The goal of this paper is to provide reasons why narrative competence ought to be included in the list of core competencies for ethics consultation. In order to achieve the goal, I shall first show that ethics consultants are now regarded as experts who strive to encourage dialogues and foster mutual understanding between conflicted parties. Then I shall present three narrative competencies required to become a skillful ethics consultant.

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The ruling made by the Supreme Court of Japan in 2000 regarding "Case of Research Hospital of the Institute of Medical Science, the University of Tokyo" is considered to have established a temporary standard for the appropriate response to the refusal of blood transfusion by "Jehovah's Witnesses." However, judging from recent civil litigations related to treatment without blood transfusion of "Jehovah's Witnesses" and news coverage regarding refusal of blood transfusion by "Jehovah's Witnesses," it seems that civil, criminal or ethical issues arising from refusal of blood transfusion based on religious beliefs cannot be solved simply by relying on the Supreme Court ruling. These issues will be presented herein so as to encourage further discussion in the future.

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Nowadays the ethical problem of how incidental findings should be managed in human subjects research is hotly debated. Less discussed is why researchers should handle the problem of incidental findings. In this paper, I will outline two ethical arguments which try to ground the researcher's obligations to handle incidental findings: the argument from general beneficence and the argument from researcher's privileged access to subjects' private information and bodies. Then I will discuss what these arguments imply on the limits of researcher's duties to subjects, specifically in light of the duty to reduce the risk of false positive/negative error. At the end of the discussion, it is suggested that the difficulty in grounding researchers' obligation to handle incidental findings is closely related to the ambiguity of distinctive professional integrity in human subjects research.

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This study aims to analyze how neuroethics research and clinical application will be regulated in the legal system of France. Neuroethics is not mentioned in the report of the Council of State, which revised the 'law relating to bioethics' "unified" in 2004. At the public hearing of the Parliamentary Office for the Evaluation of Scientific and Technological Choices and in the report by the investigating commission on information of the National Assembly, some representatives claimed to be taking research on the brain into consideration. It is also argued that there is a need to revise the 'law relating to the protection of participants in biomedical research' (1988). The bill proposed by representatives Mr. Jarde and others provides three categories of research on persons, which intends to make the procedure clear. In the bill modified by the Senate, upon first reading, the category was roughly divided into two. Problems designated as neuroethics should be dealt with as problems of bioethics, when clinical application of the result is carried out and the patient is incompetent to give consent, even if they are being treated under the law relating to research. Ultimately, ethical problems on the forefront of scientific research compose the core of bioethics.

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During clinical trials of interventions to prevent mother-to-child transmission of the Human Immunodeficiency Virus in developing countries in the late 1990s, there was an acceleration of ethical discussions for placebo control groups in clinical trials internationally. Recently, carrying out Placebo-controlled clinical trials has been accepted and promoted in the United States and Europe. International ethical guidelines (Declaration of Helsinki, ICH-E10, CIOMS guideline) have been established and revised, and it is permitted to use placebos in certain circumstances. While placebo-controlled trials (e.g. Randomized Controlled Trials) have the merit of obtaining highly scientific findings, they have the unethical aspect of leaving some subjects untreated in spite of already known effective treatment. In the case of placebo-controlled trials, medical researchers should consider the ethical aspect of the subjects' welfare carefully, and think up trial designs to ensure high-quality science as much as possible. It is necessary that placebo-controlled trials should not be carried out indiscriminately, and to consider the option of non-placebo-controlled trials designed to ensure scientific quality.

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This study reviews the ethical issues encountered by Japanese medical residents and surveys the postgraduate ethics education offered to them. We surveyed 120 residents in the Kumamoto University Hospital Group in 2008 to identify their experiences and attitudes regarding ethics education. Thirty-seven residents returned valid responses yielding a response rate of 31%. The ethical issues encountered included Do Not Resuscitate orders (DNR), informed consent, truthful communication, and allocation of scarce healthcare resources. Many residents indicated that they routinely ask a supervising physician for advice regarding the resolution of ethical dilemmas, but the treatment plan as determined by the supervising physician does not often adequately reflect the ethical perspectives of the residents. Although many residents reported that they consider ethics education to be an important component of residency training, some claimed that priority should be given to acquisition of clinical skills over ethics education. Respondents indicated that they encounter ethical problems on a daily basis, but lack appropriate ethics education courses in their residency programs. We therefore conclude that development of a comprehensive ethics education program for Japanese medical residents is urgently needed. Unfortunately, the present study is preliminary in nature and surveys only a small number of clinical residents in Kumamoto. A nationwide cross-sectional survey of Japanese clinical residents and educators is needed.

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A "non-compliant" or "non-adherent" patient presents an ethical dilemma that commonly arises in chronic care. It occurs when a patient fails to follow a mode of self-management that medical professionals assume to be appropriate for the patient to practice daily. Or a patient who does practice self-management, does it in a way that is considered incorrect by medical professionals. As one factor of the dilemma, we will point out that the "teaching/educating approach" to support patients' self-management is widely prevalent among medical professionals who treat patients with chronic illnesses. We will also examine the ideas of QOL and EBM on which the teaching/educating approach is based to show that for the purpose of maintaining patients' QOL, it is important to clarify the appropriate treatment approach. Second, we will show that it is also important to pay close attention to each element of the patient's QOL. Finally, pointing out a flaw in the "teaching/educating approach," we will attempt to present a strategy to resolve the dilemma of non-compliant or non-adherent patients.

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Terminal care can be done without advanced medical technique, but attention must be paid to holistic care focusing on the three indivisible facets of the human condition-body, mind and spirit. In Japan many advances have been made in the physical treatment of terminal patients, but psychosocial care is lagging behind. The aim of this study was to examine terminal care in ancient societies, such as India, Greece, and Egypt, that emphasized support for the mind and spirit rather than the body alone. The research was carried out by analyzing terminal patients with incurable diseases in the ancient Ayurvedic literature, Hippocratic collection, and Egyptian medical papyri. In ancient India, the physician should not treat patients with the signs of impending death, because a physician, treating an incurable disease clearly could suffer from loss of wealth, academic knowledge and reputation and from censure and unpopularity. He should not disclose the approaching death to a patient or his relatives if it is liable to result in the patient's collapse or distress to somebody else. Hippocrates said the physician should refuse to treat those who are overwhelmed by their diseases, realizing that medicine is powerless in such patients, and he should learn and declare beforehand those who will die and those who will get better. In ancient Egypt, observation of the patient's condition was stressed before making a prognosis which was unfavorable. Conclusions: All texts in these three ancient countries showed the physician should not treat terminal patients. In India the physician should not disclose the diagnosis and possible fatal outcomes to a patient and his or her relatives; however in other countries, the physician should reveal their opinions. This may show a cross-cultural difference, and might provide new perspectives on terminal care in Japan.

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Male caretakers have been increasing along with the aging of the Japanese society. This paper presents a comparative verification of mother-adult son relationships and mother-adult daughter relationships within dementia care to reveal distinct characteristics, challenges and issues of adult sons when taking care of mothers with dementia, based on the previous research study conducted in 2008 which studied challenges and struggles of caretaker daughters when their mothers were placed into nursing-care facilities, "A consideration of process in using nursing-care facilities -from the viewpoint of mother-daughter relationships within dementia care". Interview-style surveying was conducted to care-giving sons whose mothers were placed in nursing-care facilities for dementia. As a result, differences were revealed that adult son caretakers rely on outsourcing to collect detailed knowledge and information about dementia, and they feel positive about using the Adult Guardianship System and nursing-care services. On the other hand, there is a risk of abusive treatment caused by the closed environment when they want to bear the burden of caretaking by themselves or within their families. Understanding these characteristics and issues specific to male caretakers may help us to draw up a basis for taking measures that correspond with the needs of the elderly with dementia in the future.

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The Japanese Ministry of Health, Labour and Welfare adopted present medical safety policy ten years ago. This policy mandated hospitals to develop an in-house system for medical safety management, and appoint a medical safety manager. In this paper, I will show the difference between the performances of nurses as medical safety managers and of doctors in the same role by analyzing the results of a nationwide survey that I conducted in 2007; this survey involved medical safety managers working in hospitals that were accredited for medical safety by the Japan Council for Quality Health Care. Furthermore, I will focus on the problems that nurses as medical managers considered to be significantly more difficult as compared to doctors, and determine the reasons behind this tendency. The study revealed the following tendencies of nurses in the above role: first, nurses as medical safety managers usually found it difficult to maintain cordial relationships with other medical staff members. Second, they found it difficult to compile and analyze incident and accident reports. Third, they underestimated the doctors' awareness about medical safety. Fourth, they believed that the primary problem in medical safety management was the medical staff's low awareness about medical safety. Fifth, they tended to point out the inadequacy of informed consent as one of the chief causes of malpractice suits. I believe that the above tendencies might reflect the work attitudes of nurses in hospitals and the professional perspectives of nurses with regard to other medical staff members and patients. In order to promote medical safety management and patient care, it is essential for hospital and medical staff members to identify the difficulties encountered by nurses as medical safety managers.

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The purpose of this article is to clarify the necessary ethical considerations when nonpharmaceutical interventions (NPI) such as isolation and quarantine are executed to prevent the spread of infectious diseases. A key issue is that preventing the spread of infectious diseases invariably limits individual rights such as freedom of movement and protection of privacy. In such cases, it is almost impossible to sacrifice individual liberties to protect people's health. Similarly, it is difficult to balance individual rights with common/public good. Therefore, ceaselessly seeking such a balance, for example, talking with individuals who are exposed to NPI and holding public discussions about whether a public health measure is appropriate, is an essential ethical consideration.

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We reconsidered the message of Luis Kutner who first conceived the living will (LW). He advocated LW as follows.: 「When the patient is incompetent, the law assumes a constructive consent for him to be treated. Intentional nonfeasance to cause death is murder. Death due to inaction by the physician's desire not to prolong the patient's suffering is clearly distinguishable from active mercy killing. There is no reason in which active euthanasia with patient's consent is criminal, but inactive euthanasia with patient's consent is not criminal. An individual has the right to refuse treatment, even if such treatment would prolong his life. The physician would then be precluded from treatment, and the patient would be permitted to die by virtue of the physician's inaction. The suggested solution is that the individual, while fully in control of his faculties and his ability to express himself, indicates to what extent he would consent to treatment.」 His LW seems to shorten the life in which the sufferer directs discontinuance of treatment on the basis of the right to self-determination. This is thought to be a voluntary inactive euthanasia. This concept appears different from natural death (dying with dignity) in which life-prolonging procedures are prevented from prolonging the dying process. We studied the transformation of LW and explored questions on the rationality and variety of LWs.

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Increasingly in kidney treatment we confront the need of caring for the end-of-life stage patients after years of dialysis. In the present study, we examine the characteristics of care for the end-of-life dialysis patients, and offer a proposal that, over a long period of the patient's undergoing treatment, it is desirable for medical staff to understand each patient's will and its changes. Furthermore, medical staff, especially nurses, need to cooperate with the patient and his/her family to help the patient to come up with the patient's will for his/her own end of life. Nurses, who have been caring for the patient for a long period through the initiation of dialysis, its continuance, and the end-of-life stage, are likely to play an important role as mediators between physicians and patients and therefore should prepare for that role.

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Organ transplantation contributes to the improved quality of life of many patients and saves the lives of many more. Due to developments in medical technology, the demand for transplant organs has increased and this has led to a chronic shortage of organs. The European Commission made an action plan to increase the supply of organs throughout the EU and suggested the needs of coordination at EU level regarding organ donation. The essential and common principle of transplantation in the EU is voluntary unpaid donation. However, the legal process for establishing donor consent varies from member state to member state and may take the form of either an "opt in" or an "opt out" system. Japan amended its organ transplantation law as follows. If the wishes of the deceased are unknown, then a relative can give vicarious consent. This should ease the gap in supply and satisfy the demand for organs. Some EU countries have switched from an "opt in" to an "opt out" system in order to increase the number of donors. First of all, we will examine the background of organ transplantation policy, starting at EU level. Secondly, we shall consider the legislation on the consent system related to organ donation in the Member States of the EU. Finally we will discuss the impact of the presumed consent system on organ donation and ethical issues raised by consent systems. The conclusion will demonstrate the importance of international coordination of organ donation policy to combat organ trafficking, preserving the independence of action of individual nations concerning the application of ethical principles related to the issue of organ consent. We will see that is because systems for evaluating the donor's will have been formulated based on the cultural historical and ethical background of each country.

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The present study was conducted to assess the actual state of clinical nurses' ethics education, the moral sensitivity and related factors of clinical nurses with the goal of making ethics education proposals for improving nurses' ability to take ethical action. Questionnaires were distributed to 1746 clinical nurses and 722 responses to the questionnaire, excluding incomplete responses, were analyzed. 67.6% of nurses had experienced ethics education during basic training at nursing school, and 39.8% had participated in professional training in ethics since graduating. Regardless of whether or not they had opportunities for ethics education, 91.1% of nurses responded that they had little or no knowledge in relation to ethics. Further, little evidence was found of difference in response to items investigating the relationship of characteristics of the hospital or nurses and moral sensitivity, and it was found that existing ethics education does not affect moral sensitivity. Based on these findings, issues in evaluating ethics education for nurses and their competency in matters involving ethical judgment and behavior are discussed.

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Considering the conditions of pregnant women's decision making processes is indispensable in the case of maternal-fetal surgery (MFS), because the surgery involves severe invasion into healthy women's bodies. This paper examines the ethical issues of MFS, focusing on the invasiveness of the surgery. First, we discuss the argument regarding fetuses as patients, which takes a positive stance on the surgery. We point out that it is important to verify the authenticity of a woman's decision about the surgery, even if it is appropriate to regard a fetus as a patient who has the moral status of a person independent of the pregnant woman. Second, we examine the factors that effect women's decision making processes for the surgery. For MFS, pregnant women's decision making is based on the comparison of the costs and benefits of the surgery. For pregnant women, the surgery has no benefit but only brings costs and risks from the medical (physical and physiological) perspective. The potential benefits women expect from the surgery are psycho-social ones like a reduction of the disabilities of a child after birth. We examine the contents of these psycho-social benefits and clarify the necessery condition for the surgery.

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Decision making as the end of life nears is of crucial importance for both patients and professionals and, in the USA, ethical-legal frameworks have been created to facilitate patient choices. The "Living Wills", and "Physician Orders for Life-Sustaining Treatment" are documents intended to assist patients in EOL decision making. The most prominent ethical principle behind these documents is respect for the "personal autonomy" of patients. This strong desire for "autonomy" has led citizens, first in Oregon and most recently (November, 2008) in Washington State to pass legislation entitled the "Death with Dignity Act." This framework moves beyond the former right of patients to withhold or to stop unwanted life support to a more aggressive right for patients expected to die within six months to request a lethal prescription that enables them to end their lives by self-administering the medication. This author interviewed health care professionals at the University of Washington in the fields of medicine, nursing, ethics, law and spiritual care to gain an understanding of this context. It appears that since the passage of Oregon's law, in 1998, there have been significant improvements in palliative care for dying patients in both states. Thus, Washington's Death with Dignity Act seems to reflect the strong desire of some, to control the timing and circumstances of their death, a factor more prominent than pain control and symptom management.

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From the viewpoint that it is significant to confirm the intention of the elderly concerning end-of-life care at an early stage in order to properly provide elderly-centered end-of-life care, this paper aims to ascertain how elderly people's intention is confirmed when they move into such facilities providing end-of-life care and to review ideal ways for confirming their intention. We randomly selected 1000 welfare facilities for elderly requiring care (those providing end-of-life care) to conduct a mail survey in August 2008, and we obtained 336 valid responses. Out of them, 76.2% confirm elderly people's intention upon their entry, but the following were pointed out as reasons that make it difficult to confirm their intention: (i) some elderly people lack the ability to make decisions; (ii) it is considered taboo to talk about death; (iii) such talk may shock the elderly; and (iv) neither the users nor their family feel the need for such confirmation. Even in cases where the elderly have the ability to make decisions, 28.6% of those facilities only confirmed the intention of their family, and in most cases the intention was confirmed again only after the elderly were judged to be in their terminal phase. The survey suggested that further efforts should be necessary to establish proper procedures to confirm the intention of the elderly, focusing on the process from entry to a facility to the end of life, to clarify from whom or where the explanations on end-of-life care are available, and to standardize the contents of such explanations.

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In July, 2009, the Organ Transplant Law was amended in Japan. However, the debate in the Diet on the amendment bill was confused and far from complete, with the result that the revised law-especially Article 6-remains problematic. This paper elucidates the issues in the amendment bill and Diet deliberations concerning it, in addition to setting out the framework for an alternative plan. In the first section, an examination is made of the problems in the second clause of Article 6 of the amendment bill. No persuasive argument was made in the Diet for the concept the bill introduces of brain death being equal to actual death, and consequently this means that key issues remain unsolved and that the bill lacks clarity. In the second section, the conditions for harvesting organs prescribed in the first clause of Article 6 are outlined, and the issues surrounding changes in the regulations for organ donation decision makers are discussed, as well as shifts in people's thinking regarding organ transplants. In the final section, a system for organ transplantation that permits opting-out and mutual insurance based on reciprocity is proposed as a potential alternative to the current system in which transplant donations rely on benevolence (voluntary and altruistic), and which has hitherto been uncritically propounded.

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The aim of this study was to identify the relationship between experiences in nursing practical training and five items learned in a class on bioethics, using a free description questionnaire survey. The survey subjects were first and fourth year students who had gone through practical training. The responses of 98 first year students and 73 fourth year students were qualitatively analyzed. The five items were "respect for life," "patient QOL," "patient self-determination," "informed consent," and "patient's best interest." These items had 15, 27, 13, 35, and 18 categories respectively. To ensure reliability of results, the findings were checked by two researchers experienced in qualitative analysis who were unrelated to this study. The key bioethical item learned in clinical practical training was "respect for life." Important categories were "life maintenance," "personalization," "independence," and "self-determination." Nursing students thus learned the essence of bioethics in medical care based on maintenance of life.

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Public interest in research ethics has grown, and society makes increasing demands in this area. There is also a concomitant demand for the provision of a system that can enable "on-site" researchers to avail themselves of immediate consultation when concerns and/or issues arise regarding ethical review applications and related matters. In the United States, a growing number of institutions are providing research ethics consultation as part of their measures to support researchers. However, the approach to the particulars and methods of research ethics consultation differs from institution to institution, and discussion regarding its conceptualization and evaluation has only just begun. For its part, the Institute of Medical Science at the University of Tokyo (IMSUT) established the Office of Research Ethics in August 2008. This is the first such office in Japan made up mainly of academic staff. Since April 2009, it has provided research ethics consultation including pre-screening for ethical review applications. This paper considers the future issues emerged from the IMSUT experience and the concept of research ethics consultation with reference to the present situation in the United States.

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We surveyed the current state of placebo use in clinical practice by ward head nurses working in hospitals of Japan using self-written unsigned answer sheets. The survey includes two parts: one is from 955 hospitals having over 300 beds all over the country; the other is from 337 hospitals having 20-299 beds in the Tokyo Metropolitan area. The result showed that 22.4% (the country) and 59.0% (the Metropolitan area) of the head nurses answered that they have executed the placebo treatment within the past year. The treatment was done without explanation by doctors in 53.4% and 45.7% of cases, and without consent of patients in 66.1% and 52.8% of cases respectively, showing that the majority of placebo treatments were executed without informed consent. To the question "Is the placebo treatment unethical?", 53.5% and 81.5% respectively answered "No". These results show that a considerable majority of head nurses have a paternalistic attitude about the placebo treatment.

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