In the discussion on informed consent, we find some doctors may think they should not give patients some information, even if the patients think it indispensable. And vice versa. This results from moral gaps. Therefore, informed consent needs to bridge moral gaps. L. Kohlberg points out gaps among developmental stages as well as among ideas about values. He suggests bridging the former by making the latter comprehensible to all concerned. However, doesn't the person on the higher moral stage think the lower inmoral? No, according to Kohlberg, because the higher moral stage includes the lower stages as reintegrated components. But K. Wilber criticizes Kohlberg saying that the higher moral stage doesn't include the lower, unlike the higher cognitive stage. Which is right? In order to answer this question, I investigated the relation among stages and sent out questionnaires. Theoretically speaking, the higher moral stage doesn't include the lower stages, because unlike cognitive stages, moral stages don't have only cognitive structures, but also content formed by the structures, namely, the meaning of roles as human relations. The higher moral stage includes the lower cognitive structures, but no lower social meanings. Thus the morally higher person won't discuss things on the lower stage. Therefore, to bridge these moral gaps is possible only by raising the lower people up to the higher stages. And the higher stage 5 is easy to reach for adults, because they have already reached the cognitive stage necessary to reach moral stage 5. Furthermore this stage itself enables moral development by promoting role-playing, another antecedent of moral development. And my questionnaires also show that stage 5 can bridge moral gaps. Thus the discussion for informed consent must be based on moral stage 5. Concretely speaking, hospitals should offer not only doctors but also patients as many chances to participate in their everyday decisions as possible.
The role of personalized treatment has always posed problems in considerations of Japanese medical history. Japanese medical treatments in medieval times were inextricably related to Buddhistic and ethnologic factors, just as European medical treatments were to Christian factors. To be more exact, Japanese medicine was almost totally influenced by Buddhism. The problems, however, exist in determining why medical treatments became Buddhistic or ethnologic, and how they became personalized. Wherever ideological paradigms were corrupted, naturalistic medical treatment would supplant the then existing personalized treatments. In this thesis, such replacement processes are traced back and considered in terms of the exorcisms and maledictions performed in esoteric Buddhism, relief measures taken for leprous patients, clinical examinations of the death of human beings, and in sensitivity to death in literary and religious terms.
The aim of this paper is to look for the ways the medicine of today might take root in the fundamentals of life, that is, in terms of environmental ethics. Highly technological medicine should be grounded in such fundamentals if it wants to be medicine for human beings. But in order to reach this goal we must consider the ambiguity that is intrinsic in bioethics. On the one hand, the historical current of ethics, according to R. F. Nash, is irreversibly expanding, taking the relevance of ethics out of itself and beyond its egocentric viewpoint. Bioethics should be also placed in this stream, so as to admit the rights of nonhuman beings. On the other hand, applications of high medical technologies cause us to restrict the boundaries of our humanity, and this brings about various difficult problems for bioethics. We should attempt to get over these difficulties by proposing a new medical system based on a self-organizing system. It must be open to all other social systems and would make possible the fundamental communication between the self and the other. To realize this system, I think, it is necessary to establish a new ontology that requires us to transcend anthropocentric ethics and to discover the continuity between nature and humanity.
At first in this article I consider the ethical aspects of the mutilation of a living donor's healthy body for renal and liver transplantation. Transplantation can be permitted ethically with two catholic ethical principles, that is, the principle of totality and the principle of double effect. However, to perform transplans a balance between donors' risks and recipients' merits is necessary. For this reason, the following requirements should be satisfied. 1) These transplantations should be permitted only in cases where you have no alternative method for therapy. 2) These transplantations should be permitted only in cases where you have a therapeutic possibility of success. For this reason, ・ It is necessaly to limit them to appropriate medical centers. ・ It is necessary to select donors and recipients strictly. 3) It is necessary to reduce the risks of death for donors to a minimum. 4) It is necessary to make sure no pressore is applied on the prospective donor's during the decision-making process. 5) It is necessary to get clear informed consent from both donors and recipients. Especially in cases of liver transplantation, you should open the process of informed consent in principle. 6) It is necessary to prohibit the buying and selling of organs. 7) It is necessary to resolve cost problems, especially for liver transplantation. 8) It is necessary to require strict morals among medical staffs.
The study of genes, with the development of molecular biology, raises ethical issues in the basic and applied life sciences, including biotechnology and biomedical sciences. The ethical issues are connected with recombinant DNA experiments, the Human Genome Project, experiments on organisms with recombinant DNA in the field, gene diagnosis, gene therapy, etc. In this papar, I am particularly concerned with the structure of ethical problems in gene therapy and I consider it in terms of the biological meanings of genes. Ethical problems in the study of genes at the molecular level have occurred today because we can manipulate genes directly. However, when we know the biological meanings of genes, it is not easy for us to manipulate genes from the ethical point of view. The gene has three meanings: (1) It is the product of evolution, (2) It is what creates the identity of each human being, (3) It is the source of the continuity of the human species. Therefore, gene manipulation is connected with individual problems, the relations among generations, the problems between human beings and the ecosystem, and the whole world of organisms. When we consider the ethical problems in human gene therapy in terms of the three meanings of genes, we can see new problems concernings gene therapy as follows: Can we avoid the problems which appear among generations even if we can practice gene therapy not with somatic cells but with germline cells, given meanings (1) and (3) ? Moreover, will gene therapy exacerbate problems connected with the evaluation of genetic information for each person in terms of eugenics, given meaning (2) ?
This paper is developed from the symposium, "The New Image of Pharmacists in Medical Practice" held at the last study meeting of this association. Experience is a human behavior in the interaction between man and world (man is a part of the world), so that it has in all cases the interactive structure of knowledge (self-conscious and objective) and act, and also the nature of motion between the mover (agent) and the moved (patient). The meaning of this motion includes growing and changing. Invention is a creative modification of the world (man) by discovery of the nature of the world (man). At all times, medical practice is an experimental and inventive treatment of man by medical practitioners (agents-physicians, pharmacists, nurses, and so on) for man as patient. The experimental knowledge and act are case by case always imperfect, and the inventive (creative) treatment of man for man carries in itself responsibility, that is to say ethics. The medical practitioners must each and all be specialists who recognize correctly such essences of medical practice. Their teamwork in medical practice will be realized only by mutual understanding of these essences, and in addition, in the future, teamwork will become increasingly necessary. So, from now on, pharmacists must be required especially to be more active, more self-conscious, and more responsible for their own share of medical practice.
At the beginning, I would like to express my opposition to the Ad Hoc Committee on Brain Death and Organ Transplantaion in Japan. Although I have treated many brain dead patients as a neurosurgeon, my conclusion seems not to be derived from scientific knowledge, but from an unexplainable but perhaps natural reaction to Japanese culture. I know very well as a scientist that brain dead patients are all but dead as a human beings. However, they are usually not dying alone, but have their deeply sorrowful family members around them. Their psychological states can never be relieved or be replaced by "humanism" in such moments. Rather, I would like to let them die in dignity, withholding further active treatments, acting instead as the representative of God or as a priest at the farewell ceremony between the dying patient and the family members and close friends. I would also like to avoid organ transplantations. The reason is that I think there is a severe shortage of donors in Japan, unlike in the United States or the European countries. The health care system in our country is so complete that every patient who wants and has a reasonable indication of the need for transplantation has the right to be so treated. It would be chaos in Japan, much more severe than in any other country, if patients realized that transplantation works very well and they were in competition for donors.
"Doing Better and Feeling Worse." This phrase is the title of a book which criticized modern American medicine in the nineteen-seventies, and it means that the better the medical personnel do, the worse the patients feel. Now in Japan, many people, not only patients and laymen but also medical personnel, may be discontented with modern medicine in the same way. This paper was prepared for discussion in the symposium titled "Concerning the Humanism of a Medical Environment in Transition". It emphasizes the importance of the socio-cultural viewpoint in inquiring into medicine, for medicine is a socio-cultural system and ideology. Using the key concept "medical pluralism", this pape tries to describe the diversity of patients' (laymen's) concepts of disease, the variety of their illness-behaviors, and the relativity of patients (laymen) and medical systems.
The technical improvements in medication in the late twentieth century have caused a great change in the relationship between medical specialists and patients. Medical specialists tend to treat a patient as a pure object of technology; they tend to take into account only information as to the patient's physical conditions, which is derived from high-tech medical tests. But it must be noted that many diseases such as adult diseases cannot be cured by technological means only. In those cases, medical specialists have to care not only for the patient's body, but also for the patient's psychological conditions, social relations, and so on. In the field of "ultramodern medication", medical specialists intervene directly in the life and death of the human being by using the technologies of reproductive-medicine and those of transplantation-medicine. Such interventions are ethical, I think, only on the conditions that 1) patients are well informed about those treatments and they themselves want them voluntarily, and 2) there is a social agreement on utilizing those treatments.