eubios journal of asian and international bioethics...eubios journal of asian and international...

Eubios Journal of Asian and International Bioethics

EJAIB Vol. 27 (3) May 2017

www.eubios.info ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA) Copyright ©2017 Eubios Ethics Institute (All rights reserved, for commercial reproductions).

Contents pageEditorial:EthicalBoundaries 69

-DarrylMacerAttitudesofFutureDoctorsofBangladeshtoPharmaceuticalIncentivesandMedicalEthics 70

-TonmoyBiswas&DarrylR.J.MacerTheperceptionofMuslimmotifsandjuridicalauthoritiesoftheconceptofhealthanditsfunctioninissuingfatwasonabortion 81

-SaeidehSayari,DRJMacer,SitiNuranibintiNorTheEthicalDilemmaofHumanGermlineEditing 95

-CarolRizkallaCircusanimals-howmuchis‘unfair’? 99

-OanaIftimeABARenewalandEJAIBSubscription 103

EJAIB welcome papers! EJAIB charges no fees forpublication and the on-line version has been openaccesssince1990Editorialaddress,andallcorrespondenceto:Prof.DarrylMacer,Ph.D.,Hon.D.President, American University of Sovereign Nations(AUSN),Arizona,USAEmail:[email protected]://www.eubios.infoRegistered address of EJAIB: P.O. Box 16 329, Hornby,Christchurch8441,NewZealand(Donotpost itemshere;pleaseuseemailforallcommunication)

Editorial:EthicalBoundariesSetting boundaries is a theme of the papers in this

issue of the journal. In a growing number of countriescircuses are no longer using live animals because ofethicalconcernsthattheuseofliveanimalsharmsthem,and this theme is explored by Oana Iftime.Entertainment is a major business, but there aredecreasing opportunities for children to see circuses.Many circus operators have found that without liveanimalsfewerpeoplecome.

In a related case, SeaWorld in San Diego, California,has found that in the first year after cancellationof theOrca(killerwhale)showthenumberofvisitorsfellbyaquarter. Clearly the bioethical choice was not to keeptheorcasincaptivity,andtoinsteadencouragepeopletogo whale watching on boats in the ocean (if donesensitively). Many years ago human freak showswereattractions, andevenSiamese twinsweremade famous

(and could generate an income) by being entertainers.Exploitationhowever is aneasyboundary to cross, andsetting boundaries and standards lessened theopportunity for blatant exploitation of the vulnerablethatusedtooccur.

Tonmoy Biswas and Macer explore the attitudes ofmedical students in Bangladesh towards what areacceptable gifts from the representatives ofpharmaceutical companies. This issue is of concern allaround theworld,but the results indicate that it isonewhich needs to be better discussed in medical ethicseducation. There aremany avenues for education, butinterestingly the students whose parents werephysiciansseemedtobemoresensitivetothequestion,at least in their attitudes expressed in the survey. Thepaper includes an analysis of correlationswith gender,academic year, exposure to pharmaceutical reps, andothersfactorinalotoftables.Internationalcomparisonsare made, and further research on this topic will beuseful.Itwillbeparticularlyinterestingtoseeexamplesofcorrelationofattitudewithspecificteachingmaterialsinthecurriculum.

SaeidehSayarietal.callforabroaderexaminationofreligious ethical principles in Muslim countries thatimpose very restrictive regulations on abortion. Abroaderconceptofhealthofthemotherwillbeusefulforethical judgment in many moral dilemmas. Abortion isclearlyacontentious issue,butweneedtoconsider thebroadergoalsofloveoflife,andthehealthofthefamily.

Carol Rizkalla reviews some of the dilemmas ofhumangerm-lineediting.Assomeonewhowroteaboutthese issues inthe1990s,wecanseethatdespitesomemoratoriums on germ-line genetic interventions, assome medical interventions such as mitochondrialdonation have become safe, we have to reconsider theboundaries.

One of the concerns of the therapy-enhancement“divide” is boundaries. Shouldwe simply allow law todetermine what is ethical? How much do theseboundaries change over time and place? Should welegislateandpunishviolatorsofsomeboundarybetweenthe legal and illegal? These are central questions ofbioethics that allow us to move closer to promoting a“good-life” for all moral agents. Education is clearlycritical for students, legislators, and all citizens toexploretheunderlyingmoralvalues.

-DarrylMacer

Eubios Journal of Asian and International Bioethics 27 (May 2017) 70

Attitudes of Future Doctors of Bangladesh to Pharmaceutical Incentives and Medical Ethics -TonmoyBiswas,MBBS,MBGPHPhysician,FaridpurMedicalCollegeHospital,BangladeshEmail:[email protected],PhD,HonDDirector,EubiosEthicsInstitute,JapanEmail:[email protected]

Abstract Introduction: Pharmaceutical companies offervarious gifts to physicians to encourage them toprescribe their products. This collaboration hassome negative and positive aspects. Differentcountries have established guidelines to limit thecollaboration and reform such relationships. ThisstudyaimstodeterminetheattitudeofBangladeshimedical students towards pharmaceutical gifts,physician-pharmacistcollaboration,andassociatedfactors.Methods: An online cross-sectional andcorrelational study was conducted through emailand Google-Forms among Bangladeshi medicalstudents. A total of 435 students from differentmedical colleges completed the questionnaires inMayandJune,2016.Results: Monthly parental income was moderateamong themajorityofmedical students.Less than16%hadaphysicianorpharmacistparent.Mostofthe students (89%) were taught about medicalethics,but73%werenottaughtabouttheethicsofphysician-pharmacistcollaboration.About85%didnot have any experience of interaction withmarketing representatives.Drug samples andpen-notepads were the most appreciatedpharmaceuticalgifts.Jewelryandgiftscostingmorethan100thousand(BangladeshiTaka)weresaidtobe the least appreciated pharmaceutical gifts.Attitudes towards drug companies andrepresentatives were assessed by fifteenstatements. Medical students had a variety ofattitudes regarding its ethical justification.Attitudes were correlated with gender, parentalincome, physician parents, academic years, andhaving been taught about pharmaceuticalcollaborationwithphysicians.Conclusion and Recommendations: medicalstudents should elaborate on ethical reasoningbefore accepting pharmaceutical gifts. Medicalcolleges and curriculums should teach themabouttheinteraction.Anationalguidelinemaybeneeded.

1. Introduction 1.1.BackgroundIt is common practice that pharmaceutical

companies offer various gifts and incentives tophysicians to encourage them to prescribe theirdrugs. What are the advantages and risks of thiscollaboration? Are the doctors really influenced?Doesthis influenceaffectprescribingproperdrugsfor patients? Can this interaction lead to a biaseddecisionfortherapy?Aretheseinteractionsethicaland lawful? Is receiving incentives ethicallyjustified?Whendoesitfallintothecriteriaofbribeorkickback?Whatarethedoctors’viewsregardingthis issue?Are they aware of the guidelines aboutthis concern?All thesequestions are knocking themind of scholars formany years. But the answerschange from time to time, person to person and,place to place as discussed in Biswas and Macer(2017).There isa complex relationbetweenphysicians

and pharmaceutical companies. Pharmaceuticalcompanies offer various gifts, incentives, sponsorCME (Continuing medical education), and providenotepads, pens, and samples in many countriesworldwide. The approach somehow can influencethe decision of physicians in the treatment ofpatients which is based on trust driven byphysicians’ autonomy. Many countries like theUnited Sates have restrictions by law uponphysician-pharmaceutical interactions (Cicero etal., 2011, Conn and Vernaglia, 2011). AmericanMedicalAssociations’(AMA)“EthicalGuidelinesforGifts to Physicians from Industry” in 1998 is anexampleofrecommendationsthatissettomaintaintheinteractionwithinethicallimits(ChimonasandRothman, 2005). However, the dilemma in thisfield has remained unsolved (Quan, 2007). Theguidelines are updated year by year to pace withchanginginteraction-policies(Austadetal.,2013b).Canada also set up an ethical guideline in 1991 todeal with this complex phenomenon and topreserve the morality of physicians (Woollard,1991).Japan,Korea,France,andDenmarkalsohaveaddressed this issue with great concern (Rodwin,2011; Harris, 2009; Kwon, 2003). Some foreignresearchers showed that physicians might have agreat role in drug industries directly (being apharmaceuticalphysician)and indirectly(Lopesetal., 1993; Hayward, 2011). Physician-pharmacistcollaboration is not an unethical matter always.Therearemanypositiveoutcomesiftheincentivesarewithin ethical limits and prescriptions are notbiased.ACanadianstudyfoundthatphysiciansandpharmacists both agreed in principle over thecollaboration, but differed in the areas ofcollaboration(Kellyetal.,2013).Medical students are future doctors. A Saudi

studyresearched theattitudesofmedical students

Eubios Journal of Asian and International Bioethics 27 (May 2017)

71

towards the incentives from drug companies andfound interesting results (Zaki, 2014). If theattitudesofmedical students canbeevaluated,wecandeterminetheir levelofethicalperceptionandinvestigate how these issues are being taught tothem. Therewas no previous study in Bangladeshinthismatter.Therefore,thisstudyaimstoanswerthese questions from a Bangladeshi standpoint.Whatdomedicalstudentsthinkaboutthegiftsandincentives? What are their views about theinteraction? Are there any demographic orcorrelatedfactorsthatinfluencetheattitudes?

1.2.RationalePharmaceutical representatives offer incentives

tophysicians.Thesekindsofinteractionsmayleadphysicians to irrational prescribing, selection biasof drugs, kickback issues, and other ethicaldilemmas. There is a greater chance that thedoctors may prescribe the drugs of that companyfromwhere they have received some gifts, even ifthe drugs are costly and less effective. Thus,medicinal prices may increase and concerns overtheethical call forbeneficence topatients ismademoredifficult.However,positively,representativeshelp physicians to learn about new products andprovideneededfinancialassistance..

1.3.Objective

The general objective was to explore theattitude of future doctors regarding incentivesoffered by pharmaceutical companies. Specificobjectiveswere:− To determine the demographic data, exposure,andexperienceaboutpharmaceuticals.− To determine the attitude of medical studentstowardspharmaceuticalgiftsandincentives.− To evaluate the attitudes of medical studentstowardsdrugcompaniesandrepresentatives.− Tofindoutthecorrelatedandassociatedfactorsofattitudebystatisticalanalysis.− To compare the resultswith other countries intheliterature.1.4.Physician-PharmaceuticalInteractionsPhysician and pharmaceutical interactions

influence physicians’ behavior and prescribingpatterns (Rubin, 1994).Drug representatives offergifts, drug details, and samples to physicians(Ciceroetal.,2011;Jain,2010).Especiallyfinancialassistance and kickbacks raise ethical dilemmas(Rodwin, 2011; Quan, 2007). Some educationalprograms, continuing medical education (CME),and academic events are sponsored by drugcompanies in medical schools (Johnson, 2001). Indevelopedcountries,physiciansoftenparticipateinclinical trials and lectures are facilitated bypharmaceutical companies (Ashar et al., 2004).

Meetings between different health professionalstake place there (Huang et al., 2005). Theinteraction is sometimes ethically acceptable andsometimesnot (Quan,2007).Many countrieshavelaws, legislations, and ethical guidelines regardingthis issue (Gorlach and Pham-Kanter, 2013; Connand Vernaglia, 2011; Harris, 2009). the UnitedStatesandKoreahavedonepharmaceuticalreform(Tobbell, 2008; Kwon, 2003). The attitude ofmedical students andphysicians to the interactionis different country by country (Kelly et al., 2013;Austad et al., 2013a). Public perception of thisinteraction varies and is not always positive(Arkinsonetal.,2010).2. Development and implementation of the Survey 2.1.EthicalImplicationsA questionnaire was developed and after pilot

testingitwasused.Thisresearchwasapprovedbythe American University of Sovereign Nations(AUSN) IRB. The survey was anonymous andconfidential, and gave enough autonomy to theparticipants.2.2.IndependentDemographicVariablesThisisacross-sectionalandobservationalstudy.

Itemsinclude:Gender,currentyearofstudy,typeofmedical college, parental income, doctor parents,pharmacist parents, known medicalrepresentatives, being taught about physician-pharmacist collaboration, interaction withpharmaceuticalcompanies.

2.3.DependentVariablesThere aremany types of gifts, including:Meals,

dry food and snacks, drug samples, pens andnotepads, textbooks, stethoscopes, penlight andmedical equipment, stationary, clothes, gifts(<10,000BDT), gifts (10,000 to 50,000BDT), gifts(50,001 to 1,00,000 BDT), gifts (>1,00,000 BDT),hospital trips, personal or family trips, conferenceregistration fees, travel fees to any conference,cosmetics, jewelry, computer, and its accessories,home electronics, home cooking accessories,uniquegadgets,homeequipment,gameequipment,festivalrelatedgifts,andheardofanyother.

2.4.AttitudestowardsPharmaceuticalCompaniesThiswasassessedbyfifteenstatements(AtoO):

A) the information provided by drugrepresentatives about their products can betrusted. B) The information from drugrepresentatives is important for the physicians. C)It isokforthephysicianstoacceptgiftsfromdrugcompanies because the drug companies haveminimal influence on them. D) Most seminars


sponsored by drug companies are helpful andeducational. E) Drug representatives are a usefulway to learn about new drugs. F) Drug companysponsored seminars are often biased in favor oftheir products. G) Gifts from drug companies todoctors lead to increased prices of medicines. H)Receiving gifts or incentives from pharmaceuticalrepresentatives increases the chance that I willeventually recommend/prescribe the drugcompany’s products. I) Drug companies actunethically in promoting and advertising theirproducts. J) Students should not have anyinteractionwithdrugcompaniesinmedicalschool.K) Pharmacists should be accountable to thepatients for the drug they provide. L) If a drugcompanyagreedtopayfortheprintingcostsofallmy class notes in the undergraduate medicalschool, Iwouldnotmindthe logoof thatcompanyappearing in thebottomcornerof the firstslideofclass lectures. M) It is acceptable for drugcompaniestosponsorevents/educationalseminarsduring medical school. N) Five drugs from fivedifferentcompaniesare identical in termsofprice,and therapeutic efficacy. I would preferentiallyprescribe a drug from one of the companies thatprovidedmewithgiftsor incentives.O)There isaneed for guidance regarding the relationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum.Two scenario questions were also included.

Attitudetowardsgiftsandincentiveswereassessedby three levels scale and attitudes towardspharmaceuticalcompanieswereassessedbyafive-level Likert scale. These variables have beenidentified from previous studies by extensiveliterature review and an online focus groupdiscussion. The distribution of the variables isclarified in the questionnaire (Attached inAppendices)

2.5.StudyPopulationandSamplingThis study involved third, fourth, and fifth-year

medicalstudents(astheyhaveexposureinclinicalwards and hospitals) of differentmedical collegesin Bangladesh. Simple random samplingwas doneamong the medical students who were invited toparticipate in the study.Thosewhogave informedconsent were included. Incomplete questionnaireswere excluded. According to sampling statistics, aminimum sample size estimation is 384.16 ≈ 384(n= Z^2 pq/d^2, Z= 1.96, p = 0.5, q= 1-p= 0.5, d=10%ofp=0.05, in95%confidence interval).Totalsample sizewas targeted to bemore than 400. Atlast 435 clean responses were gathered from thesurvey.

2.6.ValidityofGoogleQuestionnaireandFocusGroupDiscussion

The Google Questionnaire was created byconsidering the questions used in manyquestionnaires and results of previous studies(Siddiqui et al., 2014) (Sergeant et al., 1996;McCormicketal.,2001;Gibbonsetal.,1998;Yehetal., 2014). The questionnaire was reviewed byestablished validation criteria and measurementscales (Van Winkle et al., 2011). Some previousstudies used Google questionnaires on the sametopic had been validated and indexed in PubMed(Zaki,2014).AFocusGroupDiscussion (FGD)wascarried out in the social media where a questionwasaskedtothemembersofamedicalgroup,bothphysicians and students. To include gift-types asmuch as possible, everyone was asked to sharetheirexperienceaboutgiftsandincentivesfromthepharmaceuticals. About two hundred medicalstudentsandphysiciansansweredinthediscussionforum and twenty six types of gifts were finallyadded in the questionnaire for the Likert scale ofappropriateness.

2.7.ProceduresandMethodsofDataCollectionRespondents were contacted through social

media or personal contacts. The study had takendouble informed consent from the participants. Atfirst, verbal informed consent was taken beforesending theonline link to theconsent form. In thelink there was a detailed consent form (availableupon request). The survey needed only 10 to 15minutes. Once the questionnaire was filled,respondents were asked to submit. Data obtainedfromthissurveyweretotallyanonymous.Nonamewas taken in the questionnaire. After submission,theresponseswereunlinkedfromtherespondentsandcouldneverbeidentified.Asthiswasanonlinesurvey, retrieved responses were archivedautomatically in a Google spreadsheet and thenfurther downloaded and saved as Microsoft Excelfile.

2.8.DataAnalysisFrom Excel, data were converted into SPSS

software for analysis. After interpretation, thepotential correlations among different variableswere analyzed using SPSS software version 21.0.PearsonChi-squaretestwasusedtofindsignificantcorrelations.Two-sidedPvalue less than0.05wasconsidered significant in 95% confidence interval.Statistical Significance is indicated by S=Significant; NS= Non-Significant. Cross tabulationwas done keeping independent variables in a row(considering 100% in a row) and dependentvariables in a column.Bivariate analysiswasdoneto assess the relation of attitude with any othervariables.


73

3. Results 3.1.DemographicsandExperienceThere were more female respondents (53%)

than male. Most of the students (59%) werestudyinginthefifthyear(finalyear)ofMBBS,with23%inthefourthyearand18%inthethirdyear.Amongtherespondents,45%werefromPrivate

ornon-governmentinstitutionsormedicalcolleges,and the rest of them (55%) were from Public orgovernment institutions.Most of the students hadparental income between 20,000 BDT to 50,000BDT((80BangladeshiTaka=1USD).Only 12% of the respondents had physician

parents and the rest (88%) of them did not haveanyparentworkingasaphysician. Similarly,mostof the respondents (96%) did not have anypharmacistparentwhileonly4%ofthemhad.67%of the respondents did not know any medicalrepresentative of any company. But 33% of themknewatleastonepharmaceuticalrepresentative.Most of the respondents (89%) claimed that

they were taught about medical ethics in theirmedical college. But most of the students (73%)said that theywerenot taught about guidelines ofphysician-pharmacist interaction or collaboration.While asking ‘where and when were they taughtabout physician-pharmacist interaction’, 67respondentsgavespecificanswers.Most of the respondents (85%) said that they

did not have any experience of interaction with apharmaceutical company. 57 respondents detailedabouttheplaceandtimeoftheinteraction.

3.2.AttitudestowardsGiftsandIncentivesThe most positively valued gift was drug

samples, where 89% of the respondents agreed(Figure 1). The least valued (only 13%)was Giftscosting 50 thousand to 100 thousand BDT (80Bangladeshi Taka = 1 USD), because it was notconsidered appropriate. Specifically”inappropriateness” was perceived most for giftscostingmorethan100thousandBDTwhere75%ofthe respondents said so. Only 4% respondentsthoughtofapenandnotepadasinappropriategifts.Attitudes and opinion about different gifts andincentives offered by pharmaceuticals aredescribedinFigure1and2Respondents were asked whether they heard of

anymoretypesofgiftsandincentivesornot.Afewrespondents reported hearing of Car, Television,Automobiles, Mobile, Commissions, Flats orApartment, and other Vehicles as gifts bypharmaceuticalcompanies.3.3.AttitudestowardsDrugCompanyandrepresentatives

Attitudes towards drug companies andrepresentativesweredeterminedby15statementsandlevelsofagreementarepresentedinTable1.

Figure1:OpinionsonAppropriatenessofDifferentGiftsandIncentives(set-A)Horizontal axis presents percentages of respondentsopinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 BangladeshiTaka=1USD).4. Two More Attitude Questions and Self-judged Biasness A scenario was given to assess the attitude of

future doctors. The scenario was the following: Adrug companywants to increase its visibility to themedicalprofessionandhasrecentlyapproached themedicalschool.Theywouldliketoprovideaone-dayseminar regarding their product at the end of thesecond year. In return, theyarewilling topay forafraction of the second year tuition for each studentwho attends their seminar. As a medical studentfaced with increasing tuition costs, I think that itwould be fair if the pharmaceutical company paysthis percentage of my second-year medical schooltuition.

32.4

26.7

4.1

3.7

8.3

10.8

7.1

24.6

60.7

46.7

61.6

69.4

74.7

29

26.7

6.9

10.8

14.7

15.6

15.2

23.2

20.5

18.6

19.3

17.7

10.8

38.6

46.7

89

85.5

77

73.6

77.7

52.2

18.9

34.7

19.1

12.9

14.5

0 20 40 60 80 100

Meals

DryFood_Snacks

DrugSamples

Pen_Notepad

TextBook

Stethoscpoe

MedicalEquipment

Stationery

Clothes

Gifts_<10KBDT

Gifts_10Kto50KBDT

Gifts_50Kto100KBDT

Gifts_morethan100KBDT

OpiniononappropriatenessofGifts-Incentives-SetA

Appropriate Neutral Inappropriate

Table1:AttitudestowardsDrugCompaniesandRepresentatives(%)Statements: Strongly

disagreeDisagree Neutral Agree Strongly

agreeA. Theinformationprovidedbydrugrepresentatives

abouttheirproductscanbetrusted11.0 28.7 34.3 25.1 9

B. Theinformationfromdrugrepresentativesisimportantforthephysicians

8.5 10.8 18.6 52.0 10.1

C. Itisokforphysicianstoacceptgiftsfromdrugcompaniesbecausedrugcompanieshaveminimalinfluenceonthem

21.6 32.2 22.5 22.1 1.6

D. Mostseminarssponsoredbydrugcompaniesarehelpfulandeducational

6.9 6.0 20.2 55.6 11.3

E. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

8.7 20.7 12.9 46.7 11.0

F. Drugcompanysponsoredseminarsareoftenbiasedinfavoroftheirproducts

7.9 6.0 14.5 53.3 19.9

G. Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

10.6 18.6 23.2 37.0 10.6

H. ReceivinggiftsorincentivesfrompharmaceuticalrepresentativesincreasethechancethatIwilleventuallyrecommend/prescribethedrugcompany’sproducts

12.2 22.8 15.2 37.7 12.2

I. Drugcompaniesactunethicallyinpromotingandadvertisingtheirproducts

7.6 12.0 23.7 42.8 14.0

J. Studentsshouldnothaveanyinteractionwithdrugcompaniesinmedicalschool

12.6 13.3 16.3 40.0 17.7

K. Pharmacistsshouldbeaccountabletothepatientsforthedrugtheyprovide

9.4 6.7 19.8 42.1 22.1

L. Ifadrugcompanyagreedtopayfortheprintingcostofallmyclassnotesintheundergraduatemedicalschool,Iwouldnotmindthelogoofthatcompanyappearinginthebottomcornerofthefirstslideofthelecture.

28.5 15.4 16.8 32.0 7.4

M. Itisacceptablefordrugcompaniessponsorevents/educationalseminarsduringmedicalschool.

11.0 7.8 17.0 50.8 13.3

N. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

33.3 26.2 16.8 18.2 5.5

O. Thereisaneedforguidanceregardingrelationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum

10.1 5.7 14.9 40.7 28.5

Based on the above scenario, medical students

gave their opinions.Half (54%)declined to acceptany percentage of tuition fees. But 7.4% of themwanted1 to10%feessupport,9.9%wanted10to20% fees support, 9% wanted 20 to 30% feessupport, and 19.6% wanted more than 30%payment of tuition fees by pharmaceuticalcompany.Another statement examined the attitude of

medical students towards profit and interest ofdrug companies. More (62%) of respondentsagreedtoastatementthatsaid:“Theyareprimarilyinterestedinprofit:however,theystilltrytoworkinthe best interest of doctors and patients”.But 21%respondents agreed with the statement, “They are

fundamentally interested in profit and never on thesideofeitherdoctorsorpatients”.17%agreedwith,“Theyarefundamentallyonthesamesideasdoctorsandpatientsandshouldberegardedasanimportantpartofthehealthcaresystem”.Respondentswere askedwhether any previous

experienceorinteractionbiasedtheirresponsesornot. Only a few respondents admitted thepossibilityofbiasedresponses.


75

5. Association and Correlation among Variables 5.1.GenderandExperienceaboutPharmaceuticalsGenderhadastrongcorrelation(Pvalue=0.000,

chi-square) with personally knowing any medicalrepresentative. Only 22% of female respondentsknew any medical representative, compared to46% of male respondents who knew at least onemedicalrepresentative.Moreover, ‘Gender’ and ‘Experience of

interaction with pharmaceutical representative’had also a strong correlation (P value=0.015, chi-square). Only 10% of female respondents hadexperienceof interactionwith representatives,but19% of male respondents had experience of thatinteraction.

Figure2:OpinionsonAppropriatenessofDifferentGiftsandIncentives(set-B)Horizontal axis presents percentages of respondentsopinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 BangladeshiTaka=1USD).5.2.EffectofGenderGenderwasstronglyassociatedwithopinionson

12 items (dependent variables) shown as “S” inTable 2. Thirteen out of fifteen statements ofattitude were associated significantly with the

genderoftherespondentsasdetailedwithPearsonchi-square2-sidedPvaluesinTable3.Table2:ItemsofSignificantCorrelationbetweenGender(IndependentVariable)andOpiniononGiftsandIncentives[Dependentvariable PearsonChi-

squareTest:Pvalue(2-sided)

StatisticalSignifican

ceOpinionaboutGifts

Meals 0.007 STextBooks 0.025 SStationeryoptions 0.016 SClothes 0.000 SGiftslessthan10,000BDT 0.000 SGifts50,001to100,000BDT 0.019 SGiftsmorethan100000BDT 0.011 SPersonalorFamilyTrip 0.003 SConferenceTravelFees 0.023 SComputerAccessories 0.000 SGameEquipment 0.025 SFestivalGifts 0.000 S5.3.EffectofAcademicYear

A correlation test was run between academicyear and personally knowing any medicalrepresentative. Data showed percentages ofknowing representatives increased withadvancement of academic year, but there was nostatisticallysignificantcorrelation(2-sidedPvalue0.150 in Pearson chi-square test) between thosetwovariables.

Currentacademicyearofstudyhadasignificanteffect on opinion about different gifts andincentives. Academic yearwas strongly associatedwith opinions on meals, text books, stethoscope,stationary items, clothes, gifts less than 10thousands, personal or family trip, conferenceregistration fees, conference travel fees, computeraccessories, unique gadgets, game equipment, andfestival gifts. A significant correlation was foundbetweenacademicyearand13dependentvariablesofopinionsongiftsandincentives(Table4).

Seven out of fifteen statements of attitudewereassociatedsignificantlywithacademicyearofrespondents(Table5).5.4.EffectsofParentalincome

Parental income was strongly associated withopinionsondrugsamples,clothes,giftslessthan10thousand BDT, personal or family trip, computeraccessories, home electronics, cooking accessories,uniquegadgets,andhomeequipmentasdescribedinTable6.Five out of fifteen statements of attitude were

associated significantly with parental income ofrespondents(Table7).

16.3

52.2

20

19.5

64.1

73.8

49

59.5

63.2

42.8

56.6

59.1

32

23.2

19.8

23.7

23.2

16.6

12.2

19.5

18.2

17.7

24.8

20.2

21.8

22.3

60.5

28

56.3

57.2

19.3

14

31.5

22.3

19.1

32.4

23.2

19.1

45.7

0 20 40 60 80

HospitalTrip

Personal/Family_Trip

Conferenceregistration

Conferencetravelfees

Cosmetics

Jewelry

ComputerAccessories

HomeElectronics

Cookingaccessories

UniqueGadgets

HomeEquipment

GameEquipment

FestivalGifts

OpiniononappropriatenessofGifts-Incentives-SetB

Appropriate Neutral Inappropriate


Table3:AttitudesofSignificantCorrelationbetweenGender(IndependentVariable)andAttitudestowardDrugCompaniesandRepresentatives

Dependentvariable PearsonChi-squareTest:Pvalue(2-sided)

StatisticalSignifican

ceAttitudetowardsdrug

companies

A. Theinformationprovidedbydrugrepresentativesabouttheirproductscanbetrusted

0.000 S


0.012 S

C. Itisokforphysicianstoacceptgiftsfromdrugcompaniesbecausedrugcompanieshaveminimalinfluenceonthem

0.017 S

D. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

0.000 S

E. Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

0.000 S

F. ReceivinggiftsorincentivesfrompharmaceuticalrepresentativesincreasethechancethatIwilleventuallyrecommend/prescribethedrugcompany’sproducts

0.000 S

G. Drugcompaniesactunethicallyinpromotingandadvertisingtheirproducts

0.044 S

H. Studentsshouldnothaveanyinteractionwithdrugcompaniesinmedicalschool

0.002 S

I. Pharmacistsshouldbeaccountabletothepatientsforthedrugtheyprovide

0.014 S

J. Ifadrugcompanyagreedtopayfortheprintingcostofallmyclassnotesintheundergraduatemedicalschool,Iwouldnotmindthelogoofthatcompanyappearinginthebottomcornerofthefirstslideofthelecture.

0.019 S

K. Itisacceptablefordrugcompaniessponsorevents/educationalseminarsduringmedicalschool.

0.005 S

L. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

0.014 S

M. Thereisaneedforguidanceregardingrelationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum

0.014 S

Table4:SignificantItemsofCorrelationbetweenAcademicYear(IndependentVariable)andOpiniononGiftsandIncentives.Dependentvariable PearsonChi-


Statistical

Significance

OpinionaboutGifts

Meals 0.001 STextBooks 0.016 SStethoscope 0.002 SStationeryoptions 0.010 SClothes 0.030 SGiftslessthan10,000BDT 0.006 SPersonalorFamilyTrip 0.028 SConferenceRegistrationFees 0.002 SConferenceTravelFees 0.017 SComputerAccessories 0.001 SUniqueGadgets 0.012 SGameEquipment 0.004 SFestivalGifts 0.003 STable5:AttitudesofSignificantCorrelationbetweenAcademicYear(IndependentVariable)andAttitudetowardDrugCompaniesandRepresentatives


Statistical

Significance

Attitudetowardsdrugcompanies

A. Mostseminarssponsoredbydrugcompaniesarehelpfulandeducational

0.048 S

B. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

0.041 S

C. Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

0.008 S

D. ReceivinggiftsorincentivesfrompharmaceuticalrepresentativesincreasesthechancethatIwilleventuallyrecommend/prescribethedrugcompany’sproducts

0.014 S

E. Studentsshouldnothaveanyinteractionwithdrugcompaniesinmedicalschool

0.015 S

F. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

0.016 S

G. Thereisaneedforguidanceregardingrelationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum

0.004 S


77

Table6:CorrelationbetweenParentalIncome(IndependentVariable)andOpiniononGiftsandIncentives.Dependentvariable PearsonChi-


StatisticalSignificanc

eOpinionaboutGifts

Meals 0.309 NSDryFoodsandSnacks 0.308 NSDrugSamples 0.028 SPenandNotepad 0.397 NSTextBooks 0.255 NSStethoscope 0.430 NSMedicalEquipment 0.050 NSStationeryoptions 0.050 NSClothes 0.021 SGiftslessthan10,000BDT

0.037 S

Gifts10001to50,000BDT

0.178 NS

Gifts50,001to100,000BDT

0.158 NS

Giftsmorethan100000BDT

0.341 NS

HospitalTrip 0.081 NSPersonalorFamilyTrip 0.019 SConferenceRegistrationFees

0.393 NS

ConferenceTravelFees 0.062 NSCosmetics 0.052 NSJewelry 0.122 NSComputerAccessories 0.004 SHomeElectronics 0.043 SCookingAccessories 0.000 SUniqueGadgets 0.011 SHomeEquipment 0.001 SGameEquipment 0.358 NSFestivalGifts 0.211 NS5.5.EffectsofPhysicianorpharmacistparentsThe variable ‘Physician Parents’ is strongly

correlated with the opinions about five gifts thatare meals, hospital trip, conference registration,cosmetics, and computer accessories (Table 8). Asonly16respondentshadpharmacistparents(only3.7%oftotal),nocorrelationstatisticswasdoneforthe variable ‘pharmacist parents’. Respondentshaving physician parents are named as ‘PPGroup’andothershavingnophysicianparentsarenamedas‘NPPGroup’.Only 25% of PP Group said meals were

appropriate gifts while 31% said they wereinappropriateand44%wereneutral.Comparingtothat, 41% of the NPP Group said a meal was anappropriate gift, while 33% said it wasinappropriate and 27% were neutral. 44% of PPGroupacceptedahospitaltripasappropriatewhile63% of NPP group said it was appropriate. In thecase of conference registration fees, 59% of NPP

group agreed with appropriateness while 40% ofPPgroupagreed.Appropriateness of cosmetics was agreed by

19% of NPP group and 23% of PP group. It wasconsidered inappropriate in the sense of 67% ofNPP group and 46% of PP group. The strongestcorrelation was found for the opinion aboutcomputeraccessories.Only11%ofPPgroupfounditappropriatewhere34%ofNPPgroupthoughtso.Having physician parents and experience about

the pharmaceutical issue were not found to haveanystrongcorrelation(2sidedPvalue0.069).Table7:SignificantCorrelationsbetweenParentalIncome(IndependentVariable)andAttitudetowardDrugCompaniesandRepresentatives


StatisticalSignificance


A. Theinformationprovidedbydrugrepresentativesabouttheirproductscanbetrusted

0.017 S


0.000 S

C. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

0.030 S

D. Pharmacistsshouldbeaccountabletothepatientsforthedrugtheyprovide

0.033 S

E. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

0.009 S

Table8:ItemsofSignificantCorrelationbetweenPhysicianParents(IndependentVariable)andOpiniononDifferentGiftsandIncentivesDependentvariable

PearsonChi-squareTest:Pvalue(2-

sided)


OpinionaboutGiftsMeals 0.020 SHospitalTrip 0.034 SConferenceRegistrationFees

0.017 S

Cosmetics 0.005 SComputerAccessories

0.000 S

Four out of fifteen statements of attitude were

associated significantly with physician parents ofrespondents(Table9).


Table9:SignificantCorrelationsbetweenPhysicianParents(IndependentVariable)andAttitudestowardDrugCompaniesandRepresentatives




A. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

0.011 S

B. Drugcompanysponsoredseminarsareoftenbiasedinfavoroftheirproducts

0.045 S

C. Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

0.015 S

D. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

0.028 S

5.6.EffectsofExperienceaboutPharmaceuticalCompaniesandRepresentatives

Correlation between personally knowing amedical representative were strongly correlatedwith the opinion about seven gifts - text books,medical equipment, Gifts of 50 thousand to 100thousandBDT,hospital trip, computeraccessories,cooking accessories, and festival gifts (Table 10).Respondents who personally know medicalrepresentativesarenamedas ‘EGroup’andotherswhodonotknowanyrepresentativearenamedasNEgroupwhereEstandsforExperience.

About 84% of E group accepted a textbook asgifts whereas 74% of the NE groups accept that.And only 5% of E group said it inappropriatewhereas 10% of NE group said so. Acceptance ofmedical equipment as gifts was also stronglycorrelatedwithknowinganyrepresentatives.Withmore respondents of E group (85%) agreeing toaccept it while 74% of NE group said so. Theinappropriateness of medical equipment as giftswaslessinEgroup(2.8%vs9.3%).

17%ofEgroupfoundgiftsof50thousandBDTto100thousandBDT(80BDT=1USD)asappropriatebutonly11%ofNEgroupthoughtso.Thestudyfoundthat67%ofEgroupacceptedappropriatenessofhospitaltrip,butonly57%ofNEgroupacceptedthat.NeutralityincaseofhospitaltripwaslessinEgroup(15%vs28%)

Computeraccessorieswereappreciatedasgiftsby 36% persons of E group, but only 29% of NEgroup.MorerespondentsofEgroup(26%)thanNEgroup (16%) thought cooking accessories wereappropriate.FestivalgiftsaremoreappreciatedbyEgroupthanNE(53%vs42%).

Table10:CorrelationbetweenPersonallyKnowingaMedicalRepresentative(IndependentVariable)andOpiniononGiftsandIncentivesDependentvariable PearsonChi-



OpinionaboutGifts

Meals 0.989 NSDryFoodsandSnacks 0.170 NSDrugSamples 0.780 NSPenandNotepad 0.166 NSTextBooks 0.043 SStethoscope 0.254 NSMedicalEquipment 0.018 SStationeryoptions 0.900 NSClothes 0.312 NSGiftslessthan10,000BDT

0.096 NS

Gifts10001to50,000BDT

0.078 NS

Gifts50,001to100,000BDT

0.004 S

Giftsmorethan100000BDT

0.394 NS

HospitalTrip 0.011 SPersonalorFamilyTrip 0.514 NSConferenceRegistrationFees

0.691 NS

ConferenceTravelFees 0.513 NSCosmetics 0.093 NSJewelry 0.476 NSComputerAccessories 0.010 SHomeElectronics 0.128 NSCookingAccessories 0.015 SUniqueGadgets 0.574 NSHomeEquipment 0.186 NSGameEquipment 0.165 NSFestivalGifts 0.028 S

None of fifteen statements of attitude wereassociated significantly with personally knowinganyrepresentativewithPearsonchi-square2-sidedtest.5.7.EffectofBeingTaughtaboutPhysician-pharmacistCollaboration

The variable ‘Taught about Physician-Pharmacist Collaboration’ is strongly correlatedwith opinion about computer accessories only.About40%of respondentswhosaid that theyhadbeen taught about it said it inappropriate while52% of other respondents said so. Among therespondentswhowasnottaughtaboutit,only27%accepted it as appropriate, but 41% of therespondentswhohadbeentaughtsaiditwas.Five out of fifteen statements of attitude were

associated significantly with ‘Taught aboutPhysician-PharmacistCollaboration’(Table11).


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Table11:SignificantCorrelationbetweenBeingTaughtaboutPhysician-PharmacistCollaboration(IndependentVariable)andAttitudestowardDrugCompaniesandRepresentatives




A. Theinformationfromdrugrepresentativesisimportantforthephysicians

0.029 S

B. Itisokforphysicianstoacceptgiftsfromdrugcompaniesbecausedrugcompanieshaveminimalinfluenceonthem

0.033 S

C. Drugrepresentativesareausefulwaytolearnaboutnewdrugs

0.000 S

D. Drugcompanysponsoredseminarsareoftenbiasedinfavoroftheirproducts

0.036 S

E. Fivedrugsfromfivedifferentcompaniesareidenticalintermsofprice,andtherapeuticefficacy.Iwouldpreferentiallyprescribeadrugfromoneofthecompaniesthatprovidedmewithgiftsorincentives.

0.001 S

6. Discussion 6.1.SummaryofResultsThemostcommonmonthlyparentalincomewas

between 20,000 to 50,000 BDT for medicalstudents. Less than 16% medical students had aphysician or pharmacist parent. More than half ofmedicalstudentsdidnotknowanypharmaceuticalrepresentative personally. Almost all the students(89%) said that they were taught about medicalethicsinmedicalcolleges.Butthreequarters(73%)said that they were not taught about ethics ofphysician-pharmacistcollaboration.Mostofthemedicalstudents(85%)didnothave

any experience of interactionwith pharmaceuticalcompany representatives though they were inclinical phases of their education (3rd, 4th, and 5thyear). Drug samples and pen-notepads were themost appreciated pharmaceutical gifts, whereasjewelry and gifts costingmore than 100 thousandBDT (1200 USD) were the least appreciatedpharmaceuticalgifts.Attitude towards drug companies and

representativeswere exploredand themajorityofstudentsfeltthat:• Informationprovidedbydrugcompaniesarenotalways authentic. But the information isimportantforphysicians.

• It is inappropriate to receive pharmaceuticalgifts in spite of the minimal influence ofpharmaceuticalsonphysicians.

• Receiving gifts from pharmaceuticals willeventually affect my prescribing behavior infavorofthem.

• Most drug company sponsored seminars areeducational. Although the programs are biasedinfavorofcompanyproducts.

• Drug companies are an important way oflearningnewdrugs.

• Receiving gifts by physician cause increase ofdrugprices.

• Drug companies act unethically in promotingtheirproducts.

• Companiesshouldbeaccountabletopatientsforthedrugsprovidedbythem.

• Students should not have any interaction withdrug companies in medical school. But drugcompanies can sponsor seminars andeducationalprogramsinmedicalschools.

• Ifadrugcompanyagreestopayfortheprintingcost of all class notes in the undergraduatemedical school, the logo of that companyappearinginthebottomcornerofthefirstslideofthelectureisacceptable.

• Drug companies should not assist students’tuitionfees.

• They will not choose a drug based on givenincentivesorgiftsfromabunchofdrugsofsametherapeuticefficacy.

• There is a need of guidance about therelationship of pharmaceuticals and physiciansintheundergraduatemedicalcurriculum.

• Pharmaceuticals are primarily interested inprofit.However,theystilltrytoworkinthebestinterestofdoctorsandpatients.

TheabovestatementswerefoundtobetruebasedonattitudesofmedicalstudentsofBangladesh.6.2.IdentifiedCorrelations

The sample was enough to represent thepopulation according to the single proportionformula of sample size calculation. Based onstatisticalsignificance,distributionofvariables,chi-squaretest,andPvalues,thefollowingcorrelationsareproposedinBangladesh:Genderofthemedicalstudentisassociatedwith

experience about pharmaceutical reps. More malemedical students know medical representative sandhavehadinteractionsthanfemalestudents.I. More female students think clothes, gifts

costing more than 50 thousand BDT, gameequipment, and personal and family trip areinappropriate gifts than do male students. Thestudy found that the majority of male studentsthink it appropriate to receive gifts less than 10thousand BDT, festival gifts, and computeraccessories: whereas the majority of femalestudentsthinkitinappropriate.Moremalestudents


acceptmeals,textbooks,andconferencetravelfeesappropriate than female students. Only stationeryitems are accepted by more female students thanmalestudents.Change in gender also changes the attitude

towards drug companies and representatives asshown in Table 3. Generally male students weremore supportive of the interactions still themajority of female students than that of malestudents support the following statements: Drugrepresentatives are a useful way to learn newdrugs; Receiving gifts or incentives frompharmaceuticals increases the chance eventuallyfor me to prescribe that product. The majority ofmales agree but majority of female disagree withthefollowingstatement:“Ifadrugcompanyagreedtopayfortheprintingcostofallmyclassnotesintheundergraduatemedicalschool,Iwouldnotmindthelogoofthatcompanyappearinginthebottomcornerofthefirstslideofthelecture”The academic year of study has no association

withtheexperienceaboutpharmaceuticals,buthasastrongassociationwithopinionsonsomespecificgifts and incentives. The percentage of studentsagreeing to the appropriateness of textbooks,stethoscope, stationery items, conferenceregistration fees, and conference travel fees isinversely proportional to the academic year. Themore academic year advances, the more thepercentage falls. The proportion of medicalstudents perceiving inappropriateness of clothes,meals, personal or family trip, game equipment,uniquegadgets,andcomputeraccessoriesasgiftsisproportional to the academic year. The moreacademic year advance, the more the proportionrises.Thirdyear students couldbeabetter target for

drugcompaniesthanlateryears,butthisstudydidnot explore whether that would have a lastinginfluenceonattitudes.Festivalgiftsareacceptedtomore third year students than the fourth and fifthyear. Current academic year affects the attitude ofmedical students significantly. More third-yearstudents than other years support the followingstatements: Drug companies’ sponsorededucational seminars are helpful; Receivingpharmaceutical gifts by physicians increase drugcosts; Students should not have interaction withpharmacists inmedicalschools; Iwillnotchooseadrug from a bunch of drugs of same therapeuticefficacybasedongivenincentivesorgifts. Morefourth-year students than other years appreciatedrugcompaniesasausefulwaytolearnaboutnewdrugs.Parental income has a strong association with

the opinion ofmedical students on some gifts andincentives,andhasa strongcorrelationwithsomestatements of attitudes. Comparing to any other

groups, a majority of students having parentalincomemorethan150thousandBDTconsiderthatthe information provided by drug companies areuseful for physicians. More students havingparentalincome100to150thousandBDTagreetothe following statements than any other parental-income groups: Drug representatives are a usefulwayto learnaboutnewdrugs;Pharmacistsshouldbe accountable to the patients for the drug theyprovide. The majority of medical students havingmonthly-parental-income less than 20 thousandBDT disagree to choose a drug based on givenincentives or gifts from a bunch of drugs of sametherapeuticefficacy.Having physician parents has a strong

association with the opinion on some gifts andincentives. Meals, hospital trips, conferenceregistration fees, and computer accessories areappropriate to more students of non-physicianparents than students of physician parents. Itseems like the students with physician parentswere more sensitive to the influence ofpharmaceutical companies, and that education athomemay have been a positive influence on theirethics.More students who know any medical

representative personally accepts textbooks,hospitaltrip,giftscosting50to100thousandBDT,computer accessories, cooking accessories, festivalgifts, and medical equipment as appropriate giftsmorethanthatofthosewhodonotknow.Teaching on physician-pharmacist interaction

does not affect opinion on gifts and incentivesexcept for computer accessories. Teaching onphysician-pharmacist interaction has an effect onthe attitude of medical students towards drugcompanies and representatives. Support for thefollowing statements increases after teaching:Information of drug companies as important forphysicians;physiciansshouldnotacceptgifts frompharmaceuticals in spite of minimal influence onthem; I will not choose a drug from a bunch ofdrugs of same therapeutic efficacy based on givenincentivesorgifts.Drugcompaniesareacceptedasa usefulway to learnnewdrugs tomore studentswho had not been taught compared to thosestudentswhosaidtheyhadbeentaught.6.3.LimitationsoftheStudyThe study findings should be viewed in the

background of certain methodological limitations.The data collection took place via Google formsonline, so thestudentswhodidnothaveaccess tothe internet couldnotparticipate. Sincedatawerecollected on self-administered questionnaires, wecould not rule out information bias. There is alsosome non-response bias. Anonymity andconfidentialityof therespondentswereensured in


81

thestudy.Hencewedidnothavetheopportunitytoidentify and re-invite the non-responders on aseparateoccasion.Thestatementswereinsufficienttomeasureeveryaspectofattitudes.Alongitudinalorcohortstudycouldprovidemoredata.7. International Comparisons 7.1.ComparisonstotheUnitedStates

MedicalstudentsoftheUnitedStateshavemoreexperience of interactions with pharmaceuticalindustry thanBangladeshimedicalstudentsof this

study. But less American medical students thanBangladeshi students do not agree that receivinggiftswill affect their prescribing behavior (Austadet al., 2013b, Sierles et al., 2005). Austad et al.reported attitude of first and final year students,Sierlesetel.Reportedthird-yearstudents,andKimet al. reported preclinical students (Sierles et al.,2005,Austadetal.,2013b,Kimetal.,2012).DetailsofcomparisonarepresentedinTable12.

Table12:ComparisonoftheattitudesofmedicalstudentstowardspharmaceuticalindustryinBangladeshandtheUnitedStates(%agreeingtothestatement) Bangladesh(this

study)-Finalyearstudents

TheUnitedStates(Austadetal.)-finalyearstudents(Austadetal.,2013b)

TheUnitedStates(Sierlesetal.)-Third-yearstudents(Sierlesetal.,2005)

TheUnitedStates(Kimetal.)-Preclinicalstudents(Kimetal.,2012)

PhysicianParents 12.8 24.8 - -Personallyknownpharmacists

36.6 6.7 - -

Experienceofinteractionwithpharmaceuticalrepresentatives

18.7 44.4 93.2 -

Agreementtothefollowingstatements:Itisacceptableforphysicianstoacceptgiftsfrompharmaceuticals

23.7 - - 41.1

ReceivinggiftsfromrepresentativesincreasesthechancethatIwilleventuallyprescribethedrugcompany’sproducts

52.2 36.3 31.2 -

Educationalprogramsorroundsbydrugcompaniesareeducationalandhelpful

68.1 36.6 89 -

Drugcompaniesshouldsponsorprogramsinmedicalschool

64.1 - - 61.5

Drugcompanysponsoredprogramsareoftenbiasedinfavoroftheirproduct

71.6 76.9 67.4 -

Representativeofdrugcompaniesandtheirmaterialsareusefulwaytolearnnewdrugs

56 30.1 71.3 71

Medicalstudentsshouldnothaveinteractionwithpharmaceuticalrepresentativeinmedicalschools

60 69.8 17.3 56.5

Iwaseducatedaboutphysician-pharmacistinteraction

33.5 69.1 - -

7.2.ComparisontoCanada

No Canadian research on medical studentsregardingthisthemeisavailable.ButSergeantetal.studied the attitude of the Canadian familymedicine residents towards pharmaceuticalindustry (Sergeant et al., 1996). Details ofcomparisonarepresentedinTable13.7.3.ComparisontoGermany:

German medical students have moreexperience of interaction with pharmaceuticalindustry than Bangladeshi medical students. Butless German students than Bangladeshi students

agree that receiving gifts will change theirprescribing behavior. And less German studentsthan Bangladeshi students deny that studentsshould not have interaction with pharmaceuticalsinmedicalschool(LiebandKoch,2013).DetailsofcomparisonarepresentedinTable14.7.4.ComparisontoPakistan

Siddiqui et al (2014) conducted a similarstudy in Pakistani medical students. Indemographics Siddiqui et al. has 31.2%, 44.3%,24.5% medical students of the third, fourth, andfifth year respectively. But we have 17.9%, 23%,


and 59.1% respectively. More Pakistani studentsthanBangladeshistudentsacceptdrugscompaniesto sponsor educational events in medical schools.But More Bangladeshi students than Pakistanistudentsconsidermeals,textbook,pen,stethoscopeas appropriate gifts. Other attitudes sound prettysimilar(Siddiquietal.,2014).DetailsofcomparisoninpresentedinTable15.Table13:ComparisonofattitudestowardspharmaceuticalindustrybetweenmedicalstudentsofBangladeshandResidentsofCanada.Agreementtothefollowingstatements:

BangladeshiMedicalStudents(thisstudy)

CanadianFamilyMedicineResidents(Sergeantetal.,1996)

Theinformationfromdrugrepresentativesisimportantforthephysicians

62.1 58.5

ReceivinggiftsorincentivesfrompharmaceuticalrepresentativesincreasesthechancethatIwilleventuallyrecommend/prescribethedrugcompany’sproducts

49.9 43.4

Thereisaneedforguidanceregardingrelationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum

69.2 45.6

Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

47.6 35.9

Table14:ComparisonoftheattitudetowardspharmaceuticalindustrybetweenmedicalstudentsofBangladeshandGermany. Bangladeshi

MedicalStudents(thisstudy)

GermanMedicalStudents(LiebandKoch,2013)

Experienceofpharmaceuticalinteraction

14.7 87.9

Agreementtothefollowingstatements:Mostseminarssponsoredbydrugcompaniesarehelpfulandeducational

56.9 48

Drugcompanysponsoredseminarsareoftenbiasedinfavoroftheirproducts

73.2 89

Drugrepresentativesareausefulwaytolearnaboutnewdrugs

57.7 61


49.9 25

Studentsshouldnothaveanyinteractionwithdrugcompaniesinmedicalschool

57.7 22

Table15:ComparisonofattitudestowardspharmaceuticalindustrybetweenmedicalstudentsofBangladeshandPakistan Bangladeshi

MedicalStudents(thisstudy)

PakistaniMedicalStudents(Siddiquietal.,2014)

Physicianparents 12 27.1Pharmacistparents 3.7 3Agreementtothefollowingstatements:Medicalstudentsshouldnothaveinteractionwithpharmaceuticalrepresentativeinmedicalschools

57.7 41.3to46

Physiciansshouldnotreceivegiftsinanyform

43.8 25.4to29.1

Acceptablegifts:meals,pen,stethoscope,textbook

38.6to85.5

36.3to40.4

Iwillnotchooseadrugfromabunchofdrugsofsametherapeuticefficacybasedongivenincentivesorgifts.

59.5 56.1to56.5

Theinformationprovidedbydrugrepresentativesabouttheirproductscanbetrusted

34.1 15.8to41.8(significantvariation

amongmedicalcolleges)

Itisacceptablefordrugcompaniessponsorevents/educationalseminarsduringmedicalschool.

64.1 79.8to83.2

Ifadrugcompanyagreedtopayfortheprintingcostofallmyclassnotesintheundergraduatemedicalschool,Iwouldnotmindthelogoofthatcompanyappearinginthebottomcornerofthefirstslideofthelecture.

39.4 39.1to49.1

Thereisaneedforguidanceregardingrelationshipbetweenthepharmaceuticalsandthephysiciansintheundergraduatemedicalcurriculum

69.2 54.9to84.2

(significantvariationamongmedicalcolleges)

7.5.ComparisontoSaudiArabia

No Saudi study on medical studentsregardingthisthemeisavailable.ButtheattitudeofSaudi physicians has been studied (Zaki, 2014).More Saudi physicians than Bangladeshi medicalstudents find information of drug companies asimportant. But less of them accept that drugcompanies are unethically promoting their drugs.More Saudi physicians than Bangladeshi medicalstudentsdisagree thatpharmaceutical incentive tophysiciansincreasesdrugcost.However,lessSaudiphysicians than Bangladeshi medical studentsadmittedbeingaffected inprescribingbehaviorbyreceiving gifts. Other attitudes are more or less


83

similar (Zaki, 2014). Details of comparison inpresentedinTable16.Table16:ComparisonofattitudestowardspharmaceuticalindustrybetweenmedicalstudentsofBangladeshandPhysiciansofSaudiArabia.Agreementtothefollowingstatements:

BangladeshiMedicalStudents(thisstudy)

SaudiPhysicians(Zaki,2014)

Educatedaboutphysician-pharmacistinteraction

27.4 22.8

Personallyknowingadrugrepresentative

33.1 28

Agreementtothefollowingstatements:

Theinformationfromdrugrepresentativesisimportantforthephysicians

62.1 80

Drugrepresentativesareausefulwaytolearnaboutnewdrugs

57.7 65

Mostseminarssponsoredbydrugcompaniesarehelpfulandeducational

56.9 45

Itisokforphysicianstoacceptgiftsfromdrugcompaniesbecausedrugcompanieshaveminimalinfluenceonthem

23.7 20

Theinformationprovidedbydrugrepresentativesabouttheirproductscanbetrusted

34.1 42

Drugcompaniesactunethicallyinpromotingandadvertisingtheirproducts

56.8 31


49.9 34

Giftsfromdrugcompaniestodoctorsleadtoincreasedpricesofmedicines

47.6 27

Drugcompanysponsoredseminarsareoftenbiasedinfavoroftheirproducts

73.2 63

7.6.FurtherInternationalComparisonsofAttitudestowardsGiftsVarious countries reported attitude of medical

students and physicians towards pharmaceuticalgifts.SomecomparisonsarepresentedinTable17.7.7.AttitudestowardsPharmaceuticalGiftsandAssociatedFactors

Among Bangladeshi medical students in thisstudy, drug samples were found to be a moreacceptablegiftthanotherexamples.Itmightbedueto the educational purpose. Drug samples help tolearn about new drugs and formulary. Drugsamples are also appreciated by most students ofSaudi Arabia (Zaki, 2014). But it is not that

acceptable to German and American medicalstudents(LiebandKoch,2013,Sierlesetal.,2005).Pen and notepads are also highly appreciated bymedical students in this study. Probably it helpstheminacademicpurposealot.AbouthalfofSaudiArabian physicians support it, though not thatmuchasBangladeshistudents(Zaki,2014).Jewelrywas most depreciated among the participants inthis study, perhaps because it is a luxury productunrelatedtomedicineoreducation.

More than one-third of students in this studysupported meals as gifts. This proportion is lessthanSaudiArabianphysiciansandGermanmedicalstudents(Zaki,2014,LiebandKoch,2013).Ontheotherhand,averyhighacceptanceofmealsasgifts(more than 70%) is seen among the medicalstudents in Norway and the United States (Lea etal.,2010,Sierlesetal.,2005).Theprobablereasonmay be the difference in economic condition andsocialculture.

Among the academic gifts, textbook andstethoscope were highly appreciated byBangladeshi medical students in this study. It iseven higher than Saudi physicians, medicalstudents of Germany, Norway, and the UnitedStates (Zaki, 2014). More than half of this studyparticipants accepted conference travel fees asappropriate.TheratioisprettysimilartoGermanyandNorway(LiebandKoch,2013,Leaetal.,2010).Evenmore than half of Saudi physicians accept ittoo (Zaki, 2014). But less percentage of the U.S.medical students accept conference travelassistanceasappropriate(Sierlesetal.,2005).More thanhalf ofBangladeshimedical students

in this study considered stationary items asappropriate gifts. But only 36% Saudi physicianssupport that (Zaki, 2014). The acceptance rate ofpersonalorfamilytripsasappropriategiftsis20to30%inthisstudy,inSaudiphysicians,andtheU.S.medical students. But it is only 11.7% amongGermanmedicalstudents(Zaki,2014,Sierlesetal.,2005,LiebandKoch,2013).We also investigated attitude towards some

more gifts such as dry food, medical equipment,clothes, gifts in thedifferent amount, hospital trip,and cosmetics etc. But no significant data isavailable in the literature about them. However,this results also showed a significant correlationbetween opinion on some gifts and students’academic year. This correlation is supported bysomestudiesof theUnitedStates too(Bellinetal.,2004, Fitz et al., 2007). This may be due to thechange in experience and exposure topharmaceutical interaction in different years(Bellinetal.,2004).

This results showed that themore the cost ofgiftsincreased,themoreinappropriateitbecametomedical students. Thus, medical students might

Table 17: International Comparison of Attitude of Medical Students and Physicians towardspharmaceuticalgifts(%inAgreement)Agreementtoappropriatenessofthefollowinggifts:

BangladeshiMedical

Students(thisstudy)

SaudiPhysicians(Zaki,2014)

GermanMedicalStudents(LiebandKoch,2013)

NorwegianMedical

Students(Leaetal.,2010)

TheUnitedStatesMedical

students(Sierlesetal.,

2005)Stationery 52.2 36 - - -Textbook 77 55 64.2 69.1to84.4 71.1Stethoscope 73.6 39 56.5 - -ConferenceTravelFees 57.2 63 52.2 47.7to82.2 35.4ConferenceRegistrationFees

56.3 67 - - -

Pen-Notepad 85.5 50 - - -PersonalorFamilytrip 28 26 11.7 - 30.2Drugsamples 89 66 33.4 - 21.4Meals 38.6 28 46.4 75.5to90.5 77.4

emphasize on ethical behavior more than self-beneficence. Female students felt more neutral orinappropriate about most of the gifts than male.Probablytheyweremoreconcernaboutethicsoritwas a part of the female behavioral difference.However,thisissueshouldbeinvestigatedfurther.We found that textbook, stethoscope, and

conference fees were more popular among thejuniorstudentsthantheseniors.Itmightbeduetoa fact that juniorswere lessexposed to those.Themore students expose to them or use thempersonally, themore acceptability of gifts declines(Bellinetal.,2004).Clothes,gamingandcomputerequipmentandtripsaremoreacceptabletoseniorstudents. But the reason behind it is unknown,shouldbestudied.7.8. Attitudes towards Drug Companies andAssociatedFactorsThe reliability of the information provided by

drug companies was questioned by almost allstudents in this study. They might think thatinformation as fabricated for better promotion bydrug companies. But despite unreliability, theythoughttheinformationasimportantofphysicians.Change in gender and parental income affectedtheir opinion. Literature also suggests thatinformationprovidedbythemhavesomepotentialbias (Kalb, 2004). Most Canadian residents andphysician trainees consider the information asuntrustworthy.Mostof themalsowant toban thistypeofpharmaceuticalpromotion(Hodges,1995).Bangladeshi medical students declined the

appropriateness of accepting pharmaceutical giftswhether they have minimal influence or not,accordingtothisstudy.Femalegenderandformallylearnedstudentsabout the interactiondepreciatedthegiftsmost.Incontrast,asystemicreviewshowsthatmoreclinicalstudentsthanpreclinicalstudentssupport to accept gifts (Austad et al., 2011). Andmost physicians do not perceive any ethical

problem in accepting gifts (Brett et al., 2003,Korensteinetal.,2010).Evenmedicalstudentsalsoappreciate getting gifts or financial support frompharmaceuticals if they have a financial problem(Grande et al., 2009). And when pharmaceuticalcompaniesapproachstudents,theirmainintentionis to introduce themrepeatedlyabout thenameofdrugs and company. In that way, most of thetargeted students easily memorize brand names,promotional products, book titles, and companyname(Sandbergetal.,1997).Although most seminars sponsored by drug

companies are biased in favor of their products,they are helpful and educational, according to thisstudy participants. The academic year of studentsaffected that attitude of them. Similarly,U.S. studyshows that more than half of the U.S. medicalstudents believe those programs as educational.The attitude of students varies from school toschool,regiontoregion,andyeartoyear.Variationof opinion is also seen between exposed andunexposed to pharmaceutical interaction (Grandeet al., 2009). A systemic review shows that moreclinical students than preclinical students supportthoseprogramsaseducational(Austadetal.,2011).About 80% of the U.S. physicians also find theprogramshelpful(Korensteinetal.,2010).Astudyamongmedicalstudentsshowsthatmorethantwo-third of them agree with the biasness of theprograms(Grandeetal.,2009).Abouttwo-thirdofthe U.S. physicians think alike (Korenstein et al.,2010).Evennearlyhalf ofpharmacy students alsothink so (Ashker and Burkiewics, 2007). Butpharmacy students are found to be more taughtaboutdrugmarketingandprofessionalethics thanmedical students. They are generally moresupportive to pharmaceutical gifts and sponsoredseminars(Monaghanetal.,2003).Future doctors of Bangladesh in this study

considereddrugrepresentativesasausefulwaytolearn new drugs. Gender, academic year, parentalincome,physicianparents,andformaleducationon


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physician-pharmacist interaction affected theirconsideration. Variation of the agreement wasfound in different years. Similarly, a systemicreview shows that more clinical students thanpreclinical students agree to the efficacy ofrepresentatives about educating on new drugs(Austad et al., 2011). About 65% U.S. physiciansalso think this as a way to learn new drugs(Korensteinetal.,2010).Pharmaceutical gifts to doctors increase

medicinalprices, this students thought so.Gender,academic year, andphysicianparents affected thisattitude.However,Bangladeshhasnosuchdataofawareness of physicians about patients’ out-of-pocket expenses. In the United States (U.S.),physicians are often unconcerned about thatmatter. A study shows that 88% of the U.S.physiciansagreethatpatients’drugcostsshouldbewithin their financialability.Butonly59%prefersless costly drugs to prescribe.While searching forreasons, only 25% of them believe that it is aresponsibility of physicians. And 69% of thembelieve that it is a responsibility of pharmacists(Shranketal.,2005).Most of this students agreed that receiving

pharmaceutical gifts would change theirprescribingbehaviorinfavorofthatcompany.Lessfemales agreed to that act than males. Academicyearalsoaffectedthatopinion.Similarly,asystemicreview also supports the variation in differentacademic years. It shows that more clinicalstudents than preclinical students are afraid ofbiasness of their futureprescribing after receivinggifts (Austad et al., 2011). A study among the U.S.medicalstudentsshowsthat from29.4%to63.3%students agree to the influence on prescribingwhichmayvaryfromschooltoschool,andyeartoyear(Grandeetal.,2009).Manyfacultiesofmedicalschools of the Unite States think that personalrelationshipaffectsprescribingmorethanreceivinggifts.Theyaskformorerestrictiveregulationsonit(Banks3rdandMainous3rd,1992).MostCanadianresidentsandinternsdisagreetohaveaninfluenceof gifts on their prescribing behavior. And theyadmit having the same behavior and prescriptionwithout any gifts and incentives (Hodges, 1995).Many physicians of Iraq prefer low-cost gifts thanhighcosts.Theyalso switch togenericprescribingoccasionally (Mikhael and Alhilali, 2014). Butpharmaceutical representatives usually have animpact on the prescribing behavior of physicians,claimedbymanystudies(Cleary,1992,Korensteinet al., 2010). Educational assistance, selling andpromoting strategies of pharmaceuticals have asignificant effect on physicians’ prescription(AndaleebandTallman,1995).IntheUnitedStates,giftsorquasi-giftsbyrepresentativesinfluencetheprescribing pattern of physicians (Berger, 2003).

Only detailing by a drug representative can causeselection bias by a physician (Datta and Dave,2016).So, incentivesmayeasilyalteraphysician’schoice of drugs. And if that happens, it will goagainstphysicians’autonomy(Kalb,2004).Drug companies act unethically in promoting

andadvertisingtheirproducts,thatiswhatmostofthe Bangladeshi medical students thought. Moremale students thought it than female studentsdid.However, it can be true. Even sometimesrepresentatives also may feel ethical dilemmas inmarketingproducts.Especiallywhentheydescribethebenefits of their products andoffer incentives,theymaysenseethicaldilemmabutdonotexpressit (Tengilimoglu et al., 2004). Moreover, it ispossibletochangeformandcontentofadrugafterproving its scientific credibility. Sometimesmarketing and promotional strategy becomedifferent in different time and circumstances (vander Hoogte and Pieters, 2010, Bergman et al.,2016).Students should not have any interaction with

drugcompaniesinmedicalschool,accordingtotheopinions of this study participants. Gender andacademic year affected that attitude. Similarly,about33%of theU.S. physicians also suggest thatprohibiting policy (Korenstein et al., 2010). Butsomestudentsmaydesireforthisinteractionwhichvaries in different academic years. A systemicreview suggests that preclinical students thanclinicalstudentsliketohavemoreinteractionwithcompanies(Austadetal.,2011).Most Bangladeshi future doctors think that

pharmacists should be accountable to the patientsfor the drug they provide. Gender and parentalincomewereassociatedfactorofthatopinion.Moremale than female agreed of pharmaceuticalaccountabilitytopatients.However,itistruethatifany drug provided by pharmacists does any harmtopatients,physiciansandpatientscantakelawfulactionagainstthatcompany(Cacciatore,1997).Most participants agreed to have the logo of a

drug company on the first lecture slide if thecompany agrees to pay for the printing cost of allclass notes in themedical school. Gender affectedthatagreementgreatly.More femaledisagreedbutmoremaleagreed.Thisstudyalsofoundthatmostmedicalstudentsacceptdrugcompaniestosponsoreducational events in medical schools. More malethan female significantly supported that matter.Similarly, a systemic review shows that moreclinicalstudentsthanpreclinicalprefereducationalseminars in their medical school (Austad et al.,2011). Moreover, 70% of U.S. physicians alsosupportthatmatter(Korensteinetal.,2010).Evenpharmacy students also support those educationalevents.Astudyshows thatmostof themthink the


eventshelpful toacquiremoreknowledge(AshkerandBurkiewics,2007).FuturedoctorsofBangladeshinthisstudywould

not like tochooseadrug fromabunchofdrugsofsametherapeuticefficacybasedongivenincentivesor gifts. Gender, academic year, parental income,physicianparents, and formal education about theinteraction affected that attitude significantly inthis study. Similarly, a review suggests thatmorethan half of medical students think that gifts willnotinfluencetheirfutureprescribingbehavior.Andmore than one-third think that interaction withpharmaceutical will not affect their prescribingpattern(CarmodyandMansfield,2010).There is a need for guidance regarding

physician-pharmaceutical interaction in theundergraduate medical curriculum of Bangladesh,according to the most opinions in this study. Asonlyafewmedicalstudentsgotaformaleducationabout it. The scenario of other countries alsosupports the fact. A systemic review shows thatmostly less than of half medical students learnabouttheethicalinteractionintheirmedicalschool(Austad et al., 2011). Even in the developedcountries, the knowledge of faculties or residentdoctors about drug marketing, drug cost,pharmacist collaboration can be limited (WatkinsandKimberly,2004).Astudyshowsthatonly40%ofthephysiciansofWashingtonDCagreetohaveastructured curriculum. More of those curriculumssupporttheinteraction.Butmostofthemwanttheinteraction to be with institutional affiliation. Thesourceofdruginformationandethicsofphysician-pharmacist interaction are the most commonsubjects among the curriculums (Evans et al.,2016). Education does influence the attitude ofmedical students and physicians. So, it is highlydemanded. There will be a positive change inbehaviorafterlearningprosandconsofphysician-pharmacist interactions (Vinson et al., 1993)(Hopperetal.,1997).

8. Conclusions and Recommendations 8.1.ConclusionsThe interactions between physicians and

pharmaceutical producers has continued forcenturies. But sometimes, questions of ethics andconflictsofinterestscreatedebates.Pharmaceuticalcompanies offer various gifts to physicians thatvary to be low or high cost, rational or irrational,and ethical or unethical. Gifts, on one side, helppeople to remember the names of new productsand companies. On another side, it may causeselection bias in physicians’ prescriptions. InBangladesh, drug samples, textbooks, stethoscope,pen-notepad, hospital trip, and conference travel-registration fees are highly appreciated amongmedicalstudents.Thechoicesaredifferentinsome

countries. Meals and festival gifts become moreinappropriate as the academicyear advances,maybe due to an increasing professionalism. Parentalincome greatly affects the attitudes towards gifts.Students with low parental income appreciatecomputer accessories and low-cost gifts. Thechoices can have a link to their financial problem.Because,themoreparentalincomegrows,themoreinappropriateness of low-cost gifts increases.Having physician parents also affects the attitudetowards gifts considerably, making them moreneutral. Moreover, personally knowing arepresentativeaffectsthechoiceofgiftstoo.Anditissurprisingthatteachingonpharmaceuticalsdoesnot have any association with gift choices. Thereasonsshouldbethoroughlyinvestigated.The information provided by drug

representatives is not always fully accurate.Potential biases for drug marketing can be seenthere, Bangladeshi students also do support that.There is an ethical question in drug marketingperceived by many medical students,representatives,andpharmacists.Medicalstudentsconsiderpharmaceuticalsasawayoflearningnewdrugs. No ethical problem is revealed in learningnewdrugnames.AcceptinggiftsaredepreciatedbythemostBangladeshimedicalstudents,becauseoftheir ethical concern. They are aware thatpharmaceuticalgiftsmaybias theirprescription inthe future. Most of the medical students do notagreetochooseadrugfromagroupofdrugswithsame therapeutic efficacy based on companyincentives. And it is an obvious unethical matterthat many physicians in the world write biasedprescriptions in favorofcompanieswhogivegifts.The duty of physicians is to recommend themostappropriate drug with high efficacy rate at theirknowledge. Pharmaceutical incentives mayincrease the cost of drugs,manymedical studentsand physicians know that. But they might notconsider it during prescribing. Both pharmacistsand physicians should be concerned aboutmedicinal prices for greater benefits of patients.Evenpharmacistsshouldbeaccountabletopatientsforthedrugstheyprovide.However, pharmaceutical companies often

sponsor educational events in medical schools.Mostofthestudentsandphysiciansknowthosearebiased to theirproducts.But they still support theevents considering the educational value andfinancialneeds,thesupportvariesamongacademicyears. Many students also have interaction withpharmaceuticals in medical schools. Thephenomena are more common in developedcountries than in Bangladesh. But, many studentsand physicians of the world want to prohibit thepharmaceutical interaction in medical schools.However, the attitude of medical students is


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affectedbygender,academicyear,parentalincome,physician parents, and formal education onpharmaceutical interaction. The attitude may alsovary in different settings, medical schools, andcountries. But it is really astonishing thatpersonallyknowingrepresentativesdoesnotaffecttheattitude.Medicalschoolsdonotprovideenoughteaching

onpharmaceuticalinteraction.Formaleducationonmedical ethics and ethics of physician-pharmacistinteraction can promotemore promising behaviorandethicalmedicalpractice.Formaleducationalsomay help students to set a better attitude.Collaborationbetweenphysiciansandpharmacistsisdefinitelynecessaryforbetterhealthcare.But itis better if the collaboration occurs in a moreethicalway.8.2Recommendations

The following recommendations are suggestedaccordingtothisstudyfindings:A. RecommendationforMedicalStudents:1. Medical students should learn themselvesaboutethicalaspectsofpharmaceuticalgifts.2. Thefinancialproblemshouldbebalancedwiththeacceptanceofpharmaceuticalgifts.3. Drug samples, pen-notepad, textbook,stethoscope, and other educational equipment canbeacceptabletocertainlimits.Medicalschoolscandeterminethelimits.4. Students can accept hospital trips, conferenceregistration-travel fees, and financial assistancefrom pharmaceuticals within a certain limit onlythey are in financial crisis and if they disagree towritebiasedprescriptionsinthefuture.5. Medical schools should form guidelines onpharmaceutical gifts for students with pros andconslisted.6. Theyshouldbeintroducedbymedicalschoolsto sources of drug information other thanrepresentatives.7. Studentsshouldevaluatethepossiblepositiveand negative aspects of the information providedbypharmaceuticals.8. Medical schools should train studentsonhowcan they avoid the influenceofpharmaceuticals inthefuturepracticallife.9. Studentsshouldtakeonlytheeducationalpartwhen theyattendanyseminaroreventsponsoredbydrugcompanies.10. Studentsshouldinteractwithmorepatientsinthe clinical wards and know more about theirfinancialproblemstobuydrugs.11. Students should evaluate themselves aboutpositive-negative and ethical-unethical aspects ofthemarketingstrategyofdrugcompanies.

12. Students should have less interaction withpharmaceuticals in medical schools, they shouldnotinteractbeforelearningethics.13. Students should avoid financial assistancefrom drug companies unless they are in extremefinancial crisis. Medical schools can increasefinancialaidstostudents.14. Studentsshould learnappropriateprescribingofdrugsfromagroupofdrugsofsametherapeuticindicationandefficacy.B. An inclusion of ethics of physician-pharmaceutical interaction should be includedintheundergraduatecurriculum.Thefollowingtopicsshouldatleastbetaught:1. Ethicsofphysician-pharmaceuticalinteraction,nationalandinternationalguidelines2. Ethicsofdrugprescribing3. Physician-patient and pharmacist-patientrelationship4. Limitsandeffectsof receivingpharmaceuticalgifts5. History of pharmaceutical reform in differentcountries6. Current policies and scenario in differentcountries7. Marketingstrategyofpharmaceuticals8. Ethicsforpharmacists9. Difference in ethics for medical students andphysicians10. EffectofprescribingonmedicinalpricesC. Recommendationforphysicians:1. Physiciansshouldtrytominimizetheeffectofdrugrepresentativeswhileprescribingrationally.2. Physicians should consider drug prices whileprescribingforpoorpatients.3. Physicians should rationally evaluate theinformationprovidedbydrugcompanies.4. Physiciansoughttobeconcernedaboutethicalmeasuresofpharmaceuticalmarketing.5. Physicians canmove to generic prescribing iftheyfeelethicaldilemmaduringpractice.6. If some drugs have same therapeutic efficacyand equally indicated for a patient, a physicianshould choose the cheaper one, not the promotedonebypharmacists.7. Physicians should decrease their dependenceondrugindustries8. Physicians should adhere to all statements ofmedical ethics and ethics of pharmaceuticalpracticebyallmeansD. Recommendations for pharmaceuticalcompanies:1. Pharmaceutical companies should promotetheirproductswithintheethicallimit.


2. New drugs with same therapeutic efficacyshouldnotbemarketedforbetterbusiness.3. Pharmaceutical companies should makethemselves concerned about medicinal price andpatients’affordability.4. Helping people should be prioritized thangainingprofits.5. Pharmaceuticalcompaniesshouldalsoreceivetheideaof‘donoharm’forpatients.6. The companies should be accountable topatientsforthedrugstheysupplied7. Drug companies shouldhaveanethicalboardregulating ethical matters of promotion.Representatives should report their activities tothatcommittee8. Pharmaceuticalsshouldreportnationalethicalcouncilabout theirannualmarketingandbusinessforethicalclearance.RecommendationsfortheGovernment:

The government should establish an ethicalbody tomaintain ethics in the health system. Theethical body can maintain all issues in nationallyincluding physician-pharmacist collaboration.Pharmaceuticals should report their annualactivitiestothatethicalboard.Anationalguidelinein this issue is needed to be structured soon.Guidelines on ethics of receiving pharmaceuticalgifts and interaction should bemore clarified. Thegovernment can train teachers and faculties ofmedicalschoolsinthisissuesothattheycanpassiton to medical students. The national ethical bodycanestablishethicalmonitoringboardsindifferenthospitals to maintain different aspects of medicalethics.

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The perception of Muslim motifs and juridical authorities of the concept of health and its function in issuing fatwas on abortion -SaeidehSayariUniversityofMalaya,KualaLumpur,MalaysiaEmail:saeideh_sayari@aol.com-DarrylMacerAmericanUniversityofSovereignNations-SitiNuranibintiNorUniversityofMalaya,KualaLumpur,Malaysia Abstract Muslim jurisprudents and muftis issue fatwas onabortion based on Ijtihad. Three fundamentalprinciplesofIjtihadindicatethatjurisprudencehasto consider the changes of the time and place, thepublicinterest,andtheleastharminissuingfatwas.However, many ignore these principles since theystick to the traditional concept of health which istheirbasistoissuefatwas.Inthispaper,weanalyzehow Islamic jurisprudence, through using theseprinciples in perception of the concept of health,can help to solve the illegal abortion crisis inMuslimcountries.1. Introduction Abortion is a global health issue and illegal andunsafeabortionsleadtothedeathsofanestimated68,000 women every year. Many of these deathsoccur incountrieswitha largeMuslimpopulation,and in someof these countries the lawsarebasedonIslamiclaw.AsummaryofthelegalprovisionsispresentedlaterinthispaperinTable1.

Since two main sources of the polices forlegislation about abortion are the political policiesandreligioustransitions,inIslamiccountrieswhichfollowtheIslamiclaw(shari‘a)theguidanceontheact of abortion originates from religious decreeswhich jurisprudents extract from the sources ofreligion,Qurʾānandtradition.

The jurisprudentsextract somedecreesbasedon dignity of human life and hadith (narrationsfromtheprophet’s lifeanddecisions) inwhichtheprophetandotherreligiousleadersmadedecisionsbasedontheconceptsofhumanlife.Thekeypointhereisthatthesedecreesnormallyoriginatedfromthejurisprudents’interpretationsofthehadithandalsothemaindoctrineofthedignityofhumanlife.Theseinterpretationsreflectthehistorical,cultural,social, political, economic, ethical, and scientificrealities of the era. In other words, thejurisprudents issue the decree based on theirknowledge of their time and concepts which theyhave, for example, the concept of human life and

human health. According to Muslim juridicalattitudes,healthylifeisidentifiedasphysicalhealthalthough some of jurisprudents recently alsoconsidermentalhealth in issuing fatwas.Basedonthis approach, juridical authorities issue fatwasonabortion in the cases in which mother’s life isendangered.

According to the holistic concept of healthdefined by theWorld Health Organization (WHO),health includes physical, mental, and social well-being and not merely the absence of disease. 1Therefore, healthy life is considered as acomplicated, integrated, intertwined, andmultidimensionalnetwhichisrelatedtoallaspectsof human life, such asphysical,mental, social, andspiritualaspects.Theeliminationofanyaspectsofthismulti-facetedphenomenonmayleadtomakingharmfuldecisionsonhumanlife.

In this paper, we argue that the reductionistideas of some Muslim juridical authorities on theconceptofhealthfollowsonthetraditionalconceptofhealth according towhich the conceptofhealthwaslimitedtophysicalhealth.Wewilldiscussthatthe adherence to the traditional concept of healthcauses us to ignore the fundamental principles ofijtihad(makingeffort toextract the rules form theQurʾānandSunnah).Theseprinciplesare:1-Lawschangewithchangesintimeandplace2-Choosingthelesseroftwoharms3-Preservingpublicinterest2

Theimportanceofdiscussingthesubjectisthat

notonlywecanseetheeffectsofthereligiousideasand decrees about the concept of the heath onreproductive behavior in Muslim countries, eventhosesuchasTurkeywithasecularparliament,butalso they are seen among theMuslimmigrants inthesecularcountries(Arousell&Carlbom,2016). 2. Methods This study is qualitative using published data andanalyses, and academic papers on a variety oftopics about abortion, and uses philosophical andtheologicalanalysis.ThisresearchlooksattheissuethroughthelensofIslamicjurisprudence.

1 Preamble to the Constitution of the World HealthOrganization as adopted by the International HealthConference, New York, 19-22 June, 1946; signed on 22July 1946 by representatives of 61 States (OfficialRecordsoftheWorldHealthOrganization,no.2,p.100)andenteredintoforceon7April1948.2 SubhiMahmassani,Falsafatal-Tashri‘ fial-Islam,Daral-‘Ilmlil-Malayin,Beirut,1961,pp.200-207,408;AzizahY.al-Hibri,“Islamicconstitutionalismandtheconceptof democracy.”CasewesternreservejournalofInternationallaw.24,1(1992):3-10.


3. The traditional vs. the modern concept of health The traditionalnotionofhealthwasconsideredasbeing in a disease-free state.While this concept issilent about the mental and social aspects, theWorld Health Organization (WHO) refers to threeaspectsofhealth,physical,mental,andsocialwell-being.AccordingtoBalgo(1978),health isdefinedas, “astateofbodyandmindfunctioningwellwhichaffords man the ability to strive towards his bothfunctionalobjectivesandculturallydesiredgoals.”

Inthepast,healthylifewaslimitedtophysicallife since human knowledgewas limited to simplerulesofthephysicalbody.AlthoughPlato,Aristotleandotherphilosophersdealtwiththenon-physicalpart of the human being as the soul 3 , theirexplanations were connected to moral rules.Therefore,theirattitudesrefertotheresponsibilityof the human being to improve her/his soul.However, psychology as a scientific field beganaround 200 years ago with Fechner’s critique ofKant’sstrictureagainstquantitativestudyofmind.4Then, many schools and fields developed inpsychology. These developments in psychologyclarified the effects of the physical body on thementalaspect,andviceversa.

Ontheotherhand,newfindingsthrewlightonthe dependence of the social and environmentalfactors on the physical andmental part of humanbeings. In fact, human life was considered as asystem in three dimensions, physical, mental, andsocio-environmental. Hence, the healthy life alsodependsonthethreementionedparts.Asaresult,in 1946, WHO declared that health includesphysical,mental,andsocialwell-beingandnotonlyphysical health. Therefore, the policy of health inmany countries changed. For example, the UKgovernment published a document as a policy forhealth in2010.Thisdocument states that, “mentalhealthandwell-beingarealsocriticaldimensionsofhealth.Weknowthatmentalillhealthisresponsiblefor a high proportion of the overall burden of illhealthandprevalencehasbeenrising.Wealsoknowthat mental health and well being are importantfactors for physical health” (Our Health and WellBeing Today, 2010).5Islamic countries, especiallythe countries mentioned in this research aremember countries of WHO. Therefore, since thedefinitions, rules, and principles of WHO includethemembers,Islamiccountriesarealsoexpectedtofollowitsrules.

3 Aristotle's Psychology. Stanford Encyclopedia ofPhilosophy.4ThomasH.Leahey,AHistoryofModernPsychology,3rdEdition,Pearson,2001.5 Our Health and Well Being Today, Department ofHealth,WellingtonHouse,2010,p.3.www.dh.gov.uk.

Infact,byaddingthesocialandpsychologicalaspects, WHO (and thus all member statesofficially) acknowledge that the concept of healthand illness are multi-causal, and the focus shiftedfrom a strictlymedical perspective in the absenceof illness to evaluation of a person’s status(Boruchovitch & Mednick 2002). Over history wecan see cycles of over-emphasis on law and over-emphasis on love as the guidance of religions andpractice, but the abortion laws need to considermoreoftheloveoflifeforallmoralagents,notjustforthefetus(Macer1998).

4. The traditional concept of health in contrast to the fundamental principles of ijtihad 4.1. The first principle: Laws change with changes in time and place As mentioned above, in the past, healthy life wasconsidered as life without physical illness.Therefore, twootheraspectsofhealth,mentalandsocial well-being were generally not consideredamong the authorities in health and among lawmakers. Muslim jurisprudents were notexceptional. In issuing the fatwas, they consideredthe traditional conceptofhealth, as theydo today.However, based on the fundamental principle ofijtihad,lawschangewithchangesintimeandplace.

In Islam, God has the supreme legislativepower; however, God changed His commandswhichHesenttopeoplethroughprophets.GodsaidinQurʾān, “NoneofOurrevelationsdoWeabrogateor cause to be forgotten, but We substitutesomething better or similar: Knowest thou not thatAllah Hath power over all things?”6 We can findmanyexamplesontheissue.

Changing the divine rules and command(abrogation) does happen within a religion orbetweenreligions.Forexample, theTorahallowedthebelieverstodivorce;7however,Christrejecteditfor his followers.8Another example is about theabrogationofadivinelawwithinIslam;Godatfirstcommanded to strict punishment for women whocommitted adultery; then God changed thepunishment into the milder law. 9 The reasonbehind these changes, in general, is that changeshappened in the human cultural, social, historical,political, individual, and even physiologicalcircumstances.

Therefore, the fundamental principle ofchanging the laws based on the time and placeoriginate from God Himself. In many cases, the 62:106.7BookofDeuteronomy,chapter2.8TheNewTestament,GospelMatthew:19;GospelLuke:16.9Qurʾān,4:15and16;24:2


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juridicalmuftischangedtheir fatwas.Forexample,to have more than one wife for men in Islamicrealm was accepted; however, in some Islamiccountries such as Iran, it has caused manyproblemsforfamilies,childrenandwomen.Finally,some jurisprudents reformed their fatwas; in thiscase, they argue that if a woman considers thisIslamic rule as an insulting law to herself as ahuman being, it should be prohibited in thatsociety.10

4.2. The second principle: Choosing the lesser of two harms Oneofthemostimportantreasonsforchangingthelaws (the first Principle) is to reduce harms inhuman life.Forexample,before Islam,marriage totwosistersatthesametimeforamanwasallowedin some Abrahamic traditions11but Islam forbadeit12since itwasharmful to thesiblingrelationship.The clearest example of this principle is theprohibition of drinkingwine in the Qurʾān. “Theyask thee concerning wine and gambling. Say: ‘inthem is great sin, and someprofit, formen; but thesin is greater than the profit’.”13God explained topeople about the advantages anddisadvantages ofdrinkingwine,however,sinceitsdisadvantagesaregreater, Muslims were not allowed to drinkalthoughitwasnotforbiddeninpreviousreligions(e.g.JudaismandChristianity).

Therefore,thesupremelawmaker,God,enactsbasedonthelessharmfulside.Somejurisprudentsalso followed this principle in social cases; forexample, marriage to non-Muslims often wasforbidden but recently some Islamic scholars orjurisprudents rejected that and allowall people tomarrytopeopleinotherreligions.14

4.3. The third principle: Preserving public interest Thethirdprinciplehighlightsthepublicinterest.InIslamic jurisprudence, there are many cases inwhichmuftisissuedorchangedthefatwasbecauseof public interest. For instance, in 1892, AyatullahShirazi, one of the muftis in Iran, issued a fatwaaccording to which using tobacco was forbidden(ḥarām)forIranianMuslims;then,peoplebrokeallhookahs,sothekingwasforcedtocancelthetreatywithatobaccocompanyinUK.Inanotherexample,in 1808, Russia attacked Iran and the governmentneededtoaskpeopletofight.Then,thekingasked

10http://fararu.com/fa/news/10568.30April2008.11SuchasthemarriageofJacobtoShuaib’sdaughters.12Qurʾān,4:23.13Qurʾān,2:129.14 Ahmad,Ghabel. 2013. jurisprudence, functions andcapabilities . SHariate Aqlani publisher, www. Ghabel.Net.

themoftiestoissueafatwaforencouragingpeopleto fight with enemy. They also allowed thegovernment to take religious payments such aszakāt to provide theneeds of the soldiers.15Thesejurisprudents issued the fatwa based on a well-known principle in Islamic tradition; the profit ofMuslim community must be kept, therefore,everything which is harmful or has disadvantageforMuslimsshouldbeavoided.

5. The concept of health on abortion according to principles of Ijtihad The current fatwas on abortion indicate thatabortion is generally forbidden except in seriousconditions in which mother’s life is endangered.Table1showstheabortionlawsinvariousIslamiccountries.Thebaseofthese lawsare fatwaswhichareissuedbyreligiousauthorities.

The first principle of Ijtihad refers to changesintermsoftimeandplace.Theconceptsoftimeandplace, indicate the social, cultural, economic, andpolitical conditions. Jurisprudents issue fatwasaccording to the need of people for a better life.Also, they issue fatwas in conditions in whichsociety faces a problem. Based on these facts,abortionisacrisisinmostoftheIslamiccountries,suchasIran,Indonesia,Bangladesh,andPakistan.16Tosolvetheproblem, lawmakersneednew fatwasinIslamiccountries.

The crisis is not limited to individuals orfamilies, but it affects all the society of a countryandeventheglobalsociety.Thehighrateofunsafeabortions, of unhealthy children, of maternalmortality, and of economic crises clearlydemonstratesaneedtorevisetherulesandfatwas.

Accordingtothesecondprincipleofijtihad,thejuridicalcirclesmust issuea fatwawith lessharm.We argue that legal abortion has somedisadvantages such as physical and mentalproblems after the abortion; however, illegalabortions and unwanted children impose a hugecostonsociety.Inlegalabortion,motherandfamilywill get over the physical and mental problemsaftera fewweeksora fewmonths,but inthecaseof unsafe abortion, it may lead to the death ofmother or serious infections or disabilities. Besidethis, in thecaseofunwantedchildren,mother, theunwantedchild,theexistingchildren,family,and

15ShykhJafarKāshif al-Gheṭā,kashfal-ghiṭā,n.d.,Qum,daftartablighatislami.16 “New project to help reduce unsafe abortion death rates in disaster zones “University of Leicester-led research aimed to implement intervention measures for reproductive health issues in disaster-prone countries. http://www2.le.ac.uk/offices/press/press-releases/2015/november/new-project-to-help-reduce-unsafe-abortion-death-rates.


Table1Thenumberofreasons(1,2,…)justifyinglegalabortionsinMuslim-majoritycountries(2011)

1 2 3 4 5 6 7AfghanistanL ComorosL.PH AlgeriaL.PH.MH BurkinaFasoL.PH.F.I/R AlbaniaBangladeshL IranL.F ChadL.PH.F GuineaL.PH.F.I/R AzerbaijanBruneiL JordanL.PH GambiaL.PH.MH BahrainDjiboutiL MaliL.I/R KuwaitL.PH.F KazakhstanEgyptL MaldivesL.PH MalaysiaL.PH.MH KyrgyzstanGuinea-BissauL MoroccoL.PH NigerL.PH.F TajikistanIndonesiaL PakistanL.PH QatarL.PH.F TunisiaIraqL SaudiArabiaL.PH SierraLeoneL.PH.MH TurkeyLebanonL SudanL.R TurkmenistanLibyaL UzbekistanMauritaniaL NigeriaL OmanL SenegalL SomaliaL SyriaL UnitedArabEmiratesL YemenL 18(38.30%) 9(19.15%) 8(17.02%) 2(4.26%) 0 0 10(21.28%)Grounds:L:Abortionallowedtosavethelifeofthewoman;PH:Abortionallowedincaseswherethepregnancythreatensawoman’s physical health; MH: Abortion allowed in cases where pregnancy threatens the woman’s mental health; F:Abortionallowedincasesoffetalimpairment;I/R:Abortionisallowedincasesofincestorrape;SER:Abortionallowedonadditionalenumeratedgroundsrelatingtosuchfactorsasawoman’sageorcapacitytocareforachild.Source: Gilla K Shapiro, “Abortion law in Muslim-majority countries: an overview of the Islamic discourse with policyimplications,”Healthpolicyandplanning,2014:29,483-494.

the society will be influenced by physical, mental,andsocialhealthproblems.

Finally, regarding the third fundamentalprinciple of ijtihad, juridical authorities shouldconsiderthepublic interestwhichisnot limitedtojustonesocietybut relates to thewholeofhumansociety. For example, according to the Center forBiological Diversity, “A 2009 study of therelationship between population growth and globalwarmingdeterminedthatthe“carbonlegacy”ofjustonechildcanproduce20timesmoregreenhousegasthanapersonwillsavebydrivingahigh-mileagecar,recycling,usingenergy-efficientappliancesandlightbulbs, etc. Each child born in the United Stateswilladdabout9,441metrictonsofcarbondioxidetothecarbon legacy of an average parent. The studyconcludes, “Clearly, the potential savings fromreduced reproduction are huge compared to thesavings that can be achieved by changes inlifestyle.”17

17“Humanpopulationgrowthandclimatechange”.Centerforbiologicaldiversity.http://www.biologicaldiversity.org.

According to the United Nations PopulationFund,“humanpopulationgrewfrom1.6billionto6.1billionpeopleduringthecourseof the20thcentury.During that time emissions of CO2, the leadinggreenhouse gas, grew 12-fold. And with worldwidepopulation expected to surpassninebillionover thenext 50 years, environmentalists and others areworriedabout theabilityof theplanet towithstandthe added load of greenhouse gases entering theatmosphereandwreakinghavoconecosystems.”18 6. Conclusion Ijtihadreliesonthreefundamentalprincipleswhichindicate the flexibility of shari‘a’s laws in terms ofthechangesinthehumansocieties.Theconceptofhealth on which jurisprudents issue their fatwaschangedinthenewworld.Inthepast,thisconceptrefereedtomerelytheabsenceofillness.However,now, this concept includes physical, mental, andsocialwell-being. Juridical authorities issue fatwasabout abortion based on the previous concept ofhealth. This fatwas ignore the fundamental 18 “Does population growth impact climate change?” Scientific American. https://www.scientificamerican.com.


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principles of the ijtihad from which these fatwasoriginated.

References Ahmad,Ghabel. 2013. jurisprudence, functions andcapabilities. SHariateAqlanipublisher,www.Ghabel.Net.

J, Arousell, A. Carlbom. 2016. “Culture and religiousbeliefsinrelationtoreproductivehealth.”Bestpractice& research clinical obstetricsandgynaecology. 32: 77-87.

Balog,J.E.(1978).Anhistoricalreviewandphilosophicalanalysis of alternative concepts of health and theirrelationship to health education (Unpublisheddissertation). Maryland: University of Maryland, p.115.

Boruchovitch,E.Mednick,B.R.(2002).“Themeaningofhealth and illness: some considerations for healthpsychology.”Psico-USF.7(2):175-183.

Macer, D.R.J.,Bioethics is the Love of Life. Eubios EthicsInstitute,1998.

Gilla K Shapiro, “Abortion law in Muslim-majoritycountries: an overview of the Islamic discourse withpolicy implications,”Healthpolicyandplanning,2014:29,483-494.

The Ethical Dilemma of Human Germline Editing -CarolRizkallaRoyalCollegeofSurgeonsinIreland,Dublin,Ireland[PostalAddress:104PanatellaRiseNW,Calgary,Alberta]Email:[email protected] 1. Introduction Geneeditingprovidesuswith theability todesignandeditgenomesofbiologicalentitiesgivingthemnew properties. A new technology named theCRISPR/Cas9 system allows for fast andinexpensivegeneediting(1).ApieceofRNA,calledguide RNA, contains a set of bases which arecomplementarytothetargetsequenceontheDNA.The Cas 9 enzyme will follow the guide and willmake a cut across bothDNA strands. The affectedcell then recognizes the DNA damage and tries torepair it; this is thepointwhere scientists canuseDNA repair methods to introduce a geneticmutation(2).

Deliberatelymanipulatingthehumangermlinefor the avoidance of severe inherited diseases hasgenerally been viewed as acceptable, whereas for‘enhancement’ofhumancapabilities insomecasesit has been deemed ethical, but in others not. Adisease is any disturbance to the structure orfunction of the body. There are various types ofdiseases, ranging frommetabolic to inflammatory,from neoplastic to degenerative, and of course,

there are also genetic diseases (3). If there was away to prevent one of these diseases, shouldfurther exploration be encouraged? Assuming asolutionisfound,woulditbeacceptabletousethetechnology for human enhancement? Or are theethicaldifferencestoogreattoovercome?

Should a temporary or permanent global banonhumangermlineeditingbeintroducedand,ifso,on what basis? Is there an ethical differencebetween using gene editing for the avoidance ofsevere inherited diseases or for ‘enhancement’ ofhumancapabilities?SincethegeneticchangesmadeintheDNAofgametesandembryoswillimpactandwill be inherited through the generations, a broadrangeofdiscussionsontheprospectofenforcingaglobal ban due to the implications of thistechnologyhasbegun(4). 2. Offside effects Regarding theCRISPR/Cas9 technology,oneof theconcerns that have developed is regarding itsaccuracy. In theory, it will bind to the targetsequence and no other region. However, whenworking with enzymes that cleave the chains ofnucleotides, such as CRISPR/Cas9, there are off-target effects towards other locations in thegenome that share similar arrangements with thedestination (5). Since the side effects will be anissue, there have been cultural strategies (6) andchemicalmolecules (7) thathavebeenreported toincrease the efficiency of genome editing. Furtherexamination is required to test the possibledetrimentaleffectsoncellsorembryosexposedtosuchconditions.

However, in themeantime,bioinformaticshasdeveloped a predictive scoring system thatidentifies determinants that influence Cas9efficiency towards targets, which should improveoutcomesbydecreasing themosaicismrate (whenthe genetic makeup of some cells varies fromothers)(8).3. Human embryos, a requirement for the development of research in the field The concern regarding the inability to predict theconsequences of such a procedure highlights theneed for more data on the safety of suchinterventions, and techniques that could increasethe efficiency (9). The preferred solution todiscarding affected embryos would be using non-viableembryos.TheseembryosmayresultfromInVitro Fertilization, but consent from the donorcouplemustfirstbeobtained.


Figure 1: “An international regulatory landscaperegardinghumangermlinegenemodification.Thirty-ninecountriesweresurveyedandcategorizedas“Banbased on legislation” (25, pink), “Ban based onguidelines”(4,faintpink),“Ambiguous”(9,gray),and“Restrictive” (1, light gray). Non-colored countrieswereexcludedinthissurvey.”(14)

Likewise, adult somatic cells give rise to

human induced pluripotent stem cells, thereforelessening the ethical concerns. Recent discoverieshave reported that human induced pluripotentstem cells can differentiate into male germ cellswiththeuseofbonemorphogeneticproteins.Thereis no record of hiPSCs differentiating into humanoocytes, but the scientific community ishopeful inthedatatocomefromcurrentexperimentsonmice(7). Further research must be conducted on theviabilityof inducedgermcells todetermine if theycan successfully undergo fertilization and produceviableembryos.

Therefore, a necessary component in thepreclinicalstageassessmentmaybeusingembryoscreated from human embryonic stem cells as acomparison tool to ensure the reliability ofembryos formedusinghiPSC’s.However, toobtainembryonic stem cells, the destruction of theembryoensuesaftercellextraction(10).Themoral

dilemmahereiswhetherthedutytopreventfuturesuffering is greater than the obligation to respectthevalueofapotentialhumanlife.Thereisabroadrange of views concerning whether or not theembryohasthestatusofaperson;thishascreateda barrier to further discovery due to currentrestrictionsinvariouscountries.4. Varying national laws Many countries or states have different ethicalpolicies regarding the use or creation of a humanembryo for research. In some countries, wherethere is an overabundance in cryopreservedembryos originally intended for In VitroFertilization, researchers are permitted to utilizethem with informed consent from the donorparents and bymeeting guidelines of institutionalreview boards (11). Of the countries that allowusing embryos for research purposes, there is arestriction to the culture period: 14 days or untiltheprimitivestreakforms(7).

In some countries, using germline genemodification is prohibited until gene correction isenhanced (China, India, Ireland, Japan). The USNational Academy of Sciences and the NationalAcademyofMedicinehavecomeoutwithareport(February2017)outliningseveral criteria toallowgermlineeditingclinicaltrialstocontinue(12).The


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rules include that the benefits must outweigh therisks, a risk of damage to the human embryowillprohibitadvancement(13),andtheobjectiveoughtto be the prevention of a severely debilitatingdisease.Incontrast,theUKdoesnotbantheuseofhuman embryos for the sake of reproductiveresearch as long as theHFEA (regulator in theUKresponsibleforoverseeingthehandlingofembryosand gametes in research and fertility treatments)approves(14).5. Making a distinction The Liang Study used non-viable triponuclearzygotes with a debilitating disease to investigatetheuseofCRISPR/Cas9geneeditingonhumancellsto improve data on clinical applications of thistechnology (15). This study underwent a publicoutcry; people were calling it the making of‘designerbabies’(16).

Some individuals may find it more morallyappropriate to administer genetic interventions inonecaseoveranother.Interventionsforgeneticallyhealthypersonsareenhancements,whereas in thelattercase theyareconsidered therapy.Somemaysay that enhancement expresses dissatisfaction;conversely, some see it as an opportunity toimprove. However, the concept of improvement isnotmorallycontentiousaswedomanyactivitiesinour lives to improve ourselves, some of whichbeing:education,research,andfitness.

Eachpersonisentitledtorelief;weseethatthedistinction solely focuses on the etiology ratherthan the degree of suffering (17). A physician'sprofessional responsibility to choose the optimaltreatment that promotes quality of life, andrespecting an individual's reproductive autonomyare valid reasons to move forward with germlineinterventions(18).6. Addressing influential factors There are two aspects to a disability: themedicalaspect and the social aspect. Society oftencategorizes individuals with impairments asdisabled,whichprevents them from takingpart ineveryday life (19). Disabilities are more oftenacquired through an individual’s environmentrather than inherited; meaning that the socialaspectofadisabilityisavalidconcernthatoughttobeprioritizedtoencouragepeoplewithdisabilitiesto live ordinary lives (20). On the other hand,individualswithmedicaldisabilities,inwhichtheirbody is impaired in some sort due to a geneticabnormality, can benefit tremendously with thistechnology.Theethical,legalandsocialframeworkthat will result from the broad adoption of thesetechnologies must be considered. The ever-occurring question when addressing humangermline editing for severe inherited diseases is:

what is seen as a ‘severe’ genetic disease? Ethicaldiscussions must take place as anticipatorygovernance; we cannot have a future stall intechnologicaladvancementduetoalackofdialogueinourcurrenttime(21).7. Establishing an ethics committee dedicated to human germline editing Before considering clinical applications, thereshould be a committee in place for each countrythatpermitsthepracticeofgermlinemodifications.The research group at the Francis Crick Instituteobtained approval from the HFEA in regards toconducting experiments involving CRISPR/Cas9editingofhumanpreimplantationembryos(22).

The UK Health Ministers appoint HFEAmembers based on guidelines (the ‘Nolan’guidelines) that ensure appropriate merit. Also,members of the HFEA have a broad range ofexpertise tomaintain an objective view. Membersrange from professions in the field ofmedicine tothe field of law and from philosophy to religion(22). Further, the fertility clinics and researchcentres ought to adhere to the ethical rules andsafetyprotocolsestablishedbytheUKgovernment.Regular inspection of these locations by theHFEAwill ensurecompliance. Further, adherence to theethical rules and safety protocols set by the UKgovernmentwillbeenforcedby theHFEAthroughregular inspection of UK fertility clinics andresearchcentres(22).

Knowing thattechnical concerns willeventually be resolved by additional scientificresearch,moralconsiderationsmustbethepointoffocus of public debate (10). Countries shouldestablish an ethics committee to tackle the ethicaldilemmas according to the ethical rules placed bythe country’s government. After carefulconsiderationof theethicalandsocial implicationsofsuchatechnology,acountrywillthenbeabletoestablishpoliciesbettersuitedfortheirvaluesandbeliefs.8. Just distribution scheme The ethics committee dedicated specifically to theediting of human genomes will need to developpolicies thatwill be the sole source of consolationwhenitcomestoethicalpuzzlestoavoidmisusebycertainindividualsororganizations.

Toaddresstheconcernof‘designerbabies,’weshould discourage inventions that promotepositional advantage and rather posit a justdistribution scheme. Neither race nor sexualorientations are conditions that require geneticintervention. Ifgeneticengineering isusedtoalteran unborn child’s skin color, sexual orientation orsex, the parents risk advancing discriminatory


attitudes. Therefore to ensure just distribution,genetic interventions ought not to increasediscriminationorracism(23).

Treatment for genetic diseases often requiresintervention at a single particular locus, whereasphenotypic traits often result from the interactionbetween several genes and the environment,makingitdifficulttoinfluencethesecomplextraitsthrough germline modification without a greaterunderstanding of epigenetics (16). The increaseddifficultymayresultinonlya‘selectfew’beingableto afford the intervention, making geneticenhancement morally unacceptable as a factorinvolved in the ever-increasing gap between therichand thepoor.Geneticalterationsoughtnot tobe restricted to a particular sect of society tocoincidewiththejustdistributionscheme.9. Conclusion Research towards improving the specificity andreducing theoff- target effects of theCRISPR-Cas9system isdeveloping towardsa safe level thatwilleventually permit clinical applications in humanpatients. In light of the considerable number ofcountries that are ambiguous, or are awaitingfurther developments in the technology (14),establishingatemporaryglobalbanisappropriate.This temporary global ban will result in thecountries with the ethical policies in place, to laypressureonthecountriesundecidedontheissueathand. Due to the global demand, rather thancontinuing to remain without an opinion, thistemporary ban will provide the incentive forcountries to focus on the ethical, social andevolutionary implications of this biotechnology,resulting in legislation based on their country’svalues.

Any discovery that seeks to fulfill medicine’sethical mandate to help the sick will generatepressuretomovefromthelab,towardsthehumanbody (9). Should a country support humangermline editing, they ought to establish a plan ofconducttopreventabusesofthistechnology.Whenit comes to administering human germline editingto thosewho are considered to have normal bodyfunction and to those of whom are consideredimpaired, the distinction is in the etiology.Conducting this technology with the aid of a justdistribution scheme is recommended to ensureproper allocation of skills. With ongoingreassessment and public participation precedingany heritable germline, the ethical concerns thatarisewillbeacknowledged,andthetechnologywillbeabletomovetowardsclinicaltrials. 10. References 1.VassenaR,HeindryckxB,PecoR,PenningsG,RayaA,Sermon K, et al. Genome engineering through

CRISPR/Cas9 technology in the human germline andpluripotent stem cells. Human reproduction update.2016;22(4):411-9.

2.RanFA,HsuPD,WrightJ,AgarwalaV,ScottDA,ZhangF.GenomeengineeringusingtheCRISPR-Cas9system.NatProtocols.2013;8(11):2281-308.

3.Crowley L. An Introduction to Human Disease:Pathology and Pathophysiology Correlations: Jones &BartlettLearning;2012.

4.Chan S, Donovan PJ, Douglas T, Gyngell C, Harris J,Lovell-Badge R, et al. Genome Editing Technologiesand Human Germline Genetic Modification: TheHinxton Group Consensus Statement. The Americanjournalofbioethics:AJOB.2015;15(12):42-7.

5.Miller JC,TanS,QiaoG,BarlowKA,WangJ,XiaDF,etal. A TALE nuclease architecture for efficient genomeediting.Naturebiotechnology.2011;29(2):143-8.

6.HatadaS,SubramanianA,MandefroB,RenS,KimHW,Tang J, et al. Low-Dose Irradiation Enhances GeneTargetinginHumanPluripotentStemCells.Stemcellstranslationalmedicine.2015;4(9):998-1010.

7.Yu C, Liu Y, Ma T, Liu K, Xu S, Zhang Y, et al. Smallmolecules enhance CRISPR genome editing inpluripotentstemcells.Cell stemcell.2015;16(2):142-7.

8.Moreno-Mateos MA, Vejnar CE, Beaudoin JD,Fernandez JP,Mis EK, KhokhaMK, et al. CRISPRscan:designing highly efficient sgRNAs for CRISPR-Cas9targetinginvivo.Naturemethods.2015;12(10):982-8.

9.Sugarman J. Ethics and germline gene editing. EMBOreports.2015;16(8):879-80.

10.Denker H-W. Stem Cell Terminology and‘Synthetic'Embryos: A New Debate on Totipotency,Omnipotency,andPluripotencyandHowItRelates toRecent Experimental Data. Cells Tissues Organs.2014;199(4):221-7.

11.Ishii T, Pera RA, Greely HT. Ethical and legal issuesarisinginresearchoninducinghumangermcellsfrompluripotentstemcells.Cell stemcell.2013;13(2):145-8.

12.Sciences NAo, Medicine NAo, National Academies ofSciencesE,Medicine.HumanGenomeEditing:Science,Ethics,andGovernance.Washington,DC:TheNationalAcademiesPress;2017.300p.

13.CommitteeonGuidelinesforHumanEmbryonicStemCell Research NRC. Guidelines for Human EmbryonicStem Cell Research: The National Academies Press;2005.

14.Araki M, Ishii T. International regulatory landscapeand integration of corrective genome editing into invitro fertilization. Reproductive biology andendocrinology.2014;12(1):108.

15.LiangP,XuY,ZhangX,DingC,HuangR,ZhangZ,etal.CRISPR/Cas9-mediated gene editing in humantripronuclear zygotes. Protein & cell. 2015;6(5):363-72.

16.LanphierE,UrnovF.Don'teditthehumangermline.Nature.2015;519(7544):410.

17.Allhoff F. Germ-line genetic enhancement andRawlsian primary goods. Kennedy Institute of EthicsJournal.2005;15(1):39-56.

18.WivelNA,WaltersL.Germ-linegenemodificationanddisease prevention: some medical and ethical


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perspectives. SCIENCE-NEW YORK THENWASHINGTON-.1993;262:533-.

19.Garland-ThomsonR.Disabilityandsocialtheory:newdevelopmentsanddirections.Taylor&Francis;2014.

20.Genetics CfR, Committee HG. Position Paper onHumanGermLineManipulation.1992.

21.WolbringG,DiepL.TheDiscussionsaroundPrecisionGenetic Engineering: Role of and Impact on DisabledPeople.Laws.2016;5(3):37.

22.Fertilisation H, Authority E. HFEA-7th Code ofPractice.2009.

23.Ishii T. Germ line genome editing in clinics: theapproaches,objectivesandglobal society.Briefings infunctionalgenomics.2015:elv053.

Circus animals - how much is ‘unfair’?

-OanaIftimeFaculty of Biology, University of Bucharest,RomaniaEmail:[email protected] 1. Introduction In early 2017, eleven out of the thirty-two retiredcircus animals that were kept in a facility nearBucharest, Romaniawere killed in a fire (Popescu2017). The public debatemoved quickly from theregrettable accidental death of the poor beasts tothe general subject of circus animals. A petitionentitled“Weputanendto theexploitationofwildanimalsincircuses”(Magor2017)askingforabanon the use of wild animals in circuses collected62,096signaturesbyFebruary7th.On January29,the General Council of the Bucharest Municipalityreleased a draft decision to ban animalperformances intheStateCircus.Also, theanimalsbelongingtotheStateCircusaretoberelocatedbyanNGO(Klodnischi2017).

The use of animals for organizedentertainment goes back to Antiquity. AncientGreekandRomanterritories,Egypt, India,Assyria,Babylon, or China have all known the practice ofkeepingwildanimalsfordisplayandgames.IntheRoman Empire, thousands of local and exoticanimals were captured and shipped in poorconditions to the Capital and other large cities. Atdestination, the animals participated in venations(demonstrative hunts taking place in the arena),parades and other types of entertainment. In lateantiquity, Roman arena games had to transform,due to diminution of resources. Animals invenations were no longer hunted on the spot butpreserved for return shows. Also, circus-typeperformance of tricks by the animals becameencouraged(Mackinnon2006). InmodernEurope,arena shows were re-discovered by Philip Astleywho started a riding school in 1768, with his

famous performances at Astley's RoyalAmphitheatre inLondon includingacrobaticriding(Frost1881). 2. The underlying reasons Why do people enjoy animal encounters andperformances? More than a few hypotheses wereformulated on why we cast a special status uponcertain creatures, represented mainly but notexclusively by pets (Serpell 1996). Beyond theendless speculationson theoriginof thisbehaviorone element stands: in many cultures, someanimals are regarded as special and evenpersonalized and ‘befriended’. People give themnames,includethemintheirsocialworld,exchangelots of affectionwith them and often comment ontheirhuman-likeattitudes.IncontemporaryEuropepetscangetclothesandaccessoriesandbeburiedin cemeteries, as humans do. One might also findthis fact interesting that from Aesop’s fables tocontemporary books (animation movies or videogames) thepublic isattractedbyandevenacceptsmoral criticism from characters represented byanthropomorphic animals (Dunn 2011). Why dopeopleexhibitsuchattitudesremainsunclear,with‘humanization’ being identifiable as an aspectratherthanthecauseofthosepeculiarinteractionsbetween humans, and animals. Yet, it is easy toobserve that circus animals are also valued fortraitsthatarealientotheirnormalbehaviorinthewild and rather human-like. Circus is a display oftheunnatural,butthisunnaturalisattractiveasitisrooted in ‘humanization’ of the animals. Circusanimals are clever unusual beasts that are able tolearn and perform. They are trained to react inwaysthatseem‘human’intermsofdetermination,coordination and performance, which attracts,amazesandamusestheaudience.

Many continue to seek spectacular animalencounters in spite of the efforts of variousorganizations to educate the public on animalwelfare that might have led to some success interms of concern over the animals in circuses anddisapproval of animal performances (Wells &Hepper 1997; The Scottish Government 2015;Zanola2007).Duringthe lastyears,astandhasaswell been taken by variousWestern travel brandsand tour operators against exploitation of wildanimals (such as elephants, tigers, and snakes) inthe form of travel attractions such as riding orvarioustypesofperformance.Still, thedemandforanimal attractions is increasing and new marketsare developing in the world (Baran 2016). Also,animalscontinuetobepresentinsomecircuses.

Are those speaking against animal circusperformances merely ‘obsessed’ by animal rights?The July 2013 newsletter of the World Circus


Federation (FédérationMondiale du Cirque 2013)seems to promote this perspective, whilstcelebratingthelegalvictoryofonerenownedcircuscompany against animal rights organizations andcalling circus fans to organize some sort of acounter-movement in support of maintaininganimal performance in circuses. The Federationquotes a pro-circus student activist: “... taking thecircusawaywouldbeunfairtothepublic,thecircusperformers,andaboveall, theanimals that circusesstrive to take great care of and preserve forgenerationstocome”.

As it can be easily observed, the quotedargumentiscenteredonatermpertainingtoethicsthat can inherently bear a highly variable content,depending on whom do you ask about itssignificance:unfair.Inthiscontext,onemightwanttotryandunderstandwhatisactuallyunfairandtowhomwhenitcomesaboutanimalsincircuses. 3. The unfairness Violence tends to be generally viewed asunfair. Ithas been argued that violence and cruelty onceused in taming and training of circus animals hasgradually been replacedwith less brutalmethods.Yet, the training tools andmethods that shouldbeemployed for corrective non-violent purposes arestill used by some in a harmful way, so that theanimals get wounded both physically andpsychologically (Humane Review 2012; Kharb2013; Zoocheck 2016). The case of trainers RogerandMaryCawley(a.k.a.MaryChipperfield), finedfor cruelty to animals becamewidely known (BBC1999). The undercover footage Elephants inCircuses: Training and Tragedy (PETA 2007)revealed to the world certain tamers’ shockinglybrutal perspective. As for the law suit so proudlymentioned in the World Circus Federation’snewsletter, a legal analysis published by Beverage(2010) reveals a series of details about howanimalswereabusedandconvincinglyargues thatthe ‘victory’ of the entertainment company wasrather technical, due to ‘ambiguities andcounterproductive provisions’ in certain laws andtheir regulatory schemes.Also, circuses havebeenrecurrently cited by theUnited StatesDepartmentof Agriculture for neglect and abuse of animals(Bradshaw2007).

Furthermore, not only physical violence butalsoharmingalivingbeingbyforcingitbeyonditsnatural limits tends to be generally consideredunfair; failing to provide proper shelter, food andwater toan individual, be ithumanornon-humanconstitutes a basic example. Again, how far cantherefore humans push animals so thatwe decidethat it is unfair? Even circus animals that are notsubject to brutal treatments remain creatures

deprived of a free natural life, convinced to learntricksbymethodsthatmaybelessunpleasantthantheold-fashionedonesbutarestillunpleasant,andobliged to observe a strict schedule for our likingonly.

Ecological and behavioral research hasestablished that there is a deep unavoidablecontradiction between wild animals’ nature andcircuslife,asnoneofthewildspeciesemployedincircusperformancemeets the ‘ideal’ ofhaving lowcognitive function, lowecologicalandsocialneeds,such that it would be proper for living in anartificialenvironmentthatbearsthecharacteristicsof a circus (Iossa et al. 2009). As their feeding,social and reproductive behavior are altered andlimited by the specific living conditions, theconclusion that circus animals live an ‘inevitablyimpoverished life’ comes natural (Harris et al.2006).Hand-rearing, training andperformance, aswellasfrequenttravellingaffectthem(Bekoffetal.2015).Theyareexposedtoriskfactorsanddevelopvarious health problems and abnormal behaviorsrelated to ‘circus life’, with all that such existenceimplies (Rose et al. 2006; Animal DefendersInternational 2009; Hopster & de Jong 2014;Machačováetal.2015;Dorningetal.2016).

The amount of unfairness has been certainlyconsidered sufficient by some professionalveterinaryorganizationssothattoexpressnegativeopinionson thewelfareof animals in circusesandeventuallyrecommendthattheuseofwildanimalsforperformancebebanned(e.g.BritishVeterinaryAssociation 2012; Federation of Veterinarians ofEurope2015;VeterinaryIreland2016).

Worldwide, a number of regions, counties,municipalities, and states have banned totally orpartially the use of animals in circuses. Such bansare in effect in Argentina, Austria, Australia,Belgium, Bolivia, Brazil, Bosnia and Herzegovina,Bulgaria, Canada, Chile, Colombia, Costa Rica,Croatia,Cyprus,CzechRepublic,Denmark,Ecuador,El Salvador, Estonia, Finland, France, Greece,Hungary, India, Iran, Ireland, Israel, Latvia, Malta,Mexico, the Netherlands, Norway, Panama,Paraguay, Peru, Poland, Portugal, Republic ofIreland,Singapore,Slovenia,Spain,Taiwan,UKandUSA (Robinson et al. 2015; Dorning et al. 2016;AnimalDefenders InternationalCircusbans). Stepsare now taken for enacting more bans in the UK(Ares&Cromarty2016).

Public authorities may ban the use of wildspeciesinperformances,simultaneouslyadvancingsolutions for rehabilitation of the rescued circusanimals. A very good example is represented byIndia,whichin1998bannedtheuseoflions,tigers,leopards, bears and monkeys and by 2004 theCentral Zoo Authority reported rehabilitation of314 lions and tigers from circuses. Confiscated


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animals are sheltered in lifetime-care facilitiesestablished in the off-display area of the zoos(Gupta&Chakraborty2005).

Over time, circus has had to adapt and copewithvariouschallengesandchanges in thesocietyand it managed to survive and continue to benumbered among the forms of entertainmentvalued by many generations (Loring 2007). Thecontemporary world might also accommodate toviewingtheanimalsincircusesnotassomesortofinheritedculturalcommoditybutasvaluablelivingbeings belonging to the realm of nature that wenow so much struggle to learn to respect andprotect,asG.A.Bradshaw(2007)sopowerfullyputit “animals are not defined by their circumstancesbut affected by them”. Circus can very well existand entertain the public without animalperformances. In cirque nouveau,which combinestraditional circus arts with elaborate scenographyintoathematicshowofhumanartistry,soundandlight, the art of entertainment has shown newperformances that keep attracting the public formorethanthirtyyearsnow.

Wehave thepower todestroy and thepowertobuild,thepowertoenslaveandthepowertosetfree,thepowertoforceotherlivingbeingstoserveus and the power to force our egoistic wishes tomake room for kindness and compassion. Whatshall we choose, for this world, which is not onlyoursbutalsofuturegenerations’?

4. References AnimalDefendersInternational,Circusbans,availableathttp://www.stopcircussuffering.com/circus-bans/;

Ares E., Cromarty H.,Wild Animals in Circuses. Briefingpaper Number CBP05992, 29 April 2016, House ofCommons, UK, available athttp://researchbriefings.files.parliament.uk/documents/SN05992/SN05992.pdf;

Baran M., Sensitivity to animal exploitation is up. So isdemandforwildlifeencounters,Travelweekly,October31,2016;

BBC, UK Circus trainers fined for cruelty, BBC News,Friday, April 9, 1999, available athttp://news.bbc.co.uk/2/hi/uk_news/315146.stm;

Bekoff M., Bruene M., Buyukmihci N. C., Byrne R., deVicenteI.,DurhamD.,FerdowsianH.,GandiniG,HarrisS., Hernandez J. M., Inkamba-Nkulu C., Kalcher-Sommersguter E., Mangas Sanchez M., Merskin D.,NiekischM.,PooleJ.H.,PreuschoftS.,RedmondI.,ReissD.,SchwarzenbergerF.,SommerF.,SouchalA.,SpruijtB.,vanLeeuwenE.,VisalberghiE.,VonkR.,WranghamR. (2015)StatementonEthologicalNeedsandWelfareofWildAnimals,EurogroupforAnimals;

Beverage E. (2010), Abuse Under the Big Top: SeekingLegal Protection for Circus Elephants after ASPCA v.RinglingBrothers,VanderbiltJournalofEntertainmentandTechnologyLaw,Vol.13,No.1,pp155-184.

Bradshaw G. A (2007)Elephants inCircuses:Analysis ofPractice, Policy, and Future, Animals and SocietyInstitute,MI,USA.

Dorning J., Stephen Harris S., Pickett H. (2016), Thewelfare of wild animals in travelling circuses, aspecialists’reportpreparedfortheWelshGovernment,available athttp://www.ispca.ie/uploads/The_welfare_of_wild_animals_in_travelling_circuses.pdf.

Dunn.E.A. (2011)TalkingAnimals:ALiteratureReviewof Anthropomorphism in Children's Books, A Master’sPaper,UniversityofNorthCarolina,ChapelHill,NorthCarolina.

Fédération Mondiale du Cirque (2013) Newsletter.Animal special, No. 3. July 2013, available athttp://www.circusfederation.org/uploads/newsletters/july_2013.pdf

FrostT.(1881)CircusLifeandCircusCelebrities,London,Chatto and Windus, available athttp://www.circushistory.org/Frost/Frost5.htm;

GuptaB.K.,ChakrabortyB.(2005)TheRoleofZoosintheRehabilitation of Animals in the Circus, Journal OfAppliedAnimalWelfareScience,8(4),285–294;

HarrisS.,Iossa,G.,Soulsbury,C.D.(2006),Areviewofthewelfareofwildanimalsincircuses,RoyalSocietyforthePreventionofCrueltytoAnimals;

Hopster H., de Jong I.C. (2014)Welfare of sea lions intravellingcircuses,WageningenURLivestockResearch,Lelystad,TheNetherlands,ResearchReport770;

Iossa G., Soulsbury C. D., Harris S. (2009) Are wildanimals suited to a travelling circus life? AnimalWelfare,Vol.18,No.2,pp.129-140;

Klodnischi S.,Draftdecisiontobananimalperformancesat Bucharest 'Globus' Circus & Variety Company,AGERPRES,Jan29,2017;

LoringP.A.(2007)TheMostResilientShowonEarth:TheCircus as a Model for Viewing Identity, Change, andChaos,EcologyandSociety,Vol.12,No.1:9;

Machačová T., Bártová E., Sedlák K., Silvestre P.,Laricchiuta P., Veneziano V. (2015) HighSeroprevalenceofToxoplasmagondii inZooandCircusAnimalsinItaly,ProcIntConfDisZooWildAnim2015,p.1-3;

Mackinnon M. (2006) Supplying Exotic Animals for theRoman Amphitheatre Games: New ReconstructionsCombining Archaeological, Ancient Textual, HistoricalandEthnographicData,Mouseion,SeriesIII,Vol.6,No.2,pp.137-161;

Magor C. (2017) Punem capat exploatarii animalelorsalbatice in circuri, public petition available athttps://campaniamea.de-clic.ro/petitions/punem-capat-exploatarii-animalelor-salbatice-in-circuri;

PETA (2007) Elephants in Circuses: Training andTragedy, video resource available athttps://www.youtube.com/watch?v=ZTUol7VrHTg;

PopescuI.,11animalsdeadascircusbuildingcatchesfireinBucharest,BucharestInsider,Jan12,2017;

Rose N., Farinato R., Sherwin (eds.) (2006) The CaseAgainst Marine Mammals in Captivity, The HumaneSocietyof theUnitedStatesandtheWorldSociety fortheProtectionofAnimals;

Serpell J. (1996) In the Company of Animals: A Study ofHuman-Animal Relationships, Cambridge UniversityPress;


The Scottish Government (2015) Should the use ofwildanimals in travelling circuses be banned in Scotland?Consultation Analysis, available athttp://www.gov.scot/Resource/0048/00480385.pdf;

Veterinary Ireland,VeterinaryOrganisation’sOpiniononthe Needs of Wild Animals in Travelling Circuses, July29, 2016, available athttp://www.veterinaryireland.ie/images/Veterinary_Ireland_Press_Release_on_Wild_Animals_in_Travelling_Circuses_29th_July_2016.pdf

Wells D. L., Hepper P. G. (1997) Pet Ownership andAdults' Views on the Use of Animals, Society andAnimals,Vol.5,No.1,pp.45-63;

Zanola R. (2007)Major influences on circus attendance,DepartmentofPublicPolicyandPublicChoice–POLIS,Workingpapern.99,October2007,in"POLISWorkingPapers", Universita’ del Piemonte Orientale “AmedeoAvogadro”Alessandria,Italy;

Zoocheck (eds.) (2016) Take action for elephants. Aresourceguide,Zoocheck,Toronto,Canada;

*** (2012) The Circus - A Nightmare For Animals,HumaneReview,Spring/Summer2012.

For forthcoming conferences see: www.eubios.info or www.ausn.info Email for information: [email protected]

Bioethics, Law, and Society: Joint AUSN, Center for Ethics of Science and Technology, and Eubios Ethics Institute Conference 24-26 June 2017 at the International Peace Park@kaeng Krachan, and Chulalongkorn University, Bangkok, Thailand. Organizers: Center for Ethics of Science and Technology, Chulalongkorn University, Thailand, American University of Sovereign Nations (AUSN), USA, the International Peace and Development Ethics Centre, and Eubios Ethics Institute.

Social Work, Human Security, Ethics and Human Ability, 1 July 2017, UKM, Kuala Lumpur, Malaysia. Organizers: UKM; American University of Sovereign Nations (AUSN), USA, Asia-Pacific Forum on Ethics.

Intensive courses on research ethics and bioethics in the Philippines:

Catanduanes State University, Virac, 6 July 2017

Bicol University, Legapzi, 7-8 July 2017

University of San Jose-Recoletos, Cebu, 10-12 July

Visions of Social and Ethical Change in ASEAN, and Beyond, 17 July 2017 (9:00-17:00) Chulalongkorn University,

Bangkok, Thailand. Organizers: Center for Ethics of Science and Technology, Chulalongkorn University, Thailand, American University of Sovereign Nations (AUSN), USA, Youth's UNESCO Club, and Eubios Ethics Institute.

Joint AUSN-Bangladesh Society of Bioethics Intensive Bioethics Training Course, 15-16 July 2017 in Dhaka, Bangladesh.

International Bioethics Roundtable: Bioethics Across and Between Continents and Peoples for the Betterment of All AUSN, Arizona, USA, 2-5 September 2017

Eighteenth Asian Bioethics Conference: The Future of Bioethics and Healthcare (ABC18), 25-28 October 2017 in Seoul, Republic of Korea, followed by a Joint AUSN-Gangneung-Wonju National University Intensive Bioethics Workshop(ABA Satellite meeting) 29-30 October 2017 in Gangneung, Korea. The Eleventh Kumamoto University International Bioethics Roundtable: Philosophy and practice of bioethics across and between cultures, 18-19 November 2017, Kumamoto University, Japan. Contact: Kimiko Tashima, [email protected] EJAIBEditor:DarrylMacerAssociate Editor: Nader Ghotbi (Ritsumeikan AsiaPacificUniversity(APU),Japan)EditorialBoard:AkiraAkabayashi(Japan),SahinAksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),Alireza Bagheri (Iran), Gerhold Becker (Germany),Rhyddhi Chakraborty (India/UK), Shamima Lasker(Bangladesh), Minakshi Bhardwaj (UK), Christian Byk(IALES;France),KenDaniels(NewZealand),OleDoering(Germany), Amarbayasgalan Dorjderem (Mongolia),Hasan Erbay (Turkey), Soraj Hongladarom (Thailand),Dena Hsin (Taiwan), Rihito Kimura (Japan), AbbyLippman (Canada), Umar Jenie (Indonesia), NobukoYasuhara Macer (Japan), Masahiro Morioka (Japan),Anwar Nasim (Pakistan), Jing-Bao Nie (China, NewZealand), Pinit Ratanakul (Thailand), Qiu Ren Zong(China), Hyakudai Sakamoto (Japan), Sang-yong Song(RepublicofKorea),TakaoTakahashi(Japan),NoritoshiTanida(Japan),AnanyaTritipthumrongchok(Thailand),YanguangWang (China),DanielWikler (USA), JeongRoYoon(RepublicofKorea).


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EubiosEthicsInstitutePublications(BookssentbySALpost,JournalbyAirmail-Priceincluded)EubiosJournalofAsianandInternationalBioethics(Annualsubscription) NZ$90

ShapingGenes:Ethics,LawandScienceofUsingGeneticTechnologyinMedicineandAgriculture NZ$50byDarrylMacer,Oct.1990,421pp.

EquitablePatentProtectionintheDevelopingWorld NZ$40byWilliamLesser,May1991,150pp.

AttitudestoGeneticEngineering:JapaneseandInternationalComparisons(Bilingual) NZ$40byDarrylMacer,May1992330pp.

HumanGenomeResearch&Society Eds:NorioFujiki&DarrylR.J.MacerJuly1992 NZ$40ISBN0-908897-03-0(English),230pp.ISBN0-908897-04-9(Japanese),240pp.

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BioethicsforthePeoplebythePeoplebyDarrylMacer,...May1994ISBN0-908897-05-7,460pp. NZ$50

BioethicsinHighSchoolsinAustralia,JapanandNewZealand,byD.Macer,Y.Asada, NZ$50M.Tsuzuki,S.Akiyama,&N.Y.MacerMarch1996,ISBN0-908897-08-1,200pp.(A4)

ProtectionoftheHumanGenomeandScientificResponsibility(EnglishandJapaneseBilingual) NZ$40Editors:MichioOkamoto,NorioFujiki&D.R.J.Macer,April1996,ISBN0-908897-09-X,210pp.

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BioethicsisLoveofLife:AnalternativetextbookbyDarrylMacer,July1998ISBN0-908897-13-8, NZ$40152pp.(Note2ndeditionpublishedoniTunesStoreasaniBookin2015)

BioethicsinAsiaEds:NorioFujiki&DarrylR.J.Macer,(includes118papersfromNov.1997 NZ$50conferences,ABC’97KobeandFukuiSatellite)June1998ISBN0-908897-12-X,478pp.October1999ISBN0-908897-14-6(Japanese),320pp.

EthicalChallengesasweapproachtheendoftheHumanGenomeProject NZ$40Editor:DarrylMacer,April2000ISBN0-908897-15-4,124pp.

BioethicsEducationinJapaneseHighSchools(inJapaneseonly) NZ$40Editor:DarrylMacerApril2000ISBN0-908897-16-2,112pp.

BioethicsandtheImpactofHumanGenomeResearchinthe21stCentury NZ$50Eds:NorioFujiki,MasakatsuSudo,&D.R.J.MacerMarch2001(EnglishandJapanesebilingual,350pp).

BioethicsinAsiainthe21stCentury Eds:SongSang-yong,KooYoung-Mo&DarrylR.J.Macer NZ$50August2003ISBN0-908897-19-7,450pp.

ChallengesforBioethicsfromAsiaEd:DarrylR.J.Macer NZ$70November2004ISBN0-908897-22-7656pp.

ACrossCulturalIntroductiontoBioethics,Editor:DarrylMacer2006,300pp.(A4) NZ$50(Note2ndeditionpublishedoniTunesStoreasaniBookin2015)BioethicsinIran,Editor:AlirezaBagheri,2014.ISBN978-0-908897-25-4262pp. NZ$50BioscienceEthicsEducationCurriculumforPre-SchoolerstoElementaryAgeChildren, NZ$50IrinaPollardandAmaraZintgraff,.2017ISBN978-0-908897-28-5,60pp.(A4) GettingAlong:TheWild,WackyWorldofHumanRelationship,LauraR.Ramnarace2017 NZ$50ISBN978-0-908897-29-2,73pp.(A4) MostBookscanbedownloadedforfreeonlineatwww.eubios.infoPleasechargemyVISA/MASTERCARDcardforNZ$

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