As far as the early document about the euthanasia in Japan is concerned, it is often referred to as “Takasebune” (1916) by Ogai Mori. However, before this, Ogai translated the article “Über die Euthanasie” (1897) by Martin Mendelsohn, which was one of the leading papers in Germany at the time, with the title “Kanmin no setsu” (1898). This can be called “the first euthanasia document” in Japan. However, Ogai wrote “Mendelsohn” as “Mendelssohn” by mistake. So, the article has hardly been studied without the original being identified until recently. In this study, I try to clarify an aspect of “beginning of topic regarding euthanasia in Japan (Anrakushiron kotohajime)”through collation of the original and the translation by Ogai. It is concluded that Ogai was initially interested in “indirect euthanasia” more than “active euthanasia,” because Mendelsohn used the word “Euthanasie” in a very broad sense from “active and passive euthanasia” to “palliative care.” In addition, the subject of “Takasebune” is re-examined by the above viewpoint.

    This paper explores the essentials of moral case deliberation (MCD) as an alternative or opposite way against the dominant styles of clinical ethics practice in the United States, where clinical ethics committees and experts such as ethics consultants are fully utilized. While MCD has been developed by several schools primarily in the Netherlands, and has been implemented in the northwest countries of Europe, little attention has been paid to it in East Asia. There is no exclusive form of MCD. Rather it is a generic term, or a common framework of different procedural ways. The very conception of MCD consists of the following features: it is not an expert-based, but rather a “multidisciplinary team on the ward” - based practice. It is not based on abstract principles but on conversational dynamism. It does not put priority on consensus-based hurried resolutions of ethical problems, but on a better understanding about the cases that haunt medical teams in charge. MCD broadens our perspective about clinical ethics methodology, so that we can relativize the general tendency to look at and follow American trends. We should, however, examine the challenge for MCD. Its procedural protocols may sometimes promote, but may also sometimes constrain, conversational deliberation. We should try to develop some innovational form of MCD.

    In this study, I conducted a survey (Questionnaire survey targeting 1,000 care workers who work for nursing home in Japan. The number of survey distributed: 1,000; The number of survey collected: 494; The response rate: 49.4%) to ascertain the current status of the basic education and on-site training provided to frontline care workers, as well as their awareness of ethical issues and how they deal with them. The results indicate that caregiver behavior (i.e. words used and attitude) is apt to cause problems and that tailoring care to individual elderly persons is unlikely to be possible. The survey also revealed that ethical issues frequently arise in relation to toilet support, bathing services, meal assistance, and when ensuring care recipient safety. According to the survey, problems often remain unaddressed because care workers do not know how to deal with them and/or because regulations and established systems hinder improvement efforts. Ethics education is considered to be effective in promoting shared staff values, enhancing care quality, and deepening understanding of the individuality of elderly people. In addition to instruction in basic knowledge, many care workers also require education on how to exercise proper judgment and solve concrete problems in the field. It is urgently necessary that further research into ethical issues arising in the care services field be conducted and that ethics education be enhanced.

    This report describes a case of preventive surgery for non-ruptured brain aneurysm detected during a checkup and discusses factors that dissociate physiciansʼ discretion and patientsʼ self-determination regarding the following: (1) characteristics of preventive interventions such as the present brain surgery, (2) comparison between merits and demerits of preventive intervention, (3) effect of medical treatment guidelines for non-ruptured brain aneurysm on this dissociation, and (4) the ethical principles of preventive intervention treatment that physicians must observe.
    This report presents some factors enhancing physician discretion and/or patient self-determination regarding the selection of appropriate preventive interventions. These factors are as follows: (1) physicianʼs tendency to usually consider preventive intervention as regular medical treatment, which convinces patients to undergo the experimental interventions; (2) medical treatment guidelines that might make physicians render experimental interventions as standard medical therapy; and (3) non-maleficence for predictive intervention as an ethical principle among physicians to maximally reduce invasiveness, as these interventions may be invasive to a healthy patient with no complaints.

    We might face a problem with a patient who does not provide adequate reasons for disagreeing with life-or-death treatment. Although medical staff and family might consider the patient's self-determination important, they would not know how to cope with it without understanding his/her reasons accurately. Thus, deciphering the silence of patients becomes essential. In this study, I attempt to consider the ethically problematic case of an incurable neurological disease, Multiple System Atrophy (MSA), by analyzing Herman Melville's famous controversial short story, “Bartleby, the Scrivener.” The primary character Bartleby refused to do the work that the lawyer, his boss, requested of him and did nothing at the office. The lawyer made an effort to communicate and support Bartleby but agonized over his inactivity and became frustrated. The motif of this novel shares several common aspects with my case so I utilize various theoretical explanations proposed by literary critics, recent medical ethicists, social scientists, and postmodern philosophers to understand the unsolved puzzle of Bartleby. As a result, I diversify the viewpoints into potential patients' protests against the healthcare system, intractable disease patients in Japan, and unintentional paternalism. Thereby I reveal that the autonomy of patients is easily distorted under these circumstances. Through this study, I clarify the significance of comparative studies between literary works and medical ethics cases that has not been attempted sufficiently thus far.

    “Welfare” is one of the foundational concepts of bioethics and provides direction to questions regarding life. However, the following questions related to welfare have not been discussed sufficiently: (1) whose welfare is guaranteed? and (2) how is welfare guaranteed? This paper considers these two questions in relation to the idea of “human dignity,” which is the basis of welfare. I examine the ideas of dignity proposed by Martha Nussbaum and her critic Eva Feder Kittay. My analysis clarifies that the concepts of human welfare and dignity are complementary. Nussbaums's position is valid, in that she regards human dignity as an intrinsic value. However, it should not be reduced to qualities, such as capabilities. To recognize and respect the dignity of a human being, individualized care for each plays an indispensable role. In this regard, Kittay's position, which accepts that a strong relationship exists between human dignity and care, provides us with an important insight into human dignity.

    This study clarified the importance of practical wisdom for ethical issues in perioperative nursing using Aristotle's Phronesis. Data were collected through interviews with 13 Certified Nurses in Perioperative Nursing. This analysis used different themes to ensure the data were as contextualized as possible. The results showed five different themes: 1) nurses know the importance of surgery for the patient and preserve its value, i.e., “preserve patient dignity”; 2) the primary nurse in the perioperative period should be actively engaged with patients, i.e., “be with the patient”; 3) nurses work with the surgical team to identify ethical outcomes, i.e., “guide the team”; 4) nurses make use of trends in operative medicine and needs of the times for patient care, i.e., “look into the times”; and 5) nurses ask themselves what they need to create better practices, i.e., “pursue better things”. From these themes, it was conceived that practical wisdom shows five temporal and spatial expansions. Our results suggest that it is important to develop practical wisdom to allow flexible responses to diverse ethical issues.

    The purpose of this paper is to introduce the discussions which took place during the legalization process of the “Therapeutic Abortion Law” (2005) in the Islamic Republic of Iran, along with the factors which affected the process in local contexts. Additionally, an overview of some changes after the enactment of the Law is presented. After the Iranian Revolution, induced abortion was considered unlawful in Shi'a Islam jurisprudence. The mothers and practitioners of abortion were severely punished under the statute laws, unless it was necessary in saving the life of the mother. Partial de-criminalization of induced abortion was pursued, in order to deal with the high prevalence of health hazards to women resulting from illegal abortions. In the discussion of the Bill, medical reasoning of induced abortion was focused, and the Islamic principle of “protecting mothers from turmoil” was invoked to justify induced abortions of fetuses with impairments. As a result, the “Therapeutic Abortion Law” was approved, permitting the abortion of fetuses with impairments, as well as protecting mothers from life-threatening situations. The enactment of the bill is understood as a step forward in the easing of the conditions of lawful abortion. However, there was not enough discussion about the rights of the disabled to live with impairments or illnesses. After the implementation of the “Therapeutic Abortion Law”, the estimated number of illegal abortions has not decreased, though selective abortion has increased and has become more socially acceptable.

    To examine the acquisition of informed consent (IC) from patients with dementia in Japan, an anonymous self-administered questionnaire was mailed to neurological specialists (N ＝ 302) in the Tokai area (4 prefectures: Aichi, Gifu, Mie, and Shizuoka). The questionnaires were returned by 120 specialists (representing a 39.7％ response rate). Of these, 62.5％ routinely evaluated patients' decision-making capacity when acquiring IC from patients with suspected dementia. Additionally, 99.2％ of the specialists obtained IC from patients' families as well as from patients with suspected dementia themselves, 64.2％ had difficulty obtaining IC from patients with suspected dementia, and 22.5％ assumed that special consideration was required when enrolling such patients in clinical studies. Comments by specialists included: “We need to obtain IC from patients multiple times because patients' understanding varies and is unreliable” and “Consultation with a physician should be heavily relied upon.”
    The findings confirm that the reality of the situation in this type of medical setting is that families are heavily involved in the treatment of patients with dementia.

    In order to clarify whether autonomic decision regarding child vaccination is available for guardians, an independent survey has been conducted from a perspective of Bioethics. In a questionnaire survey of guardians having children at the age of 18 or younger, they described concern about side reaction as well as suspicion against safety of vaccine most frequently as reasons why they didn't or hesitated to choose vaccination, while it has been revealed that informed consent was not obtained sufficiently at the time of vaccination in many cases. In consideration of such situation that they have no choice but to worry about anyone else due to directions they may receive from nursery school, kindergarten and school if they made a decision not to select vaccination, it may be said that they are put under a situation incapable of self-determination even if risk of side reaction is responsible for themselves. Even though some working parents desired more efficient vaccination on the other hand, it simultaneously implies such child-rearing environment behind the scene that they concern about fatal accident after vaccination and cannot allow enough time to face with their children's health and diseases carefully. It is necessary to build up a reliable network for guardians, in addition to administrative organizations and medical institutions, to ensure their autonomic decision based on diverse information.

    Preimplantation genetic diagnosis (PGD) has largely been prohibited by law in Germany, Austria and Switzerland. In recent years, however, these three countries have revised their laws in succession to allow restricted access to preimplantation genetic screening. This paper provides a view of new PGD laws in these countries and discusses the similarities and differences among them, with an eye toward future development of legislation on PGD in Japan.
    The laws of the three countries have five major characteristics in common. First, all allow clinical application of PGD only under certain conditions, and violators can be punished by the authorities. Second, it is prohibited to use PGD for the purpose of selecting the gender of children or creating a savior sibling, both of which are irrelevant to detection of specific genetic abnormalities. Third, only authorized medical institutions are allowed to use PGD for treatment of patients to ensure the quality of the screening. Fourth, such authorized medical institutions are obliged to keep records of their application of PGD. Lastly, genetic testing must be done only after providing pre-PGD counseling for patients and obtaining written informed consent.
    One of the major differences is that physicians in Germany and Austria may not be compelled to use or become involved in PGD and, regardless of whether they choose to use PGD, they are protected against negative treatment by an employer. There are no such stipulations in Switzerland. Another clear difference is that ethical committee consent is required for every PGD application in Germany, but not in Austria and Switzerland.
    A comparative study of PGD in terms of legislation, including official records of discussions during development of the legal process, in Germany, Austria and Switzerland can serve as a useful reference for this process in Japan. It is also important to continue to watch how PGD is applied under the legal systems of the three countries.

    Genetic testing has become popular in Japan, and people can now undergo DNA testing at a reasonable price, 70 years after the first AID (Artificial Insemination by donor's semen) was implemented. Therefore if donor-conceived children come to doubt their genetic relationship with their fathers, they are able to confirm that they have no genetic relationship despite their parentsʼ attempt to hide the truth. This means that we are now in an era in which donor anonymity is now longer secure. Given this background, this paper points out the risks faced if donor anonymity is maintained and discusses issues associated with the infringement of donor privacy and the relationship between parents and donor-conceived children. In Japan, the policy of donor anonymity remains in effect because of anxiety over a possible shortage of donors. However, the result is to ignore the various problems created by donor anonymity. This is problematic from the perspective of justice. At the same time, if donors continue to receive no explanation of the possibility that donor anonymity may become insecure, they will become anxious about having their identities traced. This situation is injurious to donors. I conclude that it is necessary to legally clarify the relationship between parents and donor-conceived children, and based on that definition to respect donor offspring's “right to know identifying information of their donors” and abolish donor anonymity.

    The Patient Self-Determination Act, which permits the withholding and withdrawing of lifesustaining treatment from non-terminal patients, was enacted in Taiwan in 2016. Patients having the clinical conditions of 1）irreversible coma, 2）persistent vegetative state, 3）late-stage dementia, and 4）rare diseases are permitted to write advance directives and express their wishes concerning life-sustaining treatment. This paper examines the background of this legal change and explains how the concept of “good death” and the reasoning about the patient's autonomy have led to the enactment of this new law. As the old law “Hospice and Palliative Care Act” has scope for ambiguous interpretation regarding the patient's autonomy pertaining to end-of-life care, patient groups have asked lawmakers for a new law and one that clarifies the patient's right to self-determination since 2014. During the debate surrounding this legal change, the concept of “good death” was used and is stated in the first article of the act as its purpose. As “good death” is limited to specific clinical conditions, this paper concludes that the right to self-determination is not necessarily equivalent to the right to “good death,” and that more discussion is needed before the implementation of the new act.

    Cancer is one of Japan's biggest healthcare issues. Cancer patients play an important part in clinical trials that develop innovative therapies. Researchers should ethically minimize participants' “therapeutic misconception,” which is confusion between the objectives of clinical trials and personal therapies. However, few studies have investigated patients' experiences of and perspectives on cancer trials.
    We conducted an in-depth interview survey of 11 cancer patients to investigate their attitudes and perspectives about clinical trials. The types of cancer and clinical trial varied among the participants. We focused on the process of entering the clinical trials regarding the way that trial information was obtained, informed consent (IC), and motives for participation.
    The participants understood IC as “disease notification” or “having a proposal for clinical trial participation” rather than “receiving appropriate information for decision making for participa tion.” It seemed difficult for the participants to use IC to distinguish between the clinical trials and their personal therapies. Participants who expected a personal benefit from a clinical trial were more likely to report therapeutic misconception than were those who gave altruistic reasons for participation. Some participants considered clinical trials the “last resort” way to cure their cancer despite having an accurate understanding of the goal of clinical trials. These participants might have made “rational wagers” rather than therapeutic misconceptions.
    Some participants did not identify themselves as research participants through the process of IC. Thus, more discussion is needed on effective ways to provide information to patients to encourage voluntary participation. Patients' sense of commitment to a clinical trial might vary, and their personal motivation (e.g. hopes for a cure) might be acceptable in the decision-making process. Researchers should understand each individual patient's motivation so that IC is developed to enhance the effectiveness of gaining patients' acceptance of clinical trials.