the filipino physician and elds

8/3/2019 The Filipino Physician and Elds

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THEFILIPINOPHYSICIAN

ANDEND-OF-LIFEDECISIONS

THE ROLE OF CULTURE IN BIOETHICS

SR. MARIA ELENA ADRE, FDCC

THEOLOGY 264

Submitted to FR. PETER POJOL, SJ


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BACKGROUND

Bioethics and culture

Culture stamps practically all our activity; even in the more supposedly clinical field of

medicineAlthough we have grown to expect that doctors will treat us according to our sicknesses,

we probably never even averted to the fact that where one gets sick determines the treatment one willreceive.1

This is generally true with the exception of those who have lived outside the Philippines

and experienced getting sick enough to warrant consult and see the difference.2

Even granting that physical medicine can be regarded in a certain sense as transcultural, its premises

as a human activity are decidedly cultural. Its theory and practice are subject to influences such as

world views, religion, anthropologiesother historical experiences.3

That being said, the point is clear. Culture somehow determines the treatment one receives

and as the Filipino would say, Hiyang ako sa gamot (o duktor) na yan pero dun sa isa, hindi.4

So is there such a thing as a Filipino bioethics5? According to Miranda, As we attempt

anunderstanding of bioethics in the Philippines, we find a field which is yet to be explored and

in dire need of serious development.6

He claims that

There seems to be nothingat present, certainly not in systematic formWhat we presently have is

bioethics in the Philippines, in the sense that whatever of formal and systematic bioethics which is

currently taught, is almost without exception of the Western variety.7

Indeed, a young doctor active in the hospice movement expressed the same: that there is no

such thing as Filipino bioethics, rather a Western bioethics that is applied as far as that is

1 Dionisio M. Miranda, SVD, Pagkamakabuhay (On the Side of Life): Prolegomena for Bioethics from a Filipino-ChristianPerspective (Manila: Logos Publications, Inc., 1994), 21. In support of this, see also the article, Acculturation and End-of-Life

Decision Making: Comparison of Japanese and Japanese-America Focus Groups in Bioethics Volume 21 Number 5 (2007):

251-62.2 A case in point is that of a Filipina religious who, in the course of participating in an international assembly in Italy,

suffered severe and debilitating sciatica that made her wheelchair-bound. She was given daily intramuscular injections withoutrelief until a Chinese sister applied a combination of massage, acupuncture and some counseling. The Filipina was out of thewheelchair in less than 2 days.

3Ibid., p. 22.

4The medicine/doctor suits me but not the other one.

5 Bioethics is here defined as proposed by Dionisio Miranda, SVD: the systematic study of human conduct in the areas ofthe life sciences and health care. (Miranda, op. cit., p. 19).

6Ibid., p. 49.7Ibid., p. 47.


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possible in the Philippine setting or context. Well, why couldnt we settle for that already

packaged and ready to use? After all,

Filipino culture is a complex blend of Eastern and Western influencesThe global, highly

technological, materialistic, culture developing in and intruding from the West has a strong influence

onthe Philippines. 8

Perhaps, this is even more true and impactful in this age of globalization which almost

tantamount to Westernization.

The unacceptability stems from very real contrasts between the Western and non-Western

views regarding the practice of medicine and health care. Again, Miranda in his book,

Pagkamakabuhay, lists a few which include the Filipinos (non-Western) view of reality as

more palpably religious than secular and that religion is the context out of which medicine

has no meaning; also a view of reality that is oriented more to the affect than to reason; the

concept of health and suffering as not just physical but more mental and spiritual and wholistic;

the emphasis on personalist procedures, the efficiency and effectiveness of which are not

measured by physical recovery alone but a sense of personal well-being and integration; the

acceptance of death as part of life rather than a tragedy against which one must be anesthetized.9

One might theorize then that unless we have a truly Filipino bioethics, clinical decision

making with regard to health care delivery, especially as it deals with death and dying;

family planning; human experimentation; and other biomedical issues10

may be sorely

inadequate if not unfit for Filipino moral categories.

8 Angeles Tan Alora and Josephine M. Lumitao, ed., Beyond a Western Bioethics: Voices from the Developing World(Washington DC: Georgetown University Press, 2001), 6.

9 Miranda, op. cit., p. 39.10

Alora and Lumitao, op. cit., p. 14.


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The Filipino Physician and the Filipino Patient

One Filipino cultural characteristic that may influence bioethical behavior is respect and

submissiveness to persons with status (authority figures).11

Doctors are considered persons with

statusbecause they are perceived to hold the key to life and death12

and second only to God

in healing power.13

This generally makes Filipino patients inhibited in participating in their

own care (autonomy tends to be a non-value) and prone to shaping their thoughts and

behavior according to the doctors advice and deferring to the doctors decisions because he/she

knows best.14

It may get worse with issues related to death and dying as these are negatively

valued in Filipino culture and therefore rarely spoken of directly.

15

The doctors exalted status makes it one of the primary concerns in the Filipino

healthcare context because of the potential for abuse of authority16

(wittingly or unwittingly).

He/She is understood to be in authority over the patients medical care17 and often made to

bear the burden of timely declarations regarding the inappropriateness of further treatment18

yet may not take the time or effort to obtain what Western bioethicists would consider morally

appropriate informed consent because the paternalistic context of Filipino medicine does not

regard (it) as a necessary aspect of the physician-patient relationship.19

All these may make end-of-life decision making in the Philippine health context a rather

complex and perhaps messy moral issue by Western standards.

11 Fausto B. Gomez, O.P., Vicente G. Rosales Jr. M.D., and Hanzy F. Bustamante, R.Ph., ed., Bioethics: The JourneyContinues (Manila: UST Publishing House, 1997), 88.

12Ibid.13 Alora and Lumitao, op. cit., p. 17.14

Gomez, Rosales and Bustamante, op. cit.,p. 88.15

Alora and Lumitao, op. cit., p. 16.16Ibid., p. 17.17Ibid.18Ibid., p. 16.19

Ibid., p. 17.


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End- of- life decisions

To date, there is apparently no consensus regarding a precise definition of end-of-life

even while its components have been articulated.20

Various articles dealing with its related issues

seem to take this for granted but for simplicitys sake, we shall adopt the view taken by the U.S.

National Institutes of Health.21

THETASKATHAND

This paper is an initial attempt to identify the factors Filipino physicians are most likely

to consider in making end-of life decisions (ELDs) and to see if certain Filipino cultural

characteristics are at play in determining the same. A straightforward and informal survey

questionnaire (see Appendix 1), was fielded via internet to twenty-five Filipino doctors who all

had their medical training in urban-based colleges/universities and graduated between 1990 and

2011. Specifically, it looked at factors related to: consideration of aggressive treatment22

;

assessment ofmedical futility23

; consideration ofpreparation for death and who will carry

this out; unconditional prolongation of life; and euthanasia and physician-assisted suicide

all in the context of the terminally-ill patient.24

20There is no exact definition of end of life; however, the evidence supports the following components: (1) the presence of

a chronic disease(s) or symptoms or functional impairments that persist but may also fluctuate; and (2) the symptoms orimpairments resulting from the underlying irreversible disease require formal (paid, professional) or informal (unpaid) care andcan lead to death. Older age and frailty may be surrogates for life-threatening illness and comorbidity; however, there isinsufficient evidence for understanding these variables as components of end of life. (National Institutes of Health State-of-the-Science Panel, Statement on Improving End-of-Life Care: National Institutes of Health State-of-the-Science ConferenceStatement December 68, 2004, http://consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm (accessed September 25,

2011).21 Ibid.22 A patient receiving aggressive care will receive the benefit of every medication, technology, tool and trick that doctors

can devise to treat his or her illness. Chemotherapy, dialysis, radiation therapy, surgery, antibiotics, and other medicalinterventions designed to preserve and prolong life would be considered aggressive care. If a patient is receiving aggressive care,it is an indication that there is a belief -- among medical professionals, or at least among family members authorizing thetreatment -- that the patient will recover or will receive an extension of life of a quality considered to beacceptable. (http://special children.about.com/od/medicalissues/g/aggressive.htm)

23 The absence of a useful purpose or useful result in a diagnostic procedure or therapeutic intervention; The situation of apatient whose condition will not be improved by treatment or instances in which treatment preserves permanent unconsciousnessor cannot end dependence on intensive medical care. (From Ann Intern Med 1990 Jun 15;112(12):949) http://medconditions.net/

futile-treatment.html)24 A terminal illness is generally an active and progressive illness for which there is no cure and the prognosis is fatal. It

isan irreversible illness thatwill result in death in the near future or a state of permanent unconsciousness from which


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Factors included patient characteristics25

and factors that are physician-related.26

In

addition, respondents were also asked to consider technology-27 and financial-related matters.28

Motivations for or against unconditional prolongation of life as well as the consideration for the

practice of euthanasia and physician-assisted suicide in the terminally-ill were elicited but not for

the other choices made.

There was no attempt to evaluate the morality of these decisions but only to identify the

factors, particularly cultural, that may have influenced them. However, these will undoubtedly

impact morality in so far as they consider what is true and good to the culture and to the

teachings of the Catholic church or Christianity as athe dominant faith tradition in the country.

SUMMARYRESULTSOFSURVEY29

ANDDISCUSSION

Eighty-four percent of the survey questionnaires fielded were returned by respondents

with nearly equal gender distribution. The doctors were practicing in various fields of specialty

with those into Family and Community Medicine comprising nearly 25%. A little more than half

had no bioethical background of any sort while the rest (save for one) had widely varying

backgrounds from a single lecture to a bioethics course integrated in the basic medical

curriculum for four years.

recovery is unlikely. Some examples, among others, of terminal illnesses may include advanced cancer, some types of headinjury, and multiple organ failure syndrome. The length of life expectancy may vary from entity to entity. (http://definitions.uslegal.com /t/terminal-illness/)

25 Age, current level of consciousness (referring to the range from full wakefulness to coma), presence of comorbidities

(especially chronic ones which may not necessarily be debilitating), presence of physical or mental disability, degree of suffering

(biological i.e., pain or other physical symptoms; psychological i.e, anxiety or fear or depression; and social i.e., family problems,financial issues); It also included the patients wishes for him/herself as well as the wishes of his/her family. It does notconsiderthe specific agent/s that led to a status of being terminally-ill.

26 Doctors personal wishes and his/her assessment of medical futility. Other factors in this category that may influence thedoctors considerations include: the presence/absence of training in bioethics (without details of the course or curriculum) and thefact that they all had their medical training in urban-based colleges/universities in the Philippines within the last two decades.Data concerning physicians geographical area of practice and faith background/life stance were not collected.

27 (in)accessibility of extraordinary treatment; availability of an expert on the treatment procedure; success rate of treatmentoption

28 cost of treatment and affordability to patient29

See Appendix 2 for detailed results


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The survey results reveal that in making ELDs, Filipino doctors put a premium on the

patients level of consciousness. One can logically surmise that with decreasing level of

consciousness, coupled with decreasing success rate of the treatment options (second most

preferred factor), doctors would more likely declare medical futility and withhold or withdraw

aggressive treatment and recommend preparing a patient for death. This may indicate that they

value quality of life more than quantity (duration) and yet this is contradicted by the majority

preference forunconditionalprolongation of life premised by their belief that such is their duty

and the oath they have taken as physicians.30

This contradiction may be compounded by the

Filipino perspective of the moral world as organized around a network of personal obligations

(e.g., to provide physical care, emotional support and mutual assistance)31

rather than as

objective moral standards32

which consequently lead to Filipino families instructing the doctor

to do everything possible for their patient. While perhaps premised by very different beliefs this

unconditional prolongation of life is characteristic of Western medicine.33

Rather surprisingly, in a culture with close family ties and strong interdependence, the

wishes of the patients family was only a top consideration (rank 2) with the use of aggressive

treatment and not in other variables. Within the context of this culture, the sick family member

accepts a role of dependency and passive toleranceassured that others will care for and

supportespecially when terminally ill.34

Thus, it is also remarkable that the patients own

wishes seemed to have figured even more highly with regards to aggressive treatment and, in

30 That life belongs to God alone and only He can take it away was not a belief expressed in relation to this variable but

rather to the refusal to consider euthanasia and physician-assisted suicide. However, it is highly probable that given the Filipinosreligiosity that these physicians may tend towards aggressive treatment in the bid to prolong life at all costs. (Lumitao, JosephineM. Death and Dying in Beyond a Western Bioethics: Voices from the Developing World, edited by Angeles Tan Alora andJosephine Lumitao. 94-99. Washington, D.C.: Georgetown University Press, 2001.

31 Alora and Lumitao, op. cit., p. 8.32

Ibid., p. 9.33

Our (Western) culture seems to infer that, if all life is sacred, then the patient must try every possible medical treatmentthat could conceivably prolong physical existence. Artificial interventions must never be removed and the person mustexperience a high-tech death. But in fact this same culture ironically fails to treat all life as sacred. (from Charles Meyer, AGood Death Challenges, Choices and Care Options, (CT: Twenty-Third Publications, 1998), p. 40.

34Gomez, et al, op. cit., p.83.


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addition, in the assessment of medical futility, when personal autonomy and control are easily

given up in times of sickness and generally viewed as principles which are individualistic,

atomistic and marked by a degree of anomie.35

These are in contrast to the Filipino culture

where the focus and social unit of greatest value is the family.36

In praxis, do these doctors really

and directly consult their terminally-ill patient in making ELDs? And if they do, how acceptable

has this approach been for these patients? Conceivably, what may be in line with culture in terms

of these observations is the fact that, neither the patients wishes nor those of his/her family were

considered directly in the doctors decision to prepare a patient for death. As mentioned earlier,

death is not a topic directly spoken of, and this is easily verified in the behavior of the hospital

health care team around patients assessed to be terminally ill.

One noticeable pattern that emerged in the results is the presence offinancial matters as

ranking fifth (out of at least ten considerations) in all three variables surveyed. In their chapter

entitled, An Introduction to an Authentically Non-Western Bioethics, Alora and Lumitao posit

that even when health care costs become prohibitive, the family of the patient may not have

treatment withdrawn (or withheld), pursue all that is medically technologically possible, while

hoping the financial problem will resolve itself. So what might these results imply? Possibly,

that these doctors are keenly aware of the limited resources of the country in the area of health

care (among many others) and (consciously or unconsciously) applying the principle of

stewardship, deem that the use of (health) resources must be in proportion to the health

condition of the health care beneficiary, to his own or his familys capacity to avail of such

resources given their cost, and to the good and needs of the community as a whole37

Or

again, having some practical sense (since majority do not have bioethical background) that any

35 Alora and Lumitao, op. cit., p.15.36Ibid., p. 7.37 Leonardo Z. Legaspi, O.P., D.D., Bioethical Challenges in the New Millennium, Impact Volume 40, Number 5 (May

2006): 10.


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treatment imposing excessive expense on a patient, his family or the community is judged to be

disproportionate treatment38 these doctors are not morally obliged to deliver such treatment.

Having conjectured thus, a caveat is in order:

there is a danger that judgments about futility mask a covert motive to allocate resources. Both

futility judgments and allocation decisions are sometimes necessary, but the two should be understood

for what they are and not confused. Rationing refers to the withholding of efficacious treatments which

cannot be afforded. Futility refers to ineffective treatments. Efforts to define futility for the purpose of

cost-saving measures would be just that, not rationing measuresWhen life and death decisions are

being made, cost savings motivations may seem offensive, and further, they are generally not a helpful

or realistic feature for defining futility. Futility standards should not be used as covert mechanisms for

cost savings...39

How comfortable would Filipino patients be in having doctors taking financial matters as one of

their top considerations in managing the terminally-ill? This may even run counter to the

Filipinos penchant for personalism manifested in persons and personal allegiances taking

precedence over abstract philosophical and political issues such as justice and fairness.40

It is also to be noted that respondents tended to favorbiological (pain or other physical

symptoms) and spiritual (sense of meaninglessness; need related to forgiveness and

reconciliation) suffering over the psychological and social as considerations in preparing a

patient for death. Instead, Miranda claims that for the Filipino the psychological (anxiety or fear

or depression) and spiritual suffering take precedence over the biological.41

Moving to the doctors choice of person to prepare the terminally-ill for death, the

obvious preference is for a spiritual expert followed by a family member. The ranking of choices

in this category is consistent with a number of Filipino cultural characteristics. The choice of the

38Ibid.39 Council on Ethical and Judicial Affairs (CEJA) Report 2 I-96 Medical Futility in End-of-Life Care, http://www.ama-

assn.org/resources/doc/code-medical-ethics/2037a.pdf (accessed August 25, 2011). See also the article, Legitimizing the

Shameful: End-of-Life Ethics and the political Economy of Death, in Bioethics Volume 21 Number 1 (2007): 23-31.40 Alora and Lumitao, op. cit., p. 9.41

In the Filipino view, the core of ones person is loob, ones subjectivity. In relationships of conflict one prefers to be hurt

more in ones body than in ones loob; emotional sensitivity is greater than physical sensibility. Saktanmo na (angkatawan)ko, huwaglangangloob ko.(Hurt me physically if you must, but not my feelings.) At the same time, intervention on a personsbody is always potential intervention on the whole person: its values, concerns and commitments. (Miranda, op. cit., p. 296)


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spiritual expert who is perceived as having an eminent relationship with the God of life and

death is consistent with the Filipinos religiosity. Many Filipinos pray and ask for prayers in

times of sickness and more so with approaching death.42

The choice of the family member is

consistent with the dynamics ofclose family ties. The attending physician ranks only third as

preference but its recurrence in all rankings is interesting because it may indicate that the

respondents, as doctors, seem to shy away from having a primary role in preparing a patient for

death and would rather give it to others. As Filipinos, this may be in harmony with their own

religiosity (relegating the duty to a pastor/religious) which may be further expressed in their

continuing to spend time with these patients and sometimes even praying with and for them.

43

Yet this may also reveal the effect of Western mentality that finds discomfort in taking any

active religious role in the physician-patient relationship.44

It may be enlightening to study how

Filipino patients would actually rank their doctors for this role because of the role of the shaman

in this culture.45

To the query about whether as doctors, they would unconditionally prolong the life of a

patient, eighty-one percent answered yes, mostly stating reasons related to a doctors duty,

oath or training which they may or may not see as vocation and thus cannot be hypothesized as

having a link to religiosity. Instead, as is common in the West -

42 The Filipino patient is often seen clutching a rosarysurrounded by holy pictures and blessed objects, seeking Godshelpeven when accepting a terminal illness (from Gomez, et al, op. cit.,p. 86).

43 Alora and Lumitao, op. cit., p. 16.44

Ibid.45 The shamanic figure (in the Philippines)reminds us in its comprehensiveness as a symbol that all healers are part of a

healing communityUnless one makes it explicit, patients assume that their healer shares the tradition and is willing to ast not

only as a professional but also as a political patron and religious minister or whatver else is implied. On the other hand, unlike the

shaman, most scientific healers prefer to distinguish and separate the many functions assigned to them and select only those they

feel comfortable with according to their interests. Failure ot examine these expectations born by unconsciously type-casting the

doctor as baylan, can lead to confusion, disappointment and even resentment - on the part of clients of they are not realized, on

the part of healers if they are demanded. (Miranda, op. cit., p. 83).


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The presumption of the medical community is still in favor of aggressive treatment, even in the face

of death. People who chose comfort, hospice, or home care with family, are often denigrated or seen as

quitting, giving up, not fighting with everything possible for as long as their bodies will stand the

assault.46

Instead of seeing death as the natural, normal, expected outcome of overwhelming disease or

accident (or simply old age)we medicalized death and began treating it as one more illness to beconquered by overwhelming it with vast amounts of medicine, time, and technology in an acute care

institution or intensive care unit.47

For taking the option of euthanasia or physician-assisted suicide, only one answered in

the affirmative with a reason basically about a patients autonomy and control the right to

decide when to end ones life. The majority said no for varying reasons (see Appendix 2) but

predominantly mentioned either conflict with ones religious belief or Gods sovereignty over

life. This is clearly aligned to the Filipinos deeply ingrained religiosity while not presuming that

these doctors have any in-depth reflection and consistent application of such a belief in the

different dimensions of their daily living.

CONCLUSIONSANDRECOMMENDATIONS

It would seem that the favored factors for ELDs among Filipino doctors results from a

rather complex blend of Western and non-Western, scientific and religious influence that can

lead to serious conflicts (moral and otherwise) with their patients and their families. This

hodgepodge is a fact not only in bioethics but perhaps in all, if not most, areas of any Filipinos

life.48

Still, Miranda writes (in his work published in 1994) that In the mainit is observed that

there is no felt need to integrate them, not urgently at least.49 It would be unfortunate, to say the

least, if such a disposition were to persist today because -

46Meyer, op. cit., p. 36.

47Ibid., p. 9.

48 In RP culture,scientific and religious views converge and diverge. The tradition persists even as it assimilates somemodern views; modern views are not altogether accepted without some residual anchorage to the tradition. (Miranda, op. cit.,p.290).

49Ibid.


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The test of bioethics as a discipline lies in its responsiveness to the ethical problems of Filipinos

todaydevelopment of a Filipino bioethics as a perspective is not a luxury but a necessityIt must be

different from Western bioethics in form as well as content, i.e., theory, method and praxis.50

This endeavour being only a small and initial step in looking at how Filipinos doctors do

bioethics, has many obvious limitations. The researcher chose a topic related to end-of-life

decisions which involves issues with many ramifications in various fields of society. The

resources for a local praxis of bioethics are also still limited, particularly for this topic; only

general statements have been published.

If one were to seriously take up the challenge to participating in that first essential

movement (is) from moral theology in the Philippines for Filipinos to moral theology of

Filipinos and moral theology by Filipinos,51 one could do similar studies (truly systematic

ones) or build/improve on this one using a statistically significant sample size involving

preferences of Filipinos (doctors and non-doctors), looking at other additional potentially

significant factors influencing ELDs vis--vis aspects of Filipino culture; even looking at who

should ultimately make ELDs for the terminally-ill. Miranda suggests a scheme52

for the process

as well as some questions53

to adress in the inculturation of bioethics.

50Ibid., p. 57. Although I cannot agree 100% that a Filipino bioethics must be totally different for a Western one.

One must acknowledge that even cultural values are evolving and mutating as globalization impacts all these.51Ibid., p. 52.52 Secondary Inculturation: one form of this process would proceed in this manner: (a) Examine the scientific medical

facts an judgments. (b) Examine the cultural philosophy of the human being with regard to these facts and judgments. (c)Examine the traditional Christian theology with regard to both. (Ibid., p. 54).

53In the face of disvalue (e.g., death, disability, disease, illness) and its sources (e.g., naturopathic, psychopathic,demonopathic), the problematic will be constructed around thes issues: What are the conditions (e.g., socio-historical contexts

and pervasive structures) and means (e.g., medicine and technology) for the affirmation, defense and promotion of the specific

values involved (e.g., health and integrity)? (Ibid., p. 57-58).


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BIBLIOGRAPHY

BOOKSAlora, Angeles Tan, and Lumitao, Josephine M., ed. Beyond a Western Bioethics: Voices from

the Developing World. Washington, D.C.: Georgetown University Press, 2001.

Gomez, Fausto B., O.P., Rosales, Vicente Jr. G., and Bustamante, Hanzy F., RPh, ed. Bioethics:

The Journey Continues. Manila: UST Publishing House, 1997.

Meyer, Charles. A Good Death Challenges, Choices and Care Options. CT: Twenty-Third

Publications, 1998.

Miranda, Dionisio M., SVD. Pagkamakabuhay (On the Side of Life): Prolegomena for Bioethics

from a Filipino-Christian Perspective. Manila: Logos Publications, Inc., 1994.

JOURNALS

Legaspi, Leonardo Z., O.P., D.D. Bioethical Challenges in the New Millenium. Impact

Volume 40 Number 5 (2006): 8-11.

Mortier, Freddy, Luc Deliens, Johan Bilsen, Marc Cosyns, Koen Ingels, and Robert Vander

Stichele. End-of-Life Decisions of Physicians in the City of Hasselt (Flanders, Belgium).

Bioethics Volume 14 Number 3 (2000): 254-67.

INTERNET

Council on Ethical and Judicial Affairs (CEJA) Report 2 I-96 Medical Futility in End-of-LifeCare, http://www.ama-assn.org/resources/doc/code-medical-ethics/2037a.pdf (accessed

August 25, 2011).

National Institutes of Health State-of-the-Science Panel, Statement on Improving End-of-Life

Care: National Institutes of Health State-of-the-Science Conference Statement December 68,

2004, http://consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm (accessed

September 25, 2011).

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