In this article, the author considers how the Japan-specific diagnosis of a vegetative state contributes to clinical practices worldwide. The Japan-specific diagnostic criteria for the vegetative state provide patients with equal care and rehabilitation, regardless of whether or not their awareness appears to be intact. This approach may help researchers with epidemiological data acquisition about the minimally conscious state (MCS), the nature and clinical condition of which is still uncertain. However, the current clinical system in Japan cannot utilize the advantages of this approach. Additionally, we must resolve some serious problems regarding resource allocation in order to construct an ideal system of care. Although this article does not provide a proposal for a concrete and realistic system of care itself, the author discusses the preliminary considerations to develop an appropriate system of care. It is necessary to consider i) what should be done to alter the image of the Vegetative' state and ii) how should some significant concepts (e.g. 'justice' and 'consciousness') be applied to clinical problems to provide ideal care and rehabilitation.

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The argument about the pros and cons of surrogacy needs to examine the ethical issues because the discussion has often been chaotic in the Japanese Academia. The purpose of this paper is to clarify the most essential ethical issue by examining the history and development of surrogacy and the transition of social frameworks for the recognition of surrogacy. The practice of surrogate pregnancy and delivering of babies by other than the mother has been widely conducted around the world. It was banned in many cultures due to the influence of Christianized sexual norms and sensitivity to human rights. The primitive need for surrogacy has been hidden by modernization. However, since some surrogacy agencies represented by the American lawyer Noel Kean, recast this method into modern frameworks such as techno-progressivism and a feminism theory which maintains women's autonomy, the latent need for surrogacy has now surfaced. Nowadays, this modernized surrogacy is widely utilized in society. From the historical development of surrogacy, the essential issue is an ethical question regarding the concept that another's body is made available for people to take advantage of.

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In July 2010, the Minister of Education, Culture, Sports, Science, and Technology received the first notification of the procedure for creating human-to-animal chimeric embryos by inserting human induced pluripotent stem cells (IPS cells) into animal blastocysts. This case drew attention to the necessity of reviewing the regulations of human-to-animal chimeric embryos under the Act on Regulation of Human Cloning Techniques and the Guidelines for Specified Embryo. I have begun this paper by organizing the concept of "human and animal chimera" - including human-to-animal chimera and animal-to-human chimera - which eventually became quite complicated. Subsequently, I have discussed the problematic issues of the existing regulations and the agendas for reviewing the regulations of creating and using human-to-animal chimeric embryos. As a result, I have clearly listed four problems of the existing regulations: for example, the duration that the human-to-animal chimeric embryos can be maintained is lacking validity. In addition, I have proposed the discussion for human and animal chimera with wider vision which includes the scientific, ethical, legal, and sociological aspects . In the end, I have mentioned three important points that need to be discussed including what kind of human and animal chimera can be allowed to be created.

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In this paper, I will make clear that 30,000 suicide people or more do not decrease at all for the suicide prevention measures that are the problems of a present age in Japanese society and people's concerns on the problems have not spread either. Though the suicide research in Japan, which is the clue of the suicide prevention measures decision is depends on "Medical model", for the suicide, a diversified analysis from a social psychology and cultural economic point of view is necessary. Because there are sensitive about social factors that do not appear in statistics like a way of life, sense of values, the community, and the work place. The conversion of the viewpoint of the suicide research is proposed by an idea of "Bio- psycho- social model" the system theory as a viewpoint of the suicide research in the future. In addition, the definition of the suicide and the self-decision in the suicide are examined from the culture and the social perspective, and the point where the analysis from the culture and the social perspective is important.

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In a scenario involving the withholding or withdrawal of life-sustaining treatment from an extremely preterm infant or a brain-dead child, one of the questions considered is whether the treatment is medically futile. The notion of "medical futility" first appeared in the 1980s. Chapter 6 (Seriously ill newborns) of Deciding to forego life-sustaining treatment (by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Behavioral Research) states that "when there is no therapy that can benefit an infant, as in anencephaly or certain severe cardiac deformities, a decision by surrogates and providers not. To try predictably futile endeavors is ethically and legally justifiable." Similarly in Japan, the section "Based on medical validity and appropriateness" of the Guidelines concerning terminal care (announced in 2007 by the Ministry of Health, Labor, and Welfare) is related to the concept of medical futility. If the parents of an infant disagree with physicians concerning the withdrawal of life-sustaining treatment from their infant and are told that the treatment is futile, they may interpret it as meaning the treatment is not worthwhile or a waste of time. However, when a physician uses the term "futile," it means that the treatment in question cannot achieve a certain goal, and the use of the term strongly reflects the physician's feelings concerning the continuation of the treatment. In this paper, I call attention to the complexities of "medical futility" and show that the notion of futility has a very limited role to play.

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In view of casuistry's basic ideas, conception, historical development, concrete method, and some criticism against it, we investigate the probable potentiality, limits and challenges of modern casuistry as a methodology in clinical ethics case analysis. Casuistry is a practical way to provide sound moral judgments to individual morally perplexed cases not through the deduction of higher principles or ethical theories but both understanding of the details of human experiences and lives in given cases and rhetorical reasoning. While we should appreciate its conception in that casuistry has tried to face directly with each particular case in the clinical setting, it must be addressed that casuistry lead us to reach just probable and tentative solutions rather than absolute and universal ones. We examine each criticism of casuistry to find that some are disputable; some are plausible-, the unclearness, inevitable bias or arbitrariness in the process of the drawing geometrical tableaux of cases. Then we raise and focus on three questions or objections. First, why does Jonsen, a vigorous advocate of modern casuistry, often give misleading explanations as if the "four box method," which is in fact just a part of casuistry, itself alone could help health care professionals decide the divisive issues in clinical ethics cases? Second, casuists do not explain how to read and interpret each case at hand both to fill in "four boxes" and to form the judgment out of them. Lastly, while he stresses the significance of the circumstances of each case, why and how does he insist that casuistry should and can be absolutely distinct from contextualism?

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The purpose of this paper is to clarify the significance of the narrative approach when a social worker is involved in terminal care and to ascertain the possibility of advocacy through a case study. Mr. A., the client in the study, had initially been stuck to the the dominant story of "my life has been totally useless." However, through conversations with the author, and as our relationship developed, he became able to reflect upon his life, and to make up an alternative story of wishing to be useful to others and restoring lost relationships. This process of building up a relationship seems to be significant in the narrative approach during terminal care. Furthermore, to provide clients with an appropriate environment in which they can realize their wishes also seems to be significant for advocacy.

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The derivation of gamete lines from iPSC and their utilization for ART will be good news for certain infertile patients. Although several artificial cells have the potential to differentiate into gamete lines, iPSC is the optimal choice to use for ART. Some researchers are of the opinion that we must discuss the study of the derivation of gamete lines from iPSC, while others mention that scientists must meet the needs of Japanese infertile patients who want children to be related to them. The Ministry of Education, Culture, Sports, Science and Technology revealed guidelines for the study of iPSC that recognizes the derivation of gamete lines from iPSC in May 2010. These guidelines prohibit the creation of human embryos with the resulting gamete lines, which reflects the situation in most western countries. When engaging in the study involving confirmation of the gamete function of the gamete lines, the destruction of 'human embryos' created by gamete lines derived from iPSC is inevitable. An ethical issue is involved, as to whether we should determine some difference between the 'human embryos' created by iPSC-derived gamete lines and the usual donated 'human embryos'. When the study comes to clinical utilization, many papers cite the expanded utilization of gamete lines derived from iPSC for ART and other areas. Ethical issues concerning gamete lines derived from iPSC must never be underestimated. This issue will affect the next generation of humans, hence the related discussion should be continued.

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Japan has introduced discussions surrounding decision-making guidelines for determining the treatment of neonates born with critical illnesses. While parents are encouraged to participate in these decisions, their opinions and preferences are rarely valued and they therefore tend to passively follow the doctor's treatment plan. This paper compares the discussion guidelines in Japan to the Groningen Protocol of Netherlands. Our objective is to find a way for Japanese parents to be more respected and integrated in the decision making process regarding medical care for their infants. The Groningen Protocol requires the recording of the names of all people (including parents and medical staff) involved in a case of an infant born with a critical illness, as well as all their opinions and the final consensus. Therefore, the opinions of the parents are recorded in writing. This makes both medical staff and the parents themselves recognize the parents' responsibility for their child's treatment. Although the discussion guidelines in Japan do encourage parents to participate in decision-making, they do not clearly state the parents' duty and responsibility. Additionally, the Japanese discussion guidelines were drawn up to set standards for neonatal medical professionals and as such their application is mainly left up to them. Parents rarely know about the guidelines or understand how to use them. As a result, infants born with critical illnesses tend to be treated according to preferences of the doctor and the parents tend not to be involved in these crucial decisions. Japanese discussion guidelines should clearly state the parents' responsibility regarding medical care of their infants. Guidelines should be addressed to both medical professionals and the parents. This should allow parents to recognize the value and responsibility of participating in the discussion, as well as ensuring that medical professionals value parents' input. Proper cooperation between parents and medical staff will ensure that the best interests of the infants can be pursued.

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In opposition to a 2003 report by an advisory committee to the Ministry of Health, Labor and Welfare which prohibited the use of eggs from women connected to the patient for assisted reproduction technology (ART), a Kitakyushu-based member clinic of the Japanese Institution for Standardizing Assisted Reproduction Technology (JISART), a private organization of infertility clinics, has started to provide ART by egg donation from sister to infertile women (2008). As members of the institutional review board (IRB) of the clinic since 2009, we describe in this report the outline of IRB, JISART guideline, the decision-making process for approval of applied treatment projects and the opinions and attitudes of the persons concerned towards issues related to egg donation and children to be born, and discuss social and legal problems associated with lack of governmental regulation of ART practices in this country. Based on the discussion, we point out urgent need of governmental regulation of ART in order to protect children to be borne from social prejudice against ART practice and propose the highest priority to be set on their welfare for arguments toward the legislation.

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The philosophy underlying the public support system for patients with intractable diseases in Japan is being questioned. Presently, we face not only the problem of an increased number of patients with incurable diseases but also that of a shortage of financial resources and a lack of public support for them. Thus, the renewal of the framework of the system is a pressing issue. These problems can be summarized as follows: the intensive allocation of limited resources to the minority; this is also an often-discussed bioethical theme. We reconsider this issue from the perspective of economic efficiency. First, considering the history of the system, we point out that the initial purpose of the support, philanthropy, remains. In addition, familial labor for care has compensated for the lack of public support owing to the influence of the traditional sense of values. These cause a decrease in economic efficiency and necessitate a renewal of the system. Otherwise, we cannot avoid the possibility of restricted budgets for intractable diseases in the event of a revenue shortfall. Second, we reveal that intractable diseases have become common risks exposed together owing to increasing of the total number of patients who are suffering from various ones which are rare alone. Theoretically, insurance schemes are so effective in responding to risks that it is possible to increase support for intractable diseases with a function of social insurance to improve economic efficiency. In conclusion, to increase economic efficiency, we cannot necessarily reduce the allocation of resources for patients with intractable diseases, and we need to develop a new philosophy in place of philanthropy.

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Background: Currently medical tourism has become a topic increasingly discussed among the Japanese government officials, medical professionals, travel agencies and media reports. The purpose of this paper is to review the effects of medical tourism on healthcare services in destination countries, where medical tourism is already been done, and to discuss some issues that Japan will face as a medical tourism provider by taking into account current Japanese situations. Method: Literature research through international and national databases of academic articles. In addition, information about the recent developments regarding medical tourism in Japan was collected through the websites of the government and newspaper articles. Results: Three aspects of the effects of medical tourism on healthcare services in destination countries were extracted from the reviewed sources: improvement of the national healthcare system brought about by the profit gained though medical tourism, encouragement of national medical professionals both in quantity and quality, and international standardization of healthcare services. The followings were found as the current characteristics of medical tourism in Japan: 1) the government and local government, and some of the medical community have taken action on the preparation for accepting medical tourists, 2) it is expected that Japanese medical community will have things to offer in their strong areas such as health checkups or medical examinations using abundant medical equipment, and 3) the local cities rather than the metropolitan areas are eager to launch medical tourism. Conclusions: Arranging policies about medical tourism in order not to affect the healthcare access for domestic patients and to prevent generating healthcare inequity in destination countries, and the change of the physician-patient relationship in cases where medical tourism exacerbates a profit-seeking aspect of the healthcare, are important issues to be considered when medical tourism is implemented in Japan.

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In August of 2010, a US federal district court issued a preliminary injunction to temporarily halt federal government funding for research on human ES cells because such research violated the Dickey-Wicker Amendment. This treatise reviews the injunction's background and progress along with subsequent events, as well as disputed issues on the amendment's interpretation, which are considered from a bioethical perspective.

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In December of 2010, the US Presidential Commission for the Study of Bioethical Issues published a report entitled "New Directions: The Ethics of Synthetic Biology and Emerging Technology," signaling the US government's intention to facilitate comprehensive efforts on synthetic biology, including safety, etc. In Japan, however, the government has never examined this issue extensively. This treatise reviews the content, background and progress of the US Report. Furthermore, the necessity of countermeasures in Japan, such as regulation, is considered from the perspectives of safety, security and ethics.

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In Japan, "brain death and organ transplantation" is the most controversial problem in bioethics. The "brain death dispute" made the vast and many social, public debates till the organ transplantation act was enacted in 1997. The organ transplantation act was amended in July 2009. The purpose of this paper is to consider "the amendment dispute in 2009" by contrasting it with former brain death disputes, especially with focus placed on various aspects of "society." In brain death controversies in recent years, neurological standards have been challenged by severe critics. Therefore, the philosophical and biological grounds of neurological standards have been reconstructed, and organ procurements have become even more important. In Japan, the amendment disputes demonstrate three features: the social discovery of "chronic brain death," the importance of "gaiatsu (pressure from outside the country)," and, the disappearance of "social consensus debate." The social discovery of "chronic brain death" and the social construction of "gaiatsu" show the same character; the importance of "family". This feature is also demonstrated in brain death disputes during the 1980s and 1990s. The disappearance of "social consensus debate" indicates the change of bioethics in society. Therefore, we should consider the socio-cultural aspect in Japanese bioethics.

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