In the field of international health cooperation, global issue such as population, AIDS, and environment are important and it needs bioethical consideration on their prevention and care. Epidemic of HIV/AIDS in Thailand are examined from the viewpoint of four principles of health care ethics of Kennedy Institute of ethics, Georgetown Univ. HIV/AIDS in Thailand are serious problems to be 10% of total population in the next century and there are bioethical problems such as beneficence, non-maleficence, autonomy, and justice, which should be considered in the health cooperation of Japan in future.

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I investigated clinical incidents in which physicians neglected patient's rights in Japan during 50 years after World War II. In the first term (1945-59), the sufferers were the infants and mentally handicapped persons mainly. Some pyhsicians thought their human experiments were not ethical, but they could not change the plan of the experiment. Because their professor had strong powers and decided the plan. In the middle term (1960-79), public health insurance system were accomplished for all people. Since then, they could see a physician easily. But medicines were used carelessly and many patients were damaged by them, for instance, thalidomid, quinoform. The other main incidents were "Wada" heart transplantation and assault or robotomy on a mentally handicapped porson. In some cases physicians lodged a complaint with a police or the Japanese Society of Psychiatry and Neurology. Then the medical association adopted some principles of human experiments. In the latter term (1980-95), brain-dead patients were disturbed upon human rights, though ethic committees which examine human experiments were established in many medical schools. The members of the ethic committees have been almost insiders and males. and deliberated not open to the public. The damages from medicines including the blood products contaminated with HIV occured one after another in this term too. The Ministry of Public Welfare established a standard of human experiments for new medicines, but admitted oral consent from a patient as well as consent by a document. Some physicians organized a patient's rights conference or a board of investigation of malpractice. For the establishment of patient's rights, medical associations should criticize main clinical incidents after World War II.

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In recent years, there exists worldwide tendency to stress patient's autonomy instead of doctor's paternalism in daily medical practice. This tendency must be appreciated as'every human being of adult years and sound mind has a right to determine what shall be done with his own body'. But this autonomy sometimes conflicts with the doctor's personal integrity which is essencially pro-life one. In informed consent or refusal, the procedures are suggested from doctors, but the active requests from patient's side sometimes call difficulty. In some western countries, such a request from autonomy is legally admitted even in life-shortening procedures such as an abortion or euthanasia in the terminally ill patients. In 1994,Japanese scientific council made a report concerning'death with dignity'and declared that the withdrawal of foods from PVS patients should be proceeded under his or his supposed will. And in a criminal case decision in 1995,criteria for the active euthanasia in the terminal patients are proposed. In both situations, the actor, they say, should be a doctor. These life-shortening procedures might be appreciated for the autonomy of patient and be legally permitted. But conscientious refusal of doctor against proceeding these acts from patient's request must be also admitted, as the philosophy of each doctor about the sanctity of terminal life is different from doctor to doctor as in lay persons.

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The quality of clinical practice varies according to how properly "subjective judgment" of a patient will be identified. In a traditional model of medicine such as "the doctrine of informed consent", humane beings are supposed to be always rational enough to make a reasonable self-determination. This view is scrutinized here, and replaced by another one that subjective judgment is a living process composed of abundant contradictions. This led us to schematic presentations of three clinical types of interventions : voluntary treatment, involuntary treatment, and uninformed treatment. By a further consideration of the models, it was suggested that every clinical practice is composed of some portion of "self-determinations", "compulsions", and "deceptions". Any attempts to explain a treatment by only one of the three components, make treatment unreal and inhumane.

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It is the traditional argument that medical paternalism can not appear and work until a patient's right to self-determination disappears and stops working. We have, however, an alternative argument : a patient's right to self-determination and a doctor's paternalism are two ways to maintain and / or increase a patient's subjective interests, and which way to choose depends on the circumstances around the patient, including, especially, expected interests of proposed medical treatment, and his restricted competency. The traditional argument is simple and clear based on the absolutism of self-determination, but lacks a sensitive tool to balance a patient's autonomy and a doctor's consideration. Contrarily, the alternative argument is furnished with the tool, but its application is often unclear because it is based on the relativism of self-determination and paternalism.

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With availability of new methods for genetic testing, we will be able to get certain benefits from such testing. But at the same time, the development of DNA testing provides employers with additional methods of medically evaluating employees and potential employees. The practice of genetic screening in the workplace will raise some ethical issues. We are afraid some people may be discriminated in employment on genetic information obtained in such testing. Not only carriers of hereditary diseases such as Huntington's disease and FAP, but also individuals carrying genes that predispose diseases such as cancer and diabetes may be treated unfairly in the workplace. So we have to protect the right to conceal our genetic information obtained in the genetic screening. Furthermore, while unpleasant information may be disclosed to the patients without their requests, the results of testing may not be disclosed to them. Physicians may ignore the procedure of informed consents for testing, and the duty of confidentiality may be breached. So we have to protect the patients'right of access to the results of testing, the right of not knowing the results, and the right to decide to whom such genetic information can be disclosed, as well as the right to conceal their genetic status. In this article, positive conception of privacy is recommended as a legal and ethical means to protect people against genetic discrimination. Recently, right to privacy has been conceived positively. In the 'positive' meaning, the right of privacy is conceived as the right to control the circulation of information relating to oneself. The positive conception of privacy can be recognized as a legal and ethical base for certain rights regarding genetic information.

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We can say apotosis is the mechanism that a cell kills itself actively, i, e, genetically. It has been shown lately that Alzheimer disease can be caused by apotosis, i. e. there can be a gene that causes it. The meaning of the disease, i. e. the reason why life has gotten such disease, can be understood by the view of evolution. In general, diseases can be thought as abnormal process of life. Then alzheimer disease brings about a contradiction, because it can be considered as normal process of life. The expression [disease caused by normal process] means that the concept of disease we have had doesn't expect the new situation brought by the new research of alzheimer disease. The way of the cure is thought to suppress or to remove the gene. But this does not think about the meaning of the disease caused by apotosis as a normal process of life. Indeed every cure may beartificial, but the cure seems interference in nature. From the viewpoint of history of science, or philosophy of science, we can understand how or why they get to such a way of curing. It is due to the reductionistic view of diseases that is derived from cartesian mechanism. In this view, human body is a machine composed of each parts and the disease is thought to be result of the disorder. Therefore, if the cause or the place of a disease is identified, the cure is completed by the removal. Transplantation is typical of the thought. But this lacks holistic view of human body, so cartesian mechanistic scientists or doctors will not see the holistic, or evolutionistic significance which cell death caused by alzheimer disease has. Now we can say cartesian reductionistic mechanism challenges our death acquired through evolution. We should think about such a disease caused by apotosis as alzheimer disease from holistic view.

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There are two ways to think of the term bioethics, one is as descriptive bioethics-the way people view life and their moral interactions and responsibilities with living organisms in life. The other is prescriptive bioethics-to tell others what is good or bad, what principles are most important ; or to say something / someone has rights and therefore others have duties to them. Both these concepts have much older roots, which we can trace in religions and cultural patterns that may share some universal ideals. This is especially true when we talk of reproduction and genetics, themes of family, which have been discussed for millenia. One of the efforts of universal prescriptive bioethics is the work of the UNESCO International Bioethics Committee to develop guidelines and an UN "Universal Declaration on Protection of the Human Genome and Human Rights" which attempts to protect humanity from future abuses of human genetics. The idea of "genethics"may seem to be reinforced by the creation of a special Declaration to look at its bioethics. However, if we look at all of its twenty articles we see them all in previous laws and Declarations. What this Declaration does is to bring them together in focus in one document, to supplement the existing laws, and act as a catalyst to make us remember what bioethics we should have, and how we should treat our fellow person and the world in which we live. In this paper the use of surveys such as the International Bioethics Survey as a method to study descriptive bioethics is also discussed. When we prescribe bioethics we need to consider not only ethical principles, but the descriptive face of bioethics, to attempt to have bioethics for the people by the people. The importance of international bioethics networks such as Eubios Ethics Institute is also discussed (which is also on Internet <http : //www. biol. tsukuba. ac. jp/〜macer/index. html>).

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Saga Medical School is a new medical school established in 1976 and is actively trying some bioethics education. In the premedical course, students are to spend one full day at an institution for handicapped to help them and one evening at the University Hospital to experience practical nursing. Then, we started workshops to debate the modern problems of bioethics in this year. In the clinical course, we have "Interviewing training" which aims to understand the feeling and the spirit of the patient by role play and simulated patient, and "Clinical Ethics" by the discussion of ethical problems which the students met in their clinical training. These programs are done by the collaboration of premedical teachers and clinical physicians mostly working at the department of general medicine. The main goals of our bioethics education are to notice ethical dilemma in daily medical practice and to analyze the dilemma by the method of clinical ethics and to find the best solution respecting the patient autonomy and considering a matter in various aspects. We hope to train the students who have much interest in bioethics. They will be core members who are able to discuss the ethical problems in the daily practice and to organize the ethical consultation system which opens for any ethical subject at any time.

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R. Veatch (bioethicist, USA) said, "If there were alignments, "value pairings" based on the most fundamental worldviews of the lay person and professional, then there would be some hope in clinical medicine."(1994) Therefore, having one's own worldview would be a necessary and essential part of health care in the near future in Japan, too. Developing the ability to think by oneself is one of the most important aims in bioethics education for nursing students. For this goal, teaching bioethics only by lecture would not bring good effect on students (especially not on lower-grade-class students). Because it cannot increase their motivation and interest in bioethics issues. Using videos in conjunction with lecture would be very effective in cultivating the ability to recognize ethical issues and it can well for motivating students and facilitating their creative thought, if they are used efficiently.

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Bioethics in general is not the ethical study itself, but it is the study or survey of new medical and other social thrusts of ideas or issues. The proper study of bioethics could be focussed on how those issues can be morally examined and ethically explained. The study, therefore, needs to find the foundation of our evaluation of daily life. This foundation will support our self-decision concerning the things which we encouter in our daily life. In this paper, I will describe my own experience of teachinng bioethics in the college curriculum of undergraduate level.

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Recently ecological ethics has become popular. Do human beings have enough knowledge about animals and their complex environment for meaningful discussion? The purpose of this study was to show the importance of trying to understand animals objectively discussing them from observations, in our case, of Gorillas. An analysis of how captive Western Lowland Gorillas (Gorilla gorilla gorilla) used their new openair-enclosure was attempted. The observed subjects were six adult Western Lowland Gorillas (two males and four females) that have lived in a new open-air-enclosure which was used from June 1994 in Tokyo Ueno Zoological Garden. They were gathered from several zoos in Japan to breed. This is the first attempt to form a Gorilla group in Japan. The observation was done from May to December in 1994 with a time-lapse VTR system. The results showed Gorillas never used their place as we had anticipated before. For example, some of them liked to climb artificial trees which were made because wild Lowland Gorillas were observed to spend long periods of their time on trees while others did not. Some of them liked to stay on the concrete space though people had thought the concrete space to be less comfortable than the ground or grass. There were individual differences and the relationships between individuals seemed to affect usage. More data will be needed to understand them better. Such attempts will be useful to improve their well-being in the Zoo. It is not so easy for us to understand even apes, the nearest species to humans. When discussing the relationships between humans, animals, and environments, it should be done based, not on our'image', but on facts derived from scientific studies.

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Do we have an obligation to consider for Animals? We could try to answer this question in various ways, say, individualistically and holistically. The individualistic approaches include biocentrism, Prevention of Cruelty to Animals movement in the Victorian Age which considers for animals in the interests of human beings, and P. Singer's Animal Liberation based on the Principle of Equal Consideration of Interests, T. Regan's Animal Rights, who claim the direct obligation to animals. Considering for Animals requires to examine moral extensionism, humane moralism and moral monism of their view.

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As B.J. Callicott once pointed out, there are possibly fundamental conflicts between human-centered ethics, animal liberationists'ethics, and ecocentric environmental ethics. I'd like to argue here that animal liberationists'(P. Shinger's) or animal rights theorists' (T. Regan's) claims are mistaken in overstressing animals' pain or their abilitities like humans, and so their criticism of traditional ethics as 'speciesism'is not persuasive. But this doesn't mean that we may treat animals as having merely instrumental value. We should admit that animals have their own interest. So, we need to consider some priority principles between human interests and animal interests. In particular, it is between human non-basic interests and animal basic interests that difficult problems occur. In this case, we cannot solve these problems merely by reffering one monistic principle that animals basic interests always have priority over human non-basic interests. We should consider them from a historical and pluralistic point of view including environmental concerns.

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It is indispensable for teachers in bioethics to be able to establish a certain framework, which gives guidance to students as to how to think about and discuss practical cases involving moral dilemma in medical / health care settings. Unfortunately, there has been no such framework in medical / health care practices, not even in theoretical methodologies ; e.g. Principlism, New Casuistry or Rawlsianism can not function as a mediator to connect medical / health care practice and philosophical thinking. This mediating requires, as its pre-condition, differentiating among practical fields or domains, and among decision-making levels. The framework in each domain should be composed of the following elements : (1) Fundamental features, values and goals, and responsibilities of all those involved in each domain. (2) Steps and well-ordered intrinsic topics which should be considered in a particular decision-making process. (3) Moral issues involved in those steps or topics which are transformed into systematic concepts or questions. Such general ideas will later be applied to a special domain of a medical / health care one in detail. In conclusion, practical or applied philosophers in bioethics should not judge or act directly by themselves. But they should establish an intrinsic framework for the medical / health care domain, consider questions or concepts from philosophical, historical and cultural viewpoints, and give basis to the discussion of moral dilemma. As a result, they will help all those involved in medical / health care practices to reflect themselves critically and make appropriate decisions.

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It is often said that texts and atlases of anatomy can serve only to assist the medical or dental students and human anatomy can be learned only from the human body which has been called as a silent teacher. Students are burdened with the hard preparations for dissection and the long dissecting work. The usual dissection in Japanese medical or dental schools has many problems on the medical education of today. We are facing to the time of a change for the better. The author indicates several controversial points in the usual methods of dissection and offers new seven possible steps, and also states a need of bioethics education at the premedical course.

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Today we are interested in the idea of euthanasia. In the present study, the understanding on euthanasia was studied in 75 nurse students. The questionnaire consisted of 4 questions ; 1) for or against to the euthanasia, 2) right to die or duty to live, 3) right or wrong of state intervention in individuals, and 4) burden to his family. The results as follows ; 1) 80% of the subjects agreed on the euthanasia and 13% did not agree. 7% of the subjects were indecisive because of the difficulties of this issue. 2) In the subjects who agreed to the euthanasia, euthanasia was took for human right and was considered not to be prohibited by the law, Regarding to the burden to his family, many subjects did not answer. 3) In the subjects who did not agree to the euthanasia, legislation of euthanasia was felt misgivings because it may cause a mental blow in the people in a difficult social position. These results suggest that students basically agreed to the euthanasia but they considered that it is necessary to examine other basic problems, such as cultures and the system of medicines in Japan, for the legislation of euthanasia.

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I think that the consciousness for "nature"appears in the matters such as "death with dignity" and "natural funeral"and so on in today's Japan. The natural world at one time meant not only a present meaning, but also "divineness" that traditional terms contained. Judging from the state of nature, the concept of brain death is too artificial to be accepted. Although there is no way to survive, some people who will not transplant their organs often hold an idea that respects the natural span of life or "the order of nature". I conclude that a sense of incongruity against brain death and organ transplants is derived from the sense or the consciousness of establishing nature as a standard.

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Today, philosophically and juridically, the theory of rights, which extends the right of self-determination even to so-called incompetent persons is flourishing in bioethics. At the same time, some argue that an alternative language of resoponsibility is essential for conceiving bioethics, since the language of rights serves so well as a preemptory appeal in adversarial situations. It can also be pointed out that extending the right of self-determination to incompetent persons forces individual responsibility upon them and is a form of oppression. Nonetheless, arguments critical of the theory of rights are coming into fashion in medical ethics in the United States. Moreover, these critics argue that the concept of responsibility encourages reflection on the social and institutional structures of medical practice and assert that a communal responsibility should be established in medicine, since illness itself is defined by the community and socially experienced. Among those who adovocate changing the existing concept of individual responsibility, some maintain that the absence of agency should protect the incompetent from individual responsibility. Others separate individual responsibility from its social-bearing costs in order to protect the incompetent. Particularly noteworty is the vulnerability model which traces our responsibilities for the incompetent to their vulnerability to us. Although, this line of argument may be inadequate to the task of rigidly defining the concept of responsibility and in concretely reforming the social and institutional structure of medical practice, I think that this tendency to convert the concept of individual responsibility into a communal one should be central to the project of reconstructing and developing bioethics. The primary aim of this paper is to examine these changes in the concept of responsibility and to suggest the significance of establishing a concept of communal resoponsibity in bioethics or medical ethics.

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When a physician cannot determine solely medically which course of action he or she should take, his or her decision-making in patient care often requires value judgments on an individual basis. Such a decision with value judgments is usually regarded as ethical decision-making. Ethical decision-making tries to resolve ethical dilemmas that raise when a clinical problem in patient care has plural countervailing resolutions. A physician has to make a choice among several unsatisfactory alternatives in clinical practice. In situation where conflicting two or more actions seem equally legitimate, it is not always possible to resolve ethical dilemmas themselves, rather, his or her decision has to be made even amidst unsolved ethical dilemmas. Furthermore, as far as clinical judgment regarding what is ethically right or wrong depends on value judgment, ethical decision-making made by an individual physician would be unavoidably biased by his or her idiosyncratic value. Under these circumstances, clinical ethics can offer a physician standard guidelines and fair procedures to deal with ethical dilemmas confronted in patient care. Ethical guidelines including decision-making priority used in clinical ethics provide physician's ethical decision-making with consistency and fairness. A framework of ethics consultation is useful to identify, analyze, and cope with ethical dilemmas in systematic manner. Even if an approach in clinical ethics failed to resolve ethical dilemma themselves, its procedure could result in a fair decision acceptable to a patient, physician, and all other parties. Ethical dilemmas in modern medicine may not be resolved, but clinical ethics would help a physician deliberate ethical problems and negotiate a mutually acceptable decision amidst disagreement.

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In spite of severe criticism in the 1970s that genetic engineering was nothing but playing God, research has continued through the 80s and 90s. Gene therapy seems to be the most promising technology to have arisen from this research. It is expected to save many patients who suffer from severe genetic defects. But on the other hand we must keep our eye on the application of gene therapy to enhancement genetic engineering. It is difficult to delineate between therapy and simple wish fulfillment. Infertility is not a disease : women who never experience pregnancy nonetheless lead healthy lives. In some cases reproductive technology has given some people test-tube babies but in others it has driven some women to 'medicating their lives'. To make something possible is not always to gain something. We should be aware of the fact that we may lose as many things as we gain by the intervention of genetic engineering, when a new project is realized. Once a new and narrow goal is set up, there is a tendency for people to feel obliged to attain it. As the adage goes, "first it is illegal, then they make it legal and next they make it compulsory". Contraception, abortion, prenatal diagnosis, and perhaps next divorce have tended to conform to this pattern. We must recognize that to increase physical choice may inadvertently lead to an eclipse of tolerance. Choice is as much psychological as physical. To keep human society tolerant and to leave as much choice as possible are integral to human rights. Tolerance of variety is most important. Paradoxically genetic engineering threatened to reduce social, and other forms of, variety.

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