The word 'trust' is used in a variety of situations. We often use the word to describe the people's perception of institutions. For instance, WorldCom and Enron were called trustbusters, mainly because they did not fulfill the moral standards expected of their businesses. We also use the word to describe the relations between persons. Here, the ambiguity of "A trusts B" becomes more apparent. Sometimes it is used in the context of business transactions, meaning "B will carry out the contract he made with A." But we also use it to describe a particular aspect of personal relationships, such as "She has cared about my welfare so much, working long hours, and so I have full trust in her." Following Annette Baier's analysis, we can divide the meaning of 'trust' into two categories : reliance (reliance on others' particular attitudes and reactions, or on their dependable habits) and trust (a special kind of reliance, i. e. reliance on another's good will toward one). In the medical context, reliance can be strengthened by reducing medical errors and implementing measures to protect and respect patients' welfare, while it seems there are no easy prescriptions for medical professionals to earn trust, since it is difficult for a patient to see directly whether her medical providers have good will towards herself. All they can do is to create a climate of trust where trust could possibly grow. To aim at gaining trust directly will be self-defeating and sometimes even bring about undesirable consequences. Today many emphasize the importance in medical settings of trust relationships between lay and professional, as distinct from mere reliance relationships. I contend, however, that what is needed is to try to increase patients' reliance on medical providers' attitudes and the medical world in general, and if things go well, medical professionals may earn trust as a result of their efforts.
The purpose of. this paper is to reconsider the ethics of truth-telling through analyzing the theory of Catholic bioethics and its practice in the in-home palliative care provided by the Association Romanini in Rome. Catholic bioethical theory obliges doctors to tell the truth only to the extent that their patients demonstrate the willingness and ability to accept it. Following Catholic ethics, medical staff of the Association Romanini first tell the truth to their patients' families, and then in discussion with these families decide whether or not it is preferable to tell the patients. In practice, however, they tend to refrain from telling the truth to their patients. This is primarily because they wish to avoid negative effects, such as the patient's 'loss of hope', and secondarily because establishing a relationship of trust between the medical staff, family, and patient is considered more important than the act of truth-telling itself. Family participation in decision-making is common in Japan as well. It has sometimes been criticized as a result of Japan's socio-cultural tendencies to emphasize group decision-making. Indeed, family decision-making may infringe paternalistically on the patient's autonomy. However, the case of the Association Romanini illustrates the importance of human relationships of trust - not only between the medical staff and their patients but also including their families - that cannot be reduced simply to contractual, clinical or 'provider-consumer' relationships.
This paper aims to elucidate some ethical and social issues raised by designing life and to examine them in connection with eugenics. Advanced medical technology has made possible some methods of designing life, such as sperm/egg or embryo selection, germline genetic modification and the production of life by cloning. The subject of our investigation is germline genetic modification or manipulation, especially the enhancement of capabilities or traits of children at the request of their prospective parents. "The voluntary choice of the individual" is both a main argument justifying that form of intervention and also a strong ground for supporting the "new eugenics," which is distinguished from old, state-sponsored eugenics. On the one hand, new eugenics is a body of thought and practices based on the premise that the choice of a "desirable quality" is part of the reproductive freedom of an individual as a consumer or client. This type of new eugenics is closely related to the way of redesigning society sought by Neoliberalism, which values the self-determination of the individual, the free-market and deregulation. On the other hand, new eugenics is an attempt at improving the gene pool of future generations by remodelling human beings, and it advocates a new evolution of humankind. In some arguments presented by new eugenics to justify germline genetic enhancement, serious ethical and social problems are found, namely a distortion of the way of relating to others, discrimination against disabled people, harmful effects on children etc. So we should severely scrutinize the connection between that form of technology and new eugenics.
Organ transplants receives scant social approval if the persons who offer to donate their organs are the weak. Acceptance that a brain dead patient is a dead person does not take root in Japan, and as of May 31, 2002 the number of liver transplants from brain dead persons is only 18 cases from 16 donors. On the other hand, the number of liver transplants from living donors has already exceeded 2000 cases albeit the registry of such cases is not exhaustive. The Japanese people recognize the donation from a living person as proper because the organ is transplanted from a healthy person to a weak one, but actually one third of the liver transplants from living donors is said to be transplants from a child to one of its parents. Thus whether or not the principle of "from the strong to the weak" is followed in all cases must be checked continuously. An ethical problem occurs in the case of the donation from the child to its parent, especially in the case of a young child who is living together with its parents. There were a few reported examples of such liver transplants : for example recently the offer from a 20-year-old daughter to her father was reported. The operating surgeon said that if the donor is over 20 years old, the organ donation is made by the free will and hence becomes possible legally. The surgeon further asserted that if the donors are under 20 years old, it is sufficient to wait until they become 20 years old. But the premise that parents are always the child's best advisers does not hold good under all conditions ; the decision-making of 20-year olds needs an environment where no social, economic, and religious pressure is exerted. When such an environment is lacking, the rational choice of an organ donation to one's parent is not guaranteed.
The fact that the conception of care has drawn our attention expands the definition of the moral realm of Kantian moral theory. It means that we must listen attentively to the "excluded other." And we must resolve the dichotomy between "reason, culture, and law belonging to man" and "nature and sensation belonging to woman." Therefore the concept of care should make us think anew about the relationship between care and the other in health care. Because I do not think that a modern moral theory that includes care which adequate to the way of life lived in complex modern societies can be formulated without some universalist specification of impartiality, I find it more fruitful to construct the concept of care not as a rejection of universalism, but rather as a contribution to the development of a non-formalist, contextually senstive, and postconventional understanding of ethical life. I will describe two conceptions of "care and the other" that delineate both moral perspectives and interactional structures in health care. Following Seyla Benhabib, I shall refer to the first as the standpoint of the "generalized" and the second as the "concrete" other.
The technology of drugs to treat physical pain has progressed and become widely available. Therefore, the number of persons terminally ill with cancer who suffer from physical pain has decreased in recent years. However, there is a fear that the treatment of such pain has become so routine, that the patient who discovers meaning through physical suffering is deprived of that meaning. It seems that the meaning attributed to physical pain by a person terminally ill with cancer differs from that of a patient after an operation. In the latter case, physical pain prevents the consciousness that faces life. On the other hand, in the case of the terminal cancer patient, pain is "the magnetic field" which fixes the consciousness that faces death. This magnetic field may fix that consciousness in such a way that it tends to face to life rather than death. It is said that for terminal cancer patients informed consent concerning pain management is as indispensable as is consent for other medical treatments. Some persons may think that there is no problem in the "routinization" of pain management, because a patient himself is holding the helm in this treatment and is able to control by his own will the physical pain which would act as a magnetic field fixing his consciousness on death, and moreover he is even able to escape the pain. However, if such treatment causes him to mistake his medical situation so as to believe that a terminally ill cancer patient can live comfortably without physical pain, informed consent is unable to be applied to him.
This paper discusses the debate in the Journal of Medical Ethics over the ethics of care between P. Allmark and A. Bradshaw. For the last 20 years, since C. Gilligan's work, the possibility of an ethics based on the concept of care has drawn considerable attention. Allmark argued that an ethics of care could not be based on the premise that care encompassed moral values because the word "care" itself could be applied to good or evil situations. Bradshow argued that care ethics could be comprehensible only when linked to the Judeo-Christian tradition. Allmark said that Bradshaw's care ethics had normative and descriptive points in so far as defined what should be cared for and haw it should be done, but that she did not respond to his assertion that a moral sense might not be derived from care itself, and also that her understandings about care contained philosophical and historical difficulties. Allmark is justified in arguing that, in general usage, care is a neutral term, and that as a result it can not be said to have moral overtones. Care can be used in the moral sense only if its subject and methods are clearly defined. Further, Allmark's attempt to cast doubt on Bradshaw's view of nursing care as a God-sent profession based on the Judeo-Christian tradition is acceptable from the viewpoint of modern nursing. In the context of nursing, however, it is beyond doubt that the subject of care is the sick and that the recovery of her health is intended. The discussion of care must include a very significant way of thinking by nurses in order to achieve the level of care desired, and it should rest on a foundation of respect for individual persons. The whole discussion of care in this context cannot be invalidated simply because the term "care" is also used in torture.
When we talk about the 'quality of life' (QOL) we should inquire just into the 'quality' of human life. Generally speaking, a qualitative thing includes something original that has no substitute. Each person's existence is an irreplaceable life, and it has a unique value. QOL is a subject about the qualitative values of human life. The pursuit of QOL is the pursuit of a 'healthy' human life or 'happiness.' E. Fromm said that a person represents the whole human being, and that an individual is a physico-spiritual totality. He also said that the goal of a person in life is to be himself. According to Fromm, the fundamental human desire aims to conquer 'existential dichotomies,' such as 'life and death,' 'solidarity and aloneness.' Everyone shows one's answer depending on his/her character or personality. Only a 'productive character' can get happiness through its answer. That is the basic attitude by which 'human nature' and 'individuality' are brought into full play at the same time. Such a person gropes for a 'sane society'. And such a society ought to bring up sound persons. QOL as elements of a living environment are useful as conditions for happiness. However, the most important thing is the 'quality' of each one's life itself. This kind of QOL is shown by the basic attitude as 'personality.' A person who lives a well-filled life has a high quality of life. The scale of quality of life as the standard common to human beings is 'human nature,' which is also the foundation of human equality. This is the 'basis' of human rights. And each person will be the judge of the matter connected with 'happiness, making use of the activation of individuality. So, medical persons should not confuse QOL and 'social usefulness! Medical preference order is not a problem of QOL but purely a problem of medical technique.
In Japan, when a patient who does not have the ability to agree to his/her own health care has to receive certain care, family members usually agree to it without clear legal authority. However, it is thought that some patients need an agent with clear legal authority in order to respect their self-determination in health care. I think that an agent with clear legal authority can consent to health care on behalf of a patient in Japan, due to the new guardianship system for adults implemented in April of 2000 because of the increasing number of demented elderly people. If we make use of the adult guardianship system, the self-determination of an incapable patient is more likely to be respected because acts of a guardian can be supervised by a supervisor and a family court. In Germany, when a person without the ability to agree to health care receives certain health care, an agent with clear legal authority has to be assigned. In addition, when an incapable patient receives health care that involves a risk of death, it is necessary to obtain permission from a court. In Japan as well, there are some cases in which medical care decisions are required to be subjected to examination by an outside organization, such as a court or a hospital ethics committee. However, at present, a treatment policy cannot be decided by a court in advance of the treatment, and hospital ethics committees do not work sufficiently. We must first fortify the system of hospital ethics committees. We also need a third organization, for instance an independent governmental agent which has a quasi-judicial function and which decides a treatment policy in advance of the administration of the treatment.
Anthropologists such as Kleinman 1 and Helman 2 have pointed out that any society, whether Western or non-Western, exhibits pluralistic health care (or medical) system. Within these societies there are many persons or individuals who offer the patient their own particular way of explaining, diagnosing, and treating ill health. In the pluralistic health care system, we can identify three sectors of heath care or medicine ; the popular sector, the folk sector, and the professional sector. In order to rethink the symmetry (or equality) in the doctor (or healer) -patient relationship in each sector, this paper compared the relationships found in the three sectors. A healer and a patient in the popular sector can be equal because they are able to share the same basic values of health care and their positions, therefore, are at anytime interchangeable. Both in the professional sector and in the folk sector, a doctor (or a healer) and his/her patient cannot be equal because their positions are not interchangeable due to the professional dominance and medicalization of everyday life, especially in the professional sector. In conclusion, a lay people's empowerment by releasing health care knowledge and skills from the professional dominance and by sharing them could bring about a change in the pluralistic health care system that equalizes the doctor-patient relationship to the healer-patient relationship in the popular sector.
Nursing is an emerging profession trying to fulfill the criteria that define a true profession. The professional work of nursing is approached in a scientific manner. The nursing process is defined as an intellectual activity meant to be approached regularly and systematically now that the nursing process is the accepted method of professional practice. However, the nursing process is not the only capability required of nurses. The nursing process is nothing more than a problem-solving process by which nurses meet patients' needs. The patient's set of problems, referred to as the "nursing diagnosis," is undergoing international standardization. To standardize is to risk overshadowing the care that originally motivated the more scientific approach to solving patients' problem. Still more, with the increased complexity of medical care, nurses have taken over more and more of the activities associated with medical practice. Consequently, in the actual reality of practice, nurses sometimes lose sight of caring. What is the primary expertise to which nursing lays claim? So far, nurses have always valued the idea of caring for persons. Has nursing abandoned its caring role? Caring means that persons, the subjects of nursing care, are treated not as objects or impersonally but always in a way that considers the essence of the person, i. e., the opposite of mechanization and depersonalization. Also, what patients want and need most from nurses has been and still remains quality, humanized care. Therefore, nurses are challenged to enhance and develop the caring tradition of nursing as expressed through the nursing process.
In the argument concerning informed consent, the concept of "non-directives" has been used as a protector of patients' self-determination. This concept is especially important for medical counselors. Ethical pradoxes arise when placebos are used both in medical experimentation and in a clinical setting. A placebo is a substance that the health care professional believes to be pharmacologically or biomedically inert for the condition being treated, the placebo effect sometimes be produced without nondisclosure, incomplete disclosure, or deception. Nevertheless, a placebo is less likely to be effective if used with the patient's knowledge. This raises the question of whether nondisclosure of placebo use is morally permissible. Most controlled trials are randomized clinical trials, which are generally preferred to observatinal or retrospective studies on grounds that their results have a higher degree of validity. Even if they had no preference for one treatment over the other, some patients may have refused conventional randomization because of its uncertainty. However, some critics suspect that disclosure of information became distorted, perhaps unconsciously, when the physician knew the assigned treatment in advance. Clearly, the process of obtaining informed consent under prerandomization merits unusually careful scrutiny to ensure adequate disclosure. On the other hand, a placebo is clinically given to a patient at the medical staffs' discretion without informing the patient about its use. The therapeutic use of placebo involves intentional deception or incomplete disclosure. This parodoxe is resolved when a patient has a chance to get a second-opinion.
The medical staff of Obstetrics and Gynecology Department, Kagoshima University was considering plans to conduct clinical trials to test the embryos of Duchenne muscular dystrophy patients, but they were unable to gain approval from the Japan Society of Obstetrics and Gynecology. Groups and organizations that support the handicapped pointed out that there are problems with trying to make life and death decisions based on such tests. They argued that such testing implies a desire to lower the level of social services for the handicapped and to inflame the public's prejudices. In other words, the tests are considered as another example of discrimination towards families with a history of genetic disease, in the tradition of discrimination in jobs and marriage. However, as long as the freedom of the clients (the parents of the unborn child) for whom the tests are conducted is preserved, and their right to decide what to do with the results is protected, this reproduction medical technology does not threaten the constitutional rights of the handicapped, as provided in Articles 13, 14, and 25 of the Japanese Constitution. Allowing parents to decide whether to give birth to a handicapped child is not inconsistent with a policy aimed at improving welfare services.
The term "care" has lately attracted considerable attention in the various fields, such as psychology, education, medical treatment and social welfare. Especially, in the realms of medical treatment and social welfare, concerns arise due to the rapid progress of the aging of society, the change in disease structure and the rapid progress of medical technology. As for care in medical treatment, there is recognition that patients or clients are the center of medical treatment, because the meaning of "care" focuses not on the sickness itself, but on the living person with an illness. It is important for medical staffs to realize the dignity of the patient's personality through their care. There is an interactive relation between patients and nurses, and therefore they have their own individual values, appraisal standards and interests. I think that care is recognized and/or adjusted between them accordingly. When offering nursing, a relation with the family of a patient and nurses is also important. Because 11 hink that a family is an important person for a patient. However, there is not the study how nurses understand a patient's family, and what nurses expect of them.
In December 2000, The Welfare and Science Council of the Japanese Government released the final report concerning Assisted Reproductive Technology. That report agreed to the use of donor sperm, ova and for the In Vitro Fertilization and Embryo Transfer. I think that the final report of the Council has two problems. Firstly, it is objectionable that the client's brothers and sisters are included among the donors. This is an exception to the rule that the donor's name is withheld. Secondly, it is objectionable that children have a right to know their genomic parents. Children born by using donor sperm, ova and embryos, have three kinds of parents. They have real parents, foster parents and genomic parents. The right of these children to have access to the identity of their genomic parents is growing. The first and second problems are closely related. I try to clarify this close relationship in my report. The rights for children to know their genomic parents contradicts the rule of the anonymous donor. If these children know their genomic parents, the donor is not anonymous. I think that the client's brothers and sisters form majority of all donors. Children have been born by their uncles' sperm and their aunts' ova. The children are very shocked to learn their origins. The parent-child relationship becomes very complex. A new Council of the Assisted Reproductive Technology started in 2001. This Council discussed the rights for children to know their origins. But the Council members have, as yet, not formed any definite opinion. I think that the rights for children to know their origin is more important than the rule of anonymous donor, because children's rights take priority over parental desires.