Discourse of Japanese and American physicians on truth-telling in the care of dying patients was examined from the standpoint of metaethics. American physicians tend to display an ontological or ruleutilitarian attitude when they think about the ethics and practice of truth-telling to dying patients. On the other hand, Japanese physicians show an act-utilitarian or contextualist attitude in regard to disclosing information to these patients, as is represented in the remark by a doctor, "case by case is the principle." American bioethics has been criticized recently for its principle-based approach as well as for the priority given to autonomy and individualism. However, contextualist discourse, currently popular in Japan, has its own pitfalls, such as accepting the current limits of the situation and being vulnerable to arbitrary decisions by physicians. Attention is drawn to unexamined presuppositions in the truth-telling debate in Japan that, on the basis of esthetics, reject logical arguments and that are highly utilitarian.

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A voluntary questionnaire was conducted on all patients admitted to the surgery ward at Toyoko Hospital. The answers were compared with the present situation in regard to truth-telling in actual malignant patients. Current trends regarding informed consent are reported. The study was performed on 133 patients. No remarkable difference was observed between patients with benign and malignant tumors. More than 75% of the patients wished to know the official name of the disease. Even if there was no chance of surviving, 66% wished for an explanation of their condition. As regard to the rate of actual truth-telling, however, complete truth-telling was in 50% and obscure truthtelling in 17%. Particularly in death cases, only 20% of the patients knew completely about their status. This is perhaps because the judgement is dependent on the family and physician. Moreover, to obtain informed consent from terminal patients, we should listen to their wishes before anything. It is important that the informed consent be based upon the things that we can do for the patints.

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In the current neonatal medicine, medical decision making from ethical point of view is essential for proper care of the infants with a poor prognosis. In our institute, classification of the patients according to severity of their prognosis is established as follow : class A ; provide all possible treatment. class B ; limit invasive treatment such as major surgery, hemodialysis. class C ; observe with current treatments and routine care such as temperature control, enteral nutrition, skin care, with tenderness. class D ; discontinue all treatments. After discussions with all staff members involving the care of the patient, the most senior staff member makes the final decision, while considering family's will and wish. Patient with trisomy 18 is usually classified into class C because of its very short life expectancy, especially when the patient has lethal malformation. However, we experienced a long-term survived case with trisomy 18 who was under medical treatment for cardiac failure but lived a happy life with the family at home. Accordingly, we should not draw a conclusion from the diagnosis only, but with the medical and familial difference of each case.

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This study was conducted in patients who received a transplant over 1 year ago, to evaluate the quality of life of transplanted patients and to ascertain their thoughts about ethical issues related to transplantation. The study showed that 90% of the transplant recipients achieved the level of health that they had expected before the operation. 50 to 75% of the recipients returned to work. 70 to 80% of the recipients were willing to be contacted when the donor family wished to contact them. In order to increase the number of donor, 60 to 70% of the recipients suggested establishing an Opting-out system. There was disagreement, however, as to whether the donor family should be paid. 60 to 80% of the recipients thought using organs from animals was morally justifiable.

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Acquired immuno-deficiency syndrome (AIDS) is a new syndrome. It was recognized as being pathogenic in human beings only a little over ten years ago. At present there is no cure for AIDS. People are therefore frighten of this lethal disease and there is a strong tendency towards social segregation of HIV-infected or AIDS-manifested patients. There are a number of important bioethical issues on AIDS problems and this paper describes comments on some of these issues including public education of the correct knowledge of AIDS, how to properly deal with HIV-infected and AIDS patients and how to prevent the spread of HIV infection by introducing the universal precaution.

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Medical professionals often express reluctance to take patients' informed consent (IC), out of some 'cost-beneficial thinking', that is, there is little time to make such 'time-consuming' communication in their 'economically unhealthy' clinics. Their claims are right in that Japan's health care system has some characteristics discouraging hospital managers from promoting IC. In general, 1) hospitals gain a half or a quarter of monetary supply from public resources-insurance, tax, etc.-through physicians' general or communicational conducts, comparing what gained through their technical or prescriptional conducts accompanied by consumption of materials. 2) In a hospital, one inpatient makes around 1500 yens of red figures per day, while one outpatient creates 63 yens of gain per day. This seems leading to the fact that 3) physicians stay two or three times longer in OPD than inpatient clinics. On the other hand, medical professionals are given wide discretion to take-or not to take-IC in most cases. Only generous guidelines have so far been set recomending physicians to take patients' IC, without any concrete difinition of when and how they are obliged to take IC. IC might be a hard choice for Japan's patients.

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An Australian philosopher Peter Singer defends active euthanasia for severely disabled newborns. His ethical position, preference utilitarianism, is that when we act we have to take into account the interests of all those affected by our action equally, and we must choose the course of action that produces the greatest sum of these interests. He also asserts that sentient beings have only interest in physical pleasure or pain, and that only persons, namely those who have reason and self-consciusness, have interests in their future life. According to Singer some non-human animals are in fact persons, and some menbers of the species Homo Sapiens (fetuses and newborns for example) are not persons. Newborns have only interests in pleasure and pain, then, Singer says, when they suffer from severe congenital disabilties and even the parents hope their death, their lives are not worth living and it is better for them to be killed. Singer's this argument reminded people in German-speaking countries of the so-called euthanasia program in Nazi-Germany. Since 1989 a wide and fierce protest against Singer has arisen, and not only symposia and lectures Singer attended but also those concerning bioethics abandoned in Germany, Austria and Switzerland. It is reported that even now there is an atomosphere of anti-bioethics in these countries. In Japan there is also anti-bioethics arguments regarding bioethics as an ideology for eugenic control. So we should learn much from the Singer-Affair and the anti-bioethics movement in German-speaking countries. First, we must make clear about the past as German people did, especially about our medical crimes in World War II, in order to establish our own bioethics. Secondly, we should criticise the premises on which Anglo-American bioethics unconsciously depend. Finaly, and above all, we must maintain the freedom of speech in our society.

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In forecasting the near future of Japan, a critical issue is rapid aging of the society. With further technology development and its effects on medical care, life prolongation by five to six years is anticipated. A man lives until the end of his life expectancy and faces death. Maintaining the quality of life in later years in critical in medical care. Metaphysical logic is necessary for a man as the existence faced with death. Medicine also addresses man, a living from brain physiological point of view, and training of the frontal lobe is said to control the human values. Discussions are being continued on medical ethics, bioethics and medico-biological guidelines (such as Helsinki Declaration), and these are expected to emerge from the current chaos as disciplines. It is necessary to distinctly categorize them and have an open relation with socio-economical ethics.

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The patient-physician relationship, defined conceptually and historically as an original issue of medical care, must be today highly estimated, when we admit that several ethical problems of medicine are caused by the intensive advancements of high-technologies. Because the increase of chronic diseases, aging, terminal care and so on are changing the concept of conventional medical care. Now autonomy is espoused as the basic value for which the patient-physician relationship plays a leading role in the ethical concept. "Dialogue" between patient and physician in this relationship is indispensable and really worth selecting the medical treatments and respecting for autonomy. Moreover, I'd like to point out that we can overcome, based apon the "sympathy" which deepens in this relationship, new aspects of medical care.

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Bioethical issues concerning how to define adequate brain death criteria have been discussed on the premise that we do not have crucial medical technology which would make it possible to resuscitate or keep functioning the human higher brain with severely damaged brainstem. however, in the future, we will be able to introduce advanced artificial organ technology into the brain surgery processes, including 'the artificial skull, ' 'micro blood pump, ' and 'artificial brain vessels.' By using these techniques some parts of the higher brain may be kept alive while the other parts are dead. In these hypothetical cases the present brain death criteria should be completely reconsidered.

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It is important for good argument of brain death that we understand it correctly. From the viewpoint of knowledge for brain death, the concepts of it among 70 nurse students were investigated. The results of this study are summarized as follows. 1. The nurse students with the correct knowledge had a tendency to approve brain death and organ transplant. 2. Whether with correct knowledge or not, they had not a tendency to approve their dear person's brain death, organ transplant and right to refuse treatment. They put up living will. 3. So it decreased with the progress of their study that they had approved organ transplant.

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