The question of whether to withdraw mechanical ventilation from brain-dead patients remains nearly unexplored in Japan. This study was conducted to investigate whether physicians withdraw care from brain-dead patients, and to identify and analyze factors influencing their decisions. A retrospective, in-depth interview study was conducted with 35 physicians at emergency and critical care facilities in Japan. The process of data collection and analysis followed the grounded theory approach. Data analysis revealed that withdrawal of mechanical ventilation from brain-dead patients was not common, and four factors related to the practice were identified: (1) legal and institutional barriers that perplex physicians when dealing with brain-dead patients. The barriers include "the double standard of brain death" in Japan, in which brain-dead people are considered legally dead only when they are organ donor candidates; (2) emotional barriers that prevent physicians from withdrawing care; (3) cultural values that promote family-oriented end-of-life care; and (4) medical reasons including physicians' assumption that the patients would have circulatory cessation shortly even with continued mechanical ventilation. Data also showed that families of some brain-dead patients became exhausted waiting for circulatory cessation in the patients when the patients' somatic maintenance lasted for weeks. Meanwhile, 3 of the 35 physicians routinely offered patients' families the option of withdrawing mechanical ventilation. These physicians had certain characteristics in common, such as a different perception of the double standard of brain death. They appreciated the double standard because it allows discretion regarding when to stop providing medical care to brain-dead people. They consider that the discretion is indispensable for medical providers in Japan because currently the understanding of brain death varies according to each individual. The physicians believe that the double standard has helped them in providing better support to the family until the family accepts that the patient is dying. This research suggests that maintaining the double standard of brain death and providing the brain-dead patient's family an option of withdrawing treatment would better serve the family.

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In bioethics, there have been adopted a variety of approaches since the 1980s. However, as the normative approach has been the mainstream in the existing discussion of bioethics, the importance of a descriptive one has not been examined fully. In this paper, the problems in descriptions found in current bioethics are uncovered through a comparison with ethnographic epistemology, theory and methodology, which are the basis of anthropological understanding about human conditions. In addition, the relevance of an ethnographic approach in bioethical thinking is demonstrated through an examination of the dialectic process between description and theory construction.

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On March 23, 2007, the Supreme Court denied legitimacy to twins that were born to a Japanese couple through an American surrogate mother. At the same time, the decision required the government to enact a law concerning surrogacy. Heretofore, guidelines of the Japan Society of Obstetrics and Gynecology, the report of the Japan Federation of Bar Associations, and the report of the Ministry of Health, Labor and Welfare prohibit surrogacy, mainly because it is contrary to human dignity. Nevertheless, after analyzing public order, which is a component of human dignity, it is not clear that surrogacy is contrary to human dignity. Thus, this prohibition might result in the violation of basic rights. To productively discussing the validity of surrogacy, we need to balance the basic rights of the clients with those of the surrogate mother, to interpret these basic rights, and to evaluate life and body, which are not placed adequately in the rights-based framework, without referring to human dignity. In order to use the word "human dignity" appropriately, we should use the word as a result of consideration, and not for the purpose of consideration.

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The broad consensus on the definition of death which the Uniform Determination of Death Act of 1981 had created in the US seems to have weakened in recent years. To obtain an overview of the issue, a literature review was conducted using the Georgetown University's ETHX database. The relevant issues collected from the reviewed articles were sorted and explained under the three headings: 'issues arising from the accumulated experience of diagnosis of brain death', 'issues triggered by the tendency over the years to expand the donor pool', and 'unresolved conceptual problems'. The following discussion focused on the question: why is it that the definition of death controversies remain so hard to settle? Suggested answers were: the nature of the question "what is death?" has not received the proper examination it deserves; and the multifaceted nature of the question has made it difficult to discuss among experts from various backgrounds. With the consensus in Japan on brain-death criteria far more fragile than that in the US, and with the upcoming revision of the Organ Transplantation Act in sight, questions concerning the definition of death should be carefully examined. To do so, the controversies in the US should be closely studied.

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The purpose of this paper is to analyze the extent of interests in ordinary life and the need to use genetic technologies in areas requiring enhancement, such as "physical strength," "intelligence," and "aging". In the model for analyzing this analysis, which is the binary logistic model, the dependent variables are the extent of interests in ordinary life and the need to use genetic technologies, while the independent variables are basic properties, the structure of the family, and social attitudes toward genetic determination (points of the factor analysis). In this output, interests in ordinary life are affected by gender, age, and educational background. On the contrary, the need to use genetic technologies is affected by gender and job conditions, which differs from the former models on interests in ordinary life. Further, the first factor (physical strength and appearance), the points of the factor analysis for genetic determination, and the fourth factor (clinical medicine) are particularly significant elements favoring the need to use genetic technologies.

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The main HIV prevention activity at the moment is calling for each person that is sexually active to reduce the risk of HIV infection. Obviously, HIV prevention activity is relatively unproblematic from the moral point of view. However, the message of HIV prevention contains not only guidance for risk reduction but also some specific "values". Furthermore, it contains not only individual behavior modification, but also reconstruction of society to facilitate that behavior modification. The understanding of what it means "to be infected with HIV" is necessary before agreeing to behavior modification and reconstruction of society, if we respond independently to the message. However, it is also necessary to recognize the limitations of the individual that cannot be helped in responding to the message of prevention, when there is a fundamental limit on that understanding.

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The present study was aimed to promote discussions on optimal palliative care for improving the QOL of cancer patients, terminally-ill patients, and patients with intractable diseases in Japan by reviewing the concepts and ethical issues of palliative care in European countries with advanced palliative care. Documents were compared, including reports by the PALLIUM Project and nation-specific reports by the European Association for Palliative Care. Historically reconfirming that based on the hospice philosophy, palliative care for patients is an integration of palliative medicine with holistic care, palliative care in Europe was evaluated according to issues over the WHO's definition of palliative care. In Europe, palliative care was found to be practiced with certain standards, but in different ways depending on cultural background in systems, targets, places of bereavement, indicated periods, ways of disclosure, decision-making in terminal care, and relationships with euthanasia and assisted suicide. These findings are suggestive for the construction of Japanese health care system in which palliative care is available to all those who need it.

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Ethical problems arising in the hospital have been dealt with among concerned staff up to now. In recent years, installation of ethics committees has increased, but their role is not clear in ethical problems. We conducted the questionnaire based research for the 2164 hospitals certificated by JCQHC (Japan Council for Quality Health Care). By this questionnaire, we asked nursing administrators in each hospital about their awareness and the way to solve the ethical problems. In this questionnaire, 64% of examinees answered, "It is a concern" and 31% answered, "It depends on the person". The ways to solve the ethical problems arising in the hospitals were discussed mainly in the conference at the ward or at the department and were privately talked by staff. It was very rare that the problems were applied for the ethical committee in the hospital. Mainly the doctor's medical treatment plans or research were applied. The consideration and concern about ethical problems, the existance of the place or chance to discuss the ethical problems, the practice of the ethics consultation by ethics committees, led to the resolution and reduction of ethical problems.

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In this paper, the author proposes the necessity of a new research field of "humanities approach to life," in which researchers in arts and humanities discuss contemporary issues of life and death from a variety of angles. Japanese academic bioethics has succeeded in creating the discipline of "medical ethics" in the field of medicine. However, up until the present it has failed to create a comprehensive humanities approach to contemporary issues of life and death. The humanities approach that we are going to propose discusses topics such as, "Will the development of biotechnologies provide us with true happiness?" "How can we protect our dignity in the age of advancing technology?" "How is it possible to attain a harmonious relationship between humans and the natural environment?" and "In what kind of society can we live a truly fulfilled life?" In the United States of America and European countries, this kind of research would surely be heavily influenced by Christian doctrines. In countries like Japan, where religious circles do not have much political power in the field of bioethics, it is highly probable that researchers can discuss these topics, being freed from a heavy religious bias and influence. This will be a great advantage to the humanities approach conducted in Japan. This project requires advanced skills in informatics because we will have to provide researchers in various disciplines with internet tools for real-time communication and data sharing related to research subjects. Hence, this project should be developed as a joint venture with informatics.

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This paper discusses the revelation of quarantine policy for patients with Hansen's disease and various distinctions from hearings of 14 patients who have Hansen's disease in Taiwan. It can't be denied that the quarantine policy for patients with Hansen's disease established by the Japanese regime war continued by Kuomintang government until the early 1960's. From several pieces of evidence, it was revealed that their freedom of movement was remarkably restricted by 1970 although there was no complete curfew after the war. The anxieties of the subjects at present arising after concerned care issues accompanying the aging and various issues with demolition of leprosaria. We will look on the movement against the demolition of leprosaria by the leprosy patients as a way to restore their dignity as human beings as living witnesses.

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After a prenatal diagnosis indicating whether the fetus is handicapped (or otherwise poses eugenic concerns) a expectant mother is immediately asked to give a response to the information given. This is supposed to be self-determination and taking personal responsibility, even though she may not be fully aware of the implications: namely, that her response may involve taking the life of her baby. This study reveals that few of those who go through prenatal testing know correctly what sort of information they will be given and what unexpected consequences it may lead to. It is desirable that pregnant women themselves collect information and, together with their partners, decide what further information to obtain and thus avoid thoughtlessly undergoing risky tests. Furthermore, it is urgent to establish a system in which a third party gives the women adequate consultation and support at the appropriate time.

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In Japan, surrogacy is prohibited by the Japanese Society of Obstetrics and Gynecology because of ethical questions related to treating women as merely the means of reproduction and because of the risk for surrogates during pregnancy and at delivery. However, some couples travel overseas for this purpose and despite the prohibition, several cases have also been reported from Japan. In the state of California in the USA, surrogacy is permitted and widely practiced. In this paper, I considered the merits of legalizing surrogacy by identifying the respective plusses and minuses of prohibition and legalization with reference to the Japanese movement and philosophy regarding surrogacy and the California situation surrounding surrogacy. In California, surrogacy is frequently practiced as a business, so women's bodies are in danger of being commodified. However, a system has been constructed for minimizing the risks and problems associated with surrogacy. If surrogacy is prohibited in Japan, I believe it would not disappear but rather continue under the worst circumstances for children born through surrogacy and women who become surrogates. I conclude that we Japanese should consider accepting surrogacy and should discuss what conditions we need to assure transparency and safety regarding surrogacy.

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In Japan, although there have been many requests from many quarters to legislate medically assisted reproduction, deliberations in Parliament are still not making much progress. Reports have been issued by two bodies, i.e., the "Special Committee for Medically Assisted Reproduction," "the Health Sciences Council for Evaluating Advanced Medical Techniques" of the former Ministry of Health and Welfare, and the "Sub-Committee for Medically Assisted Reproduction" Health Sciences Council of the Ministry of Health, Labour and Welfare, released in 2000 and 2003 respectively. At present, it is clear that medically assisted reproduction techniques which were not authorized by the Japan Society of Obstetrics and Gynecology have been carried out, such as "posthumous reproduction", "surrogate conception," etc., and they have now become significant problems. The problem of "a child's right to know about his/her origins" also ranks with "surrogate conception" as a major discussion topic in this field. In this paper, we survey the state of "posthumous reproduction," "surrogate conception," and "a child's right to know about his/her origins" in Japan, from the viewpoint of legislation practiced overseas.

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In 2006, the Revised Uniform Anatomical Gift Act was drafted by the National Conference of Commissioners on Uniform State Laws in the U.S. Up to the end of 2007, it has been adopted in 20 states. One of the most important purposes of this revision is to promote anatomical gift, namely, organ donation. In this paper, I will deal with the following aspects. While this revised act is designed to respect the autonomy of individuals to donate their organs, it seems to adopt an opt-out system of presumed consent by which an individual could be deemed to be a donor unless he/she signs a will of refusal to donate. The reason why the act appears to be so is that it creates many rules grounded on the idea that people must prefer an altruistic choice to donate their organs for transplantation. In order to increase donation after cardiac death, the patient's life-sustaining measures may not be withdrawn; namely, the patient is still alive while the concerned Organ Procurement Organization or physician determines whether a potential donor meets the criteria for an organ donor. This causes a medical problem when a patient dies after non-heart-beating, and an ethical problem of conflict of interest between the patient's advance directive to withdraw life-sustaining measures and his/her will to donate organs. Is it possible to increase organ donation with the basic ethical concept of respect for individual autonomy? There is a contradiction between respect for the individual altruistic will to donate organs and the policies based on the opt-out system that this act seems to approve. It might cause distress to dying patients, their families, and physicians.

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A persistent vegetative state (PVS) raises various ethical issues in clinical services due to the difficulty in diagnosis and the inability to communicate with patients. A recent study, however, showed some patients diagnosed as vegetative state could have awareness. Here we examine the result of the experiment and demonstrate the problems in the paradigm that are likely to occur in clinical practice. To overcome the problems, we propose a new experimental paradigm, which would also play an important role in constructing a method for communicating with patients. Importantly, scientifically verifiable questions could be raised from the aspect of clinical ethics, not from that of science, which strongly suggests a novel methodology in neuroethics.

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To clarify the present situation of placebo treatment provided by clinical nurses and their consciousness related to it, we surveyed 142 nurses working at a mid-size hospital in Tokyo by self-written unsigned answer sheets. From the results of this study, 46.9% of the nurses answered that they have executed the placebo treatment in a present hospital. Also, informed consent (IC) was performed only in 20 cases (23%) before using. These results suggest the necessity of social consensus regarding placebo treatment. Most nurses practicing the placebo treatment believe it is effective and evaluate it positively. On the other hand, they are afraid that it could damage the relationship of mutual trust between a patient and the medical staff and that the mistrust of the medical service would increase after the patient as informed of the fact. These results suggest that the nurses recognize the placebo treatment only from the viewpoint of medical staff, and that they lack a consciousness of ethical issues such as the patient's autonomy, IC and so on, even though they have the problem consciousness.

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The purpose of this paper is to consider the conditions of killing oneself and of euthanasia tolerated from a Buddhist standpoint. Although Buddhism has the principle of prohibiting anyone from killing oneself and others, there are several tolerated, or rather approved instances of performing actions leading to one's own death. In examining typical examples, we find that a 'would-be suicide' ought to be among the following three situations. The first is one, who is apparently near death, satisfied with his/her life in which his/her own duties have been completely performed. The second is one trying to save others from suffering or danger even though he/she would lose his/her life. The third is one striving to accomplish his/her real aim at the risk of losing his/her life. In any case, furthermore, the preparedness for one's own death is to be agreed upon by the people close to the person. And, these conditions are essential for the manifestation of human dignity in a Buddhist interpretation, which means that each and every person lives as a central figure in the world in relation to others existing in the world. Based on this viewpoint, we propose and consider conditions under which euthanasia could be tolerated.

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Since ancient times People have relied on religion for the salvation of the dead. In the worldview of traditional Japanese folk religion, members of a bereaved family feel obligated to propitiate the dead, especially if they died with a grudge or regrets, and to send them to the "next world" where they can find a peaceful existence. This ancient mode of thought continues down to the present. In daily life we frequently reminisce about the deceased members of our family, we inherit our way of thinking from them, and we wish for the peaceful repose of their spirits. Ethics typically focuses on relationships among the living. Religion, however, presents us with a larger world of meaning which includes not just the living but also the dead, not just the present but also the past and future. Herein, no doubt, lies a significant difference between ethics and religion. When the major issues of bioethics are discussed only from the viewpoint of the living, religious people cannot help but feel that something is amiss. For example, when organ donation is performed without regard for the feelings of the deceased person or without proper confirmation of the deceased person's wishes, then how can the members of the bereaved family possibly beg forgiveness from the deceased? How could they expect the deceased to attain peaceful repose?

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It is not clear whether or not society permits substitution for gestation and delivery which are ordinarily done by one woman. This paper explains a situation of recognition of motherhood which is affected by splitting gestation and delivery from the ordinary mother experience, and then examines an ethical problem which is brought about by substituting gestation and delivery by another woman. Splitting Gestation and Delivery from motherhood allows a woman's experience to be ignored in discussions of gestational contract pregnancy, and makes it possible to presume parentage using DNA information modeled on cases of determining male parents. In addition, bestowing new meanings on the split experience makes it possible to exploit women's reproductive function. Thus, gestation and delivery is considered as an action which can be substituted by others, while the original experience is orientated to be unnecessary for human reproduction. The original experience of gestation and delivery contributes to give people a sense of the gravity of life through referral to the experience. Therefore, changing the meanings of gestation and delivery can possibily change our sense of life. In conclusion, application of substitution gestation and delivery needs more examination and careful discussion.

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The purpose of this study was to review the pre-autopsy informed consent process for bereaved families based on a survey of university students' attitudes toward autopsy. An original questionnaire was developed to assess their knowledge levels and information sources regarding autopsy, recognition of the informed consent process, images of autopsy, and what they wanted to know from an explanation of autopsy. The questionnaire was sent to 378 students who had just started to attend lectures "forensic medicine" course at Medical School of A-University, Dental School of B-University and Law Faculty (including majors in economics, engineering, etc.) of A-University. Responses were collected from 338 students (response rate: 89.4%). Many of the respondents wanted an explanation in advance about the necessity of autopsy, and more than 80% desired to know the results of autopsy. With a fear or hatred toward autopsy as well as their accumulating expertise and experience, the medical and dental school students perceived autopsy from a medical viewpoint, while law faculty students perceived it from a social viewpoint. These findings suggest that an informed consent process prior to autopsy for clarifying the cause of the death associated with medical practice requires a plain explanation to the bereaved family from their standpoint and a coordinated, informed consent procedure.

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