In 1994,the Science Council of Japan approved of withdrowal of nutrition and hydration from patients in persistent vegetative state (PVS), if they have had "living-will". The term "persistent vegetative state" was coined by Jennett and Plum in 1972 to describe the condition of patients with a state of wakefulness without detectable awareness, and the Japanese Neurosurgical Society proposed a clinical criteria of PVS for getting public financial help on these patient's family. In 1994,the American Multi-society Task Force on PVS expressed the consensus statement of the persistent vegetative state. Bioethical issuses concerning patients in PVS are 1) a vague conception, 2) obscure clinical criteria, 3) various prognosis, 4) possible very long survival (41 years), 5) usually unclear patient's will, 6) death with dignity. For each patient it is important to have a living-will, and medical staffs should be treating a patient in PVS same as conscious one, so if the patient had the living-will physician should respect it. Before deciding cease life-suporting measures physician had to have enough time to discuss about various conflicts among nureses and patient's family.

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The improvement of medical technology has raised several points in the clinical field of obstetrics. Here are presented three among those cases where the prognosis of newborns may be unsatisfactorily. 1. artificial reproduction and selective reduction operation The improvement on reproductive technology has presented a sterility couple a good news. However at the same time it has caused a high frequency of multiple pregnancy, which would make both physical and economical burdon heavier on the couple. Though an operation of selective reduction is a temporary expedient for this, it should be applicable within the limits of the Eugenic Protection Law. 2. management of delivery of extremely immature infant Usually Cesarean section is operated in case of delivery at twenty-six (26) weeks of pregnancy with breech presentation following prolapse of cord. We had this case but having Cesarean section for two times in the past and were refused for the third time. In such a case, a Hospital Committee for Bioethics should be organized right away to draw a conclusion according to the concept of bioethics. A discussion should be made by phone or even by facsimile. 3. prenatal diagnosis on congenital anomalies A prenatal diagnosis on congenital anomalies has been made an operative treatment in utero or early treatment possible by an improvement of ultrasonic technology. Any case at medical institutes in Level I or II, which an identification of disease is in suspicion is referred to those in Level III. Not only the announcement of the name of disease but also its treatment at the time, whether that treatment is a fixed one or on an experimental stage, its prognosis, etc. have to be explained to the obstetrician in detail.

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In current NICU we often have to face to the problems to manage newborn babies with poor prognosis. It is needed to make classification for treatment according to the severity of the prognosis. As follows : Class A ; provide all possible treatments, Class B ; limitted treatments, Class C ; observe with current treatments and routine care, Class D ; discontinue all treatments. On making the decision, medical information is most important but we also have to consider familial, social, legal and bioethical elements. It never means that we neglect the right to live of these babies who can not express their will. This process of decision making is arbitrary, thoughtful discussion is needed for every case.

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From an ethical viewpoint concerning citizens'movements, this paper criticizes the inadequate location of a large pathogen laboratory in a densely populated residential area of Tokyo. About two years ago, the National Institute of Health (NIH) that is Japan's largest research laboratory dealing with many species and large quantities of pathogenic agents moved to the newly constructed building located on a small site in Toyama of Shinjuku ward. During the past 7-8 years, many citizens living near the new NIH building and people of Waseda University have developed strong countermovements including a lawsuit against NIH. Regardless of the citizens'opposition, NIH dared to move to the densely populated area and began research works using various pathogens at seven containmentlaboratories of Biosafety Level 3 (P-3 Laboratories). This coercive attitude of NIH has threatened citizens'peaceful lives, giving them very unpleasant feelings. Many difficult problems are involved in the conflict between NIH and opponent citizens, for example, environmental risk assessment of biohazards caused by pathogen experiments, lack of social conscience and presence of anti-citizen sense among NIH people, inevitability of citizens'resistance against the national power that may destroy citizens'living environments, oppression of citizens'humane emotion by the national power and so forth. The present author thinks the coercive move of NIH to Toyama is against both bioethics and environmental ethics in these times. NIH should be relocated to any relevant place other than the densely populated town, Toyama. In addition, a method of environmental risk assessment for pathogen-related research facilities should be established as soon as possible by the authority concerned.

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Nursing care (eating, sleeping, excretion, cleanness, bathing, control of the environment and change of posture etc.) and palliative care (pain control, expectoration and elimination of anxiety or discomfort etc.), must be given to the patient, who can not do these activities in his daily life by himself, even if he is in a terminal stage. Therefore this care is necessary for his existence, during his whole life period, until the time of his death, to support his life (See. The penal code, Article 218,Clause 1). The same holds for the persistent vegetative patient, who needs protection for his existence. Accordingly we must take this nursing care and palliative care as basic therapy, for which all patients have the right to demand, even if the medical invasion for the cure is no longer appropriate for them. As a general rule, doctors, nurses and any other responsible protectors are under obligation to give this basic therapy to the patient. As far as it is appropriate to the patient's condition, feeding and hydration must not be withheld or withdrawn easily, even if there are documents of a living will and these have a character of medical invation. Such practices make it possible to avoid the danger of slipping on the slippery slope. When the patient is allowed to die because of a breach of this obligation of basic therapy, it may be the crime of murder, manslaughter, participation in suicide or aggravated abandonment by a responsible protector.

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After a period of principlism in the late 1970's and anti-principlism in the 1980's, the "Clinical Ethics" movement has evolved in the US. The movement has been basically initiated by the medical profession and some bioethicists. In this report, the definition, issues in teaching, research, ethics committees and future direction of "Clinical Ethics" are summarized by citing 5 articles from The Journal of Clinical Ethics, first published in 1990. The goal of "Clinical Ethics", as clearly described in these articles, is to improve the quality of patient care by identifying, analyzing and attempting to solve the ethical problems that arise in the practice of clinical medicine. The starting point for ethical analysis is the encounter between patient and health care provider and the importance of the clinicians'perspective in that interaction is stressed. A review of relevant books, conference reports, some articles criticizing this development are included. This kind of framework, which is applicable and powerful in the clinical setting, can also be developed in Japan. Old professional medical ethics should be developed into a broader concept of "Health Care Ethics" which embraces the consideration of bioethics in general. "Clinical Ethics" in Japan can be placed into one field of "Health Care Ethics", and will focus on exploring good quality of care for an individual, identified patient within a specific circumstance.

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Japanese bioethics began in the early 1970s by feminists who fought against the government's bill that seeked to limit the freedom of abortion. This means that Japanese bioethics started as feminist bioethics, simultaneous with the formation of American bioethics. Their discourses are classified under three categories : (1) The government should not intervene into private reproductive processes, (2) Women have reproductive rights including abortion, and (3) Society in which women can and want to give birth confidently is needed. We have ignored their bioethical discussions and movements in the 70s and 80s, Their works should be reappraised as Japanese feminist bioethics, and the first attempt of contemporary Japanese bioethics.

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WHO (World Health Organization) and UNICEF (United Nation International Children's Fund) declared the concept of PHC (Primary Health Care) in 1978. PHC aims for health for all by the year 2000,which included both developing and developed countries. In 1979,Dr. Kaprio of Europian regional office of WHO summarized the concept of PHC into four principles, such as needs oriented, community participation, maximum use of resources, and coordination/integration. These principles are useful for their university accepted and experince-based law of health activities. In Kennedy institute of ethics, Georgetown university, four principles of health care ethics has been developed from 1978,such as beneficence, non-maleficence, respect for autonomy, and justice. They are widely accepted as a foundation of bioethics which include multi-disciplines of medicine, philosophy, law, and religion. Two sets of principles appeared in almost same time from different regions and they are similar in their ideal, principle-based approarch. To cope with current issues of community health, it is important to have dual sights from both PHC and bioethics, considering our basis of eastern philosophy.

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Bioethical Issues-death with dignity, withdrawal of life sustaining treatment, informed consent, brain death and organ transplant, etc., -have been discussed as criminal issues. Those arguments in Japan seem to be off the point because they are dogmatical and stand on scientism deeply despite that now we are in a truning point of the scientific age. Here in Japan, criminal law could be expected not a little role on bioethical issues, especially because of its moral formative function. It should be necessary for a proper consequence of interpretation of present law that criminalists make efforts to search values for new age.

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As bioethics education has gradually evolved at universities as well as medical schools in Japan, a reliable program evaluation strategy is in great need. So far, there have been several subjective means of evaluations such as essays. However, objective and quantitative evaluation instruments have not been developed here. According to J. Rest (1992), the process of ethical problem solving can be divided into 4 steps : 1) problem identification ; 2) reasoning ; 3) judgement ; and 4) implementation. The authors have focused on the first step, problem identification. Referring to the proceeding study by Hebert et al. (1992), a self-rating questionnaire has been newly developed to assess the ability of problem identification, that is, the ability of recognize ethical issues (Problem ldentification Test : PIT). The reliability and validity of this questionnaire was assessed. The questionnaire submits three vignettes to examinees and asks them to list all the ethical issues related to each case. Each vignette was scored as to the number of issues identified and this number is regarded as problem identification ability. These issues were classified into three domains ; (1) autonomy and right, (2) beneficence and nonmaleficence, and (3) justice and contextual features. Data from 110 university students revealed that this test has internal consistency (Cronbach alpha=0.68), inter-rater reliability (r=0.83-0.90) and test-retest reliability (r=0.89). In a different study, the ability increased significantly after an 18 hour health care ethics class (p < 0.01,by paired t-test, n=31). The advantage of this instrument includes ; 1) it takes only 15 minutes to complete ; 2) it provides quantitative and objective information on ability to recognize ethical issues.

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Bioethical topics have been dealt with in Japanese high school textbooks of ethics since Aprill 1994 because of the revision of "a course of study" issued by the Ministry of Education, Science and Culture in 1989. This paper briefly describes the current situation of the bioethics education in high school. This study consists of two parts ; 1) analysis of how bioethics is taught in textbooks and teachers'guidebooks and 2) analysis of the questionnaire to clarify the attitudes of the ethics teachers toward bioethics education. As a result of 1), it was found that definition of bioethics varies in each textbook and teachers'guidebook and most of the keywords in bioethics are related to death such as euthanasia or brain death. As a result of 2), it was found that 58% of respondents had given lectures on bioethics and 51% felt that the textbook does not have enough contents of bioethics. Most of the respondents recognized the necessity of bioethics education in high school.

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