectional hiv and aids (clinical trial) adult enrolled in an antiretroviral trial indian journal of medical ethics 10 2009 southwestern and northern nigeria cross sectional clinical practice (oral health) adult dental subjects in an ongoing oral health research bmc med ethics 11 2010 southwestern nigeria cross sectional clinical practice (surgical intervention) adult surgeons and trainees jmed ethics 12 2012 ibadan, nigeria cross sectional genetic adult participants enrolled in a study examining the relationship of serum lipid to genetic variants dev world bioeth 13 2013 southern nigeria cross sectional nonspecific adults in the medical and dental schools j empir res hum res ethics 14 2013 jos nigeria cross sectional clinical practice (oral health) adult dental patients and dental professionals j educ ethics dent 15 2014 north-eastern (maiduguri), south-western (ibadan) and south-south (calabar)) nigeria cross sectional obtaining study approval adult health research ethical committee s afr j bl 16 2014 abakaliki, nigeria cross sectional non-specific adult medical specialists and trainees adolesc health med ther 17 2014 multicountry usa ibadan nigeria cohort genomic adult and children bmc med ethics 18 2014 ibadan nigeria cross sectional genetic adult breast cancer women enrolled in a genetic epidermiological study bmc medical ethics 19 2015 lagos, nigeria cross sectional clinical trial adult participants enrolled in a study of an anti malarial drug indian journal of medical ethics 20 2015 enugu, nigeria cross sectional clinical practice adult patients who underwent radiological examination bmc med ethics bangladesh journal of bioethics 2021; 12 (1):35-48 41 21 2016 osun, lagos nigeria cross sectional clinical practice(tubal litigation) adult patients who underwent female surgical sterilization journal of basic and clinical reproductive sciences 22 2017 enugu, nigeria cross sectional clinical practice (surgical intervention) adult surgical patients who were booked for elective major surgical procedures bmc med ethics 23 2018 southwestern nigeria cross sectional genomic adults plos one (public library of science) 24 2018 gombe, jos nigeria cross sectional hiv and clinical practice (surgical intervention) adult health professionals s afr j bioethics law 25 2018 nigeria cross sectional clinical practice (assisted reproductive technologies ) adult conference attendees afr j reprod health table 2: identified ethical issues in biomedical research in reviewed studies ethical issues authors number of study/frequency informed consent 8,9, 10,11,14,15,16,18,19, 20,24 11(61.1%) autonomy/voluntariness 8,9,10, 12,18,19, 21,23 8 (44.4%) beneficence 8, 9, 10, 12,18,19,21,23 8(44.4%) counseling 9, 18, 20, 21,25 5(27.8%) professional behavior and attitudes 20,21 2(44.4%) equity 20 1(11.1%) confidentiality 10,20 2(44.4%) communitarianism 23 1(11.1%) cultural, religious and social practices 17, 23 2(44.4%) trust 17, 23 2(44.4%) compensation 15, 17, 21, 25 4(22.2%) scientific integrity 13 1(11.1%) social and religious practices among some ethnic groups and tribes were reported by biomedical researchers. cultural beliefs in voodoo or juju which vary within religious groups among the yorubas resulted in participants withdrawing from studies and also led to delays and difficulties in recontacting study participants 17,23. two (11.1%) of the articles under review expressed fear of misuse of the research samples as emphasized by olaitan et al. who puts it that they feared that their saliva and/or blood could be used for evil rituals 17. equity: equity as an ethical issue in biomedical research was reported by one study (5.6%) which observed that equity was practiced during a medical procedure 20. bangladesh journal of bioethics 2021; 12 (1):35-48 42 trust: two studies (11.1%) reported that the trust as an issue in biomedical research. regardless of age, respondents identified trust in the researcher and research institution as an important factor when deciding to participate in genomic research and also whether the community will agree to the research 17, 23. trust in community leaders also will enable respondents commit their blood samples without fear it would be used for money making rituals or voodoo practices to harm individuals17,23. trust in community leaders enables the respondents allow them make decision on behalf of their community concerning their participation in the study 23. discussion: the present study tried to identify all the various ethical issues in biomedical researchers. informed consent (ic) was most studied {11/18, 61.1%} among biomedical researchers (br) in nigeria and in most studies subjects reported the purpose of the study during the informed consent discussion. the importance of ic in research involving human subjects has become so important that it’s now the basis upon which researchers or even physicians are allowed to carry out any treatment or procedures or even trials on the subjects. this also may explain why ic was described as the foundation of the subject-researcher relationship26. interestingly, all researchers have to follow the regulations of obtaining ic which has been made mandatory by all regulations and guidelines governing the conduct of clinical research7. poor understanding of the ic process and poor knowledge of the right of the subjects could be attributed to the way the information was presented to them 27. the low level of literacy, religious and cultural hindrances, pressure of work as well as uneducated and unsophisticated patient population has been attributed to pose serious challenges to conveying adequate information to subjects in developing countries like nigeria 26. problem of obtaining assent in children as reported by one study is similar to a work done by 28 who at the end reported that examination of guidelines in obtaining assent in children shows there is still confusion regarding the concept of assent. interestingly, this does not replace the fact that ethics of human research as stressed by most international guidelines requires that the principle of assent must also be applied in pediatric research 4,5. the findings in this review about ic are similar to that reported in a who sponsored review 31. the concept of voluntarism is one of the core elements of informed consent and has being elaborated in various codes of biomedical ethics and regulations 4,5 hence the fact that it is reported as one of the ethical issues of br in nigeria is not a surprise. subject participation in research is voluntary and devoid of any form of pressure. this is evidence that the researchers in sub-saharan africa especially in nigeria are not left out on issue of allowing individuals to judge freely, independently, without coercion when making decision about joining any research. this can equally be due to ability of research staffs to explain in detail study objectives during consent discussion and could also reflect the educational level of the subjects 18. the report of right to either participate or withdraw from the studies at any time as reported in this review could mean that they were giving information about withdrawal from the studies during consent and can still recall the information. failure to make such explanations and ensure understanding by subjects could be responsible for those studies whose subjects had low understanding of their right to withdrawal. the findings from this review is similar to two studies conducted in thailand 29and uganda 30 respectively where they also reported subjects making enrollment decision themselves and having good knowledge on bangladesh journal of bioethics 2021; 12 (1):35-48 43 their right to withdrawal at any time. dissimilarly, one of the studies reported various forms of pressure on the study participants 29. the report of subjects seeking external permission from spouses before making decisions is a typical culture and family setting in nigeria. it is also worthy to note that voluntary participation in research cannot be diminished by the need for spousal permission 8,12,18. the concept of voluntarism reported in this review is similar to a who sponsored systematic review on informed consent 31. the process of decision making is one of the essential elements of a valid informed consent that requires adequate information detailing the research goal, its benefits, risk among other information about any research is disclosed to the subject. counseling to inpatients clinical research offers patients alternatives to clinical procedures thus offering a wide range of choice to them. in most of the time this information is brought to the subjects by the research team during the consent process. failure on either the part of the research team or the subjects (probably as a result of differences in educational background, social economic status, age and health status) in passing and /or comprehending this information could be the reason for the findings in this review where some study subjects reported having poor information and counseling while others have enough information on the benefits and risks associated with the research, they were invited to be a part. on the other hand, it is not clear to what extent the information should be provided on various aspects of research such as benefits and risks and it’s mostly dependent on the investigator 7. the importance of given early attention to providing adequate information and counseling in clinical practice or research was noted in a study 25. biomedical researchers have a moral duty in promoting the course of action believed to be in the interest of the patient. most research subjects in sub-saharan africa and nigeria places immediate individual gain and sometimes community benefit first before making decision to participate as evident in one of the findings in this study 23,32. in the present review, there were almost equal number of studies that reported subjects having adequate knowledge of the risks and benefits that go with the studies and those who do not have this knowledge. moreover, among the participants that were aware of potential risks and side-effects, some were not able to name at least one risk and, although they understood the benefits of participating in a study, they were less aware of the uncertainty of these benefits. this is corroborated in a similar systematic review study 31. the findings could be attributable to the ethical principle of counseling the subjects during the consent process, thus, there is need to give priority to it since literacy level of participants, duration of explanation of ic and the research team explanatory skills have a triple effect on participants understanding 31,32. some benefits and risks in participating in research have been listed in previous section. benefit could either be financial or medical benefit (see ethical issue of compensation). according to article 8, declaration of helsinki, 2001, interests in science and society should not take precedence to considerations related to the well-being of the human subject 33. researchers have almost absolute responsibility to protect subject’s confidentiality by managing private information in such a way as to protect the subject’s identity. this issue of confidentiality should be addressed before any research with human subject begins. hence, the discordant report from the two bangladesh journal of bioethics 2021; 12 (1):35-48 44 studies in this review that reported on the issue of confidentiality clearly shows the need to openly address research participants on how their personal responses and information would be handled so as to build trust among them and enable them be blunt to truth in their participation. confidentiality is closely related to right to privacy and a patient’s bill of rights document published in 1975 by the american hospital association (aha) clearly affirm the patient’s right to privacy 34. a similar systematic review on ethics in medical research equally highlighted the importance of confidentiality 35. when research is focused on ethnically or culturally distinct population, community engagement is one surest way to drive research in such population. ‘community engagement (ce) has been broadly defined as a process of working collaboratively with a group or groups of people on a shared goal or common interest’ 36. during ce communities are educated about the research and information is exchanged between the research team and potential research participants about the research process over a period of time. most times outcome of research is equally communicated through same means, thus ce can occur before, during and after a research project 37. the attendant effect of ce is increase in awareness and decrease in clashes between the community and the research team leading to greater research outcomes. thus, the report of communitarianism seen in one study in this review as one of the ethical issues in biomedical research shows nigerian communities are increasingly becoming aware the role communities and its leaders play in research. community engagement in br can better be understood in similar work 38. a study in this review reported the issue of misconduct among biomedical researchers in nigeria. in a recent similar systematic review work in china on issue of research integrity, high level of misconduct was equally reported among their medical researchers 39. a national survey of scientific misconduct in united states reported low level of misconduct among her professionals 40. falsification, fabrication, and plagiarism as well as improper authorship and duplicate submission are some highlighted research misbehaviors common among biomedical researchers 13,39. this is largely as a result of inadequate knowledge and mentorship for ethical conduct of research as well as the culture of mounting pressure on researchers to publish more papers as a means of securing promotion. the way out is to strengthen research integrity training, increase the severity of penalties for scientific misconduct, improve the scientific evaluation system, develop the governance system and increase institutional effectiveness as regards to rules and procedures for reducing scientific misconduct 13,39,40. professionals in the health care industry are bound to some form of code of conduct peculiar to each profession. since these ethical procedures are linked to improving patient satisfaction, they should not be ignored by health care professionals in service delivery. through good communication, patient care skills and professional conduct must remain sensitive to the needs of the patients even when recruiting them as research subjects in clinical research or trial 41. the report of two studies in this review of professionals observing professional boundaries with their patients during treatment and also not pressurizing their patients show these professionals still work within the tenets of their code of conduct and this is similar to another study report 41. nonetheless, there is still need for bangladesh journal of bioethics 2021; 12 (1):35-48 45 training in ethical conduct and professionalism for health professionals in nigeria and increasing institutional effectiveness in monitoring the enforcement of these conducts. though issue of compensation is related to the principle of beneficence and has been widely accepted as a common practice in br, it was still usually not made compulsory for researchers 15. compensation in research needs to be regulated since it can also act as a barrier to voluntary participation in research 42. according to grady 43 ‘compensation may be handed out as refunds for expenses incurred by participants; for time, effort and inconvenience; injury or harm associated with research participation or as incentives to stimulate participants to follow the study protocol to completion’. the need to regulate this practice has been reported as a result of its associated ethical concerns of exploitation, coercion, and undue influence 44. compensation can be financial or medical benefit. financial incentives such as transport and refreshment allowances were advised when there was no direct benefit to the research participant 15. in this review, four studies reported the issue of compensation to research participants. it is becoming increasingly clear that most times research participants tie their level of involvement to the amount of compensation they will receive at the end of the process. not compensating your subjects especially when there is need for such may dampen their spirit which inadvertently will affect the overall outcome of the study as seen in this report where some private firms tied their willingness to participate to the study stipend that would be given. however, the report of incentives not offered to the participants in one of the studies could be due to the nature of the research and the statutory, policy, and legislative requirements guiding the practice as the study claimed 21. compensation as an ethical issue is contained in similar studies 45,46. two studies from this review identified ethical issue of culture, social and religious practices in br. this probably may be due to the fact nigerians value their cultural and religious practices that even in most places where the people are known christians or muslims17. the leaders or custodians of these cultures commonly referred to oba among the yorubas, igwe among the ibos or emir among the hausas have overwhelming influence on people’s decision. the practice of voodoo among the yoruba’s has caused lots of apprehension and fear which has affected research uptake among the populace and could account for the fear reported among the subjects in the two studies mentioned. the influence of socio-cultural variables in br is explained in a study 47. equity is an expression of social justice and it has to do with fair distribution of benefits from health. observing equity in br as reported in one study in this review 20 is one sure way of improving research outcomes. limitations: this study was done in nigeria alone. this is the first limitation of this study. it does not represent the africa. hence similar studies should be carried out covering sub-saharan africa and the global community of africa. .it should be noted that only english articles have been searched in this study. also, only four search platform has been searched in this study e.g. pubmed/medline, google scholar, jstor, and ajol. only eighteen articles have been discussed in this study and twelve ethical issues were discussed. therefore, further study is needed with large number of populations with more search engines and large number of articles. bangladesh journal of bioethics 2021; 12 (1):35-48 46 conclusion: we found that there are ethical issues in biomedical research in nigeria of which informed consent is most widely studied. however, participants had varying degree of understanding of their rights as research subjects. as a result, there is need to enhance the capacity of investigators to better understand these issues and also increase their explanatory skill to help participants achieve complete understanding of their various rights and process. this shall assist both the investigators and participants towards a better research approach. references: 1. the nuremberg code in: mitscherlich a, mielke f. doctors of infamy: the story of the nazi medical crimes. 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10: 11. doi: 10.1186/14726939-10-11 11. ogundiran to, clement a, adebamowo ca. surgeons’ opinions and practice of informed consent. niger. j. med ethics, 2010; 36(12): 741– 745. doi: 10.1136/jme.2010.037440 12. osamor pe, kass n. decision-making and motivation to participate in biomedical research in southwest nigeria. dev. world biothiecs. 2012; 12(2): 87-95. doi: 10.1111/j.14718847.2012.00326.x 13. adeleye oa, adebamowo ca. factors associated with research wrongdoing in nigeria. journal of j. empir. res. hum. res. ethics. 2012; 7(5):1524. doi: 10.1525/jer.2012.7.5.15 14. taiwo oo, panas r. views of dental professionals and dental patients in jos, nigeria concerning the need for informed consent prior participation in dental clinical research. j educ ethics dent. 2013; 3:14-20. http://www.jeed.in/text.asp?2013/3/1/14/126937 15. agunloye am, salami,at, lawan a. current role of research ethics committees in health research in three geopolitical zones in nigeria: a qualitative study. s afr j bl 2014; 7(1):19-22. doi:10.7196/sajbl.309. 16. onoh rc, umeora ou, ezeonu po, agwu um, lawani lo, ezeonu ct. perception of assent in biomedical research among medical specialists and trainees in abakaliki, nigeria. adolesc. health, med. ther, 2014; 5: 183-189. doi: 10.2147/ahmt.s66542 17. olaitan pb, odesina v, ademola s, fadiora so, oluwatosin om, reichenberger ej. .recruitment of yoruba families from nigeria for genetic research: experience from a multisite keloid study. bmcmed. ethics, 2014; 15: 65. doi: 10.1186/1472-6939-15-65 bangladesh journal of bioethics 2021; 12 (1):35-48 47 18. marshall pa, adebamowo ca, adeyemo aa, ogundiran to, strenski t, zhou j, et al. voluntary participation and comprehension of informed consent in a genetic epidemiological study of breast cancer in nigeria. bmc med ethics 2014; 15:38. https://doi.org/10.1186/14726939-15-38 19. adewale b, schoeman l, roussouw t. knowledge and perceptions of research participants in nigeria about clinical trials. indian j. med. ethics. 2015; 12(4):196-198. doi: 10.1136/jme.2010.037440 20. ochonma og, eze cu, eze sb., okaro ao. patients' reaction to the ethical conduct of radiographers and staff services as predictors of radiological experience satisfaction: a crosssectional study. bmc med ethics. 2015; 16(1): 68. doi: 10.1186/s12910-015-0062-4 21. adebimpe wo. a survey of clients and ethical perspectives of voluntary tubal ligations in the south-western nigeria. j basic clin reprod sci. 2016; 5(1): 21-26. 22. nnabugwu ii, ugwumba fo, udeh ei, anyimba sk, and ozoemena of. informed consent for clinical treatment in low-income setting: evaluating the relationship between satisfying consent and extent of recall of consent information. bmc med ethics. 2017; 18: 69. doi: 10.1186/s12910-017-0227-4 23. ogunrin o, woolfall k, gabbay m, frith l. relative solidarity: conceptualising communal participation in genomic research among potential research participants in a developing sub-saharan african setting. plos one. 2018; 13(4): e0195171. doi: 10.1371/journal.pone.0195171 24. joseph bn, jamil am, yahya ai, dangiwa da, jangkam dn, dapar mlp. mandatory hiv testing as a prerequisite for surgical procedures: perspectives on rights and ethics. s afr j bioethics law. 2018); 11(2):70-74. doi:10.7196/sajbl.2018.v11i2.636 25. okonta pi, ajayi r, bamgbopa k, ogbeche r, okeke cc, onwuzurigbo k. ethical issues in the practice of assisted reproductive technologies in nigeria: empirical data from fertility practitioners. afr j reprod health. 2018; 22(3):51-58. doi: 10.29063/ajrh2018/v22i3.6. 26. ezeome er, chuke pi, ezeome iv. contents and readability of currently used surgical/procedure informed consent forms in nigerian tertiary health institutions. niger j clin pract. 2011; 14:311-7 27. leclercq wk, keulers bj, scheltinga mr, spauwen ph, van der wilt gj. a review of surgical informed consent: past, present, and future. a quest to help patients make better decisions. world j surg. 2010; 34(7):1406-15 28. baines p. assent for children's participation in research is incoherent and wrong. arch. dis. child. 2011: 96{10}: 960-962. http://dx.doi.org/10.1136/adc.2011.211342 29. pace c, emanuel ej, chuenyam t, duncombe c, bebchuk jd, wendler d, et al. the quality of informed consent in a clinical research study in thailand. irb. 2005; 27(1):9-17. 30. pace c, talisuma a, wendler d, et al. quality of parental consent in a ugandan malaria study. am j public health. (2005). 95:1184–1189. 31. nguyen tt, nguyen th, le thi bt, nguyen pl, nguyen tht, kenji h. et al. participants’ understanding of informed consent in clinical trials over three decades: systematic review and meta-analysis. who bulletin 2015: 93;186-198. doi: http://dx.doi.org/10.2471/blt.14.141390 32. tamariz l, palacio a, robert m, marcus en. improving the informed consent process for research subjects with low literacy: a systematic review. j gen intern med. 2013: 28(1):121126. http://dx.doi.org/10.1007/s11606-012-21332 33. declaration of helsinki (2001). http://www.who.int/bulletin/archives/79%284%2 9373.pdf. accessed april, 2020. 34. aha a patient's bill of rights. chicago: american hospital association, (1975). 35. gurayaa sy, london njm, guraya ss. ethics in medical research. jmau. 2014: 2; 121– 126.http://dx.doi.org/10.1016/j.jmau.2014.03.00 3 36. tindana po, singh ja, tracy cs, upshur re, daar as, singer pa, et al. grand challenges in global health: community engagement in research in developing countries. plos med. 2007: 4(9):e273. doi: 10.1371/journal.pmed.0040273. 37. tindana t, de vries j, campbel m, littler k, seeley j, marshall p, troyer j, ogundipe m, alibu vp, yakubu a, parker m. community engagement strategies for genomic studies in africa: a review of the literature. bmc med ethics. 2015: 16; 24.doi: 10.1186/s12910-0150014-z 38. folayan mo, peterson k, haire b, brown b, audu k, makanjuola o, et al. debating ethics in hiv research: gaps between policy and practice in nigeria. dev world bioeth. 2015: 15(3):214225. doi: 10.1111/dewb.12064 39. yi n, nemery b, and dierickx k. integrity in biomedical research: a systematic review of bangladesh journal of bioethics 2021; 12 (1):35-48 48 studies in china. sci eng ethics. 2019: 25; 1271– 1301. https://doi.org/10.1007/s11948-018-0057-x 40. pryor er, habermann b, broome me. scientific misconduct from the perspective of research coordinators: a national survey. j med ethics. (2007). 33(6):365–9. doi: 10.1136/jme.2006.016394 41. beyer l, diedericks p. the attitude of radiographers towards patients in government hospitals in bloemfontein. south afri radiographers. 2010: 48(2):22–27. 42. nyangulu w, mungwira r, nampota n. et al. compensation of subjects for participation in biomedical research in resource – limited settings: a discussion of practices in malawi. bmc med ethics. 2019: 20: 82 https://doi.org/10.1186/s12910-019-0422-6 43. grady c. payment of clinical research subjects. j clin invest. (2005). 115(7): 1681–1687. doi: 10.1172/jci25694 44. largent ea, fernandez lh. paying research participants: regulatory uncertainty, conceptual confusion, and a path forward. yale j health policy law ethics. 2017:. 17(1):61–141. 45. rotimi c, leppert m, matsuda i, zeng c, zhang h, adebamowo c, ajayi i, aniagwu t, dixon m, fukushima y, macer d, marshall p, nkwodimmah c, peiffer a, royal c, suda e, zhao h, wang vo, mcewen j. international hapmap consortium. community engagement and informed consent in the international hapmap project. community genet. 2007. 10(3):186–198 46. igbe ma, adebamowo ca. qualitative study of knowledge and attitudes to biobanking among lay persons in nigeria. bmc med ethics. 2012: 13:27 47. al-bannay h, jarus t, jongbloed l, yazigi m, dean e. culture as a variable in health research: perspectives and caveats. health promotion intl. 2014: 29 (3): 549– 557. https://doi.org/10.1093/heapro/dat002 authors declaration: 1st author ikeagwulonu richard chinaza conceptualized the project, designed the study and carried out the database search and screening, and wrote the initial draft of the manuscript. 2nd author chigozie jesse uneke reviewed and provided substantial modification to the intellectual content of the draft manuscript. 3rd author obeta, mark uchejeso contributed in data search and extraction, reviewed the initial manuscript draft. all authors reviewed and approved the final manuscript for publication. conflict of interest: there is no competing interests between the authors. microsoft word zulkefli bangladesh journal of bioethics 2020; 11 (3): 9-20 9 awareness and perceptions on bioethical issues among pre-service science teachers zulkefli daud1*, zainab ari2 and noorafizah daud3 1. department of science, institute of teacher education malaysia, temenggong ibrahim campus, 80350 johor bahru, johor, malaysia. email: zulmydinamik@yahoo.com 2. tunku mahmood iskandar secondary school, 83200 batu pahat, johor, malaysia. email: zainab63@gmail.com 3.faculty of education, national university of malaysia, 43600 bangi, selangor, malaysia email: nooriezh11@gmail.com doi: https://doi.org/10.3329/bioethics.v11i3.50593 abstract: this study aims to investigate the awareness and perception level of bioethical issues among pre-service science teachers at one of the malaysian education institutions. a total of 67 respondents studying science major and science elective were involved. a questionnaire based survey with an alpha cronbach of approximately 0.93 was used. data were analysed using spss version 22. the results showed that the average awareness and perception level were �̅=4.218±0.758 (very high level) and �̅=3.991±0.923 (high level), respectively. there was a statistically significant difference according to religion and course. cloning showed the highest awareness level followed by organ donation, genetic modification, stem cells, abortion, gene therapy, gene screening and euthanasia. overall, the findings indicated that pre-service science teachers were aware of the existence of bioethical issues. however, the authorities may implement bioethical issues more firmly in the future to increase pre-service science teachers’ awareness and perception level. key words: bioethical issues, pre-service science teachers, awareness, perception (some part of the article was presented at the 20th asian bioethics conference, 22-25 november 2019, dhaka, bangladesh) introduction: bioethics is now becoming increasingly important around the world due to rapid advancement in science and technology (s&t), apart from the drastic changes in macroeconomic planning and globalization1. new discoveries and innovations in s&t, on the other hand have raised a number of bioethical issues2. this relationship makes the teaching and learning of bioethics in science curriculum more important than ever before2,3. in this regard, pre-service science teachers should be prepared to face bioethical issues because the malaysian national philosophy of education (npe) emphasizes that not only science teachers should be able to foster understanding of science content, science process skills, positive attitude towards science and nurture unity among students but also instil ethical and moral values in students4. malaysia's preparations to address the emergence of bioethical issues are strengthened by promoting bioethics awareness on students of higher education institutions since 20055 and establishing the national bioethics council of malaysia in 20126. understanding the importance of fostering ethics to students by teachers is important because it is part of science education7. in the malaysian science teacher education programme, bioethical issues are taught to pre-service science teachers or to science teacher trainees through integration into other subjects. some subjects that contain the topic of bioethical issues include biological diversity8, ethics and safety9, emerging issues in biology and environment, principles in bangladesh journal of bioethics 2020; 11 (3): 9-20 10 biotechnology10 and fundamental genetics11. bioethics in science has been promoted and taught, but bioethical issues still raise questions and create different views in the society. confusion among the community is exacerbated by the emergence of some groups that reject the advancement of s&t, although scientists continue to claim its benefits. the refusal and scepticism of anti-vaccine groups to accept child vaccination12 based on precise scientific facts is an example of how people reject s&t innovation. cloning, organ donation, euthanasia, stem cells, genetic modification, abortion, gene therapy and gene screening are some of the popular or most important bioethical issues13,14. usually, debates of these bioethical issues are related to potential risks or harmful effects of the application of s&t to human health, the environment and even contrary to traditional beliefs and religions. whether s&t brings a good or bad effect, bioethical issues still affect human life and environment and touch on almost every area of human endeavour15. the emergence of bioethical issues with differences of opinion in society has raised some questions in the preparation of preservice science teachers. this issue may be traceable based on their lack of awareness of ethics and their ethical perceptions. however, the level of awareness and perception of bioethical issues among preservice science teachers in malaysia is unclear due to the lack of literature on bioethics education in the science teacher programme. low, lexman and mohamed saat16 also stated that the ethical perceptions of malaysian undergraduate students are largely unknown. rodzalan and mohamed saat17 found that the level of ethics of undergraduate students is high but this study is not specific to bioethical issues among pre-service science teachers. pre-service science teachers will lead the next generation through their major role in enabling students to make decisions that are more reasonable on ethical issues. teachers play a role in shaping society18,19. in this regard, teachers can influence society by changing students' awareness and perception of bioethical issues. however, it is very important for teachers to have a lot of information and knowledge on bioethical issues before they can teach bioethics in their teaching and learning process. according to özkan and umdu topsaka20, to improve bioethics education among science teachers, it needs to be implemented while they are still in preservice teacher training. kohlberg21 supported the notion where ethical awareness should be taught in early age by providing continuous education, especially to students in higher education. pre-service science teachers are in the early stages of developing a conscience and establishing their identities and values, they may show maturity in both physical and mental form, but in reality, their values are still immature. teaching bioethics including making a good ethical decision to preservice science teachers at this age are more effective and essential than at any other time in their lives22,23,24. moreover, bioethical issues are an excellent tool to generate interest and establish the relevance of science content as well as pre-service science teachers are youth who are closely related to ethical issues such as suicide, abortion and organ donation2,25,26. according to ozkan and umdu topsaka20, if pre-service science teachers provide the awareness in bioethics, they will enable effective education. there is not much research of bioethical issues in science education in the literature20. in malaysia, several studies related to ethics among science teachers or science students have been conducted. nair, mohamed and marimuthu27 conducted the research of morals, and ethics among preservice science teachers at the tertiary level, rodzalan and mohamed saat17 conducted a study on morals and ethics among undergraduate students majoring in science bangladesh journal of bioethics 2020; 11 (3): 9-20 11 and jasimin28 has studied ethics in science among in-service science teachers. however, most studies in malaysia focus on moral or ethical practices as a science teacher rather than specializing in bioethical issues in science. therefore, it is highly desirable to investigate the awareness and perception of pre-service science teachers in malaysia on bioethical issues in science. research questions and hypotheses the following main research questions have been used to guide this study: a. what is the awareness and perceptions of bioethical issues among pre-service science teachers? b. are there significant differences in the awareness and perceptions of pre-service science teachers on bioethical issues towards gender, religion and courses? this study tests the following null hypotheses : a. there is no significant difference between male and female pre-service science teachers towards the awareness and perceptions of bioethical issues b.there is no significant difference between muslim and non-muslim pre-service science teachers towards the awareness and perceptions of bioethical issues c.there is no significant difference between science major course and science elective course pre-service science teachers towards the awareness and perceptions of bioethical issues methodology: in a present study, a total of 67 respondents of pre-service science teachers at one of educational institutions were involved. the respondents divided into two groups of gender; 28.4% (19 respondents) were male and 71.6% (48 respondents) were female. the largest number of respondents at 58.2% (39 respondents) was contributed by science major, while science elective only contributed 41.8% (28 respondents). science major refers to respondents who compulsory studied science subjects, while science elective refers to respondents who studied optional science subjects. muslims were 71.6% (48 respondents) representing the largest share, while non-muslim (buddhists, christianity and hindus) consisted 28.4% (19 respondents). this study was conducted at one of the educational institutes in malaysia. a survey based on a questionnaire to measure awareness and perception of bioethical issues with a five degree likert scale; (5) strongly agree (�̅=4.20-5.00), (4) agree (�̅=3.40-4.19), (3) moderate (�̅=2.60-3.39), (2) disagree (�̅=1.80-2.59) and (1) strongly disagree (�̅=1.00-1.79) was used. the five level interpretation was (5) very high, (4) high, (3) moderate, (2) low and (1) very low. alpha cronbach of questionnaire was approximately 0.93. this study only focuses on eight bioethical issues namely; cloning, organ donation, genetic modifications (gmo), stems cells, abortion, gene therapy, gene screening and euthanasia. these eight issues were the main and popular bioethical issues over the past few years. the data analyses were made by t-test using spss 22.0 package programme. significance level was taken to be 0.05. results: awareness of bioethical issues: the result of awareness level among respondents is shown in table 1. the overall average awareness level of the respondents regarding bioethical issues was �̅=4.218±0.758. among bioethical issues, cloning indicated the highest awareness level at 4.373 followed by organ donation at 4.358, genetic modification at 4.299, stem cells at 4.269, abortion at 4.239, gene therapy at 4.194, gene screening at 4.060 and euthanasia at 3.955. an analysis of the difference in awareness level according to bangladesh journal of bioethics 2020; 11 (3): 9-20 12 respondent’s background profiles showed a statistically significant difference according to religion (t=5.650, p<0.05) and course (t=4.862, p< 0.05). muslim displayed higher awareness levels of bioethical issues than non-muslim, and science major course showed higher levels than science elective course. male showed higher awareness levels than female, however there was no significance difference according to gender. table 2 shows the t-test result on the awareness level of bioethical issues towards the background profiles respondents. table 1: awareness of bioethical issues among respondents bioethical issues awareness interpretation average (�̅) s.d. cloning 4.373 0.671 very high organ donation 4.358 0.667 very high genetic modifications (gmo) 4.299 0.759 very high stem cells 4.269 0.709 very high abortion 4.239 0.653 very high gene therapy 4.194 0.802 high gene screening 4.060 0.795 high euthanasia 3.955 0.878 high overall awareness of bioethical issues 4.218 0.753 very high table 2: t–test on awareness of bioethical issues towards respondents’ background profiles profile categories average s.d. t p gender male female 4.290 4.190 0.568 0.632 0.596 0.553 religious muslim non-muslim 4.438 3.665 0.436 0.651 5.650 0.000** course science major science elective 4.484 3.848 0.418 0.652 4.862 0.000** **p<0.05 perception of bioethical issues: the result of respondents’ perception of bioethical issues is shown in table 3. these perceptions containing 21 statements where statements 1 to 9 were related to general information of s&t, bioethics, religion, law and policy, while statements 10 to 21 were specifically related to bioethical issues. the average perception of 21 statements was at a high level (�̅=3.991±0.923). respondents perceived s&t makes an important contribution to the quality of human life as the highest level (4.388), followed by interest in s&t as the second highest level (4.343) and bioethical issues need to be studied in the science and biology curriculum as the third highest level (4.343). the second and third highest levels had the same average value but differ in standard deviation. these three perceptions were at a very high level. for statements familiar with the term "bioethics", awareness of the emergence of bioethical issues in line with the development of science and biology and discussing bioethical issues in the classroom, respondents perceived at a high level of 3.522, 4.075 and 3.478, respectively. bangladesh journal of bioethics 2020; 11 (3): 9-20 13 further result found that for religious, law and policy statements, respondents perceived high level (4.030) for the authorities have a clear policy on bioethical issues. vice versa, religion has the ideal framework for dealing with any bioethical issues and the law needs to have an ideal framework for bioethical issues perceived at very high levels with an average of 4.209 and 4.239, respectively. table 3: perceptions of respondents on items related to bioethical issues items score interpretation average s.d. 1 science and technology makes an important contribution to the quality of human life 4.388 0.627 very high 2 i’m interested in science and technology 4.343 0.750 very high 3 i’m familiar with the term “bioethics” 3.522 0.975 high 4 i’m aware of the emergence of bioethical issues in line with the development of science and biology 4.075 0.876 high 5 bioethical issues needs to be studied in the science and biology curriculum 4.343 0.789 very high 6 i often discuss bioethical issues in class 3.478 0.943 high 7 religion has the ideal framework for dealing with any bioethical issues 4.209 0.826 very high 8 the law needs to have an ideal framework for bioethical issues 4.239 0.799 very high 9 the authorities have a clear policy on bioethical issues 4.030 0.758 high 10 genetic modification foods have been introduced in my country 3.866 0.886 high 11 the authorities allow organ donation in my country 4.075 0.841 high 12 if my family need a kidney, i will donate one to him 4.149 0.942 high 13 if my family need a kidney, i will not buy one from the black market 3.567 1.587 high 14 the authorities not freely allow abortion in my country 3.821 0.999 high 15 i’m aware of the implications of stem cell technology 4.075 0.703 high 16 stem cell technology should be introduced to all 4.030 0.816 high 17 the authorities allow cloning by law 3.642 1.111 high 18 if a gene screening test shows i have a genetic defect, i will have to do the gene treatment first, before the symptoms appear 4.300 0.738 very high 19 besides me, my family members can also be informed about my health screening findings 4.000 0.816 high 20 i will take my family members for genetic therapy, if they have a genetic defect 4.044 0.706 high bangladesh journal of bioethics 2020; 11 (3): 9-20 14 21 i aware that euthanasia is only allowed by the authorities, for reasons that justify it. 3.881 0.826 high overall perceptions on related item of bioethical issues 3.991 0.923 high statements specifically related to bioethical issues, respondents perceived at a very high level (4.3) only for the statement of performing gene treatment first before symptoms appeared if gene examination tests showed genetic defects. other statements of bioethical issues, respondents perceived only at a high level stating with statements about respondents donating kidneys (4.149), followed by authorities allowing organ donation (4.075), aware the implications of stem cell technology (4.075), taking family members for genetic therapy if they have a genetic defect (4.044), introduce stem cell technology to all (4.030), family members can inform about health screening findings (4.000), euthanasia is only allowed by the authorities for certain reasons (3.881), introducing genetic modification to the country (3.866), abortion is not freely allowed by authorities (3.821), authorities allow cloning (3.642) and finally, donating kidneys without buying from the black market (3.567). further analysis of the difference perception of bioethical issues according to respondents' background profiles found that there was statistically significant difference in religion (t=3.862, p<0.001) and course (t=4.379, p<0.001), but gender showed insignificant difference. male, muslim and science major course showed high average perception compared to other background profiles. table 4 shows t-test on the perception of bioethical issues towards the background profiles of the respondents. table 4: ttest on perception of bioethical issues towards respondents’ background profiles profil e categ ories me an s. d. t p gend er male femal e 3.9 92 3.9 35 0.4 72 0.5 29 0.4 05 0.68 7 religi ous musli m nonmusli m 4.1 25 3.6 52 0.3 97 0.5 71 3.8 62 0.00 0** cours e scienc e major scienc e electiv e 4.1 91 3.7 13 0.3 32 0.5 58 4.3 79 0.00 0** **p<0.05 discussion: the overall level of awareness of bioethical issues among pre-service science teacher was very high (�̅=4.218±0.758). this finding was consistent with other studies such as research by ilyas et al.13 and aggarwal, sandhu and kukreja26 who found that awareness of bioethical issues is quite high among respondents of hazara university and sri guru ram das university of science and medical research. according to ilyas et al.13 and aggarwal, sandhu and kukreja26, high awareness of these bioethical issues is due to its curriculum content. postgraduate respondents from molecular medicine and medical biotechnology department, where bioethics had been included in their curriculum, also exhibited relatively high level of awareness on bioethical issues29. therefore, the very high level of awareness in this study may be due to exposure to bioethical issues through the content of their curriculum as the findings of other researchers. besides well exposed of bioethical issues as above discussion, the high level of bangladesh journal of bioethics 2020; 11 (3): 9-20 15 bioethical issues awareness in this study can provide an initial overview of the level of scientific literacy among pre-service science teachers. this is because the awareness and understanding of the impact of s&t on society is one of the dimensions of scientific literacy30. according to kolarova and denev3, the topic of ethics is increasingly important as a tool to improve students' scientific literacy, therefore, the ethical topics applied in the curriculum indirectly affect the high awareness of bioethical issues. these findings may reflect awareness about bioethical issues at the societal level since literacy rate among the population aged 15 years and older in malaysia is high around 94.64%31. scientific literacy is an important element to enable people to think and critically evaluate an issue and make wise decisions, especially s&t surrounded by various ethical, social, political and economic issues32. the study also found that cloning was perceived as the highest awareness level of bioethical issues, followed by organ donation, genetic modification, stem cells, abortion, gene therapy, gene screening and euthanasia (table 1). this finding might indicate that cloning was very popular issues compared to others, while less popular issues caused euthanasia to be in the lowest awareness. the finding was in line with the ranking of the most important bioethical issues by iliyas et al.13 and alam et al.14. awareness level of each bioethical issues in this study namely cloning, organ donation, genetic modification (gmo), stem cells and abortion were found to be very high level more than 4.2, while gene therapy, gene screening and euthanasia were perceived high level between 3.4 and 4.19. these findings indicated that preservice science teachers had at least high level of awareness of each bioethical issue. the awareness of some bioethical issues in this study also showed higher awareness than in other fields and countries. for example, jeon and kim23 who studied undergraduate students of biomedical science in korea found only moderate levels for organ donation and euthanasia. this difference in high level of awareness may also be due to differences ability among students. in malaysia, the latest trend in the selection of pre-service science teachers is through strict selection, besides they must have a good academic qualification before being accepted for teacher training programme. the characteristics possessed by pre-service science teachers may influence the outcome of this study, but further research should be done in the future to confirm the relationship between respondents' ability and level of awareness on bioethical issues. based on the background profile of preservice science teachers, the results of this study found that male, muslim and science major course showed higher level of awareness on bioethical issues than female, non-muslim and science elective course (table 2). some researchers such as rodzalan and mohamed saat17 revealed that the level of ethics are different in terms of academic discipline among higher education students, jasimin28 found that muslim science teachers have different perceptions than non-muslim science teachers on ethical issues and rodzalan and mohamed saat17 found that female have higher ethical awareness compared to male in the study of undergraduate programme majoring in science. jeon and kim23 also found that awareness of biomedical ethics according to general characteristics showed a statistically significant difference towards gender, religion and major course. however, t-test of this study only found religion and course were statistically significant differences (table 2). no significant differences in bioethical issues awareness of gender may be due to the both sexes received almost identical exposure of it curriculum. religion and course had significant differences in awareness of bioethical issues, possibly due to the mastery of different disciplines and bangladesh journal of bioethics 2020; 11 (3): 9-20 16 different principles in religion as a way of their life. these results showed that several background factors such as religion and education level would influence people’s thinking33. further study on pre-service science teachers’ perception related to statement of bioethical issues was found “agree”, indicating a high level perception. the difference perception of bioethical issues according to respondents’ background profile showed a statistically significant difference only for religion and course (table 4). meanwhile, male, muslim and science major course showed high average perception compared to other background profiles. the high perception in this study is in line with the revelation of very high awareness of each bioethical issue. this may show the relation between perception and awareness because the perception is the process of becoming aware of situations, of adding meaningful associations to sensations34. the result for s&t makes an important contribution to the quality of human life and interest in s&t, respondents perceived very high level indicated that they were strongly agreed. this means that s&t will benefit pre-service science teachers live and influence their interest in s&t. this is in line with alam et al.14 who stated that most of the respondents (76.4%) in their study not only believed that s&t would benefit their lives but also expressed interest in s&t. respondents perceived high level for familiar with the term “bioethics”, aware of the emergence of bioethical issues in line with the development of science and biology and often discuss bioethical issues in class. these findings indicated that preservice science teachers aware and know about bioethics education and bioethical issues in their science and biology curriculum. these results in line with the statement of bioethical issues need to be studied in the science and biology curriculum, to which respondents had strongly agreed. this result is also in accordance with rasool et al.35 which 78% teachers and students agree that ethical issues should be included in the biology syllabus, while iancu36 suggested that bioethical education be implemented using the modern context of biological teaching. the findings of this study were in line with the implementation of bioethics education in japan, australia and new zealand, where almost all of the teachers thought bioethics were needed in education and bioethical issues were generally covered more in biology classes than in social science classes37. respondents perceived high level for class discussion on bioethical issues as mention above, but the statement showed the lowest perception. this result may be due to the factor of student busyness or the lack of curriculum content which leads to less discussion. according to mahmud et al.4, the curriculum structure of degree programs containing more general science content commonly lacks content knowledge that may affect student understanding and development of inquiry-based science teaching. the findings in the statement bioethical issues needs to be studied in the science and biology curriculum which perceived very high level, and often discuss bioethical issues in class which perceived low high level may need to be considered when designing a new science and biology curriculum by incorporating bioethical issues into the current curriculum structure. based on statement religion has the ideal framework for dealing with any bioethical issues, it can be said that pre-service science teachers agree in a religious approach in dealing with bioethical issues (table 3). this is in line with the findings of özkan and umdu topsakal20 where the respondents prefer a theological approach to bioethical issues or in other words their bangladesh journal of bioethics 2020; 11 (3): 9-20 17 decisions deal with religious rules. statements of the law needs to have an ideal framework for bioethical issues, and the authorities have a clear policy on bioethical issues are closely related to the seriousness of the authorities on bioethical issues. preservice science teachers perceived high and very high for both items indicating that the authorities should pay attention to bioethical issues. in fact, the malaysian authorities had already set up the national bioethics council in 2012 to help address bioethical issues especially those related to policy and law. based on the result from statement specifically related to bioethical issues, the finding showed that respondents agree to all statements, except statement if a gene screening test shows a genetic defect, respondents will have to do the gene treatment first, before the symptoms appear, where they strongly agree. very high perception on this statement indicated that pre-service science teachers were very aware about gene screening and willing to avoid getting sick. respondents perceived high level for other statements specifically related to bioethical issues. this means that pre-service science teachers were also aware on bioethical issues mention namely genetic modification foods, organ donation, abortion, stem cell technology, cloning, gene screening, genetic therapy and euthanasia. pre-service science teachers perceived high to introduce both genetic modification food and stem cell technology to all, which might be due to the development of both technologies around the world and their advantages. side effects from two technologies that have not been proven, do not have a significant effect on respondents. this was supported by statement of pre-service science teachers, where they were aware of the implications of stem cell technology. respondents perceived agree the authorities allowed organ donation. statements of if my family need a kidney, i will donate one to him indicated that preservice science teachers will be willing to donate organs for the needs of their families, but statement of if my family need a kidney, i will not buy one from the black market, most of them were opposed to getting organs from the black market. this showed that respondents aware about organ donation especially kidney donation even though the organ donation rate in malaysia is among the lowest in the world38. statement of if my family need a kidney, i will not buy one from the black market showed high perception but it has the lowest average perception compared to other statements specifically related to bioethical issues (table 3). this showed that pre-service science teachers were very difficult to decide on bioethical issues whether to buy kidney or not from the black market especially for the needs of their families. for abortion issue, the authorities not freely allow abortion in the country. respondents have agreed this. however, it was not perceived very high probably due to many cases that occur among adolescents in malaysia. the federation of reproductive health associations malaysia has estimated that there are about 90,000 abortions performed annually in malaysia and the reproductive rights advocacy alliance malaysia has estimated that there are about 240 clinics nationwide offering abortion services39. abortion in malaysia is mostly illegal except in certain cases when a medical practitioner deems that continuing the pregnancy poses a danger to the mother's life, physical health, and mental well-being. the findings of this study may support alam et al.14 who found abortion as the second most important bioethical issue due to the social unacceptability of premarital pregnancy rather than as a strictly bioethical issue. the highest awareness level was found for cloning as mentioned in research question i, but it was not perceived very high in bangladesh journal of bioethics 2020; 11 (3): 9-20 18 statement of the authorities allow cloning by law (table 3). this may be due to not clear about the law of the cloning and other modern technologies based on low in technical knowledge and their implications. according to ilyias et al.13, a correct picture on cloning issue only could emerge when all the pros and cons are explained to the people. for euthanasia issue, which statement about aware of euthanasia is only allowed by the authorities, for reasons that justify it was found high awareness (table 1) and high perception (table 3). this means that preservice science teachers were aware on euthanasia issue and only allowed by the authorities for certain reasons. euthanasia may be less prone to pre-service science teachers causing their perceptions and awareness not to acquire very high. ilyias et al.13 can support this, where euthanasia found the second lowest ranking according to the most important bioethical issues. jeon and kim23 also found euthanasia in second place out of 7 biomedical issues awareness. statements if a gene screening test shows i have a genetic defect, i will have to do the gene treatment first, before the symptoms appear, besides me, my family members can also be informed about my health screening findings and i will take my family members for genetic therapy, if they have a genetic defect were related to gene testing and health. pre-service science teachers' perceptions of the three statements were high with an average of more than 4. as mentioned above on statement if a gene screening test shows i have a genetic defect, i will have to do the gene treatment first, before the symptoms appear, these findings indicated that pre-service science teachers were concerned about their respective health levels. this may have caused the respondents to also give a high perception for statements family members can also be informed about my health screening findings and i will take my family members for genetic therapy, if they have a genetic defect. apart from the findings discussed earlier, this study also found that three statements approached a moderate level (3.4). the statements were i) i often discuss bioethical issues in class (3.478), ii) i am familiar with the term bioethics (3.522) and iii) if my family need a kidney, i will not buy one from the black market (3.567). this low level of perception may be due to curriculum weaknesses, student busyness, lack of bioethical exposure in the teaching and learning process and difficulty making decisions accurately according to the bioethical issues encountered, as previously discussed. therefore, these three statements should be given attention in improving the implementation of bioethics education among pre-service science teachers in the future. conclusions and recommendations: it can be concluded from the results that awareness of bioethical issues among preservice science teachers were very high, while their perceptions level were high. cloning showed the highest awareness level, followed by organ donation, genetic modification, stem cells, abortion, gene therapy, gene screening and euthanasia. statistically significant differences were found between religion and course of preservice teachers regarding bioethical issues. however, there were no significant differences between genders towards bioethical issues. it is hoped that this study will provide useful findings, particularly to assist the best implementation of bioethical issues in science curriculum among preservice science teachers. based on this study, some recommendations can be given as follows; first; pre-service science teachers should be given more opportunities to discuss bioethical issues. this may require a review of the curriculum related to bioethical education. this suggestion based on the bangladesh journal of bioethics 2020; 11 (3): 9-20 19 result of bioethical issues often discuss in class. second, bioethics must be a subject studied in science and science education. in addition, science curricula at all levels of education should incorporate ethical issues of science. this will make bioethics more familiar among the community or students. this suggestion based on the result of familiar with the term “bioethics”. third, it is important to prepare students with ethical knowledge, skills and values in order to respond to ethical dilemmas and be able to make ethical decision after entering the real world of work. bioethical issues should be discussed openly through seminars, conferences and workshops to encourage interaction between experts, academicians, researchers, students, policy makers etc. this suggestion based on the result of family need a kidney, without buying one from the black market. fourth, awareness of bioethical issues needs to be created at all levels so that people can train their own opinions instead of following others blindly. discussions on ethical issues in science education should also help students understand scientists as some students can become future scientists, while increasing their interest in science. however, the background profile of students should be scrutinized as their respective religions and disciplines of knowledge can influence their thinking on ethical education. this suggestion based on the findings of significant differences in average awareness and perception in bioethical issues towards the religion and course of the respondents. lastly, fifth; 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(ed.). 2018. https:// www.safeabortion womensright.org/10209-2/. [10 april 2020]. contributions: the 1st author dr zulkefli daud conceived the idea, did the literature review and wrote the manuscript. the 2nd author zainab ari guided the conception of the idea, the manuscript writing process and checked the manuscript. the 3rd author noorafizah daud checked and edited the manuscript meticulously. conflict of interests: the authors declare that there is no conflict of interest in this study 