[in Japanese]

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In recent years, cancer therapy has come to be considered from the aspect of the quality of life (QOL), in addition to the aspects of the survival rate and efficacy. Because the background of cancer patients and their situation are diverse, it is necessary to administer appropriate cancer therapy, taking into consideration each patient's QOL. However, to achieve this, we must consider the meaning of QOL and the method of assessment there of. With full awareness of the chronic nature of cancer, we must establish a basic approach to cancer therapy in which attention is paid to the QOL depending on the stage of cancer of each patients. From the above viewpoint, practical methods of treatment should be established, and the QOL must be analyzed scientifically. Various problems relating to the QOL in clinical oncology are discussed in this paper. Achieving good QOL in clinical oncology requires individual therapy which considers the various background factors of each patients. It should be freshly realized that cancer therapy is a medical activity which must take a holistic approach to each patient, and that it constantly affects the patient. This approach should not be limited only to terminal care but should be applied to all areas of clinical oncology.

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An outline is given of the global warming process due to increase of the greenhouse gases in the atmosphere. The recent long-term trend of the observed air temperature averaged over the global oceans shows a warming of about 0.3℃/90 years. The numerical experiment results of climate change due to increasing CO_2 is compared with the observed recent warming, and some problems to be solved are indicated. Important roles of the aerosols and oceanic thermohaline circulation are suggested.

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Forty cases of ethical dilemmas of pediatric nurses reported in 1983 were analyzed in terms of the type of bioethical problems, the Japanese Nurses' Association Code for Nurses, and the conditions of patients. 29 cases had the problems of medical decision for serious congenital malformations and handicap, and 27 cases were against the Code : the nurse provides the highest level of nursing care and is responsible for the care she gave. Parental refusals were found among 22 cases with congenital problems, and physician's medical decisions were dominant in 18 cases with acquired problems. Most nurses in both cases were not participating in decision-making and giving much direct care to those with serious conditions, with confused feelings of doubt, angry, agony, and withdrawal. From these findings, respect for children's rights, sharing thoughts and feelings among professionals, and clarifing nurses' roles in ethical decision-making were emphasized.

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Up to now, we Japanese have accepted and developed almost every kind of advanced medical treatments vigorously. On the other hand, Japanese seem to hesitate about introducing "Brain Death". The reason why we do so lies on difference of paradigms (intellectual frameworks) between the logic of Western thought and Japanese mental climate. At first, then I place modern Western medicine in the history of introducing foreign cultures in Japan. And I consider the relation between newly-developed medical treatments and introduced Western medicine that has been accepted as a practical study, a technique or a kind of natural science in Japan. Next, I refer to the <village community> consciousness that has been formed and succeeded within village communities existing in almost every period and place in Japan. And I would like to summarize the relation between a Japanese paradigm, a Japanese view of human being that are shown by the <village community> consciousness, and logics of "Brain Death" that may be derived from Western intellectual and religious traditions.

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The number of kidney transplants in Japan has increased dramatically each year. However, when compared to the United States, the total number of transplant operations performed in japan is quite small. This can be attributed to the fact that most japanese kidney transplant operations involve living related donors. If transplants in Japan (cadaver kidney, heart, and liver) follow a parallel course of development with that of the United States, then Japan will have to deal with important issues such as brain death, developing a transplant network, financial sources to support that transplants, and establish a transplant coordinator system. Organ transplantation is expensive and cannot save everyone who needs an organ. Organ transplantation involves making choices. Making choices will mean dealing with major issues such as who is going to decide who will get an organ? How should transplantation be regarded in relation to other medical treatments? Making choices will inevitably involve ethics. Before we can make difficult decisions about organ transplantation, we should examine our medical ethics.

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The decision-making in the selective non-treatment of severely handicapped newborns is one of the most perplexing problems in these days. We presented ten such clinical cases who underwent operations for meningo-myelocele or other neural tube defects in our department and discussed their quality of life. Of the ten, 5 have already deceased and of the 5 left only 2 are enjoying reasonable life. The difficulty in evaluating the patient's best interest at the birth consists in (1) that there is no way of knowing the intent of the patient himself and someone must make surrogate decision. and (2) that to tell the probable quality of life in future in the case of neonate is very difficult as they develope within his own capacity, in contrast to the adult cases. There are many judicial cases about the legitimacy of this non-treatment in western countries, but the judgements are controversial. In some cases the foregoing not only operation but also usual nurishments are admitted, but in other, the use of quality of life analysis itself is rejected. In our country where no judicial consulting system exist, physician must make decision with parent's consent. About this surrogate decision-making, it is rather difficult to obtain the usual informed consent, as parents are very upset and the burden of decision making of letting-him-die is too heavy for them. So it is, I believe, preferable that physician becomes the final decision-maker and bears the responsibility. These neonates are very different case by case in the aspects of prognosis, parent's attitude or financial situation, all these factors influence baby's future quality of life. Consequently, the legal review on this problem, even though it may act as a safeguard, must be applied very cautiously and with flexibility.

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In discussing euthanasia and death with dignity, we need take caution against that only the term precedes and the conclusion walks by itself. Therefore we have to arrange the contents of their concept and clear their communities and differencies, moreover have to consider their legitimacy and illegitimacy. In this paper we consider to find out the appropriate means of solving in intermediate phases between right of self-determination of patient and others-determination without considering the will of patient. Firstly, we classify euthanasia in (1) pure euthanasia, (2) indirect euthanasia, (3) active euthanasia, and (4) passive euthanasia. Especially in (3), judicial precedents are considered. Secondly, we classify death with dignity in (1) the case where the will of refusing medical treatment of a patient is clear, (2) the case where the will of refusing medical treatment of a patient is not enough clear, and (3) the case where the will of refusing medical treatment of a patient is not at all clear, and if necessary, refer to cases in USA. Through this method of consideration we hope that the common base on which various specialists can discuss the problems will be built.

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Now, in the case which has been ethical problems on the medical practice, Many cases of these problems have been discussed at medical ethics committee. In an occasion, conclusion of the medical ethics committees have not always consisted with each other on the same theme. This seems strange affairs. For example, Concerning of the brain death, the conclusion of ethical committees differ from each other on whether brain death is human death or not. Therefore, we should have need that has to be made the standard guide-line on the great ethical problems and need of which each ethics committees are organized all over the nation. Result of my study of ethics committee's regulations shows that these don't compose suitably to solve the great ethical problems. Each ethics committee should discuss carefully and responsibly whether own institution or physician should practice suitably or not following the standard guide-line made by organized ethics comittee.

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In European countries, and the United States, it is common practice that patients are informed about their disease even if they are terminally ill, so that they can spend the rest of their lives in a better way. In Japan medical care for the terminally ill has been a big issue, yet, it is still common not to tell them the truth. One of the reasons is the difference between the concept of life and death in Japan and that in the West. Then, I think that the Japanese should maintain their own hospices and medical care for the gravely ill in their own way, instead of just imitating the ways of Europe or the US. I would like to discuss this matter.

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Recent genetics and genetic counseling is discussed with respect to bioethics. From the standpoint of bioethics, human beings who has the right to live was called "person" and this right to live was can not denied by anyone. This concept of the right to live did not exclude the person who has congenital anomalies. And yet recent life science studies have revealed that abnormality is a valiation of normality, and that human society inevitably include a certain percentage of congenitally abnormal individuals. In Japan, fetuses 22 or more weeks old are protected by the Eugenic Protection Act. From a footing of the protect the right to live, parents have the right to decide of their fetuses less than 22 weeks old. Accordingly, parents have the right to obtain fetal information, including through amniotic fluid examination. In order to protect this right, society is obliged to improve examination facilities and to provide would-be parents with fetal information.

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The purpose of this study was to examine nurses' cognition of current issues in bioethics in our society. A questionnaire survay was conducted among nurses who were assuming leader roles in their work settings. The questionnaire consisted of the questions of 1) brain death, 2) organ transplant, 3) telling medical diagnosis to cancer patient, 4) informed consent, 5) concern about patient's rights in recent medical care, and 6) subject's own moral dilemmatic experiences. Data were obtained from a sample of 830 nurses including 481 nurse managers and administrators, 200 senior nursing staff, and 140 nurse educators (9 subjects gave no answer of their working position). Findings indicated that 48% of the subjects accepted brain death as the death of human being. On the other hand, the same ratio of the sample rejected brain death as the death of human being in present situation. The greatest amount of the rejectors (58%) mentioned "low reliability of fairness in judging brain death" as a reason of their rejection. 14% of the sample agreed on promotion of organ transplant, and 77% of the sample also agreed on the transplant on certain conditions. The top three conditions that the respondents listed were 1) effective practice of moral education for physicians, 2) fair function of human rights committee in medical organizations, and 3) making all the relevant data public. Subjects who agreed on telling diagnosis to cancer patients on no condition were only 10%, and 85% of the subjects claimed to set certain conditions for practice of telling truth. 70% of those subjects listed "patient's independency" as a major condition for the practice. Promotion of getting informed consent was supported by 56% of the subjects. Implications of those findings, and the subjects' concern about patient's rights and their own moral dilemmatic experiences were discussed.

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