We welcome the new year of 2024 with a selection of papers that typify the breadth and quality of work published by Asian Bioethics Review. This issue is a particularly apt demonstration of the myriad ways in which our journal supports a range of contributions to the field of bioethics both within and beyond Asia. Variously, these examine issues of theory and practice, always striving to stay up to date with technological and social developments whose advent illustrate time and time again the crucial importance of bringing bioethical perspectives to the challenges of the modern world.

Asian Bioethics Review strongly encourages letters to the Editor as a means both of informing our readers timeously of developments in the field as they relate to Asia, and also as a primer to think more deeply about ‘live’ bioethics as this is played out in practice. Our two epistolary contributions to this issue demonstrate this function very well. Thus, Khoo reports on the Third National Paediatric Bioethics Symposium in Malaysia that took place in August, 2023 [https://link.springer.com/article/10.1007/s41649-023-00263-4]. Importantly, the event sought to situate discussions in the post-pandemic environment and in the wake of the 2017 Kuala Lumpur Declaration on Engaging Healthcare Professionals in Paediatric Bioethics. A key theme of the meeting was rising to the challenges of leadership using bioethics as a guiding beacon. This letter is important because it does not simply report on an event per se; rather, it demonstrates a country-specific and sector-focussed examination of bioethics in action. In a similar vein, the letter by Akabayashi and Zion reflects on a wealth of experience in Japan and Australia in navigating the vagaries of ethics review and the perennial problem of the protection-inclusion dilemma [https://link.springer.com/article/10.1007/s41649-023-00265-2]. Through four insights focussed on practical wisdom, the authors highlight different ways in which the simultaneous drive to protect vulnerable persons while promoting robust ethical research reveals lessons for the future of ethics review. The comparative analysis only adds to the value and richness of the contribution.

Our first full article of this new year continues the theme of ethics in practice, notably with a focus on clinical ethics consultation in Japan. Nagao and Takimoto ask the intriguing question: what does it mean to have a functioning ethics consultation [https://link.springer.com/article/10.1007/s41649-023-00257-2]? To answer their own question the authors conducted empirical research with chairs of ethics committees and clinical ethics committees in over 1000 post-graduate clinical teaching hospitals. This extensive community engagement exercise yielded fascinating results, which the authors distil down into key challenges and effects of setting up clinical ethics consultation. The paper provides important historical and international context for the research and this also serves well for future lessons to be learned both in Japan and in other countries.

Country-specific and comparative accounts are the connecting theme of the next three papers in this issue. Thus, in the context of South Korea, Choi, Jeon, and Lee report on data from almost 85,000 patients concerning their treatment and care relating to life-sustaining treatment decisions [https://link.springer.com/article/10.1007/s41649-023-00266-1]. The analysis reveals how increasing age of the patient is often accompanied by an increased role for family members in the decision-making process. The data also show divergences in approach depending on the disease in question. These findings sit starkly with the legal position in South Korea which embodies the legal right to self-determination for all competent adults. The paper is accordingly important as evidence of divergence between the text of law and the context of bioethical practice.

Our next paper focusses on very different subject matter and a very different country context. Yet, its contribution is similar to the last paper in that it reflects on country experiences of implementing a legal regime and it reveals important insights about the process as a result. The paper by Osiejewicz and others reports on the Austrian national regulation of data processing for research and biobanking activities [https://link.springer.com/article/10.1007/s41649-022-00231-4]. Its inclusion in this journal is an important reminder that while our principal focus is on Asia, our outlook on bioethics always remains determinedly global. This open access paper illustrates the experiences of Austria in navigating European data protection law, the provisions of the European Convention on Human Rights, and domestic legal rules in giving effect to the global phenomenon of biobanking. Many countries have struggled over the last few decades to reconcile the promise of biobanking—as a purposively open-ended scientifical enterprise—with the action-limiting legal provisions that are so often present in statute to protect citizens’ privacy. As such, the paper offers interesting lessons internationally from how one country has navigated such an ethical and legal minefield.

Comparative analysis of countries’ attempts to come to terms with any bioethical challenge is always revealing at multiple deep levels. The paper by Gopalan demonstrates this very well in the context of the growing phenomenon of medical tourism, which is happening with increased frequency in the Asia region [https://link.springer.com/article/10.1007/s41649-023-00267-0]. Indeed, the particular focus of this piece is on so-called aesthetic medicine—the modification and enhancement of physical appearance through surgical and non-surgical procedures—which itself is one of the fastest growing areas of medical tourism globally. The paper examines the regulatory context in five Asian countries: India, Malaysia, Singapore, South Korea, and Thailand. Its core contribution is to serve as a diagnostic on the state of regulatory preparedness in the region, highlighting in particular the track record of mishaps in this field of medical intervention. Perhaps unsurprisingly, the picture to emerge is patchy at best. Much work remains to be done to respond well to medical tourism generally and to aesthetic medicine more particularly. This paper plants some valuable signposts for the road ahead.

Our final three papers are connected by a common concern about how best we can respond to the novel technical, social, and/or systemic threats to the human condition. Padmapriya and Parthasarthy build on the extensive literature relating to data science and artificial intelligence (AI) to explore the ethical concerns that arise when these technologies are applied to medical imaging [https://link.springer.com/article/10.1007/s41649-023-00250-9]. The authors take as their starting premise the fact that, to date, there is no universally accepted approach to handling data used for, or generated by, medical image analysis. This lacuna is ultimately filled by the proposed framework that forms the conclusion to the paper. In the steps towards that end, the authors provide a rich account of the ethical challenges that arise at the interface between data, images, and AI. Their structured approach to addressing such challenges makes a valuable contribution to the literature on data ethics more broadly, as well as to the growing field of image analysis involving patients in both care and research settings.

Images are also the focus of the paper by Ng and others, which explores ethical issues in Photovoice studies [https://link.springer.com/article/10.1007/s41649-023-00264-3]. Photovoice is, first and foremost, a research method that relies on images and words to capture the experiences of populations. It has proven to be particularly effective in conducting research with communities who have been marginalised from diverse spheres of society. Its apparent worth has been explored extensively in diverse disciplinary literatures. In this paper, however, the authors use a literature review technique to reveal the ethical issues that arise from the deployment of Photovoice, particularly in health-related contexts. The conclusion is that there is a strong unmet need to develop some means to capture, monitor, and respond well to the use of Photovoice when it is used to conduct research, especially with groups that might be considered already to be marginalised and disadvantaged.

Finally, to a regular reader of Asian Bioethics Review it might seem that it is no longer possible to read a new issue without coming across a mandatory COVID-19 paper. If so, we are unapologetic in this regard. Indeed, we are humbled to have raised awareness about ethical responses to the pandemic across the Asia region and beyond, and we will continue to publish papers on novel and emerging angles on the on-going global issues. The paper by Lee and others is a case in point [https://link.springer.com/article/10.1007/s41649-023-00249-2]. Not only does the article offer insights into ways in which the COVID-19 pandemic has heightened existing clinical concerns—in this case the question of undue influence from family members in refusing vaccination and treatment—but the form of the article also illustrates yet another kind of contribution that we celebrate in the Asian Bioethics Review. This format takes the shape of a case study—grounding in a very real scenario from Singapore—which then extrapolates the facts to a theoretical discussion drawing on various concepts and ideas now common in bioethics, such as relational accounts of autonomy. Indeed, in many ways this paper pulls together various strands from this issue: it is an account that engages with bioethics ‘on the ground’; it reveals tensions between the legal context and the professional attitudes and approaches of the healthcarers who were involved; it demonstrates how unexpected developments such as COVID-19 drive the need for more robust ethical engagement; and it highlights well how lessons from one country’s experiences can have resonance far beyond local borders.

The Asian Bioethics Review is proud to provide a platform for all of the kinds of work contained in this issue.