This study analyses private papers written by women who underwent sterilization treatment. First a comparison is made with the model of E.Suchman who pointed out "illness behavior" and "stages of illness". How big is the pain of infertility as a result of the enormous stigma attached to the inability of giving birth to one's own child? The sense of desperation is followed by hope-and then desperation again and again. Why are children of any value? Because of a particular passionate desire of caring for and nurturing children? The medical procedures they underwent and the many "failures" they experienced are described. But they say, "If we lived in a world in which infertility is not seen as a 'disease' that can be 'cured', these technological accidents and experimental procedures could be avoided." That is, pressure from society can turn a fertility problem into a curse which provokes feelings of guilt, above all the desperate belief that, 'I have to try one more time, one more procedure.' : What is "illness", and What is the object of "treatment" ? After all, this study is an analysis of the content of papers concerning cognitive factors of illness behavior.
1. Medical Philosophy, Ethics and Problems of Homosexuality. The various concepts of sexuality were invented by psychopathology in the late 19th Century. In the DSM-III-R of 1987, homosexuality suddenly became normal from abnormal. However transgender remains an illness, as it was before. It is only a political problem. Another important problem is about AIDS. In Japan, there is discrimination between AIDS caused by medicine and AIDS caused by other factors. 2. Homosexuality as Thought : Situation of modern French Thought. In France, The "May Revolution" of 1968 caused the foundation of a new university : Paris 8th (Vancennes). One of its founders, Rene Scherer began his first lecture on sexuality in the faculty of Philosophy. His partner, Guy Hocquenghem, founded FHAR. Recently, Red and Black-Homosexuals in France after 1968 by F.Martel was published. However, Prof. Scherer has told me it is a defective book. 3. Thought of G. Hocquenghem : concerning homosexual desire. The originality of Hocquenghem's thought seems to lie in his idea of forming "a group of subjects" through the anus. The creation of relations among others by anality stands against ideas of couples. Being homosexual is not a means to attain self-identification, but a means to be out of self, to become a foreigner. It is also an escape to an infinite drifting from a stiff identity. 4. The Voice of M. Foucault : Homosexuality as a form of existence. Foucault's thought about homosexuality summarizes two points. First, to be homosexual is not correct ; to become homosexual is correct. He takes "gay" to create a new form of existence. Therefore, he does not think coming-out to be inevitable. Secondly, his problem is to begin to love among individuals. It means that "I" is more essential than sexuality. Here there seems to be fascination for passivity. 5. Conclusion : In Japan, they say "gay" is already out of fashion : now "queer" replaces it. However, such nomenclature is only a matter of fashion. To my regret, regular studies on gayness or queerness are not carried out in Japan. Now, it is necessary to study homosexuality as thought. That means to meet various thoughts not only to introduce and imitate them but to get involved in them : to have a mind of "hospitality". That is a critically needed task in Japan.
From America and Europe, there is a great abundance of reports of large-scale randomized clinical trials on various medical problems. They have brought important findings to medical practice. Such knowledge is available in all over the world, including Japan. However, in Japan, we have little experience of randomized multicenter clinical trials, and only a very small number of patients have participated in these studies during the initial period. There are still many diseases and many patients with intractable pathophysiological conditions, and many requests to relieve them or to improve their health, using high-level technology. Why do megatrials fail in Japan? While some have indicated that Japanese physicians have paid scant attention to or have had no experience of large-scaled, multicenter, double-blind, prospective, or randomized clinical trials. I would rather point out the following : we have the health insurance for all Japanese ; the coverage is for anyone, anytime, anywhere in the country, and for any type of conventional treatment ; so most Japanese individuals have little pressure to develop or to resolve medical problems. However, since the consultation time is only about three minutes, the physician does not have enough time to explain details on the clinical trial, therefore the condition of informed consent is poor in Japan. In addition, the peer review system has little tradition and there is no neutral powerful agent as the FDA. Consequently patients are not confident in physicians and the Japanese health care system in general.
Ethical principales of medicine for physicians provide that a physician must have empathy with and respect for the "dignity of man". For example, the complete works of Hippocrates contain the following passage, "A physician must be impartial in his personal relations". This means that a physician needs to get along with the other persons even when there is a conflict of desires with them. Does a physician always deal with patients impartially in actual clinical practice? It is out of the question, if there is evidently a lack of fairness. But there are cases in which a physician lacks true fairness depending on the nuance of his words, although he appears to be fair formally. In this case there are several causes. In the presentation this time, we examine lack of fairness due to a physician feeling "disagreeable" toward a patient. Feeling "disagreeable" toward a patient may be devided into those cases when the physician himself is aware of it and those where he is not aware of it. For a physician to feel "disagreeable" toward a patient may be unavoidable since the patient-physician relation is a personal relation. In any case, this feeling is one of the causes for a physician to lack fairness to patients. For example, when a physician discloses medical information to a patint to whom he feels "disagreeable", the true meaning sometimes is not understood, or a distorted version is relayed to the patient intentionally or non-intentionally, even if the substance of disclosure is enough formally (or legally). Even when the same information is told in the same words, the way of relaying it and nuance can be changed by the "disagreeable feeling" toward the patient, and the inforlmation is understood quite differently by the patient. In this presentation, we study what situation also cause a physician to find a patient to be a "disagreeable person", whether it is against the ethics of medicine for a physician to feel "disagreeable" toward a patient and how a physician should deal with a patient impartially even when he thinks that patient to be a "disagreeable person".
The massive earthquake that hit the Hanshin region in January 1995 caused 6425 deaths and over 40,000 casualties. Major public utilities were cut off, so medical practitioners found medical activities extremely difficult. Rescue operations by the self-defence forces failed to function properly. This disaster has called attention to the importance of Triage regarding medical services in such large-scale disasters. Triage comes from French, and was brought into English during the First World War, and was used in classifying the wounded. The definitions of Triage are 1. Classifying the injured by the seriousness of their external injuries or illness. 2. Deciding on the order of superiority for treatment. Let us consider the ethics of Triage from the following two aspects. a. The Means : In times of crises such as a war or a large-scale disaster,traditional medical ethics do not apply. Limited medical resources will mean that a capable Triage Officer should independently and speedily sort (i.e. triage) patients based on high-quality initial diagnosis, and decide on the order in which they will be treated. The ethics will be based upon the fact that Triage is the means for attaining the maximum happiness for the maximum number of people. The appropriatenss of the means will be subject to change depending upon the situation. Therefore Triage is a process modified repeatedly. b. Education : For an inexperienced doctor, it is an ethically difficult mission to classify numerous patients in a way that is different from daily practice. There are also doctors who emphasize that practice drills for medical services in times of large-scale disasters is aiding and abetting war, and that classifying numerous patients is inhumane. Doctors know little about Trige, and the general public is uninterested, so once a disaster strikes there is major chaos. It is therefore desirable to train capable Triage leaders and at the same time have the man on the street undergo training to be ready for large-scale disasters, and have an understanding of Triage. By doing this, disaster survivors will be aware that there are many patients around them whose treatment requires priority, and they will be able to engage themselves in volunteer activities or await their turn for treatment whih understanding. In this manner, it is possible to acknowledge the high ethics of Triage in neighbourly love, or regional unity, which is needed in times of large-scale disasters.
Nursing techniques, unlike those developed in other field, arise and evolve out of interactive situations. The individually generated action performed in isolation, which, on a production line is appropriate, can be entirely inappropriate and ineffective where the question is one of care. In such a situation, therefore, the observer (the nurse) cannot handle the obsenrvee (the patient) in a mechanical fashion, as if the latter were not a sentient being but merely an object. It follows that the nurse's perceptive capabilities and judgment play a decisive role in the appropriateness and effectiveness of the techniques she or he employs. The nurse's perceptive modes must thus be examined. Living necessitates humans to maintain a constant relationship with the surrounding environment. The recognition and interpretion of and reaction to sensofy stimul are inherent features of this relationship. It is perception that establishes mutual relations between human being and his world, hence perception is crucial to nursing acts. The links existing between the various perceptive modes and the surrounding environment, together with the incorporation of such information into students'clinical training, form the subject of this paper.
From an experience of more than twenty years in undergaduate and postgraduate education of medical ethics and bioethics, the author discussed the following four problems. 1. Eduation of bioethics should be started as early as possible by parents and kindergarten teachers, and should be followed by primary and secondary school teachers prior to medical education. 2. During the past twenty years, almost every Japanese including medical students became very familiar with medicoethical and bioethical issues arising from new medical technology. However, education on citizens' everyday ethics and pupil / students' ethics are more important than medical ethics relating to modern topics such as euthanasia, in vitro fertilization, organ / tissue transplantation and so on. 3. When, by whom, where, in which stage of the curriculum, in which style, on what kind of topics, medical ethics education should be done, are all very difficult questions to answer, However, the author have reached the following answers. (1) The effect of lecture style education on medical ethics in a large lecture hall, especially in the preclinical course is very limited. (2) Small group discussion on everyday clinical practice is more important than a systematic lecture. (3) Everyday ethical and humanitarian behaviors of all practitioners to the patients and their families are more important than lectures by famous professors. 4. Why Japanese physicians show less concern about medicoethical and bioethical issues was discussed. Some of the reasons are : (1) It results largely from a cultural difference between Euro-American countries and Japan. (2) Japan is too legalistic country in which most behavior of the people is regulated by laws, most of them enacted in the 19th century, rather than by medical ethics and bioethics. (3) Medical practice in Japan is typical Managed Care controlled by government and National Health Insurance Laws. For most physicians it is rather rare to find an opportunity of ethical decision-making. (4) The Physician-Health Insurance Law relationship and patient-government relationship are very often more important as well as more powerful than the patient-physician relationship in Japan. (5) Medical education in Japan both in pre- and postgraduate courses is a typical School Medicine or University Medicine which places too much attention on medical science and modern high-technology, respecting less the humanity, human dignity and interests of the community.
It has been said there is a mutual understanding between doctors and patients, established through confidence in the doctor-patient relationship. As a result there are usually few medical conflicts on treatment and policies, despite the fact there is no actual formal informed consent. Recently however the position of the patient requires more consideration than previously when providing medical care. No doubt a portion of this increased sensitivity stems from the Nuremberg Principle of 1947 and "The Declaration of Helsinki" adopted in 1964. These credos require physicians to seek peace and give the highest priority to the well-being and happiness of human beings, and certainly their patients. I intend to bring forward in my philosophy of medical ethics issues of QOL (Quality of Life), Medical Ethics, Human Rights and Equality, and renewal. I will discuss the necessity of informed consent and the need to harmonize at a global level many of these issues. Reference will be made to historical considerations in the establishment and preservation of the Japanese view of ethics and philosophy, a comparison of Japanese and Western viewpoints, the purpose of the "Declaration of Helsinki", and these issues as they impact in new drug development during clinical trials.
This presentation considers three aspects by which an understanding of Japanese patient psychology can improve medical practice in Japan. (1) Recent advances in holistic and psychosomatic medicine illustrate that patients' psychology can influence medical outcomes. While it has long been common knowledge that bodily conditions influence mental moods, the burgeoning new field of psychoneuroimmunology is demonstrating that mental attitudes and emotions influence illness and health. The commonest stress-related ailments in Japan, from ulcers and high blood pressure to eczema and stiff shoulders, can be significantly alleviated by psychosomatic medical techniques such as relaxation and biofeedback. (2) The psychology of Japanese patients differs in many respects from that of Americans. For example, Japanese rarely strive to participate actively in their own healing processes, express individual decisions in writing, write living wills or advance directives, or consider themselves equal in status to their physicians. Given such deep-rooted cultural differences, even their best attempts to imitate Western medical practices encounter many difficultes. This section considers more suitable ways of counseling Japanese chronic and terminal patients based on their cultural expectations. (3) Similarly, the spread of bioethics has been closely linked to Western conceptions like full disclosure of information, second opinions, third-party review boards, and the legitimacy of whistle-blowing. The social hierarchies of Japanese hospitals render such practices counterproductive if not impossible. In the care of Japanese patients, mutual understanding based on discussion and family participation in decision-making produce far higher trust and satisfaction than information disclosure. This suggests that Japanese develop their own ideals and conceptions of bioethics based on their own cultual goals and assumptions.
This paper attempts to look at some of the changes that have taken place in the Japanese health care environment during the last 30 years from the point of view of the patient. In the U.S. the period after the Second World War was marked by increasing litigation concerning the outcome of health care, and this in turn created demand for second opinions and expert opinions in law cases. Hand-in-hand with this development came the concept of informed consent, i.e. that the patients had the right to know everything about their own condition and the type of treatment that they were receiving. By extension, this came to mean that in any clinical trial the patients not only had the right to know but had to know their condition and the type of treatment they were receiving. While the number of persons in metropolitan areas in Japan who wish to be fully informed about their condition has increased, questionnaires have confirmed that in rural areas there is an unchanging large amount (@40%) of patients who do not want to be told directly by their physicin. This raises the question of "right to know" actually "a duty to be forced to know" ? Furthermore, in the field of medical publications, which are essential for most persons in academic medicine who want to develop a career, it has become increasingly common to enforce the demands of the US litigation / health care environment on all those wishing to publish papers in international journals, the overwhelming majority of which are published in the United States. Reference is made to a recent study by the Council of Biology Editors concerning the questionnaire they distributed to their members. The results of the questionnaire favored the idea that it would not be correct for one country to impose its cultural values on all papers submitted to a journal submitted in that country. This paper also suggests that, in order to allow comparison of traditional oriental medicine such as acupuncture and western medicine such as drug treatment, and given the different cultural situation of various countries in Asia, they should develop their own ethical and compassionate approaches to the scientific elucidation of treatment effects without necessarily copying in every detail the present approaches used in North America.
The history of dissection in Japan began in 1754 when Toyo Yamawaki dissected first in Kyoto. Later, many human bodies were dissected in various parts of the country during the Edo era, but all the cadavers were those that had been executed or died in a prison. The people at that time had a dark image that the dissection was performed on sinners. In the second year of Meiji, a thirty-four year old woman named Miki donated her body. She wished to be dissected after her death with her own will. Hers was the first body donation in Japan. Until World War II, cadavers devoted to the medical education were mostly from criminals, as in the Edo era. As, however, the human rights movement spreading throughout the country, it became difficult to obtain and dissect such cadavers and they became extremely short supply. After 1955, groups promoting body donation were formed in order to make up for the shortage of cadavers all over the country. Initially the groups were formed only to supplement the number of cadavers. But after 1975, donors became to think that it is their great contribution to the medical education and they can participate themselves in educating ethical and humanistic medical doctors even after they die.