In recent years, 'narrative' has become a matter of remarkable concern in many research areas. Bioethics is one of these areas. It is said, "one of the recent developments in the field of bioethics has been an engagement with narrative". In health care, each patients' illness narrative, the medical staffs' listening of the story, and making a narrative that can provide richly rendered ethics cases, etc., are significant practices that attract our attention. If we want to understand moral problems in health care, it is helpful to use a literary account that places issues in a context of the lives and activities of particular characters. In philosophy and ethics, narratives deserve attention from those who research the relationship between the narrative, personal identity, and moral reasoning. Personalist moral philosophers, especially, who criticize the impartialist system of moral reasoning, have conjoined the narrative and ethics. The critical method of narrative studies can assist the analysis of moral problems. On the grounds of such research, a concern with the nature of narrative should be of pivotal concern to bioethics because the ethics case is central to the discipline. I make clear, in this paper, the significance of narrative in philosophy, health care, ethics and bioethics, and then discuss why we should use the narrative in the study of bioethics.
Pre-implantation diagnosis (PDG) is a new technique which makes it possible to investigate hereditary diseases and chromosomal defects of an embryo produced by in vitro fertilization (IVF) prior to its implantation into a woman's uterus. Embryos with unwanted genetic characteristics can then be destroyed, and only 'healthy embryos' implanted. PDG thereby is offered to couples at high risk for having children with genetic disorders. This technique is already available as a service for those couples in developed countries. In Germany, PDG is implicitly prohibited by the Embryo Protection Act (Gesetz zum Schutz von Embryonen =ESchG). Because of this under the ESchG, it is an offense to fertilise a human egg for any purpose other than to start a pregnancy in the woman who produced the egg. Also, no embryo research is permitted and the removal of a totipotent cell is prohibited. Under the ESchG, the embryo attains full moral status at conception. However, German Criminal Code (s. 218) surprisingly allows interruption of a pregnancy up to the first 12 weeks, and up to birth, where there is a risk to the woman's life, or a risk of serious physical or mental injury to the woman. In practice, the risk of mental injury to the woman is interpreted to encompass abortion following pre-natal diagnosis. There are some arguments which recognize the application of this new technique without amending the law. For example, the report of the German Medical Association takes the view that there are no differences between pre-natal and pre-implantation diagnosis, if PDG is performed on a embryo at the non-totipotent cell stage (2000). But is it a woman's right to select abortion on eugenic grounds, compatible with the view that human zygotes have moral status? In this paper I will try to discuss those ethical issues which are specific to, or intensified by, pre-implantation diagnosis.
In the case of organ transplantation of a cadaver, the donor's family members may say "He/She is still alive in recipient's body" in order to make redeeming sense out of their tragic experience. Is this statement derived from mere personal emotion? Or is it acknowledged as truth? In fact, as long as an organ is regarded as a mere spare part, the donor is dead. But, if an organ is regarded as a person, can it rightly be said that the donor is alive? Locke says, "upon separation of this little finger, should this consciousness go along with the little finger, and leave the rest of the body,'tis evident the little finger would be the person, the same person." Though this opinion may be unacceptable, substituting organ for the little finger in this sentence, consciousness goes along with the organ, therefore it would be the person. From the point of view of that consciousness is caused by the brain, it is nonsense. But from the standpoint of the donor's family, it is not absurd to conceive the donor's character in an organ which is implanted into a recipient. Furthermore, if the recipient should be conscious of the donor's memory, character, and so on, it seems that the organ has psychic and social qualities. So is it possible to admit that an organ is a person? If so, this has a grave consequence. If an organ is regarded as a person, it follows that the recipient recognizes the other person in his/her body, and then, it is impossible to distinguish the recepient from the donor by body alone. In order that the recipient may be identical as the same person before transplantation without becoming two or more persons, an organ must not be a person.
We usually emphasize the objectivity of physiotherapy because of its reliability and validity. When we usually do physiotherapy, we can find out various physiotherapeutical problems in accordance with objective evaluation of the patient. We can then set up a rehabilitation goal, and sometimes we might prescribe scientific exercise for a patient. However, is that all we need? In particular, how about the great number of chronic cases? If we persist in our scientific method, we couldn't discover the whole patient. I suggest we need to use not only a rational medical rehabilitation approach but also an existential medical rehabilitation approach for chronic patients. Existential medicine means holistic medicine. Even if we can't expect improvement in the disability of all chronic patients, we must understand what their problem is as a whole patient, and be concerned about their suffering. If so, they may communicate real narratives. This promotes healing for them. It may also build confidence between patient and physiotherapist. This would be a different kind of rahabilitation based upon caring. The point I want to make is that a existential medical rehabilitation has seen a great number of chronic patients change from a suffering existence to a healing existence.
I had to have colorectal cancer surgery in April 1999, in a local general hospital in the western part of Japan. A seemingly formal process of informed consent took place in terms of the physician's disclosure and my signing of the consent form. But the physician would never make any disclosure without the presence of my husband, even though I had asked him in advance to tell me everything directly. On the consent form, there was a list of risks and complications of the proposed procedure, but there was no mention of possible alternatives. The consent form was rather archaic in that its preface stated that they demanded of a patient a full understanding of what is to be disclosed and prohibited any protestation against the hospital's medical policies in case of an insurmountable accident (which, in fact, can only be determined by a third party). My physician-oncologist forced me to sign a consent form for an angiography and an arterial injection of an anti-cancer agent in spite of my refusal three times. Also, there was deception in the process of intravenous administration of chemotherapy. I ended up refusing the prescribed regimen because of its serious side effects. The legal doctrine and the ethical, democratic idea of informed consent are two different things. The former may easily be implemented even in Japan, as physician discretion and patient incompetence can justify non-disclosure. Legally, there is no requirement for ascertaining a patient's understanding of what is disclosed, whereas the ethical requirement demands that consent is meaningless if disclosure is inadequate and not understood by the patient. Indeed, only effective dialogue between honest and caring health-care professionals and the patient can effectuate a healing process and prevention of serious medical harm.
Two cases of schizophrenia (A : paranoid type, B : residual type according to the ICD-10 criteria) were studied, both of which were referred from a psychiatric hospital to the surgical and psychiatric departments of a University Hospital for the treatment of physical complications. Both patients were diagnosed with cancer and surgical treatment was recommended. Although case A underwent surgery along with the full informed consent requirement, case B was treated through proxy consent by her family due to impaired capacity. The difference in competence between these patients seemed to be related to their negative symptoms, for example apaty, abulia, withdrawal, and slowed thought of case B was more severe. In addition, this case study revealed that "reduction of restriction produced by phenomenological disturbances in subjective time in chronic disease" and "coordination of medico-cultural differences between psychiatry and other medical specialties" are necessary to improve the QOL of schizophrenic patients with physical complications. It is suggested that consultation-liaison psychiatry in a broad sense, including sufficient aspects of bioethics and philosophy of medicine, would be useful for the treatment of physical complications of psychiatric patients.
In 1999, the multiple organ transplantation from a heart-beating-donor was reported from Kochi Red Cross Hospital. This was the first case in Japan after the "Organ Gift Act (1997) ". The patient was transported by ambulance to the hospital on Feb. 22, 1999. The Japanese mass media should have been prudent enough not to violate the donor's privacy, such as exact age, address, family, and occupation. But they set their feet on the quiet donor's home town, and took photos and movies. Afterwards, the MHW (Ministry of Health and Welfare) and JOTNW (Japan Organ Transplant Network) forbade the direct access of the media reporters to the hospital and family members, and limited not only the streams of the non-medical information of the patient but also the medical information needed to check the correctness of the transplantation. The immediate disclosure of the medical information is essential to protect the recepients rights. Without this information, patients and families can't check the official announcements of the hospital. Their medical report might be changed by the hosptital to make it consistent with other data or reports. If so, they can know neither the accuracy of the donor's diagnosis nor the accuracy of information used to make the informed consent of the family. The Japanese mass media must make the rational guidelines to distinguish the essential medical information, needed to assess the adequacy of the choice, from non-essential information. I stress the peculiar situation of the case. This transplantation was the first heart-beating donation case in Japan except the very doubtful heart transplantation case by Wada in 1968. I think first that the donor's family must have a very strong will for the correct donation and transplantation. It is their honorable obligation to disclose enough medical data to make the medical staff protect the donor's patient rights.
In the fields of medical service, the death of patients is regarded as a failure of medical care. Patients have rights to live and exercise their rights during the therapeutic process, so the therapist should respect their rights and perform medical care with all his energy in order to save the patients' life. As a result, medical care shows a marked tendency toward excessive intervention in order to prevent patients' death. In psychiatry, there are many patients who attempt suicide. Psychiatrists should encourage them to give up the idea of attempting suicide. To help patients avoid suicide, restrictions shoild be placed on therapeutic interventions such as psychological, pharmacological and physical restrictions. Most patients will give up suicide with appropriate treatment. But only a few psychotic patients think themselves to be not alive already. They are dead mentally and socially, but not dead only physically yet. There is deep discrepancy between their mind and body. They cannot die a natural death about their body, so attempt suicide as a linkage between their dead-mind and living-body to recall their lost identity again. Excessive intervention in order to prevent them from suicide will bring them more severe despair. They think they are deprived of their death, and believe they cannot only live but also die. We must know the facts and give patients the chance to recognize their true wishes to live, and we should try to look for some pieces of hope through alternative excessive restrictions.
A body has been generally considered an object to be controlled. But a person does not own his or her body. The person is defined here as having a mind-body unity. Each patient has the embodied experience of his or her illness. The life history of the patient is, so to speak, engraved on his or her body. Nurses must try to understand the patient's illness in light of the patient's own life history. From this point of view, this paper proposes that nursing is "a physical dialogue" between nurses and patients. It is true that the nurse-patient relationship is not symmetrical. But nursing is not a one-sided action. Since it connects nurses' lives with patients' lives, nursing is an interaction. Accepting a chronic illness means that patients adjust themselves to a new situation caused by illness, i. e. a new state of self. They must find for themselves some meanings in life accompanied with their illness. The role of nurses is to support them. Patients understand their illness not only mentally, but also physically. When nurses try to appreciate the meanings which patients give their sick bodies and illness, they must interpret them through the patients' physical selves. Patients expect that nurses will give them the imagination necessary for hope. Many people today hesitate to be cared for by others, because they place much value on autonomy. But no man could live without dependence on others. Caring and interdependence should be more highly valued.
Informed Consent for medical treatment has been argued as being not only a doctors obligation but also patients' rights to obtain their desired "quality of life". Nowadays nurses are beginning to have a role in Informed Consent. We, nurses, expect that this role should exist to enhance the patients' rights. So we believe this role is needed. But especially in medical treatment, this responsibility of nurses remains ambiguous. So I expect the law should define clearly a nurses responsibility about medical treatments. Though much literature refers to the doctors obligation, there is little referring to the obligation of nurses. As a legal requirement of medicine, nurses as well as doctors must make an effort to explain the treatment appropriately and to gain the patients' understanding. But this dose not state the nurses' obligation clearly. The purpose of this paper is to define what the nurses' role in Informed Consent for medical treatments should be. So I tried to interpret the nurses' legal obligation in Informed Consent for medical treatments. And then, I tried to compare the role of legal interpretation with that of my own experienced. As a result, I found that the nurses' role does not have the responsibility for Informed Consent in principle. But if nurses practice only this legal role, they can't carry out the essential role of nursing, which is to assist so that patients can live a better life. I found that to be able to interpret the role has an obligation to pay attention to Informed Consent about medical treatments. According to this obligation, despite the legal interpretation, nurses would be able to carry out the essential role of nursing. This role would then be equal to a nurse's ethical position which is to bean, advocate of patients. Consequently, in my view, nurses must carry out the role of Informed Consent for medical treatments from an ethical position, while at the same time understanding the law in which they practice.
In the Informed Consent, there are some exceptional cases in which the explanation to a patient is not required. They are the cases of a patient in the unconscious state where the confirmation to the patient is not possible and the cases in which little risk is expected and the explanation is not required though the patient's agreement is necessary. These cases are well known in general, but considering the present situation such as remarkable progress in technology and diversification of the situation, general concern only to these cases is not sufficient. In this report, 8 judicial precedents in the past, which decided the Informed Consent unnecessary, have been critically reviewed, and the cases which didn't require the explanation have been classified in more detail. In the 8 examples, the author found that there were three types of cases. First, there were some cases that the author regards it as suitable not to explain a patient. Secondly, there were some cases that the decision of non-violation of the Informed Consent was correct at that time, but the situation has changed due to the remarkable progress in medical sciences and they need to obtain the patient's Informed Consent at present. Lastly, there were some decisions which did not understand the idea of the Informed Consent at all and the reasons for the decisions were not clear.
In recent years, with the spreading thought of "the right to know" and "self-determination", it seems that more Japanese people want to be told of their diagnosis of cancer. So a growing number of Japanese doctors tell their patients that they are suffering from cancer. Now, most Japanese tend to think that not informing patients of their diagnosis of cancer implies telling a lie and an untruth, a deception, a trick, a lack of a relationship of mutual trust, etc. In this paper, however, I argue that refusing to inform patients of their diagnosis of cancer can be advantageous depending on the circumstances, in opposition to the current thought of the times. For humans can naturally have the knowledge of the time of one's death, though they are never informed of it by others. We don't necessarily need to give the objective/scientific knowledge priority over the natural knowledge. Essentially, death cannot be controlled by one's own will power. Leaving a matter of life and death to Nature that transcends man's own will power can also be a style of accepting one's death.
This is the Second Part of a speech which was delivered in the 18th Annual Meeting of Japanese Association for Philosophical and Ethical Researches in Medicine held in October, 1999, and the author discussed here bioeethical issues alone. In the First Part of this speech the author discussed the medico-ethical issues which are omitted in this paper but have already been published (in Reference 1). Main topics dealt with in this paper are: 1. American bioethics as one of the postwar American dreams 2. Critical appraisal on American bioethics: American bioethics at the Cross-roads 3. Bioethics and environmental ethics 4. Eastern and Western bioethics: Asian and Euro-American bioethics 5. Fundamental principles of bioethics 6. Standardization and globalization in bioethics 7. "Genoethics" and "phenoethics" (Reference 15) Topics discussed in the First Part of this speech and already published in Reference 1 were: 1. General education in premedical course of senior high schools before and during World War II 2. The Foundation of Ministry of Health and Welfare in 1938 under the strong leadership of Japanese Army for the preparation and promotion of war : the principal functions of MHW were an increase in population, prohibition of induced abortion and contraception, control of pulmonary tuberculosis, veneral diseases and trachoma conjunctivitis 3. Ethical Code of Japan Medical Association and of Physicians during WWE 4. Influence of American Occupation Troops on medical education and practice in post-war Japan 5. Main trends in medical science and practice in post-war Japan 6. War responsibilities and war crimes judged at Tokyo War Crimes Trials 7. From period of National Eugenic Law (1941) which prohibited induced abortion and contraception to the years of Eugenic Protective Law (1948) which semi-liberated induced abortion and contraception
Medical care is for patients themselves. In studying a subject of "How should Medical Staff Consider Patients' Bodies?", we have to remember past mistakes such as strict isolation of patients with Hansen's disease from society under the Leprosy Prevention Act and involuntary sterilization carried out against those patients without any authorization by laws. Needless to say, it is not allowed that medical staff make injury to patients' bodies or extract internal organs of patients or handicapped parsons for the convenience and benefit of persons who take care of patients and who manage hospitals. Patients' bodies must be respected. Aren't patients' bodies deemed as training subjects in education of medical students? There exists the fact that experiments were made on human bodies in clinical cases, which infringe on the human rights of patients. An attitude that focuses on only the benefit of medical staff makes it difficult to focus on the needs of patients. The worse the patients' condition becomes, the more they go on asking for relief, give an example for their lives. Moreover, the more serious the patients' condition becomes, the more difficult it is for them to ask for relief. Although patients with persistent disturbances of consciousness lose their means to communicate their intention through words or other physical expression, they continue to ask nurses and other medical staff for relief. It is desirable for nurses, being in a position closest to patients to make efforts to consider what patients are trying to ask for through their physical expression, since they unable to speak. Further more, nurses should try to notice what patients are asking for, since they are unable to communicate their intention through their physical expression. Nurses should then try to find what care is needed and administer the necessary care.
How to handle patients' bodies has been one of the key issues in medicine. It is the same in physical therapy which is one of the special fields in rehabilitation medicine. In most cases, the patients who need physical therapy have some sort of disorders or disabilities and sometimes they have to live under those conditions throughout their life. The bodies are not just physical media but they also include the mind. Then, when we handle patients' bodies, we are handling their minds at the same time. Therefore, our philosophical view of humans determines the level of handling patients' bodies.
The developments of modern medical technology raise problems on the legal status of patient's body in the various medical fields. Firstly, in the medical treatment. Who has the authority to select the means of intervention in the patient's body? Secondly, in the humanexperimentation or crinical trial/research. To what extent can doctors use the subject's body? Thirdly, in euthanasia, death with dignity and organtransplantation. Also in these cases, patient's body occupies an inportant position. And lastly, in the life-beginning or reproduction field. Here especially women's body and enbryo's or fetus's body or life become an issue. The common subject in these cases are whether we can regard the patient's body as a part of personality, and who has the authority to dispose of his body. In this paper I'm to consider on this subject from the viwpoint of medical law.
This discussion is focused on the patient's body in routine, popular, or standard medicine, such as hypertension, hyperlipidemia, diabetes mellitus, or atherosclerosis. Medicine related to extraordinary treatment such as organ transplantation, research, and denial from the patient to be treated based upon his/her age and so on, are beyond the limits of this discussion. Since ancient times, medicine has been a method to relieve a patient's pain and suffering. Modern medicine has made new discoveries in many diseases and their pathological mechanisms, as well as many new discoveries in the physiological aspects of the human body. It has recently shed new light on cells, molecules, and genes. We are however left with many unknown diseases. Medical methodology treats a patient as an object, objectively and scientifically. However, it should be a priority to treat a patient as a person, and to respect his/her patient's rights and human dignity. The doctor should explain the diagnosis, pathophysiology, risk factors and the hygiene, treatments, alternate therapies, prognosis, etc., to the patient. My answer to this question, what do I think about the patient's body?, is that the patient's body belongs to the patient, for the time being. The human body, however, is a nature in itself. In the studies of the human body as a nature, there are still many far beyond human intelligence. Although a patient is ill with some disease, he/she has his/her own lifestyle as a human being. We, physicians and patients, should not forget the natural aspect of the patient's body or his/her own lifestyle.
In this paper, I first argue from the viewpoint of philosophy that the patient's body cannot be sufficiently comprehended by the logic of the biological mechanism. In order to make this point clear, I criticize the philosophical stand of the biological mechanism. Firstly, the position of the biological mechanism views a patient's body as an object of the world, so it cannot comprehend the reality lived by the body of patient. The patient's body, the biological mechanism reveals, is an anonymous body, not the proper living body of the patient. The biological mechanism lacks the perspective of individuality. Secondly, the understanding of disease of the biological mechanism is that of being-already-objectified, so it always remains in the past aspect of time. It lacks historicity and timeness and thus ignores the life history of the patient. Following the critical argument of the biological mechanism in modern medicine I propose a new comprehension of illness. It considers the patient's body as the milieu of the auto-expression of the patient's existential suffering. The comprehension of the patient's body should be that from the viewpoint of the unity of mind and body. Moreover, taking into consideration the relationship between medical staff and the patient, the patient's body should be understood as the body-aspair (interbodility). The patient's body reflects the body of medical staff, and reciprocally the latter reflects the former. They both form the intersubjectivity and then make themselves open into the world. So we should also understand the patient's body in the socio-cultural context. Thirdly, I propose the understanding of the body as sign/metaphor. It represents the semantics of illness. I insist upon the necessity of the hermeneutics of illness to understand the meaning the patient's body auto-expresses. The metaphor of the body bears both the meaning of discrimination and the religious-symbolic meaning. So the medical staff should transcend the discriminative meaning of the patient's body to its sacred meaning. Lastly, I argue the importance of the stand of ethics. The medical staff should constantly come face to face with the patient. We need to realize the patient's rights in accordance with the patient's actual body.