Introduction
Mabeob, Nyankomade, Salamangka – ‘Magic’ in Korean, Twi, and Tagalog. As medical students with roots in South Korea, Ghana, and the Philippines, our collaboration unearthed the magic of creativity ethos in constructing challenging ethical dilemmas while also aiming to promote diversity within the realm of Graphic Medicine. Graphic Medicine, defined as the “intersection between the medium of comics and the discourse of healthcare,” has inspired us to illustrate medical ethics in the setting of our respective cultures (Williams, 2021). Our three comics, Shaping Beauty, Best Medicine, and Conflicting Covenants, are a part of the growing field, one that is not only a tool for patient education but also one that reflects on our professional identities as students in training (Green & Myers, 2010). We aimed to craft unique storylines featuring ambiguity in patient-provider encounters.
History of Comic Development in Korea, Ghana, and the Philippines
Comics are increasingly recognized as a legitimate form of literature, communicating important philosophical, religious, and political ideas. The diversity used in different comics often reflect distinct cultural connections (Green & Myers, 2010). This phenomenon is evident in manhwa, or Korean comics, which have historical origins from the Japanese occupation of Korea in the early 20th century (Donohoo et al., 2024; Monarch, 2023). Although manhwa was originally inspired by the Japanese comic style of manga, it has since evolved into its own unique style, befitting Korea’s own political and cultural independence (Donohoo et al., 2024; Monarch, 2023).
In the early 2000s, manhwas started to focus fully on distinctive sociocultural narratives (McKinney, 2020). One such example is Gendry-Kim’s graphic novel Grass which depicts the lived experiences of “comfort women,” a euphemism for women who were forced into sexual slavery for the Japanese Imperial Army. Most women were Korean, but some came from other countries, including Australia, Burma, China, the Netherlands, the Philippines, Japan, Indonesia, and Taiwan (Ramaj, 2022). Grass was recognized as a new level of manhwa, as it accentuated the horrors these women survived during one of the most politically controversial periods of Korean history. Manhwa continues to be a significant aspect of Korean culture, widely available as “webtoons” that are digitized and easily accessible from one’s personal electronic devices (McKinney, 2020). The field of Graphic Medicine is still emerging in Korea, but the rich culture of manhwa provides an important seedbed for comics, like Shaping Beauty, that interrogate gender norms in the twenty-first century.
The history of comics in Ghana can be traced back to the 20th century when colonialism introduced Western forms of storytelling to many countries in Africa. One of the earliest comics was Tarzan, which was popular from the 1930s to 1960s (Dachowski & Oyebade, 2023). Prior to this, Ghana’s indigenous culture was rooted in storytelling through folklore, visual art, sculpture, and proverbs. These traditions created a foundation for the creation of comics as a means of illustrated narration, especially in the realms of politics and social justice (Asante & Edu, 2018).
As Pijnaker notes, a key figure in the popularization of African comics was Ghanaian comic artist Andy Akman, who created one of the first African superheroes, Captain Africa, in 1987 (2018). The comic was published in major newspapers and boosted the popularity of the medium in everyday Ghanaian society. The Captain Africa comic addressed contemporary political issues, including corruption and the everyday challenges faced by Ghanaians (Pijnaker, 2018).
Comics artists continue to use the medium as conduits for freedom of speech, political activism, and education (Pijnaker, 2018). Graphic Medicine is still emerging in Ghana, suggesting that comics may well serve as an effective way to raise awareness of critical issues in healthcare within the population.
In the Philippines, comics were first introduced by American G.I.s during World War II. Commonly referred to as komiks, they were viewed as a low form of literature originally for adults. Similar to manhwa, original Filipino komiks were significantly influenced by Japanese comic art forms. Because of this influence, the cultural legitimacy of Filipino komiks was initially questioned. In the 1940s, Francisco Coching’s works (e.g. “Hagibis”) helped legitimize the portrayal of the Filipino experience in the comics medium. Eventually, comics became widely successful for communication and entertainment in Filipino culture (Flores, 2004). As with Korea and Ghana, Graphic Medicine is currently gaining a foothold in the Philippines.
An Overview of the Ethical Issues Addressed
Shaping Beauty explores the delicate interplay of beneficence, nonmaleficence, and informed consent in the context of Plastic and Reconstructive Surgery (PRS) and aesthetic procedures. It is about the experience of a Korean ballerina who, driven by society’s standards of beauty and perfection, as well as personal career ambitions, pursues botox procedures with the goal of debulking her calf muscles. Best Medicine portrays the tension between traditional Ghanaian medicinal and spiritual healing practices and modern orthodox medicine in the setting of a child’s epileptic seizures. Conflicting Covenants probes the unique role strain of a Filipino physician who is also a Catholic deacon. He faces the dilemma of prescribing contraception to his goddaughter, realizing that to do so may violate his religious beliefs. While each of these stories highlights unique cultural dilemmas, the core ethical issues examined are applicable to the wider Graphic Medicine audience and medical learners.
Inspiration and Medical Ethics
Korea: Shaping Beauty
Prior to pursuing a career in medicine, one of Shaping Beauty’s authors was training to become a professional ballerina. She had direct experience in the ballet industry and observed that many people in this career and in South Korea elect to receive aesthetic procedures or surgeries– rhinoplasties offered by parents as high school graduation gifts, breast augmentations in the K-pop industry and, the inspiration behind this comic, calf botox for the muscular ballerina (Park et al., 2019). This culture of cosmetic perfectionism is prominent in Korean society. It is estimated that one in five women in South Korea have received some form of plastic surgery or cosmetic procedure. Plastic surgery in Korea is rooted in the idea of gwansang – facial physiognomy-based fortune-telling, which is the notion that certain facial features are associated with greater success – as well as the fierce job market stemming from rapid post-war economic growth. These factors influence the immense personal investment and cultural drive to perfect one’s appearance through aesthetic procedures (Davis, 2018).
The protagonist of the comic, Minji, struggles with external and internal pressures to achieve certain beauty standards despite the physical demands of her work as a ballerina (see Figure 1). Compounding her insecurities (see Figure 2), Minji is surrounded by advertisements for calf botox to achieve the Korean ideal of “sae dari,” which translates to “bird legs,” the straight and thin appearance of the legs many strive to achieve. We also see Minji’s hyper-awareness of the flexing and unflexing of her calves as she climbs the stairs of the subway station. This is one of many misgivings we witness throughout the storyline.
Figure 1: Minji’s perception of her bulky calf muscles after a stellar performance
from Shaping Beauty (May 2024), illustrated by Robin Ha
Figure 2: Subway advertising aspects of perfectionism culture and
Minji’s self-conscious thoughts of her calves walking up the subway stairs
from Shaping Beauty (May 2024), illustrated by Robin Ha
Situated in Korea’s booming industry of PRS, Shaping Beauty illustrates the importance of the physician-patient relationship in centering patient autonomy and shared decision-making (Yoon & Kim, 2020). Minji hears about a range of experiences from her friends and ultimately decides to schedule an appointment with a physician. At Minji’s first appointment, Dr. Cho asks Minji to confirm that she will not continue her career as a ballerina, as a botox injection could cause significant muscle weakness (see Figure 3). Readers can appreciate Dr. Cho’s hesitation and concern for Minji. It is an opportunity for deeper conversation, for her patient to confide her internal struggles as a ballerina with body dysmorphia and external struggles to conform to standards set by society. This moment in the storyline reflects the care physicians must take to ensure meaningful informed consent.
Figure 3: Minji’s first appointment with Dr. Cho
from Shaping Beauty (May 2024), illustrated by Robin Ha
From extensive research and interviews with several PRS and aesthetic clinics, we encountered stark discrepancies in how the indications, contraindications, and potential complications of calf botox for ballerinas are disclosed to patients – e.g. severe muscle weakness versus no contraindications for exercise at all. This discrepancy also exists in the literature, which mentions temporary side effects: bruising, headaches, blurry vision, and other ophthalmologic dysfunction that can occur due to systemic spread of the toxin, resulting in blockage of acetylcholine, an important neurotransmitter of the nervous system (Witmanowski & Błochowiak, 2020).
While her doctor marks the injection sites, Minji’s facial expressions and body language reveal her internal qualms about whether she is a suitable candidate for this procedure as well as the fact that she has not been entirely truthful with her doctor (see Figure 4). We depict Minji’s crisis of conscience to challenge readers to ask themselves the following questions: What are the implications for Dr. Cho of Minji’s withholding information? How might an adverse event impact the physician-patient relationship? How might it impact Minji finding another physician who could provide care for any side effects that might ensue? Shaping Beauty asks the audience to reflect on how informed consent is much more than a patient signing a form.
Figure 4: Minji’s crisis of conscience and consequently heightened anxiety
from Shaping Beauty (May 2024), illustrated by Robin Ha
Ghana: Best Medicine
Best Medicine depicts the ongoing conflict between Ghanaian traditional medicine and modern orthodox medicine. Providing care services to over 70% of the population in Ghana, traditional medicine involves not just the administration of substances but also spiritual rituals (Dachowski & Oyebade, 2022). These practices can have significant positive and negative impacts on patient outcomes.
On the positive side, traditional medicine is believed to cure ailments that are spiritual in nature. Its widespread use is largely due to its cost-effectiveness and accessibility. For instance, in Ghana the ratio of traditional practitioners to clients is approximately 1:200, whereas the ratio of orthodox practitioners to clients stands at a staggering 1:12,000. Despite its availability and affordability, traditional medicine nevertheless poses numerous risks due to its lack of regulation and standardization, and its potential interference with modern medications. As a result, many orthodox practitioners are understandably wary of its use. Many Ghanaians continue to use both modern and traditional treatments simultaneously, often against the advice of modern practitioners. Reasons for this persistence include desperation for a cure, financial constraints, and cultural familiarity with traditional practices (Anderson, 2015).
In Best Medicine a young couple initially struggling with infertility are advised to seek the help of a fetish priest (see Figure 5). Bintu and Usman successfully conceive a daughter, Fatima, but she soon begins to experience seizures. When they consult an allopathic doctor, Fatima is diagnosed with epilepsy and prescribed medication. Unfortunately, despite her parents’ meticulous adherence to the modern medical guidelines, her seizures become more severe. Desperate to help their child, Usman and Bintu return to the fetish priest, who provides a concoction for Fatima’s epilepsy (see Figure 6). Aware of its risk, the parents bring this concoction to Fatima’s physician, who cautions against using the traditional remedy (see Figure 7). Following yet another violent seizure and despite the doctor’s advice, the desperate couple give Fatima the potion. Later, Bintu and Usman return to the physician and admit their use of the traditional remedy. Aware that orthodox medicine failed to help Fatima yet mindful of the potential dangers of the fetish priest’s “medicine,” the doctor must now grapple with how best to care for this family while also honoring his professional oath to “First do no harm.” Figure 8 reveals the three options he identifies.
Figure 5: Bintu’s colleague recommends fetish priest for infertility
from Best Medicine (June 2024), illustrated by Kevin Mukoya
Figure 6: Fetish priest provides concoction for Fatima’s seizures
from Best Medicine (June 2024), illustrated by Kevin Mukoya
Figure 7: Medical doctor warns parents of potential dangers in traditional remedies
from Best Medicine (June 2024), illustrated by Kevin Mukoya
Figure 8: Physician deliberates three courses of action
from Best Medicine (June 2024), illustrated by Kevin Mukoya
The Philippines: Conflicting Covenants
Inspiration for Conflicting Covenants stemmed from the country’s predominant religion, Catholicism. More than 80% of Filipinos identify as Roman Catholics, whose official dogma holds that any form of contraception is considered immoral, or even sinful, because it counteracts the reproductive purpose of sexual intercourse (Ősz et al., 2021). The main character of Conflicting Covenants is Dr. Reyes, a Catholic physician and church deacon, who finds himself at a moral crossroads when his goddaughter asks for birth control. The ethical complexity of the situation is complicated by the probability that Maria is being abused by her partner, which heightens the tension between valuing one’s religious beliefs and simultaneously upholding the essential principles of medicine (i.e. beneficence, autonomy, nonmaleficence).
In Figure 9, the top panel displays the Roman Catholic church’s historically unfavorable view on contraception, as evidenced by the 1968 Human Vitae: On the Regulation of Birth, by Pope Paul VI. The panel below portrays the dichotomy of Dr. Reyes’s moral identity as a deacon, promoting the Catholic ideology of abstinence and his medical identity, lecturing on the benefits and medical purposes of birth control (Kay, 2004; Lagman et al., 2014). His very identity is challenged as he must find a balance between opposing covenants. Dr. Reyes’s struggles not only to abide by religious convictions for his own spiritual well-being but also for his goddaughter’s: as her godfather, he should set an example for her spiritual health and lead by example as a religious leader in the community. The added element of potential abuse increases the stakes and heaviness of Dr. Reyes’s already complex decision.
Figure 9: Conflicting responsibilities: religious vs. clinical
from Conflicting Covenants (June 2024), illustrated by Carlo Jose San Juan
Figure 10 demonstrates the complexity in accessing contraception in a country with strong spiritual contradictions, highlighting the social determinants of health that Dr. Reyes contemplates as he considers Maria’s quandary. Figure 11 illustrates the potential consequences for Maria if he denies her plea for birth control: the possibility of increasing domestic abuse, pregnancy, and public shaming for either or both. The ultimate purpose of the comic is to deepen the discussion of how to navigate complex social and humanistic conditions that may oppose one’s professional and personal identity.
Figure 10: Dr. Reyes ponders one Social Determinant of Health for his goddaughter
from Conflicting Covenants (June 2024), illustrated by Carlo Jose San Juan
Figure 11: Potential outcomes if Dr, Reyes refuses Maria’s request for contraception from
Conflicting Covenants (June 2024), illustrated by Carlo Jose San Juan
Professional Identity Formation: Three Growth Opportunities
Adaptation
Our Conflicting Covenants team had the good fortune of finding an excellent comics artist who is also a nuclear medicine physician in the Philippines: he easily understood both the artistic and the clinical angles of the project, and our work went smoothly from start to finish. Our other two teams, however, lost their initial artists when the artists’ professional schedules conflicted with our timeline. Our first artist for Best Medicine was a Somali-born pediatric resident. Unfortunately, her hospital schedule made it difficult for her to devote the necessary time to our project. It took several weeks and a web of personal connections for us to find another artist in Kenya whose style fit our comic’s content. This experience taught us the importance of adapting to circumstances beyond our control, a skill critical in medical practice, where the unexpected is a common occurrence. Because Somali, Kenyan, and Ghanaian cultures are distinct, we discovered similarities among them that we hadn’t known before embarking on this project. For example, while working with the Kenyan artist, we learned that, like Ghanaian fetish priests, Kenyan fetish priests also view illnesses like epilepsy and hydrocephalus as “spiritual.” The traditional treatments they provide often raise safety concerns with Western-trained physicians and, indeed, with the families who consult the fetish priests.
The Shaping Beauty team also lost our initial artist in the middle of the project because he was offered a teaching position to develop a new course in comics. The greatest complication was that our first artist had already created the storyboards and incorporated successive changes requested by the team. Ultimately, we were fortunate to connect with a well-known Korean American author-artist who was willing to work with the basic narrative arc and panel layout that had been established. Given her intimate knowledge of Korean culture and artistic styles, she accomplished the daunting task of blending the layout while at the same time making the artwork entirely her own. This experience provided insight into the importance—and skill—of “adapting” as teams change. Negotiations and compromises are essential so that everyone has the opportunity to contribute their own talents and feels integral to the team and its goals.
Time Management
Medical students have notoriously heavy time commitments: rounding with clinical teams, completing academic assignments, and studying for monthly exams. In addition to our roles as students, this interprofessional project required us to take on the role of “professional research collaborators” with one another, our mentor and other faculty members in ethics, and comic artists from—literally—across the globe. Sometimes the greatest challenge was as basic as finding a common time when we were all awake, much less a time that we could carve out for a meeting. Other challenges with time were more prolonged and more formidable. For example, a significant portion of our project's timeline for finalizing our panels overlapped with a period set aside by our Office of Medical Education to study for the Step 1 United States Medical Licensing Exam. These competing commitments required us to become skilled in agenda-setting and delegating tasks to fulfill our simultaneous responsibilities as professional colleagues and full-time medical students.
Ambiguity
Humanistic care of patients requires us to integrate factors such as social determinants of health into biopsychosocial and cross-cultural models of care (Mathieu & Martin, 2023). We are constantly incorporating facts and evidence-based medicine into our deliberations and conversations with our patients. But sometimes, clinical situations also require creative "thinking outside the box" approaches. Collaborating on this project challenged us to expand our thought processes—to think abstractly and imagine each of our characters’ lived experiences. We intentionally created multi-layered, culturally diverse dilemmas to mimic real-life scenarios in which there is no single correct answer. As prospective physicians, we need to listen actively and think critically to discover details and solutions that may not be obvious—as we hope these comics have prompted readers to do. The magic of Graphic Medicine is that it allows for ambiguity in which different people can read the same story yet have vastly different understandings based on each individual’s cultural contexts and lived experiences.
Conclusion
Our experience in creating medical ethics comics has instilled in us the importance of implementing humanistic principles beyond the classroom setting and into the clinical realm. While our comics are fictional, the challenges and dilemmas we will face in our profession are real for the patients we will care for. Our storytelling through three multicultural lenses led to and furthered the noble work of diversifying the field of Graphic Medicine.
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