Confucian virtues in a paternalistic medical tradition (1868-1937)

In the early seventeenth century, the Tokugawa Shogunate closed Japan to foreigners. One small Dutch trading post in Nagasaki was tolerated, but, until the end of the Edo era (1840s-1860s), contact with foreigners was prohibited and the influence of Dutch medicine remained very minor, while traditional Japanese and Chinese medicine continued to flourish. However, as the era drew to a close, restrictions were eased and Japanese physicians sought out texts on Western medicine, training themselves in Dutch methodology and practice (Rangaku) using texts available through the Dutch trading post and questioning its resident physicians.
__To this end, a document by Christoph Wilhelm Hufeland, originally published in Berlin under the title Enchiridion Medicum (1836), was translated from German into Dutch by Hermann H. Hageman (1838) and became influential among the Ranpo-I or Dutch School physicians (those trained in Dutch medical techniques). An 1849 translation, Ikai (Medical Admonition), by Seikyo Sugita, of Hufeland's chapter on physicians' responsibilities, which asserted that physicians have a duty to take care of all patients regardless of their social or economic status, was widely read and accepted by Japanese physicians (Sugimoto, 1992). A thirty-volume translation of Hufeland's writing completed in 1861 by Kôan Ogata, a great forerunner of Japanese modern medicine, established this thinking more firmly among Japanese physicians. In 1859, a book traditionally known to Japanese physicians as Ishimpô (Heart of Medicine), the oldest extant medical encyclopedia in Japan, was reprinted by the Tokugawa government and made more widely available. This popular Ansei-era edition, originally written on thirty scrolls in 982 C. E. by Yasuyori Tamba, stated in its preface that physicians should embody the spirit of Daiji-Sokuin - Daiji, the great mercy of Buddha, from the Buddhist scripture, and sokuin, meaning sympathy or benevolence (also expressed as jin), from Confucian teaching.
__In 1868, feudal samurai in particular han (local provinces), such as Satsuma, Chôshû, Tosa, and Hizen, initiated the restoration of political power to Emperor Meiji after the Tokugawa shogunate's reign of 265 years (1603-1867). The Confucian ethical teaching, dominant among the samurai during the Tokugawa shogunate, was integrated into Kyoiku Chokugo (the Educational Edict of the Emperor, 1890) as the basis for moral teaching in the elementary school curriculum; the classes were compulsory. (This edict was not abolished until 1948.) Confucian ethics, as embodied in this edict, attributes great mercy and benevolence to the emperor and affirms the importance of virtues such as loyalty to the emperor as the head of the "state-family", and filial piety and respect for parents. It also emphasizes the importance of brotherhood and sisterhood, obedience to law and maintenance of order, the necessity of education, and devotion to the state (exemplified for men in military service). Grass-roots movements for liberty and civil rights in the political process (jiyû-minken undô) were increasingly popular but were suppressed by the emperor's proclamation of the Meiji constitution in 1889, which consolidated political power in the hands of the emperor and established the Diet (Parliament) in his name. Modern Japanese medical ethics cannot be isolated from this social and political milieu. The strong paternalistic nature of Japanese medical practice is the natural outcome of Confucian teaching, which calls for respect of the master and for his authority as a source of unquestionable wisdom and truth.
__As Japan became more open to the West, the Dutch ceased to be the sole source of Western culture and other nationalities replaced them. The process of modernizing Japan began in the second half of the nineteenth century and continued into the twentieth century, aided by oyatoi gaikokujin (foreign advisers) from Western countries, hired by the Japanese government to provide development advice in industry, education, government, finance, science, technology, and medicine. Japan, seeking models for modernization, was drawn to the German approach because of the success and progress of German science and technology, and the similarity of the German authoritarian political system under the Prussian kaiser to its own under the emperor. Official acceptance of Western, particularly German, medicine guided the development of Japanese policy on medical administration and education and set the course for the future (Oshima, 1983).
__German physicians left a legacy of authoritarianism in medical education and practice that had far-reaching effects on the majority of the Japanese medical community. This approach, combined with the Confucian self-righteousness in rendering benevolence to the patient, undermined the development of any notion of patients' rights. Research became the supreme interest at many university hospitals, and patients who presented interesting cases were treated as research material. All of these influences can be seen in the Isei (seventy-six guidelines for medical administration) drafted by Sensai Nagayo in 1874. Traditional Japanese (Wahou) and Chinese medicine (Kanpou) have been out of the mainstream of medical science in Japan since the adoption of Isei, although acupuncture and moxibustion (quick, light heat from an ignited powder of medicinal leaves at key points of the body, called tsubo) have remained as folk medicine with popular support among the public (Otsuka, 1976).
__As capitalism became established in Japan, the serious social and economic inequities exacerbating the health problems (e.g., widespread tuberculosis, malnutrition) of factory workers, miners, farmers, and fishery workers became evident, particularly in the Taisho Era (1912-1926). Even through the socially privileged physicians' group was not eager to address these health issues through social reform, some young physicians and medical students working for the settlement movement, introduced into Japan from England at the turn of the century, provided medical care in the slum areas of big cities such as Tokyo, Osaka, and Kobe in the 1920s. In 1919, the Medical Cooperative Movement (Iryo Seikyo Undo), which sought to establish community medical centers offering equal access, found great support among many Japanese (Seikyo, 1982).
__During this period, Japanese medical ethics, guided by the two powerful influences of Confucian teaching and German authoritarianism, was generally understood simply to govern a physician's personal attitude in providing medical service to patients within the traditional model of a paternalistic trust relationship. It is important to note that during this time the eminent Japanese medical historian Yu Fujikawa asserted that physicians were bound by special obligations and responsibilities, and must develop a special ethical consciousness in their daily practice. His advice was not accepted by Japanese medical experts, who were obedient to the military regime during the following war years.

Medical loyalty to state and authority (1938-1968)

Increasing concern about the health of the Japanese population led to the establishment of Kôseishô, the Ministry of Health and Welfare, in 1938. The National Health Act and additional laws protecting factory workers were promulgated during the same year. Many young radical physicians dealing with serious health problems among the population, such as tuberculosis, raised questions of justice and equitable distribution of resources, but concerns associated with the war with China (which began in 1937) now dominated. In reality, one of the government's main purposes in establishing the Kôseishô was to strengthen the health of the nation to wage war. Similarly, the National Eugenic Law (1940), promulgated ostensibly for the health of the people, reflected the government's desire for increased family size and the elimination of genetically transmitted diseases and defects. To achieve the latter goal, it authorized the use of a "eugenic operation" - voluntary or involuntary sterilization of individuals with mental illness or retardation and those thought to be at risk of transmitting genetic diseases or physical deformities to offspring. (Although this law was abolished and replaced by the National Eugenic Protection Law in 1948, sterilization continued under the new law. Between 1955 and 1967, 418,178 women and 13,571 men were sterilized, 407,910 women and 9,608 men involuntarily. Data from the early 1990s show that, although far greater numbers of females than males continue to be sterilized, involuntary sterilization is almost nonexistent. In 1992, for example, 38 males and 5,601 females were sterilized, but only one operation on a female was reported to be nonvoluntary [Statistics and Information Department, 1993].) With the approach of war, the traditionally authoritarian, yet basically well-intentioned, practice of medicine came under the control of a militaristic state regime; this had dreadful repercussions for medicine and medical ethics in modern Japan.
__At this point in time, the traditional purview of medical ethics in Japan did not extend to issues of human experimentation. Several horrible and unethical human experiments performed during World War II were uncovered after the war. The similarity of response to state authority exhibited by Japanese physicians and by Nazi physicians has been viewed with dismay. German defendants accused of committing crimes against humanity were put on trial at Nuremberg; and the medical atrocities and experiments there recounted led to the development of the Nuremberg Code in hope of preventing such practices in the future. However, Japanese medical experts serving in Unit 731, officially called the Water Supply and Epidemiological Disease Prevention Corps, who carried out and supervised experiments on Manchurian Chinese captives using bacteriological infections, frostbite, and mustard and poison gases, were not prosecuted by the international military court (Powell, 1980; Williams and Wallace, 1989).
__Official classified documents exchanged between the United States and U.S. General Headquarters in Japan, now available at the U.S. National Archives, show that the U.S. military decided not to bring this case to trial. The interrogation task force of the occupation forces in Japan granted immunity to members of Unit 731, including General Ishii, chief of this corps, on the condition that all related medical records and specimens be handed over to the United States. The matter was regarded as highly important to national security because the United States wanted to prevent transfer of the medical knowledge gained through these experiments to the Communist governments in China and the Soviet Union (U.S. National Archives, 1949). The Soviets held their own military trial at Khabarovsk for members of Unit 731 they had captured. Based on documentation and the testimony of witnesses, the accused were found guilty (Ivanov and Bogach, 1989).
__The Kyushu University Medical School vivisection case also serves as an example of unethical experimentation. Eight American bomber pilots were captured in Japan after an air raid on Tokyo in 1945; some of them were sentenced to death by the local unit of the Japanese Imperial Army, but instead were used as objects of medical experimentation. To avoid prosecution by the Yokohama District Military Tribunal, one key person involved in this experimentation committed suicide; full details may never be known (U.S. National Archives, 1949). The case served as the basis for a popular novel by Shûsaku Endô, titled Umi to dokuyaku (1960), in which he dramatically depicted the quandary of a medical scientist tempted by unethical but very interesting experimentation. Endo's novel forced consideration of the meaning and place of ethics and medicine in Japanese society - which, he argued, lacked a standard of absolute value.
__Justified by state authority, professional experts in Japan sometimes lose critical consciousness and judgment. The Japanese national character nurtured during the Tokugawa era, and by an authoritarian government since the Meiji Restoration, demands absolute obedience to the state and to authority. As Endo points out in his novel, such pressure often creates serious problems when individuals must make independent, and individual, ethical decisions. As a member of a group - such as a family, corporation, or community - and as a citizen, the individual Japanese tends to follow what other people do. Harmony (wa), or getting along with others, is an important element of the Japanese ethos for maintaining good relationships. To insist on individual opinions is regarded as egoistic and arrogant. Suppressing oneself in order to cope with other people is a daily practice in every aspect of life for the Japanese. This has serious ethical implications, especially in term of weakening critical consciousness necessary in professional experts. The majority of Japanese medical experts and the lay public are not interested in drawing serious lessons from the horrible wartime human experiments because they reason that such actions are performed only in "abnormal war settings by abnormal people".
__Orders from the occupation forces led to large-scale changes in medical and nursing education, as well as in public-health policy and hospital management. An irreversible and radical shift in medical practice from the German orientation, dominant since the Meiji Restoration, to an American orientation occurred during this time. One of the first pieces of legislation implemented after the defeat of Japan was the Eugenic Protection Law of 1948. Unlike the National Eugenic Law (1940) that it abolished and the Japanese Criminal Code (1907), Chapter 29, Article 212-16, which still holds that abortion is illegal, the 1948 law permitted abortion for medical, and later for social and economic, reasons. Under the Japanese Criminal Code, abortion for other reasons remains a prosecutable offense. However, due to vigorous opposition from advocates for the disabled, it did not provide legal justification for the abortion of a genetically defective fetus. The endorsement of this abortion law by the General Headquarters of General Douglas MacArthur aroused adverse reactions from religious bodies in Japan and the United States (Kimura, 1987). MacArthur defended the policy, saying that it had arisen from and was implemented by the Japanese Diet. The law was still in effect in the 1990s.
__The way survivors of the atomic bombs dropped at Hiroshima and Nagasaki were treated by the Atomic Bomb Casualty Commission (composed of U.S. medical and genetic experts) is one of the historical sources of the development of Japanese bioethics because of its significance in discussions about the relationship between human beings and science, technology, and research. Individuals suffering from the effects of radiation came seeking treatment, but instead became material for research on radiation and collection of genetic data. This situation raised the serious issue of the researcher's responsibility to obtain fully informed consent for research. At that time, no government regulation or review boards existed to deal with the situation. The implications of this research are only beginning to be studied in Japan.
__In 1951, the Japan Medical Association (JMA) issued a statement on physicians' ethics. This action clearly ushered in a new epoch in medical practice in Japan and signaled a return to the prewar state of medical ethics. Article I explicitly reaffirmed the fundamental and central place of the ancient principle of jin, the benevolence of Confucian teaching, in medical practice and asserted that physicians, as the elite of society, must embody the spirit of jin, always thinking about the welfare of the patient and the benefit of the treatment. Further, in cooperation with other professionals, physicians should take the initiative in social reform and, as ethically oriented people, should exercise great self-discipline (JMA, 1951).
__In 1968, a series of consultations and presentations by scholars on ethical issues in medicine was held under the direction of Taro Takemi, then president of the JMA, in an attempt to update the 1951 statement. The publication of Ishi rinri ronshû (1968) was the outcome of this research, but no new ethical code was issued. During his twenty-five-year tenure, Takemi developed an interdisciplinary study project titled "Raifu saiensu no shimpu", which has focused attention on bioethical issues such as the allocation of medical resources, applications of high-tech medicine, and ethical problems. However, its professional orientation effectively excluded the lay public. Professional autonomy and authoritative decision making that excluded patients continued to be the model.
__The Japanese Constitution, which became effective in 1947, guaranteed the right to health care and social security. Article 25 provides that "all people shall have the right to maintain the minimum standards of wholesome and cultural living. In all spheres of life, the State shall use its endeavors for the promotion and extension of social welfare and security, and of public health." The effort to implement national health insurance for all Japanese, originally begun in 1938, was finally realized in 1961. Since then, all Japanese "whoever, whenever, and wherever" they are, have had access to medical treatment for all illnesses. Treatment costs are covered by the government or by government-controlled systems, except 10 percent coinsurance for insurees and 30 percent for their family members.
__Medical care for the elderly, once completely free as a result of the Health Care for the Elderly Act of 1973, now requires a payment of about 20 percent of the total fee (through a 1986 cost-containment amendment). Private medical insurance system, once almost nonexistent, have sprung up to cover the gap between the actual cost of medical treatment and the amount covered by government insurance. Such coverage is particularly needed for chronic diseases, terminal illnesses, and cancer treatments, although a high-cost medical treatment assistance system was introduced in 1973. As of 1993, the assistance system covers all expenses beyond 33,600 yen/month for low-income families and 60,000 yen/month for average-income families.
__Even Japan felt the effects of the worldwide trend in the 1960s of questioning established authority. Revolts occurred in many universities as dissatisfied medical students stood up against the traditionally paternalistic and authoritarian medical faculty they felt was exploiting them. Special legislation eased the unrest, but this first and radical challenge of the medical establishment, a very politically powerful group, had permanent ramifications for Japanese society and moved it into a new era.

Communal involvement in medical decision making (1969-1990s)

In the 1960s, numerous social issues competed for attention in Japan. Problems of air and water pollution; concerns about food additives, iatrogenic diseases, the revival of kanpo (traditional Chinese medicine), and increased emphasis on health became common concerns. The growing number of older people focused attention on the need for health care for the elderly. At present, Japan is one of the most successful countries in decreasing the birthrate, and life expectancy in 1991 was the longest in the world, eighty-two years for women and seventy-six years for men. Advances in medical technology and health care have raised additional issues for the Japanese medical profession and society in general. This time period has seen increased lay involvement in discussions about medical treatment and a strong desire to establish guidelines to protect the patient.

Organ transplantation. Progress in organ-transplant technology created a demand to regulate and endorse cornea transplantation. A special law to this effect was enacted in 1958; in 1979 it was combined with a law governing kidney transplantation. Kidney transplantation from live donors is quite common (approximately 73 percent of all kidney transplants; Kimura, 1991b), and there have been approximately 100 cases of segmental liver transplantation from live donors. __The most vigorous public debate on bioethical issues was generated by the first heart transplant in Japan (1968), in which a heart was taken from a drowning victim and transplanted to a patient in heart failure. The patient died after eighty-three days. A surgeon at Sapporo Medical College, Jurô Wada, was accused of mishandling the surgery on both the donor and the recipient, and questions arose about the justification for the transplant and about the criteria used to determine death; but Wada was never formally prosecuted. However, the aftermath of this case gave rise to strong criticism of high-tech medical applications on ethical grounds. Concerns focused on the use of brain-based criteria of death, organ transplantation from brain-dead bodies, and the need to develop ethical guidelines to control the behavior of individual physicians who might seek fame through ill-prepared and drastic use of medical technology supposedly to benefit the patient. __This incident spawned the Patients' Rights Declaration in 1970 (Wada, 1970). This short, spontaneous expression of feelings, stating that the Wada case was a violation of the human rights of the patient and an example of the corruption of medicine and ethics, occurred in the public meeting at which Wada was accused of violating the donor's right to life. Repercussions from the Wada case were so great that almost three decades later, there have been no heart transplants in Japan and the brain-death criteria have not yet been accepted as public policy. However, corneas and kidneys are transplanted from brain-dead bodies - the heart is avoided because its removal clearly will cause the death of the donor.

Criteria for death. Leading objections to brain-death criteria are the fear that organs will be removed prematurely and that transplants will be performed in unacceptable circumstances (kimura, 1991b). In Japan, transplantation of vital organs from dead bodies is rare because of a concern about causing the death of the donor. To a limited degree, anencephalic infants have been used as sources for donor organs because they will die anyway, and because it is believed that they do not possess the fundamental consciousness necessary to be a human being. Declaration of death in the cases reported has ostensibly been based on the total cessation of heartbeat. However, the use of organs from anencephalics has stopped, owing to clinical concerns about the condition of the organs from such donors and public concerns about the appropriateness of such practices. __Resistance to hastening death and harvesting organs also comes from the traditional Japanese image of human beings as completely integrated mind-body units, rather than distinct and separate units of mind, body, and spirit. This unit continues after death, so that removing an organ from a cadaver is seen as disturbing this spiritual and corporeal unity, not merely altering the physical body. It also explains why autopsies are abhorred in Japan (Fujita, 1980). According to the Buddhist and Shinto ways of thinking, this unity extends beyond the individual to all living things. To the Japanese, death disturbs the rhythm of all living things and therefore should not be hastened. Also, Confucian teaching places strong emphasis on family relationships and filial piety. There is a strong prohibition on harming one's body, because it is derived from one's parents (Kimura, 1991b). __In addition, in accepting the reality of human mortality, some Buddhists would regard the extension of life by accepting organs from another individual's body as unnatural and unethical, since the procurement of those organs depends on the death of another person. Such an expectation of the death of someone else for the purpose of egoistic extension of life is not acceptable. Also, the totality of life should be supported by the notion of arayashiki (alaya-vijnana) (the fundamental consciousness within each individual being). This Buddhist notion holds that consciousness is not located solely in the brain; therefore the cessation of any one part or one organ (including the brain) of the individual does not extinguish consciousness, and consequently cannot be regarded as the death of the individual person (Takemi, 1993; Fujii, 1991). Therefore, the basis for the uneasiness in accepting brain criteria for death and organ transplantation comes from both Confucian and Buddhist thought, which incorporate some ideas from Japanese traditional folk religions and Shintôism. __In 1990 an ad hoc research commission on brain death and organ transplantation was established under the Prime Minister's Office. Chaired by Michio Nagai, former minister of education, science, and culture, the commission made final recommendations in January 1992. The final report endorses brain-based criteria for death (the irreversible cessation of the function of the entire brain) and the permissibility of organ transplantation. However, the document also respects the traditional clinical criteria (absence of heartbeat, circulation, pulse, and respiration) as the basis for declaration of death, and permits the family and individual to choose between the two criteria (Prime Minister's Ad Hoc Committee). The opposing minority opinion, which was part of the document, was signed by four out of eighteen consultants and committee members; thus the decision was not unanimous. Even though public hearings were held in Hokkaidô, Kantô, Kansai, and Kyûshû, the committee meetings were closed to the public and no mechanism existed to ensure incorporation of public input. Almost two years after the final report of the committee, there were yet no organ transplantations from brain-dead cadavers. Draft legislation regarding these issues was presented to the Diet by the Inter-Party Committee in early 1994.

Truth-telling and death education. A complicating factor in obtaining permission for organ transplantation from terminal patients is that Japanese physicians normally withhold information about diagnosis and prognosis from patients, particularly in the case of cancer, and many Japanese hospices and palliative-care units make it a customary rule not to tell patients that they are dying, although there are some exceptions. Several studies examining the patient-physician-nurse relationship have been published, and several more, to examine the Japanese way of telling the truth to the patient, are proposed (JMA, 1990, 1992). Hospice care in Japan was initiated by Christian Hospitals in the 1970s. Hospice units based on Buddhist beliefs were established in the 1980s, while the Japanese government began to endorse such palliative care only in 1990. As of December 1993, there were approximately twenty hospice-care systems, including ten palliative-care units, that were officially endorsed by the Ministry of Health and Welfare. There are a number of groups focusing on the study of death and dying. One of them, organized by a leading expert on death education, Alfons Deeken of Sophia University in 1982, has been expanding its network throughout Japan.

Euthanasia. Media coverage has made euthanasia one of the most debated topics in Japanese bioethics. The Japanese Euthanasia Society was established in 1976, and the first international conference on euthanasia was held at Tokyo in the same year. As of August 1993, the society, now called the Japanese Society for Dying with Dignity (JSDD), had a membership of 60,000. The Ninth International Conference of the World Federation of Right to Die Societies was organized by JSDD at kyôto in 1992. No legally established procedure exists in Japan, but as in many other countries, the use of elevated doses of narcotics to relieve suffering and pain is acceptable even at the risk of hastening death (Murakami, 1979). According to Buddhist thought, the prolongation of life and suffering is not absolutely necessary, and ending the life of a dying, suffering patient might be regarded as a merciful act (Murakami, 1979). __A 1962 precedent-setting decision by the Nagoya High Court, which accepted the idea of euthanasia in principle, involved the case of a son who prepared poisoned milk as a result of his terminally ill father's repeated requests to die; the glass of milk was found by the man's wife, who, not knowing it was poisoned, gave it to her husband. Although the court found this case to involve unacceptable mercy killing, it established six criteria for allowable mercy killing: (1) the patient's condition must be terminal and incurable, with no hope of recovery, and death must be imminent (as determined by modern medical knowledge and technology); (2) the patient's pain must be so severe that no one should be expected to endure it; (3) the purpose of the act must be solely to relieve the patient's suffering; (4) a sincere request and permission are required from competent patients; (5) in general, this act should be performed only by physicians; and (6) only an ethically acceptable method must be used. Since the 1962 decision, no case that has come before the courts has been found to meet the criteria established for acceptable mercy killing, although the case of a doctor accused of the euthanasia of a patient in 1991 was still undecided as of 1994.

Treatment of the mentally ill. The Japanese Mental Health Act was passed in 1950 to prevent private home confinement of the mentally ill in violation of an identified right to be cared for in institutional situations. However, in the 1980s, disclosures of violations of rights of psychiatric patients led to serious questioning of the routine admittance and institutional treatment of the mentally ill. In 1987, an important amendment to this act, which adopted more rigorous procedures for involuntary hospitalization of the mentally disabled and established rehabilitation and treatment centers to protect the rights of patients with mental disabilities, passed after a nationwide campaign in its favor by the mass media and a strong recommendation for its passage by a special investigative mission of the International Commission of Jurists in Geneva. The commission's involvement underscores the importance and necessity of international cooperation on bioethical issues, especially those related to patients' rights.

Education of the public in bioethics. Bioethical issues raised in the 1960s caught the attention of much of Japanese society, and in the 1970s concerned citizens formed bioethics study groups in Tokyo, Kyôto, and Nagoya. By the 1980s, these groups participated as bioethics volunteers in medical service organizations. The nationwide concern with health and medical services in Japan led to the new declaration of patients' rights (1984) issued by a group of patients, lawyers, physicians, and journalists (Kanjya, 1992). While this document carried no official authorization, it was more systematic than its 1970 precursor and showed the impact of discussions in other countries. The General Assembly of Japanese Medical Cooperatives, an official medical service organization of the Japanese Association of Life Cooperatives Union with 250 hospitals and clinics and a membership of 1.5 million individuals, endorsed its own version of a patients' bill of rights in May 1991 - the first such action by a medical organization (Kanjya, 1992). The Patients' Rights Legislation Movement, largely initiated by medical malpractice lawyers and other members of the lay public, began in 1991 to urge passage of a statute on informed consent and respect for patient autonomy in medical decision making.

Ethics committees: Reproductive interventions. The first medical ethics committee in Japan was established at Tokushima University Medical School in 1982 in order to review in vitro fertilization (IVF) technology and its application to infertile women. In Japan, a great deal of social and familial pressure exists to have children, so there is a great demand for IVF research. Artificial insemination by donor and artificial insemination by husband have been used since the early 1950s. The Yomiuri newspaper (April 15, 1993) reported that there were 199 registered clinics (registration is not required), and that the number of children born as a result of IVF seems to be increasing steadily. As of 1992, each of the eighty medical schools finally had its own medical ethics committee reviewing cases such as segmental liver transplantation, gene therapy, and IVF. Owing to a lack of national legislation regarding these committees, each has a different composition, although the majority of members are from the same medical faculty and are male (Kimura, 1989b). In 1991 the Greater Tokyo Metropolitan Government established the first hospital ethics committee with membership of nonmedical practitioners and opened all their meetings to the public. This committee serves as a policymaking body for the fourteen hospitals operated by the Tokyo Metropolitan Government.

Bioethics Organizations. Since the mid-1980s, medical professionals and government organizations have been involved in the study of bioethical issues. In 1984, the Ministry of Health and Welfare set up the Special Advisory Board on Life and Ethics; it published an official report in 1985, after a series of research conferences, then ceased activity. The JMA also set up the interdisciplinary Bioethics Council, consisting of medical experts and professionals from philosophy, anthropology, biochemistry, law, and industry. The council dealt with topics related to technological applications in clinical settings such as IVF (1986), sex selection of the fetus (1987), brain death and organ transplantation (1989), and explanation and informed consent (1990). __The Japanese Association for Bioethics, established in 1987, publishes a journal and a newsletter, and has more than eight hundred members who attend the annual national meeting and international meetings. The Japanese Association for Philosophical and Ethical Research in Medicine, the Japanese Society of Ethics, and the Japanese Society of Medical Law are also concerned with bioethical issues as they affect their respective disciplines. In addition, the members of the Japanese Diet participate in a study group called the Diet Members' Federation of Bioethics. Proceedings of the study meetings, including texts of lectures by guest speakers, and questions and answers relating to issues such as brain death, organ transplantation, anatomical gift of the body, aging, and allocation of medical resources are published and publicly available.

Bioethics education and publications. In 1987, bioethics became a compulsory course in the Japanese higher education system, at the newly established School of Human Sciences at Waseda University. This course, team-taught by professionals from medicine, biology, and law, covered the beginning and end of life, the quality of life, and environmental problems. Increasing numbers of medical schools include courses in bioethics or medical ethics with their clinical curriculum, although there are very few faculty members who teach only this subject. There are now four research institutions in Japan that focus on bioethics: Kitasato University, Kanagawa; Kyôto Women's University, Kyôto; Waseda University, Tokyo; and the Eubios Ethics Institute, Tsukuba. __Beginning in the early 1980s, several books have influenced the thinking of the Japanese public and biomedical professionals on a range of ethical issues. They include Hisayuki Omodaka's I no rinri (1971), based on his teaching experiences at Osaka University's medical school as chair of the "General Introduction to Medicine" as well as full-time professor of philosophy; a book with the same title (1977) by Omodaka's successor, Yonezô Nakagawa, a leading scholar in medical humanities; and Takeshi Kawakami's book Seimei no tameno kagaku (1973), which criticized the medical establishment's cooperation with the bureaucratic health-policy planning of the local and central governments, and touched on issues of patients' rights and the ethical tasks in medical service. Clinical physician Shigeaki Hinohara, clinical pharmacologist Shigeichi Sunahara, biochemist Shunichi Yamamoto, bacteriologist and medical historian Yoshio Kawakita, medical law expert Koichi Bai, anatomist Kazumasa Hoshino, and lawyer and bioethicist Rihito Kimura write books and give lectures on bioethics in Japan (Kajikawa, 1989).

Concluding remarks The contemporary discussion of bioethics in Japan started as a movement among the lay public in the late 1970s. This fact remains symbolic and important in many respects, as evidenced by the increased degree of individual decision making about desired medical treatment, as well as all areas of daily life. Optimistic attitudes toward the science and technology enabled Japan to move toward the successful achievement of modernization since the Meiji Restoration. However, the devastating aftermath of the atomic bomb and the focus on economic and technological success after World War II exacted an enormous human toll in terms of pollution, health problems, and karoushi (sudden death from overwork). Because of this history, the Japanese people have a negative memory of rapid, uncontrolled, professionally oriented science and technology and its misuse, and quite naturally express a desire to have a more cautious process of social adaptation and application of science and technology. The Japanese public's fear of unwanted and unwarranted medical practices, both before birth and after death, has led to greater control of the medical profession and a serious demand for the information necessary to make informed medical decisions about the beginning and end of life. __Japan continues to struggle to recognize bioethics as integral to all spheres of life and to discuss public policy and the environment, as well as to deal with the tension between Western values and its traditional cultural practices. In Japan, bioethics is increasingly recognized as a suprainterdisciplinary endeavor embracing all traditional academic disciplines in equal partnership, for the valuable exchange of ideas and criticism each field has to offer. In Japan there are specific cultural values and customs that are distinctive and non-Western in pattern, but there is heterogeneity, too, and in any case, ethical values change, particularly among the younger generations. We need to ask: What kind of future do we want to construct? We are and will be seeing a globalization of values. In this age of global community it would be native to overemphasize the uniqueness of a particular cultural heritage in human, family, and social relations. It is true that different cultural and ethical values should be respected, such as key concepts of the dignity of each human person, the importance of the family unit, and community life. But justification of any act or behavior against human dignity and the rights of the person for the sake of cultural tradition is not acceptable. __It may be that in the international community of the twenty-first century, with a globalization of values focusing on a universally accepted notion of fundamental human rights, the reality of limited resources and the increasing necessity of mutual cooperation, the notion of "related-autonomy" and the Japanese principle of wa may find greater voice in bioethics.

RIHITO KIMURA WITH THE ASSISTANCE OF LAURA BISHOP

While all the articles in this section and the other sections of this entry are relevant, see especially the companion article in this subsection: JAPAN THROUGH THE NINETEENTH CENTURY. Directly related to this article are the entries AUTHORITY; BUDDHISM; CONFUCIANISM; PATERNALISM; and TRUST. For a further discussion of topics mentioned in this article, see the entries ABORTION; AGING AND THE AGED; BENEFICENCE; BIOETHICS EDUCATION; COMPASSION; DEATH, DEFINITION AND DETERMINATION OF; EUGENICS; HEALTH-CARE DELIVERY; HEALTH-CARE FINANCING; HOSPICE AND END-OF-LIFE CARE; INFORMATIONN DISCLOSURE; LOVE; MEDICAL CODES AND OATHS; MENTAL HEALTH; MENTAL ILLNESS; NATIONAL SOCIALISM; ORGAN AND TISSUE TRANSPLANTS; PATIENTS' RIGHTS; PROFESSIONAL-PATIENT RELATIONSHIP; PUBLIC HEALTH; REPRODUCTIVE TECHNOLOGIES; RESEARCH, HUMAN: HISTORICAL ASPECTS; RESEARCH, UNETHICAL; RESEARCH ETHICS COMMITTEES; and VIRTUE AND CHARACTER. See also the entry MEDICAL ETHICS, HISTORY OF, section on EUROPE, subsection on NINETEENTH CENTURY, article on EUROPE, and subsection on CONTEMPORARY PERIOD, article on GERMAN-SPEAKING COUNTRIES AND SWITZERLAND. Other relevant material may be found under the entries COMPASSION; FREEDOM AND COERCION; JUSTICE; and RIGHTS.

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