The concept of "autonomy"has a central position in bioethics. It means originally selflegistration and selfadministration, but since Kant paid attention to an individual's volition, "autonomy"has been considered as individual's selfdetermination especially in today's bioethics. The concept of "autonomy"requires that, as well as its precise essential conditions, the principle of respect for autonomy should be effective. To this principle reciprocity is not sufficient, and then fundamentally some common values are to be necessary. If we cannot admit any selfdetermination without some limitation, the common values will be useful to definite its effective range. Realizing that mankind is a limited being, we can probably obtain such universal values only by a trialanderror method. "Autonomy" is not complete in an individual, but has some common connections.

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Why does it seem to us that many diciplines or domains involved in Bioethics, e.g. medical ethics, health care ethics, research ethics, public health ethics, or environmental ethics, etc., do not have close connections with each others. My answer is that a clear and whole conceptual framework of 'health'has been lacking in Bioethics. In this paper, through critically analysing and assessing of such influential definitions or theories as WHO's and L. Nordenfelt's concerning 'health', G. Canguilhem's on "biological normativeness"and A. Sen's on "capabilities", I try to put forward a whole framework of wellness and health. In my theory, we have the 'wellness' of personal 'life' within mutual relationships among three life levels, namely, biological life level, human living level and life as a whole level. Under these relationships, 'health' is defined as 'norm' of wellness/illness on the biologically individual life level. Although 'health' essentially is the norm, it also usually means a well-state according the norm. Furthermore, the biological level is so related with the other two levels, that the wellness or illness on itself generally supports the possibility of wellness or not on the human living level and, on the contrary, is restrictively valued by the latter. This is, I think, the reason why the idea of health has been seen complex or ambiguous.

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It is a common attitude in the context of organ transplantation to discuss upon 'allocation' of donated organs among recipients and its justice. And it is illuminating to analyze the process of the allocation and to identify several phases in it. But there is a doubt clinging in my mind whether the whole pool of donated organs is something from which organs are socially to be distributed. Since we have a variety of conceptions of justice, it might be possible to see the problem of organ allocation against the background of a different sort of justice other than social or distributive. Then we will find donors rather than recipients at the center of this allocative prosess whose judgements are rightly to determine the outcome.

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We have 'eugenic preferences', so with the spread of prenatal diagnosis, the number of patients with certain congenital diseases may decrease, as a result of our 'free choices'and 'kindly advice' of the physicians. Selective abortions are justified on the reasons such as 'the baby will not be happy', 'the family will have to endure economical burdens', 'if the babies with inborn disorder are aborted before the birth, the sum total of the medical expenses will decrease'. But these reasons are all dubious. In this article, I suggest following items as ethical conditions for a selective abortion ; the baby will suffer from severe pain ; there is no cure for the disease ; with all available treatments, the baby will be dead in few years ; the patients request abortion and the physician admit it. Only if these conditions are all satisfied, the abortion may be morally permitted.

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In Japan the organ transplantation act was enacted in October 1997. Once again, questions were raised which were intensely discussed during its consideration. One question concerns the requisite for organ removal from the donor, namely who has the right to permit it, the donor himself, his family or the society. In this paper, the comparison between Japanese act and the uniform act of the USA, the transplantation act in France and Germany will be made regarding the three parties. All these three acts, American, French and German, commonly declare the first principle to be the right to self decision making of the person concerned. They allow removal when the person expressed his agreement either in writing or orally and forbid it when he expressed his refusal. In the case his will is unknown, his family may make decision for him in the USA and Germany. On the contrary, in France, removal is allowed without the will of the family. For the society supports the transplantation, it may suppose that its member shares the same will tacitly. In the case of the removal from the living donor, not only in France but also in Germany, the will of the society overrules the individual will in order to protect his body. The removal from living minor is forbidden. As in the USA, France and Germany, the Japanese act also respects the autonomy of the person concerned. However, in the case of brain death, the veto of his family is respected even when he himself expressed his agreement. It might be necessary to have a consistency concerning the priority of the self decision making, at least in the text of the act. Japan still has no act regulating the living donation in general. The declaration of the protection of the body by the social will is required.

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In 1972,Jennet & Plum proposed the name 'persintent vegetative state' to the patient with severe brain damage due to trauma or ischemia and prolonged unresponsiveness. They used the term 'persistent' instead of 'permanent' as they are not sure about the irreversibility of consciousness. Recently, some authors in western countries use the term 'permanent vegetative state', if the unresponsiveness continues more than 12 months and permit withholding foods. Some author dares to discuss the possibility of using such patient as a donor of heart transplantation (Truog, 1997). American multi-society task force on PVS also uses 'permanent vegetative state' and permanent means 'irreversible' though it is empirically based. In PVS, we can not assure the irreversibility of consciousness, as some Japanese doctor reported the PVS patient gradually recovered consciousness, one after 3 years and the other 5.5 years (1981,Higashi). Moreover, words, persistent and permanent, both start with 'p' and I am afraid PVS sometimes is taken as 'permanent vegetative state'instead of 'persistent'. Japanese Neurosurgical Society defined PVS in 1974,in which the duration of unconsciousness should be more than 3 months. Obviously, it can not be taken to be permanent. Though there exists the possibility of the discussion of withdrawing foods from PVS patient based upon his or her 'living will'or upon financial bases, we must be careful in PVS, the irreversibility is not scientifically assured.

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The aim of this study is to characterise the essential factors in decisionmaking of whose undergoing to the genetic amniocentesis. The employed semi-constructive in face-to-face interviews and there were discourse analysis. The interviewees are 22 couples (21 pregnant women and 5 husbands) who have taken part in the class for explanation about the Amniocentesis. The majority of them have known about the examination and already decided to undergo the examination prior to attened the class. Some couples wanted to undergo without taking physicion's explanation. The motivation to undergo the amniocentesis was arisen from two ways ; depending on the physician's information or own knowledge by themselves about the examination. In general, the essential factors in decisionmaking to undergo the amniocentesis were as follows ; husband's attitude toward the examination, the understanding of Down's syndrome or the handicapped, the experience of abnormal pregnancy, physicion's attitude toward the amniocentesis, and there decisions when should be imformed with the abnormal pregnancy.

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We live now forgetting of our death and highly evaluate the life of this world, so we yearn the eternal life and won't know what our death really means. And scientists promote the hope and seek the way to remove the mortality from us. But Hans Jonas, an American philosopher born in germany, asks whether it is right to combat not merely premature death but death as such, that is, whether lengthening life indefinitely is legitimate goal of medicine. To answer this question, he starts from the essential function of organism, metabolism. Organisms must always obtain the life through metabolism, which means they separate themselves from the outer world but touch it at the same time. Because the world has its potential danger to them, there is always the strained relaion between organisms and the outer world. Organisms include death as the inevitable aspect of the life, which Jonas calls the possibility of death. On the other hand, there is the certainty of death, which means every organism has its own limit of life. Jonas views the meanings from two standpoints. One is that of human beings. the other is of the each individual. From both points he finds death as blessing. From the former standpoint, it makes place for new comers to the world and they make new cultures and civilisations, which are peculiar to human beings. From the latter point, because of the physical capacity of the brain, or the memory, two ways could be thought to those alive beyond the natural limit. One ist that they would lose its past, that is, its identity, and the other is that they would have only the limited span of memory. The former means the loss of themselves who longed for their eternal life, and the latter means they could not respond to any of the present phenomena of the outer world, as if they would be in the heavy condition of dimentia. It is doubtful that people still hope for their longer life in these conditions than their natural limit.

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In Japan, it is often assumed that the idea of informed consent is well received by the American public, since the self-determination is part of the American values. If we look into the series of verdicts which established the idea, however, we find that the courts'concern is not only with the patient's right to self-determination based on information disclosure, but also with the patient's well-being. The latter concern, it could be contended, arouse out of the fact that patients may find the uncertainties inherent in medical practices, especially various risks accompanying medical procedures, too overwhelming and hard to cope with. The same concern can be found, in different forms, in various writings on informed consent in the field of bioethics.

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Because people in Japan have not been donating kidneys, Japanese patients who need kidney transplants have turned to developing countries for donated kidneys and the associated surgery. Local doctors and donors make money from these procedures, and there is a suspicion of the purchase and sale of organs. Although the media has reported on this issue sporadically, no research has yet studied the whole picture. This paper reports the scale, nature and ethical aspects of this issue with data gathered in Japan and in developing countries for nine years, including interviews with donors, patients, brokers, and doctors. According to this research, the Philippines, India, Thailand, Bangladesh and China are the main countries where such kidney transplant tourism is taking place. About sixty Japanese patients are known to have gone abroad to get kidneys. One patient paid sixty nine milion yen (about five hundred and ninety five thousand U.S. dollars). This reseach also revealed that six Japanese patients died of infection due to these procedures. The new Japanese organ transplant act, which came into effect on October 17 in 1997,prohibits the purchase and sale of organs, but some Japanese brokers still continue their business.

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Three courses in 1997,and four in 1998 were dealing with bioethical issues and available to first year students at Niigata University School of Medicine. However, these were elective courses, or a compulsory course in which ethical topics were lectured as a small unit. At the clinical stage, a compulsory independent bioethics course was established for 5th year students in 1997. The curriculum seemed to be vertically integrated in that courses were programmed at both preclinical and clinical stages, and multidisciplinary teaching was provided in that teachers of medical and non-medical departments took part in the courses. The horizontal integration into the medical curriculum can be the most serious defect, because of the lack of the opportunity for medical teachers to be trained to participate in bioethics education. To establish a core organization will be essential to refine the program, but will be hard to be achieved without the support of national policy.

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At Saga Medical School, I teach clinical ethics to fourth-year medical students as one component of their introduction to clinical medicine. In this course, students are taught about the 4-Box Analysis of Clinical Ethics (medical indication, patient preference, QOL, and contextual features) devised by A.R. Jonsen (Univ. of Washington). We also teach an elective course entitled "Clinical Ethics"for the sixth-year medical students. In this course, the students choose cases of ethical dilemmas which they have encountered during their bedside assignments. This case discussion is carried out not only with other physicians but also with teachers of law, sociology, philosophy and psychology from the general education section of this medical school. The cases and their analyses are sent via the Internet to bioethicists, doctors and lawyers in Japan and in foreign countries to ask for their comments. This case study course is truly an interdisciplinary and international education. The students have evaluated this experience as both exciting and practical. We hope they will continue to think seriously about ethical dilemmas in the future as they practice as physicians.

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According to Kojienn, a Japanese-Japanese dictionary, "genetic (heredity)"is defined as "the transmission of genetic characters such as the shape and the color of the body from parents to offspring."However, about 100 years ago, G.J. Mendel (1822-1884) conduced an experiment on peas and discovered a phenomenon in which the shape or the color of the parents is not tranmitted to offspring and thought of existence of recessive inheritance."Later, it has been discovered that the gene itself is a chemical substance named DNA (deoxy-ribonucleic acid) which exists in cell nuclei of all living creatures, and genetics has come to be called "science of individual difference." It has become clear that "heredity is the transmission of gene and the body and the mind are formed from gene so transmitted" and, futhermore, "gene is related to survival of living beings."It has become possible to say that "a living being is a form of existence of gene" after the example of F.Engels. However, in today's world, importance is attached to only economic efficiency (moneymaking) of DNA theory, and it is now the time when "DNA-nomy"forgetful of the principle of Mendelism prevais. The biggest weakness of DNA-nomy lies in failure to protect the human right of hereditary disease patients and absence of the vision of protecting "survival of man."

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Legislation was proposed concerning euthanasia in late 19th century England. The propriety of legalising euthanasia was also debated in Japan as early as 1882. This paper introduces new materials by way of surveying the historical development and present situation in various countries regarding the concept of self-determination upon death. In recent times the debate about euthanasia has focused upon the concept of death with dignity, including physician-assisted suicide. This paper investigates the following three areas of discussion : (1) Problems coucerning death with dignity (2) The propriety of legalising euthanasia (3) Matters for concern and proposals for the future in Japan. In (1) the concepts of death with dignity and therapy abatement in Japan are introduced, and comparisons made with Australia, Germany, the Netherlands, the United Kingdom and the United States of America. Part (2) deals with present circumstances regarding legalisation of euthanasia in Japan and other countries, and looks into the propriety of legalisation by subeying theories, reports, judical precedents and statutes. In part (3) I make suggestions regarding the future of patient-determined death in Japan.

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Organ Transplatation Act has been enacted in Japan. In the US and in EU countries, dead donor rule, primacy of consent and prohibition of organ purchase are main ehical principles of organ transplantation. But in Japan, dead donor rule and primacy of consent are not adequately regulated. And also, this act does not have close relation with public policy, unlikely closely connected in the US and in EU countries. In order to ensure these main principles, medical profession must be honest and open in organ transplantation, and patients'group or civil organizations must be active in organ procurement campaign.

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Psychiatric patients often experience ambiguous and multiple wills. In the case discussed here, a female patient with delusions of persecution also had an ambiguous will. She strongly refused to be hospitalized, while at the same time having a certain degree of dependency on medical care. Evaluated from a traditional bioethical viewpoint, the judgment would be that she lacks autonomy and psychological capacity, justifying her involuntary hospitalization. In this case, however, the patient, her family, and the medical staff had a lengthy talk about her illness and hospitalization, expressing their own opinions and experiences. As a result of this process, the patient seemed partially or implicitly to accept her hospitalization. Thus, the decision-making process dictated by standard bioethical principles gave way to a clinical ethnographic process which promoted recognition and exchange on an experiential level, allowing the reconstruction and fluidity of the problem itself to be recognized.

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Organ transplantation, a long-term controversial problem, was legislated in Japan on 16th October 1997 and we Japanese can legally give and take organs of a brain-dead person. However, this does not mean the controversy has completely settled. This problem still remains worth careful reconsideration in terms not merely of objective but also of subjective matter. Profound and suggestive thought has often been produced from a delicate balance between these two attitudes. It might not be meaningless to ask, of course without any sarcastic nuance, if the proponents of organ plants could simply be honest about their opinion when their beloved has become brain-dead. What is logically correct is not necessarily morally right. Now that we have reached the point of no return where the desire to prolong our life by using others'organs is legally and technically realizable, we should be more careful than ever in exercising the right. We sometimes need to moderate and even control it on our individual responsibility by nurturing sympathy, the sense of humanity, for both a donor's and a recipient's sides.

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From one viewpoint of moral philosophy, the concept of "self-determination"is "the absence of restraint by other people and the ability to choose between alternative courses of action." According to this viewpoint, genuine "self-determination"in the case of abortion means that a women has the choice whether to have a baby or not and can choose not to have a baby. One must distinguish genuine "self-determination"from the inevitable decision. It is not obvious that a woman's right of "self-determination" takes in any case precedence over a fetus's right to live. The woman's right doesn't include the right to kill the fetus that is able to survive outside the mother's body. On the other side only the woman's consent can give the right to use the mother's body to the fetus that isn't able to survive outside the mother's body. I think that the woman is allowed to give the consent when her pregnancy is realized.

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