Clinical ethics support, including ethics consultation, has become established in the field of medical practice throughout the world. This practice has been regarded as useful, most notably in the UK and the USA, in solving ethical problems encountered by both medical practitioners and those who receive medical treatment. In Japan, however, few services are available to respond to everyday clinical ethical issues, although a variety of difficult ethical problems arise daily in the medical field: termination of life support, euthanasia and (...) questions about patient autonomy. In light of these conditions, a group of 17 volunteer educators and researchers from the area of biomedical ethics, including the authors, have formed the Clinical Ethics Support and Education Project, and began providing Japan’s first small team clinical ethics consultation service in October, 2006. Members include scholars of biomedical ethics, scholars of philosophy and ethics, legal professionals and legal scholars, nurses and doctors, consisting of five women and 12 men. Consultation teams, made up of a small number of members, were organised each time a request for consultation was received. Over approximately 15 months (October 2006–December 2007), the programme received 22 consultation requests from medical practitioners and medical institutions, and three from the families of patients. In this paper, we will discuss the status of our consultation service and examples of consultation cases we have handled. In addition, we will examine the process of evaluating small team clinical ethics consultation services, as well as the strengths and weakness of such programmes. (shrink)

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding (...) medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed. (shrink)

Currently in Japan, it is extremely difficult to realize the basic wish of protecting personal dignity at the end of life. A patient’s right to refuse life-sustaining treatment has not been substantially warranted, and advance directives have not been legally enforceable. Unfortunately, it is not until the patient is moribund that all concerned parties start to deliberate on whether or not death with dignity should be pursued. Medical intervention is often perceived as a worthwhile goal to not only preserve life, (...) but also provide psychological benefit to the family, regardless of its effect on the patient. To feel they are doing something, family members tend to act against the imperative “Do not inflict on others what you would not wish done to you,” and permit extraordinary measures they would not want themselves. Another complication in Japanese culture is the necessity of unanimous decisions for end-of-life care. If there is conflict between a patient and his/her family on accepting medical intervention, the view of the latter is more likely to prevail due to different perceptions of human dignity. As a result, incapacitated patients in Japanese clinical settings often suffer through extraneous medical procedures, particularly during end-of-life care. Patient dignity is in danger from a national refusal to accept major bioethical principles such as having respect for patient autonomy, serving the best interests of the patient, doing no harm, and ensuring fairness at the end of life. We argue that more education about human dignity and legislation for death with dignity are necessary. Peace of mind for patients during end-of-life care will never be achieved in this society unless drastic changes take place in medical ethics and law. (shrink)

Purpose This study aims to map Swedish students’ attitudes towards Snowden’s revelations and their effects in the political and socio-cultural environment of Sweden. Design/methodology/approach A questionnaire was answered by 190 Swedish university students. The quantitative responses to the survey and qualitative considerations of free text answers were statistically analysed. Findings Swedish students had a high level of knowledge about the Snowden revelations; they actively searched for information, gave a positive judgement of Snowden’s actions and were willing to follow his example (...) in Sweden, although not in the USA. They trusted their country and most of its institutions and authorities except for secret service agencies and the internet and computer software companies. Practical implications This study could be used as a design of education for university students, especially in information technology programmes. Social implications The study can be used for developing and applying policies on privacy, surveillance and whistle-blowing. Originality/value This study is part of a bigger international study to map students’ attitudes towards Snowden’s revelations and their opinions about privacy, surveillance and whistle-blowing opening up for cross-cultural analyses. (shrink)

In Japan, few studies and ethical debates have addressed medical futility, but articles suggesting the practice of such treatment exist. The present study aimed to explore attitudes about this by examining personal practical experiences of those who have been involved in judging treatments as futile. We employed a qualitative descriptive design with content analysis of semi-structured and focus group interviews with 11 Japanese physicians and 9 nurses of a university hospital in Japan. The interviews mined their practical experience to identify (...) why they provided treatment that was regarded futile, factors for determining futility, and attitudes toward foregoing futile treatments. All participants had provided treatments judged as futile for various reasons, such as patient request, inadequate decision-making processes, request from another physician, and the lack of standards with which to judge futility, among others. In addition to medical science factors , participants also considered non-medical science factors to determine if a treatment was futile. Almost all participants agreed that futility should be defined and that such treatments should be foregone, but they did not take a proactive stance towards this due to factors related to the healthcare worker‟s situation or the patient. Although the implications of the present study are somewhat limited, our results indicate that futile treatments are provided at multiple treatment departments. Health-care workers employ a variety of factors to determine futility, including non-medical science factors. As provision of such treatment is not always performed for reasons of patient autonomy, diverse approaches should be employed to cope with situations regarding futile treatments. (shrink)

In Japan, where a prominent gap exists in what is considered a patient’s best interest between the medical and patient sides, appropriate decision-making can be difficult to achieve. In Japanese clinical settings, decision-making is considered an act of choice-making from multiple potential options. With many ethical dilemmas still remaining, establishing an appropriate decision-making process is an urgent task in modern Japanese healthcare. This paper examines ethical issues related to shared decision-making (SDM) in clinical settings in modern Japan from the psychocultural-social (...) perspective and discusses the ideal decision-making process in present Japan. Specifically, we discuss how five psychocultural-social tendencies – “surmise (Sontaku),” “self-restraint (Jishuku),” “air (atmosphere or mood, Kuuki),” “peer pressure (or tuning pressure, Docho-Atsuryoku),” and “community (Seken)”—which have often been referred to as characteristics of present-day Japanese people, may affect the ideal practice of SDM in Japanese clinical settings. We conclude that health care professionals must be aware of the possible adverse effects of the above Japanese psychocultural-social tendencies on the implementation of SDM and attempt to promote autonomous decision-making, thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life, experiences, goals, preferences, and values. (shrink)

Background A baby hatch called the “Stork’s Cradle” has been in place at Jikei Hospital in Kumamoto City, Japan, since May 10, 2007. Babyklappes were first established in Germany in 2000, and there are currently more than 90 locations. Attitudes regarding baby hatches are divided in Japan and neither opinions for nor against baby hatches have thus far been overwhelming. To consider the appropriateness of baby hatches, we present and examine the validity of each major objection to establishing baby hatches. (...) Discussion There are various objections to baby hatches as follows: It violates a child’s right to know the identity of his or her biological parents by allowing anonymous birth; it neglects fulfillment of the biological parents’ basic obligation to raise their child and its very availability induces abandonment of infants; some people abuse it for very selfish reasons; it cannot save babies’ lives; the rights of one parent can be ignored if the other surrenders a child without his or her consent; it puts a baby in medical jeopardy; and it has no clear legal basis. The authors would argue that there are many plausible refutations for each objection mainly based on priority of child’s right to life, pregnant women’s vulnerability and necessity of anonymity, social responsibility to protect and raise children, differences between dropping a child off at a baby hatch and child neglect, limited function of social childcare center, inevitability of abuse by a minority of people, necessary distinction between outcomes that occur only because baby hatches exist and those that occur regardless of their existence, important local direct and upmost measures for women in trouble, and difference between ambiguous legality and illegality. Summary We argue that a certain number of baby hatches should continue to be established as a last resort, in a form that can maintain anonymity if the parent dropping the child off so desires. It should be supported if it is initiated with good intentions; if the maximum possible effort is made at said facility to protect the interests, rights, and safety of the child; and if no clear evidence of harm exists. (shrink)

Background Evidence concerning how Japanese physicians think and behave in specific clinical situations that involve withholding or withdrawal of medical interventions for end-of-life or frail elderly patients is yet insufficient. Methods To analyze decisions and actions concerning the withholding/withdrawal of life-support care by Japanese physicians, we conducted cross-sectional web-based internet survey presenting three scenarios involving an elderly comatose patient following a severe stroke. Volunteer physicians were recruited for the survey through mailing lists and medical journals. The respondents answered questions concerning (...) attitudes and behaviors regarding decision-making for the withholding/withdrawal of life-support care, namely, the initiation/withdrawal of tube feeding and respirator attachment. Results Of the 304 responses analyzed, a majority felt that tube feeding should be initiated in these scenarios. Only 18% felt that a respirator should be attached when the patient had severe pneumonia and respiratory failure. Over half the respondents felt that tube feeding should not be withdrawn when the coma extended beyond 6 months. Only 11% responded that they actually withdrew tube feeding. Half the respondents perceived tube feeding in such a patient as a "life-sustaining treatment," whereas the other half disagreed. Physicians seeking clinical ethics consultation supported the withdrawal of tube feeding (OR, 6.4; 95% CI, 2.5–16.3; P < 0.001). Conclusion Physicians tend to harbor greater negative attitudes toward the withdrawal of life-support care than its withholding. On the other hand, they favor withholding invasive life-sustaining treatments such as the attachment of a respirator over less invasive and long-term treatments such as tube feeding. Discrepancies were demonstrated between attitudes and actual behaviors. Physicians may need systematic support for appropriate decision-making for end-of-life care. (shrink)

In Japan, people are negative towards life-prolonging treatments. Laws that regulate withholding or discontinuing life-prolonging treatments and advance directives do not exist. Physicians, however, view discontinuing life-prolonging treatments negatively due to fears of police investigations. Although ministerial guidelines were announced regarding the decision process for end-of-life care in 2007, a consensus could not be reached on the definition of end-of-life and conditions for withholding treatment. We established a forum for extended discussions and consensus building on this topic.

This study aims to unveil the process of whistleblowing. Two nursing staff members who worked in a psychiatric hospital convicted of large-scale wrongdoing were interviewed. Data were analyzed using a modified grounded theory approach. Analysis of the interviews demonstrated that they did not decide to whistleblow when they were suspicious or had an awareness of wrongdoing. They continued to work, driven by appreciation, affection, and a sense of duty. Their decision to whistleblow was ultimately motivated by firm conviction. Shortly after (...) whistleblowing, wavering emotions were observed, consisting of a guilty conscience, fear of retribution, and pride, which subsequently transformed to stable emotions containing a sense of relief and regret for delayed action. It is necessary for nurses to recognize that their professional responsibility is primarily to patients, not to organizations. Nurses should also have professional judgment about appropriate allegiance and actions. (shrink)

Since Japan adopted the concept of informed consent from the West, its inappropriate acquisition from patients in the Japanese clinical setting has continued, due in part to cultural aspects. Here, we discuss the current status of and contemporary issues surrounding informed consent in Japan, and how these are influenced by Japanese culture.

Although euthanasia has been a pressing ethical and public issue, empirical data are lacking in Japan. We aimed to explore Japanese nurses’ attitudes to patients’ requests for euthanasia and to estimate the proportion of nurses who have taken active steps to hasten death. A postal survey was conducted between October and December 1999 among all nurse members of the Japanese Association of Palliative Medicine, using a self-administered questionnaire based on the one used in a previous survey with Australian nurses in (...) 1991. The response rate was 68%. A total of 53% of the respondents had been asked by patients to hasten their death, but none had taken active steps to bring about death. Only 23% regarded voluntary active euthanasia as something ethically right and 14% would practice it if it were legal. A comparison with empirical data from the previous Australian study suggests a significantly more conservative attitude among Japanese nurses. (shrink)

This article presents a critique of the health promotion policy of Japan, which is based on an examination of the social importance of and justification for health promotion. This is done to suggest the proper direction that the future Japanese policy could take, and to question the adequacy of the term of ‘health promotion’. We find the ‘social progress’ characterization of the ‘Second Term of National Health Promotion Movement in the Twenty-First Century - Health Japan 21 ’ to be problematic. (...) While there are clear restraints found in terms of social costs related to the policy, the aims toward social justice provided by the policy are not clear. Considering the social importance and justification of health promotion, and the present conditions seen in Japan, we believe that it is necessary clearly to position health promotion as a form of social justice. Having said this, the term ‘health promotion’ is in itself misleading and can belie the range of activities required to action these policies. Therefore, we propose considering the selection of a different and more appropriate term for health promotion that concretely defines policies that actively work toward definitive health equity. (shrink)

In many countries, prenatal testing for certain fetal abnormalities is offered via publicly funded screening programs. The concept of reproductive autonomy is regarded as providing a justificatory basis for many such programs. The purpose of this study is to re‐examine the normative basis of public prenatal screening for fetal abnormalities by changing our perspective from that of autonomy to obligation. After clarifying the understanding of autonomy adopted in the justification for public prenatal screening programs, we identify two problems concerning this (...) justification: first, the extent to which the government is obliged to meet this demand is not evident; and, second, it is not clear whether the provision of public screening is the most appropriate way to promote autonomy. Next, to tackle these problems, we focus on Onora O’Neill’s argument of rights and obligations. Drawing on this argument, we show that, in addressing the problems above, it is important to change our normative perspective from rights or autonomy to obligation. Our argument will show that since the government does not have an incontrovertibly fundamental obligation to promote autonomy, this obligation needs to be constrained in terms of compatibility with other fundamental obligations. In addition, even if a government is obliged to promote autonomy to some degree, there could be more appropriate means to achieve it than providing public prenatal screening; therefore, it is not necessary for government obligations to extend to the provision of public prenatal screening. (shrink)

Previous studies have suggested that auditory hallucination is closely related to thought insertion. In this study, we investigated the relationship between the external misattribution of thought and auditory hallucination-like experiences. We used the AHES-17, which measures auditory hallucination-like experiences in normal, healthy people, and the Deese–Roediger–McDermott paradigm, in which false alarms of critical lure are regarded as spontaneous external misattribution of thought. We found that critical lures elicited increased the number of false alarms as AHES-17 scores increased and that scores (...) of AHES-17 predicted the rate of false memory of critical lures. Furthermore, we revealed that the relationship between AHES-17 scores and the rates of false alarms to critical lures was strictly linear. Therefore, it might be said that individual differences in auditory hallucination-like experiences are highly related to the external misattribution of thought. We discussed these results from the perspective of the sense of agency over thought. (shrink)

When participants observed a rubber hand being touched, their sense of touch was activated . While this illusion might be caused by multi-modal integration, it may also be related to empathic function, which enables us to simulate the observed information. We examined individual differences in the RHI, including empathic and schizotypal personality traits, as previous research had suggested that schizophrenic patients would be more subject to the RHI. The results indicated that people who experience a stronger RHI might have stronger (...) empathic and schizotypal personalites simultaneously. We discussed these relationships in terms of self-other representations. (shrink)

No laws or official guidelines govern medical assistance for dying in Japan. However, over the past several years, cases of assisted suicide or voluntary euthanasia, rarely disclosed until recently, have occurred in close succession. Inspired by these events, ethical, legal, and social debates on a patient’s right to die have arisen in Japan, as it has in many other countries. Several surveys of Japanese people’s attitudes towards voluntary assisted dying suggest that a certain number of Japanese prefer active euthanasia. Against (...) this background, it is important to discuss voluntary assisted dying cases in Japan and the Japanese views on them and to consider their implications. We review three recent Japanese voluntary assisted dying cases and discuss the various objections to voluntary assisted dying that have been published in response to these in various media outlets. Our counterarguments include the double suffering of people who are unable to give up their desire to die, individuality of death, variability of culture, problem of being an annoyance to (burden on) others, a slippery slope argument supporting voluntary assisted dying, and unfair claims about responsibility and excessive burden on people who are unable to give up their desire to die. We also point out the psychocultural and social problems in Japanese society that these objections reflect, and argue that voluntary assisted dying can be ethically acceptable under certain conditions. We conclude that Japanese society must change in order to enable those who sincerely wish to die to do so in a better way. (shrink)

To consider whether or not we should aim to create a perfect healthy utopia on Earth, we focus on the SF novel Harmony, written by Japanese writer Project Ito, and analyze various issues in the world established in the novel from a bioethical standpoint. In the world depicted in Harmony, preserving health and life is a top priority. Super-medicine is realized through highly advanced medical technologies. Citizens in Harmony are required to strictly control themselves to achieve perfect health and must (...) always disclose their health information to the public and continuously prove their health. From a bioethical standpoint, the world in Harmony is governed by a “healthy longevity supremacy” principle, with being healthy equated to being good and right. Privacy no longer exists, as it is perceived ethical for citizens to openly communicate health-related information to establish one’s credibility. Moreover, there is no room for self-determination concerning healthcare because medical interventions and care are completely routinized, automated, centralized, and instantly provided. This is a situation where the community exhibits extremely powerful and effective paternalism. One can argue that healthy longevity is highly preferred. But is it right to aim for a perfectly healthy society at all costs? Should we sacrifice freedom, privacy, vivid feelings, and personal dignity to achieve such a world? In our view, the answer is no, as this would require the loss of many essential values. We conclude by proposing an alternative governing principle for future healthcare, and refer to it as the “do-everything-in-moderation” principle. (shrink)

Progress in artificial intelligence technological innovation raises questions about the role of medical staff and the meaning of medical specialization. This study involved a qualitative survey of medical professionals and ordinary citizens to expand knowledge of this topic. A combination of Neo-Socratic Dialogue and Transfer Dialogue techniques, was used to acquire knowledge related to emerging forms of medical care and changing work demands after the implementation of AI, qualitatively analyzing the TD transcript only. Eleven subjects participated in two surveys. The (...) main points raised during TD were classified into five categories: i) Functions which AI could perform/would find difficult to perform, ii) Changes in medicine caused by AI, iii) Necessary preparations for the application of AI to medicine, iv) Concerns about AI, and v) Others. The survey findings suggest that initiatives to promote the acceptance of each individual in society and appropriate technological development are essential to the process of preparing for the changes in medicine following the implementation of AI. These preparatory conditions cannot be limited to medical professionals, and must extend to workers across all disciplines and to society as a whole. (shrink)

Objective—To demonstrate Japanese doctors' and nurses' attitudes towards and practices of voluntary euthanasia (VE) and to compare their attitudes and practices in this regard. Design—Postal survey, conducted between October and December 1999, using a self-administered questionnaire.Participants—All doctor members and nurse members of the Japanese Association of Palliative Medicine.Main outcome measure—Doctors' and nurses' attitude towards and practices of VE.Results—We received 366 completed questionnaires from 642 doctors surveyed (response rate, 58%) and 145 from 217 nurses surveyed (68%). A total of 54% (95% (...) confidence interval (CI): 49-59) of the responding doctors and 53% (CI: 45-61) of the responding nurses had been asked by patients to hasten death, of whom 5% (CI: 2-8) of the former and none of the latter had taken active steps to bring about death. Although 88% (CI: 83-92) of the doctors and 85% (CI: 77-93) of the nurses answered that a patient's request to hasten death can sometimes be rational, only 33% (CI: 28-38) and 23% (CI: 16-30) respectively regarded VE as ethically right and 22% (CI: 18-36) and 15% (CI: 8-20) respectively would practise VE if it were legal. Logistic regression model analysis showed that the respondents' profession was not a statistically independent factor predicting his or her response to any question regarding attitudes towards VE. Conclusions—A minority of responding doctors and nurses thought VE was ethically or legally acceptable. There seems no significant difference in attitudes towards VE between the doctors and nurses. However, only doctors had practised VE. (shrink)

BackgroundIn the coming years, surrogate decision-making is expected to become highly prevalent in Japanese clinical practice. Further, there has been a recent increase in activities promoting advance care planning, which potentially affects the manner in which judgements are made by surrogate decision-makers. This study aims to clarify the grounds on which surrogate decision-makers in Japan base their judgements.MethodsIn this qualitative study, semi-structured interviews were conducted to examine the judgement grounds in surrogate decision-making for critical life-sustaining treatment choices in acute care (...) hospitals.ResultsA total of 228 participants satisfied the inclusion criteria, and 15 were selected for interviews. We qualitatively analysed the content of 14 interview transcripts, excluding one that did not meet the inclusion criteria. Based on this analysis, we extracted 4 core categories, 17 categories, 35 subcategories, and 55 codes regarding judgement grounds in surrogate decision-making. The four core categories were as follows: patient preference-oriented factor (Type 1), patient interest-oriented factor (Type 2), family preference-oriented factor (Type 3), and balanced patient/family preference-oriented factor (Type 4). The Type 4 core category represented attempts to balance the preferences of the patient with those of the surrogate decision-maker.ConclusionsSurrogate decision-makers based their decisions on important aspects related to a patient’s life, and they considered not only the patient’s preferences and best interests but also their own preferences. As the need for surrogate decisions will increase in the future, decision-makers will need to consider judgement grounds from a more diverse perspective. (shrink)

BackgroundHealthcare professionals use the ethics of justice and care to construct moral reasoning. These ethics are conflicting in nature; different value systems and orders of justice and care are applied to the cause of actual moral conflict. We aim to clarify the structure and factors of healthcare professionals’ moral conflicts through the lens of justice and care to obtain suggestions for conflict resolutions.MethodSemi-structured interviews about experiences of moral conflict were conducted with Japanese nurses recruited using the snowball sampling method. Interviews (...) were conducted based on the real-life moral conflict and choice interview. Interviews were recorded and transcribed verbatim, then analyzed based on the interpretive method of data analysis. Verbatim transcripts were read four times, first to get an overall sense of the conflict, then to understand the person’s thoughts and actions that explain the conflict, and third and fourth to identify perspectives of justice and care, respectively. Each moral perspective was classified into categories according to Chally’s taxonomy.ResultsAmong 31 responses, 2 that did not mention moral conflict were excluded, leaving 29 responses that were analyzed. These responses were classified into six cases with conflict between both justice and care perspectives or within one perspective, and into two cases without conflict between perspectives. The “rules” category of justice and the “welfare of others” category of care were included in many cases of conflict between two perspectives, and they frequently occurred in each perspective.ConclusionsThe nurses in this study suggest that they make moral judgments based on moral values that are intertwined with justice and care perspectives complex manner.Organizational, professional, and patient-related factors influenced conflicts between justice and care. Additionally, multiple overlapping loyalties created conflicts within justice perspectives, and multifaceted aspects of care-provider’s responsibility and patient need created conflicts within care. Decision-making biased towards one perspective can be distorted. It is important to consider ethical issues from both perspectives to resolve conflicts, especially the effective use of the ethics of care is recommended. (shrink)

ABSTRACT Objectives: the purpose of this study is to explore laypersons’ attitudes towards and experiences of medical research, and to compare them with those of physicians in Japan. Designs and Participants: fourteen Japanese adults from the general public and seven physicians participated in one of three focus interviews. Setting: Osaka, Japan. Results: trust and distrust in the physician by whom the participants were invited to participate in research played a considerable role in their decisions about participation. That the participants felt (...) an obligation to participate was also expressed. The lay participants perceived medical research as something entirely outside of their world. A greater willingness to volunteer for research was expressed if there were direct benefits to themselves or their families. Research methods such as use of placebos, double blinds, and randomisations seemed to cause negative attitudes to medical research. All physicians were convinced of the need for medical research, including double‐blinded randomised control trials, and its significant role in medical progress. Most physicians thought that the greater awareness of the need for medical research in the community and a better understanding of the psychology of potential research participants were necessary and urgent. Conclusions: there is a good possibility that the lay public and medical professionals have sharply different beliefs about and attitudes towards every aspect of medical research. Building up a better and equal patient‐doctor relationship based on trust is a key issue in medical research, and it is mandatory to fill the gap in perception regarding medical research between them through fully informed debates. (shrink)

As of 2009, the number of donors in Japan is the lowest among developed countries. On July 13, 2009, Japan's Organ Transplant Law was revised for the first time in 12 years. The revised and old laws differ greatly on four primary points: the definition of death, age requirements for donors, requirements for brain- death determination and organ extraction, and the appropriateness of priority transplants for relatives.In the four months of deliberations in the National Diet before the new law was (...) established, various arguments regarding brain death and organ transplantation were offered. An amazing variety of opinions continue to be offered, even after more than 40 years have elapsed since the first heart organ transplant in Japan. Some are of the opinion that with the passage of the revised law, Japan will finally become capable of performing transplants according to global standards. Contrarily, there are assertions that organ transplants from brain- dead donors are unacceptable because they result in organs being taken from living human beings.Considering the current conditions, we will organize and introduce the arguments for and against organ transplants from brain- dead donors in contemporary Japan. Subsequently, we will discuss the primary arguments against organ transplants from brain- dead donors from the perspective of contemporary Japanese views on life and death. After introducing the recent view that brain death should not be regarded as equivalent to the death of a human being, we would like to probe the deeply-rooted views on life and death upon which it is based. (shrink)

Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the (...) sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

Background Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and (...) the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Main text Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. Conclusion There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

The global increase in patients with chronic conditions has led to increased interest in ethical issues regarding such conditions. A basic biomedical principle—respect for autonomy—is being reexamined more critically in its clinical implications. New accounts of this basic principle are being proposed. While new accounts of respect for autonomy do underpin the design of many public programs and policies worldwide, addressing both chronic disease management and health promotion, the risk of applying such new accounts to clinical setting remain understudied. However, (...) the application of new accounts of respect for autonomy to clinical settings could support disrespectful attitudes toward or undue interference with patients with chronic conditions. Reconsidering autonomy and respect using Kantian accounts, this paper proposes respect for persons as an alternative basic bioethical principle to respect for autonomy. Unlike the principle of respect for persons in the Belmont Report, our principle involves respecting any patient’s decisions, behaviors, emotions, or life-style regardless of his or her “autonomous” capabilities. Thus, attitudes toward patients should be no different irrespective of the assessment of their decisional or executive capabilities. (shrink)

In medical ethics, an appropriate national healthcare system that meets the requirements of justice in healthcare resource allocation is a major concern. Japan is no exception to this trend, and the pros and cons of introducing a two-tier healthcare system, which permits insured medical care services to be provided along with services not covered by social health insurance, have been the subject of debate for many years. The Supreme Court ruled in 2011 that it was valid for the government to (...) ban mixing medical treatments and both the Ministry of Health, Labour and Welfare and Japanese Medical Association oppose the introduction of such a system. In this paper, we examine the main arguments against the introduction of a two-tier healthcare system and ideas that form their basis, which can be broadly divided into opinions based on the importance of equality and those derived from the logical conclusion that the outcomes would be detrimental. We point out issues and shortcomings of each standpoint and argue that the introduction of the system would not necessarily threaten equality and social solidarity in Japanese society, and that abuses of a self-pay tier would be controllable to a certain extent. Then, the authors—who do not actively promote the introduction of a two-tier healthcare system—conclude that the allegation that is completely devoted to one side and the theory that social healthcare is collapsing, which makes the public excessively nervous, cannot be accepted. (shrink)

In the present super-aging society, issues concerning what treatment should be given for incapacitated patients have become more important than ever before. This paper discusses whether or not an incapacitated patient’s refusal of treatment should be respected. The authors present a complete hypothetical scenario involving a 75-year-old moderately demented man suffering from malignant lymphoma. Of primary importance are the respect for patient dignity and the protection of human rights. Acts such as coercion, disregard, restriction, and surveillance can be unethical in (...) many situations. The effectiveness of chemotherapy for malignant lymphoma and its adverse outcomes could offset each other, leaving no net benefits for the patient. The patient is vulnerable and this very vulnerability requires the utmost protection and care. However, protection must be sensitive and comprehensive and the protection of his life at the expense of many other valuable factors is not justifiable. Coercing unwanted treatment would be intrusion, not protection, because of the physical and psychological suffering. When the refusal is explicit, consistent, and stable enough, it should to be viewed as true and current desire. Due to moderate dementia, the patient has lost his rational capacity, but his emotional capacity remains. If the remaining portion of his personality is rooted in his feelings, these feelings should be respected as much as possible. Those involved in the care of the patients who refuse treatment should not force them to undergo it simply on the grounds that it may be an established standard in their own country. What must be asked first is whether or not forced treatment would promote the patient’s subjective well-being. Additionally, treatment decisions should not be distorted due to the selfishness or discriminatory feelings of those involved in his care. In situations in which patients lack decisionmaking capacities, overriding the patients’ refusals of treatment should be regarded as an exception, rather than a standard course of action. Even in patients who are incapacitated, treatment refusal could stem from the feelings of the individual. Their subjective wellbeing would not be improved through close observation, restraint, denial, and coercion, the purpose of which they does not understand. (shrink)

Empirical surveys about medical futility are scarce relative to its theoretical assumptions. We aimed to evaluate the difference of attitudes between laypeople and physicians towards the issue. A questionnaire survey was designed. Japanese laypeople (via Internet) and physicians with various specialties (via paper-and-pencil questionnaire) were asked about whether they would provide potentially futile treatments for end-of-life patients in vignettes, important factors for judging a certain treatment futile, and threshold of quantitative futility which reflects the numerical probability that an act will (...) produce the desired physiological effect. Also, the physicians were asked about their practical frequency and important reasons for futile treatments. 1134 laypeople and 401 (80%) physicians responded. In all vignettes, the laypeople were more affirmative in providing treatments in question significantly. As the factors for judging futility, medical information and quality of life (QOL) of the patient were rather stressed by the physicians. Treatment wish of the family of the patient and psychological impact on patient side due to the treatment were rather stressed by laypeople. There were wide variations in the threshold of judging quantitative futility in both groups. 88.3% of the physicians had practical experience of providing futile treatment. Important reasons for it were communication problem with patient side and lack of systems regarding futility or foregoing such treatment. Laypeople are more supportive of providing potentially futile treatments than physicians. The difference is explained by the importance of medical information, the patient family’s influence to decision-making and QOL of the patient. The threshold of qualitative futility is suggested to be arbitrary. (shrink)

We investigated output-monitoring errors over speech based on findings in the research on the sense of agency. Several words were presented one-by-one, and we asked participants to say the word aloud, mouth the word, or imagine saying the word aloud. Later, participants were asked whether each word was said aloud. We found that the “said aloud” response was higher for generated words than that for observed words; it was decreased when the pitch of the feedback was lowered but still higher (...) than when no feedback was received, and it was the same when no feedback was received and when feedback was replaced by another’s voice. Furthermore, we found that the “said aloud” response did not decrease even when the altered feedback was received with a short delay. These results were discussed according to the sense of agency and agency memory. (shrink)

ABSTRACT In this brief article, we examine the document entitled Universal Draft Declaration on Bioethics and Human Rights, published by UNESCO in June 2005. We examine it in terms of its content and its appropriate role in global bioethics movements in the future. We make clear our view on the Declaration: the Declaration, despite a variety of serious problems, remains a valuable bioethical document and can contribute in substantial ways to the happiness of people throughout the world.

A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth-telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision-making and (...) mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient-provider relationships, the public's trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception. (shrink)

Self-determination is a central concept in the field of bioethics and the most critical decision among the myriad of decisions concerning medical care is the decision to choose to die; “self-determination of death.” The purpose of this paper is to clarify the basic positions on self-determination of death held by present Japanese people and we tentatively sorted these positions into 10 arguments. We discuss the problems and implications of these positions revealed within our present review and conclude that a society (...) needs to deny unnecessary intrusion and tolerance for different views might be a keyword in our oncoming society. (shrink)

Should a patient in a persistent vegetative state live? Is the life of a patient in a mere biological state worthwhile maintaining? I would argue that the life of a PVS patient is instrumentally valuable in so far as it can satisfy the family’s preference to keep it alive. A PVS patient should live if the patient’s family desires it Conversely, the PVS patient should be allowed to die or be actively killed if no one desires him or her to (...) live. Mere biological life has no value at all when no one finds it valuable and it is morally permissible to destroy something valueless to everyone.Under what circumstances should the desires of a PVS patient’s family be disregarded? Their desire to keep the patient alive should not be unlimited if that would evidently harm other patients. The objection based on just resource allocation could set the limits of a family’s desire to keep the patient in a certain condition. I would argue that when only one bed is available in intensive care unit, the life and interests of conscious patient should override these of PVS patients and preferences of the family to keep the PVS patient alive. This is because harm that the conscious patient suffers is much more serious than that suffered by the family.Whether to use organs of PVS patients is also discussed. Is the family’s donating the patients’ organs a minimum duty of no harm or an act of beneficence? It is uncertain. It might be a supererogatory action for the family to do so in a certain situation. (shrink)

This article will focus on issues concerning the provision of artificial nutrition and hydration to patients who are extremely old, completely bedridden, and totally dependent on others. These patients have no advance directives, no malignancy, suffer from persistent but unstable disturbance of consciousness as well as severe cognitive impairment, and cannot eat sufficient amounts of food to maintain their lives. Should ANH be provided? Some would agree while others would maintain otherwise. The underlying values and normative theory behind each argument (...) are quite different. In this paper, I will present opinions, comments, and arguments concerning the provision of PANH to such patients and examine each using the Takahashi‘s three levels structure analysis. Utilitarianism is a fitting ethical theory for the third level in arguments against the provision of PANH to patients in question, and the non-religious sanctity of life doctrine covers the opposite position. (shrink)

ABSTRACT In this brief article, we examine the document entitled Universal Draft Declaration on Bioethics and Human Rights, published by UNESCO in June 2005. We examine it in terms of its content and its appropriate role in global bioethics movements in the future. We make clear our view on the Declaration: the Declaration, despite a variety of serious problems, remains a valuable bioethical document and can contribute in substantial ways to the happiness of people throughout the world.

ABSTRACT In this brief article, we examine the document entitled Universal Draft Declaration on Bioethics and Human Rights, published by UNESCO in June 2005. We examine it in terms of its content and its appropriate role in global bioethics movements in the future. We make clear our view on the Declaration: the Declaration, despite a variety of serious problems, remains a valuable bioethical document and can contribute in substantial ways to the happiness of people throughout the world.

Background: The introduction of healthcare AI to society as well as the clinical setting will improve individual health statuses and increase the possible medical choices. AI can be, however, regarded as a double-edged sword that might cause medically and socially undesirable situations. In this paper, we attempt to predict several negative situations that may be faced by healthcare professionals, patients and citizens in the healthcare setting, and our society as a whole. Discussion: We would argue that physicians abuse healthcare AI (...) through their excessive and dependent use of it, and they will focus only on the AI services in their office and patient medical data and information, and forget to observe the patient in their clinical encounters. In the era of AI introduction, data from the wearable terminal or AI advice will become the primary target of the physician’s interest, and could be regarded as a patient surrogate. Paternalism would be paradoxically resurrected by the introduction of state-of-the-art AI. A physician’s conflict of interest related to AI as a commercial product could strongly influence his or her actions in clinical settings. We also worry that the general public will become uneasy and hypersensitive slaves to information, compulsively and uninterruptedly requesting healthcare information concerning their own health and advice from AI. An AI system capable of expressing proper and timely empathy to suffering patients could deprive healthcare professionals of their roles in terms of hospitality and emotional exchange. Finally, entire societies would soon share and consolidate healthcare sensitive information from all in the general public as part of a totalitarian healthcontrolled society where individual privacy and personal secrets could be neglected. The advent of the healthcontrolled society could lead to the metamorphosis of the concept of privacy itself into something completely different. Conclusion: Although AI which surpasses human healthcare professionals may never appear, hoping for the best and preparing for the worst is the best approach to take. To this end, we present some potential countermeasures including conducting clinical research and social investigations concerning problems surrounding the introduction of AI and developing guidelines for its appropriate use. (shrink)

How should the Japanese death penalty system stand in the future? While banning the death penalty has become a global trend, Japanese public opinion still supports it, and the government continues to strongly insist retention of the system. Despite worldwide criticism towards Japanese opinion, until very recently have been no reductions in death penalty sentences or executions. Both abolitionist and retentionist countries have strong arguments to support their opinions, thus there is no decisive argument that overwhelmingly refutes others. Consideration for (...) the feelings of the murder victim’s family is significant, and there are certain actions perpetrated by the criminal which seem unforgivable and for which nothing can compensate. At the same time, homicide is a violence that should never be acceptable and therefore cannot be justified, and human error will always allow for the possibility of wrongful convictions. The authors argue that the death penalty should be abolished in principle, but we cannot deny the existence of a criminal for whom the death penalty would be appropriate. Ethically, it would be questionable to accept life imprisonment without parole as an alternative. We are of the position that there is no definite conclusion concerning the ethicality of the death penalty. (shrink)

Prevention and control of chronic conditions are global healthcare challenges. Patient self-management has been deemed essential for treating chronic conditions and improving the quality of patient life. However, the current Japanese system for supporting patient self-management of chronic conditions has received little ethical assessment. The first aim of this article is to provide an ethical analysis of current Japanese support for self-management of chronic conditions with reference to international discussions concerning self-management, developed mainly in western societies such as Europe, the (...) United States. The second aim is to clarify the challenges faced by Japanese biomedical ethics concerning selfmanagement support by focusing on the ethical concepts of quality of life and autonomy. This article identifies the following two challenges: [1] dispelling conceptual confusion concerning basic ethical concepts such as quality of life and autonomy, and [2] exploring the conceptual relationship between these ethical concepts, as they relate to providing support for chronically ill patients. By addressing these challenges and constructing a theoretical basis for radical change in support mechanisms, bioethics in Japan could contribute to efforts to construct a comprehensive support system for patients with chronic conditions, which organize variety kinds of supports, such as medical professional supports, supports from patient’s groups, local community supports, familial supports, support in patients’ workplace, and supports for patients’ family members as well. (shrink)

For most death discharge patients, hospitals in Japan offer seeing-off services, a practice characteristic of Japanese culture. When a patient dies, nurses usually perform after-death procedures before transferring the body to the mortuary, where the nurses and doctors gather to provide the seeing-off service. This study was carried out to determine differences between the nurses’ and bereaved families’ opinions and thoughts regarding the seeing-off service. Semi-structured interviews were conducted with 17 nurses and 6 bereaved families . The interviews assessed: the (...) reasons why nurses provided seeing-off services; thoughts during the seeing-off service; impressions of the mortuary rituals; and the necessity for the seeing-off service. The results indicated that nurses expressed their courtesy and sense of appreciation during the seeing-off service, which was recognised as an important nursing role. In contrast, bereaved families felt thankful but also doubtful, particularly as regards the mortuary rituals. In light of the differences in perspective between nurses and families, it may be that the level of satisfaction with the seeing-off service is largely affected by the relationship between the family and the medical professionals before the patient's death. Our study also notes that Japanese people respect the dead body and treat it with care, reflecting the unique culture and customs of Japan. (shrink)

In Japan, although various arguments exist regarding the appropriateness of the death penalty, nationwide public opinion polls regarding the death penalty revealed that 85.6% of respondents supported maintaining the death penalty in 2009. Under these circumstances, it is worthwhile to deliberate the ethical and social issues surrounding the death penalty as depicted in Japanese films from medical humanities perspectives. In the present paper, we discuss two recent films concerning the death penalty, 13 kaidan directed by Masahiro Nagasawa, 2005 and Kyuka (...) directed by Hajime Kadoi, 2007. The two films describe the impact of execution on the executioners, secrecy of executions, rehearsal of the execution, and voluntary participation in execution. They depict the current situation surrounding the death penalty and execution, as well as everyday life on death row, in detail. Serious concerns about current execution procedures were also described. The two films seem to try to tell the audience that there is something strange in killing people in perfect order with good will in the name of law and justice. They show the officer‘s instinctive aversion provoked by the execution and make us think about what it means to kill a human. (shrink)

In the present paper, we evaluate the grounds on which therapeutic approaches are determined in elderly demented patients as a typical group of patients who are conscious but lack the ability to make competent judgments. It is argued that none of the factors that the patient as an individual being has at present and that are complete in that individual - the age of the patient, dementia, personhood, and the ability to feel pain - is likely to be a genuine (...) reason for care-providers including health care workers and patient’s family to discontinue the treatment for severely demented patients. It is also claimed that reasons for discontinuation of the treatment for severely demented patients arise from the relationship between the patient and the care-providers, especially the patient’s family. The human relationships between the patient and the family may be maintained as long as the latter find some significance in the presence of the severely demented patient and recognize him/her as “one of them”. When the patient ceases to be “one of them” for the family and is excluded from “their company”, the reason for supporting the demented member of the family is lost. The benefit to the patient and the value of his/her presence lose the individuality or specificity and are subjected to interpretation by the family. Therefore, the reason for discontinuation of the treatment for a severely demented patient is termination of the relationship between the patient and his/her family. The significance of our conclusion is briefly discussed. (shrink)