The bioethical concept of"death with dignity"is discussed in the context of three patients with malignant brain tumor, whose histories are presented here. According to Emanuel [reference], the factors that should be taken into account when deciding whether to withhold life support or withdraw active treatment are the chances for a successful treatment, the projected quality of life (QOL), and the predicted survival of the patient. The first patient was 75-year-old man diagnosed with intracranial malignant lymphoma. His prognosis was explained to him, and he prepared a living will declaring his refusal of surgical treatment. After four months of hospital care during which his QOL was good, followd by four months of terminal care, he died with dignity without using respirator. The second patient was 36-year-old woman with glioblastoma in the basal ganglia. The tumor recurred after six months of chemotherapy and radiation treatment, and the patient suffered from impaired consciousness. She became bedridden. Her husband requested that she receive immunotherapy and home care. She was treated at home. with occasional visits to the outpatient clinic for six months. She died peacefully in the hospital three days after admission. The third patient, a 13-yeasrs-old girl with a malignant ependymoma in the cerebellum, had undergone an operation 10 years previously. The tumor recurred, enlarged rapidly, and invaded the brain stem. Her parents were truthfully informed about her illness and her chances for survival. Based on this information, they requested terminal care for their daughter. She died peacefully about two months later. Health care professionals can help their patients achieve death with dignity by giving them honest information about their illness and by providing home care or terminal care that takes patient's QOL into account. A living will and informed consent are tools that pateints can use to avoid prolonging their life when the prognosis is bleak. Children and individuals with impaired cognition are not in a position to take these steps. Informed consent, palliative treatment that ensures a good QOL, and a team approach to decision-making are essential to the concept of death with dignity. Although several advanced therapeutic regimens are being developed for treating malignant brain tumors, the prognosis is hopesless for some patients. They should be allowed to die with dignity after all other options have been considered.

View full abstract

When the cardiopulmonary function of a patient stops, the physician as a general rule immediately perform cardiopulmonary resuscitation. But there are some cases, in which cardiopulmonary resuscitation does not succeed. And in other cases, the patient might recover for a time, but soon collapse again, and his cardiopulmonary functions cease. In some cases, cardiopulmonary resuscitation will put too heavy a strain on the patient. Because cardiopulmonary resuscitation is considered futile for patients in these cases, physicians will issue DNR Orders in order to withdraw or withhold cardiopulmonary resuscitation. The judgement about the futility of cardiopulmonary resuscitation and the decision to issue the DNR Orders belongs to the professional medical discretion of the physician. Therefore, the physician thinks he doesn't need to hear the opinion of the patient and his/her family. The physician tends to consider the futility of cardiopulmonary resuscitation from a broad and paternalistic view point. On the other hand, the patient and his/her family think about the cardiopulmonary resuscitation only from the viewpoint of the patient recovering cardiopulmonary function at that moment. Because of these gaps in perception, there can occur between the physician and the patient some conflict. When a patient unexpectedly has a cardiac arrest, the physician has to perform cardiopulmonary resuscitation in any way necessary to preserve the life of the patient. But when the physician can predict in advance possibility of a cardiac arrest, he must talk with the patient and his/her family about what treatment should be performed if an arrest occurs. In these cases, the attending physician must explain to his patient and his/her family about the effects and the dangers of cardiopulmonary resuscitation and the prognosis for the patient. And he must decide after obtaining the consent of his patient, whether to resuscitate or not to resuscitate. Once the attending physician has decide not to resuscitate in the event of a cardiac arrest, he must enter the DNR Orders on the medical record, and must review this order every week with the patient to make certain that the patient still consents to it.

View full abstract

An advance directive, in an American context, is understood to be a declaration by a person that stipulates the forms of medical treatment to be provided by caregivers and/or designates someone to act as a proxy should the person at some future date lose decision making capacity. In written form, an advance directive is often referred to as a"Living Will."In order to investigate the acceptability of advance directives in Japanese society, a questionnaire study for healthy people was conducted, asking their knowledge, experiences, and attitudes related to advance directives. Two hundred and ten male subjects who visited 2 urban general hospitals for their physical checkups were asked to fill out a self-administered questionnaire. More than 80% of the respondents knew the term"Living Will"and they wanted to express their preferences on their medical care they will get in the future. Regarding contents, more than 70% of them wanted to leave their preferences on treatment plan for incurable diseases such as terminal cancer, brain-death, persistent vegetative state as well as pain control. More than 80% answered they would give a lot of leeway to surrogates to override their preferences, and did not feel necessity for detailed, concrete directives such as preference for cardiopulmonary resuscitation and respirator. More than 60% answered oral statements were enough, while about 30% recognized the necessity for written documents. As for a surrogate decision maker, 80% answered they would designate"family or relatives", in most cases, a spouse. On the other hand, those who do not want to express their preferences in advance (18.1%) listed reasons against it. These include, psychological resistance to talk about death and dying ; difficulty in imagining the future situation, which represents the theoretical limitation of advance directives ; and entrusting to their family (omakase), etc. Written advance directives might be useful in the Japanese settings when 1) a person do not want to give surrogates and/or caregivers a lot of leeway ; 2) there exists uncertainty and caregivers feel the necessity to ascertain the preference by written documents.

View full abstract

Those who talk about terminal care in the U.S.A. or Australia generally refer to"Pastoral care."However, the word"pastoral care"is not yet well known by the Japanese. Therefore, the purpose of the paper is to let Japanese know what pastoral care is and, hopefully, to introduce it to many hospitals in Japan.

View full abstract

In recent years, the term of'informed consent'has become popular in Japan and the respect of patient's autonomy in daily medical decision making has been increasingly stressed. We, Japanese doctors'may have been too paternalistic against patients, and I personally feel we should appreciate and promote the informed consent principle. But the application of the doctrine of informed conset as a vehicle in law suit decision seen in US is a different matter. In recent years, the number of court-decisions using this doctrine are increasing in Japanese society. In the field of neurosurgery, among 7 reported cases concerning the operation of intracranial aneurysm or arteriovenous malformation, 5 cases are about the breach of disclosure. Under the informed consent doctrine, once the court acknowledges doctor's betrayal of patient's autonomy, doctor is forced to compensate not only the consolation money but also the bodily damage itself which is essentially the result of the statistical risk of the operation, even though there exists no technical negligience at all. Consiquently doctors are forced to let his patient make his own decision which is sometimes too burdensome for the patient. According to the questionaire study of a comission of the ministry of welfare 1989,more than half doctors considers that doctor had better make decision for his patient considering patient's opinion, whereas only 20% doctors cosider patient should have priority in decision-making. Though there are a few exceptions, patients are not so self-established or strong enough to make a decision about his bodily operation which may result in death-selection. Under such circumstances I personally believe the introduction of informed consent doctrine in Japanese medical law suit is not preferable. It may sometimes be more harmful than beneficial for the patient-doctor relationship or for the patient's human right.

View full abstract

What is a nurse? What is nursing? Nurses exist for people who require nursing care. Nurses especially give support to people who are faced with serious and emotionally upsetting situations in their lives. Recently, Bioethics has been one of the main issues among medical staff. It is also very important in nursing education. However, lectures on Bioethics alone would not have a good effect on students. From this point of view, we used the videotape. The Case of Euthanasia, as a teaching material to motivate students and to facilitate their creative thought. In this paper, we describe our experience of teaching quality of life to nursing students.

View full abstract

Through amendment of the burial act and the both 1984 and 1994 the Netherlands Supreme Court decisions. Euthanasia in Holland has attracted many people's attentions in the world states. Both one famous Dutch lawyer and one same Dutch physician were invited for reporting the Euthanasia situations in the Netherlands at the University of Manitoba, Canada, 1992. On September 17-18,1992,a conference was held at the University of Manitoba on the theme, Euthanasia in the Netherlands : A Model For Canada? This time, I have replaced a conference theme in Canada with the theme, Euthanasia in the Netherlands : A Model For World States. The points at issue are four. : (1) Is Euthanasia the medical measure of last resort? (2) In respect of patient's Autonomy. (3) Is the mental suffering a necessary condition of euthanasia and assisted suicide? (4) May the request of euthanasia and assisted suicide be permitted before the terminal condition? I approve of the former two ((1) and (2)) points at issure, but could not admit of the latter two ((3) and (4)) points at issue.

View full abstract

In hospice and home care, patients begun to choose how to die by refusing some treatment that resulted in prolonging life in an unbearable distress. For the purpose, "the right to die"had been introduced based on the right of self-determination. Mill JS wrote, "Over himself, over his own body and mind, the individual is sovereign", which was a typical antecedent of self-determination. Another new problem arose here. If the individual had the right of self-determination, he might be able to insist on the right to kill oneself when he was in an unbearable psychological distress. Here, "the right to kill oneself"was not only insisted on, but some doctors even assisted suicide by prescribing lethal drugs or by using"suicide machine". In this article, three medical states (persistent vegetative state, terminal state and suicide) had been compared and discussed to formulate"the right to kill oneself". It was pointed out that there was an important distinction between"the right to kill oneself"that was done as a kind of medical practice, and"the freedom to die"that was the inviolability of privacy from medicine. It was concluded that"the right to die"was not"the right to choose one's death", but it was a right to choose the way of dying when"the elimination of the patient as a subject"clearly existed because the death was biologically urgent and inevitable by the disease process itself. The difference between euthanasia and assisted suicide was discussed from the formulation mentioned above.

View full abstract

In Japan there is an unusual reluctance to accept the neurological criterion that determines brain death and the need for transplant organs. This study was based upon the medical imformation which were gained from mass communication, dealing with the brain death and organ transplantation. In the present study, frequency of word in medical topics written in Japanese news papers (the Yomiuri) between 1987 and 1995 were analyzed by using JSORT program and BGREP program. In light of the result, these words such as"isi", "honnin", "kazoku"and"sontaku"contained the arguments towards the psychosocial problems. This paper will be discussed with historical focuses and a further hypothesis on these issues.

View full abstract

In Japan futile debate concerning brain death and organ transplantion have been going on for years. I will offer a compromize proposal regarding these debates. It is based on the anaimous conclusion of the Provisional Commission on Brain Death and Organ Transplantation, as stated in its Final Report : "We find it hard to find a reason to object if persons who, while they are alive, strongly desired to donate their organs, do so after they fell into this type of irreversible state". My proposal is as follows : (1) To confirm the wish of donation, written documents are required. This condition may be too strict to promote transplantations, but it is necessary for the present in order to appease the people's distrust of physicians. (2) In the Organ Transplantation Act now being deliberated in the Diet, brain death should be defined as death of a person in order to avoid prosecution for murder. (3) The definition of death by brain death should be restricted to the Act. Otherwise, the concept of death will be confused in relation to many other existing laws with references to death. (4) Brain death should be diagnosed only when an organ transplantation is scheduled or medical treatments are discontinued according to the patient's advance directives. This condition should be written in the guidelines for physicians. Except for these two occasions, most cases where brain deaths are strongly doubted can be managed by gradually narrowing down the range oft reatment, keeping pace with the process of resignation and grieving of the relatives. Finally, we must eracidate brain deaths by preventing traffic accidents and cerebral vascular diseases. Oragan transplantations from brain-dead patients should be eventually replaced by ideal artificial organs.

View full abstract

The ability to secure property interests in technological processes, products and know-how encourages development of technology. One factor to evaluate competitiveness in biotechnology is intellectual property law. The intellectual property law most relevant to biotechnology are those dealing with patents. The patents relating to the protection of biotechnological inventions and related know-how were compared and contrasted in Japan and the United States. The major differences are as follows. 1) Japanese patent excludes method inventions in the field of therapeutic or diagnostic treatment of humans, although patent protection can be obtained for them in the US. 2) The patented process may be used in other countries to make the same products, which can then be imported into the U.S. and compete with the product made by the owner of the U.S. process patent. Although Japan defines this action as infringement of that process patent, the U.S. does not. 3) A grace period between the date of any publication by the inventor relating to the invention and the filing of a patent application, is for 1 year in the U.S. and for 6 months in Japan.

View full abstract

One university professor has said, "In today's society, smaller numbers of babies are being born and smaller numbers of people are dying. Genetic mutation is thus somthing that cannot be avoided. If selection is at work, as it was in Japan in the past, genetic abnormalities will not accumulate in society, but they will natually accumulate in today's society. As a result, by conducing genetic tests, abortions should be performed, otherwise society as we know it will cases to function."He adovocates the spread of genetic tests before birth and unconditional artificial abortion when a genetic abnormality is detected. After lectureing for a while at a women's college, I asked the students two true/fals question : (1) Both of my parents are healthy and all of my blood relatives are healthy. Thus, I have no bad genes. (2) If all people with a genetic disease decided not to have children, then there would be no-one on earth with a genetic disease. They are both"fals."The ratio of correct answers for question 1 was 254/377 (67.3%) ; for question 2,314/377 (83.8%). These two examples shine light on the ethical problems that human geneticists of today avoid and will not discuss, such as, Who decides the right and wrongs of a particular disease? When, and with what authority? ; Are all genetic disease bad and must be eradicated? Will it be possible to eradicate all genetic diseases by artifical selection?. Should a society force artifificial abortion on people? ; Should such question be decided only by specialists and public officials without counslting the general public, including the patients themselves?

View full abstract

Is such a thing possible that we respects the subjectivity of the patient in persistent vegetative state? I analyzed the reports among 233 nursing students after debate and appreciating VTR about the care of the patients in persistent vegetative state. About 60% of them are agreed that will should be respective above the other. But they had felt that the patients wished the death with dignity. On the other hand, abort 40% students are agreed that life should be valued above the other, but they wished the death with dignity"If I had been in persistent vegetative state."These result suggest that almost students agreed to respect the will and life of the patient in persistent vegetative state, but potentially they valued the person with self-conscious and self-determining.

View full abstract

The aim of this study is to identify the structure of ethical dilemma that arises in nurses'everyday practice, using a semistructured questionnair survey of 25 nurses with four-year and more experience. Based on the questionnair, a total of 52 situation, considered to be an ethical dilemma, were selected in the problematic situations that nuses felt, and were discussed in this study. In such situations, two or more ethical principles seemed to coexist or antagonize. Based on Engelheart's principles of"autonomy"and"beneficence", and the Nurses Code of Ethics, 54 situations were classified into as follows : (1) those dilemmas that resulted from conflict between principles"autonomy"and"benefit"(2) those dilemmas that resulted from inconsistency of principle"autonomy", and (3) those dilemmas that resulted from inconsistency of principle"benefit". It was revealed that these dilemmas arised in connection with their personal relationships and were also linked closely to Nurses'Code of Ethics. In addition, it appeared that nurses tended to assume these dilemmas as problematic situations which resulted from their incompitence because they did not realize that these dilemmas were actually ethical problems.

View full abstract

Japanese pysicians often confront various ethical dilemmas in clinical settings. Our study showed that 20 to 40% of clinical cases involved difficult ethical dilemmas. Such dilemmas often happened in the context of physician-patient-family relationship. We, therefore, presented actual clinical cases involving difficult ethical dilemmas and tried to analyze them in order to consider the validity of both of processes and decision made, using 13-item framework. A proposed framework includes the following questions : what is an ethical problem at stake, who consider it problematic, what is medical situation, what opinions the parties concerned have, are there any emotional problems or conflict of interest, who disagrees with the proposed plan, what do (did) they do to resolve ethical dilemmas, are all of the parties convinced or satisfied with the decision made, and finally, is the decision made ethically valid? This process could make an obscure sense of discomfort in clinical cases clear and enable all of the parties concerned to discuss the problem, focusing on the point the parties or persons concerned disagree. A standard process would also be useful to distinguish ethical problems from emotional ones or conflict of interest. On the other hand, judging ethical validity of each decision is still difficult because there is no consensus in regard to what ethical principle should be applied to clinical decisions in Japan at this moment. Thus, it is crucial for us to decide what is ethically right in Japan and how to use ethical guidelines that could be a basis for deliberation on ethical validity. We need to develop validated and consistent process to reach the ethically appropriate decision.

View full abstract

In Japan people are engaged in the search for terminal care that specifically addresses the current situation in this country, but medical care practitioners seem hardly at all disposed to seek cooperation from people of religion. At the root of this situation we find a narrow conception of religion that attempts to separate from quite ordinary Japanese people what is broadly seen as"religion"in present-day society, and apply special significance to it. As a matter of fact, there are not a few medical care practitioners who understand religion to mean having"a certain belief, "point out the tenuous connection between religion and the Japanese, and evince doubts about collaboration with religion. But since ancient times the Japanese have had a looser relationship with religion, in which people combine a variety of elements from certain religions as the sustenance in their everyday lives instead of believing in a certain religion. The view of religion needed in Japan's terminal care should presume this tenuous relationship between the Japanese and religion, and assume a broad-based form that can take into consideration the religious sense of the Japanese, which comprises elements compounded from various religions, instead of a narrow view of religion that suits only a mere handful of people.

View full abstract

The basic ways in which medical care practitioners provide terminal care can be divided into (1) requiring effort from patients, and (2) accepting patients as they are. This paper explores this matter in relation to Buddhism (rehgion). To begin with, we human beings must once again make ourselves aware that we are weak beings afflicted by worrice and suffering. In terminal care it is none other than the real condition of people that we should concern ourselves with, and unless that is the basis for discussion, we cannot have care in the true sense of the word. We ordinary people need the kind of unconditional magnanimity that is defined by the terms"maternal religion"and"religion providing salvation".

View full abstract

In order to examine possible guidelines for education, researcn and practice in the area of Bioethics in Japan, three cases of Bioethicists, namely Mr.T.Yanaka, Mr.S.Ishikawa and Dr.N.Mavuchi.

View full abstract

Cochlear implantations (Cl) is a newly developed technology to improve/restore hearing partially. While this has been received favourably by the deafened people, there has been a growing controversy over the linguistic and ethical aspects over the Cl among deaf children. Background of this is the recognition that based on their distinct sign language, Deaf people form a cultural and linguistic minority. The World Congress of the Deaf in 1995 decided not to recommend Cl among deaf children. More information on the Deaf community and sign language should be available to parents of deaf children so that parents can make an informed decision on behalf of their children. It is very important for the Deaf organizations to provide information as well counselling to parents. With these, Cl will be more useful.

View full abstract

Ethics committees could be established in the following 6 settings in Japan : 1) university hospitals ; 2) medical research institutes ; 3) general hospitals ; 4) academic societies ; 5) government administrative offices ; 6) health professional organizations such as The Japan Medical Association. Understanding the present situation in all these 6 dimensions is necessary for further discussion. The purpose of this study is to investigate the current status of ethics committees and decision making procedures in general hospitals in Japan. A self-administered questionnaire was sent to directors of 3098 general hospitals, asking about the presence of ethics committees, attitudes toward ethical problems, and their experiences. A complete survey for hospitals with more than 300 beds [group A] ; 20% random sampling for hospitals with 100-299 beds [group B], and 20-99 beds [group C]. The recovery rate was 44.3% (51.0% in group A, 42.5% in group B, 34.6% in group C, respectively). Ethics committees have been established in 24.4% of group A, 5.7% of group B, and 2.0% of group C. 13.2% of the total respondents answered that they had certain guidelines for the patients who refuse blood transfusion because of their religious beliefs such as Jehovah's Witness. The necessity of ethics consultation for individual cases as well as education was highly recognized in all groups. Certain guidelines indicating how to set up and manage an ethics committee in a general hospital setting is badly needed. On the other hand, for those hospitals with smaller numbers of beds where an ethics committee is difficult to be set up, certain systems other than an ethics committee should be established to deal with ethical problems in the daily clinical settings. The roles and responsibilities of ethics committees at each level should be further explored and clarified in order to legitimately formulate an ethics committee system for ethical decision making in the clinical setting.

View full abstract

A survey was carried out about physician's attitudes toward amniocentesis. Five hundred eighty obstetricians and pediatricians concerned in clinical neonatology were asked whether or not they would recommend amniocentesis to a mother of a child with Down Syndrome at their pregnancy of second child. Among the 305 completed questionnares, approximately 70% physician's answered they would explain about amniocentesis but would let a client decide to take it or not. On the other hand, 20% replied that they would recommend it. Their answers have been affected by their specialties. Implementation of amniocentesis should not depend on physician's individual ethics but should include genetic counseling in its process.

View full abstract

In Japan, the controversy concerning the brain death does not yet come to a settlement. In this article, I consider its reason. It is said that the oppositions about the brain death are based on the difference of one's veiw of body. But, in this paper, I point out that they are rather complementary to each otrher, and just for that reason, it is hard to solve them.

View full abstract