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  2. Is There a Global Bioethics? End-of-Life in Thailand and the Case for Local Difference
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  4. A Study Guide for Physicians and Physicians-in-Training

Behr, L. Di Giacinto, O. Moll-Murata Eds. Truth telling. Springer International. Rudnick Ed. China's birth control program through feminist lenses.

A Transcultural Interpretation

Scully, L. Fitzpatrick Eds. Guo, N. Annotated bibliography: Primary sources and secondary literature in Japanese, Chinese and English. Nie, N. Guo, M. Kleinman Eds. London and New York: Routledge. Kleinman, A. Introduction: Medical atrocities, history and ethics. On the alter of nationalism and the nation-state: Japan's wartime medical atrocities, the American cover-up, and postwar Chinese responses. The discourses of practitioners in China. McCullough Eds. Cambridge University Press.

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Medical ethics through the life cycle in China. Japanese doctors' experimentation, , and medical ethics. Radical disagreements of Chinese views on fetal life and implications for bioethics. Ip Ed. New York: Springer. Exploring the core of humanity: Cross-cultural perspectives on the concept of personhood. Kwan Ed. Waldkirch: Edition Gorz.

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Is There a Global Bioethics? End-of-Life in Thailand and the Case for Local Difference

The specious idea of an Asian bioethics: Beyond dichotomizing East and West. Ashcroft, A. Dawson, H. McMillan Eds. After Cheng Sincerity : The professional ethics of traditional Chinese medicine. Sheehan Eds. State violence in twentieth-century China: Some shared features of Japanese army's atrocities and the cultural revolution's terror. Takayama Eds. Baden-Baden, Germany: Nomos. Feminist bioethics and the language of human rights in the Chinese context. Tong, A. Dodds Eds. Bioethics in New Zealand: A historical and sociological review.

Cherry Eds. So bitter that no word can describe it: Mainland Chinese women's moral experience and narratives of abortion. Tong Ed. Fan Ed. The Netherlands: Kluwer Academic Publishers. Roberts, K. Attempting rigour and replicability in thematic analysis of qualitative research data: A case study of codebook development.

The crisis of patient-physician trust and bioethics: Lessons and inspirations from China. Developing World Bioethics , 18 1 , Jones, D. Does Confucianism allow for body donation? Anatomical Sciences Education , 11 5 , The vicious circle of patient-physician mistrust in China: Health professionals' perspectives, institutional conflict of interest, and building trust through medical professionalism. The social practice of medical guanxi personal connections and patient-physician trust in China: An anthropological and ethical study.

From knowing silence to curious engagement: The role of general practitioners to discuss and refer to complementary and alternative medicine. Pickering, N. Kennedy Institute of Ethics Journal , 26 3 , Erosion of eldercare in China: A socio-ethical inquiry in aging, elderly suicide and the Government's responsibilities in the context of the one-child policy. Ageing International , 41 4 , Connecting the East and the West, the local and the universal: The methodological elements of a transcultural approach to bioethics. Healing without waging war: Beyond military metaphors in medicine and HIV cure research.

American Journal of Bioethics , 16 10 , Thirthalli, J. Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China. Lancet Psychiatry , 3 7 , Truth-telling to the patient, family, and the sexual partner: A rights approach to the role of healthcare providers in adult HIV disclosure in China. The benevolent polity: A Confucian socio-ethical vision of eldercare.

Asian Bioethics Review , 7 3 , Tormented by competing moral duties: A "lost" Chinese abortion doctor. Tucker, J. Patient—physician mistrust and violence against physicians in Guangdong Province, China: A qualitative study. BMJ Open , 5 , e Qiao, S. Medical professionalism in China and the United States: A transcultural interpretation. Journal of Clinical Ethics , 26 1 , Gillett, G. The human spirit and responsive equilibrium: End of life care and uncertainty. Brody, H. Cambridge Quarterly of Healthcare Ethics , 23 2 , China's one-child policy, a policy without a future: Pitfalls of the "common good" argument and the authoritarian model.

Cambridge Quarterly of Healthcare Ethics , 23 3 , Hu, L. Chinese physicians' attitudes toward and understanding of medical professionalism: Results of a national survey. Journal of Clinical Ethics , 25 2 , The fallacy and danger of dichotomizing cultural differences: The truth about medical truth telling in China. Virtual Mentor , 14 4 , Non-medical sex-selective abortion in China: Ethical and public policy issues in the context of 40 million missing females.

British Medical Bulletin , 98 1 , Limits of state intervention in sex-selective abortion: The case of China. Multiculturalism and Asian bioethics: Cultural war or creative dialogue? In this regard, the U. The regulations are silent, however, as to SFPs. Lawmakers and industry favor a regime of informed consent and liability waivers over governance for SFPs due to the novelty and numerous uncertainties of private spaceflight.

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As a result, the interpretation and implementation of this requirement fall under the purview of the medical examiner and commercial operator. Here professional ethics would suggest that a general practitioner performing a pre-flight evaluation on a SFP collaborate with a qualified AME, whether this is required by the launch operator or not.

Relevant aerospace medical knowledge is essential to provide necessary preventative and post-flight treatments tailored to the particular SFP, particularly those with any preexisting conditions, and in relation to the specific flight activity and duration. For instance, with pharmaceutical treatments, drugs metabolize differently in microgravity environments, and a person may experience related physiological events even after returning to Earth [ 5 ].

Mitigating and preventative treatments therefore need to consider all stages of spaceflight. In addition, health, safety and medicine are closely aligned in spaceflight, as it is in aviation. If the SFP were to become impaired in flight due to the effects of a medication or an exacerbated preexisting condition this could jeopardize the safety of the individual, as well as that of the crew, mission and potentially other third parties.


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The expertise of an aerospace medical practitioner and access to professional aerospace medical research networks e. Civil Aerospace Medical Institute are thus invaluable resources for certifying physicians in determining individual risks for health events and appropriate courses of medical intervention for commercial SFPs. It has long been acknowledged that physicians owe a duty of care to their patients—this entails both a professional ethical and legal obligation.

Since health and fitness screenings of SFPs are left largely to the approval of the commercial launch operator under US law, it is essential that a physician is clear of potential conflicts of interest. For example, physicians and medical personnel contracted by commercial launch operators to screen SFPs for spaceflight could present a conflict of interest if, for instance, they receive any incentive or benefit from anyone for doing so. In any case, physicians are morally and legally obligated to maintain their professional integrity, standard of care and patient confidentiality regardless of third party e.

In a conflict of confidentiality situation where doctor-patient confidentiality may be justifiably limited—where the physician owes a duty to both an organization such as government agencies, astronaut corps NASA , military, schools and an individual—the individual-patient must be clearly informed of the limitations and scope of doctor-patient confidentiality [ 7 ]. This may also include scenarios involving remote medical assistance and telemedicine. In addition, where medical screening, profiling and the exchange of medical data are conducted for studying and augmenting medical knowledge, the situation requires delineated procedures and communications to the SFP.

Ultimately, additional discussions between industry and government are still necessary to further clarify the ethical and legal parameters for conflicts of issues, as these scenarios will inevitably arise in the near future and the current personal liability waiver regime may not suffice in such instances.

Another issue that has yet to be addressed is the lack of standardization in space medicine. Standardization is a traditional tool in science and technology fields that seeks to reduce risk and enhance reliable quality results by implementing technical and operational control mechanisms across people, time and space [ 8 ]. Space agencies use medical standardization to some extent to determine astronaut flight readiness, establish baselines, guide countermeasures, assessments and any necessary post-flight rehabilitation to return the astronaut to preflight health status.

However , the global medical community acknowledges distinctions in medical practices across cultures. Among national human spaceflight programs and agencies recognizable cultural differences exist in medical philosophies and approaches, diagnostic equipment and treatment in orbital human spaceflight [ 9 ]. Differences also exist internationally in the medical recognition of psychological disorders.

In the case of the International Space Station ISS , an Integrated Medical Group, comprised of representatives and experts from partner agencies, cooperate and compromise in leading the multilateral implementation plan for astronaut-patient health and space medical research [ 10 ]. As a treaty agreement based endeavor, differences in medical practices are limited to the cultures of partner nations. Commercial spaceflight, on the other hand, presents a broader challenge, especially as a prospective means of private and global public transportation. Some practical ethical questions and issues that remain to be clearly addressed for commercial space transportation include: Whether the experimental nature of spaceflight raises a higher duty of care or ethical concern among the private persons and entities involved physicians, operators and SFPs?

What are the ethical implications for compiling, analyzing, and sharing medical data on commercial SFPs? Whether an appropriate medical consultation forum should be established similar to aviation to provide physicians, prospective and actual crew and SFPs etc.

What protocols, safeguards and operations need to be established for telemedicine to guarantee medical standards, ethics and patient confidentiality are maintained where members of the public are engaged in spaceflight? Obviously, this is a not an exclusive list. Additional professional and practical ethics questions for physicians and passengers alike will inevitably arise as spaceflight emerges from its current experimental phase and becomes a norm of transportation. When spaceflight qualifies as common carriage and flight access is granted to a wider sector of the public, known health and safety risks may require standard physician ethical responsibilities to patients as well as to society in determining and certifying fitness-to-fly.

Ethical and medical concerns for conditions that may present safety concerns for spaceflight, may be analogous to cases of epilepsy and driving today. These issues have yet to be discussed. Professional ethical compliance is largely self-regulated within the medical profession and national ethics committees. While some conflicts of interest may appear straightforward other ethical issues may arise in the application of commercial human spaceflight—these scenarios will likely be fact, mission and personnel dependent.

Legal consequences, such as malpractice suits, may also follow where a breach of duty occurs. For instance, where negligence occurs in assessing, screening or treating an SFP with a precarious medical condition, or failure to detect or divulge potential critical medical information to the SFP. In the event of an incident, contributory negligence on the part of the SFP or crewmember to honestly and promptly report medical events may also be raised in accordance with the appropriate jurisdiction and applicable law.

The United States Code USC , Title 51, Section c further restricts the scope of regulatory authority over design and operations to where health and safety are concerned. Consequently, orbiting space stations e. The FAA voluntary guidance on human spaceflight requirements is likewise limited in scope to a brief human presence in space.

In the absence of a comprehensive space regulatory regime and the acknowledged fact that spaceflight is an inherently dangerous activity, the ethical obligations for commercial launch operations and space station operators are heightened. Ethical practices and public policy would suggest that operators adopt similar standards of care as that of other analogous public transportation providers—airlines and ocean cruise liners, for instance—even when not legally mandated.

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The higher the ethical standards adopted in practice the less likely a commercial space operator is to be found negligent in the event of an accident. In law, negligence constitutes a breach of duty which implies an ethical and legal responsibility , so applying the highest standard of care towards SFPs as well as crewmembers from the outset, even if more costly, significantly serves the commercial operators best interests and greater good.

For instance, a demonstration of a high standard of care may include: instituting clear informed consent procedures throughout the space flight and in-orbit residence; ensuring up-to-date emergency training, medical preparedness, technologies and accessibility; in-flight biometrics and health monitoring; engaging relevant expertise and experts on substantive questions and concerns; establishing reliable communications, event reporting practices; and customized personnel passenger assistance.

As a result the legal, public policy and ethical dimensions of this issue are convoluted. The current regulatory exclusion of minors from spaceflight therefore suggest a distinct periphery of risk that society has not yet deliberately addressed. Research on humans in space may feature in several ways, as an active participant consenting to a medical study or test; or indirectly, as a SFP or crewmember whose medical screening and health data is collected and analyzed for studying the effects of spaceflight on healthy individuals, those with particular pathologies, or for comparative demographic purposes.

In point of fact, NASA astronauts routinely serve as test subjects in space for medical and scientific purposes, and private astronauts to the International Space Station have been sponsored by national space agencies to conduct medical research and tests on themselves while in space. Consequently, it is foreseeable that these activities will occur with commercial SFPs. Given the novelty of the technology and scope of uncertainty in regard to spaceflight on human physiology, psychology and sociology, the pioneers in commercial spaceflight, whether deemed healthy crewmembers or SFPs, are in many ways participatory subjects of an ongoing experiment.

Moral and legal issues of collecting medical data from pre-flight and post-flight screenings and assessments from adult participants may be satisfied by applying ethically established protocols, procedures, and obtaining valid informed consent from each participant. Commercial companies and individuals interested in leading human studies and trials in space should follow the proper channels for conducting human research studies. This usually means obtaining authorization from the appropriate university or Institution Review Boards, independent ethics committees, national ethics committees etc.

Following the example of governmental space agencies e. NASA, ESA commercial research investigators in space should also comply with the research principles of the World Medical Association incorporated in the Declaration of Helsinki, and relevant national regulations and guidelines e.

When the industry matures to the point of enabling safe routine flights and lawmakers allow for minors to participate in spaceflight activities as SFPs, these ethical concerns and duties will likely be heightened. As with adults, at some point healthy children will become space pioneers if the medical and space communities are to obtain any significant medical data on the physiological effects of spaceflight on this demographic.

In general, ethics is the study of what should to be done. What should be done does not equate with what can be done. In theory, philosophical arguments hold that ethics are universalizable—a valid ethical principle that applies to one should apply to all. However, in life value principles, rules and practices frequently diverge across cultural groups [ 12 ].

This is particularly true in the field of bioethics and where human initiatives carry risk and great uncertainty, such as exploration and invention. The more an action, implementation measure or enterprise deviates from the certainty of the status quo, the higher the unprecedented risk.

A Study Guide for Physicians and Physicians-in-Training

Some distinctions indicate comparative perspectives between western and non-western cultures and values. Yet distinctions can also be found within similar cultural regions. Looking forward, decision-makers and international space forums will benefit from engaging in transcultural dialog and value reciprocity discussions on human risk and commercial ventures in space.

Uphold beneficence—using spaceflight to benefit society, this includes transportation, entertainment, scientific research and exploration. Seek and maintain a favorable and acceptable balance of risk of harm and potential for benefit in spaceflight operations. Fidelity—recognize individual contributions of crew and SFPs as appropriate, and honor societal obligations to employees. Risk is a social construction, a determination subjective to culture, context, perception and communication of an identifiable or potential hazard versus opportunity [ 14 ].

This understanding is particularly relevant to the nature, risks and perceived benefits inherent to human spaceflight. The United States and Russia, for instance, present great risk-taking cultures and histories, particularly in regard to rocket launches and spaceflight activities. On a practical level both these nations also have greater technological capabilities, government sponsorship, and the national resources to take on big risks, such as transporting humans into Earth orbit and beyond.

On the cultural level individual independence and autonomy are deemed fundamental values in American culture, and this is particularly evident in the national space culture. While legally it may be permissible for individuals to engage voluntarily in extremely hazardous activities in countries and cultures that are neutral or favorable to voluntary risk, there is no clear comparative ethical evaluation on moral standards directly addressing the issue in the public debate on spaceflight.

One of the precepts of an ethical principle is its universalizability. If a principle should apply to one person, ethics generally dictates that it should apply to all. Fairness and equity for instance are principles applied in ethics, public policy and law, and yet even here societal value determinations can diverge between cultures. A particular gap can be seen between existing spacefaring nations and non-spacefaring nations. Which implies that voluntary risk is not purely a matter of individual autonomy but also coincides with a vested interest of society in maintaining a collective value.

This is where public policy comes in and requires a practical balancing approach to leverage these two distinct ethical rights. With regard to ensuring public health and ethics in public policy, questions have been raised that distinguish the choices and consequences of the wealthy over the non-wealthy. But is there a moral distinction? Spaceflight advocates argue that people should be allowed to take risks that they voluntarily choose to participate in, and can pay for this may include event tickets, mandatory insurance, and applicable fees.

A prime example can be seen in extreme sports, such as undertaking to climb Mount Everest—a high-risk activity that does in fact claim lives every year, and that routinely calls on state resources for emergency response. From a legal perspective there is no significant distinction between one who voluntarily engages in an extreme sport or activity costing tens of thousands of dollars and the average person who wins or is gifted a ticket. Both are engaging in the activity and both persons must provide voluntary and informed consent to partake in the activity. From an ethical perspective, valid points of consideration call for an evaluation of the fundamental issue at play: should we indulge the whims of the wealthy because they can choose to pay for an experience?

If so, how far does this autonomy extend? And how do principles of ethics and justice apply to commercial spaceflight? These are questions that merit acknowledgement and discussion looking forward. There are varying degrees of paternalism that allow for less or more abrogation of personal autonomy analogously seen, for example, with bioethical questions involving body modification, extreme surgeries, drug use etc.

The overall question that deserves to be acknowledged here for spaceflight is to what extent can the average reasonable person engage in an extreme and dangerous activity? And what are the ethical parameters for state interference in regard to this autonomy? These ethics questions deserve acknowledgement because practically the conclusion may differ depending on the subjective country, culture, social norms and values, the type of legal system e.

Raising and evaluating these ethical and bioethical issues, serves to maintain the overarching human good—the fundamental reason for morality—through respect for human autonomy, dignity and life [ 12 ]. Consequently, the resulting issue presented here is how to identify, define and approach an optimal bioethical framework that can and should be applied to the commercial space transportation industry as a whole.

The Outer Space Treaty applies only one requirement to individual spacefarers. This is the only personal duty required of astronauts under the international space law regime, and stems from traditional maritime principles and law of the sea. Thus it is unclear whether commercial launch operators and SFPs fall under this treaty provision. The significance of distinguishing SFPs from astronauts under the treaty directly relates to implications of SFP health, safety and law. A legal duty to render assistance would exclude SFPs who are unwilling or unable to do so.

For instance, Stephen Hawking would be unable to render assistance to another person on a suborbital flight even if cleared by a physician and launch operator. This also raises additional liability issues for the SFPs and the launch operator as the personal liability waiver is not generally concluded between passengers. Any commercial astronaut with limited fitness and related restrictions will likely fail to comply with this international obligation. What then?


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The underlying ethical question raised here is whether a moral duty to render possible assistance to other persons in space exists, regardless of whether one is a SFP or crewmember. This is also a question of public policy. The practical ethics and legal implications of this question have yet to be addressed by the greater space community. The objectives of human health and safety are fundamental values where technology is concerned. Given the wide scope of commercial space activities proposed and human spaceflight experience gained to date, future health and medical events are a high possibility.

This leads to two ethical implications for space technology and ethics pertaining to human spaceflight: Duty to report safety concerns —One of the acknowledged lessons of the Challenger accident is the reminder of professional responsibility and ethics of engineers and operation managers to voice concerns in regard to launch activities.