The Cambridge textbook of bioethics

system of Aboriginal bioethics. Table 47.1 defines a number of Aboriginal terms that are used in this chapter.

A review of the literature revealed that little has been published on the subject of Aboriginal health ethics (Garie´py, 1999). In the scope of cultural bioethics, Aboriginal systems are unique in their respect for the visions and beliefs of the individual and concomitant respect for the community (Hultkrantz, 1987). Aboriginal values are frequently discounted by Western colonial culture. Primarily rooted in the context of oral history and culture, Aboriginal ethics are best understood as a process and not as the correct interpretation of a unified code (Garie´py 1999; Ong, 1982, pp. 57, 86, 145). In their approach to ethical decision making, Aboriginal cultures differ from religious and cultural groups that draw on scripture and textual foundations for their ethical beliefs and practices. Despite these challenges, common themes and the diversity within Aboriginal ethics may be highlighted. Research conducted with Aboriginal elders provides

the basis for identifying widely held values in Aboriginal frameworks for decision making (Ellerby, 2005).

Themes in approaches to communication and caregiving

Some essential qualities of ethical approaches to communication and caregiving involving Aboriginal peoples are summarized in Table 47.2. Although these ethical values are important to understand and apply, examining specific applications of ethical care in detail is not as useful as developing a more generalized understanding of how to approach ethical decision making with Aboriginal people in actual clinical settings. Aboriginal ethical decisions are often situational and highly dependent on individual values and on the context of the family and community. In general, Aboriginal ethical values include the concepts of holism, pluralism, autonomy, communityor familybased decision making, and the maintenance of

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quality of life rather than the exclusive pursuit of a cure. Most Aboriginal belief systems also emphasize achieving balance and wellness within all domains of human life (e.g., mental, physical, emotional, and spiritual). Aboriginal North American cultures share some ethical practices, such as the need to respect the integrity of the human body after death (Hultkrantz, 1987; Garie´py, 1999). Spirituality and cultural understandings of death, loss and the existence of Spirit Beings often play a role in the bioethical decisions of Aboriginal patients and families (Garie´py, 1999). Acceptance is a common, deeply rooted aspect of Aboriginal relationships to death and the passage of time during illness (Hultkrantz, 1981 [pp. 11–28], 1989, 1992 [pp. 15–16, 164–8]; Deloria, 1993 [pp. 62–77, 165–84]). Maintaining quality of life is commonly seen as paramount to extending life. Simultaneously, life is to be preserved and should be pursued whenever meaningful quality can be maintained. Affirming the dignity of life is essential (Brant, 1990).

Some Aboriginal people have a problem with advanced technology, and it is important to acknowledge this in treatment. Problems arise when a cultural heritage of nature-based medicine encounters biomedical treatment emphasizing technological interventions. Healthcare institutions such as urban teaching hospitals may be associated with a ‘‘culture of colonization,’’ emphasizing technological solutions. There are diverse perspectives in Aboriginal communities regarding the use of technologically advanced and aggressive treatments such as transplantation, dialysis, and mechanical ventilation. However, many Aboriginal people, particularly the young, may be open to and desirous of using the full range of medical technologies available.

Barriers

Ethical care of Aboriginal peoples may include the current emphasis in bioethics on the moral context of individual relationships in clinical interactions. However, this approach does not fully engage the broader structural context of barriers that impede

access to care or interfere with healing processes. Barriers include language problems, lack of cultural competence among healthcare providers, problems of transportation and communication in service delivery to remote communities, and institutional discrimination.

Applications of the bioethical principles of autonomy, beneficence, and justice in contemporary relationships must recognize the historical context of power relationships between Aboriginal people and providers of health and social services. The dominant emphasis on respect for individual autonomy in bioethics may need to incorporate Aboriginal values emphasizing non-interference. The Aboriginal psychiatrist Clare Brant (1990) observed, ‘‘the ethic of non-interference is a behavioural norm of North America Native tribes that promotes positive interpersonal relations by discouraging coercion of any kind, be it physical, verbal or psychological.’’

Approaches to guaranteeing autonomy in communication involving consent and truth telling must accommodate this value of avoiding coercion. Direct, unmediated communication of bad news involving terminal prognosis or risks of impending death may violate the values of some individuals and communities. Cultural and spiritual traditions, including those of Navajo people in the USA and Dene people in Canada, assert that speaking explicitly about terminal illness and death may hasten death (Carrese and Rhodes, 1995; Kaufert et al., 1999). Some families may, therefore, ask to be present to mediate communication of bad news and support the family. One potential way of recognizing alternative approaches to truth telling in consent may resemble Freedman’s (1993) concept of ‘‘offering truth.’’ This framework avoids ‘‘imposing truth’’ by allowing the person to define the level and explicitness of the information they require to interpret care options.

Emphasis on guaranteeing informed consent and minimizing risks to individuals in the decisionmaking process may be unduly influenced by historical relationships that discount Aboriginal values, which emphasize protection of the family

and the community. In making consent decisions, Aboriginal patients and their families may balance the risks and benefits to the individual with the interests of the family and community. For example, a patient may defer to the wisdom of an elder or healer or elect to use a proxy decision maker from the family in signing consent agreements or advance directives (Kaufert et al., 1999).

In ethical decision making, power differences may be accentuated by language barriers among patients who are monolingual speakers of Aboriginal languages or who have limited fluency in English or French. In these situations, ethical communication should involve the use of trained Aboriginal health interpreters, who have competence in both biomedical terminology and Aboriginal concepts of health and healing.

Diversity and pluralism

Diversity and pluralism are essential dimensions of Aboriginal ethics. Aboriginal ethics emphasize a pluralistic perspective that accepts that a wide spectrum of values and perspectives may be held by family members. In allowing for the expression of a plural spectrum of values, autonomy among individual family members is emphasized and respected. Aboriginal cultures and communities are diverse, and therefore it is difficult to develop generalizations about values or decision-making practices. Across North America, for instance, and within individual states, provinces, and territories, there is a wide spectrum of cultural and language groups, and variations between individual Aboriginal communities and regional organizations. For example, Manitoba is home to Cree, Ojibway (Annishinabe), Me´tis, Inuit, Dene, and Dakota people. Despite some shared beliefs, each cultural group must be treated with respect and an understanding of inherent diversity.

In considering the diversity of beliefs among Aboriginal people, one needs to recognize the impact of Christianity on Aboriginal communities. In many communities and families, the introduction of Christianity increased the diversity of values

influencing ethical decision making. In some cases, the result has been division and animosity between family and community members who hold traditional Aboriginal values and those who assert Christian values.

Why is Aboriginal bioethics important?

Population

The population of Aboriginal people who may benefit from culturally appropriate ethical decision making is growing. There are alternative ways to define the Aboriginal population. For instance, data from the 1996 Canadian census indicated that about 800 000 people identified themselves with one or more Aboriginal groups: North American Indian, Me´tis, or Inuit (Statistics Canada, 1996). The population includes about 41 000 who identified themselves as Inuit and about 210 000 as Me´tis. Approximately 44% of Aboriginal people live in urban areas (Royal Commission on Aboriginal Peoples, 1996). Of the more than 550 000 respondents who identified themselves as ‘‘North American Indian,’’ approximately 60% indicated that they were a member of a First Nation or Band or had treaty status as defined by the Indian Act of Canada (Statistics Canada, 1996; see Table 47.1). The ongoing transfer of control over health services to individual First Nations or Bands will mean that mandates to apply Aboriginal values in ethical decision making will be emphasized in primary and tertiary health programs.

Access to care

The importance of understanding Aboriginal perspectives on health ethics is often linked with differences in health status and utilization of health services. Lower health status and barriers to medical care access are engaged within the ethical context of distributive justice and equality. Research documenting the disproportionate burden of morbidity and mortality and high levels of health service utilization among Aboriginal people is often cited in

medical literature. However, some Aboriginal health policy makers have recently emphasized that epidemiological comparisons do not express the importance of individual and community historical relationships or contemporary experiences of racism in residential schools, social welfare program, or the healthcare system (O’Neil et al., 1998). In addition, there are many culturally distinct practices among Aboriginal people that necessitate a unique ethic of care.

Equitable access to high-quality health services is a central focus for both rural and urban Aboriginal people. Because of the centrality of family in Aboriginal people’s experience of illness and treatment, and restrictions in the access of friends and family members, Aboriginal patients often feel isolated when in hospital. Aboriginal approaches to decision making commonly involve members of the extended family, and offering opportunities for family involvement should be considered a prerequisite of providing ethical and culturally appropriate services (Kaufert et al., 1999).

How should I approach Aboriginal bioethics in practice?

To understand Aboriginal health ethics in clinical practice, several fundamental dimensions need to be recognized. Healthcare providers must recognize the risks of applying stereotyped values and spiritual beliefs, as well as the futility of attempting to develop generalized ethical formulas for communicating with Aboriginal patients. Plural belief systems and variation among individuals preclude the direct application of knowledge in reconciling Aboriginal beliefs with biomedical and bioethical criteria.

Aboriginal bioethics can best be viewed as an interpersonal process. Immediate and clearly defined approaches should not be expected. Aboriginal bioethical positions are largely situational; adopting a case-specific approach is, therefore, important. Healthcare providers working with Aboriginal people must first try to acknowledge the importance of autonomy, the centrality of family to health and

identity, the diversity in beliefs and practices among Aboriginal people, and the value of developing and maintaining personal and emotionally sincere relationships with patients. Provider ethics emphasizing the maintenance of professional distance may contravene the Aboriginal affirmation of the power of human relationships in the healing process. Trust is paramount.

Healthcare providers might consider adopting the role of learner, allowing Aboriginal elders and each patient to lead in the articulation of the ethical principles guiding care. Not only is the process of family consultation critical in making decisions about acute and emergency care, but it is also an important dimension of day-to-day primary care. Healthcare providers should recognize that biomedical values may not always be reconcilable with Aboriginal values, despite improved communication methods or increased cross-cultural awareness.

If healthcare providers ignore differences related to Aboriginal culture, they will not be able to understand the wide spectrum of beliefs and attitudes that Aboriginal people draw on in making ethical decisions. For example, although certain values such as respect for dignity, non-interference, sharing and the importance of family and community are widespread, other beliefs such as those about truth telling may differ, even among members of the same family. Healthcare providers cannot take Aboriginal beliefs for granted and need to explore these carefully with each person. As well as respecting beliefs, healthcare providers need to respect the decisions of patients and families who request involvement of Aboriginal healers, elders, and medicine people in their care (see Table 47.2).

The future of ethics and Aboriginal people

Aboriginal cultures can be identified as premodern in the sense that there is no separation between the self and the universe; between self, family, and community; or between mind, body, and spirit. Therefore, healing is not possible without spirituality, nor without relationships to family and community, and to the cosmos. Restoring these values and beliefs

can balance biomedical treatments and lead to healing of the person as well as cure of disease.

Recent Western history has emphasized scientific and technological advances at the expense of, and exclusion of, spirituality. The consequences of this have been traumatic for many traditional Aboriginal people. When in need of healthcare, many Aboriginal people view healthcare institutions as dehumanizing: they experience mind–body separation and separation from family and community, and they are asked to participate in ethical decision making guided by biomedical values.

The postmodern paradigm, which questions the existence of universal norms, scientific truth, and ‘‘superior’’ cultures, presents an interesting challenge to modern medicine and its claims of exclusive efficacy in achieving cure. The current popularity of alternative healing methods, such as Aboriginal medicine, and the thirst for spiritual values are but two indications of a postmodern culture that is more inclusive and holistic and thus more akin to traditional Aboriginal culture.

Aboriginal ethics is an important area of study because of its potential to make exceptional contributions to more generalized understandings of bioethical practice in increasingly diverse clinical and sociocultural environments. The emphasis in Aboriginal ethics on pluralism, diversity, and the maintenance of a high level of respect for individuality challenges Western biomedical paradigms to adjust to become more responsive and dynamic in their approach to ethical decision making. By incorporating a model of ethics that acknowledges pluralism and cultural context, medicine has the opportunity to develop models of ethics and care that are relevant to the cross-cultural treatment of the whole person (Dacher, 1996).

The case

The young female interpreter, out of respect for Mr. A’s age, sex, and status, cannot discuss the urological procedure with him directly. However, by adhering to Ojibway beliefs, she does use a genera-

lized term to refer to cancer and thus avoids contravening the belief that ‘‘speaking the future may bring it to pass.’’ Although the male interpreter is able to use anatomic language without disrespect, Mr. A’s son feels that explicit truth telling about cancer is against traditional practice. In giving his son permission to be his interpreter and to be a proxy decision maker, Mr. A is not undermining his own personal autonomy and instead is demonstrating shared family and communal responsibility in decision making. This is in contrast to the usual Western view of autonomy as conceding supremacy to the individual rather than to anyone else in making decisions. Only recently has the importance of relationships, especially as propounded in feminist ethics, been given a place in bioethics. Though it is worrisome for some that a cognitively competent individual is not being involved in making decisions about his future, Mr. A has chosen to delegate responsibility to his son. Given the principle of non-interference among Aboriginal people, the father’s values and beliefs may differ considerably from those of his family. An important task of the interpreter and caregivers is to determine whether such differences are present. Aboriginal language interpreters are, therefore, necessary not just for translation but also to bring cultural awareness and sensitivity to interactions between patients, family members, and healthcare providers. If differences in values are present, the physician may need to ‘‘offer truth’’ to ensure that Mr. A’s views are respected. For example, Mr. A might be asked, ‘‘Are you the sort of person who likes to know all available information, or are you happy for your son to make decisions for you?’’ In this case, it is reasonable that the father is not immediately told about his prognosis, since curative treatment is not being recommended. By being given extra time and a cultural medical treatment (i.e., a sharing circle in which caregivers, family, and the patient participate), Mr. A achieves balance between his diagnosis, the biomedical view, and his spiritual beliefs in a culturally appropriate manner. Following the sharing circle and a family meeting, the son, the urologist, and the interpreter meet

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with Mr. A, his wife, and two of his other children. After this process of family consultation and gradual and prolonged truth telling by the family, Mr. A understands his diagnosis and the implications of metastatic cancer. Together with his family, he consents to palliative care, including pain control and palliative radiation.

REFER ENCES

Brant, C. C. (1990). Native ethics and rules of behavior. Can J Psychiatry 35: 534–9.

Carrese, J. A. and Rhodes, L. A. (1995). Western bioethics on the Navajo reservation: Benefit or harm? JAMA 274: 826–9.

Dacher, E. (1996). Towards a post-modern medicine. J Altern Complement Med 2: 531–7.

Deloria, V. (1993). Thinking in time and space. In God is Red: A Native View of Religion, ed. V. Deloria. Golden CO: Fulcrum, pp. 62–7.

Ellerby, J. H. (2005). Working with Aboriginal Elders: Understanding Aboriginal Elders and Healers and the Cultural Conflicts Involved in Their Work in Health Care Agencies and Institutions. Winnipeg: Aboriginal Issues Press, University of Winnipeg.

Freedman, B. (1993). Offering truth: one ethical approach to the uninformed cancer patient. Arch Intern Med 153: 572–6.

Garie´py, G. J. (1999). End of Life Issues in Aboriginal North America. Winnipeg: University of Manitoba.

Hultkrantz, A. (1981). North American Indian religion in a circumpolar perspective. In North American Indian Studies: European Contributions, ed. P. Houins. Gottingen the Netherlands: Hovens, pp. 11–28.

Hultkrantz, A. (1987). Native Religions of North America: The Power of Visions and Fertility. San Francisco, CA: HarperCollins.

Hultkrantz, A. (1989). Health, religion and medicine in Native North American traditions. In Healing and Restoring:

Health and Medicine in the World’s Religious Traditions, ed. L. E. Sullivan. London: Macmillan, pp. 327–58.

Hultkrantz, A. (1992). Shamanic Healing and Ritual Drama: Health and Medicine in Native North American Religious Traditions. New York: Crossroad.

Kaufert, J. and Koolage, W. (1984). Role conflict among culture brokers: the experience of Native Canadian medical interpreters. Soc Sci Med 18: 383–6.

Kaufert, J. M., Putsch, R. W., and Lavalle´e, M. (1999). End- of-life decision making among Aboriginal Canadians: interpretation, mediation, and discord in the communication of ‘‘bad news.’’ J Palliat Care 15: 31–8.

O’Neil, J., Reading, J., and Leader, A. (1998). Changing the relations of surveillance: the development of a discourse of resistance in Aboriginal epidemiology. Hum Organ 57: 230–7.

Ong, W. J. (1982). Orality and Literacy. New York: Methuen. Pohl, A. (2000). Building International Awareness on Aboriginal Issues. Toronto: Citizens for Public Justice. Preston, R. J. and Preston, S. (1991). Death and grieving among northern forest hunters: an East Cree example. In Coping with the Final Tragedy: Cultural Variations

in Dying and Grieving, ed. D. R. Counts and D. Ayers Counts. Amityville, NY: Baywood, pp. 135–56.

Royal Commission on Aboriginal Peoples (1996). Gathering Strength. Ottawa: The Commission.

Statistics Canada (1996). Census 1996: Population by Aboriginal Group. Ottawa: Statistics Canada.

Related websites

Aboriginal healing and wellness links (Turtle Island Native Network): www.turtleisland.org

Association of American Indian Physicians: www.aaip.com

Health Canada First Nations and Inuit Health Programs: www.hc-sc.gc.ca/msb/fnihp

Indian Health Service, US Department of Health and Human Services: www.ihs.gov

Mrs. B is aged 35 and lives in a remote part of the Chiang Mai region of northern Thailand. She is an agricultural worker with only a basic education. She does not use contraception because there is no local family planning facilities. She is married with three children, and has just found out she is eight weeks’ pregnant. She and her husband barely earn enough to support their existing children, and a fourth child would place an unbearable economic strain on family resources.

The Venerable C, a Burmese monk resident in the USA, suffered a severe stroke at the age of 59. He had a history of diabetes, poorly controlled high blood pressure, atrial fibrillation, congestive heart failure, and chronic obstructive pulmonary disease. He had undergone a cardiac bypass operation several years earlier. The prognosis was guarded at best, even with surgery. The attending neurosurgeon asked whether Venerable C would want emergency surgery or if he would prefer to forgo aggressive measures. The monk had not discussed his wishes previously with his fellow monks or students, had made no advance directives, and remained unconscious throughout (Hood, 2005).

What is Buddhist bioethics?

Buddhism is a body of religious teachings attributed to an historical individual called Siddhartha Gautama, who lived in northeast India in the fifth century BCE. Following a profound spiritual transformation at the age of 35, he became known by the honorific title of ‘‘Buddha’’ (‘‘enlightened one’’). In common with other Asian traditions, Buddhism believes in reincarnation and teaches that individuals undergo a potentially infinite series

of rebirths. However, Buddhism is distinctive in lacking a belief in a supreme being, as well as denying the existence of a personal soul. Buddhists follow the Buddha’s teachings (or Dharma) in the hope of putting an end to rebirth by attaining the transcendent state of nirvana. Buddhism has no head or central authority, and in resolving moral dilemmas Buddhists are encouraged to reflect on the teachings preserved in scripture, to seek the guidance of advanced practitioners such as monks, and to meditate on all aspects of a situation in order to ensure that any decision they reach is in harmony both with the spirit of the teachings and their conscience. There are no international organizations or colleges of Buddhist physicians that serve to formulate policy for the guidance of healthcare professionals. Despite this lack of central authority, there are fundamental moral values and principles that virtually all schools of Buddhism accept. Chief among these are compassion (karuna) and ‘‘non-harming’’ or respect for life (ahimsa), which between them underpin Buddhism’s approach to bioethics.

The most widespread set of precepts in Buddhism are the Five Precepts, and the first of these prohibits causing harm or injury to living creatures (human and otherwise). This is interpreted quite strictly and has an important bearing on bioethics, especially in relation to questions such as abortion and euthanasia. At a theoretical level, recent studies have suggested that Buddhism can best be understood as a form of virtue ethics (Whitehill, 2000; Keown, 2001a, 2005a; Cooper and

James, 2005), and if so this offers an opportunity for dialogue with similar approaches to bioethics being developed in the West. The literature on Buddhist bioethics itself, however, remains limited at this time (e.g., Ratanakul, 1986; Harvey, 2000; Keown, 2001b; Tsomo, 2006).

Buddhism is a world religion with a large following both in Asia and the West. However, Buddhists are influenced not just by the formal teachings of their religion but also by the beliefs and practices of their indigenous cultures. In some cases, the influence of the latter may be so strong that it overrides the former, leading to the impression that there is little agreement or uniformity among Buddhists as a whole. For example, there is general agreement among Buddhists in Asia that abortion is contrary to the First Precept, but wide variation among countries where Buddhism is practiced as to what is legally permitted. There is also a diversity of views on this question among Buddhist converts in the West. In traditional Buddhist countries, the nucleus of social concern – as in many Asian cultures – is the extended family rather than the individual, and ethical questions, therefore, tend to be analyzed primarily in terms of duties rather than rights.

Since Buddhism is a transcultural phenomenon, it is impractical to discuss questions of law and policy here at any length. By way of example, some reference will be made to particular Buddhist countries, but readers should bear in mind that there is considerable legal and cultural diversity in the regions of Asia where Buddhism is practiced. More detailed information on local conditions may be found in the references.

Why is Buddhist ethics important?

Buddhism has had a major influence on Asian culture, spreading to every part of Asia and is now growing rapidly in the West. There are approximately five million Buddhists in the USA and around one million in Europe. The total number of Buddhists worldwide is put at 500 million. Given its

global distribution, many individuals now look to Buddhist teachings for ethical guidance when facing problematic decisions on medical treatment. It is, therefore, important for physicians and other care providers to understand the underlying values that may influence Buddhist patients in taking treatment decisions. Furthermore, as an Asian culture, Buddhism can provide a complementary perspective on ethics and may have much to contribute to Western discussions.

How should I approach Buddhist ethics in practice?

Buddhism imposes few special requirements on either patients or physicians in connection with medical treatment, and there is no reason why the care of Buddhist patients should pose any special problems. The only exception would be that it would not be appropriate for a monk or nun to be on a mixed ward, and it would be preferable for them to be treated by a physician of the same sex. Unlike Western clergy, Buddhist monks do not function as chaplains, nor do they visit hospitals in a pastoral role or to perform religious services for the sick.

Buddhism is a flexible and moderate religion in which concepts of taboo and religious purity have little, if any, part to play. Religious law imposes no special requirements or limitations on medical treatment, nor are there any special hygiene, purificatory, or dietary requirements (while many Buddhists are vegetarians, others are not). Cremation is the most common means of disposing of the dead.

In practice, local custom tends to have a greater bearing on the physician–patient relationship than Buddhist doctrine. It is difficult to generalize about local customs, but provided the conventions of normal medical etiquette are respected there is no reason why difficulties should arise. This is particularly so in the case of the many Westerners who have converted to Buddhism and who are unlikely to have any problems with the conventions of

Western medical practice. As with all societies there is diversity among Buddhist populations arising from socioeconomic factors and level of education, which makes it difficult to generalize how any individual Buddhist is likely to react. At the village level in Asia, for instance, Buddhism coexists with animism, and belief in the power of local gods and spirits to cure illness is widespread. Allowance, therefore, needs to be made for such variation, and the temptation to generalize should be avoided.

Notable differences are found across Asia, particularly between the countries of East Asia, such as China, Japan, and Korea, and those of South Asia, such as Burma, Thailand, and Sri Lanka. The former group follow the Mahayana form of Buddhism, while in the latter the more conservative Theravada form predominates. To highlight just one example, in Japan, the criterion of brain death is deeply unpopular because of its association with cadaver transplants. Being a party to what is seen as the desecration of the corpse of a close relative, particularly a parent, causes deep unease (LaFleur, 2001). There is also skepticism about the validity of the brain death criterion itself as a reliable test for human death, a skepticism increasingly voiced by dissidents in the West (Youngner et al., 1999; Potts et al., 2000).

Another distinctive feature of the Buddhist perspective is the emphasis it places on mindfulness and mental clarity, as seen in the practice of meditation. Buddhism emphasizes the importance of an unclouded mind, particularly when a patient is close to death, as it is believed this can lead to a better rebirth. Some Buddhists may, therefore, be unwilling to take pain-relieving drugs or strong sedatives, and even those who are not in a terminal condition may prefer to remain as alert as possible rather than take analgesics that will impair their mental or sensory capacities.

Abortion

Most Buddhists regard fertilization as the point at which individual human life commences and

believe that the embryo is entitled to moral respect from that time onwards. Abortion is, therefore, seen as morally in the same category as the intentional killing of an adult. The only exception is likely to be when the procedure is necessary to save the life of the mother.

The contemporary legal position varies from country to country. The more conservative Buddhist countries of southeast Asia, such as Thailand and Sri Lanka, have laws prohibiting abortion, except when necessary to save the life of the mother. Nevertheless, illegal abortions are common. Somewhat surprising for a country in which Buddhism is the state religion, abortions in Thailand are running at some 50% higher than the number in the USA for the equivalent number of citizens. Married women, who appear to use it as a means of birth control, account for 85% or more of abortions. Recent studies refer to an estimated 300 000 abortions per year, the vast majority of which are illegal. The Thai Penal Code of 1956 allows abortion in only two circumstances: first, ‘‘if it is necessary for the sake of the woman’s health’’ and, second, in cases of rape. Official figures from the 1960s record as few as five legal abortions in some years. Opinion polls in Thailand also reveal an intriguing paradox: while most Thais regard abortion as immoral, a majority also believes the legal grounds for obtaining it should be relaxed (Florida, 1991, p. 22).

In east Asian countries, attitudes are more liberal. The rate of abortion in Japan has been very high in recent years, perhaps peaking at over a million (some would put the figure much higher) before decreasing in the last few years as the contraceptive pill has become more easily available. Central to the contemporary Japanese experience is the phenomenon of mizuko kuyo, a memorial service held for aborted children. This service involves erecting a small statue to commemorate the lost child and includes an apology to the spirit of the aborted fetus. William LaFleur (1992) has explored the complex symbolism and cultural history of the practice, and a feminist perspective has been provided by Hardacre (1997).