In the history of medicine as well as in the modern clinical setting, conflicts between two contrastive models of explanation have been observed, the "pathogenic model" and the "recovery model". The pathogenic model focuses on how the pathological process is generated, and has its theoretical background based on the modern mechanistic view of nature. The recovery model focuses on how the recovery process occurs, and has its origin in the ancient Hippocratic school and teleological standpoint. In the context of modern science, the recovery model has always been criticized as a vitalistic and non-rational way of thinking. Some clinicians, however, have reported beneficial effects of certain symptoms. For instance, clinicians may use two different descriptions in the treatment of a fever: 1) the fever should be brought down because it is harmful to the body, or 2) the fever has a beneficial effect on the course of disease. Much research suggests that fever both benefits and harms the body. Therefore, clinical judgments will be based on assessments of these two aspects. Antagonism of the two models is one of the most fundamental themes in the history of medical theory. Hippocrates often referred to the "vis medicatrix naturae" and insisted upon the benefit of symptoms. On the other hand, scientists of the 17th century denied the existence of a "vis medicatrix naturae". To solve this conflict and obtain a basic theory of a model of recovery, we examined the concept of the norm with reference to the philosophy of G. Canguilhem.
The purpose of this paper is to clarify the logical construction of Robert J. Levine's model for the distinction between research and therapy. Levine's model has been adopted in well-known ethical guidelines such as the Belmont Report (1979) and the CIOMS guidelines (1993). Levine introduced into research ethics two theoretical models, the intent-based model and the approval-based model, for the distinction between research and therapy. He also recommended that physician-investigators deal with "innovative therapy" as research, which should be reviewed by IRBs. Levine criticized two assumptions which were largely shared in the medical community in the 1960's. Some physician-investigators thought that it was impossible to distinguish research from therapy because all medical practice was in a sense experimental. Others thought we should distinguish therapeutic research from non-therapeutic research and that the former can be conducted according to relatively relaxed standards. This was also the standpoint of the Declaration of Helsinki in 1964. These assumptions interfered with effective regulation of clinical research. Levine's model introduced a new perspective into research ethics and became a foundation of the contemporary regulation of clinical research. The purpose of this paper is not only to reconstruct past discussion and share its heritage but also to obtain suggestions for the regulation of clinical research in Japan.
Few of the current guidelines on clinical research mention ex post issues. For example, the Declaration of Helsinki includes as such an issue only its 30th Article and note. As for concrete ethical requirements, that is, Informed Consent, Assessment of Risks and Benefits and Selection of Subjects, the chief aim covers all aspects of applying the regulations to the preconditions. Emphasis was for a long time focused on how ethical principles regulate ex ante issues. In recent years, based on reflection on this situation, the need for ex post ethics has gradually become clear. Patricia A. King notes, in Belmont Revisited, that fairness requires specific compensatory justice and procedural justice, both of which were ignored in the Belmont Report. This paper aims to construct the idea of ex post ethics, which we call aftercare ethics, through examination of the principles of biomedical ethics. Chapter 1 confirms the fact that compensation and free medical treatment for accidental injury or damage are extremely rare in guidelines for clinical research. In Chapter 2, we address the problems of the emotions of the injured and the compensation. The reason why they were absent from clinical research is examined. In Chapter 3, it is shown that if we reinterpret the principles of respect for persons and of justice, we can see that the ethical necessity referred to in the preceding chapter can be derived from the said principles. Finally, in Chapter 4, we present the basic idea of aftercare ethics.
Advance directives are statements made beforehand by a person who was competent at the time about the care he/she wishes to receive if he/she were to become incompetent in the future. They are thus means of determining the patient's will when surrogate decision-making is needed. However, difficult problems may arise if advance directives conflict with the interests of the patient as judged by the people around him/her. This paper will explore this issue, focusing on advance directives of dementia patients. Theorists have varying opinions on the advance directives provided by dementia patients when they were competent. R. Dworkin argues that if someone has made a prior expression that "I will refuse any medical treatment at the terminal stage of dementia", we should not give the person any treatment at all. In contrast, R. Dresser asserts that "a dementia patient is a 'different person' from the person who made the advance directive", so that advance directives should be overridden if the current benefits of treatment the dementia patient may obtain are greater than the burden resulting from it. M. Quante asserts that advance directives should be respected as long as they do not cause actual pain or harm to dementia patients. The differences between these assertions are, in my view, based on differing views regarding the "personality" of incompetent dementia patients. Dementia patients have lost their personalities, according to Dworkin and Quante, while they have a "different personality" according to Dresser. However, a dementia patient and the person he/she used to be cannot be completely severed, for he/she is a being who lives one human life. Therefore, in order to make decisions on behalf of the patient, I suggest the need to distinguish him/her from the person who he/she used to be while at the same time regarding him/her as a person who lives one human life.
In Japan, the Council for the Ministry of Health, Labour, and Welfare recognized the right of children born by DI (Donor Insemination) to knowledge of their blood relationships, in the final report in 2003. This right will become a significant issue, because the report admitted the legality of reproduction by an egg donor. It goes without saying that the right to knowledge of blood relationships is important, since genetic knowledge has medical, psychological, and social effects. In the Japanese adoption system, the family registers makes it possible for adopted children to determine their blood relationships when they get older. But DI children can not know the information, so there is an imbalance in family register system between DI resulted children and adopted children. How do we solve this imbalance and retain the rights of donor offspring? In this paper, I consider the current situation in Japan and cases of other foreign countries as reference.
Dr. Makoto Kondo, a radiologist at Keio University, has suggested that one should not fight against cancer. His arguable claims are that (1) cancer screening is ineffective and that (2) cancer is divided into two categories: true cancer and pseudo-cancer ("gan-modoki" in Japanese). The former has a strong potential to be invasive and has already reached the invasive state on detection by screening. The latter is noninvasive and therefore the affected patients need not undergo medical treatment unless they exhibit some symptoms. Kondo highlights the evidence provided by medicine and informs us of how poor its basis is. It should be noted that he reached this conclusion through in-depth reflection on findings regarding cancer, without submitting to the opinions of the authorities. From the perspective of philosophy of medicine, we may state that his attitude is that of a philosopher. However, he also discourages patients who believe that cancer screening and treatment are effective. On the other hand, Dr. Toru Abo, an immunologist and a professor at Niigata University, has developed a theory regarding the close relationship between the autonomic nervous system and the immune system, and maintains that cancer can be cured by activation of the latter. In contrast to the claims of Kondo, many of Abo's claims lack medical evidence, but he offers hope to patients. Kondo's theory is based on positivism, and he does not raise the hope of patients. Kondo's position is very effective in revealing the insubstantial basis of medical science, but he confronts patients with nihilism, while Abo offers hope without considering the fact humans are mortal. Based on the opinions of these two doctors, we can reflect on the limits of application of positivism in medicine and the importance of the optimism that patients display and their individual initiative.
In moral discourse, people often appeal to emotion as opposed to reason. This is particularly true when they discuss the moral status of the use of new biomedical technology. Sometimes we may be unable to articulate an argument against organ transplantation from a brain-dead person, host surrogacy, human embryonic stem cell research, etc; we may then only say that "these acts are disgusting." What exactly do we mean when we say that someone's act is "disgusting"? In the first half of this paper, I shall distinguish three cases: (1) a person who seeks to reach a "reflective equilibrium;" (2) a communitarianist; and (3) a moral realist, each of whom may appeal to emotions in his or her own way. The purpose of the latter half of the paper is to examine and refute the manner in which moral realists appeal to emotion. Consider, for example, incest, cannibalism, rape and murder. It may seem that these acts are objectively evil, and that they provoke a negative emotional reaction. These facts might lead one to believe a realistic idea that human beings are biologically equipped with a special kind of emotion whose function is to detect objectively existing moral evilness. In order to show a fallacy involved in this inference, I shall point to a fact that has been reported in the literature of empirical psychology.
Under the banner of "structural reform without sanctuaries", the government is attempting to promote the introduction of market principles into the medical care system. Although the primary purpose of this reform is to reduce the total national medical expenses, it is also expected that the market mechanism will contribute to the improvement of medical services. However, if we consider the managed care system in America, it is clearly evident that the deregulation of the medical care system produces numerous adverse effects and that the market mechanism does not work as expected. From an ethical point of view, the most serious problem is that excessive deregulation leads to the corruption of medical quality and "social exclusion" of the vulnerable; this is because market principles, by definition, do not include any ethical norms in the regulation of the market itself. Considering the supposed nature of the medical care system, we should control the power of market principles. The national medical care system must be considered as a public issue, and not as a matter of "self-interest"; therefore, it requires the higher principle of "fairness" as its moral foundation.
The main envisioned contribution of professional ethics education for nurses has been that it offers a clear and concrete antithesis to the previous professional ethics education methodology, according to which it was supposed that nurses would be able to make correct ethical judgments if a set of given standards were applied to clinical problems. It was assumed that students who became medical professionals would be able to make ethical judgments in the clinical workplace if the general principles of these standards were clarified. On this basis, students were taught the principles of these standards as part of their training. The antithesis by professional ethics education for nurses was to spotlight caring which had been ignored because a change to a clear knowledge of science had been impossible. Specifically, case studies were adopted as a method of education, and emphasized the following four points: (1) stimulating moral imagination, (2) recognizing ethical issues, (3) developing analytical skills, and (4) tolerating disagreements and ambiguities. However, in practice, professional ethics education for nurses based on case studies supplies the training of proof, rather than the training of creativity and flexibility. In this paper, I propose the possibility of use of case methods in place of case studies. Case methods offer the possibility of going beyond the limitations of case studies, since they require training in unfettered judgment unrelated to occupational evaluations.
Patients with Capgras syndrome complain that real persons close to them have been replaced by identically looking imposters. This syndrome is interpreted as the total replacement of the "haecceity" that is distinct from one's attributes. Capgras syndrome suggests that possible worlds around a person come in two different series: one of possible worlds in which the attributes of the real person change in a variety of forms with his "haecceity" unchanged, and the other of possible worlds in which the "haecceity" of the real person is replaced by something else with his attributes unchanged. Possible worlds involving these two series could develop without limitations, and hence impart unlimited diversity to the variants of myself living in possible worlds. Thus, the variants in possible worlds must include some who possess both haecceity and attributes that are identical to those of others in the real world. It can thus be speculated that others in the real world are nothing but variants of myself who have turned up in the real world from possible worlds they originally inhabited. In this context, it may be assumed that I am keeping in touch with my own variants every day here in this real world. In the real world, I myself always create a singular point characterized as "I," "now," and "here". In a certain possible world, however, another person generates this singular point. As a result, I myself become the other to him. Such worlds where I turn up as the other probably include ones whose contents are exactly the same as those of the real world. Because these worlds are perfect mirror images of the real world, we mistakenly assume that they are the same one world. Because of this confusion, we see many generators of the singular points coexisting in the real world.
We can objectively observe the speech and behavior of others but are not privy to their thinking. Even in face-to-face conversation I cannot understand everything you experience. This is the problem of intersubjectivity, which is achieved through agreement and negotiation between different, mutually independent perspectives. This paper seeks to understand the perspectives of others using A. Schutz's concept of relevance as a means of unraveling the problem of intersubjectivity. Based on records of conversations between nurses and a mother who gave birth to a disabled child and letters written by that mother, this paper explores the mother's narrative and presents it as an example of understanding others. The paper also indicates how analysis of the mother's perspective at different times using the concept of relevance is linked to ascertaining the mother's stream of consciousness.
It is believer that the concepts of mental illness, mental disease, and mental disorders, which represent the theoretical basis of psychiatry and psychiatric medicine, are more likely to bring about problems in use than the concepts of physical illness, physical disease, and physical disorders. In this paper, I will consider two such problems : (1)the concepts of mental illness, mental disease, and mental disorders often bring about more conflicts among experts regarding the diagnosis than that of physical illness, physical disease, and physical disorders ; and (2)there are more conflicts over whether some mental illness, mental disease, and mental disorders are illnesses or disease in a relevant sense as compared to physical illnesses, physical illnesses, physical disease, and physical disorders. Szasz, Boorse, and Fulford have all responded to the question of why these problems have com about. In this paper, I will critically examine their responses and then propose my own response to this question in the following manner. First, the concepts of mental illness, mental disease, and mental disorders bring about more conflicts among experts than that of physical illness, physical disease, and physical disorders because there is no consensus on whether the painters' condition damage their natural primary goods. According to Rawls, primary goods are "things that every rational man is presumed to want." Some primary goods such as health, vigor, intelligence, and imagination are natural goods ; although their possession is influenced by the basic structure of society, they are not directly under its control. Second, there is much debate about whether particular mental disorders, such as personality disorders, are illness or disease in a relevant sense as compared to physical disorders. This is because the evidence for biological deviations corresponding to mental disorders is often more lacking than that for physical disorders.
The purpose of this survey was to determine whether there are differences in the knowledge, opinions, and way of thinking about state-of-the-art health care and bioethics among students from different disciplines who attended bioethics-related classes in departments of medicine, Buddhist studies, social welfare, and dietetics. The survey was conducted with 303 students in 4 departments in 3 universities by a questionnaire completed by each person. Some differences were found among the disciplines in self-evaluation concerning knowledge of "bioethics" (p<0.01). On the other hand, there were no significant differences among the disciplines in opinions or ideas concerning bioethical topics such as "development of research" and "organ sale". Experience with study in the academic field or biology made a difference in students' self-evaluation concerning knowledge of bioethics, but did not affect answers to questions regarding opinions or ideas. This held true for a comparison between students (n=169) who took classes on bioethics and those who did not. It appeared that while self-evaluation regarding knowledge of bioethics was enhanced by study experience, opinions and ideas on bioethics were significantly correlated with study experience.