Evely_ Reinoso_Lacson

Bioethics was a challenge for me because it was
something new and, you know, if you want to
learn something, age does not matter
Evelyn Reinoso Lacson, the Philippines, Master of Bioethics graduate
A doctor from the Philippines
Dr. Evelyn Lacson has been a practising obstetrician-gynaecologist (ob-gyn) for the last 23 years. She works at a hospital in
Bacolod City as well as running her own private practice. As an obstetrician, she has helped to deliver over five thousand children over
two generations. Evelyn is a highly regarded member of the Philippine Obstetrical and Gynecological Society, which is concerned with
the training of medical personnel in obstetrics and gynaecology. An active member of the society, she was appointed Regional Director
and Chair of the Women’s Advocacy Committee. This work took her around the country promoting adolescent reproductive health and
campaigning against domestic violence. Bioethics became her professional interest five years ago, when she attended courses in
Manila and started teaching bioethical issues in obstetrics and reproductive medicine at the University of St. La Salle in Bacolod. The
desire to deepen her knowledge prompted her to apply for an Erasmus Mundus Master’s degree in Bioethics.
At the age of fifty, Evelyn travelled to Europe to become a student again. Her first and only plan - to return to the
Philippines after completing her studies in Europe - was determined by her great attachment to her home country and by her social
and professional positions there. After nine months of studies at Radboud University Nijmegen in the Netherlands, at the Catholic
University of Leuven in Belgium and at the University of Padova in Italy, she went back to her country and initiated several
programmes to introduce and propagate bioethics in teaching and clinical practice. Being the first graduate in the Philippines with a
European Master's degree in bioethics, she was given the task of establishing and chairing a research ethics board at her university
and clinical ethics committees at its affiliated hospitals. She proposed significant changes in the bioethics curriculum and developed
a teaching program in bioethics for medical students at the University of St. La Salle. As a Fellow of the Philippine Obstetrical and
Gynecological Society, she has been asked to teach and train other doctors in issues regarding clinical ethical decision making.
Bioethics in the Philippines is now beginning to emerge as an academic discipline with practical applications. Although actively
involved in her full-time obstetrical-gynaecological clinical practice, Evelyn still finds time to do pioneering work in introducing
elements of European bioethics practice and standards into teaching, research, clinical practice and policy making in her region.
Evelyn is a person full of power and enthusiasm who is devoted to her family, community and profession and is always ready to
take up challenges, with great heart.
Photos: Evelyn’s work in the hospital
With the task of learning about Evelyn’s personal and professional achievements, as well as the impact of the
Erasmus Mundus programme on her career, the team landed at Bacolod City on Negros, one of the 7,100 islands that make
up the Philippines. The population of the country is 88 million people, who speak 180 different languages and dialects, of
which English and Filipino (Tagalog) are in official use. About 80% of Filipinos profess to be Catholics, and even though the
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separation of church and state is formalised in the Filipino constitution, the Catholic Church has a great influence on national
and local politics and social life. As we learned from Evelyn, the average Filipino earns about 238 Euros a month, however,
about 30 million people live on less than 2 Euros a day. Thus, poverty is a highly visible problem in this country, almost as
visible as the physical beauty of its inhabitants.
Photo: Filipinas, famous for their beauty
Photos: The oldest church in Manila, San Augustin (dating from 1587). Other Catholic churches in various styles in
Bacolod
The team visited the Philippines during the wet season, which lasts from June to September. About twenty typhoons
whip across the Philippines each year bringing heavy rains and strong winds and causing millions of dollars worth of
damage. A few weeks before our visit, one of them hit the central part of the archipelago, where Negros lies. Fortunately the
destruction was relatively minor, although the electricity supply to Bacolod was cut off.
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Photos: Views around Manila and heavy rains during the wet season
In Evelyn’s case we wanted to investigate how her interest in bioethics had started and what had motivated her to
go to Europe to study for nine months, a decision that meant interrupting her flourishing medical practice. Her short
explanation shone a light on her motives: “Five years ago, I was asked to be a part-time professor teaching bioethical issues
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in obstetrics and reproductive medicine to 2 , 3 and 4 year medical students at the College of Medicine of the University
of St. La Salle. In order to teach competently, I attended bioethics courses offered locally. Through the courses, I realized
that bioethics was a much wider field and not merely limited to ethical issues regarding doctor-patient relationships which I
learned back in medical school. It has come to encompass research, new biotechnology, property rights, genetics, law, social
behaviour, philosophy and a whole lot more. To disseminate that knowledge, a core bioethics curriculum had to be
developed. To me, it was all so exciting.” Thirsty for knowledge and encouraged by the university, she chose to apply for an
Erasmus Mundus scholarship for the Master's degree in Bioethics offered by a consortium of European universities: “I chose
to give up my medical practice for nine months, be away from family and friends and be a student once again. People said I
was foolish and crazy to want to do it.”
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Evelyn is leaving.
After our arrival in Bacolod and a short rest, the team went to Evelyn’s house to meet her parents, Agerico and Rosario
Reinoso, her son Kenneth and her brother Benedicto. We were invited to a traditional dinner of roast pork, local vegetables and rice.
The family members, wearing beautiful traditional dress, made of pinya and cotton, initiated the meal with a prayer. After the meal we
asked Evelyn’s parents about her decision to go to Europe. Her 89-year-old mother joked that her daughter was a brave girl, but that
the time when Evelyn went to Europe was hard for her mother’s heart. Interestingly, her daughter’s departure had resulted in her
becoming familiar with ICT – she learned to use a computer with Skype and a webcam to speak to her “girl” every day. This is how
Rosario remembers that time: “When Evelyn told us that she will be going to Europe for further studies, I was a little bit sad but knowing
that we have trained her since childhood, and with the training that we gave her and the education she got from college, our fears were
nipped or subsided because we knew that she could tackle anything in Europe. And I had to put the Internet in my house in Manila so
that I could always see her and talk to her and be assured that she was safe in Europe. Before, I used to pay only little amount for my
telephone bill but when she went to Europe I have to add more pesos so that I could see her every day. That's how much we love her.
You know I love my children, they are my life, as well as for my husband. So, when we learnt that she might do her studies in Europe,
we were very happy, very compensated. And so, our dreams were fulfilled. This is a part of her life as a doctor: to be acquainted with all
these modern facilities and European heritage. If she wants to do something, she wants to do it well or not at all. She stayed in Europe
for nine months. That was quite a long time. And thanks to the Internet I used to see her, talk to her everyday, my fears subsided. I
knew she could live there alone and I learnt that she had made friends with all her classmates. She has been an adventurous girl since
she was small. She enjoyed her studies more and more as the months went on. She went to other places where I didn't dream or
thought that she could go, but she did. She is a brave girl, just like her father taught her. Her father, being an army man, taught her how
to be brave since she was small.” Evelyn’s father told us the story of his participation in the Bataan Death March in 1942. This was the
forcible transfer of 66,000 Filipino and 10,000 American soldiers who were Japanese prisoners of war. Agerico and his companions
were forced to walk 120 kilometers from the Bataan peninsula to their new prison camps. He survived marching for nearly a week in
the tropical heat, with almost no food and water, witnessing horrible acts of wide-ranging physical abuse and murder committed by the
Japanese soldiers. In total, 20,000 people died along the way and another 25,000 died in captivity. After World War II, one of the
priorities of Evelyn’s parents was the education of their children. They provided her and her six siblings with access to education, and
as a result of their efforts, all seven graduated at a tertiary level. They are now economists, teachers, entrepreneurs, company directors
and doctors.
Photos: Evelyn’s parents, Agerico and Rosario, and her brother, Benedicto
Evelyn’s brother, Benedicto Reinoso, who is also a doctor and neonatologist by specialisation, told us that he was very
surprised on hearing about her plan to study in Europe: “When I heard that my sister was going to Europe to study bioethics, I was
surprised because her practice as an obstetrician was already at its peak. She had already plenty of patients. And when I heard that
she was going to Europe and will stop practising obstetrics temporarily, I was surprised because with her practice she didn't need any
more bioethics course. But I know my sister. When she wants something, she gets it. So I just left it all up to her." Benedicto was also a
little sad when he first learnt that his sister was going to Europe, because they were very close to each other. But this was not the only
reason - they were also working together and sharing patients in the same hospital. He was in paediatrics while she was practising
obstetrics: “Initially I thought I would lose some of the patients. She delivered these infants, these babies, and I would be one who
would take charge of these babies. But after a while, I put in my mind, that after one year she would be back. And I was also surprised
that one year was really so fast. Right now we are the same big family again. She is back to her practice. And aside from her practice
as an obstetrician she takes time to work in the university, teaching bioethics to our medical students.”
The team was interested in the education Evelyn had received, a good education that her parents had provided her with
and one that had shaped her later life. We visited her upper primary and secondary school, Saint Scholastica’s Academy, run by
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Benedictine nuns. While visiting the classrooms, Evelyn’s thoughts went back to the eight years she had spent there, from the 4 to the
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7 grade of primary school, followed by four years of high school: “Those were happy times for me because they were times of
innocence and great learning from the Benedictine sisters. They gave me the values of prayer and work which I've carried on to my
career.” Sister Rebecca Magalang, the school's current headmistress, explained to us the kind of education they provide and the
values Evelyn was brought up with: “When the Benedictine sisters started in the Philippines they had a common goal: that was to teach
women to become good housewives. Later on, as the system of education developed, their goal changed into the total development of
a woman. And basically, since Saint Scholastica’s motto is “ ora et labora”, the emphasis is on prayer, work and the Benedictine gospel
values - hospitality, cooperation, community building, and humility as well as service to the unfortunates.” Her schooling also meant that
Evelyn had the chance to become acquainted with European philosophy: “The German sisters taught me about German philosophers
and philosophy in general which was introduced to us during our 4th year. So when I went to my university years, at the University of
Philippines, these philosophers were familiar to me and I understood what they wanted to impart, especially when you speak about
philosophical ideas in bioethics.”
Photos: Sister Rebecca Magalang and the interior of Saint Scholastica’s Academy
Later in the afternoon the team listened to Evelyn’s Mundus story. She clarified to us the circumstances in which she had
gone to Europe. In her case, the Mundus scholarship was an institutionally driven idea: her university had encouraged her to apply for
the grant so that she could go deeper into bioethics in order to bring new ideas and approaches to medical education and practice to
the Philippines. She eagerly agreed with the highest of intentions – she wanted to give back to her community and her country
everything she would learn, thus contributing to the medical profession: “Like my brother said, I had a very successful clinical practice.
And after having brought up my children and made them independent, after training people to take over treating people, having
travelled abroad and having studied; I asked myself "What else is there to do?" So taking up bioethics was one of the ideas that came
to me because I was interested in teaching, giving back to my community and to my country what I have learnt and I wanted to
contribute to my medical profession. So I decided to teach in a medical school. I spent my time with medical students, making plans
and sharing bioethics with them. However, I thought I was not teaching enough and didn't have enough knowledge. I resorted to taking
courses in bioethics in Manila. My university advised me to take this Master's course in bioethics in Europe. Information about the
scholarship was offered to me by the university because they thought they needed some expertise in bioethics. So I took it. When I told
my family that I was leaving and leaving my practice, and becoming a student again, they were shocked. They were thinking "She must
be crazy! She has everything in life and now she wants to leave." Bioethics was a challenge for me because it was something new, and
you know, if you want to learn something, age does not matter. I wanted to have a new lease in life and, how would you call it, a new
motivation to be able to live a good life. So, when some of my friends were telling me "What's bioethics? Why do you want to take it?
You must be crazy, giving up everything" I told myself that at this point in my life, it is what I want. And I did it. I passed the requirements
and they told me I was accepted to the programme. Being able to live in Europe for almost a year was one of the best things that
happened to me. I have visited Europe several times before and I always wanted to learn its culture, to learn some of its languages.”
Obviously, leaving was not easy. It meant a lot of concerns about her family, especially her ageing parents: “Of course I had to set
some money aside to be able to support the family when I was away. And I had to leave my parents, who were ageing and they were
sickly. That was also one of the concerns I had, but we, my brother and I, set up an Internet connection, I purchased a webcam and I
was able to talk to them during the course of my studies. And that was, you know, a relief for them, because they were able to
communicate with me when they wanted.”
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In Europe
Studying in Europe was, for Evelyn, a mind-opening experience. She became familiar with Western
philosophy, the secular approach and new points of view: “I appreciated the openness and the expertise our professors
had in imparting knowledge to us. I learned to appreciate Western philosophy and its contributions to bioethics. I
learned the latest bioethical issues and arguments regarding genetics, reproductive technology, health care and public
health, research ethics, clinical ethics. Issues on palliative care and euthanasia. How other religions view these ethical
issues. How the European concepts of solidarity and dignity enrich bioethics. How immigration has challenged these
concepts. I still continue to do clinical practice and have slowly introduced the concept of CHOICE and informed
consent to my patients and co-workers. My Mundus studies have enriched my career by putting substance to the
materials I teach. They have given me a wider perspective, which I can share with my students and colleagues,
regarding current ethical issues seen from a secular point of view. It has exposed me and made me understand
Western philosophical thinking, sociology and current public health issues which I now use, and will use, for helping to
set guidelines and policies. I found bioethics to be a rich combination of clinics, philosophy and the social sciences
what allowed me look at problems in a holistic manner. This enhanced my lectures in reproductive ethics to include
other views held by a secular and pluralistic society.”
Evelyn described in her Mundus story her intellectual gains from her studies in Europe. The bioethical debate
examined in lively discussions opened Evelyn’s eyes to new concepts. She also gained a lot from her exposure to the
worldwide perspectives on bioethics brought to the class by the other course participants: “The level of teaching was so
elevated, the discussions were so lively and there were new things that I learnt, especially in philosophy and theology,
which were not discussed in my country, like stem cells and cloning, public health issues, pandemics and how to
allocate resources. These were all new to me, a practitioner coming from the clinics of just obstetrics and gynaecology.
For me, coming from a Catholic country with very limited options, it opened my eyes that women have choices. The
course enriched my knowledge and my experience, which I am now including into my bioethics classes at the
university. It gave me a wider perspective which I can now share with my students and colleagues. Enlightened about
conditions in other countries, I found myself looking at my country from the perspective of highly developed nations of
the West, Europe and North America, from the newly emerged European nations, from Africa, the Middle East, China,
India and Thailand and found that my country’s situation was not unique. We all face similar problems: allocation of
scarce resources, equity in health care, allocation of organs for transplant, setting up research ethics boards, health
technology assessment, protection of vulnerable segments of society, addressing problems of information exchange
versus commercial interests and intellectual property rights, setting priorities for research in a resource-poor country.”
Exposure to the teaching practice at the three prestigious universities delivering the Erasmus Mundus Master's
degree in Bioethics encouraged Evelyn to introduce interactive methods of teaching: “I do more of discussions in class
and it's more of interactive discussion. I encourage them to speak, whereas before I was just giving lectures. Now they
are able to speak their minds and we have a fruitful discussions, very enlightening, especially recently as we have a
student from Germany, we have a Korean and a Burmese. So this interaction of different cultures also enriches our
discussion.” Evelyn conducts research, writes papers to conferences, and now does not exclude the possibility of
doing a PhD in the future: “I am encouraged to do more biomedical ethics research based on my experience doing my
thesis paper. As a clinician used to seeing the immediate results of one’s work, going back to research was a tedious
process but well worth the effort.”
Among her personal gains from studying in Europe, Evelyn lists the chance to explore other places and
countries that allowed her to understand different cultures through their art, language and cuisine. Inspired by the rich
European cultural heritage, she has developed a passion for photography and painting: “Spending nine months in
Europe on a budget was challenging but nevertheless a dream come true. From my earlier trips to Europe, I have
always wanted to immerse myself in its immensely rich cultures, its art and its languages. History and art have always
fascinated me. Inspired by what I had seen, I took up photography and painting in oil as a hobby. The beautiful thing
about studying in Europe is that you not only learn its languages, you also learn its culture. And it was very rich. When I
walked down the streets of Rome and felt history at my feet, that was awesome. Standing there, you realize that
through all those thousands of years of civilisation, you are now standing at this moment in time, being part of history.”
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Photos: In Venice, studying at the University of Padova, and Evelyn and one of her paintings
What Evelyn especially liked were the cordial relationships among the students on the course: “Living away from family
and friends, I found new friends. My classmates became my family. Through them, I have learned to enhance my communication
and coping skills. I have learned to live with other people of different cultures, my classmates. We shared the food we cooked, we
shared the simple joy of passing exams and being there for each other whenever we felt homesick. I have found my cure for
homesickness shopping in the local markets. By and large, I came back from the course a richer and better person.” There was
also time for fun and adventure in the wonderful atmosphere which she experienced in the international student community: “Having
26 other classmates with 16 different cultural backgrounds, I learned about the cultures they came from and I found new friends for
life. We shared stories. We shared home -cooked meals and traded recipes. We learned the art of wearing a sari. We explored
cities together and got lost together. We hired and rode the bus together to get from one campus to the next. We studied together
and shared the joy of passing exams. In a sense, we bonded together and became a family.”
For Evelyn, being a student once again, at the age of fifty, was a challenge: “When I went to Europe as a student, it was
a totally different world for me. I had to go back to lessons. I had to learn new things. I had to interact with 16 nationalities and, of
course, there were 26 of us in the classroom and, you know, different ideas, different people, I had to adjust to all of that.”
She recollected having a typical problem that Mundus students face - having to adjust to different cuisine - which gradually
turned into the joy of exploring European food: “The first thing we did was to seek out Asian stores and we bought familiar food that we
normally ate. However, as time went on, we started becoming adventurous. We tried out different kinds of food in cheap restaurants
and student meals provided by the cafeteria. For me the best food was in Italy because it was more to my taste and the flavours were
more exciting. In Belgium and the Netherlands, I couldn't take milk because I was allergic to it and so I had to stick to fruits, bread and
salads. My professors were very kind and they all know we had different tastes and they tried to accommodate us. Some of them took
us to their homes and gave us dinners, so we wouldn't be so homesick. I had several female classmates with whom I used to go
shopping to the local markets. We found ourselves lost in all the choices we had to make, compared to simple lives we have been living
in our countries. And the choice was so enormous that sometimes we didn’t know what to take to eat.”
Photos: Evelyn with Prof. Corrado Viafora, the University of Padova.
Graduation, group photo of Master's in Bioethics students and professors
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Return and action
In Evelyn’s case there was only one acceptable scenario - to go back to the Philippines after her studies in Europe. Her
attachment to her home country, the positions that she had attained there and the strong bonds with her family had determined this.
As one of the very few doctors in the Philippines who had been educated in the area of bioethics, she returned with the plan of
sharing the knowledge and experience she had gained in Europe: “I chose to come back to my country because I knew there was
much work to be done. I asked myself: How can my European bioethics education be relevant under such conditions? I saw
opportunities where my learning could be applied: teaching in medical school, being adviser for policies and guidelines as member
of the Philippines Obstetrical and Gynaecological Society, establishing research ethics boards in both the university and affiliate
hospitals, introducing clinical ethics in the hospital workplace to balance paternalism, and long-range putting together a core
curriculum for bioethics education for my country.”
The pioneering work of introducing European bioethics required problem solving, deep consideration and the overcoming
of obstacles: “The immediate challenge I encountered was how to incorporate what I learned into the student curriculum.
Fortunately the university’s administration was supportive and gave me a free hand in revising how reproductive bioethics was
taught. I found it most challenging how to stimulate the students minds and make them actively interact with me. My problem was
how not to overwhelm them too much. Eager to do research, I had a difficulty accessing bioethics journals and resource materials,
since most needed institutional or personal subscription were too expensive even for the school.”
The team accompanied Evelyn for five days. On one day, we followed her from the early morning. After breakfast, we
followed her as she left home and drove her car through the town to the clinic. We saw her, surrounded by nurses and students,
paying visits to postnatal rooms and talking to patients. Then the team was able to see her private practice. The waiting room was
full of patients so in the afternoon we left Evelyn to her work and went for a look around Bacolod. As we found out the next day,
Evelyn had continued working until midnight, and two more healthy little Filipinos had been born with Evelyn’s assistance. And this
was a day like every other day. To earn her living, she works or is on call 24 hours a day, 7 days a week, giving fully devoted
medical service to the people of Bacolod.
Photo: One of the thousands of babies Evelyn has helped to deliver,
in the arms of a happy patient and mum, Jeminah Jarder
Bacolod, a city with a population of 600,000, prospered in the past from its sugar factories, as did the whole of Negros,
which is largely agricultural with thousands of hectares of sugarcane plantations. Today, it does its best to attract tourists to its
annual Masskara Festival and the nearby heritage houses of Silay City, the beautiful residences of which recall the XIXth century
fortunes earned through sugar. It is number one on the list of medium-sized Filipino cities in terms of infrastructure and quality of life,
being considered in some surveys to be the “best place to live in the Philippines”. Known as a friendly city with the nickname “the
City of Smiles”, Bacolod indeed charmed us with the genuine warmth and hospitality of its inhabitants. We visited the main plaza
where we surprisingly found an elegant bandstand inscribed along the sides of the roof with the names of European musical
composers: Beethoven, Wagner, Haydn and Mozart.
The next day, we visited the University of St. La Salle, a private Catholic institution of higher education. Evelyn explained
to us her post-Mundus activities consisting of introducing changes in the curriculum, establishing a Bioethics Research Board and
developing an operating manual for conduct in medical research with human participants: “The decision to come back also was
based on the fact that I promised the university that I would continue to teach. They gave me more teaching assignments. They
gave me the opportunity to make changes in the curriculum. And, of course, I told them that one of the important things that I had to
do was to create a research ethics board, which was primarily the reason why I left. Europe gave me the tools to be able to do it. So
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the first thing I did was to meet up and choose the key people to compose a board. When you speak about the research, you have
to protect your participants. You have to make sure they are not abused or exploited as means to get results. We have done that
and we have come out with a manual, a basic operating manual for the ones who are to come after us.”
When we visited the University, the team first met Dr. Carmelo C. Canto, the Dean of the College of Medicine, where
Evelyn teaches bioethics and chairs the bioethics board. He explained to us the importance of a knowledge of bioethics in daily
medical practice. He based his words on his own professional experience in encountering life-threatening situations, which require
him to make choices whether to let the patient die or to continue the treatment: “Bioethics has never been given an important role in
many medical schools here in the Philippines until recently. It was incorporated in ‘perspectives in medicine’ and other subjects of
curriculum. At the same time we are very much aware of the importance of bioethics in our medical practice. Being a neurosurgeon,
I deal with situations where I have patients with serious head injuries and most of these patients come from poor families. Given
that they have a very poor prognosis, all the resources of the family are channelled to this person. I have thus to choose whether I
follow the book or I follow my conscience. And this is where bioethics, I think, is important and needed. I wasn't taught formally
bioethics before. I made my decisions based on my own moral, Christian principles.”
Photo: Evelyn with Dr. Carmelo C. Canto
When Dr. Canto read the advertisement about the scholarship programme for the Master's programme in bioethics, it
appeared to him to be tailored exactly to Evelyn’s profile and interests. He explained that it was a corporately taken decision to send her
to Europe for the purpose of bringing back this much-needed knowledge: “Three years ago our then University President forwarded me
an invitation about the scholarship programme for a Master's in Bioethics in Belgium in the framework of the Erasmus Mundus. At that
time only one of our faculty members, Dr. Evelyn Lacson, had shown an enthusiasm towards bioethics. She has been attending
courses on medical ethics and bioethics in Manila, at the University of the Philippines. So when this invitation for the Erasmus Mundus
programme was forwarded to me, I presented this to Dr. Lacson and she was in fact ecstatic. Of course, at that time there was no
guarantee yet whether she would be accepted to the programme but we managed to complete all the documents, including my
recommendation and she was lucky enough to be chosen to participate in that programme, along with three other Filipinos. Ten
months later she came back. Of course, it took a while for her to adjust again to our lifestyle here. Then she started to talk with the
faculty about improving our bioethics courses. Some of the improvements that she proposed concerned bigger awareness of the law
and justice in practice of medicine, especially in medical trials. And then she also expanded a lot more in clinical ethics in terms of
medical futility, palliative care.”
Evelyn reorganized the university ethics board which she now heads and disseminated the concept of bioethics among
the medical practitioners. To get an illustration of the board’s work, the team attended one of its meetings, chaired by Evelyn, which
was devoted to discussing medical trial protocols. Dr. Canto explained the idea and operation of the board and similar bodies that
had been established in affiliated hospitals: “This ethics research committee is composed of people from different sectors of society;
they have a priest, they have a lawyer, a teacher and of course Dr. Lacson as a physician. Our school is fortunate to have her back
with us and incorporate what she learnt from that course in Europe and improve not only our curriculum, but also disseminate the
concept of bioethics among doctors. For the past several months she has been invited by hospitals, affiliated to our university to
head also their ethics boards because right now Philippine law has been more and more conscious regarding the role of medical
ethics in medical practice.”
Next, the team left the College of Medicine to get an idea of Evelyn’s role in the development of the Health Ethics
Committee in the Dr Pablo Torre Memorial Hospital. First we were given an introductory statement by Dr Rudolfo Nonato, the
medical director of the hospital: “Dr. Evelyn Lacson is the chairman of our hospital ethics committee and when she arrived
from Belgium after the Master’s degree she was of a great help for our hospital. The Health Ethics Committee here is
a young body and we needed somebody to guide us. The first thing that she did was really make things in order and teach us
how to go about it. Even all these controversial issues that we have to meet in our daily practice was greatly assisted by Dr.
Lacson. And this Master’s degree that she took in Europe was really a blessing as far as we are concerned.” Evelyn added
that, in clinical practice, doctors encounter many difficult ethical dilemmas, which pushed the committee to create guidelines
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for conduct in particular cases. The guidelines help doctors to make decisions such as when to start resuscitating or giving or
withdrawing treatment: “When I came back from my studies in Europe I was appointed as chairman of the bioethics
committee. We had to sit down and make guidelines regarding chronically ill patients. We had to make guidelines on how we
are going to ask the family to help and be involved in our treatment planning and taking care of these patients. One of the
questions we had to asked them were: are we going to resuscitate your family member, or not? We also had to make
guidelines for the doctors: when are we going to tell ourselves that ‘enough is enough’ and the patient is beyond any help,
and when extraordinary means are being used in terms of treatment”. Thanks to the guidelines, the doctors are able to learn
who should make decisions in cases where the patient is incapable of doing so, or when the involvement of a psychiatrist or
a psychologist is needed in order to support the patient or his or her family: “We also had to take care of the patient,
especially if she or he was incompetent or couldn't make any decisions for himself or herself. We had to make guidelines on
who would be the surrogate decision-maker, who would be taking care of future plans in terms of changing capacities to give
consent, like in cases of patients who have Alzheimer’s. We also had to make guidelines on comatose patients, who are lingering
and who have cancer, and the families don't know what to do with them. So part of this was of what we had to do and tackle in the
bioethics committee. The other rules we were taking in this bioethics committee concerned doing research. This hospital is well
recognized and clinical trials are carried out here and several medications are being placed on clinical trials. So we have to
evaluate protocols and make sure that the participants in the research are protected and not exploited. The other issue we had to
take, especially with paediatric patients, newborns in the nursery intensive, when we start resuscitating or giving treatment or
withdrawing treatment, especially in case of very young newborns. These are very difficult decisions to make for most families
because we, the Filipinos, are very compassionate and we would rather give our lives than make our children suffer. So, it's a very
difficult decision for a mother and a father to tell us: ‘I give up’. A part of our guidelines say when we have to ask a psychiatrist or
a psychologist to talk to these parents to be able to guide them through this special decision and grief.”
Photos: Patients and medical personnel in the Dr. Pablo Torre Memorial Hospital
From the private and well-equipped Dr Pablo Torre Memorial Hospital, the team moved on to the Corazon Locsin
Montelibano Memorial Regional Hospital, a state institution facing a difficult financial situation. Dr Epifania Simbul, a paediatrician and
the present director of the regional hospital, has to cope every day with limited and insufficient financial means and shortages in staff:
“Our hospital is a regional hospital, tertiary and a training hospital. It receives about 120 million pesos which is equivalent to 2 million
Euros and it takes care of about 36,000 Filipino patients and it has only about 430 staff which is really very much below the needed
staff in a tertiary hospital. And how to solve our problems with the money that can pay only the salaries of the hospital staff and nothing
is left for the operations? So we are really counting on donors from other agencies of the government and also on private donors and
organizations so that we can treat these underprivileged citizens of our region.”
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Photos: Dr. Epifania Simbul and patients and medical personnel
in the Corazon Locsin Montelibano Memorial Regional Hospital
Financial problems are not the only difficulty the Philippines health care system has to face. An equally serious
problem is the brain drain of qualified medical personnel. The country is the largest supplier of nurses to other countries
around the world. It is estimated that up to 100,000 doctors educated in the Philippines work abroad.
The brain drain in the Philippines
The team got a glimpse of the scale of the problem by interviewing Dr Federico Macaranas, an expert on the subject from the
Asian Institute of Management in Manila. He is concerned with the scope of migration and the brain drain in the field of healthcare that
has lead to the hospital crisis in the Philippines: “In the medical and health professions a sizeable portion of our professionals actually
work abroad. In the nursing field over 200,000 in the past 5 years. It can easily double in the next 5 years. So, this would be a very big
percentage. We are the number one exporter of nurses to the world. Unfortunately, some doctors have become nurses, about 10,000,
for the purpose of migration to the rich industrial countries. This is going to be a very bad drain on our hospital system. There are about
perhaps 80,000 to 100,000 doctors already employed around the world and this is going to be further aggravated by these doctors who
have become nurses. And in the consequence our hospital system suffers. Over 200 hospitals have closed for good and another 400
have closed 1 or 2 wards over the past 7-8 years. We feel that the increased number of deaths in certain age brackets may be
attributable to this shortage of qualified nursing and doctor staff in provincial hospitals”
Photo: Dr. Federico Macaranas
Financial reasons cause many doctors to work abroad as nurses, with the result that the ageing populations of the developed
world are being cared for by overqualified migrant staff. While visiting the two hospitals in Bacolod we saw only very young nursing
staff. By law, all nursing graduates have to work for two years in the Philippines, as a service to the nation, before they are allowed to
go abroad. After this time, having received practical training and having gained experience, they leave the country to be replaced by the
next group of new graduates. There is a constant need to train new cohorts of medical staff that are likely to leave the country after
getting their education and some experience: “Many of the doctors actually are underpaid compared to, of course, their equivalents in
rich countries. And sadly, these doctors, although they are very qualified, look at the salary and compensation package of nurses.
Because nursing is easier to enter as a profession in many developed countries, these doctors prefer to become nurses. Now, the
doctor situation in the country is even made more problematic by the increasing closure of schools of medicine because of the lucrative
nursing profession, as more of the students prefer to go to nursing.”
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Photos: Nursing students, potential overseas workers
Dr. Federico Macaranas is working with other international experts on an overall action plan including global structural steps
aimed at sharing the benefits of the human capital flight between the developed and the developing countries: “I believe this is a global
problem of imbalance in the supply and the demand for medical practitioners and professionals in the health field. Therefore, if it is a
global problem, there must be a global solution. In general, the health care system of the world is still national in character. States take
care of their own people, but in the case of the Philippines we are unable to take care of our own people, because our professionals
leave. So, if it becomes a global problem, we must immediately ask for an international body that will discuss the policy issues at the
national and global level, not just local”. There is much that can be done immediately, for example, in education: “We could be assisted
in video conferencing that excellent teachers in the developed world could lecture on psychiatric nursing and gerontology even without
having to come to the Philippines. We could immediately broadcast that to several schools. We have 417 nursing schools spread all
over the country. If, through the Internet, the best teachers are able to bring good educational materials to the classroom, then we can
upgrade the quality of these nurses. And this is exactly what global cooperation can do. If there were a sphere where the benefits from
the developed world can be shared with the developing countries it may be education. It is expensive to retrain a Philippine nurse in the
United States. They can be better retrained here in the Philippines. It's more cost-effective for the whole world. And I hope such a kind
of international discussion will be available at the Global Forum on Migration and Development to be held here in Manila in late October
2009 following a similar one in Brussels last year.”
Dr. Therese Jochico, Vice Chancelor for Academic Affairs at the University of St. La Salle presented her views on the
challenges resulting from the brain drain in the medical sector. She considers this socio-economic phenomenon as something that can
not be stopped: “The issues related to brain drain are very much a part of our reality today. It is actually based on mutual needs, for
example, in the health care profession. The Western and developed countries have an ageing population in need of our health care
professionals. In turn, the Philippines, like other developing countries, have professionals who are in need of financial security. So they
go abroad and look for career and job opportunities there. What do we do about this problem? In the University of La Salle we have an
increasing population of nursing students and, like it or not, they all have dreams of going abroad, gaining more experience and of
course getting a good, high-paying job. So they can help maybe their brothers and sisters in school, maybe their families in return. So
these are the realities we have to face. So what can we do about that?” Not much, she answers herself. Instead, she proposes to look
for opportunities to take advantage of the expertise of Filipino professionals working abroad in the teaching process: “I think what it calls
for is taking advantage of advances in information technology to have our more experienced professionals abroad being able to share
their experience and their new knowledge with our students here; through networking and through information technology. What is to
stop us from having cyberspace classrooms enriching our curricula?”
Dr. Jochico then gave examples of the reverse brain drain at her university – cases where overseas-trained healthcare
professionals who had been exposed to the latest techniques had returned from abroad and had contributed to the staff of her
institution: “Realistically, there are also professionals who have been trained abroad and who have worked there for a while and who
are coming back, coming back to their families because they have accumulated financial resources. These professionals again
become our brain gain not just a brain drain. People trained abroad, after coming back, share their knowledge and enrich further
training. In our community, in our institution we have professionals like Rhoderic Samonte. He is our director for international linkages
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and he's come back after a 4-year stay abroad, in North America. With his vast experience he is now helping us to network, to open
resources and opportunities for term abroad studies. If we, in the education sector, put on our think-out-of-the-box and challenge
ourselves to make use of whatever resources there are to strengthen our training programmes, if we continue to train very competent
professionals, there will never be a total brain drain. We can supply a continuous resource and train people and some of our welltrained professionals will come back and help us to enrich our programme. So it can become a circle.”
Photo: Dr. Therese Jochico
Our interviewee was not much concerned about the brain drain: "It is out of our control that the world is in motion, but there
are also possibilities for sending people to countries to get benefits of this process, not only being a constant provider of skilled
staff”. Possibilities are emerging, among others, from the cooperation with the European Union, Dr. Jochico continued: “After all,
global migration is an issue wherever you go in the world today. There is an estimated 3% of the world population that is mobile and
they establish their careers and homes in countries other than the ones they were born in. It's a reality we have to face. If we meet
the challenges, then we will be all successful. We will fulfil mutual needs of both Western and Eastern civilizations. We can have
a mutual networking between developed and developing countries. I am very optimistic. For example, if we strengthen our
partnership with the European Commission and European countries, there is a lot we can do to address the brain drain issue. And
we can actually turn it around and make it a brain gain issue for everyone concerned.”
After a few days in Evelyn’s city we noticed that, even though Bacolod is known as “the City of Smiles”, it is far from free from
the problems of the developing world. Poverty is one of them. Evelyn, as an obstetrician, knows many of the city’s inhabitants and
many of them leave their country in search of a better future. They send remittances to support their numerous relatives, helping them
to improve their level of living, supporting them in getting food and better housing conditions, and paying for the education of their
children, opening the way for them to go abroad after they graduate.
Photos: A poor area in Bacolod
Nearly 10% of Filipinos are overseas workers. Official figures show that they send about US $8,5 billion back home every
year, which amounts to about one-tenth of the GDP, although the true figure of remittances is probably much higher. The overseas
Filipino worker - a nurse in Canada, a construction worker in Qatar, a maid in Singapore, or a sailor somewhere on the high seas has become a kind of national hero, actively supported by the government through a purposely-created department, The
Philippines Overseas Employment Department. The government strategically encourages the temporary emigration of skilled
workers for their remittances and for the acquisition of skills and expertise.
The team accompanied Evelyn while she visited her patients - Joseph and Jeminah Jarder - a young couple with a baby. As
remitting migrants, their case is typical for the Philippines. They have been working in Qatar for 6 years and we were only able to meet
them because at the time of our visit they were taking holidays and maternal leave in Bacolod. Joseph works as a safety technician,
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and Jeminah as a secretary. “We have decided to move out of the Philippines and seek work abroad to be able to help not only our
family but also individually our own families. The reason why we work abroad is first and foremost the financial reason. The salary
abroad is much, much bigger compared to seeking jobs here in the Philippines and the opportunities you can grab abroad is much
more wider compared to what you can find here in our city. Most of my family is working abroad also. My older sister is in California and
my younger sister is a flight attendant in Qatar Airways. But my eldest brother is still studying as a nurse so he wants to follow working
abroad as well” said Joseph. His wife added that they would love to live in their home country but after 6 years spent working abroad
they still have a 15-year perspective on their working emigration: “The most of our family, I think, plans to work abroad or to find
opportunities abroad to be able to save for the future, to be able to save more money and most probably invest back home when the
right time comes. We've been working for six years so we have invested in a house. It helps a lot that you work and earn more. We still
have plans, like, to stay 10 to 15 years more to save, finish all of our investments and make sure that our child is able to get a good
education and, hopefully, have own business one day and be able to stay back here in the Philippines.”
Photo: Jarder family
The brain drain of medical personnel to developed countries is a particular problem in the Philippines. Evelyn arranged a
meeting for us with her friend, Febrian Ditchella, who has been working in the USA for six years as a nurse. Today he owns a house in
an exclusive district. He told us about his work in the States and his desire to enter politics when he returns home permanently: “I
graduated from nursing school back in 1991 and I was fortunate to have a job in America. I started in Ohio in July 2002 and I stayed
there for 15 months working in nursing home. Then we decided, me and my family, to move to New Jersey, where most of my friends
are working in another hospital. I have been working there for 5 years, in a recovery room, in the company where I'm working right now.
So I have been in America already for six years. I was very fortunate to have this opportunity to work in America as a nurse because it
allowed me to have a better life compared to the one earned in the Philippines. We were able to have a house built last year and to buy
a new car, and send our kids; my seven-year old boy and three-year old girl, to a much better private school here in Bacolod City. I
would say that America is a land of dreams, a land where you can fulfil most of your dreams as long as you work hard, because you
are able to send money back home. One thing with the Philippine culture is also that, while we are working abroad, we are not only
working for our family but we are also working for most of our relatives here in the Philippines. Last year we decided to move back to
the Philippines and my wife with two children decided to stay here while I will go back to America to work. Of course, I had to send
money for their bills and for their allowance so they have a better life compared to the usual life the most Filipinos have nowadays.”
Soon it would be time for him to leave his family. We admired their beautiful house in a protected area, but the cost of it was high.
Febrian Ditchella will come back in two years and plans to get involved in local politics to make his dreams of helping the community
come true: “I am a frustrated lawyer. I never really thought that I would be a nurse. But I am very thankful to be a nurse right now
because I'm earning much better. And at the same time I have plans to join politics here in the Philippines. That is the reason why we
have our house built as early as now, before our retirement, which we plan to be like 20 years from now. I will be joining politics by 2
years from now and, hopefully, I can be a better public servant than a nurse because I have that childhood dream to help the less
privileged of my fellow Filipinos. Hopefully, in the year 2010 I'll be able to join politics and be of service to the city where my father was
born and my wife was born.”
Photos: Febrian Ditchella, the view in front of the Ditchella’s new house
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Goodbye Evelyn
After five days spent in Bacolod with Evelyn, the team took a flight back to Manila in order to meet Dr. Corazon
Zaida Gamilla, an obstetrician-gynaecologist who is the current president of the Philippine Obstetrical and Gynecological
Society. The team met her at the University of Santo Thomas where she is head of the ob-gyn department. She explained
Evelyn’s role in the Society, underlining her work in propagating bioethical practice in solving various problems: “In the
National Society, we are about 3000 members and Dr. Lacson is a prominent regional leader coming from Negros. She
has been serving the Society in various capacities as both leader in the region of Negros and also in the national capital
region. Her life has been devoted to the practice of obstetrics and gynaecology and propagating bioethical practice in
Negros. As obstetrician-gynaecologists we are often involved in bioethical medical conflicts like maternal foetal conflicts,
and in bioethical general issues like the resolution of allocation of resources for which, in our region, we don't have that
much resources as well as in the prioritisation of projects, decisions on logistics and also whom to treat first. All it
becomes problems of greater magnitude, maybe not found in Singapore, maybe not found in Hong Kong and others.”
Dr Gamilla stressed how much she appreciates Evelyn’s work in the region, in remote areas, something that is
particularly needed in this archipelagic country: “We need people like Evelyn to be able to be our voice far away from
here. We have about 7,000 islands and its clearly impossible for each one of us, a good number of us, to sustain there
these principles and propagate them in action. We need people like her and we welcome the fact that she has done hope
to us already with a degree and with a professional advancement that she took upon herself.” The President of the
Philippine Obstetrical and Gynecological Society acknowledged Evelyn’s efforts and stressed her professionalism and her
devotion to propagating bioethics principles, as well as her caring and giving character: “We really welcome her
professionalism, her nurturing spirit of propagating bioethic principles. The more, as we can not offer that much of
competency all over the Philippines. It will be a good start nonetheless and the society is all the more richer because we
have one like her. We don't have as much of the financial capability to sustain the projects if without the people that are
kind-hearted and as generous as doctor Lacson.”
Photo: Dr. Corazon Zaida Gamilla
Evelyn is full of enthusiasm to continue propagating, introducing and implementing bioethics in her country and
her plans for the future include conducting further research in bioethics and publishing papers. She told us at the end
of our visit: “My country is in the process of creating bioethics committees in research, clinical ethics and policy making.
I expect to be part of that process by making myself available and involving myself in bioethics projects. I am fortunate
that my career path has led me to occupy positions of authority in the past that make fund raising and networking easy.
I intend to attend other courses that will help me increase my capacity to help build a dynamic learning environment for
bioethics. Perhaps a PhD in the future!”
The team was sad to have to leave Evelyn, and thankful for her kind hospitality and smooth organisation
during the visit. We departed from the Philippines with the memory of Evelyn in her house, a place thousands of
kilometres away from Europe, playing Beethoven’s Fur Elise on her piano. Maybe one day we will meet again. Maybe
she will come back to Europe again for some time: “I will never forget my experience and I'm grateful for the European
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Union and Commission for giving me this opportunity to be able to study even if it were only nine months. And if I am
able to go back and learn more, I would be very happy to do that.”
Evelyn’s case, illustrated in this book and the accompanying film, gives an example of the valuable effect of the
Erasmus Mundus program, something that is a source of satisfaction for our Mundificent heroine: “Thank you for the
opportunity to be a voice of Mundus impact. It makes the experience not only tangible but totally relevant to what I am doing
in my life right now. Slowly it is all coming together... all what I have learned and experienced and what I am contributing to
my little part of the world by way of bioethics.”
Photo: Evelyn playing the piano for her brother and son
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