The 30th annual meeting of the Japan Association for Bioethics (JAB) was held in Kyoto in December 2018. At this anniversary event, we had a poster presentation that looked back on the past 30 years of JAB under three themes: major events regarding bioethics in Japan, an outline of the activities of JAB, and the transition of the “Journal of Japan Association for Bioethics.” This article aims to describe and rewrite these posters with some additional analysis and discussion. During the last 30 years, many bioethical social issues have arisen, and regulations based on various laws and ethical guidelines have been enforced in some areas. In line with the social flow, JAB itself has also experienced various changes. The Journal of Japan Association for Bioethics has published studies on various topics, thus leading the discussion on bioethics in Japan and contributing to the spread and deepening of bioethics. Finally, we would like to express our gratitude to all the people who have contributed to the 30-year development of JAB so far, and we hope that this article will provide an opportunity for further growth of bioethics in Japan.

　　Since 2014, when Swedish researchers delivered the first living baby from a mother who had undergone uterus transplant from a living donor, uterus transplantation (UTx) has become a new practical option for women with absolute uterus factor infertility (UFI), who desire to give birth to their own children. Japanese women suffering from UFI are no exception, and some researchers have considered the application of this method. In UTx, organ transplantation from living or deceased donors is used under the goal of assisted reproductive technology. This article aims to provide an overview of the ethical considerations of UTx from three aspects: justification and feasibility of UTx as organ transplantation; comparison with other alternatives of assisted reproductive technology such as surrogacy; and the interests of the children borne by women through UTx. Finally, it examines the ethical challenges that should be resolved if UTx is applied to clinical medicine in Japan, considering the possibility of artificial womb as another alternative to UTx. Indepth discussions are necessary to settle these issues before clinical trials of UTx for women with UFI are implemented in Japan, so that all the stakeholders, including women with UFI, potentialdonors of a uterus, and the children born with the help of UTx would not suffer from this emerging technology.

　　It is important for clinical nurses to be virtuous. Nurses would acquire knowledge of “arête” by interacting with and caring for patients on clinical practice. However, if the nurses prioritize medical safety, such as preventing accidents in clinical situations, nurses would never acquire knowledge of “arête”. Nurses should seek virtue for their patients so that nursing practice is a scientific practice containing virtue. Two case studies are described in this article. One involves the clinical problem of using physical restraints for older patients undergoing dialysis. The second concerns barriers that prevent older patients from accidents, such as falling out of bed. Both cases indicate that preventing any accidents in clinical situations might induce other ethical dilemmas such as damaging patients' rights, or creating uncomfortable feeling for patients. Nurses should take actions in clinical situations such as listening to patients' real concerns, supporting their autonomy, gaining perspective on their own values, getting a perspective beyond that of medical staff, knowing oneself, and recognition of diversity of opinions. Part of the solution would be for hospital administrators to arrange sufficient nursing staff to enable successful patient-centered care and then to support education for acquiring in “arête” for ethically informed practice.

　　Children requiring constant medical care are those who need medical support such as ventilator or gastrostomy even after discharge. Along with advances in medical technology, the number of children requiring constant medical care is increasing annually, but the support for their school attendance has not progressed accordingly. Many of these children have no mental and physical impairments other than requiring 24-hour medical care, which does not interfere with everyday life. Therefore, depriving them of opportunities to receive education according to their conditions is a grave infringement of their basic human right. This study aimed to examine the factors that impede the school attendance of children requiring constant medical care. The research considered the current legal and institutional situation, in which laws that should support children requiring constant medical care give educational institutions an excuse for refusing their acceptance. Moreover, referring to the decades of serious efforts for inclusive education in the UK and U.S., we pointed out that in Japan, there is a tendency to regard the establishment of the law as the goal, as well as the lack of attitude to strive to approach the ideal by constantly correcting inadequacies in the law. Finally, we proposed the needed policies to guarantee the right to receive education for all children requiring constant medical care.

　　This paper attempts to consider an aspect of the ethical issues involved with xenotransplantation, using the concept of “technologization of human nature” as a clue. First, we present an overview of the challenges with xenotransplantation, and examine some representative ethical issues among them. Second, we examine concerns about “unnaturalness” that accompany xenotransplantation. Using the concept of “technologization of human nature,” introduced by Habermas, we discuss the sense of value that is considered to be behind this concern. Particularly from an ethical standpoint, three issues are frequently mentioned: human dignity, the boundaries and integrity of the species, and the use of animals. From a technological viewpoint, these three issues are not likely to cause such serious ethical problems. However, if a vague hesitation over xenotransplantation remains, there may be a lingering concern about its unnaturalness. Although unnaturalness does not directly lead to an ethical conclusion, it is premature to eliminate the concern about unnaturalness as mere conjecture so that society may accept xenotransplantation. In discussing this concern about unnaturalness, we focus on Habermas's concept of “technologization of human nature.” Habermas's discussion guides us to an assumption of fears behind the concern about unnaturalness: that the body may be instrumentalized, that the sense may be lost that the body is vulnerable and incapable of manipulating as intended, or that the sense of awe for life may be impaired. Apparently, the idea of awe for life has religious connotations. However, Sandel used the term “giftedness of life” and demonstrated that awe for life is comprehensible without depending on any particular religion. Discussions of Habermas and Sandel could infer that the concern about unnaturalness may not be duly eliminated so simply. However, they do not deny the intervention for disease treatment. Xenotransplantation may deserve further research if the expected benefit is large. For that very reason, the issues arising from targeting its clinical application should be on the table now.

　　In Japan, a need exists for more gamete donors. The present study, which is based on the experience of donors in New Zealand and the UK, explores what types of people constitute ideal donor candidates from the perspective of mitigating future risk, as well as what are the most effective methods of recruiting donors to satisfy the growing demand in Japan. As of 2019, there are no laws or regulations regarding donor conception in Japan. However, based on global trends, it seems likely that in the future, laws will be enacted to prohibit compensation to gamete donors and to abolish anonymous donation. In this study, I focus on gamete donors in New Zealand and the UK, two countries where compensation of gamete donors is prohibited and the right of donor offspring to know the gamete donor's identifying information is secured by law. I conducted semi-structured interviews with a total of five gamete donors in 2017. Based on those interviews, it appears that the ideal donors are those who donate their gametes altruistically, who are able to disclose their identities to donor-offspring, who disclose the experience of gamete donation to their partners and children, and who have personally experienced infertility or are acquainted with infertile people. It is not easy to secure such donors, but the effort to do so is worthwhile in order to avoid future troubles related to gamete donation. An effective way to recruit such donors in Japan would be to follow these two countries in posting advertisements at fertility clinics and on public bulletin boards, where they are likely to be seen by those who have experienced infertility treatments or have infertile acquaintances as well as by married couples and others with children.

　　The process of decision making regarding respiratory care for patients with multiple system atrophy (MSA) should be considered as an ethical issue. MSA is an intractable disease which causes various neurological symptoms. Because of dysarthria and motor disturbance, patients become difficult to communicate with not only via speech but also by using communication devices. MSA also gives rise to respiratory failure which may provoke sudden death, as is frequently the case. In spite of insufficient evidence that tracheostomy positive pressure ventilation (TPPV) may improve respiratory disorders and bring relatively stable long-term survival, a few patients nonetheless undergo artificial ventilation treatment. Most of them were probably led to deciding not to use TPPV, that is, to die because their objective quality of living as evaluated by others might be deemed irreversible and intolerable decline. Moreover, the theory of personhood distinguishes persons who have moral standing and nonpersons- who may be left to die- and should be thought to affect our perception of the situation of MSA patients who are almost incapable of any communicative expression. However, even in these situations, there can remain a possibility of the patient retaining various criterion of person hood. This study was conducted via a series of interviews on three patients with MSA and their families. They revealed how they avoided being induced to give up respiratory care (especially TPPV) and determined- by themselves- to continue living using ventilators. Even with patients who are in the most progressive stages, care givers who have been communicated with by patients for a long time can read and realize patients' thoughts and intentions by the subtle movement of their upper limbs and facial expressions. Hence, they can effect a translation of sorts into concrete meanings in specific patient contexts. Latterly, this should be recognized as a kind of language-game (as developed by Wittgenstein in his Philosophical Investigations). Furthermore, patients' autonomy should be respected due to the ability to engage in elaborate communication means such as those described.

　　Research ethics consultation services (RECS), which function as an advisory service to facilitate resolution of complex ethical issues in the context of clinical research, have been proliferating over the last decade. However, the qualification of an individual who provides RECS, or “a research ethics consultant,” has not been thoroughly investigated, in contrast to healthcare ethics consultants, whose core competencies have been well discussed and identified. In this study, we have investigated core competencies required for a research ethics consultant, referring to the core competency models of ethics consultants developed in the healthcare practice context, and propose a competency model for research ethics consultants.

　　A program that allowed family members to be present during resuscitation was started in America in 1982, in response to the demands of the family members of patients. The advantages and disadvantages of family presence during resuscitation from the perspectives of patientsʼ family members, healthcare providers and patients are reported. Although the American Heart Association and the European Resuscitation Council support offering family members the choice to be present during resuscitation, its ethical grounds have not been fully examined. This paper examines the validity of the argument based on the standards of surrogate decision making when the patient undergoing cardiopulmonary resuscitation (CPR) has not expressed any wish for family presence. In conclusion, the argument based on the standards of disclosure is valid, rather than surrogate decision making.

　　Recently, the issue of ancillary care in the context of medical research, especially research conducted in developing countries, has been gaining attention. Although the most influential theoretical model on this issue is the ʻpartial-entrustment model' proposed by Henry Richardson, this model has been controversial due to its limited scope. After providing a brief overview of the partial-entrustment model, I discuss the controversy surrounding the model, especially in light of an important objection raised by Dickert and Wendler. I then discuss Richardson's reply to the objection. The discussion will reveal that the partial-entrustment model is facing a dilemma stemming from its limited scope. I end the discussion with two proposals for addressing this dilemma, together with problems that remained unsolved. More studies will be needed to identify other potential grounds of ancillary care obligations of medical researchers and to provide a comprehensive picture of these obligations.

　　In April 2015, the “Ethical Guidelines for Medical and Health Research Involving Human Subjects” was enacted. As per this, members of ethical review committees were obliged to receive the necessary education and training so that they could conduct reviews from an ethical and scientific viewpoint before taking on the responsibility for conducting reviews and performing other duties. It also obligated that the organizers of ethical review committees take necessary measures to ensure that the members receive such education and training. After the Guidelines were enacted, it was estimated that the implementation rate of education and training had improved greatly; however, to implement effectively, a method was needed to measure and evaluate the effect of these programs on review committees and their members. This study examined the usefulness and limitations of Kirkpatrick's Four-Level Model, which is considered highly suitable as an evaluation method for HRD (Human Resource Development) to evaluate education and training programs for members of ethical review committees. On confirming that the four levels in the model could be applied to evaluate these programs, an evaluation model was developed, which can be used on a trial basis.

　　Moral case deliberation (MCD) is a general term for semi-structured methods of clinical ethics, implemented to deeply understand difficult cases at hand and to explore concrete measures to solve ethical problems. It is a specific multistep way of reflective dialogue among healthcare professionals from various backgrounds on wards with minimum guidance by trained facilitators. MCD is distinct from clinical ethics consultation or clinical ethics committees in that MCD does not give privileged positions to external experts. The dilemma method, one of most influential MCD methods, was developed in the Department of Medical Humanities at VU University Medical Center Amsterdam in the late 2000s. As its name suggests, the dilemma method starts with a certain dilemma experienced by the professional bringing the case. While formulating a dilemma can indeed at times make the start of MCD easier, it can at times make it more difficult. It happens that not a few participants balk at being urged to reduce several ethical problems to one single dilemma. This may be related to cultural differences. This paper examines the steps of the dilemma method and inquires about the necessity of sticking to the dilemma framework. To help in doing this, we turn to the original or prototypical version of the dilemma method developed by Jacques Graste in the early 2000s. We find that, while his prototypical protocol also starts with clarifying a dilemma, it is not intended to stick to, but to be released from, the dilemma framework. Finally, we suggest a re-modeled or abbreviated form of the dilemma method that does not urge participants to worry too much about dichotomous schemata.

　　This paper demonstrates that the model of an easy-to-understand urination system invented by the author can be used as an effective teaching material for care work education. And as care work students become Certified care workers, this knowledge will help enable students to give care & life support based on ethical principles. In order to achieve this goal a model was created, demonstrated & taught to students, further modified to make it more attractive, presented at an industry/university cooperation promotion event, and finally manufactured (and videoed) along with the technical assistance of a corporate partner. The function of the kidney is difficult for some students to understand, but by using this urinary system model urinary flow becomes visible and students are able to see why some patients experience problems in excretion. This is expected to contribute to care work education that is required to achieve high ethical retention.