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Teaching Resources and Notes:A Cross-Cultural Introduction to Bioethics85

Teachers Resources and Notes for

A Cross-Cultural Introduction to Bioethics

Darryl R.J. Macer, Ph.D.


(draft version 3, 22 January 2007)

Eubios Ethics Institute 2006

Eubios Ethics Institute

Bangkok Christchurch Tsukuba Science City

The Eubios Ethics Institute is a non-profit group that aims to stimulate the discussion of ethical issues, and how we may use new technology in ways consistent with "good life". An important part of this dialogue is to function as an information source for those with similar concerns. Other publications are listed at the end of this book. The views expressed in this book do not necessarily represent the views of the Eubios Ethics Institute or UNESCO.

Copyright © 2006 Eubios Ethics Institute

All rights reserved. The copyright for the complete publication is held by the Eubios Ethics Institute. No part of this publication may be reproduced except for personal use, and non-profit educational use, without the prior written permission of the Eubios Ethics Institute.

Cataloging-in-Publication data

Teaching Resources and Notes for A Cross-Cultural Introduction to Bioethics / editor, Darryl R.J. Macer.

Christchurch, N.Z. : Eubios Ethics Institute ©2006.

1 v. 100 pp. A4 size. ISBN 0-908897-24-3

1. Bioethics. 2. Medical ethics 3. Environmental Ethics 4. Bioethics Education 5. Genetics 6. Neurosciences I. Macer, Darryl R.J. (Darryl Raymund Johnson), 1962- IV. Eubios Ethics Institute. V. Title (Teaching Resources and Notes for A Cross-Cultural Introduction to Bioethics).

Key Words: Asia, Biodiversity, Bioethics, Bioethics Education, Biotechnology, Body, Cloning, Education for Sustainable Development (ESD), Economics, Energy, Environment, Environmental Ethics, Eugenics, Genetic Engineering, Genetic Screening, Genetic Therapy, Human Genetic Disease, Human Genome Project (Scientific, Ethical, Social and Legal Aspects), Medical Ethics, Medical Genetics (Diagnosis, Treatment and Prevention), Patenting of Life, Peace, Reproductive Technology, Surrogacy, Sustainable Development.

On-line version and teachers guides, references, Internet links

Project site </index.php?id=2508>

On-line version of the textbook / resource book can be downloaded from


On-line version for latest edition of Teacher Resources can be downloaded from


Further copies can be obtained from the Eubios Ethics Institute.

c/o Darryl Macer, Ph.D.,

Director, Eubios Ethics Institute

c/o UNESCO Bangkok,

920 Sukhumvit Road, Prakanong, Bangkok 10110, THAILAND

Tel: +66-2-391-0577 ext 141

Fax: +66-2-664-3772

Email: d.macer@ 

The above address should also be used to send feedback forms from teachers and students!

Content list

Preface 5

Evaluation and Goals of Bioethics Education

1: Goals of Bioethics 7

2: Evaluation 8

3: Stages in moral development 11

4: Ongoing reassessment and evaluation 14

5: Participatory Methods 16

6: References 17

Explanation of chapters (Page numbers refer to the page in the textbook)

A. Bioethics and the Ethics of Science and Technology

1. Making Choices, Diversity and Bioethics 1

2. Ethics in History and Love of Life 6

3. Moral Agents 18

4. Ethical limits of Animal Use 22

5. Ethics and Nanotechnology 27

B. Environmental Ethics

1. Ecology and Life 30

2. Biodiversity and Extinction 36

3. Ecological Ethics 40

4. Environmental Science 43

5. Environmental Economics 51

6. Sustainable Development 63

7. Cars and the Ethics of Costs and Benefits 73

8. Energy Crisis, Resources and Environment 78

9. Ecotourism 85

10. The Earth Charter Initiative 93

C. Genetics

1. Genetics, DNA and Mutations 98

2. Ethics of Genetic Engineering 102

3. Genetically Modified Foods 107

4. Testing for Cancer Gene Susceptibility 110

5. Genetic Privacy and Information 113

6. The Human Genome Project 117

7. Eugenics 121

8. Human Gene Therapy 122

9. Universal Declaration on the Human Genome and Human Rights 129

10. International Declaration on Human Genetic Data 134

D. Medical Ethics

1. Informed Consent and Informed Choice 145

2. Telling the Truth about Terminal Cancer 147

3. Euthanasia 153

4. Brain Death 158

5. Organ Donation 164

6. Brain Death and Organ Transplant Drama 170

7. The Heart Transplant 175

8. SARS (Severe Acute Respiratory Syndrome) 176

9. AIDS and Ethics 177

10. Ethical Principles for Medical Research Involving Human Subjects 183

11. Bird Flu 188

12. Indigenous Medicines and Access to Health 189

E. Reproduction

1. Lifestyle and Fertility 192

2. Assisted Reproduction 198

3. Surrogacy 204

4. Choosing Your Children’s Sex and Designer Children 205

5. Prenatal Diagnosis of Genetic Disease 208

6. Female Infanticide 211

7. Human Cloning 214

8. United Nations Declaration on Human Cloning 215

9. Human Genome Organization (HUGO) Ethics Committee Statement on Stem Cells 222

F. Neurosciences

1. Advances in Neuroscience and Neuroethics 224

2. Learning to Remember: The Biological Basis of Memory 229

3. The Neuroscience of Pleasure, Reward and Addiction 235

G.Social Ethics

1. Revisiting the Body 241

2. Child Labour 251

3. Peace and Peace-keeping 253

4. Human Rights and Responsibilities 269

Movie Guides and Questions (Samples) 277


This teacher’s guide is available for use to accompany the textbook, A Cross-Cultural Introduction to Bioethics, which is available in both hard copy or as a soft copy to download without charge from the Internet. The teaching resources and notes include academic references, further reading, Internet sites and other information that supplements the text/resource book. This book may be useful for teachers as they teach bioethics, and for students who wish to write reports and do their own research on the topics in the textbook.

The first section is a general introduction to evaluation of bioethics that I have written to help teachers examine what bioethics is. There are many goals of bioethics and they are discussed here.

The order of the teaching resources and notes for each chapter follows the same order as in the textbook. This book will be regularly updated on-line. Please refer to the textbook itself for the authors who contributed to the chapters, and who have compiled reference lists for those who wish to examine the background behind the chapters. The student and teacher feedback forms are printed in the textbook, and can be downloaded with the preface of the book. The on-line version of that book can be downloaded from </ccib.htm>

Bioethics could be defined as the study of ethical issues and decision-making associated with the use of living organisms. Bioethics includes both medical ethics and environmental ethics. Bioethics is learning how to balance different benefits, risks and duties. Concepts of bioethics can be seen in literature, art, music, culture, philosophy, and religion, throughout history. Every culture has developed bioethics, and in this book there is a range of teaching resources that can be used that are written from a cross-cultural perspective by a variety of authors.

In order to have a sustainable future, we need to promote bioethical maturity. We could call the bioethical maturity of a society the ability to balance the benefits and risks of applications of biological or medical technology. It is also reflected in the extent to which public views are incorporated into policy-making while respecting the duties of society to ensure individual's informed choice. Awareness of concerns and risks should be maintained, and debated, for it may lessen the possibility of misuse of these technologies. Other important ideals of bioethics such as autonomy and justice need to be protected and included when balancing benefits and risks.

Bioethics is not about thinking that we can always find one correct solution to ethical problems. Ethical principles and issues need to be balanced. Many people already attempt to do so unconsciously. The balance varies more between two persons within any one culture than between any two. A mature society is one that has developed some of the social and behavioural tools to balance these bioethical principles, and apply them to new situations raised by technology.

The objectives of this guide and the on-line multilingual resources at UNESCO Bangkok website and the teaching pack on the Eubios CD are to provide a free on-line resource teachers and students can use to learn about bioethics, and think more widely about life. A variety of styles are used, and we would like feedback from teachers, students, anyone who wishes to use it.

List serves function in English for educators and students, and persons from a wide range of countries have tried these resources, and contributed to this project over the past three years.

Internet site </index.php?id=2508>

Internet site </betext.htm>

Education listserve </group/Bioethicseducation/>

Student listserve </group/ Bioethics_for_students/>

Teaching Guides, References, Internet links (this document)


This project aims to produce free on-line teaching materials for bioethics education in different countries. The main products will be: 1) Materials for teaching bioethics; 2) A textbook that could be used in school and university classes to teach about bioethical issues; and 3) A network of teachers in different countries.

The Eubios Ethics Institute website has over 2000 files available for download, including the UNESCO/IUBS/Eubios Living Bioethics Dictionary, and regular News updates. Further copies of chapters and updates, teaching guides, evaluation sheets, etc. are available upon request. We are also interested in assembling student projects and different teachers' materials in a global site that all can use, and can inform us all. We welcome improvement and additions to this project.

The project described herein will continue under the framework of a Bioethics Education Textbook Project of UNESCO Bangkok, continuing to gather more teaching resources in multiple languages from around the world and make them openly available. A network of educators to improve global bioethics education has been developed under the International Bioethics Education Network. The lessons from the project need to be developed in the context of policy and curriculum in a number of countries.

Darryl Macer, Ph.D.


All suggestions to

Darryl Macer, Ph.D.,

Director, Eubios Ethics Institute

c/o UNESCO Bangkok,

920 Sukhumvit Road, Prakanong, Bangkok 10110, THAILAND


Evaluation and Goals of Bioethics Education

1: Goals of Bioethics

There can be several goals of bioethics education, and each could be associated with different measures in evaluation. There does not exist a consensus in the academic literature and teaching community on the most important goals to measure nor on the best criteria to assess whether the education is successful. For more than 60 years it has been recorded that both quantitative and qualitative data are important in social science research, as was said by Merton and Kendall (1946), "Social scientists have come to abandon the spurious choice between qualitative and quantitative data: they are concerned rather with the combination of both which makes use of the most valuable features of each. The problem becomes one of the determining at which points they should adopt the one, and at which the other, approach". Thus an appropriate methodological tool should contain methods to utilize and assess both types of data.

The goals of bioethics that were important to measure were found to include: 1) Increasing respect for life; 2) Balancing benefits and risks of Science and Technology; 3) Understanding better the diversity of views of different persons; 4) Understanding the breadth of questions that are posed by advanced science and technology; 5) Being able to integrate the use of scientific facts and ethical principles and argumentation in discussing cases involving moral dilemmas; 6) Being able to take different viewpoints such as biocentric and ecocentric perspectives. We do not need to achieve all goals to consider a class to be successful, and different teachers and schools put a different amount of emphasis on each goal.

One important goal ofteaching about bioethical issues is to get students to critically evaluate the issues (Conner, 2003). In a Mexican case (Rodriguez, 2005), bioethics classes were used as a way to improve the general behaviour and study aptitude of students. Each institution is likely to put a different amount of emphasis on each goal. Also, different activities are likely to enable some goals to be met and not others (Macer, 2004c). Therefore we do not need to assess all the institutional objectives when evaluating the success of the trials. Instead, case studies of how students and teachers responded were also sought to give a wider descriptive account of various approaches.

One of the goals of this project was to examine criteria that could be used to measure the success of bioethics education, and the effectiveness of different forms of education for making mature citizens. There is a consensus among many Western scholars that the balancing of four main bioethical principles, which are Autonomy, Justice, Beneficence and non-maleficence, is central to making better decisions (Beauchamp and Childress, 1994). These principles are introduced in chapter 1 of the text. Autonomy includes ideas such as respect for privacy, respect for personal choice. Justice is to respect the autonomy of others, and to treat persons equally. Beneficence is to try to do good, and non-maleficence is to avoid harm. When solving or trying to reach a consensus about bioethical problems, these four main principles can be a good guide in balancing which ideas should be mostly weighed. One measure of bioethics education could then be whether students are able to use these principles in decision-making, which was examined by presence of these keywords in discourse (oral or written). In the future the use of principles as expressed in the UNESCO Universal Declaration on Bioethics and Human Rights (2005) will also be analyzed to broaden the description of bioethical reasoning.

Still, reaching a good decision is often difficult, which also may not be the same if made in different times and situations. Another approach that is common in education is to teach learners to break down ethical dilemmas into manageable problems, for example, the separation of action, consequence and motives connected to a moral decision. This separation is reflected on the different bioethical theories, and some of these are introduced in chapter 2. Utilitarianism is an example of a bioethical theory, which looks at the consequences of an action, and is based on the work of Jeremy Bentham and John Stuart Mill. This principle asserts that we ought always to produce the maximal balance of happiness or pleasure over pain, or good over harm, or positive value over disvalue. Utilitarianism can be then broken down into rule utilitarianism, and act utilitarianism. “A rule utilitarian may use moral rules as authoritative instrumental rules, so the morally right action is conformity to a system of rules, and the criterion of the rightness of the rule is the production of as much general happiness as possible (Macer, 1998a)”. Act utilitarians on the other hand, look at the particular act only, and object to moral rules to be only an approximate guides, which could be broken if maximal good is not obtained. Another example of a bioethical theory is rights based theories of Immanuel Kant, and human rights law (Beauchamp and Childress, 1994; Macer, 1998a). The use of utilitarian-style logic and rights arguments were also examined among the discourse. The evaluation tools developed here could be extended to look for presence of other concepts such as virtue ethics for example.

Integration of scientific facts is also important in moral reasoning. Science educators discovered during the last few decades that the most efficient way to educate science is to discuss the science together with examples of technology and put the facts into the social context. This method of teaching is generally called the Science, Technology, and Society (STS) approach (Yager, 1990; Ramsey, 1993). Advances in biology and medicine have led to another pressure upon educators, namely how students can be prepared to face the ethical dilemmas that the technology often raises. Many chapters in the text incorporate both teaching of biological facts and ethics. The ethical issues associated with biology are generally grouped under the phrase "bioethics". Bioethics is one part of the approach of STS, and a survey of bioethics teaching is also one method to measure the extent that society issues are included (Macer et al., 1996; Macer, 1999). In general there are less teachers using STS approaches in Asia than in the USA (Kumano, 1991), and Australasia (Macer et al. 1996), but it is growing still. Even within one country, such as the USA, there are a diversity of views on how to effect efficient education of social issues and even the science itself (Waks & Barchi, 1992). In the project in Korea the partner teachers at high school level are a STS network of teachers, and the Chinese school has a STS approach to teaching biology. In some other countries, such as New Zealand, STS approaches are integrated into a broad participatory paradigm of education across all subjects.

2: Evaluation

Crucial to the exercise of development of bioethics is a method of evaluation that allows for improvement of materials and meeting better the needs of students in different countries. This project has looked at several methods of evaluation including: development of specific evaluation forms for student and teacher responses to chapters and the textbook or course; ways to analyze the content of student essays and reports; forums where educators and researchers can discuss and improve the content of the textbook and materials, and discuss evaluation; and ways to assess various styles of student feedback from different programs.

In the text there are evaluation sheets that were developed as an evaluation tool, and are included in the second edition of the Bioethics Text/Resource book, A Cross-Cultural Introduction to Bioethics (Macer, 2006). The publication of this book and some translations of the chapters in the book in several languages, including Chinese, Japanese, Korean, Tamil and Thai, allows trials of the textbook to be also conducted in local language in selected pilot countries. Comparisons in the way which bioethics dilemmas are used in different countries are made, though longer term comparisons will be required. There are also country-by-country update summaries included here.

In current assessment of high school students there is a trend from merely making lists of many examples, or listing the positive and negative sides of an argument towards making students exhibit their reasoning as well. One of the common goals of school education is that students can produce a good argument. Stephen Toulmin’s model has become popular in development of students’ argumentation skills (Toulmin et al. 1984). It is summarized in the figure below, that an argument consists of integrating the following:

A conclusion or claim – assertions or conclusions about an event or theory

Facts – data that is used as evidence to support the assertion

Warrants – the statement that explains the link between the data and the claims

Backing – underlying assumptions which are often not made explicit

Rebuttals – statements that contradict the data, warrant or backing of an argument


To create an argument a person needs to state their claim, then support it with facts (data) that are arranged logically. For each fact, they should give the evidence for the fact (warrant), and for each warrant, state the quality of its validity (backing). Then for each warrant and its backing, people should think of an opposing point of view (rebuttal). They then consider further possible warrants and backing for the rebuttals. At the end then they review, having argued the rebuttals, do they need to qualify their original claim?

The mental mapping project, or human behaviourome project (Macer, 1992) identified 9 classes of ideas, and attempts to explain the linkages between ideas in the construction of moral choices by different persons (Macer, 2002). The practical applications of that model are yet to reach a stage at which teachers could simply assess the moral development of their students. The Ideas, Evidence and Argument in Science Education (IDEAS) project of Osborne et al. in the UK [http://www.kcl.ac.uk/depsta/education/ideas.html], has as its a goal the assistance of teachers in developing their skills to teach about ideas, evidence and argument in science. The materials they wish to develop include worksheets and video clips to enable teachers to teach children to develop and evidence scientific argument. They suggest teachers should focus on the features of argument shown in the right of the diagram below and suggest that prompt sheets, based around Toulmin’s model of argument are helpful in promoting children's ability to argue.

The IDEAS project suggests the following criteria can be used in evaluating students’ arguments. Is there a claim? Does the argument have data to support the claim? Does the argument link the data to the claim? Are there further justifications to support the case? Is there any anticipation of a counter argument and how it could be opposed?

Ratcliffe and Grace (2003) outline the knowledge, understanding and skills that students studying ethical issues in science acquire and that can be used to design assessment questions. They listed several different levels of knowledge:

Conceptual knowledge: Learners can demonstrate understanding of: underpinning science concepts and the nature of scientific endeavour; probability and risk; the scope of the issue – personal, local, national, global, political and societal context; and environmental sustainability.

Procedural knowledge: Learners can engage successfully in: processes of opinion forming/decision making using a partial and possibly biased information base; cost-benefit analysis; evidence evaluation including media reporting; and ethical reasoning.

Attitudes and beliefs: Learners can: clarify personal and societal values and ideas of responsibility; and recognize how values and beliefs are brought to bear, alongside other factors, in considering socio-scientific issues.

As with the above examples of questions that Kohlberg used for the linkage of student arguments to moral stages of development, there are a number of ways that could be developed into evaluation tools for assessment of bioethics education.

One of the difficult questions in bioethics education is how to evaluate the usefulness of the materials provided, beyond mere student or teacher satisfaction. One concept that has been used by Macer is whether students demonstrate "bioethical maturity" in some way. “Bioethical maturity assumes a certain level of recognition of weighing up the different arguments that can be used to discuss an issue, the different ethical frameworks that can be used, and comparisons and balancing of the benefits and risks of the dilemmas (Macer, 2002). This process also gives an indication as to how many different ideas people have, and the way they understand the dilemmas, and is ongoing as part of the behaviourome project (Macer, 2002; 2004b). Classroom observations, audio and video tape recordings, and written essays and homework done by the students were collected. This feedback is being continually used to modify the texts and accompanying questions and materials for teachers. Another way to assess the usefulness of the materials for developing ethical principles in making ethical decisions was to look for key words and concepts in the answers students give to oral questions.

Evaluation must be done ethically (Alderson & Morrow, 2003), and there are a variety of methods in research which can be applied for evaluation depending on the style of class and purpose (Cohen et al., 2003). It is very important to examine the future direction of bioethics education and how this might enable people to question scientific endeavours and what impact their moral decisions will have on them as individuals and upon their societies. The skills that are required to do this involve the ability to identify existing ideas and beliefs, listen to others, be aware of multiple perspectives, find out relevant information and communicate the findings to others. These skills cannot be ‘given’ to students through a didactic approach to teaching, where the teacher imparts the knowledge. Instead, students need to experience situations that will allow them to develop these skills through interacting with the teacher and with each other. This project allows sharing of cases and experience in a range of cultures as well.

When bioethics is applied to professional behaviour, such as in medical ethics, methods to evaluate have included the way students conduct a patient examination (http://wings.buffalo.edu/faculty/research/bioethics/eval.html). In Buffalo University Bioethics program (Singer et al., 1993), they applied the technology of the objective structured clinical examination (OSCE) (Cohen et al., 1991) using standardized patients to the evaluation of bioethics. Methods to evaluate the clinical-ethical abilities of medical students, post-graduate trainees, and practising physicians that have been used include multiple-choice and true/false questions (Howe and Jones, 1984), case write-ups (Siegler et al, 1982; Doyal et al., 1987; Redmon, 1989; Hebert et al., 1990), audio-taped interviews with standardized patients (Miles et al., 1990), and instruments based on Kohlberg's cognitive moral development theory (Self et al., 1989).

The reliability and validity of these methods have seldom been examined. Auvinen et al. (2004) applied the use of Kohlberg’s stages of moral development to assess ethics teaching in nursing students in Finland, and they found significantly higher ethical maturity when nurses actually had to deal with ethical dilemmas in their practical training in clinics.

3: Stages in moral development

In discussions held during project meetings in 2005 there has been a consensus that the theory of moral development developed by Lawrence Kohlberg, and what has come to be called Kohlberg's stages of moral development, does not universally apply when teaching bioethics. The problems are not only with non-Western students, but researchers in Australia and New Zealand have also found that it does not serve as a model. Kohlberg's (1969) theory holds that moral reasoning, which he thought to be the basis for ethical behavior, has developmental stages that are universal. He followed the development of moral judgment beyond the ages originally studied by Jean Piaget looking at moral development thoughout life, and created a model based on six identifiable stages of moral development (Scharf, 1978).

Kohlberg's six stages were grouped into three levels: pre-conventional, conventional, and post-conventional. He claimed it is not possible to regress backwards in stages nor to 'jump' stages; each stage provides new perspective and is considered "more comprehensive, differentiated, and integrated than its predecessors." A brief explanation follows.

Level 1: Pre-Conventional

The pre-conventional level of moral reasoning is especially common in children, and said to be up to the age of 9 in U.S. children he studied, although adults can also exhibit this level of reasoning. Reasoners in the pre-conventional level judge the morality of an action by its direct consequences. The pre-conventional level consists of the first and second stages of moral development, and are purely concerned with the self (egocentric). In stage one (obedience), individuals focus on the direct consequences that their actions will have for themselves. For example, an action is perceived as morally wrong if the person who commits it gets punished. In addition, there is no recognition that others' points of view are any different from one's own view.

Stage two is a self-interest orientation, right behavior being defined by what is in one's own best interest. Stage two reasoning shows a limited interest in the needs of others, but only to a point where it might further one's own interests, such as "you scratch my back, and I'll scratch yours." In stage two, concern for others is not based on loyalty or intrinsic respect. Lacking a perspective of society in the pre-conventional level, this should not be confused with stage 5 (social contract) as all actions are performed to serve one's own needs or interests.

Level 2: Conventional

The conventional level of moral reasoning is typical of adolescents (age 9+ years) and adults. Persons who reason in a conventional way judge the morality of actions by comparing these actions to societal views and expectations. The conventional level consists of the third and fourth stages of moral development. In Stage three, the self enters society by filling social roles. Individuals are receptive of approval or disapproval from other people as it reflects society's accordance with the perceived role. They try to be a good boy or good girl to live up to these expectations, having learned that there is inherent value in doing so. Stage three reasoning may judge the morality of an action by evaluating its consequences in terms of a person's relationships, which now begin to include things like respect, gratitude and the golden rule. Desire to maintain rules and authority exists only to further support these stereotypical social roles.

In Stage four, it is important to obey laws and social conventions because of their importance in maintaining a functioning society. Moral reasoning in stage four is thus beyond the need for approval exhibited in stage three, because the individual believes that society must transcend individual needs. If one person violates a law, perhaps everyone would - thus there is an obligation and a duty to uphold laws and rules. As a cultural observation, this is a very common attitude in Asian and Pacific communities.

Level 3: Post-Conventional

The post-conventional level, also known as the principled level, consists of stages five and six of moral development. Realization that individuals are separate entities from society is important in North American society where Kohlberg developed his theory and so he judged it to be a higher level of morality. In that culture one's own perspective should be viewed before the society's is considered. Interestingly, the post-conventional level, especially stage six, is sometimes mistaken for pre-conventional behaviors. In Stage five, individuals are viewed as holding different opinions and values, all of which should be respected and honoured in order to be impartial. However he considered some issues are not relative like life and choice. Laws are regarded as social contracts rather than dictums, and those that do not promote general social welfare should be changed when necessary to meet the greatest good for the greatest number of people (a utilitarian view).

In Stage six, moral reasoning is based on abstract reasoning using universal ethical principles. Decisions are made in an absolute way rather than in a conditional way. In addition, laws are valid only insofar as they are grounded in justice, and that a commitment to justice carries with it an obligation to disobey unjust laws. While Kohlberg insisted that stage six exists, he had difficulty finding participants who use it.


After Kohlberg's stage 4, the transition from stage four to stage five, people have become disaffected with the arbitrary nature of law and order reasoning and he said they become moral relativists. This transition stage may result in either progress to stage five or in regression to stage four. As has become clear during the bioethics education project, there is such a range of cultural, family and school value systems across the world, that students of one age in one country will most likely be in different stages at different times, even if all persons did follow this progression from stage 1 to stage 6 in moral reasoning, and not revert back to other levels. Stage six would correspond to a person that followed the textbook bioethics of Beauchamp and Childress (1995). Macer (1998) has argued that bioethics is love of life, and that principalism based on following the standard ethical principles alone is not sufficient as an explanation of why people behave the way they do. The role of religious values is also obviously important, as concepts like karma and removal of oneself from the matters of the world do affect the values systems people use when approaching moral dilemmas.

Kohlberg used moral dilemmas to determine which stage of moral reasoning a person uses. The dilemmas are short stories that describe situations in which a person has to make a moral decision, yet they provide no solution. The participant is asked what the right course of action is, as well as an explanation why. This style is still commonly used as case-based ethics teaching. There is a need to develop more local cases for dialogues between Asian and Pacific cultures.

A dilemma that Kohlberg used in his original research was the druggist's dilemma:

Heinz Steals the Drug In Europe. A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $ 1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: "No, I discovered the drug and I'm going to make money from it." So Heinz got desperate and broke into the man's store to steal the drug for his wife (Kohlberg, 1969).

Should Heinz break into the laboratory to steal the drug for his wife? Why or why not?

Like many cases of bioethics, from a theoretical point of view, it is not important what the participant thinks that Heinz should do. The point of interest is the justification that the participant offers. Below are examples of possible arguments that belong to the six stages. It is important to keep in mind that these arguments are only examples. It is possible that a participant reaches a completely different conclusion using the same stage of reasoning:

Stage one (obedience): Heinz should not steal the medicine, because he will consequently be put in prison.

Stage two (self-interest): Heinz should steal the medicine, because he will be much happier if he saves his wife, even if he will have to serve a prison sentence.

Stage three (conformity): Heinz should steal the medicine, because his wife expects it.

Stage four (law-and-order): Heinz should not steal the medicine, because the law prohibits stealing.

Stage five (human rights): Heinz should steal the medicine, because everyone has a right to live, regardless of the law. Or: Heinz should not steal the medicine, because the scientist has a right to fair compensation.

Stage six (universal human ethics): Heinz should steal the medicine, because saving a human life is a more fundamental value than the property rights of another person. Or: Heinz should not steal the medicine, because that violates the golden rule of honesty and respect.

One criticism of Kohlberg's theory is that it emphasizes justice to the exclusion of other values. As a consequence of this, it may not adequately address the arguments of people who value other moral aspects of actions more highly. His theory was the result of empirical research using only male participants (aged 10, 13, and 16 in Chicago in the 1960s). Carol Gilligan argued that Kohlberg's theory therefore did not adequately describe the concerns of women. She developed an alternative theory of moral reasoning that is based on the value of care. Among studies of ethics there is a tendency in some studies to find females have higher regard for ethics theories (Ford and Richardson, 1994). Gilligan's theory illustrates that theories on moral development do not need to focus on the value of justice. Other psychologists have challenged the assumption that moral action is primarily reached by formal reasoning. People often make moral judgments without weighing concerns such as fairness, law, human rights and abstract ethical values. If this is true, the arguments that Kohlberg and other rationalist psychologists have analyzed are often no more than post hoc rationalizations of intuitive decisions. This would mean that moral reasoning is less relevant to moral action than it seems (Crain, 1985).

4: Ongoing reassessment and evaluation

After pilot trials the set of evaluation sheets that appear in the initial pages of A Cross-Cultural Introduction to Bioethics (Macer, 2006; pp. vii-xvii), were developed. There was a balance in the development of specific evaluation forms for student and teacher responses to chapters and the textbook or course between examination of the way that the thinking progressed and the privacy of the respondents. In the simple questions the respondents were asked to choose from one of: SA (Strongly agree), A (Agree), PA (Partially agree), NA (Not applicable), PD (Partially disagree), D (disagree), SD (Strongly disagree). The results to date show that the students are very positive to the materials and topics. Significant numbers wanted to have longer to discuss the materials and topics, though in these trials the class times varied. In all classes the students felt that they had enjoyed a meaningful discussion, as would be expected given that I had tried to use participatory methods for involving students and long question and answer periods during points in the reading of the written chapters. The teachers were unanimous in strongly disagreeing with Q8, thus judging the materials to be adequate, and strongly agreeing with the chapter’s utility. They also wanted more time for the discussion.

The comments given in the response forms are the most useful parts of the form. The open question (Q2) asks students to list keywords, and the students usually wrote a few keywords about the chapter, often the title plus a principle that was emphasized during the lecture. The open comments in Q9 looked at what the students had learned through reading the chapter and in response to this question usually a sentence or two were written. The answers are coded and analyzed, for example as to whether the comment illustrated they had learned about both sides of view. If the questionnaire directly asked whether they had learned about different points of view more would say so, but still most students focused on the facts or keywords of the chapter in their comments.

One of the concerns in developing cross-cultural materials is whether some contents are not appropriate in a culture. This concern was also raised in Catholic schools that used the first edition of the textbook, though they judged all the contents to be appropriate. Q10 asked whether there was any content not culturally appropriate. This is a decision teachers must make, and feedback on this is useful as both students and teachers may have different impressions.

At the end of the questionnaire (Q19) there was a space for student comments and suggestions. This type of feedback was very useful for the future of the materials and the pilot programs, and for providing feedback to the government Ministries and Boards of Education for the increased coverage of bioethics. As had been called for by teachers for many years (Asada et al. 1996; Macer et al. 1996; Pandian and Macer, 1998; Macer and Ong, 1999), the students also request more bioethics classes.

Text analysis of student reports for keywords is one of the valuable ways to evaluate students thinking also. Currently we are extending categorization methods that have been developed (e.g. Maekawa & Macer, 2005, 2006). The abbreviations used for some of the general coding categories are below:

Both Sides of View (BV): More than one side of an argument or a question being mentioned. Sometimes the views were not clearly stated in individual sentences so the judgment of the report containing a BV or not had to be made after the full evaluation of the report.

Personal vs. Other Persons’ Views (PO): The writer’s point of view (e.g., an “I think” statement) plus other people’s point of views being stated regardless of whether they concurred with those of the writer or not. Views/feelings of non-humans were not included in this category.

Scientific Facts (SF): A concrete and/or detailed scientific fact more intellectually demanding than common sense or the broad theme of the report. Generally this was not merely the citation of sentences from reference material(s).

Quantitative Facts (QF): The use of statistics and/or numbers in a factual manner.

Environment and Biocentric Ideas (EB): A statement made mentioning concerns for the environment or ecological concerns, or for example the care or treatment of animals raised as a concern. Generally people tend to reason and write from an anthropocentric viewpoint.

Utilitarian Views (UV): A utilitarian view is judging an act as being morally acceptable based on the opinion that the benefits of the action to one group or individual will outweigh the risks or harm produced affecting a larger population. It is also considering the balancing of society versus individuals .will be greater than that for an individuals, not limited to human beings.

Principles and Keywords (PK): A keyword denoting an ethical principle or connotation of one regardless of whether being directly stated or not. If only the term “rights” was mentioned, it was marked as R and not PK. Keywords included specific bioethics principles and keywords such as benefit & risk assessment, informed consent, enhancement, public welfare, autonomy, justice, equality of life, animal welfare etc.

Rights (R): Clear mention of a right or a connotation of a right. This was limited to the rights of human beings. R is a specialized category of PK.

Number of Ideas (NI): An idea is a distinct message unit, statement or concept that may be from the materials or from the writer’s own thinking. Key words and concepts were numbered when going through the reports and the same idea when repeated was not scored twice.

Main Idea (MI): The selection of a main idea was based on the main themes of the argument. It is related to the causal relationship between two or more ideas. Often the sentence answering the topic question was chosen as the main idea.

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