The New Bioethics

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Beyond a Western Bioethics in Asia and Its

Implication on Autonomy

Mark Tan Kiak Min

To cite this article: Mark Tan Kiak Min (2017) Beyond a Western Bioethics in
Asia and Its Implication on Autonomy, The New Bioethics, 23:2, 154-164, DOI:
10.1080/20502877.2017.1345091

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Published online: 08 Jul 2017.

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the new bioethics, Vol. 23 No. 2, 2017, 154–164

Beyond a Western Bioethics in Asia and

Its Implication on Autonomy
Mark Tan Kiak Min
St. Mary’s University, Twickenham, United Kingdom

Despite flourishing as a multidisciplinary subject, the predominant view in

bioethics today is based on Anglo-American thought. This has serious impli-
cations for a global bioethics that needs to be contextualized to local cultures
and circumstances in order to be relevant. Being the largest continent on the
earth, Asia is home to a variety of cultures, religions and countries of different
economic statuses. While the practice of medicine in the East and West may be
similar, its ethical practices do differ. Thus, the Western understanding of
autonomy may not be wholly applicable in the Asian setting, especially in
the setting of breaking bad news, giving consent, determining best interests
and deciding on end-of-life care. This article explores these topics in depth,
attempting to find shared integrating factors, but at the same time arguing
for a modified ethical application of autonomy, based on Asian beliefs.

keywords Asian bioethics, autonomy, consent, end-of-life care, best

interests

Introduction
The American oncologist Van Potter is often credited as the first person to coin
‘bioethics’ as a new discipline in 1970 (Trosko and Pitot 2003, p. 1724). Its aim
was to identify and understand ‘all the relevant features including the particular
social context’ in order to answer a particular bioethical dilemma (Dawson 2013).
To acknowledge the universality of bioethical issues that arose, Potter introduced
a new term ‘global bioethics’ in 1988. His vision was to integrate ethics into a new
interdisciplinary endeavor to address global problems. However, his ideas failed to
gain much support until after a lecture he delivered in Italy resulted in the use of this
term as the title of a journal published by the Italian Society of Bioethics
(Ten Have 2012).
Since then, bioethics has flourished as a multidisciplinary subject involving theo-
logians, philosophers, scientists, physicians, other health care professionals and
lawyers in an ‘inclusive global discourse’ that culminated in the establishment of

© 2017 Informa UK Limited, trading as Taylor & Francis Group DOI 10.1080/20502877.2017.1345091
 BEYOND A WESTERN BIOETHICS IN ASIA AND ITS IMPLICATION ON AUTONOMY 155

the International Association of Bioethics (IAB) in 1992 (Pellegrino 1993;

Holm 2016).
Unfortunately, the predominant view in bioethics as we understand it today is
based on Anglo-American thought and has led to concerns from non-Western
bioethicists about its implication on global bioethics (Akabayashi et al. 2008),
while others have regarded it as a new form of colonization where the West attempts
to influence other cultures to learn and embrace Western bioethics (Pellegrino 2001).
As Fox and Swazey (2010, p. 279) aptly state, ‘bioethics may have become inter-
national, but it has yet to be internationalized’.
This becomes problematic as the increase in migration results in a complex mixing
of cultures and presents us with novel ethical problems (De Castro 1999). In addition,
the enlightenment of non-Western cultures and civilizations has increased the realiz-
ation that there may be a mismatch of Western and non-Western values that influence
bioethical principles and thoughts (Sakamoto 1999; Tai 2013). Consequently, it has
become increasingly accepted that bioethics needs to be contextualized to the local
culture and circumstances in order to be relevant not only in Asia, but also in
Africa, Latin America and other parts of the world (Campbell 1999).
All these factors echoed Potter’s call to move towards a more global bioethics that
is grounded on the traditional ethos of each region in order to accurately reflect the
influence of present day multi-cultural post-modernism (Campbell 1999; Sakamoto
1999). However, in order for this to happen, we need to first communicate our ideas
collaboratively, recognizing that while there will be significant regional variations of
characteristics, it will still be possible to find shared integrating features within them
(Akabayashi et al. 2008).
Tai (2013) argues that once common values can be identified, each culture can
then be left to develop their own ethical application because the universality of
global bioethics is in its foundational values and not in its derivation of applications.
He also argues that any attempt at outright adaptation of Western ideas in Asia will
inevitably result in problems and rejection because of cultural differences, but ‘if
Western principles are adopted, then they must be re-interpreted and even modified,
if necessary, in light of Asian beliefs’ (Tai and Lin 2001, p. 51). This view will also be
relevant to other non-Western cultures.
What has been described so far is the problem faced in the establishment of a
global bioethics, including the need to move beyond a Western view, and the recog-
nition that differences in values influence bioethical discourse across different cul-
tures. The focus in this article is to highlight some of the differences within
bioethics in Asia, and to examine the implications it brings to the understanding
of autonomy with reference to some clinical scenarios. Underpinning these are the
questions ‘should bioethics in Asia use the same approaches as the West’ and ‘can
a more authentic Asian approach be taken in bioethics’ (De Castro 1999).

The Asian dilemma

Unity in diversity
Asia is the largest and most populous continent on the earth and is home to a variety
of cultures and religions. Its cultural composition is complex, with variations
156 MARK TAN KIAK MIN

existing within each ethnic group and also within different geographical regions,
sometimes within a single country. Religious beliefs in Asia also tend to change
according to geography, with a predominance of Buddhism and Taoism in East
Asian countries like Japan and China; Christianity in the Philippines; Hinduism in
South Asian countries like India and Islam in Central Asia and the Middle East.
Animism also continues to be practiced by many indigenous tribes in South East
Asia, although more countries like Malaysia and Singapore are emerging as multi-
cultural and multi-religious states.
A key consideration that needs to be taken into account is that bioethical dis-
course in most parts of Asia is still in its infancy. A truly authentic and distinctly
Asian discourse in bioethics has yet to mature, leading to an apparent transplanting
of western concepts into Asia. Some Asian countries are still heavily influenced by
the culture and ideology of their colonial masters, while others are gradually
being influenced by Western lifestyles and values. This gradual enlightenment may
provide an opportunity for Asians to develop a concept of bioethics based on
their traditional cultures and to critically assess the aspects of Western bioethics
that should be embraced, revised or rejected.
While the few developed countries in Asia concentrate on ethical concomitants of
biomedical advances and on research ethics, the majority of developing nations still
face ethical issues resulting from the adverse effects of poverty, natural disasters and
social deprivation on health, the inequitable access to health care, and the conse-
quences of the emergence and re-emergence of infectious diseases (Fox and
Swazey 2010). However, while the developing world may be regarded as financially
impoverished, it is often spiritually rich (Engelhardt 2001).
The diversity detailed herein illustrates the extensive and difficult, or even see-
mingly impossible, task to find a unified Asian bioethics. This has led to some con-
tention that perhaps, ‘the comparison of Asian and Western bioethics is less helpful
than a discussion centered on the development of bioethics in Asia’ (Akabayashi
et al. 2008, p. 271). However, others have argued that a bioethics that is drawn auth-
entically from the developing world is required to help us hold firm to Asian culture
and against the dominant Western secular account of bioethics (Sakamoto 1995).
Efforts should be focused on how the Asian context can benefit the global
bioethics discourse based on three areas: adding new dimensions, raising new ques-
tions and helping to shift perspectives (Nie and Campbell 2007). Nevertheless, we
must not fall into the trap of universalizing (even among Asians) a single Asian
ethical perspective (De Castro 1999).

Shared integrating factors

Shared integrating factors are important considerations for universalism and ethno-
centrism as it attempts to focus on the core values that are seemingly universal to
Asian culture, and specifically on the role of the family and the community.
This is perhaps the most obvious contrast to the West — that the family, and not
the individual, is regarded as the basic unit of community. According to Tai and Lin
(2001), the family community has always carried a greater weight in Asian value
systems. Sakamoto (1999) affirms this by stating that a holistic harmony is said to
 BEYOND A WESTERN BIOETHICS IN ASIA AND ITS IMPLICATION ON AUTONOMY 157

be the Asian ethos, contrasting this to the modern European inclination of dualistic
individualism.
In a culture where public opinion is often influenced by religious views, this
concept is also consistent with the teachings of Confucianism (Tai 2013), Hinduism
(Gawande 2015) and Islam (Chamsi-Pasha and Albar 2013) and has long been
embedded (as we shall discover later) in the practice of various Asian cultures.
The role of the family is the underlying consideration that leads us to contrast
bioethics in Asia which is based on duties and obligations, to that of secular
western bioethics which is rights-based, with a strong emphasis on individual
rights. In order to explore its impact deeper, this article discusses some different con-
cepts of autonomy, and then explores how it impacts medical practice in terms of
breaking bad news, consenting to treatment, determining best interests and
making decisions about end-of-life care.

Bioethics in Asia and autonomy

Concepts of autonomy
Autonomy is an extremely complex and controversial concept often discussed in
bioethics. The principlist concept of respect for autonomy refers to individual auton-
omy and requires autonomous agents to have liberty (the independence from con-
trolling influences) and agency (the capacity for intentional action) (Beauchamp
and Childress 2013). It also acknowledges their rights to choose freely and accept
responsibility based on their values and beliefs (O’Neill 2002).
The prominence of individual autonomy in the West can be traced to the influence of
the Civil Rights Movement in America in the 1970s and has played a significant role in
the evolution of medical practice from paternalism to what we have today — a modern
medical practice that recognizes the patient’s right to be in control of his own body, and
to choose whether to accept or decline any proposed treatment, even if it is considered a
bad choice by the medical profession (Kukla 2014). Admittedly, there have been cri-
tiques of this view of autonomy and suggestions of alternative perceptions of under-
standing autonomy such as ‘principled autonomy’ and ‘relational autonomy’
(Greaney et al. 2012). However, the individualistic view of autonomy that is described
here remains the dominant view and will be considered the de facto standard for pur-
poses of our discussion and has often been linked to the European Convention for
Human Rights and the United States Constitution (Herring 2014).
In Asian culture however, autonomy does not necessarily belong solely to the indi-
vidual. As discussed earlier, Asians recognize the influence of the family and commu-
nity on their decisions, especially in life and death situations. This can be seen clearly
in the medical setting whereby family members typically accompany the patient for a
consultation, and stay with them throughout their hospitalization. A family member
frequently also acts as an aide, interpreter and advisor, helping to move the patient
around, providing the patient’s medical history and even participating in the
decision-making process (Alora and Lumitao 2001).
While being an independent member of the family, these patients also realize their
interdependence on the family. Within a concept quite alien to the West, the individ-
ual is regarded as a smaller self within a larger self, where the well-being of the whole
158 MARK TAN KIAK MIN

family is considered when making a decision and where familial autonomy becomes
more important than individual autonomy (Tai 2013). In other words, for most
Asians, family-sovereignty is placed before self-sovereignty and autonomy
becomes collective rather than individualistic (Tai and Lin 2001). This view will
be referred to as the Asian standard in our subsequent discussion.
Further evidence to substantiate the Asian standard can be found in Alora and
Lumitao’s (2001) account of how Filipinos consider the West as having lost impor-
tant moral and social structures, especially those associated with an extended family,
and how the use of pagmamalasakit (a term used to describe the deep concern one
has for the welfare of the other) and pakikisama (the seeking of harmony with others
that can be seen when individuals agree to act in ways they would otherwise not
choose in order to please the group) help Filipinos to understand autonomy. Aka-
bayashi and Hayashi (2014) and Lee (2014) also describe similar views by Japanese
and Korean societies respectively, while Tai (2013) details how Confucian thoughts
have influenced the Chinese with xiao (filial piety). Likewise, Gawande (2015)
also tells how families in India subscribe to similar thoughts, and Chamsi-Pasha
and Albar (2013) describe the influence of Islam in considerations of the family
and autonomy.
Other forms of autonomy such as moral autonomy and cultural autonomy exist
(Fan 2014), but our subsequent deliberations will be focused on the argument
that while Western respect for individual autonomy can be an example of good
bioethics, similar recognition can and should be accorded to the Asian standard
of collective decision-making (Tai 2013).

Autonomy and breaking bad news

Breaking bad news is one of the hardest tasks for physicians, but receiving bad news
is often harder for the recipient patient. A good physician therefore requires good
communication skills and prudence to judge how much to disclose to the patient
and when to stop.
The de facto standard dictates that competent patients are autonomous over their
own bodies, and therefore have the right to be informed of the bad news first, and
then decide who to share it with or whether to share it with anyone at all. On the
other hand, based on the Asian standard, it is not uncommon for physicians to
discuss patients’ diagnosis with their family members or next-of-kin first, especially
if they are elderly. This may result in patients being sometimes excluded from
making decisions on their own treatment, as the head of the family is charged
with the final say (Lee 2014).
The above practice may seem unacceptable in the Western context, but interest-
ingly patients in the Asian context generally appear happy with this arrangement.
Once again, arguments for this practice often cite the preference of familial auton-
omy instead of individual autonomy (Akabayashi and Hayashi 2014). Other argu-
ments commonly proposed include the beneficent intentions of the physician to
spare the patient the anguish of receiving news that he may not be able to accept,
and that the patient may accept bad news better if it is conveyed by a family
member (Tai 2013; Lee 2014). Kuan and Lumitao (2001) argue that in the Philip-
pines, family members see it as their responsibility to take care of the sick patient
 BEYOND A WESTERN BIOETHICS IN ASIA AND ITS IMPLICATION ON AUTONOMY 159

and this includes protecting the patient from stressful information and difficult
choices.
There may also be times when families decide that withholding a diagnosis or
information about a treatment may be in the best interest of the patient, and the
doctor may duly oblige this request (Lee 2014). A recent radio show titled In
Defense of Ignorance described a Chinese family’s elaborate attempt to keep their
matriarch ignorant of her diagnosis of lung cancer and staged a wedding reception
as an excuse for all her family members to be gathered with her for one last time and
pay tribute to her role in the family (Glass 2016).

Autonomy and consent

In the de facto standard, consent is considered to be valid if a patient who is compe-
tent, informed and free from any coercion indicates his agreement, and these criteria
are recognized in Western legislations (Kukla 2014). They also place a duty on the
doctor to disclose information to the patient in order for an informed consent to take
place. In the United Kingdom (UK), the decision of Montgomery v Lanarkshire
Health Board (2015), influenced by the General Medical Council guidance titled
‘Consent: patients and doctors making decisions together’ (2008), recently set a
new precedent case law for the standard of information disclosure.
Becker (2014) uses the argument of increased legal and ethical liability in the West
to justify the importance of informed consent. He claims that the prominence of
informed consent is not based solely because on the notion of individual autonomy,
but also because the ‘mushrooming range of medical decisions leaves doctors legally
and ethically liable to justify their choices’ (Becker 2014, p. 751). Furthermore,
Becker argues that informed consent is also important as it fulfills the patient’s
need to feel respected and cared for. According to him, this is because very few
patients truly understand the consent forms and patients tend to follow their
doctor’s recommendations in any case. Therefore, he reasons that the real reason
why Western bioethics has adopted informed consent is not because patients
make more autonomous or intelligent choices, but because they feel more respected
than if it did not exist.
Asian standards however may not consider consent to be informed until the
patient has informed the family and a decision has been agreed on. In Malaysia,
recent court rulings appear to hold that spousal consent is required if
the female patient is dependent on her husband or if patients undergo gynaecological
procedures.
In Gurmit Kaur Jaswant Singh v Tung Shin Hospital & Anor (2013), the Malay-
sian High Court held that a husband’s consent is required if the patient undergoes a
hysterectomy. The same court in the case of Abdul Razak Datuk Abu Samah v Raja
Badrul Hisham Raja Zezeman Shah & Ors (2013) also ruled that a husband’s
consent is necessary where the patient is dependent on him.
This highlights the dissenting opinion of the local esteemed judge, even though
precedence may have been established in other Common Law jurisdictions. While
it results in judgments that take into account the local culture and situation, their
applicability is limited by the boundaries of legal jurisdiction.
160 MARK TAN KIAK MIN

In addition, doctors are still regarded as respected members of society, and law-
suits are far less common in Asian societies because of trust. This same trust is the
basis for Akabayashi and Hayashi’s (2014) proposal for an alternative family facili-
tated approach to informed consent. In this approach, they propose that the patient
is only required to give tacit consent to a decision made by family members and
argue that such a method of consenting would not be inconsistent with patient
autonomy, at least not in Japanese culture.

Autonomy and best interests

Despite what has been described so far in relation to breaking bad news and giving
consent, the concept of ‘best interests’ appears to be common among both Western
and Asian cultures. In F v West Berkshire HA (1989), the UK courts used a necessity
test based on the patient’s best interests to legitimize treatment for incompetent
adults and Section 4 of the Mental Capacity Act (2005) demands that a person’s
potential capacity, current views and past views should be considered in determining
best interests. The Mental Capacity Act 2005 Code of Practice also states that all rel-
evant factors and not just those that decision-makers deem to be important need to
be considered in deriving the best interests of a person who lacks capacity (Depart-
ment of Constitutional Affairs 2007). Additionally, decision-makers must not act or
make a decision based on what they would want to do if they were that particular
person (ibid.).
The de facto standard then, refers to the best interests of the patient, as determined
by the patient himself if he has the capacity. For patients lacking capacity, medical
professionals and ultimately the court should decide what is in the patient’s best
interests (Herring 2014).
The Asian standard on the other hand, appears to offer an alternative view that
again considers the role of the family. This difference is evident when we consider
the question of whose best interests take precedence, and who determines this.
Can the best interests of the family or the community sometimes be more important
and can these be determined by someone other than the patient?
The role of the family in medical decision-making has already been acknowledged
in this article. In the Philippines, the role of decision-making is taken over by the
family and the patient has no choice but to listen to the opinion of his close
family members about the treatment he should accept (Kuan and Lumitao 2001).
For Lee (2014) however, the way autonomy and best interests interact in medical
decision-making in Korea can sometimes be problematic. On one hand, the elderly
patient does not want to be a burden to the family; but on the other hand, caring for
parents is considered a fundamental duty of a human being. The result of this in
practice is that families who have the patient’s best interest in mind may want the
patient to remain in hospital in order to receive the best (albeit more expensive)
care, while the patient who has the family’s best interest in mind may want to
return home in order to avoid excessive expenditure on healthcare services.
This scenario is frequently encountered when faced with a ‘quantity vs.
quality-of-life’ situation where one is faced with a choice of whether or not to pay
for expensive and modern medicine in the form of chemotherapy for an advanced
 BEYOND A WESTERN BIOETHICS IN ASIA AND ITS IMPLICATION ON AUTONOMY 161

cancer. It is not uncommon for some patients to decide to forego this treatment
because they do not want to become a financial burden to the family, or because
the same money can be used for the education of their children, for example.
Similarly, in many other Asian countries, children often feel duty-bound to keep
their parents alive and provide them with the best possible care available, regardless
of the chances of survival or the immense cost that will be incurred. This potentially
creates a problem whereby the ‘sacrifices’ of the family in the best interests of the
patient may result in more patients spending their last days in an ICU attached to
ventilators, instead of remaining at home surrounded by their loved ones.

Autonomy and end-of-life care

The issues highlighted in the previous scenario fit well into the consideration of
autonomy and end-of-life care. This article has already established the importance
of the family in providing care for their sick loved ones in the Asian standard. It
has also highlighted the interplay of independence and interdependence of the
patient with his family, and how trust is an essential element in a family facilitated
approach to decision-making (where the existence of a patient–family fiduciary
relationship and a patient–family interdependent identity are essential elements
required for this approach to work).
The loss of autonomy and independence at the end-of-life are the main reasons for
patients to choose to undergo physician-assisted suicide (PAS) or euthanasia (Hiscox
2007). In an individualistic society where the duty of care of the elderly is delegated to
the government, physically dependent people often do not have adequate support and
resources and end up with very little by way of self-determination. The resultant per-
ception of loss of independence because of the loss of self-determination is a culturally
situated reality, and the fear of dependence on others is not due to dependence being
inherently wrong, but because of the cultural context and stigmatization associated
with it (Kukla 2014). This fear is what leads patients to demand for rights to deter-
mine when and how they should die while they are still competent.
Admittedly, there have been instances where people have sought to end their life,
sometimes with the help of others, such as those in the context of social protest in
Buddhism or dishonor in defeat in Japan. However in the context of end-of-life
care, the concepts of PAS and euthanasia in an Asian society where strong family
and community support is evident remain alien. It appears incomprehensible that
a discussion on a planned death will be able to take place in Asian culture where
the mere discussion surrounding a natural death is already considered taboo in
the first place. In addition, end-of-life decisions in the religion-centred Asian
culture may be guided more by the ethics derived from religious principles and
laws that prohibit euthanasia than by purely medical considerations (Chamsi-Pasha
and Albar 2013).

Conclusion
In summary, this article has explored the difficulties of establishing a universally
binding bioethics due to variations in cultures and value. It has described how the
162 MARK TAN KIAK MIN

de facto standard of bioethics and the Asian standard of bioethics influence the
concept of autonomy and the implications it brings to everyday medical practice.
It has also illustrated the need to respect human cultures in order for bioethics to
fulfill its fundamental role in determining ethical principles or values that all
members of society are answerable to (Ho and Lim 2010).
While the medicine practiced in the East and West may be similar, its ethical prac-
tices do differ. Many Asian societies, especially the developing nations, are more con-
cerned with issues of overcoming starvation and poverty rather than the promotion
of human rights. For them, priority remains over who gets access to modern medi-
cine and how society can fairly deliver health care to all its citizens rather than over
how one uses medical technology humanely (De Castro 1999). Despite this, Asians
continue to pursue a holistic happiness involving the welfare of the family and
community — a stark contrast to the Western concept of individualistic happiness
(Sakamoto 1999).
While a meaningful bioethics must contain philosophical and analytical rigor, we
should accept that there can be different sets of principles and rules for different
peoples in different cultural settings (Ho and Lim 2010; Robertson 2005). Asians
and other non-Western societies must first attempt to discover the traditional
values of their own bioethical teachings in order to develop a bioethics culturally rel-
evant to them (Tai and Lin 2001).
Shared integrating factors are important, and it is through exploring these factors
that the realization of a single bioethics, differing only by way of its application can
be achieved. In a time when morality is threatened by an individualistic,
rights-seeking Western culture, some of these non-Western values may eventually
influence the West, leading to a global bioethics. It is an opportune time for non-
Western civilizations, especially those in Asia, to return some of their values to the
West for the enlightenment of their former colonial masters and to address the
basic problems of human flourishing.

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Notes on contributor
Mark Tan Kiak Min is currently Principal Assistant Director at the Medical Legis-
lation and Globalization branch of the Ministry of Health Malaysia. He completed
his undergraduate training in medicine in 2011 and was awarded both an
MBBChBAO degree and also a BMedSc (Hons) for research in Medical Education
by the National University of Ireland. He subsequently completed his internship at
the Penang General Hospital before being fully registered with the Malaysian
Medical Council. He then continued his medical practice at the Sabak Bernam Dis-
trict Hospital before pursuing an MA in Bioethics and Medical Law at St. Mary’s
University Twickenham in 2015. He has since rejoined the Ministry of Health
Malaysia after completing the MA with a Distinction Grade.
Correspondence to: Mark Tan Kiak Min, Medical Practice Division, Ministry of
Health Malaysia, Malaysia. Email: markwilliamtan@gmail.com.