Journal of Medicine and Philosophy 0360-5310/98/2306-0563$12.

00
1998, Vol. 23, No. 6, pp. 563–580 © Swets & Zeitlinger

Critical Care in the Philippines:

The “Robin Hood Principle” vs. Kagandahang Loob

Leonardo D. de Castro and Peter A. Sy

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University of the Philippines

ABSTRACT
Practical medical decisions are closely integrated with ethical and religious beliefs in the
Philippines. This is shown in a survey of Filipino physicians’ attitudes towards severely
compromised neonates. This is also the reason why the ethical analysis of critical care
practices must be situated within the context of local culture. Kagandahang loob and
kusang loob are indigenous Filipino ethical concepts that provide a framework for the
analysis of several critical care practices. The practice of taking-from-the-rich-to-give-to-
the-poor in public hospitals is not compatible with these concepts. The legislated defini-
tion of death and other aspects of the Philippine Law on Organ Transplants also fail to be
compatible with these concepts. Many ethical issues that arise in a critical care setting
have their roots outside the seemingly isolated clinical setting. Critical care need not
apply only to individuals in a serious clinical condition. Vulnerable populations require
critical attention because potent threats to their lives exist in the water that they drink and
the air that they breathe. We cannot ignore these threats even as we move inevitably
towards a technologically dependent, highly commercialized approach to health manage-
ment.

Key words: critical care, Kagandahang Loob, medical ethics, Philippines, Robin Hood
Principle.

The words “critical care” suggest medical attention given in a clinical

setting, perhaps in an intensive care facility. In a world characterized by
rapid advances in the development of medical technology, critical care
would likely involve the use of expensive equipment and radically innova-
tive procedures. A developing country with moderate economic means is
likely to encounter much difficulty in making such equipment and proce-
dures available to everyone in need.
This article takes up some ethical issues that arise in connection with
critical health care in the Philippines. Some of the issues have to do with

Correspondence: Leonardo D. de Castro, Ph.D., Professor and Chair; Peter A. Sy, Assist-
ant Professor, Department of Philosophy, University of the Philippines, Diliman, Quezon
City 1100, The Philippines.
564 L.D. DE CASTRO AND P.A. SY

the allocation and prioritization of meager resources for health care. In

particular, there is a discussion of what some have labeled as “Robin Hood
Practice,” which has existed in public hospitals as a means of coping with
treatment needs. An evaluation of the practice relates it to the concepts
kagandahang loob and kusang loob, both indigenous Filipino philosophi-
cal concepts. These concepts are also considered in the discussion of ethi-
cal issues that have to do with the transfer and use of technology intended
to respond to critical care needs. The article also takes up various issues

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that arise in critical care pediatric practice. The final section is devoted to
policy issues and their implications for critical care. Whatever the issues
may be, their nature and significance may be best appreciated when one
understands the character and role of indigenous perspectives on health as
well as on other aspects of life.

I. PHILIPPINE HEALTH CARE: AN OVERVIEW

The average Filipino’s life expectancy at birth was 67 years in 1997 (HDN,
1997, p. 156). This is an improvement on the recorded life expectancy of
63 in 1987 (CRC, 1990, p. 419). In 1993, life expectancy at birth was 63
for males and 67 for females (CCH, 1993, p. 30). Among the top causes of
death are pneumonia, tuberculosis, diarrhea, and measles (NCSO, 1993, p.
102) – diseases which sanitation, immunization, a healthy environment
and primary care can help eradicate. The population is estimated to be 71.8
million, with an annual growth rate of 2.3%. Seventy five percent (75%)
of Filipinos live below the poverty line (Asiaweek, 1997, p. 76). Malnutri-
tion is a major problem.
The Philippines spends less on health care than its Asian neighbors.
From the World Bank Report for 1990, the Philippines’ national health
spending as percentage of GDP was 2.0%, while Thailand was 5.0% and
Malaysia 3.0%. In the 1997 National Budget, the appropriation for the
health department was only about 28% of the appropriation for the Depart-
ment of National Defense and about 25% of the appropriation for debt
servicing (1997 General Appropriations Act).
In keeping with a general policy of devolution, the administration of
health services is gradually shifting from the national government to local
government units. The emerging pattern of government health care spend-
ing indicates that health care is a low priority issue. This is particularly
true in municipalities and towns where projects are set by local politicians
who generally do not consider health care an issue which they can use to
gain political ground.
 CRITICAL CARE IN THE PHILIPPINES 565

Distribution of health care facilities throughout the country is poor. It is

estimated that only 25% of all barangays have health stations. One half (1/
2) of all doctors and two thirds (2/3) of all dentists are in the National
Capital Region, whereas the majority of the population (54%) lives in
rural areas. The best hospitals are in Metropolitan Manila. These include
specialized government-run hospitals like the Lung Center, the National
Kidney and Transplant Institute, the Philippine Children’s Medical Cent-
er, and the Philippine Heart Center. Outside Metro Manila, the reasonably

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equipped hospitals are found in other metropolitan areas like Cebu and
Davao. About 33% of the hospital beds in the country may be found in the
National Capital Region (CRC, 1990, p. 119).
Compounding the problem of distribution of health facilities is the lack
of health insurance for most Filipinos. As much as 55% of the population
has no coverage. The government-implemented compulsory insurance
scheme (Medicare) covers only 39% of the population. Moreover, it offers
only in-patient benefits. Health Maintenance Organizations and other re-
lated private establishments cover only 1% of the population (CCH, 1993,
p. 101). The bulk of health care spending, therefore, comes from health
care users themselves and not from the government or from insurance
companies. Even so, private spending for medical care has been very
small. The 1994 Family Income and Expenditure Survey (p. 117) shows
that only 2.3% of family expenditures goes to medical care. This is equal
to the average family expenditure on alcoholic beverages and tobacco. In
rural areas, alcoholic beverages and tobacco constitute 3.1% of average
household expenses whereas families spend only 2.1% on medical care.

II. IMPLICATIONS FOR CRITICAL CARE

In 1991, Filipino households accounted for 53.6% of medical care spend-

ing and government accounted for 36.3% (CCH, 1993, p. 101). Household
expenses were made up primarily of direct, out-of-pocket financing for
actual health care services. Since the expenses were incurred without the
involvement of medical insurance, patients presumably paid at a time
when they were in a vulnerable state. Patients who were in an extreme
emergency or critical condition would most likely not have had a pre-paid
health care plan.
Medicare accounts for only 8.5% of total medical care expenditures. It
does not cover the unemployed. It has also been thought to perpetuate an
unjust program whose “tax system is regressive with the lower income
group bearing more of the financial burden” (CCH, 1993, p. 102). This
566 L.D. DE CASTRO AND P.A. SY

means that there are large segments of the population that have to fend for
themselves when emergencies occur. They cannot be assured of govern-
ment assistance. Perhaps the only safety net that exists for them is provid-
ed by the public hospital system. Public hospitals are obligated to make
their services available to the general population, and many patients turn
to their charity wards for emergency care. Hence, they often are over-
booked and short on critical care supplies.
Department of Health (DOH) statistics in 1998 show that there are 88,

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431 beds in 1, 812 government and private hospitals. Of these hospitals,
only 221 have intensive care units.1 And of the 221, only 82 are run by the
government. Since the poor who do not have medical insurance cannot
afford the cost of medical services at private hospitals, they only have
access to the emergency facilities and intensive care units at the 82 gov-
ernment institutions throughout the country. Hence, in emergency situa-
tions, many patients do not even have a chance of reaching a critical care
facility. When ordinary hospital beds are available, these take the place of
intensive care units, albeit without much needed equipment. One study has
observed that “for too many Filipino children and their families, emergen-
cy resources seem to be available only at the Philippine General Hospital.”
An alarming number of emergency patients come from places which are
hundreds of kilometers away from the location of the Philippine General
Hospital in Manila (Carlos & Abad, 1995, pp. 51–52).
This kind of situation partly explains why there is anecdotal evidence of
patients having to be removed from respirators prematurely so that others
can be accommodated. Doctors find themselves having to play the role of
judge – and executor – in such instances. What is worse, they often do not
have the benefit of formal guidelines that could assist them in making the
critical decisions or in coping with the stress and anxiety that accompany
making such choices. Some doctors also complain of having to put up with
politicians or influential persons who insist that patients to whom they
have connections be given preferential attention. Such factors affect the
distribution of scarce medical resources without taking into account con-
siderations of justice or fairness.
Carlos and Abad have also observed that “emergency services are be-
coming the primary source of health care with an increasing percentage of
patients seen as ‘emergencies’ even though the emergency is more felt
than real” (Carlos & Abad, 1995, p. 50). They point out that at the Philip-
pine General Hospital’s Pediatric Emergency Room infectious diseases
have been the most prevalent reason for emergency visits. Most patients
have presented themselves for diseases that could have been prevented or
treated in “pre-emergency” settings: gastroenteritis, bronchopneumonia,
 CRITICAL CARE IN THE PHILIPPINES 567

benign febrile convulsions, urinary tract infections, and blood dyscrasias.

Also contributing to the competition for intensive care facilities is the fact
that some private doctors and hospitals refer cases of indigent patients to
public hospitals as “emergencies” because these patients cannot afford
their own medical attention. Some patients have had to feign emergencies
in order to gain access to Medicare or other publicly funded facilities
(Carlos & Abad, 1995, p. 52).
It is in this context of inadequate resources that we must understand any

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ethical issues arising in Philippine critical care settings.

III. THE “ROBIN HOOD PRINCIPLE” VS. KAGANDAHANG LOOB

AND KUSANG LOOB

The insufficiency of critical medical supplies at public hospitals has chal-

lenged young interns, clerks and other front-line health care practitioners
to find innovative ways of providing for the needs of indigent patients in
emergency situations. In many institutions, health care personnel have
established ties with non-governmental organizations (NGOs) that are will-
ing to solicit material help for needy patients. Elsewhere, medical students
and young practitioners have set up their own groups for the purpose of
ensuring that material support is given to the needy. Many front-line pub-
lic health care workers have felt compelled to engage in these charitable
activities because, having seen how critical the situation is, they have
accepted the responsibility to make their services truly useful and effec-
tive. Without organized support, they have often had to use their own
money to buy emergency fluids, antibiotics, syringes, bandages, and other
medical necessities for their patients.
Apart from turning to these support mechanisms, public health care
personnel have resorted to a dubious practice under the guidance of what
some have called “The Robin Hood Principle.” The practice involves pre-
scribing to patients who are able to pay for their treatment more than what
they actually need. The idea is for the excess to go into a reserve pool, and
the reserve pool is then made available to patients who cannot afford to
buy critical emergency supplies for themselves.
The practice apparently has been sanctioned by hospital administrators
who are frustrated by government’s failure to provide much needed sup-
port. When interviewed, a department head at one of the largest public
hospitals in Manila acknowledged that “it’s not supposed to be done” but
he feels that he could not do something about the practice because if “I
stop them from doing that … patients [would be] dying.” The supplies
568 L.D. DE CASTRO AND P.A. SY

simply are inadequate: “Why will you stop [your staff] from doing this
when you cannot give them the materials that they need?”
One may look at the practice from the standpoints of charity and justice.
From the standpoint of charity, what one sees is a case of the financially
capable giving support to the poor. From the standpoint of justice, one can
view the provision of aid as a social responsibility on the part of those who
can spare part of what they have so that the poor may have the emergency
care they need.

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One challenge to the ethical grounding of the practice arises from the
lack of a fully informed consent on the part of persons said to be perform-
ing the acts of charity or justice. In the first place, patients are being asked
to buy more than what they need without actually being told about the
excess. They are being given the impression that everything they pay for is
for their own consumption. Doctors interviewed concerning the practice
do not deny this. Even if patients are given accurate information and their
consent is sought, they are not in a position to give such consent freely.
Being hospitalized constitutes a kind of duress that obstructs free choice.
The presence of duress and, hence, the lack of informed consent, means
that the act does not truly flow out of a sense of charity. While the doctors
or medical clerks may be “taking” in behalf of the indigents, there is no
voluntary “giving” on the part of the “donors.” Because this necessary
element is missing, there is no real donation. The act of charity does not
take place because of the absence of an essential ingredient.
This is not to diminish the impact and significance of the benefits re-
ceived by an indigent patient in such critical situations. One cannot doubt
the value of the medical care that becomes possible because of the invol-
untary contribution. This contribution is made available to somebody who
otherwise could die or suffer painful consequences. Nevertheless, the provi-
sion of benefits can not be characterized as an act of charitable giving. The
explanation for this failure lies partly in the Filipino concept of kaganda-
hang loob or “good will.”
The concept of kagandahang loob (roughly, a good will or deed) is
central to indigenous interpretations of ethical concepts and principles.
The focus of this concept is on the value of spontaneous initiatives in the
fulfillment of duties and obligations. Although the entire phrase “kagan-
dahang loob” refers to actions, attention must be given to the use of the
word loob, which literally means “inner part” and refers primarily to one’s
feelings and sensibilities. The prominence given to loob indicates the sig-
nificance given to the intentional component of human behavior. The use
of the phrase in the Filipino language also serves to highlight the integra-
tion of intention or will with the physical component of actions. It would
 CRITICAL CARE IN THE PHILIPPINES 569

be inappropriate to make ethical judgments of physical acts independently

of the motives and intentions of the person acting.
This means that any act of charity must be a manifestation of the loob,
i.e., an act that flows spontaneously out of a person’s inner will to help a
fellow human being. When consent is not sought, the will to help is taken
out of the equation. The “donor” is left out of the picture altogether.
Something is taken away from him that he actually does not have the
chance to give. Somebody else does the giving for him without his consent

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or knowledge. There is no real opportunity for him to exercise kaganda-
hang loob, and so his “donation” cannot be considered an act of charity.
What is questionable about the practice then is not only that the “donor”
has material goods taken away from him for the use of others without his
informed consent but that he is robbed of a chance to manifest his inner
goodness through a kagandahang loob.
The same observations can be made if the practice is examined from the
perspective of justice. The social responsibility to provide for the critical
health care needs of those who cannot finance their own care has to be a
spontaneous response flowing out of the loob of a moral agent. Kabuti-
hang loob may be manifested in the fulfillment of a duty or obligation out
of kusang loob (similar, but not equivalent to “free will”). An act must be
done out of kusang loob if it is to have moral value. To be able to act out of
kusang loob, the agent ought to act (1) without external compulsion, (2)
“out of the goodness of his heart,” and (3) without having to be motivated
by possible reward. These three ingredients amount to a spontaneity of
will that is essential to kusang loob. This spontaneity of will can only be
generated if the agent is equipped with adequate information for rational
and independent assessment. Hence, financing medical care based on the
“Robin Hood Principle” fails to manifest this spontaneity. It does not flow
out of kusang loob.
Admittedly, government has the power to coerce individuals to contrib-
ute to the good of all in the exercise of its mandate to provide for the basic
needs — including critical health care — of the dispossessed. But even on
those occasions when government has to exercise this prerogative, it must
recognize the need to consult the public (directly or indirectly) and pro-
vide them the information necessary for responsible participation in deci-
sion-making. On the other hand, the “Robin Hood Practice” bypasses all
of these procedures and ignores the kusang loob of financially capable
patients. What it institutionalizes is a system that lacks transparency and
reduces the financially capable patients concerned to mere instruments
— rather than active agents — of social justice. They are deprived of an
opportunity to manifest their inner goodness through kagandahang loob.
570 L.D. DE CASTRO AND P.A. SY

Table 1. Attitude towards exerting every possible effort, including the use of both ordinary
and extraordinary means, to sustain life.

Every possible effort, including the use of both ordinary Hospital 1 Hospital 2
and extraordinary means, should be made to sustain life (Public) (Private)

Yes 37.0% 38.5%

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IV. ETHICAL VALUES IN CRITICAL CARE SITUATIONS

As part of a recent survey on ethics consciousness among the medical staff

at two Metropolitan Manila hospitals, the respondents were asked ques-
tions to determine their attitudes towards using every possible effort to
sustain the life of severely compromised neonates. Respondents were asked
if they believed “that in all circumstances every possible effort, including
the use of both ordinary and extraordinary means, should be made to
sustain life.”2 Table 1 summarizes the responses given.
These responses – 37 to 38.5% – may be contrasted with the results of
surveys using the same question in Victoria, Australia (Singer et al, 1983,
pp. 274–278) and in Calgary, Canada (Bay and Burgess, 1991, pp. 139–
149). In Victoria, only 1.8% of the respondents said that they should make
every possible effort to sustain life. In Calgary, 2.4% of the respondents
gave the same response.
The Filipino pediatricians attributed their response to the influence of
religious views on their practical ethical principles. Table 2 shows how
they responded to the question: “Would you describe your belief as based
primarily on: _____a. secular (non-religious) ethical principles? _____ b.
ethical principles deriving from religious views? _____ c. others? - please
specify.”
Once again, there is an opportunity to draw a sharp contrast. Whereas
22.2% and 38.5% of Filipino pediatricians in Hospital 1 and Hospital 2,

Table 2. Primary basis of beliefs.

Primary basis of beliefs. Hospital 1 Hospital 2

(Public) (Private)

a. secular (non-religious) ethical principles 14.8% 0.0%

b. ethical principles deriving from religious vieuws 22.2% 38.5%
c. others – medical standpoint 7.4%
 CRITICAL CARE IN THE PHILIPPINES 571

respectively, explained their beliefs in terms of ethical principles deriving

from religious views, only 0.9% and 2.4% gave similar responses among
pediatricians in Victoria and Calgary, respectively.

A. Ordinary vs. Extraordinary Means

Although the Philippine study dealt with pediatricians in only two Metro-
politan Manila hospitals, the contrast provided by the responses generated
in foreign institutions offers a revealing starting point for further explora-

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tion. It would be interesting to see the full extent and significance of the
marriage of religious beliefs with critical medical decision-making among
Filipino pediatricians. This integration is something that the pressure of
inadequate medical resources is likely to put under extreme test.
Indeed, it is puzzling that medical practitioners who come face to face
with severe shortages of medical supplies very often can afford to main-
tain the attitude “always to exert every possible effort, including the use of
both ordinary and extraordinary means, to sustain the lives of severely
handicapped neonates.” One can only surmise that when the pressure on
the health care system brought about by the inadequacy of medical sup-
plies intensifies, the helplessness that characterizes the situation will force
medical personnel to abandon their aggressive disposition towards suste-
naining life. They will have no option but to accept the reality of scarcity
and the futility of expensive procedures.
Perhaps, as a consequence, medical practitioners increasingly find refuge
in distinctions such as ordinary versus extraordinary means of treatment.
The idea is that they can only sympathize with perspectives on available
medical options that are consistent with their individual attitudes towards
life and medical well being. In a sense, such distinctions serve as security
blankets that enable doctors and patients who value the aggressive suste-
nance of life to accept remedies that could allow – or, possibly, even direct-
ly cause – early death. Such doctors and patients do not want to give up their
commitment to life, but they are open to alternative ways of viewing critical
care management options. They can be attracted to conceptual tools that
allow them to cling to their commitment to life while accepting the inevita-
bility of death. Distinctions between “ordinary” and “extraordinary,” be-
tween “withholding” and withdrawing,” and between “killing” and “letting
die” may be counted among such conceptual tools. These distinctions serve
to justify actions that would otherwise be inconsistent with one’s beliefs.
For instance, to label a means as “extraordinary” is to provide an excuse for
failing or refusing to employ it even if early death could be the result.
In the Metropolitan Manila surveys cited above, respondents were asked
if they thought it important to distinguish between “ordinary” and “ex-
572 L.D. DE CASTRO AND P.A. SY

Table 3. Importance of distinguishing ordinary from extraordinary treatment.

Hospital 1 Hospital 2
(Public) (Private)

63.0% 61.5%

traordinary” means of prolonging life in deciding whether or not to contin-

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ue the treatment of severely compromised neonates. Table 3 indicates the
percentage that said “yes” at each medical center:
The figures for the Philippine hospitals are about 15 to 34 percentage
points lower than the figures for Victoria (Singer et al., 1983) and Calgary
(Bay and Burgess, 1991), where 77.5% to 95.2% considered the distinc-
tion important. One would think that the lower figures could be correlated
with a stronger resolve to exert every possible effort, including the use of
both ordinary and extraordinary means, to sustain life. But as local doctors
come to accept the futility of expensive and aggressive critical care, many
will find it useful to rely on distinctions such as that between ordinary and
extraordinary means. The aim is to reconcile their individual beliefs with
the practical remedies called for by a situation of scarcity and insufficien-
cy.

B. Involvement of Nurses in Critical Care Decision-making

Critical care decision-making requires a great degree of consultation among
caregivers and the patient or his surrogates. It is dependent on input com-
ing from everybody who can have something relevant to contribute. In the
above-mentioned surveys, the subjects were asked if they discuss critical-
care decisions with nursing staff, parents and other doctors. The results
showed that most respondents discuss cases with parents of patients and
with other doctors. However, only 37% of the respondents in Hospital 1
and 30.8% of the respondents in Hospital 2 indicated that they consult
nursing staff when a decision has to be made whether or not to continue
treatment. These are obviously low figures. The results obtained by Singer
et al in Victoria and by Bay and Burgess in Calgary showed that 90.9%
and 95.2%, respectively, consult nursing staff on similar decisions.
The low rate of consultation with nursing staff in the Philippine hospi-
tals surveyed confirms the prevalence of a paternalistic and physician-
centered approach to health care practice. Consistent with this approach is
the attitude that nurses and other caregivers ought only to be peripherally
involved in making treatment decisions. This makes for swift and author-
itative critical care decision-making. However, there are some drawbacks.
 CRITICAL CARE IN THE PHILIPPINES 573

Doctors are generally regarded as authority figures. In Philippine socie-

ty, ordinary persons approach them with great respect and hesitation. They
are generally trusted, but conversation with them is often guarded. On the
other hand, one can expect freer communication with nurses, who are not
regarded with as much awe as doctors. Considering the large amount of
time that nurses – compared to doctors – spend with patients and their
relatives, it would be very useful to consult them. They can have greater
access to the family’s feelings and the patient’s personal situation. They

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can provide pertinent information that may prove invaluable in the man-
agement of the patient. Hence, their voice in decision-making can only
enhance critical care.
This point acquires greater significance in light of cases where “do not
resuscitate” orders or withdrawal of life support are under consideration.
As the stress of decision-making on the family increases, the role of the
nursing staff becomes more important. They can provide support and in-
formation that only those who spend a lot of time with the patient and the
family are capable of giving. Among the members of the treatment team,
they are the ones with whom family members can be more frank in dis-
cussing personal feelings and preferences. They should not be left out of
the consultation process if the integrity of treatment decisions is to be
preserved and the autonomy of the patient and family is to be enhanced.
It is relevant also to note that in Philippine hospitals, rarely are do-not-
resuscitate, home-against-medical-advice, or other similar arrangements
formalized. There are hardly any policies requiring strict documentation.
In Congress, all attempts to pass legislation that would allow patient self-
determination through advance directives have failed thus far. Given this
lack of formality, it is important that the parties involved make every
effort to determine the real sentiments of patients and their families. Nurs-
es have a special role to play in this regard. This role should not be over-
looked.

V. ETHICAL ISSUES RELATING TO THE TRANSFER AND

APPLICATION OF HEALTH CARE TECHNOLOGY

The transfer of medical technology has been an indispensable feature of

attempts to meet critical health care needs in developing countries. In
order to keep pace with burgeoning health care requirements, societies
characterized by slow growth of medical technology have had to rely on
the importation of products and procedures developed elsewhere. But there
is a difference between transferring medical technology and ensuring that
574 L.D. DE CASTRO AND P.A. SY

it can be adapted to a new context. The importance of innovative products

and procedures must be reckoned not only in terms of their utility and
technological sophistication but also in terms of their adaptability to vary-
ing situations. They must be compatible with the traditions and cultural
values prevailing in the environment to which they are transferred. Other-
wise, their introduction could negate the gains that the medical establish-
ment hopes to achieve.
People seek new technologies in response to problems they consider

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priorities. Within their particular socio-cultural context, their values deter-
mine which problems require immediate attention and what solutions are
acceptable. In this manner, the process of invention and discovery is
launched by locally relevant values.
Technology transfer always involves a value transfer. When technology
is transferred, a foreign remedy is offered for a local problem. This is not
bad in itself. But new technologies require screening within the value
framework of the receiving country. To rely only on the experience in the
country that developed the technology in making an assessment is to over-
look the socio-cultural peculiarities of different populations. If so, the
result could be counterproductive because the available solutions would
determine the interpretation of the problems that ought to be addressed.
A much-publicized organ transplant experience in the Philippines illus-
trates the importance of ensuring that the transfer of critical care technolo-
gy is characterized by cultural and social sensitivity (see, for example, De
Castro, 1997, 193–205). Controversy erupted when well known doctors
were sued by the ombudsman for alleged murder after they took the kid-
neys, liver and pancreas of an accident victim. Newspaper headlines car-
ried stories announcing that the surgeons had been charged with “remov-
ing organs … and selling them to paying clients,” “stealing vital organs”
and “butchering a patient to get vital organs.”
The controversy involved an accident victim for whom the Director of
the National Kidney Institute issued an authorization to remove organs for
transplant purposes. When relatives of the victim eventually found out
about the accident and the subsequent transplant, they sought legal action.
The ombudsman charged the doctors with murder.
The defense relied on the provisions of the Act Authorizing the Legacy
or Donation of All or Part of a Human Body After Death for Specified
Purposes. The Act establishes the definition of death either in terms of the
absence of unaided cardiac and respiratory functions or in terms of brain
criteria. It also authorizes the retrieval of organs from “brain dead” pa-
tients even when their relatives are not available to give permission, pro-
vided that a judicious attempt to locate them is carried out for at least 48
 CRITICAL CARE IN THE PHILIPPINES 575

hours. On the basis of these provisions, the court ruled that the supposed
victim was legally dead already. The hospital director was well within his
legal authority in authorizing the removal of the organs.
Notwithstanding his presumed legal knowledge, the government lawyer
assigned to investigate the case could not reconcile his personal under-
standing with the definition of death provided in the law: “assuming [the
victim] to be … clinically or brain dead, yet for all intents and purposes
and in reality he was still alive when his vital organs were … taken from

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him” (Sandiganbayan, 1994, p. 14, emphasis supplied). The legal defini-
tion could not cause him to abandon a different notion of death “for all
intents and purposes and in reality.” For him, as well as for most Filipinos
scandalized by the event, the reality was different from what the law
dictated.
The point is that although the urgency of critical care needs requires
openness to innovative as well as imported technology, sensitivity to the
cultural values and traditions of local users is necessary in the application.
In the case of the above-mentioned accident victim, it was particularly
important to note that death is not merely a legal construct. It is a culture-
bound philosophical concept that is tied up with deeply held values and
traditions. It has important implications for the disposal of human bodies
and the treatment of dying persons.
The concept of kagandahang loob also explains the kind of response
that surrounded the application of the new law. When the organ “donors”
are brain-dead and unidentified, they clearly are not in a position to gener-
ate kagandahang loob. A donation under such circumstances fails to meet
the requirements of kusang loob. The spontaneity associated with unsolic-
ited initiatives cannot be actualized since somebody else does the giving
for the “donor.” It is the hospital administrator who is vested with legal
authority, but he is not perceived as speaking for or on behalf of the brain-
dead person. The effect is that in such cases he takes (upon authority of the
law) something from the dead person to give away. This happens without
the owner (or somebody perceived in the particular cultural context as
speaking for him or on his behalf) giving permission. The transfer is
authorized by the law but not necessarily perceived to be legitimate by the
ordinary person. Thus there may be a legal transfer, but there is no genuine
donation.
With the publicity that was given to the controversy one can see that the
consequence could be counterproductive for legislated critical care ag-
gressiveness:
576 L.D. DE CASTRO AND P.A. SY

The celebrated case of four government doctors accused of killing a

patient so that they could transplant his organs to wealthy patients has
cast doubts on medical efforts to save lives through organ transplanta-
tion (Tampus-Cuadro,1994, p. 1).

Even though the government doctors successfully evaded conviction in

the case, the credibility of the medical profession in general and the effort
to promote organ donations and transplants may have suffered.

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Recently, several versions of legislation seeking to classify medical
malpractice as a criminal act have been filed in Congress. Although there
is no evidence to link this development directly to the organ transplant
controversy, it is clear enough that the public has become aware of a need
to exercise vigilance with respect to medical practice.

VI. TOWARDS CRITICAL CARE OUTSIDE A CLINICAL SETTING

This article’s account of some problems arising in critical care delivery

and the ethical dilemmas to which they give rise should not be taken as an
attempt to indict the medical profession in the Philippines. As the econom-
ic situation in the country improves, the government finds itself in a better
position to put a fair and efficient system of health insurance and health
care delivery into effect. In the short run, expanding demand will intensify
pressures on available health resources. But government planners are com-
ing to realize that more than merely increasing the supply, it is necessary
to institute policy reforms and structural adjustments that could rationalize
the delivery system.
Currently pending in congress is a bill creating the Emergency Medical
Services System (EMSS) in the Philippines. The Bill provides for the
professionalization of paramedical personnel and aims to establish the
EMSS in a pre-hospital setting. More importantly, it institutionalizes the
kind of support that existing legislation can only provide haphazardly.
Extant laws prohibit “the Demand of Deposits or Advance Payments for
the Confinement or Treatment of Patients in Hospitals and Medical Clin-
ics” and penalize “the Refusal of Hospitals and Medical Clinics to Admin-
ister Appropriate Initial Medical Treatment and Support in Emergency
and Serious Cases.”
Also significant from the perspective of critical care is a bill “declaring
the rights of patients.” The Patients’ Rights Bill recognizes a patient’s
right to self-determination and provides for the use of advance directives.
This kind of provision will appeal to those who are uncomfortable with the
 CRITICAL CARE IN THE PHILIPPINES 577

predominantly ad hoc character of decisions in local clinics concerning

do-not-resuscitate orders, home-against-medical-advice discharges,and the
withholding or withdrawing of treatment. However, decisions concerning
the care of critically ill patients traditionally has rested on relatives or
other surrogates. Even when the particular patients concerned have not
completely lost the capacity for rational deliberation, Filipino society has
recognized that close family members can make decisions on their behalf.
Thus it will be interesting to see how the public reacts to legislation that

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offers them an opportunity to exercise an individual freedom that has not
had a prominent place in Filipino life.
Another legislative measure with implications for critical care is the Act
Instituting a National Health Insurance Program for All Filipinos and
Establishing the Philippine Health Insurance Corporation. The Act has
provisions for universal coverage and for the grant of premium subsidies
to indigents.
Complementing government measures are various private sector initia-
tives. There are health-oriented non-governmental organizations (NGOs)
providing assistance to underserved communities or public sectors. These
NGOs have organized medical-dental-surgical missions in urban slums,
remote rural barangays, and disaster-stricken areas. Many foreign funding
institutions have struck partnerships with these organizations for the dis-
tribution of medical assistance.
Also gaining ground are new private Health Maintenance Organizations
(HMOs). Many of these HMOs have been either established or contracted
by employers to provide medical, dental and occupational health services
to their employees. They are engaged in robust competition among them-
selves, and their aggressive marketing strategies will undoubtedly have
the effect of increasing their aggregate share of health care financing.
Eventually, they will be able to take over the social function of govern-
ment as provider of health security. It adds to their long-term prospects
that, historically, private corporations have been much more efficient –
and viable – than government-run enterprises. However, as these private
HMOs seek to stamp their dominance on the country’s health care financ-
ing horizon, there are some implications for critical care that require mon-
itoring for important ethical concerns.

The Congressional Commission on Health has observed that:

a. Policies set by … HMOs exclude from coverage the disabled, the
senior citizens, those who are irregularly employed in high-risk occu-
pations and those who have pre-existing illnesses.
578 L.D. DE CASTRO AND P.A. SY

b. Health plans offered by . . . HMOs often emphasize high-cost, tech-

nologically advanced care. Benefits offered tend to be anchored on
the use of modern technology with physicians as their main provider
(CCH, 1993, p. 105).

The first observation is ethically significant from the perspective of fair-

ness. If access to health care is to be regarded as a universal right, the
mechanisms for providing such access must not discriminate against some

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segments of society, much less against those that are already vulnerable in
certain respects. The consequences of discriminatory policies will be par-
ticularly pronounced in the area of critical care since the procedures in-
volved are often expensive and beyond the financial reach of an over-
whelming majority of Filipinos.
The second observation reminds us of a growing trend towards high-
technology approaches to medical care. While advanced technology has
brought wonders for clinical management, we cannot afford to depend on
it too much. The critical nature of public health care can be attributed also
to factors that have to do with more basic necessities in life.
We ordinarily understand critical care to refer to what is needed to prevent
immediate death or permanent disability. It is crucial for the preservation
of life or for the maintenance of a reasonable level of subsistence. The
patient involved probably needs constant attention and monitoring. In many
cases, expensive equipment is also indispensable.
This article has dealt with ethical issues pertinent to this notion of
critical care. The indigenous concepts kagandahang loob and kusang loob
provided the backdrop for an evaluation of the “Robin Hood Principle”
and of a controversy arising from the application of the Philippine law on
Organ Transplants. The discussions highlighted the importance of respect-
ing the values that are wedded to a people’s way of life. The survey of
ethical issues arising in the practice of pediatric critical care also noted the
integration of religious beliefs with ethical principles as they are applied
to practical clinical decisions.
There is an important sense in which health care may be considered crit-
ical even when the diseases involved are not so serious. The vulnerability of
patients may lie not in the critical nature of their illness but in the serious-
ness of the attitudinal and systemic obstacles to the distribution of vital
health services. For instance, critical care is necessary when large popula-
tion groups are threatened and death, though easily preventable, looms as a
distinct possibility because of inefficient links in the health care system.
We cannot overlook the idea of health care being critical in this sense
when we examine the mortality and morbidity profiles in some countries.
 CRITICAL CARE IN THE PHILIPPINES 579

In the Philippines, diarrhea and bronchitis have been the two leading caus-
es of morbidity for many years (NCSO, 1993, p. 43). Diarrhea is also
among the leading causes of mortality. These two types of diseases do not
ordinarily require sophisticated equipment for their management. Instead,
what they require are sources of potable water, good sanitation and a safe
and reasonably spacious environment.
It is not an exaggeration to say that due to the absence of these basic
necessities, there are thousands of poor Filipinos who are in constant

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danger of dying. They require critical care not because they have already
been struck by an illness that is either crippling or deadly, but because it is
always easy for them to pick up a potent threat to their lives in the water
that they drink or in the air that they breathe. They require critical care
because they live daily in critical surroundings. As long as our concept of
critical care is tied down to a technologically dependent, highly commer-
cialized approach to health management, these unfortunate Filipinos will
not get the kind of sympathetic attention that they deserve.

NOTES

1. Unfortunately, no detailed statistical information about ICUs in the Philippines is

available in the literature.
2. The entire questionnaire used in the study was the same one used by Singer et al. in a
survey of pediatricians in Victoria, Australia. The authors of the Philippine study are
grateful for the permission given by Peter Singer for the use of the instrument.

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