Since the "Law of Organ Transplant" was enacted in 1997, transplants of organs from brain-dead patients have been performed in Japan. I interviewed physicians working for a hospital providing organs from brain-dead patients. The results are reported here. The discussion points are as follows: 1: There are four specific physician related roles to be found in the process of extracting organs from a brain-dead patient, as follows: A physician engaged in life saving (Physician for emergency), two physicians who diagnose brain death (Neuro internal physician and neurosurgeon), two physicians who manage a donor (Anesthetists), and two physicians supporting the extraction (Anesthetists). 2: The physicians had different opinions depending on their role. In particular, the anesthetists in charge of donor management felt that good quality medical treatment was not being provided, since the medical conduct was only the same as that for ordinary patients in the Department of Anesthesiology. 3: The anesthetists really felt that death occurred upon the extraction of the heart of the brain-dead patient. 4: Because the provision of an organ in an organ providing hospital is conducted under a division system, and feedback from a transplant hospital to an organ providing hospital is not conducted, physicians from the organ providing hospital could not understand the conditions of the recipient and could thus not evaluate transplants from the braindead patient. 5: Because observance of the law is more important than medical conduct, physicians don't need to ask questions about treatment that concern them.
There have been many discussions, from various positions, about what kind of care is needed with regards to terminal care for the elderly with dementia. Although it is generally thought that extraordinary treatment and care are not necessary, in reality, there is a marked tendency for excessive treatment to be performed in our country, because most physicians have difficulty accepting natural death. This is due to many physicians' strong belief that the death of a patient means a defeat for medical treatment. The elderly with dementia will not die by the disease directly, but from a complication such as pneumonia. Therefore, keeping the patient from such a complication extends a patient's life for a longer period of time. The situation of the elderly with dementia is reminiscent of the Struldbruggs in "Gulliver's Travels". In this story, these immortals must live eternally and cannot die even though they age with dementia. Furthermore, endless life-prolonging is not the purpose of terminal care. Certainly, the intellectual faculties of the elderly with dementia weaken, but, they continue to be able to maintain their emotional faculties when interacting with others. Such coexistence and feelings of emotion are basic of care and are not invasive conduct. If the medical care provider accepts the patient's death and is sympathetic to them, it is thought that appropreate medical treatment and care should be carried out naturally.
Concerning the issue of Informed Consent, it is still common in Japan for ethical standpoints tobe easily affected by the legal viewpoint, though law and ethics should be under different jurisdictions. In the dispute about actual legal judgments, there are three points at issue. They are as follows: 1) Respecting doctors' judgments as professionals 2) Patient responsibility, based on the premise that patients can deal with their medical situation rationally 3) Respecting the understanding and judgment of individual patients Each point has its own merit and demerit, but the author thinks that the third idea, that is, respecting individual patient's understanding and judgment, is the most suitable when considering the concept of Informed Consent from the ethical point of view. Under the present situation, when we looked into prior judicial precedents, judgments have mainly been made on the basis of the first idea of respecting professionals' opinions. Furthermore, there are some cases where judgments were made from an ambiguous viewpoint, mixing the two or three points mentioned above. Under these circumstances, the author thinks that, in Japan, ethics should voice more about the issue of Informed Consent, and should make efforts to bring judgments based on Informed Consent closer to the ideal and appropriate form regardless of any legal dispute from the past.
The concept of 'imperfect duty (or right)' is forgotten in modern ethics. But this concept is very efficient for medical ethics. For example, if we examine the duties of a physician and the rights of a patient by giving our eyes to imperfect duties and rights, we can get a clue to the fine understanding of the physician-patient relationship. Now that paternalism in the physician-patient relationship is said to be rejected, the autonomy of the patient is a kind of trump card. And many bioethicists and laymen adjudge that the physician-patient relationship must base itself on the 'contract.' But Japanese 'SEKEN1 ('the world' or the traditional Japanese human relationship) between a physician and a patient postulates one sort of physician's paternalism. And the physician-patient relationship based on a contract would bring some moral hazard to a physician. We must understand what is the moral problem in the physician-patient relationship, and the examination of imperfect duties (and rights) will lead us to the solution of that. In many respects, we follow the study of the history of ideas on the imperfect duty in Millard Schumaker's "Sharing without Reckoning."
In this paper, I will inquire about justice theories with regard to the public policy of assisted reproduction (AR). In the first part, I will criticize the classic four-principle-based frameworks of American bioethics. Firstly, it is not all-embracing, because it rejects any "communitarian" argument dependent on substantial common values such as human dignity. Secondly, it is not neutral, because practical advantage is given to liberal argument that permits any kind of AR. These liberal points of view are further analyzed as follows. (1) They impose empirical demonstrations on the autonomy-based negation of AR, (2) They permit the harm/benefit-based argument dependent on medical habits which are basically affirmative for AR, (3) They have traditionally concentrated on distributiv e justice, that is, nothing is discussed about newly developed AR, until it becomes a social resource. I will then introduce categorical and methodological expansions of justice theory as follows: (1) When we establish another category, which I call 'resourcification justice', in justice theory by questioning 'on what basis the health care service is justifiable', it will allow us to identify the nature of the conflict over AR. (2) When we adopt the two Rawlsian principles of justice only formally, rejecting any material premise, they require us to identify justly who is the worst off in the context of AR. Furthermore, the only guiding principle of fairness requires us to adopt a methodological justice, which I call 'narrativejustice', in that identification. This does not allow us to take ourselves only in the public context of policy makers and the worst off. It requires us to take ourselves at the same time in the private context of the narrator and the narratee.
Something is called a placebo when it is used to cause a favorable effect on an unknowing patient, even though it is known to have no pharmacologically effective action. A favorable effect, if any, is called a placebo effect and is referred to in a non-medical context as well, where an act of comforting or pleasing with verbal or non-verbal expressions or gestures is found successful. This latter case may be quite innocuous and need no particular justification. Ethical problems arise when placebos are used either in a clinical setting or in medical experimentation. Clinically a placebo is given to a patient at the medical practitioner's discretion without informing him/her about its use. In 1955 Henry Beecher published a study on the placebo effect. He believed he could prove the existence of a placebo effect in the 30 to 40 percent of all patients. Two camps seem to have formed differing assessments of Beecher's thesis. One literally believes a placebo is effective as a result of the mysterious process of the human mind-body relationship, while the other camp wants to dismiss the whole thesis as groundless. For the latter, placebos are a form of deception or manipulation and should not be taken seriously or used at all. Physician-ethicist Howard Brody tries to make sense of the placebo effect philosophically. He shows that a reductionist approach cannot explain it, while giving credit to anti-positivist approaches that define a person in a culturally meaningful context. He states that a good medical practitioner can cause a placebo effect without using any placebos by engaging in simple good conversation. But as to the use of placebos in double-blind controlled studies, physicians, including Brody, are usually permissive and do not question the use of placebos or non-treatment for the research subjects, who are, at the same time, patients in need of medical care. The use of placebos or non-treatment for patient-subjects contradicts the idea and practice of informed consent. Only volunteers should take part in a medical experiment. What is puzzling is why things given to the control subjects are called placebos.
EBM (Evidence-based Medicine) has been prevailed in the medical world since the last decade of the 20th century. It was originally called Clinical Epidemiology. The advocates of EBM declared that it brought about a paradigm shift into clinical medicine. As compared to biomedicine, which gives pathophysiological explanations of clinical phenomena, the methodology of EBM is phenomenological and probabilistic, while that of biomedicine is ontological and deterministic. However, these two are inseparable sides of scientific medicine. EBM has several advantages. Because it is a kind of inductive inference, the results obtained by using EBM can be shown as clear evidence to everyone. In policy making EBM contributes to establishing the standards of healthcare. Through EBM we can see that all the laws of medicine are only probabilistic and medical judgments are always falliable. Science is neutral in regard to the system of human values. Therefore, EBM is a new tool which we can employ to develop our good values.
Evidence-Based Medicine (EBM)can be defined as a procedure to evaluate objectively the clinical efficacy of treatment from the viewpoint of a statistical appropriateness. It can also illustrate guidelines for diagnosis and treatment, make the most sophisticated up to date system of medical applications shared by medical professionals beyond individual and cultural difference, and finally, aim at standardization of medicine. As an ethical viewpoint, EBM may be able to provide more positive and essential informed consent by showing better evidence of the treatment to patients. EBM also meets social needs by allocating medical resources effectively, for it can supply, from the very beginning, the most effective treatment. Even in clinical cases, in which the etiology or pathology is unknown, or symptomatology is too complex or multidimensional, EBM can give an active guideline for the treatment to physicians, concentrating only on the efficacy of clinical application, temporarily neglecting the etiological factors. As the only principle to justify medical intervention is the risk/profit ratio, it is extremely important to evaluate usefulness of treatment objectively before introducing the treatment method. Concerning this point, EBM can provide the foundation for medical ethics. Especially in psychiatry, because of difficulty in identifying etiological factors, EBM has a very important role in ethical consideration. However, on the other hand, the popularization of EBM could possibly offer various problems. We must take note of the easy use of EBM as a manual-book, overconfidence or misunderstanding of its "objectivity", neglecting the notion of "Comprehension" (Jaspers K) and related psychopathology, and alteration of patient-physician relationships evoked by a preponderance of objective data.
The 'personhood' argument is one of the basic principles of bioethics. But various forms are possible within this principle. The high evaluation of the patient's will is one form of personalism. The superiority of a person's value over a life's value is another form. But the famous 'personhood' argument today maintains a personhood is 'a necessary condition for the right to life'. This argument is linked with 'the denial of the right to life for potential persons' and 'the criticism against the speciesism'. This argument indeed provides some guidelines for abortion and the vegetative state, but it will admit almost any cases of the recent reproductive technology, especially ES cells. So, I want to define the person again from the viewpoint of 'moral personalism'. In this paper, I want to introduce my interpretation of Kant's 'categorical imperative', and then try to define a person on the basis of it. 'A categorical imperative' can be interpreted as 'a practical categorical syllogism'. We can discover two conditions for valid categorical syllogisms. And from these conditions moral practical laws can be deduced. Then, I define 'a person' as 'one who can perform such practical reasoning and act according to it'. A person means a moral being. This definition makes a new understanding on 'autonomy' possible, too. This definition of person is made from the viewpoint of the 'faculty', not the 'actual will'. Therefore we can consider the difference between 'a human being' and 'a chimpanzee', and also can view 'a potential person' as a person potentially possessing this faculty. This argument is not based upon a necessary condition for right to life, but upon the moral value we must esteem. I believe that from this point of view we can give some guidelines to the recent reproductive technology, ES cells.
If the meaning of self-determination is 'voluntary determination about one's own fate and course of action while remaining free from controlling interferences from others', the following patient decisions are comprehended as self-determination: (1) choosing unwillingly one treatment considering various circumstances; (2) choosing one treatment from choices represented by a doctor; (3) choosing one treatment from more choices than the above, getting information on various treatments from other sources than the doctor's information; (4) leaving one's own decision about treatment to the doctor. An explanation of these four situations follows:(l) an unwilling decision is self-determining, because this decision is derived from free will. With regard to (2) and (3), (3) is maybe more self-determining than (2), fer a patient gets the information through his/her own efforts. However, both are self-determining because both are voluntary decisions. (4) Though the patient gives up his/her own determination to choose the treatment, he/she decides voluntarily to give up his/her choice to the doctor. Therefore, patient decisions are self-determining in these four situations. For this reason, if self-determination is understood to be of great advantage to a patient, it needs to consider its relationship with the various situations, for example, how to inform the patient about his/her condition and various treatments, and the circumstances.
People living at home with chronic respiratory failure must struggle to live in the face of various difficulties and distress. But their experience has not been investigated up to now. This study focuses on the experience of people living with this chronic respiratory failure. It is also an experiment in practical nursing research. Four patients and their families agreed to be participants. The patients are sufferers of chronic respiratory failure undergoing long term oxygen therapy at home. The methods used fieldwork at such places as outpatient departments, patient group activity situations and the patients' homes. Several formal and informal interviews were also conducted over a period of six months. Through fieldwork and interviews, I endeavored to come into contact with their actual sense and experience of life. I have described the findings under three headings : "Breathing and Moving", "Living with Suffering", and "Devising Life Strategies". First, I describe the experience of "Breathing and Moving". The participants actually feel that each and every breath supports their life. They must concentrate their consciousness to breathe in order to make each movement, and choose every movement carefully. For those people living with chronic respiratory failure, the simple act of breathing becomes the primary action supporting their life. They cannot entrust their lives to their body's automatic breathing, but must always be conscious of their breath. Second, I describe the experience of "Living with Suffering": The participants find hope and courage for themselves from contact with other patients' lives. When they observe something, they perceive a meaning in it to apply their life. They face the inevitability of life, and make new efforts to live themselves. Thus they maintain their will, and resolve "I want to do this" or "I don't want to become that". Lastly, I looked at the concept of "Devising Life Strategies": There are produced from their earnest desires. The patients devise the strategies themselves through a long groping process. The strategies may be called a technique for living. However, it is important to emphasize that they do not talk freely about the Strategies to medical workers. In conclusion, those living with chronic respiratory failure live in a world experienced through their body. Understanding of their subjective experience is produced through contact between the lives of patients and that of the researcher. The world of meaning and emotion world cannot be approached merely from an objective perspective.
The purpose of this quasi-experimental study was to foster ethical sensitivity among nursing students. Nurses and nursing students face many moral and bioethical problems in clinical practice. The development of ethical sensitivity in nursing students has paralleled the development of nursing as a profession. The subjects (n=19) were students who entered the Training Course for High School Teachers of Nursing Faculty at Hirosaki University Japan in 1999. The method of this experience of death with people in their immediate circle while a small number of students had experiences of great impact. Some students were very sympathetic to the experiences of others and felt the experiences of their counterparts as their own experiences. The discussions about death were meaningful for the students. They are well motivated to be nurses in the future and therefone had to think about many kinds of death first person death, that is their own death, second person death, that is death of their relatives, and had no other choice but to be involved in many third persons deaths. They thought seriously about how to take third persons deaths and the discussion contained the essential points concerning what "death" is and "deaths of the first, second, and third persons." The discussions had a favorable impact on the students and motivated them to think more deeply about death. In concusion, discussions about death help to raise the ethical sensitivity of students.