Wright’s “adaptive landscape” has been influential in evolutionary thinking but controversial, especially because the landscape that organisms encounter is altered by the evolutionary process itsel...

In Japan, terminating life-sustaining treatment in non-terminal patients is legally and ethically problematic given the lack of legal regulations regarding the termination of LST, including dialysis treatment. This article describes an ethically problematic case that happened at a hospital in Tokyo in March 2019, in which a patient died after a physician withdrew kidney dialysis upon the patient’s request. Most national newspapers in Japan reported the case extensively and raised the question of ethical and legal permissibility of withdrawing dialysis treatment (...) from non-terminal patients. In this article, we first examine the case within the current policy framework in Japan and then discuss how Japan can improve its end-of-life practice, focusing specifically on the patient’s right to self-determination and treatment refusal. We recommend that policymakers consider legalizing the termination of LST and the patient’s right to refuse treatment based on the principle of respect for autonomy. (shrink)

BackgroundRegulations on forgoing life-sustaining treatment (LST) have developed in Asian countries including Japan, Korea and Taiwan. However, other countries are relatively unaware of these due to the language barrier. This article aims to describe and compare the relevant regulatory frameworks, using the (more familiar) situation in England as a point of reference. We undertook literature reviews to ascertain the legal and regulatory positions on forgoing LST in Japan, Korea, Taiwan, and England.Main textFindings from a literature review are first presented to (...) describe the development of the regulatory frameworks surrounding the option of forgoing LST in each country. Based on the findings from the four countries, we suggest five ethically important points, reflection on which should help to inform the further development of regulatory frameworks concerning end-of-life care in these countries and beyond. There should be reflection on: (1) the definition of – and reasons for defining – the ‘terminal stage’ and associated criteria for making such judgements; Korea and Taiwan limit forgoing LST to patients in this stage, but there are risks associated with defining this too narrowly or broadly; (2) foregoing LST for patients who arenotin this stage, as is allowed in Japan and England, because here too there are areas of controversy, including (in England) whether the law in this area does enough to respect the autonomy of (now) incapacitated patients; (3) whether ‘foregoing’ LST should encompass withholdingandwithdrawing treatment; this is also an ethically disputed area, particularly in the Asian countries we examine; (4) the family’s role in end-of-life decision-making, particularly as, compared with England, the three Asian countries traditionally place a greater emphasis on families and communities than on individuals; and (5) decision-making with and for those incapacitated patients who lack families, surrogate decision-makers or ADs.ConclusionComparison of, and reflection on, the different legal positions that obtain in Japan, Korea, Taiwan, and England should prove informative and we particularly invite reflection on five areas, in the hope the ensuing discussions will help to establish better end-of-life regulatory frameworks in these countries and elsewhere. (shrink)

BackgroundAlthough, moral distress presents a serious problem among critical care nurses in many countries, limited research has been conducted on it. A validated scale has been developed to evaluate moral distress and has enabled cross-cultural comparison for seeking its root causes.Research aimsThis study aimed to (1) clarify the current status of moral distress among nurses who worked in critical care areas in Japan, (2) compare the moral distress levels among nurses in Japan with previously reported results from the United States (...) (US), and (3) explore the factors associated with moral distress.Research designA nationwide cross-sectional study was conducted.Participants and research contextWe conducted a self-administered questionnaire survey using the Measure of Moral Distress–Healthcare Professionals (MMD-HP) among critical care nurses who were randomly selected from hospitals across Japan. The mean differences between the two countries were compared using a Student's t-test with summary statistics. The factors associated with higher levels of moral distress were examined using a multiple regression analysis.Ethical considerationsThe study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214 and M2019-045).ResultsWe obtained 955 valid responses from 94 facilities. In Japan, the items with the highest moral distress scores were those related to aggressive/inappropriate treatment. The total MMD-HP score was significantly higher in Japanese nurses compared to US nurses (122.8 ± 70.8 vs 112.3 ± 73.2). Some factors, such as leadership experience, were associated with higher moral distress.DiscussionThe top root causes of moral distress were similar to potentially inappropriate treatments in both countries.ConclusionThis study revealed the factors associated with higher moral distress and its characteristics in each country. These results can be used for reducing moral distress in the future. (shrink)

Jecker and Au’s paper raises important issues concerning health equity in pandemic responses, and the importance of considering the long-term effects of pandemic strategy on population health and well-being.1 We welcome their focus on the experience of Asian countries, including Japan. However, we have some concerns with both the distinction which they draw between elimination and mitigation, and their account of the nature and origins of the Japanese response to the COVID-19 pandemic. First, we believe that the distinction between elimination (...) and mitigation is not fine grained enough to capture the various strategies which countries have taken towards the pandemic. Many of Jecker and Au’s criticisms of the elimination strategy relate to specific policies such as lockdowns, travel restrictions and restrictions on businesses, which have been employed by numerous countries irrespective of their end goal. By contrast to the simple elimination/mitigation dichotomy with which Jecker and Au work, Baker et al have identified five separate COVID-19 strategies, namely: exclusion, elimination, suppression, mitigation and no substantive strategy.2 Baker et al define an elimination strategy as ‘maximum action to exclude disease and eliminate community transmission’ with the goal of reaching ‘zero [disease] transmission in the community’. On this account, Japan’s strategy does …. (shrink)

Background:Moral distress has various adverse effects on nurses working in critical care. Differences in personal values, and between values and self-perception of behaviour are factors that may cause moral distress.Research aims:The aims of this study were (1) to identify ethical values and self-perception of behaviour of critical care nurses in Japan and (2) to determine the items with a large difference between value and behaviour and the items with a large difference in value from others.Research design:A nationwide, cross-sectional study was (...) conducted.Participants and research context:We developed a self-administered questionnaire with 28 items, which was completed by 1014 critical care nurses in Japan. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The size of the difference in value from the others was judged by the standard deviation of each item.Ethical considerations:The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214, M2019-045).Results:The items with a large difference between value and behaviour sources were related to the working environment and decision-making support. The items with a large difference in value from others were related to hospital management and disclosure of information to patients.Discussion:Improving the working environment for nurses is important for reducing moral distress. Nurses are faced with a variety of choices, including advocating for patients and protecting the fair distribution of medical resources, and each nurse’s priorities might diverge from those of other team members, which can lead to conflict within the team.Conclusion:This study revealed items with particularly high risks of moral distress for nurses. The results provide foundational information that can guide the development of strategies to mitigate moral distress. (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)

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)

The evolution of altruism and reciprocity has been explained mainly from ultimate perspectives. However, in order to understand from a proximate perspective how humans evolved to be such cooperative animals, comparative studies with our evolutionary relatives are essential. Here we review several recent experimental studies on chimpanzees’ altruism and reciprocity. These studies have generated some conflicting results. By examining the differences in the results and experimental paradigms, two characteristics of prosociality in chimpanzees emerged: chimpanzees are more likely to behave altruistically (...) and/or reciprocally upon a recipient’s request, than without request, and chimpanzees also show a tendency to regard others and help in contexts not involving food. Supposing that these two characteristics of altruism, recipient-initiated altruism and non-food altruism, were present in the common ancestor of chimpanzees and humans, it is possible that increased social cognitive abilities, capacity for language, necessity for food sharing, and enriched material culture favored in humans the unique evolution of cooperation, characterized by voluntary altruism and frequent food donation. (shrink)

BackgroundNo laws or official guidelines govern voluntary assisted dying (VAD) in Japan. A legislative bill on the termination of life-sustaining measures has yet to be sent to deliberations for legislation, due to strong opposition that has prevented it from being submitted to the Diet. However, Japan has recently witnessed several cases involving VAD.Main textAgainst this backdrop, we argue that Japan should begin discussion on VAD legislation, referring to the Voluntary Assisted Dying Act 2017 (VADA2017), which was established in 2017 in (...) Victoria, Australia. VADA2017 puts in place a wide range of stringent safeguards and is considered worldwide to be the safest and most conservative policy on a physician offering assisted dying based on the patient’s premeditated request. We consider what opposing opinions from society would arise in response to the VADA2017. Among these will include arguments against VAD itself, those against the validation of this act, and opinions that oppose even the initiation of the dialogue on VAD.ConclusionsWe conclude that to protect the right to life among those placed in vulnerable positions and, at the same time, to respect decision-making of those who wish for immediate death due to unbearable suffering, the dialogue must immediately begin with that on introducing a policy more conservative than that of the VADA2017, which solidly considers arguments against VAD. (shrink)

In everyday medical settings in Japan, physicians occasionally tell an elderly patient that their symptoms are “due to old age,” and there is some concern that patient care might be negatively impacted as a result. That said, as this phrase can have multiple connotations and meanings, there are certain instances in which the use of this phrase may not necessarily be indicative of ageism, or prejudice against the elderly. One of the goals in medical care is to address pain and (...) suffering that develops with age in elderly individuals, and whether or not aging is a disease is inconsequential. However, assuming that an individualized and thorough examination has been performed, there are some conditions that can be attributed only to age. Accordingly, physicians must acknowledge the merits and drawbacks of using the phrase “due to old age,” and exercise caution when using it. Both physicians and their elderly patients must share a common awareness of the incomplete and limited nature of modern medicine and its scope, and physicians must help their elderly patients accept and live with the aging phenomenon. (shrink)

BackgroundInstances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan.MethodsA cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors (...) and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process.ResultsOf the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates’ considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings.ConclusionsSurrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning. (shrink)

Graphical AbstractEnvironmental oxygen might have been the key for the evolution of novel developmental mechanisms, such as the interdigital cell death of amniotes. Increased amount of oxygen can also induce cell death in interdigital regions of an amphibian that typically lacks it. To learn more about the role of environmental oxygen in the evolution of new traits, see the article number 2000025 by Ingrid Rosenburg Cordeiro and Mikiko Tanaka. Cover image by Itoko Tanaka and Mikiko Tanaka.

Oxygen is a key regulator of both development and homeostasis and a promising candidate to bridge the influence of the environment and the evolution of new traits. To clarify the various ways in which oxygen may modulate embryogenesis, its effects are reviewed at distinct organizational levels. First, the role of pathways that sense dioxygen levels and reactive oxygen species are reviewed. Then, the effects of microenvironmental oxygen on metabolism, stemness, and differentiation throughout embryogenesis are discussed. Last, the interplay between ecology (...) and development are reexamined with a focus on the evolution of tetrapods, including during the emergence of a novel mechanism that shapes amniote limbs—interdigital cell death. Both genetic and environmental components work together during the formation of organisms, highlighting the importance of a multidisciplinary approach for understanding the evolution of new traits. (shrink)

The present study assesses imitative ability in chimpanzees and human children. A direct comparison of these two species was conducted in an object-manipulation task. The subjects were required to copy the model stack by stacking colored blocks in the same order as the model. Four juvenile/adolescent chimpanzees failed to copy the model stack even after a long training-period. Two adult chimpanzees eventually learned to copy the model stack of two blocks. However, they failed to copy the model of three blocks, (...) and analysis of their stacking patterns revealed that they only focused on the color of the top block in the model. Human children started to copy the model of two blocks when they were two years of age and gradually increased the number of successfully copied blocks. The results from both chimpanzees and humans are discussed in terms of the social intelligence involved in object manipulation. (shrink)

The present study assesses imitative ability in chimpanzees and human children. A direct comparison of these two species was conducted in an object-manipulation task. The subjects were required to copy the model stack by stacking colored blocks in the same order as the model. Four juvenile/adolescent chimpanzees failed to copy the model stack even after a long training-period. Two adult chimpanzees eventually learned to copy the model stack of two blocks. However, they failed to copy the model of three blocks, (...) and analysis of their stacking patterns revealed that they only focused on the color of the top block in the model. Human children started to copy the model of two blocks when they were two years of age and gradually increased the number of successfully copied blocks. The results from both chimpanzees and humans are discussed in terms of the social intelligence involved in object manipulation. (shrink)

Although Japanese society has become aware of some types of robots, social acceptance of robots is still not widespread. This study conducted an online questionnaire survey to investigate the relationships between experiences with and knowledge of vacuum, pet-type, and communication robots and acceptance of these robots, including the intention to use and trust. The results suggested that experiences with, knowledge of functions, and acceptance of the robots differed depending on the type of robot, and the influence of these factors on (...) acceptance of the robots also differed depending on the robot types. (shrink)

Graphical AbstractYeast prion might be a disease state in most situations, but it might help cells survive under some stress environments.

Synchronized movements with external periodic rhythms, such as dancing to a beat, are commonly observed in daily life. Although it has been well established that some vocal learning species (including parrots and humans) spontaneously develop this ability, it has only recently been shown that monkeys are also capable of predictive and tempo-flexible synchronization to periodic stimuli. In our previous study, monkeys were trained to make predictive saccades for alternately presented visual stimuli at fixed stimulus onset asynchronies (SOAs) to obtain a (...) liquid reward. The monkeys generalized predictive synchronization to novel SOAs in the middle of trained range, suggesting a capacity for tempo-flexible synchronization. However, it is possible that when encountering a novel tempo, the monkeys might sample learned saccade sequences from those for the short and long SOAs so that the mean saccade interval matched the untrained SOA. To eliminate this possibility, in the current study we tested monkeys on novel SOAs outside the trained range. Animals were trained to generate synchronized eye movements for 600 and 900-ms SOAs for a few weeks, and then were tested for longer SOAs. The accuracy and precision of predictive saccades for one untrained SOA (1200 ms) were comparable to those for the trained conditions. On the other hand, the variance of predictive saccade latency and the proportion of reactive saccades increased significantly in the longer SOA conditions (1800 and 2400 ms), indicating that temporal prediction of periodic stimuli was difficult in this range, similar to previous results on synchronized tapping in humans. Our results suggest that monkeys might share similar synchronization mechanisms with humans, which can be subject to physiological examination in future studies. (shrink)

Background Physical restraints are routinely employed to ensure patient safety in Japanese acute care. Little is known about nursing students' perspectives and how they begin to question their value and knowledge in the face of restraint experiences in clinical practice. Objective To investigate nursing students’ questions about patient restraints and how they understand the ethics of the use of restraints in nursing. Research design Qualitative descriptive research using narrative analysis. Participants and research context Experiential data were generated and thematically analyzed (...) from semi-structured interviews with 16 nursing students who had completed their bachelor’s degree program requirements. Ethical considerations The study was approved by academic and clinical ethics agencies. Participants provided written informed consent. Results Physical restraints were encountered in 16 incidents, 3 with children and 13 with older patients with dementia. Students struggled to comprehend the policies and protocols of restraint use and worried their use was primarily for security rather than therapeutic purposes. Five themes were identified: (1). Questioning the tension between person-centered care, patient autonomy, and restraints, (2). Questioning the nature of restraints in which participants analyzed the policies and protocols around restraint use, (3). Questioning the professional nursing self whereby students reflected on how restraint use challenged their nursing values, and (4). Questioning professional nursing practice, in which students explored how restraints fit within a nursing perspective and positioned themselves as patient advocates. Students encountering physical restraints should ask questions based on values of patient-centeredness, autonomy, and advocacy. There is a need for education that facilitates reflection and questioning so that it informs students’ ethical thinking which may enhance nurse advocacy to reduce restraint use. Conclusions Restraints provide contexts in which students must face tensions between nursing values and clinical reality. Further research on nursing education strategies within non-psychiatric settings is needed to reduce physical restraints. (shrink)

Egg or sperm? The mechanism of sexual fate decision in germ cells has been a long‐standing issue in biology. A recent analysis identified foxl3 as a gene that determines the sexual fate decision of germ cells in the teleost fish, medaka. foxl3/Foxl3 acts in female germline stem cells to repress commitment into male fate (spermatogenesis), indicating that the presence of mitotic germ cells in the female is critical for continuous sexual fate decision of germ cells in medaka gonads. Interestingly, foxl3 (...) is found in most vertebrate genomes except for mammals. This provides the interesting possibility that the sexual fate of germ cells in mammals is determined in a different way compared to foxl3‐possessing vertebrates. Considering the fact that germline stem cells are the cells where foxl3 begins to express and sexual fate decision initiates and mammalian ovary does not have typical germline stem cells, the mechanism in mammals may have been co‐evolved with germline stem cell loss in mammalian ovary. (shrink)