Amyotrophic Lateral Sclerosis (ALS) is a motor neuron disease which evokes complicated questions in the Japanese health care system. In order to address these questions, we must analyze a wide range of ethical, legal, and social issues, paying special affention to the ethics of withholding and withdrawing mechanical ventilation. In the first section of this paper I provide a brief review of the facts concerning Japanese patients with ALS: (1) the effect of the patient's own wishes on choices concerning mechanical ventilation; (2) the barriers to home care, especially the burden placed on the families taking care of patients on ventilation, e.g. removing sputum from patients' tracheas; (3) the barrier for institutional care, e.g. the limitation of health care resources; and (4) the limited range of choices at the end stage of a patient's life. The second section is an ethical analysis of the preceding issues: (1) the relation between autonomy and dignity, which have been dissociated in recent ethico-legal arguments regarding end of life issues; (2) Consideration of the justice of allocating resources which may empower patient's autonomy and dignity. In conclusion, Sen's ideas on capability will be used as the foundation of arguments for increasing the allocation of resources to care for patients with ALS, and to expand the range of choices patients can make as to living with or without mechanical ventilation.
