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The morality of inclusion: A response to Duffy
  1. D F-C Tsai
  1. National Taiwan University Hospital and National Taiwan University College of Medicine, Taiwan;

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    In July 2002, I had the honour to be invited to give a 15 minute presentation on behalf of my country, Taiwan, on the topic of “Current system of national guidance on human subject protection in medical research” in a panel discussion of the Forum for Ethical Review Committees in Asia and the Western Pacific (Fercap), World Health Organization (WHO) international conference held in Chin-Mai, Thailand. In that conference, four delegates from Taiwan had a rare (because Taiwan is not a WHO member and is normally excluded from joining any WHO related activities) and therefore very precious opportunity to share Taiwan’s experience in establishing and promoting “human subject protection system” with delegates from 27 WHO member countries of the region. Through the vigorous exchanges of opinion in those four days, we learned much about the current trends and advances concerning protection of human subjects in the WHO, the European Union, and the USA and the progress made by other Asian-Pacific countries. All this information will help us to develop our system better. We also shared our efforts and some unique developments (such as establishing a very efficient “joint ethics review board”, using hospital accreditation standards to facilitate research ethics and medical ethics etc) in promoting research ethics at the national, institutional, and individual levels. The Taiwanese experiences were also well received and useful to other Asian-Pacific participants.

    Mr Duffy has rightly argued for the morality of inclusion that health to all is a basic human right as advanced in the WHO Charter.1 The WHO’s position in denying Taiwan a legitimate role and opportunities to benefit from, as well as contribute to, the world health community is against the WHO constitution and is damaging to the health, welfare, and human rights of the 23 million Taiwanese people and, of course, to those elsewhere in the world who would benefit from the full participation of Taiwan in the WHO. As Buchanan has indicated, “The more fundamental and pervasive a cooperative framework is in a society, the more debilitating it is for an individual if he or she cannot participate effectively in it”.2 In 2002 and 2003, Taiwan applied to be an “observer” of WHO using merely a low profile status of “health entity” in order to reduce unjustifiable political harassment in the hope that she can start to participate legitimately in the world health community but the application was rejected. As a Taiwanese citizen, a healthcare professional, and a medical ethicist, I believe, undoubtedly, that this involves serious infringement of the moral rights of the Taiwanese people. The outbreak of the SARS (severe acute respiratory syndrome) epidemic that followed in May–July 2003 eventually proved that more lives could have been saved if Taiwan had not been excluded from the WHO.

    Three questions should be answered when considering the morality of inclusion:

    1. Which beings qualify as members of the primary moral community?

    2. Under what conditions are participants in a cooperative framework obligated to include individuals who can participate effectively?

    3. To what extent is there an obligation to ensure that the nature of one of the world’s most fundamental frameworks for cooperation renders it more rather than less inclusive?3

    On deliberating these three questions, it is clear that to exclude Taiwan from participating in the WHO is not justifiable. To correct this injustice, which is also self-defeating and contrary to the constitution and the aims and objectives of the WHO, should be high on the agenda of the WHO and indeed on the agenda of every morally aware individual and country. It is hoped that medical professionals throughout the UK and other readers of the Journal of Medical Ethics from the member states of the WHO will realise and endorse the morality of inclusion by giving Taiwan the support and help she needs to have a legitimate role in participating in the primary global moral community, the WHO.


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