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Thailand: refining cultural values.

Today Thailand is frequently referred to as one of the newly industrialized countries (NICS). The present ambition of Thai policy-makers is to move the country toward realizing its economic and social potential. The concern for rapid development affects many aspects of Thai society, including the health sector. High technology medicine is increasingly supplanting traditional methods of treatment, reflecting the displacement of traditional models, with their holistic concept of health and health care, by Western models with their emphasis on technology, research, and specialized training.

Health Care Allocation

A multitude of ethical problems exists beneath the surface of benefits brought about by the introduction of Western medical models into Thailand. The most important concerns the macro-allocation of health care services, and centers on grave inadequacies in needed services. While the nation is striving to become a NIC, 80 percent of its population still lives in rural areas. Nearly all rural residents are poor and have a short average lifespan with rates of chronic illnesses many times higher than those of wealthier people living in urban areas. Yet 60 percent of Thai government personnel and 62 percent of doctors and 58 percent of nurses are concentrated in the metropolitan sector with large hospitals equipped with the most expensive technologies.

As in the case of many Western countries, government after government has tended to devote more funds and medical resources to the urban sector for diseases that affect relatively few, such as cancer and heart disease, while the majority suffer and die for lack of basic health care and services. Correcting this grave imbalance will involve finding solutions to ethical questions such as: Should money, time, effort, and personnel-always in limited supply-be used to build more urban hospitals or rural health centers? Should Thailand's limited resources be devoted to training more doctors and nurses for hospital medicine or more paramedical personnel for rural health centers?

Whatever concrete decisions are made in the macro-allocation of health care resources, they should be guided by the Buddhist principle of justice. This involves nondiscriminatory treatment of all people, and requires that government provide aU with a fair share of health care resources in proportion to their health needs and medical conditions. Grave imbalances in the allocation of medical resources and the unnecessary persistence of inadequacies in basic services are not merely unjust, but also constitute violence to others and violate the Buddhist principle of "do no harm" that is the basis of traditional Thai morality. This question of distributive justice is one of the most urgent problems the present administration will have to address if it is not to repeat the mistakes of some Western nations where only the privileged few enjoy the best medical services.

To remedy the misallocation of limited resources to rural areas, the Buddhist principle of justice may be used as an action-guide. More provincial hospitals and rural health centers must be built and paramedics trained to staff them. Perhaps more subsidies are necessary as an incentive to attract doctors and nurses to serve in the rural areas. Through control of licenses it may be possible to avoid excessive concentrations of medical personnel in affluent parts of the country. And a higher allotment of resources must go to preventive public health measures such as health education, sanitation, provision of an adequate supply of clean water, maternal care clinics, and child development programs.

Only as the imbalance in the distribution of health services is corrected can we begin to think of introducing expensive, high-tech medicine into Thai society. Otherwise, will be setting up a ten-course banquet for a few while a multitude cannot even have a simple meal of rice.


The problem of AIDS also requires urgent attention in Thailand. The attitude of the government toward this new deadly disease was at first secretive. Statistics on AIDS cases were not disclosed to the public out of fear that they might stir up panic, damage tourism, and discourage foreign investment Pressed by newspapers and international agencies, the government has become more open. According to the Ministry of Public Health's statistics of january 1989, there were 3,090 HIV carriers in the country and thirteen recorded deaths. The government's AIDS Prevention Center also estimates that by the end of 1989 the number of those testing positive for HIV will reach 24,600.

The main routes of AIDS transmission are drug addiction, prostitution, homosexuality, and blood transfusion. Blood transfusion is frequent in Thailand, and doctors are not required to ask for a patient's permission to administer it as in the U.S. Until recently there was no routine screening of all blood donated in die country. As a result of fourteen documented cases of infection with HIV through blood transfusion, HIV testing is now required for all donated blood, with special attention to blood donated by members of high risk groups. But the fact that few donors voluntarily give such information makes it difficult to know the group status of any given donor.

The public now recognizes that die AIDS epidemic must be controlled and will not oppose legal measures to stop its spread. It is agreed that HIV testing is necessary to monitor the extent of exposure to AIDS among the general population. But since autonomy and respect for individual rights are not central to Thai cultural values, most of the Thai public are reluctant to submit voluntarily to HIV testing. They are much concerned about confidentiality of testing and test results. Those at risk fear severe reprisals if friends, employers, or family members find out they have AIDS or even have been tested for HIV.

In a society where respect for individual rights is not a predominant cultural value and where people are psychologically reluctant and often economically unable to indulge in law suits, the government needs to formulate rules and regulations both to protect the interest of the people while physicians pursue their practice, and to ensure humane and holistic approaches to caring for the unfortunate victims.

Determining Death

Thai physicians do not use a uniform set of criteria in determining death. While most neurosurgeons in metropolitan Bangkok have adopted the Harvard criteria of brain death, which facilitates earlier retrieval of organs for transplantation, rural physicians working at hospitals where Western technology is lacking determine death by traditional heart-lung criteria. Though neither definition is congruent with the Thai cultural understanding of death, the public, believing that determining death is a medical matter, have given physicians authority to make such determinations. However, increasing reports of persons who "came back to life" fifteen to sixteen hours after being pronounced dead have raised doubts concerning the reliability and adequacy of these medical standards, and has led the public to question whether a prognosis based on the traditional heart-lung or the new brain-oriented criteria alone could be accurate; many thus return to their own cultural understanding of death.

This cultural understanding is based on the Buddhist teaching that over the centuries has shaped Thai perceptions and values. It upholds a holistic view and speaks of death in terms of the death of a person and not the death of cells, tissues, or organs. Death is thus defined as total cessation of mental and physical functions. For Buddhism life consists of the lifespan and the functioning of the mental and physical aggregates. Kanna, the individual's past deeds, determines his or her lifespan; if that span is not yet complete it is possible for a person to come back to life many hours after the cessation of the vital signs of life-be it the brain or the vital organs-provided that the body has not deteriorated. Nonetheless, in most cases the lifespan is held to have ended simultaneously with the total cessation of all physical and mental functions.

Given the possibility of faulty diagnoses, the uncertainties within medical practice and knowledge, the possibility of remissions or the discovery of new cures, and the unknown factor of the degree of sensitivity and awareness in even those declared irreversibly comatose or brain damaged, most of the Thai public see no reason to abandon their culturally rooted understanding of death. Yet this definition cannot accommodate developments in modem medicine in which some cells or organs may be sustained by artificial means after the cessation of all these functions. Nor does it facilitate early retrieval of organs for it does not allow physicians to declare persons dead during the optimal period for harvesting and transplanting vital human organs. In confronting such medical developments, the Thai cultural and Buddhist concept of death may eventually come to be redefined. Euthanasia

There is a growing consensus among the Thai public that euthanasia (passive or active) is morally unjustifiable. Within the framework of Thai Buddhist values, acts of killing are understood to be acts of hatred or ill-will. When a doctor performs what he believes is mercy-killing for a patient's benefit, he does so in fact because the pain and suffering of the patient are repugnant to him. Subconsciously he transfers his hatred of the suffering to the patient who embodies it. His mercy-killing" is therefore actually a result of hatred and is unwholesome both for himself and for the patient

This cultural attitude toward euthanasia makes it impossible for the Thai to allow impaired newborns to die untreated or to withhold any treatment. Thus Thai doctors usually give the best available treatment to impaired newborns. Given the expenses of maintaining such newborns and the scarcity of medical resources it will be interesting to see how long Thai physicians sustain these traditional values.

In light of these issues, bioethical enquiry in Thailand must not only examine ethical dilemmas that arise in the actual practice of medicine and research in the life sciences, but must also deal with the refinement and clarification of applicable Thai cultural and moral values.
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Title Annotation:Bioethics on the Pacific Rim
Author:Ratanakul, Pinit
Publication:The Hastings Center Report
Date:Mar 1, 1990
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