23 Asian Bioethics Review ISSN 1793-8759 Volume 9 Number 4 ABR (2017) 9:401-414 DOI 10.1007/s41649-017-0028-6 A Scientific and Socioeconomic Review of Betel Nut Use in Taiwan with Bioethical Reflections Joseph Tham, Geoffrey Sem, Eugene Sit & Michael Cheng-tek Tai 1 23 Your article is protected by copyright and all rights are held exclusively by National University of Singapore and Springer Nature Singapore Pte Ltd.. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com". ORIGINAL PAPER A Scientific and Socioeconomic Review of Betel Nut Use in Taiwan with Bioethical Reflections Joseph Tham1 & Geoffrey Sem2 & Eugene Sit3 & Michael Cheng-tek Tai4 Published online: 2 December 2017 # National University of Singapore and Springer Nature Singapore Pte Ltd. 2017 Abstract This article addresses the ethics of betel nut use in Taiwan. It first presents scientific facts about the betel quid and its consumption and the generally accepted negative health consequences associated with its use: oral and esophageal cancer, coronary artery disease, metabolic diseases, and adverse effects in pregnancy. It then analyzes the cultural background and economic factors contributing to its popularity in Asia. The governmental and institutional attempts to curb betel nut cultivation, distribution, and sales are also described. Finally, the article analyzes the bioethical implications of this often-ignored subject from the perspectives of human dignity, the good of health, vulnerable groups, cultural diversity, informed consent, and ethical blind spots. Keywords Betel nut . Bioethics . Medical ethics . Addiction . Oral cancer . Indigenous population . Vulnerable groups . Behavioral ethics Introduction A visitor to Taiwan may be surprised by the abundance of betel nut stands all over the country, often advertised with neon signs and scantily clad young women. She will be even more surprised if she is aware of the well-documented deleterious health effects of Asian Bioethics Review (2017) 9:401–414 https://doi.org/10.1007/s41649-017-0028-6 * Joseph Tham jtham@legionaries.org 1 School of Bioethics, Regina Apostolorum Pontifical University, Rome, Italy 2 Faculty of Health, School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada 3 Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong, SAR 4 Bioethics and Medical Humanities, Chung Shan Medical University, Taichung, Taiwan Author's personal copy the betel nut. Taiwan has the highest incidence of oral cancer in the world (Chen et al. 2011). From 2001 to 2012, the incidence of oral cancer increased by 20.7% (Guo et al. 2013). Esophageal cancer was the sixth leading cause of cancer death among men in Taiwan in 2003 (Wu et al. 2006). Coronary artery disease (CAD) is the second leading cause of death after cancer which accounted for 10.8% of all deaths in Taiwan in 2010 (Tsai et al. 2012). All these statistics are related to the chewing of the betel nut. The betel quid is one of the most widely used psychoactive stimulants around the world, with 10 to 20% of the global population consuming it (Lin et al. 2006). In fact, with regard to the worldwide popularity of central nervous stimulants, the betel nut ranks fourth after nicotine, alcohol, and caffeine (Chen et al. 2011). When one learns about the dire health tolls of this nut on the population and the fact that little has been done to curb its use, it seems that an ethical analysis of this oftignored social problem is overdue. In fact, a cursory search on the database of the Kennedy Institute of Ethics did not yield a single result when the words Bbetel nut^ were entered.1 While betel nut consumption is a worldwide problem, this paper will look primarily at the situation in Taiwan. We will first provide the scientific and medical facts about the betel quid, followed by the socio-economic impact it has on the Taiwanese population. We will proceed to provide bioethical reflections on the following topics: health as a fundamental good, the tension between health and cultural practices, the need to protect vulnerable populations, the need to provide correct information for decision making, and behavioral ethics in institutional and organizational responses to the problem.2 Scientific and Medical Aspects of the Betel Nut The betel quid, more commonly known as the betel nut, is composed of areca nuts wrapped in a betel leaf coated with slaked lime. The areca nut is the seed of the Areca catechu palm tree found in many Asian countries, whereas the betel leaf comes from the Piper betle vine which is a mild stimulant (Madigan 2016). There is a broad spectrum of additional ingredients that can be included when preparing the betel quid, such as small amounts of tobacco, spices such as cardamom and saffron cloves, sweeteners, lime, and catechu. The areca nut itself can be prepared in different ways: green, unripe, fermented, boiled, or sweetened (Petti et al. 2013). Preparation of the betel quid varies among countries. For instance, tobacco is never added to the betel quid in Taiwan and Papua New Guinea while this is a practice in mainland China and Malaysia (Lee et al. 2011). In India, non-perishable commercially prepared forms of betel quid have become available and may pose even graver health risks (Gupta and Ray 2004). The areca nut contains pyridine alkaloids such as arecaidline, arecoline, arecaine, arecolidine, guvacine, isoguvacine, guvacoline, and coniine. These structurally related alkaloids are intoxicating, addictive, and carcinogenic, and they release adrenaline 1 Research done on website on November 4, 2015. https://bioethics.georgetown.edu/librarymaterials/bioethics-research-library-databases/ethxweb/ 2 An abridged version of this paper has been previously published: J. THAM, G. SEM, E. SIT, M. TAI, BThe ethics of betel nut consumption in Taiwan,^ in Journal of Medical Ethics. Published Online First: 06 March 2017. doi: 10.1136/medethics-2016-103,990 402 Asian Bioethics Review (2017) 9:401–414 Author's personal copy when consumed. The methyl esters of arecoline and guvacoline hydrolyze to their respective acids, arecaidine and guvacine. This reaction is then catalyzed by the slaked lime on the betel leaf and as a result, arecoline is present in the nut as a salt (Wolters Kluwer Health 2009). The most common stimulant alkaloid in the areca nut is arecoline, which has severe effects on various neurotransmitters, especially upon cholinergic neurons. It is a parasympathomimetic agent and has the ability to stimulate sweating and salivation (Lu et al. 1993). The betel quids in Taiwan are usually prepared using a piece of unripe Piper betel fruit, which has 1% of safrole, a known carcinogen (Tsai et al. 2012). The chewing of betel quid has been strongly correlated to adverse health effects including increased risks of developing oropharyngeal cancer, oral leukoplakia, oral muscosal lesions, oral submucous fibrosis, gum disease, liver cirrhosis, hepatocellular carcinoma, obesity, metabolic syndrome, diabetes mellitus, hypertension, asthma, and cardiovascular disease (Guo et al. 2013; Tsai et al. 2012). In 2004, the International Agency for Research on Cancer declared the chewing of betel quid to be a Group 1 carcinogen (International Agency for Research on Cancer 2004). The areca nut and betel leaf have shown mutagenic, carcinogenic, and genotoxic properties in both animal and in vitro experiments. The betel quid is also known to cause cytotoxicity in mammalian cells both in vivo and in vitro. There is both a doseand durationdependent association of betel nut chewing with precancerous oral submucous fibrosis along with other types of oral cancers (Warnakulasuriya et al. 2002; Yang et al. 2001). Of all the health risks associated with chewing betel nuts, oral cancer has the strongest statistical correlation. In Southeast Asia, oral cancer is the second most frequent form of cancer and the second most frequent cause of death from cancer among males (Guo et al. 2013). Researchers have confirmed a relationship between betel nut use and the development of oral cancer (Yang et al. 2001). The incidence of oral cancer in Taiwan rose by 35.74% between 1998 and 2002 and by 20.7% from 2001 to 2012 which makes it the country with currently the highest incidence of oral cancer in the world (Chen et al. 2011). The relative risk for oral cancer for people who chew on betel nuts is 58.4%. Both the duration and daily frequency of chewing increases one's risk of developing oral cancer (Warnakulasuriya et al. 2002). Chewing the betel nut alone is associated with an increased risk of oral cancer by 17.7%, but when combined with tobacco smoking and alcohol drinking, the risk becomes 72.6% (Petti et al. 2013; Chen et al. 2011). ABC is an acronym given for alcohol, betel nut, and cigarette consumption. In the 1990s, 10% of Taiwanese people above 15 years old were ABC users (Guo et al. 2013). Another recent study shows that 17% of adults chew betel nuts, 14% smoke cigarettes, and 9% consume all ABCs in Taiwan (Petti et al. 2013). In fact, 93% of Taiwan's betel nut chewers are also cigarette smokers (Chen et al. 2011). Chewing the betel nut alone is associated with an increased risk of oral cancer by 28.2 times, but the incidence rises to 122.8 times in ABC consumers (Ko et al. 1995). Squamous cell carcinoma (SCC) causes 90% of esophageal cancer and was the sixth leading cause of cancer death among men in Taiwan in 2003. Its incidence increased by 70% between 1990 and 1999. The chewing of the betel nut plays a relevant role in the development of SCC and adds to the carcinogenetic effect of smoking and alcohol drinking (Wu et al. 2006). For women who chew betel nuts during pregnancy, several adverse effects have been proven, including spontaneous abortions, premature labor, Asian Bioethics Review (2017) 9:401–414 403 Author's personal copy and stillbirth. In addition, the mean birth weight of infants born was significantly lower for mothers who chewed betel nuts while pregnant. This is attributed to the fact that betel nuts inhibit the synthesis of nucleic acids and proteins in fetuses (Yang et al. 2001). In addition, areca nut extracts, piper inflorescence, and betel quid have been shown to enhance the cytotoxic effects of oxidized low-density lipoprotein (LDL) towards bovine aortic endothelial cells. Since smoking can enhance the oxidation of LDL and potentially lead to atherosclerosis, betel nut users who smoke have an increased risk of developing CAD. There is a 3.5-fold increased risk of CAD in betel nut users who also smoke cigarettes and have hypertension and dyslipidemia (Tsai et al. 2012). Socioeconomic Factors and Prevalence The habit of betel nut chewing is culturally, historically, and socially bound in many Indo-Asian customs with a history dating as far back as 2500 years (林昱廷 2010). It is a highly valued custom in many Asian countries including Taiwan, India, Nepal, Bangladesh, China, Thailand, Vietnam, Cambodia, and Indonesia (Gupta and Ray 2004). In Malaysia, guests are welcomed with a tray of betel nuts, whereas in Vietnam, betel nuts are used ceremonially in weddings as a symbol of love. Because of its common use during celebrations, the casual consumption of small quantities of betel nut is prevalent in these Asian communities (Warnakulasuriya et al. 2002). According to the World Health Organization, 600 million people chew some form of betel nut worldwide and this number is increasing. In Taiwan, there are currently close to 1 million habitual users (Ministry of Health and Welfare 2015, 46). In one study conducted in the Yunlin County of Taiwan, 17% of the population consume betel nuts, and those who chewed were more likely to be males, less educated, and between the ages of 40 to 64. They had a poor economic status, were physically inactive, infrequently brushed their teeth, and did not have regular dental checkups (Guo et al. 2013). In a different study conducted in the Changhua County, 53.6% of students first experimented chewing betel nuts with a family member, and those students who had at least one family member who chewed had a higher prevalence rate of chewing than those who had no family members with the habit (Lu et al. 1993). Among the indigenous populations of Taiwan, it is used as a sign of love and bondage between married couples and is given as a dowry. The betel nut is commonly served in important gatherings and feasts. People believe that spitting the juice out will drive away evil spirits and protect them (林昱廷 2010). However, betel nuts are generally consumed because they provide an energy boost as well as some psychological stress relief akin to cigarette smoking. Additional effects include not only enhanced alertness but also feelings of warmth, cardio-acceleration, salivation, sweating, and euphoria (Yang et al. 2001). This makes them popular among taxi or truck drivers who spend long hours on the road and those who are engaged in heavy physical labor. Thus, the profile of a user in Taiwan is a middle-aged male from the south and east rural area of the country with less than 10 years of education (陳昱安 2010). In the indigenous population, the prevalence rate of betel quid chewing is fourfold that of the national rate (Yang et al. 2001). The life expectancy of Taiwan's aborigines is one decade lower than that of the general population, and they are two to five times more 404 Asian Bioethics Review (2017) 9:401–414 Author's personal copy likely to develop chronic diseases than the rest of the population. Taiwanese aborigines have a high prevalence of betel nut chewing and a low rate of quitting at 8.2% for males and 6.7% for females (Lin et al. 2006). Betel nut chewing extends to the youths because of curiosity and the peer pressure to appear Bcool.^ In a study conducted in the Changhua County, 48.2% of students who chewed betel nuts gave the desire to dispel chills and to refresh themselves as the main reasons (Lu et al. 1993). The cultivation of betel nut has also harmful environmental impacts. The palm has shallow roots and many air roots which have low soil infiltration capacity, thus causing the soil to be loose. The spread-out palm leaves and the lack of decayed leaves near the roots also make it difficult for the soil to retain water. In addition, plantations are generally maintained through mechanical means, exposing the soil surfaces completely and making it highly susceptible to erosion. There tends to be more surface runoff than in the case of other forest plants. As a result, betel plantations have caused enormous damage to the land due to loss of underground water reserves and soil erosion. Betel palms grow best on flat land, but since 70% of Taiwan is mountainous, the proliferation of betel nut plantations has displaced the land used for growing staple crops (Cheng et al. 2008). Further, betel nut consumers often spit the remains on roads, leaving red stains that are difficult to clean. In order to attract customers, there are many booths on the road staffed by scantily clad, young, uneducated, and sometimes underage females. There are 60,000 such young women, attracted by the glamorous lifestyle and easy work, since booth owners offer them fashionable clothing and cosmetics to attract male customers (Sun 2006). Besides the fact that these booths may block traffic and destroy the city's image, there have been concerns that the trade might lead to possible prostitution, exploitation of women, corruption of the youth, and a general lowering of the moral standards of the society (陳昱安 2010). The betel plant is relatively easy to cultivate. Only eight persons are needed to harvest 3 acres. Thus, in 2003, there were 2.2 million people working in the betel nut industry (Kaye n.d.). In a 2010 report, betel nut farming ranked second among the crops produced in Taiwan after rice, fourth among all agriculture products including crops and animals. Taiwan's area for areca nuts has been expanding yearly. In 1981, there were 10,131 acres dedicated to the Areca catechu palm, with 6,483,000 plants, and by 1990, the planted area increased to 88,366 acres with 37,323,000 plants grown (Lu et al. 1993). The total production of betel nut is 124,000 tons in 2013. The betel nut industry nets a $100 billion NTD ($3 billion US) each year (Dolby 2003). Due to specific government policies, betel quid production grew very fast from the post WWII era to the 1990s. Each Areca catechu palm can produce on average 300 areca nuts per year, and each nut is worth approximately $0.002 NTD to produce and sold to customers for $2–50 NTD depending on the season (Lu et al. 1993). The land reform after the war made it necessary for farmers to cultivate alternative crops in order to survive, and the high profit margin of the betel nuts became a natural choice. One study summarizes the dynamics of this change as follows: Taiwan is the world's second highest producer of betel nut and most of this production is for a domestic market. According to a 2003 National Statistics Bureau report, only .4% of that product was exported. Since Taiwan entered the WTO in 2002, 1,806.5 tons of betel nut was imported a year to supplement Asian Bioethics Review (2017) 9:401–414 405 Author's personal copy national production but this import only accounted for 1% of national consumption. Taiwan has a 3.3 million consumer base and many of these consumers chew up to 50 betel nuts a day... Farmers needed a crop that could subsidize the unsustainable livelihood that the government had forced on them. Young industrial workers needed to endure long hours of repetitive work. Betel stalls also provided a social gathering ground for the industrial workers that had just migrated to the city. Betel nut-a powerful, energizing stimulant-not only sustained these laborers through their long hours but the stands where it was sold provided a sense of community around the stands. As a low maintenance cash crop, mass consumption of the stimulant also created a niche for farmers (Kaye n.d.). Actions Taken by the Taiwanese Government The serious health, environmental, and social effects of betel nut eventually prompted the Taiwanese government to curb its cultivation, usage, and commerce. As early as 1997, there was a governmental document entitled BManagement Plan for the Control of the Betel Nut Problem^ that made several proposals to this effect. The guidelines included (1) the preservation of water and soil resources, (2) the prevention of illegal betel nut imports, (3) the regulation of betel nut commerce and imposition of taxes, (4) the ban on betel nut booths that block traffic and exploit young girls, (5) the decrease and prevention of betel nut chewing habits among youth, (6) the decrease of the national rate of betel nut consumption, (7) education in schools about the harmful effects of betel nuts to a level of 95% awareness, (8) a decreased rate of consumption among soldiers, (9) fines imposed on those who spit betel nut juice in public areas, and (10) increased research of issues related to the betel nut (Council of Agricultural, Executive Yuan, Taiwan 1998). Taiwan became a member of the World Trade Organization in 2002. Thus, betel nut agriculture became regulated and taxed. Several laws were passed between 2002 and 2007 which restrict the importation and exportation of betel nuts with imposed taxes. In 2007, the Taiwanese government began to provide incentives to farmers to convert their plantations to grow other products. The same year saw a greater restriction on betel nut imports at certain times of the year and a more stringent control of private and public land used for plantation (Council of Agricultural, Executive Yuan, Taiwan 2011). The 2008 regulation entitled BDestroy the betel nut farms use them for other purposes^ (i) provided financial support of $150,000 NTD per hectare in order to destroy betel nut farms; (ii) provided reimbursement of half the fee in order to plant some other crop, up to a maximum of $50,000 NTD; (iii) stipulated that those who received this support could not grow the betel nut on their land for the next 5 years; and (iv) aimed at converting 100 ha of betel nut plantations per year for the next 5 years. The results were modest (Council of Agricultural, Executive Yuan, Taiwan 2008). Another document from September of 2014, the BManagement Plan Concerning the Betel Nut,^ intended to destroy 10,000 ha of betel nut farms over the next 3 years. It sought to investigate and deal with the illegal use of government-owned land for betel nut cultivation, decrease the number of industrial farms and government-owned land 406 Asian Bioethics Review (2017) 9:401–414 Author's personal copy that is being used for this crop beyond a certain limit, decrease the use of private lands above the accepted limits, and subsidize farmers to encourage them to switch crops (Council of Agricultural, Executive Yuan, Taiwan 2014). There were also government efforts to encourage different uses of betel nuts as an alternative food source (betel nut feast, stir fry quid, betel nut ice cream and wine), medicines, detergents, dyes, and even shoe making (潘姿吟 2015). The Taiwanese government is aware of the importance of primary prevention of betel nut-related health disorders such as oral cancer, CAD, and metabolic syndromes. In most cases of oral or esophageal cancer, the treatment options are limited and the 5year mortality rate is high: 43% for oral cancer and 83% for esophageal cancer (The Oral Cancer Foundation n.d.; Cancer.net 2015). Most consumers of betel nuts are unaware of the serious health risks associated with it until it is too late. Education efforts have been aimed at the at-risk adult population to help them quit and at the younger generation, informing them about the dangers of betel nuts. As mentioned earlier, chewing betel nuts during pregnancy can affect the development of the fetus. Since only 45% of aboriginal mothers are aware of these harmful effects, prenatal counseling in this area is sorely needed (Yang et al. 2001). There have been efforts to focus on tackling the ABC habits by promoting health awareness in Taiwan. 13.4% of betel nut users in Yunlin County were able to abstain from the habit for more than 1 year, showing that it is possible to initiate health promotion programs and reduce the rate of oral cancer. Strategies have been devised to encourage individuals who chew betel nuts to engage in physical activity or to take care of their oral health (Guo et al. 2013). Taiwan has also officially declared an annual BBetel Nut Prevention Day,^ in hopes of reducing oral cancer mortality rates by spreading awareness about its risks (Madigan 2016). Currently, in Taipei, if anyone spits betel nut juice in public, he will be fined and required to attend mandatory withdrawal classes (Hsu 2014). Even though the deleterious effects of betel nut consumption have been known since the 1990s (Madigan 2016), and the first law about curbing this problem in Taiwan was drafted in 1997 entitled BManagement Plan for the Control of the Betel Nut Problem^, it appears that regulations were not seriously implemented until a decade later. The causes for this delay are manifold. There was resistance from the farmer lobbies who had the most to lose because of the huge profit margin in betel nut sales, as well as from the indigenous representatives who saw the betel nut as a part of their local customs that should not be discouraged. Betel farming has become an important income for the Taiwanese nation, with the result that policymakers are reluctant to propose radical changes that could affect the economy (Control Yuan, Taiwan 2013). For instance, in a recent meeting on oral cancer prevention, the participants made the observation that: A 2012 follow-up report noted that there was not much improvement after the 1997 BManagement Plan for the Control of the Betel Nut Problem^. When the 14th Government Executive meeting decided to defer the issue in 2012, the different departments became more passive, leaving the Health Department to fight the war alone without a concerted effort. It was not until the 2011 BEducation Plan on Betel Nut Prevention for Children and Adolescents^ that there was active collaboration (translation from original Chinese) (Sunshine Social Welfare Foundation 2012). Asian Bioethics Review (2017) 9:401–414 407 Author's personal copy In fact, despite government efforts, the trend in betel nut chewing among teenagers has not decreased a lot in the past 10 years (Department of Health, Taiwan 2014). A 2013 report from the Control Yuan of the Taiwanese government made several strong and stinging remarks about the faults of the different governmental agencies (ETtoday 2013; Control Yuan, Taiwan 2013). The report stated that even though the IARC declared the betel quid to be a Group 1 carcinogen, not enough had been done to defend the health of the Taiwanese population. It blamed the Executive Yuan of the government for neglecting to implement with greater rigor the 1997 BManagement Plan^ and to coordinate this effort among the different branches of the government. It blamed the Agricultural Department for not being able to timely reduce and control abuses and production of the betel nut and for not being active enough in addressing the root causes. The Council of Indigenous Peoples was chastised for not giving sufficient warning about the health effects associated with the betel nut. Its policy of protecting indigenous practices (which include the use of the betel nut) contradicted government policies. The Department of Education also was not very successful in its effort to lower betel nut use among students, and the Department of Finance was not able to continue the establishment of taxes and levies on the betel nut due to a lack of manpower. The government could learn much from the policies that have been successful in reducing the habit of cigarette smoking. Such policies include labeling betel nut products with the proper health warnings. This may not be easy because while cigarettes are always sold in packages, betel nuts are sold fresh on the streets (Warnakulasuriya et al. 2002; 李家同 2014). There could also be laws to restrict the sale of betel nuts to underage groups, since the average age at which users start chewing betel nuts in Taiwan is 13 (Guo et al. 2013). Just as increased taxes on tobacco caused a definitive reduction in smoking habits, taxing the betel nut might have the same effect. However, the presence of black markets could keep up the supply at a cheap price, rendering the tax counterproductive (Warnakulasuriya et al. 2002). According to another study, a good approach would be to apply taxes on wholesalers who are easily identifiable and make the greatest profit from the industry. Applying a betel nut surcharge on them would be more acceptable to the public. The revenue from the levy could contribute to the national health insurance to treat betel nut-related illnesses and for educational purposes (Chen et al. 2011). Bioethical Reflections Betel nut consumption in Taiwan provides an interesting case study related to many bioethical issues. We have before us a culturally accepted addictive habit with dire medical consequences for a vulnerable population. The government of Taiwan is aware of the need to foster the well-being of its citizens, and its failure to do so may have a significant societal impact. The possible financial gain from the betel nut trade is offset by the enormous health burden of those affected by the consequences of its consumption. The dignity of the human person demands that great efforts be made to protect his health and thereby promote his general well-being. Here, there might be conflicts between those who emphasize health and those who emphasize their cultural identity concerning the betel nut. At the same time, the 408 Asian Bioethics Review (2017) 9:401–414 Author's personal copy indigenous population is more vulnerable because of its lack of education and social status, making it difficult for natives to make informed choices. Many of these problems are present in the public health debates on cigarette smoking, alcohol consumption, and substance abuse (Brundtland 2002). The ethical issues related to them can similarly be seen in the case of the betel nut (Sgreccia 2010, 191–267). Likewise, while the detrimental effects of smoking, alcohol, and drug abuse had been demonstrated scientifically, the acceptance of this evidence was delayed because of the huge financial investments made by multinational enterprises in these trades (Adams et al. 2010). The tobacco and alcohol industry notoriously invested in publicity and lobbying efforts to delay the introduction of regulations that could lower sales (PLoS Medicine Editors 2011). Illegal drug trafficking is a global problem involving huge sums of money, and from time to time there are initiatives to decriminalize the so-called soft drugs. Thus, government health policies invariably have had to overcome enormous obstacles posed by powerful industrial lobbies with great influence in the political, scientific, and academic circles as well as the mass media (Stenius and Babor 2010). In both cases, the time-proven approaches to curbing these addictions are taxation and smuggling prevention, the application of health danger labels, pregnancy warnings, age limits on consumers, advertisement bans, restricted use in public spaces and the workplace, and educational, health, and media campaigns (World Health Organization 2003). The obstacles and delaying tactics the opponents put up are also alike (Sandford 2003). Nonetheless, compared to the multibillion-dollar tobacco and alcohol industry, the betel nut trade is much smaller. Betel nuts are grown by local farmers, and the production chain and distribution are relatively unsophisticated. Still, we can observe very similar delaying tactics due to the interests of those who have much to lose financially. The government of Taiwan is at a privileged position to implement many of the abovementioned policies precisely because there is not a large-scale industrial production like tobacco or alcohol. Even from a utilitarian point of view, the financial burden of diseases caused by the betel nut greatly outweighs the potential benefits from the trade. In India, the availability of newer imperishable and more carcinogenic forms of the betel nut has generated a US $500 million industry in two decades, and so, Taiwan should take heed before it is too late (Gupta and Ray 2004). The indigenous population is more vulnerable because of its socioeconomic status. Indigenous persons are more prone to betel nut addiction due to their lifestyle, occupation, and other cultural factors (Gracey and King 2009). The poor and uneducated, betel nut beauties, the youth, and pregnant women are also at risk. As vulnerable groups in society, the government has the duty to protect their well-being and health interests. The 2005 UNESCO Declaration on Bioethics and Human Rights formulated the Principle of Vulnerability and Personal Integrity. Article 8 of this declaration states: In applying and advancing scientific knowledge, medical practice, and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected. Asian Bioethics Review (2017) 9:401–414 409 Author's personal copy This principle has two sides to it: it advises restraint so as not to harm or wound those who are vulnerable as well as looking out and providing for the basic or special needs of such individuals or groups. This principle also calls for an increased vigilance by governments and individuals in protecting the well-being of vulnerable subgroups (Tham et al. 2014). In the language of principlism in popular Western bioethics literature, this corresponds to the principle of beneficence and nonmaleficence (Beauchamp and Childress 2001). Related to this principle is that of informed consent, which also has a venerable tradition in the field of bioethics. In our case, vulnerable groups have the right to information about the deleterious effects of betel nut chewing so that they can make informed choices and receive aid if they desire to quit. In the West, advocates to decriminalize psychoactive agents often appeal to the liberal arguments of individual freedom and personal choice. Due to the cultural difference in Asia, however, the argument is less based on libertarian ideals. Some local groups have argued that chewing the betel nut is part of the indigenous way of life in Asia and especially Taiwan. Thus, they have pitted health against cultural identity. However, there is a hierarchy of goods: not all goods are equal. One can presume that life and health are fundamental goods that other goods-even cultural goods-depend on. However, in this case, even though betel nut consumption has been a part of the Taiwanese culture, it is neither universal nor always perceived as an unquestionable good. Cultural practices are not static. Certain habits can and do change with greater education and awareness (Tracy and Acker 2004). Cultural practice does not warrant absolute respect, and the Principle of Respect for Cultural Diversity of article 12 of the UNESCO (2005) declaration states: The importance of cultural diversity and pluralism should be given due regard. However, such considerations are not to be invoked to infringe upon human dignity, human rights, and fundamental freedoms, nor upon the principles set out in this Declaration, nor to limit their scope. It is not easy to define what constitutes culture and the extent to which cultural diversities need to be respected. However, it seems clear that chewing the betel quid is not such an ingrained practice among the indigenous culture. Given its peripheral nature and the dire health consequences, it is reasonable to argue that significant lowering of the incidence of betel nut chewing is in conformity with safeguarding human dignity and rights (Tham et al. 2017). However, cultural sensitivity is important in helping the at-risk population to cut back their habits (King et al. 2009). One study shows that the official policies that emphasize only the scientific and medical aspects of betel nut are ineffective without corresponding initiatives that address the issue of cultural and ethnic identity (林富士 2014). The recent attention given to environmental ethics also invites us to evaluate the likely damage betel palm plantations can cause on land and water conservation. Once again, the lack of greater foresight and the planning of land use can have disastrous effects on agriculture. The quick gain of a high-profit crop may cause long-term erosion that will take years to recover from. In fact, there is a greater awareness of the interconnectedness of environmental issues with the rest of human activities, 410 Asian Bioethics Review (2017) 9:401–414 Author's personal copy combining bioethics, social ethics, business ethics, and ecology in an integral vision (Pope Francis 2015). In view of these bioethical concerns, we may consider the proper institutional response to betel nut consumption. One might accuse the Taiwanese government for being negligent in not acting sooner and more decisively to reduce the trade and consumption habits. As we have seen in the history of the tobacco and alcohol trades, particular government agencies or officials may not be totally at fault because of the presence of complex forces and parties vying for their own interests. On this note, Bazerman and Tenbrusel write about the tendency of institutions or decision-makers to ignore ethical Bblind spots,^ preventing them from acting objectively and based on a long-term projection. In the new discipline of behavioral ethics, they observe that human beings often behave irrationally and unknowingly act against their own ethical standards. These Bblind spots^ can occur at the individual, organizational, and societal levels (Bazerman and Tenbrusel 2012). At the individual level, people often fall prey to psychological processes that bias their decisions. What is worse, most of the time they are unaware of the existence of these biases. They tend to make choices based on gut feelings that are not well thought out. Then, afterwards, they tend to see only the positive outcomes of their decisions while ignoring the negative effects. In this way, ethical principles are undermined time and time again due to a human tendency to justify one's own actions (Bazerman and Gino 2012). At the organizational level, a phenomenon called Bbounded ethicality^ occurs. This means that by focusing only on certain decisions, one tends to neglect the ethical significance of other actions and is not consciously aware of their problematic nature. Employees or officials can contribute to dysfunctional organizations for fear of rocking the boat. Blind spots at the government level occur when decisions are taken which ignore the future consequences and focus only on immediate interests (Messick and Tenbrunsel 1996). Bazerman and Tenbrusel gave the example of the crisis of overfishing the blue tuna. None of the countries can agree on the quota reduction in fishing, and because each country is only looking out for its own interests, the extinction of this fish and the eventual collapse of this industry seem inevitable. There is not just a lack of political will to make decisions in accordance with the greater common good, but also limited views and vested interests that make these decisions appear to be the best when they are not (Bazerman and Tenbrusel 2012). Repeatedly, we have witnessed ethical blind spots. For instance, certain sectors continue to maintain a sophisticated denial that smoking is related to lung cancer, or that alcohol and substance abuse can be harmful. What happened in betel nut prevention policies in Taiwan is not very different. How can we avoid blind spots in ethical thinking and acting? By being cautious; by recognizing our blind spots, weaknesses, and tendencies; and by evaluating ourselves accurately. Traditional ethics calls for the virtue of prudence to overcome such potential blind spots through experience, selfknowledge, objectivity, and foresight at the individual level-but this is difficult to apply at the institutional level. The recent fields of behavioral economics and behavioral ethics are making new inroads into bioethics and will offer much for future reflections (Miller et al. 2015). This article is an attempt to analyze the ethical dimension of this deadly habit. Although betel nut usage affects 10–20% of the world's population and that it is the fourth most popular psychoactive substance worldwide, not much ethical reflection on Asian Bioethics Review (2017) 9:401–414 411 Author's personal copy it can been found. Most people in the West have not heard of the betel nut, and the population at risk is often voiceless and faceless. We hope that this seminal investigation can break the silence in the medical and bioethics community so that more scholars will look into this little-known quid that touches the lives of many. References Adams, Peter J., Stephen Buetow, and Fiona Rossen. 2010. 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