This paper, reporting on selected data from a larger study, compares major end-of-life ethical problems in Japan and the West. Open-ended and force-choice questionnaire responses were collected from Japanese nurses, physicians and bioethicists (total N=121) and 102 Western counterparts. The combination, non-disclosure of diagnosis and prognosis to patients, the lack of patient autonomy, and the lack of informed consent was viewed as the major constellation of ethical problems by the Japanese respondents. In the west, treatment issues such as voluntary active euthanasia, transition from cure to palliative care, and pain management concerned the respondents most. Background factors and remedies for the major ethical dilemmas were examined from the social, cultural, and ethical perspectives.

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EBM has prevailed in the medical world since the last decade of the 20th century. At the time, it offered a new methodology to clinical sciences. Utilizing the theory of probability, predictions of phenomena in selected populations became possible within certain limits of credibility. EBM had its origin in the philosophy of positivism (A. Comte) in the 19th century. Because it is a kind of inductive inference, the results obtained by EBM can be shown as clear evidence to everyone. In policy-making EBM contributes to the establishment of healthcare standards. Through the EBM we see that all the laws in medicine are only probabilistic and medical judgments are always falliable. EBM and the old mechanistic biomedicine are two inseparable sides of scientific medicine. Science is neutral in regard to the system of human values. Therefore, EBM is a useful tool which we can employ to develop our good values.

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What we are concerned is how the remaining in ignorance of own HIV status is morally valuated. Many medical professionals advance and claim the mandatory HIV testing to a patient who would receive surgical treatments or a pregnant woman in order to prevent transmissions. Now, however, most people living with AIDS/HIV have infected by sexual activities. Due to the harm-to-others principle, we have to ask whether people in general who have sexual activities should be mandatorily tested. Furthermore, the question we have to ask here is to what extent a duty to know own HIV status is obligatory.

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In order to understand the ethical and social issues which arise from genetic technology and geneticallyrelated medical treatment, it is indispensable to think about the question "what is genetic information?" In an attempt to understand this question, this paper examines the nature of genetic information. It is believed that the nature of genetic information can be categorized into three characteristics: predicability; inheritability or sharability; and harmfulness. In order to quickly consider the peculiarities of genetic information, the arguments of George Annas and Thomas H. Murray were closely examined. Regarding the characteristics of predicability and harmfulness, genetic information is not different from other types of medical information. However, regarding the nature of inheritability or sharability, as a result of consideration from a standpoint of making a strict distinction between the "essential" nature of genetic information and the "image" we receive from this information, it is concluded that genetic information has a special nature. Over and above thinking only about genetic information, the distinction between the "essential" and the "image" will become increasingly important to see ethical and social issues arising from genetically related technology.

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Risk management has become an important issue in Japanese healthcare. This development can be explained by reasons that are internal and external to healthcare. First of all, medical malpractice litigation is increasing in Japan because American liberalism is spreading and the patients' rights movement is developing. Secondly, quality of care has become an important goal in both academic medicine and public policy. But risk management in Japan is not working well because many physicians are not familiar with the method of risk management. They also lack legal support and economic incentives that are needed in a system of risk management. The development of a good system of risk management will depend on adequate legal support, proper economic incentives, and a teaching program aimed at physicians. The role of a good system of risk management is not only to prevent medical litigation, but also to ensure high quality healthcare. To achieve the goal of high quality care, the focus must shift from narrow system of risk management to a broad system of peer review and medical audit.

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Bioethics is considered to encompass all approaches to the problems concerning life science, and has come to be considered a general term which is contextualized chiefly within the conceptual paradigm of medical and environmental ethics. The characteristics of Bioethics, however, exist as human rights in the idea of its formation. From this viewpoint, Bioethics is considered as a progressive work which reformulates new values, not be bound by past values, based on the variables of human rights. These works are characterized by the essential condition of this supra-interdiscipline that it is not tied to existing values. Recently, there has been no work based on this premise, but only discussions about life based on monolithic recognition. Such insistence was resulted in the loss of the standpoint of the protection of human rights under the name of Bioethics. Considering these discussions without such a standpointresults in the loss of its essence. Therefore, we need to reconsider the idea of Bioethics.

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John Hardwig, a professor of Philosophy in the United States of America, have argued "a duty to die" of the patient, in his paper 'Is there a duty to die? (1997)'. Four points at issue support his theory: the development of modern medicine; the imperfection of the health care system and the social negligence; the love to family; and the affirmation of patient's identity and the restoring her/his dignity. There are some criticisms to his theory on "a duty to die". But the aim of this paper is to criticize Hardwig's assertion from the viewpoint of our own. Hardwig puts a heavy stress on that "a duty to die" can be moral in so far it is, not imposed by a society or other peoples, but self-imposed voluntarily. A family is a sphere of close intimacy. Thus it is doubtful whether the possibility of voluntariness of "a duty to die" for other family members could be kept still after one decides on her/his early on death by self-awareness of that duty. In other words, when one declares undertaking "a duty to die" to the other family members, the individuals of family are necessarily bound by such a decision. Moreover we must inquire whether a pure spontaneity in itself could be realized. We think this problem bring us to more serious meta-ethical problems which underlie the ground of moral statement.

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If applied ethics has theories which are positively applicable to a real society, they must be transmitted as significant educational contents in school education. For example, the logic of inter-generational ethics, which environmental ethics maintains, will be a significant educational subject imposed on environmental education as training of judgment faculty. This subject requires also the extension of the concept of the dignity of human beings from the autonomous subjectivity centered in present time, to that subjectivity which intrinsically regulates the individual desires by giving thought to future generations as well. On the other hand, regarding the theory, which neglects the dignity of human beings, the ethical norm of education comes into confrontation with the assertion of applied ethics. Especially, the assertion which radical denies the human-centered concept, will be asked if it can be transmitted as a adequate educational content. This condition means that the transmittable norm in education can be the ethical norm, which restricts the assertions of applied ethics.

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The bioethical law in France dictates that the organ extraction from a dead body is permitted to perform inasmuch as the person concerned has not explicitly states in life his or her will to refuse the extraction (called "presumed consent"). It may seem that the duty of offering organs is implicit in this concept of "presumed consent," but this inference in fact is in contradiction to the principles of "inviolability and indisposability of a human body," the ethical principles which "the public order" requires prior to any regulation in French society. These two principles, which appear to be originated from a feeling of esteem for a human body, at first never oblige one to offer one's own organs, and then do not equalize the absence of will of refusal to any voluntarily consent, and lastly require agreement by the bereaved family in performing the organ extraction from the body in spite of the absence of the "owner." Another important concept "solidarity" may be called for in this respect to justify the duty of offering organs, but it also stipulates for the voluntary consent of both the person and the family concerned. If, however, the term "solidarity" should appear and prevail in such an ideal society that are so matured as to freely transcend the distinction between one and the others, or the individual and the society, it would be possible that "presumed consent" could be justified by the idea of "solidarity," in terms that the act of offering organs is not merely donation for others but is equal to donation for oneself, since this altruistic action operates only in a unified world of all human beings.

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This study is about decision-making at the end-of-life. The aim of the study is to show (1) the dynamics of decision-making after the patient was diagnosed with terminally illness, (2) the process these family members used to make the decisions, and (3) the factors that influenced this process. The methodology was 12 in-depth interviews. Findings included four patterns of ethical decision-making and six influence factors. The patterns were (1) patient decided, (2) family and physician discussed and decided, (3) physician decided, and (4) no direct decision because patient's death not seen as immediate. The factors that influenced these decision-making dynamics were patient and family provided information, patient told wishes clearly to family and physician, patients' personality, family values, family obligations, and family psychological distance from patient. In only two of these patterns did family members talk of the patient experiencing a good death.

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Ethical standards on using surplus human materials in medical research at the university hospital are discussed through a case deliberated in the ethics committee, and three ethical conditions and five procedures for the case are proposed from the practical view. In accordance with the Helsinki Declaration (2000), even if the confidentiality of system and the transparency of medical research are secured by the ethics committee, I judge that the use of surplus human materials without informed consent in medical research is not ethically valid. I believe that ethical standards on using surplus human materials involved the existing are as follows: 1) to have voluntary comprehensive consent of human subjects; 2) to clear the procedure that human materials are anonymous, non-connected data, and to monitor it; 3) to secure the transparency of medical research by the ethics committee. These are common to the conditions of human material bank.

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This study focuses on the conditions relating to the four ethical principles ("Be Autonomous," "Be Harmless," "Do Beneficent" and "Be Just") out of the free-writing comments in the questionnaire on medical practices in home care services, which was made about the visit nurses of 300 randomly sampled institutions across the nation, and aims to clarify ethical issues visit nurses confront in respect to medical practice at home care scenes. 314 free-writing remarks were obtained from 228 persons. The free descriptions were compared with the four ethical principles and those that related to the principles were extraced and classified. As a result, nine types of problematic situations were extracted. They are "Situations where medical treatment is given based on the doctor's intention rather than a patient's request or will," "Situations where medical treatment is given based on the family's intention rather than a patient's request or will," "Situations where a visit nurse cannot help taking an action at her own discretion upon changes of a patient's disease conditions," "Situations where a doctor's direction is considered necessary or not the best, but a visit nurse cannot help obeying it without discussion with the doctor about it," "Situations where a visit nurse feels difficulty in grasping a patient's disease conditions due to lack of information," "Situations where a visit nurse cannot help leaving observation and post-treatment to a patient's family," "Situations where a visit nurse feels the family's care is not appropriate to a patient, but it is difficult to intervene in the matter," "Situations where shortage of facilities behind the line threatens the quality and continuity of care" and "Situations where a the best medical treatment cannot be offered due to the limited supply of medicenes and medical care products." The principles of "Be Harmless" and "Do Beneficent" are concerned to every problematic situation. Also, there were the situations that relate to the principles of "Be Autonomous" and "Be Just." The above-mentioned results suggest the need for close information exchange and consultation between doctors and visit nurses for home care medicine, the responsibility of nurses to protect patients' rights and the need to change the awareness of not only patients but also doctors and nurses to realize patient-first medicine.

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Citing a growing donor-shortage crisis, the U.S. organ transplant community has been actively seeking new sources of transplantable organs in recent years. With progress in immunology and transplant-surgery techniques, the number of patients on organ waiting lists has outstripped the supply of available organs from brain-dead donors. In reaction, some medical institutions have begun procuring organs from people whose hearts have stopped beating but who are not technically brain-dead. Although a sort of non-heart-beating donation system was used in the U.S. back in the 1960s and 70s when brain-dead donors were not widely available, today's NHBD is different in one respect - they are ventilator-dependent. In addition, current NHBD protocols vary from one medical institution to another in such key areas as criteria for the declaration of death and pre-death medical interventions, indicating fundamental scientific and ethical principles including the determination of death vary. At one medical institution, its protocol says that surgeons should wait two minutes after the donor's heart has stopped beating before making an incision to procure organs, while protocols at other institutions say it should be five minutes. Some experts are opposed to the NHBD system, questioning whether the brains of such donors are dead at the time of organ procurement. They say that the system may violate the dead-donor rule. They also raise concerns that it is prone to be abused at a time when standards for patients care during withdrawal of life-sustaining therapy are evolving and continuing to be debated and studied, and it could compromise the care of the dying individual. Transplant surgeons in the U.S. seem to have started "managing" death to obtain organs.

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The study reports the present situation concerninng medical accidents in Japan. 200 questionnaires were sent to hospitals in Aich, Gifu and Mie prefectures in Central Japan. Responses were received from 54 of these institutions. Results show that in each hospital an average of 257 incidents occurred per year, incidents where the staff were alarmed but were able to prevent critical injury to patients. The 54 responding hospitals reported a total of 35 accidents in which patients were injured or died, but of these only 4 were actually reported to the local government or the Ministry of health. Reasons cited for non-reporting were lack of an adequate working definition of a "critical incident", and lack of administrative systems for reporting to the authorities. 79.6% of the responding institutions have special standing committees concerned with the prevention of these accidents and 80% responded that critical medical accidents should be reported to the authorities. This report considers the reasons many institutions do not report such accidents to the government, and proposes that the government and medical institutions share relevant information and utilize it to prevent such accidents.

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Our study was designed to investigate a ethical dilemmas in the maternal care units. Our questionnaires were consisted with two main ethical issues. 1) Nurses those who feel ethical dilemmas: (1) What is your ethical dilemmas? (2) How do you treat to solve the Problems? 2) Nurses those who do not feel ethical dilemmas: How do you treat the ethical problems when you encounter someday? As a result, 1) The most common ethical dilemmas were: (1) dignity of life 60.3% (2) nursing research in order to provide better nursing care 56.3%. 2) The most common ethical dilemmas in order to solve the problems were: (1) protect our patients 80.7%. (2) do our best 77.6%. 3) The majority ethical issues that you feel the most were: (1) protect our patients 83.9%. (2) do our best 81.4%. 4) How do you feel regarding to the origin of life? (1) at a time of the fertilization 61.8%. (2) eight weeks of pregnancy 18.2%. 5) How do you feel about discrepancy that competing a life between mother and fetus. The answers were: It is very difficult to make decision over the competing issues. Therefore, the answers were "neither mothers life nor fetus". The decision must make in accordance with criterias and cases. And it is necessary for Nursing Education about ethics and ethical dilemmas and so on.

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Questionnaire surveys were carried out to investigate the influencing factors on students to make a decision on to possess donor cards. The results showed that the possession rate of donor cards was 24.6%, The rate of which students held donor cards was 18.3% and the family's percentage of which held donor cards was 3.4%. 24.0% of students knew the definition of brain death, 19.4% of them knew the criteria of brain death. 80.0% of them hoped to receive education on brain death and organ transplantation. Students thought that friends, family and life were important to them. There was a relation between those who always possessed of signed donor cards and agreement with brain death, discussing brain death and organ transplantation with their family and friends and selfrealization. From this study, it was indicated that providing sufficient information and training in order to total judgement should be required to make a decision on possession of donor cards.

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The chronic short supply of organs for transplants has become an issue not only in Japan but also in the U.S.A. In the U.S.A., there is positive support for organ sales based on the fact that the problem would disappear if they were allowed. Henry Hansmann's paper "Market for Human Organs" is worth considering in this regard. He has proposed the establishment of an "Organ market", and this is regarded as the most radical proposal among those by supporters of organ sales. In Japan, where there is almost no support for organ sales, this paper would be regarded as nonsense. However, regardless of the moral issues, this is a practical idea containing some concrete proposals. It is therefore worth serious consideration as a current view supporting organ sales in the U.S.A.

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The new law for organ transplantation was enforced in 1997. According to this law, Brain Death (BD) is recognized as death as well as Heart-based Death (HD), which has been widely recognized as death by Japanese people. This law opened up the opportunity for the transplantation of heart and other vital organs that are essential for maintenance of life, as far as the person diagnosed as BD has signed on a donor card. The purpose of this study was to explore nursing students' views of death and willingness to donate organs. Two hundred two undergraduate nursing students voluntarily took a part in this study, and the findings were as follows. 1) More than sixty percent of the students approved HD as death. It was suggested that there must be other factors than curricula for forming views of death, for there was no relation to school year. 2) Almost ninety percent of the students expressed their willingness of donating their organs. 3) By the student group which approved BD as death, compared with the student group which approved HD as death, willingness of donating their organs at BD was high and willingness both during their existence and at HD was low (p=0.001). For the background, the education about BD in Japan, which has been strongly adhered to organ donation, can be considered.

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The primary concern of the 19th Century-West was becoming independent from God, i.e., Self-dependence. As a first and necessary step, the West had to liberate itself from the notion of God in their discussion of autonomy. After losing the old Law, Self became a new one. Autonomy was meant to be Self-centered. This process was necessary for discussing the concept of autonomy in its tradition. But, such critical issues as "What kind of Self" and "What kind of law" were unsettled. Early Buddhistm, on the other hand, was freed from the perception of God from its beginnings 2500 years ago. For Buddhists, Self was a decision-maker. But, they found that the notion of Self was the very root that prevented one from becoming autonomous. In other words, instead of liberating themselves from God, they found that they had to liberate themselves from the notion of Self. The liberation from the notion of Self and the independence from it was the primary concern for the realization of autonomy. Early Buddhists arrived at this understanding after observing and examining the mechanism of decision-making and analyzing the harmful nature of Self. They also introduced the methods of transforming heteronomous decision-making into an autonomous one. When one examines the Western understanding of autonomy from the early Buddhist perspective, one will find that the Western notion of autonomy encouraged the person to become Self-centered, while early Buddhist "autonomy" encouraged the person to be Self-less. Apparently, the former understanding is problematic. Indeed, many critically discuss the Western notion of autonomy today. The early Buddhist approach in autonomy seems to cast an insight in re-defining the Western notion of autonomy. It seems utilizable as a universal principle of ethics in approaching ethical issues in general today.

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Organ transplantation is a medical system that has a peculiar structure. It needs the third person (donor), in adition to the patient and medical staffs. Owing to this structure, it requires considerably sacrifice of life both of donor and his family. In case of organ transplantation from the donor of brain death, the body of donor has been materialized as medical resources from the certain point of time. As a result, the precious last life-time that the dying patient and his family spend together is cut off. This situation multiplies the loss and grief process of donor's family and may make the loss traumatic. We must be fully aware that we expose ourselves to the danger, having the donor-card and express our intentions to donate. From that point of view, we need some kind of qualification-test for the donor.

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In this paper, I inquire justice theories in bioethics. First, justice theories in American bioethics are criticized as follows. American bioethics has traditionally concentrated on distributive justice, and this narrow definition is often helpless in arguing current issues in the front-line of biomedicine. To illustrate my argument, reproductive human cloning (RHC) is discussed. American bioethics has been founded on secular pluralism, and rejects any kind of communitarian arguments against RHC. However, when we establish another category in justice theory, which I call "resourcification justice," justice in utilizing something as resources, the nature of the conflict can be identified specifically by questioning on what basis the health care service is justifiable. Under this categorization, then, how can we approach current biomedical issues? To clarify methodological justice in policy making on resourcification of issues like RHC, I inquire Rawlsian principles of justice in the context of those issues with fairness as only one guiding principle. According to this rationalistic analysis, without any communitarian premises, we need to be omniscient in estimating who will be the worst off. This is contrary to Rawlsian original position or veil of ignorance, and will constitute what I call narrative justice, which will be required in bridging the private narrative context of the narrator and the naratee, and the public context of policy making.

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A class example of ethics education in terminal care practiced in stage of the basic nursing education is described. It is considered that "to respect the dignity of the patient in terminal care" is "the nurse approaches the illness and suffering experienced by the patient, and supports the patient in facing himor herself". In the special subject "terminal care theory" of which the author is in charge, a goal is for "the nurse to attend to the deepest suffering of the patient by listening to the patient's true desires, and support the patient's own decisions". To begin with, we lead "the student to understand the meaning suited the patient with flexibility and sensitivity, by sitting near the patient and listening to the patient's voice, and facing the patient's true desires".

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Wrongful birth claim is generally defined that claim by parents of children born alive with disability and the fault of a doctor lies in permitting a pregnancy to continue to birth. We have four cases as to congenital rubella syndrome and one case as to Down's syndrome held in Japan. The claim brought by the mother was that, but for the negligence of the doctor in managing the pregnancy, the mother would have had a lawful abortion and child would not have suffered from injured condition. In Japan, as we do not have the provision of the fetal indication for abortion, wrongful birth claim by parents is founded upon a breach of a duty of advising the risk of the probability of a disabled child. But in practice, the doctor terminates the pregnancy of a disabled fetus. We recognize the separation of medical treatment and law. We consider the termination of disabled fetus in terms of medical treatment, law and ethics.

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Over 50,000 babies have been born by IVF in Britain alone since 1990. The issues arising are not simply ones of sience and medicine. People have quite rightly become very concerned about what the scientific possibilities are; they are more concerned today about ethicalissues than they were 10 years ago, and particularly so in the wake of the publicity surrounding the completion of the Human Genome Project and its potential. While recognising the benefits that scientific developments can bring to individuals, people are anxious about the effects on society as a whole, and fearful for the integrity of humanity. Uniquely in medicine, and almost uniquely in the world, social and legislative controls have been put in place by society over the way in which this field of medicine develops. The British Parliament recognised the mood of anxiety when in 1990 it passed the Human Fertilisation & Embryology Act which set up the Human Fertilisation & Embryology Authority (HFEA) to regulate certain assisted conception practices. In 1991 the HFEA took up its task of regulating research using human embryos, the storage of gametes and embryos and the use in treatment of donated eggs and sperm and of embryos produced outside the human body. As a regulatory body, much of the HFEA's work relates to the inspection and licensing of clinics carrying out IVF and research. The 21 members of the HFEA (and the 35 permanent staff) ensure that embryos are used responsibly and that infertile patients are not exploited at a vulnerable time. The HFEA grants research licences for certain purposes relating to infertility, but recently Parliament has permitted embryo research to extend to projects, including therapeutic cloning, intended to treat serious disease of all natures. The HFEA keeps a database of all treatments, successful or not, involving IVF, Dl and ICSI. It gives advice to government and to the patients. It regulates clinics through annual inspection and a Code of Practice. It monitors and licences new treatments, often after consultation with the public. It ensures that the legal requirement that the welfare of the potential child be considered before treatment is fulfilled. The HFEA meets 9 times a year, publishes an Annual Report and holds an annual open meeting. It applies ethical considerations in deciding whether a new treatment should be permitted. In 1998 the HFEA recommended that the permitted purposes of embryo search be extended to "ther-apeutic cloning", that is cloned embryos could be allowed to be kept for no more than 14 days outside the body with a view to procuring stem cells from them, which might one day yield new tissues for the body which would not be rejected by the patient because they would match him genetically. Reproductive cloning is and should remain banned. After a lively national and parliamentary debate, Britain legalised in January 2001 the use of embryos for research into serious disease. The research is to be licensed and monitored by the HFEA, adapting the processes already used for testing research proposals. The HFEA is concerned about controls being bypassed by scientists travelling abroad, and would welcome more international agreement about cloning, research and treatment regulation in the interests of safety and ethics.

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Human genome analysis was declared to have been completed by the Human Genome Organization (HUGO) and Celera in June, 2000. Its application to human health and for medical purposes are next targets and ethical aspects should be considered. In Japan, the government issued a guideline in 2001, but its principle was considerably different from that in the international guidelines by WHO and HUGO. HUGO Ethics Committee consisted of members from developed countries and the first statement reflected the Jewish-Christian philosophy. Now the committee includes members from Asia, Latin America and Africa in addition to members from developed countries. Basic and experimental scientists may feel that their research could be interfered by the ethical criticism, but internationally accepted ethical considerations are indispensable in Human Genome research.

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