Bioethics in the Philippines Retrospective

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Bioethics in the Philippines: a Retrospective
Article in Asian Bioethics Review · January 2009

DOI: 10.1353/asb.2009.0008
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A s i a n B i o e t h i c s R e v i e w D e c e m b e r 2 0 0 9 Vo l u m e 1 , I s s u e 4
RETROSPECTIVE
Bioethics in the Philippines: a Retrospective
LEONARDO DE CASTRO AND

SARAH JANE TOLEDANO
It has been almost 20 years since the Hastings Center Report published an
article on bioethics in the Philippines that referred to the emergence of a public
awakening. That awakening has led to widespread awareness and public debate,
though one cannot fully be confident that bioethics thinking and reasoning
have truly matured. In this paper, we review developments in the period since
the publication of that article. The presentation covers policies and mecha-
nisms for bioethics review and decision-making. It also refers to issues and
controversies that have come to public attention through various mass media.
Additionally, it attempts an analysis of some issues in relation to tension points
and concepts that have provided a framework for debate and disagreement
among various sectors.
Influence of Catholicism and Christianity

Many aspects of Filipino culture are heavily influenced by Catholicism and
Christianity. Any effort to understand developments in bioethics in the context
of the Philippines has to take this point into account. 83 per cent of Filipinos
declare affiliation with the Catholic Church and the Christian majority makes
up about 90 per cent of the total population. Muslims or other religious groups
make up the remaining ten per cent.
The influence of the Catholic Church has been widely felt in matters of
healthcare policy, especially those that have to do with abortion, the promotion
of contraceptive use, family planning, and other reproductive health issues.
Thus, public debate often takes a form that is at least partly defined by religious
orientation. This characterisation was already apparent when a Constitutional
Commission was formed in 1986 to rewrite the Philippines’ basic law as various
4 26–444
426 A s i a n B i o e t h i c s R e v i e w D e c e m b e r 2 0 0 9 Vo l u m e 1 , I s s u e 4
B i o e t h i c s i n t h e P h i l i p p i n e s : A R e t r o s p e c t i v e L e o n a r d o d e C a s t r o a n d S a r a h J a n e To l e d a n o
lobby groups sought to have nominees with their preferred religious leaning
appointed to that body. Indeed, one side was perceived to have taken the upper
hand as the 1987 Constitution emerged with a provision to protect “the life
of the unborn from the moment of conception” (Article II, Section 12). This
provision reflects a position that has repeatedly been affirmed by the Catholic
hierarchy. However, actual compliance by ordinary Catholics has been less than
enthusiastic.
A report prepared for the Guttmacher Institute1 confirms an increasing
number of induced abortions in the country, a situation that the Catholic
leadership has obviously found worrying. The authors estimate the number of
induced abortions in 2000 at 473,000 out of 3.1 million pregnancies. They fur-
ther estimate that in the same year, 27 out of every 1,000 pregnancies occurring
in the country ended up in clandestine and unsafe abortions.2 About 800 women
die annually from these unsafe abortions. In addition, the study shows that:
■ One-third of women who experience an unintended pregnancy end it in an

abortion.
■ Women who experience abortion come from all segments of society. They
resemble average Filipino women in that the majority are married, Catholic
and poor.
■ As reason for seeking an abortion, 72% of women cite the economic cost of
raising a child; 54% say they have enough children already; and 57% report
that the pregnancy occurred too soon after their last one.
■ 33% of women who eventually complete an abortion rely on a husband,
partner, relative, friend or neighbour, or take steps to end the pregnancy
themselves; 15% consult a pharmacist; and 15% consult either a traditional
healer or a street vendor. Only 29% of women obtain an abortion from a
doctor.
The findings tell us that even if the Philippines is a predominantly Christian

country with severe anti-abortion laws, the concerns of women about their
reproductive health do not lean heavily on religious considerations. Instead,
socioeconomic factors play the key role in the decision to abort. Perhaps because
the law sets heavy penalties not only for the doctors or other healthcare staff
who perform an abortion or assist in the procedure, but for the women who
feel compelled to stop their pregnancies — even if they could be the victims
of rape or highly irresponsible partners — rational bioethical deliberation is
suppressed and prevented from maturing.
The experience regarding abortion and unintended pregnancies has been
attributed to a failure to legislate a good reproductive health programme that
427
supports access to contraceptives, develops awareness of diverse family planning

methods and puts a high value on the quality of life. The Philippines already has
a long history of reproductive health bills filed in Congress. The latest, called
The Reproductive Health and Population Development Act of 2008 (RH Bill),
has generated a lot of heated debate with protagonists divided along religious
lines as mentioned above. Among other things, the bill has claimed to promote
the following: information and access to natural and modern family planning
methods; maternal, infant and child health and nutrition; breastfeeding of
infants; prevention of abortion and management of post-abortion complications;
adolescent and youth health; prevention and management of reproductive tract
infections, HIV/AIDS and STDs; elimination of violence against women; coun-
selling on sexuality and sexual and reproductive health; treatment of breast and
reproductive tract cancers; male involvement and participation in RH; preven-
tion and treatment of infertility; and reproductive health education for the
youth. There are obviously important objectives of the bill that almost every-
one will agree with. However, some of the proposed provisions have sparked
impassioned debate involving healthcare professionals, women’s groups, religious
sectors, officials at different levels of governance, and ordinary people. An end
seems to be nowhere in sight and it is likely that issues will remain unresolved,
leaving vulnerable women unprotected as they seek solutions to their reproduc-
tive health problems.
The Catholic Church has adamantly opposed passage of the RH Bill. A
Pastoral Statement issued by the Catholic Bishops Conference of the Philippines
(CBCP) claims that while the Bill has good goals relating to reproductive health
and population development, the means that it employs to attain those goals
poses a serious threat to the life of infants in the womb. The CBCP has also
been concerned about the effects on the stability of the family and the risk to
the dignity of womanhood while reiterating that “contraception is intrinsically
evil” and that only “natural” family planning methods and abstinence are
acceptable and permissible means of avoiding conception.
Opposition to the position of the Catholic Church comes from health-related
non-governmental organisations (NGOs) and feminist movements that see the
RH Bill as an important measure to curb maternal deaths and promote women’s
reproductive health. On the other hand, advocates of the Bill emphasise that
rigid adherence to the Catholic position has been a significant contributory
factor for the high incidence of maternal deaths, unintended pregnancies and
unsafe abortions. They also support the RH Bill’s role in family planning as a
national mandated priority health programme.
NGOs have thus emerged as another notable locus of power in relation to
developments giving rise to bioethics issues. Many NGOs have carried their
428
advocacies very forcefully. Those that see themselves as protectors of women’s

rights have battled with the Catholic Church and its allies in matters pertaining
to reproductive health.
Other NGOs have also been visible on the bioethics landscape in connection
with their own advocacies. For instance, there are NGOs that have focused
their energy in a campaign against the use of genetically modified organisms
in agriculture and food development. There are others that have battled to
keep pesticides out of farms. And there are those that have fought very hard
for the enactment of laws and implementation of policies that are meant to
provide broader access to effective healthcare and inexpensive medicines and
treatment.
Bioethical Activism
One offshoot of having such an alignment of players in public debate is that
government decisions often are made in response to powerful lobbying rather than
on the basis of rational arguments rooted in accepted values and principles. The
practice could be very healthy for a democracy although it does not necessarily
help to cultivate an ideal context for bioethical maturation and advancement.
Thus, one can speak of a phenomenon that may be labelled as bioethical
activism. Through bioethical activism, individuals or groups try very hard to
improve the situation and make things happen in accordance with their sense of
what is right. This is potentially a very powerful tool for political involvement
within a democratic society. However, society also has to ensure that activism
takes place within a framework of objective, enlightened and free deliberation
and debate.
It may be regarded as an outcome of such activism that even local govern-
ment officials have actively pursued an agenda that is not usually expected of
them in the normal execution of their official functions. When he was still
Mayor of the City of Manila, Lito Atienza threatened to arrest government
officials who were responsible for bringing in RU-486 (Mifepristoone) to the
city.3 He claimed to have a duty to enforce the provision of the constitution
for the protection of the unborn from the moment of conception. The Mayor
had also issued an Executive Order entitled “Declaring Total Commitment and
Support to the Responsible Parenthood Movement in the City of Manila and
Enunciating Policy Declarations in Pursuit Thereof ” on 29 February 2000, which
City Health Department officials have cited in their effort to uphold natural
family planning methods and discourage the use of methods of contraception
like condoms, pills, intrauterine devices, surgical sterilisation, and others.
429
The official stance survived a change of administration and some residents

decided to sue the city because of the practical impact of the policy. Among
other things, residents claimed that the Manila Health Center no longer made
birth control pills available at health centres after the mayor signed the order.
As a result, according to one complainant, she gave birth to six children over
the years because she could not afford to buy the pills on her own.4 The
complainants also claimed that the policy prejudiced their right to health and
well-being and resulted in the deterioration of their reproductive health because
it deprived them of access to healthcare and health development, and resulted
in numerous pregnancies.
In other jurisdictions (and at about the same time that Mayor Atienza was
in power), the Governor of the province of Laguna and the Mayor of the City
of Puerto Princesa also initiated similar policies limiting support for family
planning (FP) clinics providing only “natural” FP methods to their clients.5 Thus,
some local government officials have engaged in their own brand of political
activism. This kind of establishment-based activism should not be looked at in
the same vein as activism on the part of non-governmental organisations that
are expected to support their advocacies in a way that does not depend on the
use of government resources. When officials who have government resources at
their command use those resources in a way that promotes advocacies based on
their religious or ideological leanings, they betray the trust of the electorate by
imposing, rather than democratically espousing ideological perspectives. Thereby,
they bring a disservice to the cause of democracy and fail to advance free and
enlightened bioethics.
Assisted Human Reproduction

The first child conceived in the Philippines through the use of either assisted
insemination or in vitro fertilization6 (IVF) was delivered in 1996. Considering
the prominence of Catholic views about matters of reproduction, it is surprising
that there has been very little public ventilation of ethical issues pertaining to
assisted reproduction in the country. Interestingly, the 1995 edition of the National
Guidelines for Biomedical/Behavioral Research issued by the National Ethics
Committee anticipated the developments by containing these provisions:
(1) Prohibiting the intentional creation of human zygotes, embryos or foetuses

for study, research and experimentation, or for commercial and industrial
purposes;
(2) Limiting research on an embryo to procedures intended to improve its life
and health;
430
(3) Prohibiting the sale of human gametes or zygotes;

(4) Limiting the application of the procedures to married couples;
(5) Ensuring the emotional stability and maturity of beneficiary couples;
(6) Upholding the dignity and anonymity of the couples involved; and
(7) Prohibiting the selective reduction of embryos.
In 2006, the Philippine Society of Reproductive Endocrinology and Infertility

(PSREI) issued its guidelines pertinent to the practice of IVF.7 Notable among
the provisions are those that cover gender selection. Although the document
permits the use of techniques that utilise pre-conception sex pre-selection such
as the Shettles method and sperm sorting techniques, it states that “embryonic
gender identification for social reasons alone is not allowable” (Secs. 6, 25).
Hence, pre-implantation genetic diagnosis may be used for embryonic gender
identification only if there is a strong family history of sex-linked genetically
transmissible disease (haemophilia, muscular dystrophy, etc.).
The Guidelines also reflect the Catholic position that “the zygote, pre-
embryo, or embryo, are already considered unique human beings and are there-
fore entitled to full moral support as that of an adult” (Sec. 14). Thus, couples
undergoing the procedure must have prior agreement to cryopreservation of
excess embryos (Sec. 16). The alternative is for minimal stimulation of ovarian
follicles so that all embryos formed are transferred during the fresh cycle since
foetal reduction is not permissible (Sec. 22).
Notwithstanding the recognition that the zygote, pre-embryo, or embryo is
a unique human being entitled to full moral support, the Guidelines appear
to leave room for some exceptions through the provision in Sec. 24 that “pre-
implantation Genetic Diagnosis, whether carried out on gametes or embryos, is
an acceptable procedure when carried out to identify specific genetically trans-
missible abnormalities to help couples avoid the possibility of having abnormal
children”. Sec. 24 also gives partners significant leeway by saying that “the
disposition of the genetically abnormal embryos shall be the responsibility of
the couple and shall be ascertained before the evaluation is done”.
Access to Cheaper Medicines

In the last 20 years, major initiatives on the part of government to make af-
fordable medicines accessible to the poor have consisted of the passage of the
Generic Drugs Law and the implementation of parallel drug importation. The
Generics Act (Republic Act No. 6675) was passed in 1988 to require the use of
generic terminology in the importation, manufacture, distribution, marketing,
advertising and promotion, prescription and dispensing of drugs; and thereby to
431
ensure the adequate supply of drugs with generic names at the lowest possible
cost. It was hoped that by taking the legislative step, the government would have
achieved a measure of social justice by making essential generic drugs available
to indigent patients by setting aside some of the rights of pharmaceutical com-
panies to their intellectual property. The law mandated all drug manufacturing
companies operating in the Philippines to produce, distribute, and make avail-
able to the public the medicines they produced in the form of generic drugs. It
also required all medical, dental, and veterinary practitioners to write prescrip-
tions using the drugs’ generic names and ordered pharmaceutical companies to
indicate these names prominently in their products.
Subsequently, and also over the objections of pharmaceutical companies, the
government engaged in the importation of selected drugs that were already being
manufactured and sold by multinational drug companies in the Philippines.
The decision was triggered by the observation that many essential drugs were
being sold in the Philippines at higher prices than in a number of other
countries. The two initiatives brought some gains but many essential drugs
remained inaccessible to many needy patients. On one account, 70 per cent of
the 85 million Filipinos have no regular access to lifesaving drugs.8 According
to the same source, the country is second only to affluent Japan in the cost of
medicines, and some drugs are priced five to 45 times higher than the same ones
sold in economically comparable countries such as India and Pakistan. A fresh
effort to enable access to cheaper medicines culminated recently in the passage
of Republic Act 9052, also known as the Universally Accessible, Cheaper and
Quality Medicines Act of 2008. RA 9052 seeks to lower the cost of medicines
by strengthening competition among pharmaceutical companies by: (a) allowing
the parallel importation of patented medicines from other countries where these
are more affordable; (b) prohibiting the grant of new patents based only on
newly discovered uses of a known drug substance; (c) allowing local generics
firms to test, produce and register their generic versions of patented drugs; and
(d) allowing the government use of patented drugs when the public interest is
at stake.
The Republic Act also gives the President the power to set price ceilings on
essential drugs, upon the recommendation of the Secretary of Health. In order
to ensure the availability of affordable medicines, the new Law requires drug
outlets to carry a variety of brands for each drug including those sourced from
parallel importation, to give consumers more choices.
The provisions of the law created a stir among multinational pharmaceutical
companies and patent holders. Multinational pharmaceutical companies domi-
nate 60% of the Philippine drug market. Understandably, they opposed the
passage of the Bill very strongly as it went through the legislative mill. They
432
lobbied with lawmakers very aggressively during the period leading to voting on
the Bill in both the Upper House and the Lower House of Congress.
In an effort to ensure that the poorer segments of the population gained
access to essential drugs, the legislature has signalled a willingness to compro-
mise certain rights to intellectual property that have been regarded almost as
sacrosanct within a free market economy. After the passage of the Bill, the
government gave pharmaceutical companies an opportunity to “voluntarily
comply” with the provisions of the law by providing their respective lists of
“essential” drugs that they manufactured and the prices that they were willing
to set for each item. As the collective proposals of the pharmaceutical compa-
nies were not found acceptable, the President chose to use the authority given
her by the new law to stipulate price ceilings. After showing extraordinary
reluctance to do so on the grounds that such an action could be perceived as an
unfriendly signal by foreign investors (on whom the Philippine economy is very
highly dependent), the President issued the much awaited order.9 The executive
order that took effect on 15 August 2009 sets a price ceiling on six essential
drugs that manufacturers refused to sell at half their current prices. The drugs
for which price ceilings have been set were selected on the basis of their public
health importance in the country, their high price differentials compared to
drug prices internationally, the lack of market access particularly for the poor,
and the limited competition with their generic counterparts. Having previously
said that the proposed cuts are going to eat substantially into their profits, the
pharmaceutical companies involved are not likely to meekly submit to the terms
of the Executive Order. Hence, it remains to be seen how this long saga will
play out but it will surely serve as a test of the government’s determination
to make affordable medicines more accessible. And even if it does succeed
in reducing the prices of essential medicines substantially, it will additionally
have to ensure that those who live below the poverty line, who constitute a
big chunk of the population, are not left out of the benefits — a 50 per cent
reduction in the price of drugs may be significant enough for those who can
already afford to buy them but is definitely useless for those who are so mired
in poverty that any money earned has to go to essential food and nothing more.
Newborn Screening
Newborn screening started in the Philippines in 1996 in 24 Metro Manila hos-
pitals. However, it was only on 28 July 2003 that Republic Act 9288, known
as the “Newborn Screening Act of 2004” was enacted by the Twelfth Congress
to give rise to the opportunity to screen newborns for congenital metabolic dis-
orders. Republic Act 9288 mandated the National Institutes of Health to create
433
the Newborn Screening Reference Center (NSRC). The NSRC has the responsi-
bility to be the repository of technical information relating to newborn screening.
It houses the national testing database and case registries, and is responsible for
training, technical assistance and continuing education for laboratory staff in all
Newborn Screening Centers. The NSRC also assists the Department of Health
in establishing Newborn Screening Centers in various areas.
Article 3, Section 5 of RA 9288 holds that healthcare practitioners have an
obligation to inform new parents: “Any health practitioner who delivers, or
assists in the delivery, of a newborn in the Philippines shall, prior to delivery,
inform the parents or legal guardian of the newborn of the availability, nature
and benefits of newborn screening ….” Under the system, medical assistance
has to be given to newborns detected with life-threatening congenital metabolic
disorders before the onset of the clinical symptoms.
RA 9288 was conceived as a comprehensive programme that would promote
responsible parenthood and a good quality of life for children. It is not absolutely
mandatory and it claims to respect the decision of Filipino parents to refuse
newborn screening. However, Article 3, Section 5 limits this option of refusal
to those cases where it is made on the grounds of religious beliefs. Moreover,
this section is obviously coercive in that those who refuse screening “shall
acknowledge in writing their understanding that refusal for testing places their
newborn at risk for undiagnosed heritable conditions ….” It is not abundantly
clear that this coerciveness is warranted in light of the number of families
that could not afford the cost of screening, the lack of diligence in providing
clear and adequate information appropriate for all parents’ level of education,
the insufficient number of qualified counsellors, and the difficulty in meeting
the cost of the required remedies in the event of positive findings. By putting
the onus of responsibility on parents for “undiagnosed heritable conditions” of
their children, the law imposes a level of coercion that does not take fully into
account the inadequacy of necessary resources that are available to poor parents.
It is not surprising then that in 2007, only 17% of the 1.5 million infants
delivered were screened.
Another ethical challenge related to the screening of newborns arises from the
possible use of genetic samples collected under the programme. The Newborn
Screening Reference Center, as the responsible institution for the screening
programme, has not made clear its policies for the use of the samples collected
in biomedical research. It has not published the pertinent ethical guidelines for
the storage and management of the genetic samples that have been collected. The
sheer volume of the samples makes the collection a vast resource for research
that, however, requires sensitive handling if the privacy of subjects and the
confidentiality of information are to be safeguarded.
434
HIV/AIDS
The Philippines showed its readiness to give a high priority to ethical concerns
in dealing with the HIV/AIDS phenomenon by passing the “Philippine AIDS
Prevention and Control Act of 1998”. The Philippine legislature endeavoured
to protect infected individuals from discrimination and injustice through the
provisions of Section 16 of the Act, which specifically prohibits compulsory
HIV testing as a precondition to a broad range of rights and services including
employment, admission to educational institutions, exercise of the freedom of
abode, entry to or continued stay in the country, travel, the provision of medical
or any other kind of service, or the continued enjoyment of these undertakings.
There are also specific measures to prevent injustices in provisions that:
(1) Prohibit discrimination in matters of hiring, promotion or assignment of

employees (Section 34);
(2) Consider termination from work on the sole basis of actual, perceived or
suspected HIV status as unlawful (Section 35);
(3) Bars educational institutions from expelling, disciplining, segregating, or
denying participation benefits or services to a student or prospective student
on the basis of his/her actual perceived or suspected HIV status (Section
36);
(4) Prevents quarantine, isolation, refusal of entry or deportation from Philip-
pine territory on account of perceived or suspected HIV status (Section
37);
(5) Protects the right to seek an elective or appointive public office (Section
38);
(6) Preserves the eligibility of HIV/AIDS patients for credit and insurance
(Section 39);
(7) Preserves the right to receive healthcare services without additional cost
(Section 40); and
(8) Entitles deceased patients to decent burial services (Section 41).
The Act also promotes access to insurance by recognising that it is part of an

individual’s right to health. Section 26 directs the Secretary of Health and the
Insurance Commission to implement a viable insurance coverage programme
for persons with HIV. There is also a directive in Section 20 to all testing
centres, clinics, or laboratories to provide and conduct free pre-test and post-test
counselling for all individuals who utilise their HIV/AIDS testing services.
To uphold privacy and confidentiality, Section 15 of the AIDS law requires an
option for anonymous HIV testing. The provision for the mandatory reporting
435
of HIV/AIDS cases to authorities simultaneously directs all hospitals, clinics,

laboratories, and testing centres to ensure the “confidentiality of any medical
record, personal data, file, including all data which may be accessed from
various data banks or information systems” (Section 28). All involved offices are
mandated to protect client anonymity and to regard any information gathered
in the process of contact tracing as confidential and classified. The use of such
information is limited to statistical and monitoring purposes. Thus, it cannot be
used as basis or qualification for any employment, school attendance, freedom
of abode, or travel. One may also find detailed provisions on the handling of
all medical information pertaining to the identity and status of persons with
HIV, the limited exceptions to the mandate of confidentiality, the acquisition
of information by health workers directly involved in the care of persons with
HIV/AIDS, the conduct of judicial proceedings involving patients, and the
release of HIV/AIDS test results.
In light of these positive provisions of the HIV/AIDS Act, it is quite
paradoxical that most overseas Filipino workers are required to undergo tests
for HIV/AIDS before they could be allowed to assume employment abroad.
The Philippine government has not been able to negotiate exemptions from
these tests. And it has been an additional source of disappointment that many
reported HIV infections in the country have been imported from overseas by
Filipino migrant workers. Thus, the country has been as compliant with bioethics
standards pertaining to HIV/AIDS as possible but it has found itself unable to
encourage countries exploiting its services sector to uphold the same standards
with respect to Filipinos working abroad.
Migration of Human Resources for Health

The massive migration of human resources for health is one of the unsavoury
outcomes of globalisation. Rich countries are trying to recruit human resources
wherever these can be found, and that is usually in the developing countries.
Understandably, the best healthcare providers are trying to find employment
in places where they can get the best remunerations and that is usually in the
developed countries. This interface of supply and demand has resulted in the
heavy traffic of health manpower from developing to developed countries. It has
also created a widening imbalance as we compare the health manpower resources
in the countries of origin with the destination countries. It poses many ethical
issues that have to be dealt with on a global scale.
The global health manpower situation is being brought about by a number
of push and pull factors:
436
Push Factors
Economic: low salary at home, no overtime or hazard pay, poor health insurance
coverage.
Job related: work overload or stressful working environment, slow promotion.
Socio-political and economic environment: limited opportunities for employ-
ment, decreased health budget, socio-political and economic instability in the
Philippines.
Pull Factors
Economic: higher income, better benefits, and compensation package.
Job related: lower nurse to patient ratio, more options in working hours, chance
to upgrade nursing skills.
Personal/family related: opportunity for family to migrate, opportunity to travel
and learn other cultures, influence from peers and relatives.
Socio-political and economic environment: advanced technology, better socio-
political and economic stability.10
The Philippines happens to be the largest exporter of nurses worldwide,

having supplied nurses to countries such as the United States, United Kingdom,
Saudi Arabia, Libya, United Arab Emirates, Ireland, Singapore, Kuwait, Qatar,
and Brunei.11 One estimate of the number of nurses from the Philippines in
2003 put the level of local employment at only 15.25% compared to 84.75%
in international employment.12 Clearly, the country has been investing in its
educational system in order to supply the nursing requirements of people other
than Filipinos. On the face of it, this indicates an ethically unacceptable use of
the country’s resources.
Outward migration has also contributed to a diminishing pool of health
workers with necessary skills and experience, putting the quality of care available
at local institutions in jeopardy. As senior nurses move out, replacements are
costing more because of the undersupply. While Filipinos suffer, the recipient
countries with better facilities enjoy better care from the health professionals
that their country continues to provide.13
The impact on local hospitals has also been documented. According to the
Philippine Hospital Association (PHA), 200 hospitals closed between 2003 and
2005 due to shortages of doctors and nurses, and that 800 hospitals partially
closed by ending their services in one or two wards.14 There has also been marked
deterioration in the nurse to patient ratio in provincial and district hospitals.
The ratio was estimated at one nurse to between 40 and 60 patients, compared
437
to an already lower than ideal one nurse to between 15 and 20 patients in the
1990s.15 While previous ratios were not ideal, the current ratios have become
dangerous even for the nurses, adding to the loss of morale and desire to migrate
for those still employed in the Philippines.
The negative impact of these statistics is additionally highlighted by data
about the number of Filipinos dying without medical attention, which was esti-
mated at 70 per cent of deaths (similar to 1975 levels) at the height of nurse
migration in 2002–3.16 It has also been argued that the lack of human resources
for health has contributed to a drop in immunisation rate among children,
which went down to 59.9 per cent in 2003 from a high of 69.4 per cent
in 1993.17
The situation with nurses is only one component of the migration of human
resources for health that has hit the country. For the purposes of this paper,
the account provided above illustrates the injustice that will continue to be
perpetrated if the problems are not clearly delineated and solutions are not
found. It has been tempting for observers to pin the blame on the most visible
factors. Some have put the responsibility on health workers themselves, ac-
cusing them of a lack of nationalism while citing the national investment in
their education that they are choosing to put to use outside the country. Others
blame the national government for not doing enough to stop the haemorrhage
that has left the local healthcare system underserved and undersupplied.
Then there are those who accuse foreign governments of irresponsibly poaching
the ranks of healthcare workers from developing countries like the Philippines
in a selfish effort that is guided solely by their own needs and interests. The
situation is complicated further by the active encouragement of migration
coming from the national government as it takes into account the contribution
of remittances from overseas workers to the economy. A sensible approach to
possible solutions would have to allocate responsibility fairly to all stakeholders
so that negotiations can be undertaken that presume a fair amount of collective
global governance to deal with all parties’ intersecting and overlapping needs
and interests. This would entail fair and equitable bilateral and multilateral
arrangements for recruitment and international deployment that acknowledge
direct economic, social and ethical responsibility on the part of destination
countries for the effects of their recruitment on the source countries.
Advance Medical Directives

Since the current Philippine Constitution came into effect in 1987, various
lawmakers have filed bills in Congress seeking to provide a framework for ad-
vance medical directives. Up to this date, none of those bills has been approved.
438
Often, people who align themselves with the religious sector have led the
opposition, citing a lack of respect for human life. In the absence of formal
legislation or regulations, physicians and families of dying patients have spoken
in private of instances when relatives have been allowed to disconnect respirators
without the explicit or recorded consent of doctors and hospital staff. Hospitals
have also been known to accede to a family bringing a patient home against
medical advice. The fact that these practices have gone on without official
recognition indicates a prevailing culture that is partly encouraged by emergent
values and economic exigencies.
The complicity of doctors in these policies and practices is indicative of
the readiness of the healthcare profession to take legal risks in the absence of
actual legislation and to try to develop consensus by initiating practices while
the debate is ongoing. Of course, medical practitioners are not uniformly
daring and there are variations in beliefs among individual doctors and among
professional groups. But, in a country where doctors are generally held in very
high esteem and medical malpractice cases are rare, developing consensus by
trying risky practices is a relatively safe approach. In a society where medical
paternalism dominates, paternalistic bioethics tends to prevail.
Bioethics Committees
Bioethics committees have had a prominent role in the development of bioethics
in the Philippines. There is not a single national bioethics committee that covers
various areas of ethical concern. Instead, there are several that have a national
scope. There are also other bioethics committees whose mandate is institutional.
The ones that have a national scope are the National Ethics Committee,
the Philippine Health Research Ethics Board, the National Transplant Ethics
Committee, and the National Committee on Biosafety of the Philippines.
The National Ethics Committee was organised by the Philippine Council
for Health Research and Development in order to facilitate adherence to ethical
principles and promote values in the conduct of biomedical and behavioural
research. The Governing Council of the PCHRD initially laid down the basis
for ethical review of research in the country with the adoption of the National
Guidelines in 1986.18 The first National Guidelines provided for the creation
of institutional ethics review committees (IERCs) in all institutions conducting
research involving human subjects. The IERCs were created to review protocols
for implementation at their own institution whether these were being proposed
by in-house investigators or by external researchers. The National Guidelines
became the basis for an educational campaign throughout the country as the
IERCs were being established.
439
The Philippine Health Research Ethics Board (PHREB) was organised after the
research functions of the Department of Health and the Department of Science
and Technology were integrated under the Philippine National Health Research
system in 2003. The PHREB has formulated revised national guidelines that
now cover various types of biomedical, behavioural and related social science
research. It is also moving towards a system for the establishment of regional
ethics boards and the accreditation of institutional ethics review committees.
Issued in 2006, National Ethical Guidelines for Health Research provide the
basis for the ethical clearance of research protocols.
The National Transplant Ethics Committee (NTEC) has specific functions
pertaining to the ethics review of organ transplantation. On paper, it has the
responsibility to propose national guidelines pertaining to the subject and to
oversee the work of hospital based transplant ethics committees. However,
as currently constituted, the NTEC does not have the autonomy that ethics
committees are usually expected to have if they are to be able to function
properly. Its task of formulating national ethical standards pertaining to organ
donation and transplantation is subject to the approval of the Philippine Board
of Organ Donation and Transplantation (PBODT), some of whose members are
owners or executives of hospitals that were known to have transplanted organs
exclusively to foreigners before the recent ban took effect. The set up is no
different from having the Institutional Review Board of a hospital function as
a recommendatory body to a committee made up of Department Chairs bearing
conflicts of interest because the proposals to be examined are coming from
them. In the resolution of ethical issues, the role of the NTEC is limited to
that of assisting the PBODT. While the National Transplant Ethics Committee
that it replaced was primarily responsible for monitoring transplant facilities
for compliance with ethical standards, the current National Transplant Ethics
Committee is limited to assisting other bodies. Thus, the integrity of NTEC’s
work could be compromised and people may have reason to be cynical because
of what has been going on in the area of organ transplantation.
Organ Transplantation
The legal regulation of organ transplantation began with the passage of Republic
Act No. 7170 Authorizing the Legacy or Donation of All or Part of a Human
Body after Death for Specified Purposes. The Act allows a declaration of death
to be made on the basis of either the absence of unaided cardiac and respiratory
functions or the irreversible cessation of all functions of the entire brain, in-
cluding the brain stem. It also allows hospital officials to authorise the retrieval
of organs from brain-dead patients whose relatives could not be located after
440
a minimal period of search. In a well-publicised case, these provisions of the

law saved doctors from punishment after they removed the kidneys, liver and
pancreas of a brain-dead accident victim.19 The relatives of the victim accused
the doctors of committing murder after they learnt that a transplant had been
performed without their consent, and obviously without the consent of the
donor. They were so distraught when they inferred, based on their under-
standing of what had happened, that their relative was not “truly dead” when
the organs were taken from his body. The doctors were hounded by months
of adverse publicity before they were eventually acquitted. As a result of the
extended adverse publicity, however, people became hesitant to donate organs
for transplantation and very few transplants could be performed during the
period immediately following the unfortunate episode. It took a while before
society could recover from this trauma and the experience could actually be
blamed for some of the controversial developments that were to follow.
The bitter experience with a high profile “cadaveric donation” was probably
one of the main reasons behind the increased demand for other sources of
transplantable organs and the overenthusiastic recruitment of living organ
donors. Another controversy shook the transplant community in 1999 when
a television programme exposed a bustling organ trade in the country. The
documentary showed interviews of numerous poor unemployed men from a
poverty-stricken area in Manila who had been recruited as donors. The donors
were so easy to enlist, caught as they were in pressing economic problems, and
enticed by an amount of money they simply could not refuse. Many of them
joined the bandwagon after neighbours came back with their own individual
tales of fast money. Most of them realised too late that their participation gave
them only a brief respite from hunger and desperation. In a matter of months,
or weeks, their single transaction monetary gain was gone and many were left
even worse off than they were prior to the experience because they were being
stigmatised and employers thought they were taking a risk by hiring them.
The media accounts made people realise that the poor were being exploited in
transactions that benefitted only the rich, and most of the beneficiaries were
foreigners lured to the country by syndicates of unscrupulous middlemen taking
advantage of the ethical indifference of doctors, hospital administrators and
other authorities.
Seeing the inevitability of the unfortunate outcome for paid organ donors,
one easily understands why arguments supporting their right to receive payment
could not be accepted. The poverty and ignorance of potential recruits clearly
are being exploited and available evidence strongly supports the need to protect
them from unscrupulous agents.
441
Another controversial idea that was floated as part of the search for innova-
tive ways of dealing with the organ undersupply involved an organ for sentence
commutation exchange.20 The idea was for death-row convicts to be given a chance
to have their sentences commuted if they donated an organ for transplant.21
Thus, they would have had an opportunity to make an organ donation as a
gesture of atonement for crimes they committed. The proposal by the Kidney
Patients Association of the Philippines (KPAP) did not attract legislators to author
and sponsor a corresponding bill, even if a ranking Catholic Church leader
expressed support.22 The bishop found nothing morally objectionable about the
idea, provided the donation was made voluntarily. He also thought the proposal
involved a very creative way of seeking reparation for a crime — the giving of
life by one who had a conviction for being “anti-life”. However, it would have
been extremely difficult to find situations when prisoners could have been seen
to be making that kind of a donation voluntarily, especially because of the
nature of the reward that would have been made available to them. Moreover,
the experience in other countries with organ donation being made by prisoners
raises a lot of seemingly insurmountable practical issues. While it could be very
useful to give the truly penitent a vehicle for repentance, the possibility of their
being exploited under the conditions envisaged seems to be a stronger and more
compelling argument against the proposal.
The national policy regarding foreign recipients of transplant organs is now
clearly defined in Administrative Order No. 2008-0004-A issued by the Secre-
tary of Health on 29 May 2008: “Foreigners are not eligible to receive organs
from Filipino living non-related donors”.
This amendment to the main Administrative Order obviously is significant
in that it prohibits a practice that had prevailed in the country until recently.
Transplants from living donors to foreigners outnumbered transplants to Fili-
pinos in many private hospitals and there were centres that catered exclusively to
foreign recipients. The amendment is significant also in that it was issued just
two months after the release of the main “Revised National Policy on Kidney
Transplantation from Living Non-Related Organ Donor and Its Implementing
Structures”, which made it appear like an afterthought or, more likely, the effect
of external pressure shortly before the International Summit on Transplant
Tourism and Organ Trafficking in Istanbul. The issuance of the prohibition put
the country’s transplant policy in line with the provisions of the Declaration of
Istanbul that came out of the International Summit. The main Administrative
Order (2008-004 Sec. V, Par. 7) had given the Philippine Network for Organ
Donation and Transplantation the mandate to formulate guidelines and
limitations concerning foreign patients for approval by the Philippine Board of
442
Organ Donation and Transplantation. Before any guidelines could be prepared,

the Secretary of Health came up with the amendment banning the transplant
of organs from Filipino living non-related donors altogether. Without the
intervention of the amendment, the Guidelines probably would have allowed
compensation for transplants to foreigners in much the same way that similar
guidelines now provide for compensation to living organ donors to Filipinos.
Indeed, arguments are being floated around that foreigners ought to be given the
chance to be transplanted with organs from Filipinos since they should not be
discriminated against. Of course, such an argument glosses over the reality that
Filipinos are being discriminated against in their own country when a situation
is allowed to prevail that makes local poor citizens legitimate hunting ground
for exploitation by a predominantly foreign transplant patient population. This
narrative is continuing and is one that is worth watching. Developments in
the global transplant situation have been moving very dynamically, and have
repercussions for the Philippines. Filipinos must realise that the solutions they
provide to some of the issues are likely to be regarded as indicative of how
people in authority tend to think about the interactions between the powerful
and the vulnerable when situations of need and urgency arise.
Notes
1. Juarez, F., Cabigon, J., Singh, S., Hussain, R. and Nadeau, J.(2005) The Incidence of
Induced Abortion in the Philippines: Current Level and Recent Trends, International
Family Planning Perspectives, 31 (3), 140–9.
2. See also Perez, A., Cabigon, J., Singh, S. and Wuif, D. (1997) Clandestine abortion: a
Philippine reality, The Alan Guttmacher Institute, New York.
3. Manila Mayor Vows He would Seize RU-486 Shipments, ZENIT.org News Agency, 9
October 2000. Available at http://www.ewtn.com/vnews/getstory.asp?number=7813
[accessed 26 May 2009].
4. CA asked to void EO 003 banning contraceptives, Inquirer.net, 30 January 2008.
Available at http://newsinfo.inquirer.net/inquirerheadlines/metro/view/20080130-115839/
CA-asked-to-void-EO-003-banning-contraceptives [accessed 6 July 2009].
5. Contraception Ban Harms Philippine Women, Policy Innovations, 26 September 2007.
Available at http://www.policyinnovations.org/ideas/briefings/data/manila_ban [accessed
13 July 2009].
6. Macaso-Samson, G., Almeda, L.A. and Vera, T.R. (1998) First test tube baby in the
Philippines, Philippine Journal of Obstetrics and Gynecology, (April–June), 67–9.
7. PSREI Guidelines on the Ethics & Practice of Assisted Reproductive Technology &
Intrauterine Insemination.
8. Philippines Trying to Cut Medicine Cost, Associated Press, 14 June 2006. Available at
http://www.globalaging.org/health/world/2006/cutcost.htm [accessed 5 July 2009].
9. EO on cheap medicines takes effect Aug. 15, PDI, 21 July 2009. Available at http://
newsinfo.inquirer.net/inquirerheadlines/nation/view/20090721-216474/EO-on-cheap-
medicines-takes-effect-Aug-15 [accessed 31 July 2009].
443
10. Lorenzo, F.M.E., Galvez-Tan, J., Icamina, K. and Javier, J. (2007) Nurse Migration
from a Source Country Perspective: Philippine Country Case Study, Health Services
Research, 42 (3 Pt 2), 1412.
11. Lorenzo, F.M.E., et al., 1406.
12. Corcega, T., Lorenzo, F.M.E., Yabes, J., De la Merced, B. and Vales, K. (2000) Nurse
Supply and Demand in the Philippines, The UP Manila Journal, 5 (1), 1–7.
13. Lorenzo, F.M.E., Dela, F.R.J., Paraso, G.R., Villegas, S., Isaac, C., Yabes, J., Trinidad,
F., Fernando, G. and Atienza, J. (2005) Migration of Health Workers: Country Case
Study, The Institute of Health Policy and Development Studies, National Institute of
Health, Manila.
14. Philippine Hospital Association Newsletter, November 2005, cited in Lorenzo, F.M.E.,
et al., 1414.
15. Galvez-Tan, J. (2005) The Challenge of Managing Migration, Retention and Return of
Health Professionals, Powerpoint Presentation at the Academy for Health Conference,
New York, cited in Lorenzo, F.M.E., et al., 1414.
16. National Statistics Office (NSO). QUICKSTAT. Databank and Information Services
Division, February 2005, cited in Lorenzo, F.M.E., et al., 1414.
17. Galvez-Tan, J. (2005) The Challenge of Managing Migration, Retention and Return of
Health Professionals, Powerpoint Presentation at the Academy for Health Conference,
New York, cited in Lorenzo, F.M.E., et al., 1414.
18. Philippine Council for Health Research and Development (1986) National guidelines
for biomedical and behavioral research, Philippine Council for Health Research and
Development, Metro Manila.
19. de Castro, L. (1997) Transplanting values by technology transfer, Bioethics, 11 (3–4),
193–205.
20. Proposal to convicts: give a kidney, go free, Philippine Daily Inquirer. Available at
http://www.inquirer.net [accessed 22 June 2000].
21. Organ donation: a reparative option for lethal injection, Manila Daily Bulletin, 10
February 1999.
22. Organ for commutation plan for death convicts backed, The Philippine Star, 23 June
2000.
444
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Bioethics in the Philippines: a Retrospective

Article in Asian Bioethics Review · January 2009

Leonardo Doloroso de Castro

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Bioethics in the Philippines: a Retrospective

LEONARDO DE CASTRO AND

Influence of Catholicism and Christianity

■ One-third of women who experience an unintended pregnancy end it in an

The findings tell us that even if the Philippines is a predominantly Christian

supports access to contraceptives, develops awareness of diverse family planning

advocacies very forcefully. Those that see themselves as protectors of women’s

The official stance survived a change of administration and some residents

Assisted Human Reproduction

(1) Prohibiting the intentional creation of human zygotes, embryos or foetuses

(3) Prohibiting the sale of human gametes or zygotes;

In 2006, the Philippine Society of Reproductive Endocrinology and Infertility

Access to Cheaper Medicines

(1) Prohibit discrimination in matters of hiring, promotion or assignment of

The Act also promotes access to insurance by recognising that it is part of an

of HIV/AIDS cases to authorities simultaneously directs all hospitals, clinics,

Migration of Human Resources for Health

The Philippines happens to be the largest exporter of nurses worldwide,

Advance Medical Directives

a minimal period of search. In a well-publicised case, these provisions of the

Organ Donation and Transplantation. Before any guidelines could be prepared,

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