Compared to other advanced countries, there are few organ transplants carried out in Japan based on using organs from “brain dead” donors. The primary cause is that fewer people make provision to donate their organs. This in turn may be in part due to the fact that Japan has no organ procurement organization for transplantation. The end of the system, which is not for the public, is the reason that we do not have this kind of organization in Japan.

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脳死（全脳死）は，「脳幹を含む脳全体のすべての機能が不可逆的に停止した状態」である。これは重篤な器質的脳障害により深昏睡となり無呼吸，人工呼吸器装着となった例の一部で起こる。いったん脳死に陥ればいかに全身管理を行っても通常1～2週間程度で心停止に至るが，心停止までに数カ月，1年以上要した例もとくに小児で報告されている。わが国では脳死判定は「臓器の移植に関する法律」（臓器移植法）に基づいており，臓器移植を前提とするときに適用され「法的脳死判定」と呼ぶ。法的脳死判定の方法は，いわゆる竹内基準に基づいて作成された『法的脳死判定マニュアル』に従って行われる。2020年8月，脳死判定の標準化の必要性が国際的に指摘されている。本稿では脳死の概念と脳死判定，臓器提供・移植をめぐる歴史，現在，今後の課題と方向性について議論のよりどころ，新たな展開の糧となるべく，最新の進歩をわかりやすく紹介する。

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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 1999, the multiple organ transplantation from a heart-beating-donor was reported from Kochi Red Cross Hospital. This was the first case in Japan after the "Organ Gift Act (1997) ". The patient was transported by ambulance to the hospital on Feb. 22, 1999. The Japanese mass media should have been prudent enough not to violate the donor's privacy, such as exact age, address, family, and occupation. But they set their feet on the quiet donor's home town, and took photos and movies. Afterwards, the MHW (Ministry of Health and Welfare) and JOTNW (Japan Organ Transplant Network) forbade the direct access of the media reporters to the hospital and family members, and limited not only the streams of the non-medical information of the patient but also the medical information needed to check the correctness of the transplantation. The immediate disclosure of the medical information is essential to protect the recepients rights. Without this information, patients and families can't check the official announcements of the hospital. Their medical report might be changed by the hosptital to make it consistent with other data or reports. If so, they can know neither the accuracy of the donor's diagnosis nor the accuracy of information used to make the informed consent of the family. The Japanese mass media must make the rational guidelines to distinguish the essential medical information, needed to assess the adequacy of the choice, from non-essential information. I stress the peculiar situation of the case. This transplantation was the first heart-beating donation case in Japan except the very doubtful heart transplantation case by Wada in 1968. I think first that the donor's family must have a very strong will for the correct donation and transplantation. It is their honorable obligation to disclose enough medical data to make the medical staff protect the donor's patient rights.

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フリーアクセスは、国民皆保険や現物給付方式と並んで、日本の医療保障を支える重要な役割を果たしている。ところが、昨今社会保障財源の逼迫が喧伝されていることから、このフリーアクセスを廃止に追い込む圧力が後を絶たない。そこで、機会費用の発生可能性の視点から、フリーアクセスをめぐる政府、国民、医療者が掲げる論理、倫理問題、合意状況について考察した。その結果、このフリーアクセス制限論の中には、数多の事実誤認が含まれていることが明確になった。このため、フリーアクセスをめぐる分配問題を適切に判断するためには、政府や世論が正しい事実認識を持つことが必要である。その上で、フリーアクセスを廃止すべきか否かについて議論することが重要である。勿論、医療・社会保障財源が逼迫している状況は放置すべきではない。しかしながら、正しい事実認識を持たずに前提を安易に受け入れて、フリーアクセスを過剰に抑制すべきだという結論ありきで分配問題を評価することは一切正当化することができない。問題解決を急ぐあまり、誤った認識を前提に受け入れた政策を実践することで、医療の荒廃が生じる可能性があるならば阻止しなければならない。よって、政府や世論が適切な政策論議をするためには、これらの誤った前提を捉え直す余地がある。

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