Key Words:

bioethics, Japan, patients' rights, informed consent

I. INTRODUCTION

Japanese society and culture are changing rapidly. In this era of life manipulation, it is perhaps timely to examine the rise of bioethics in Japan and the unique features of Japanese culture in the context of life and death decisions in medical care, and to speculate on the profound impact bioethics will have on the future of Japan's civil life, health care delivery, and culture change.
Bioethical studies have developed significantly in the United States. Bioethics purports to deal with the ethical and value issues that have been brought about by the rapid developments of science, technology, and biomedicine during the past fifteen years.
In Japan, during these past fifteen years, there has been a revival of Japanese medicine in the Chinese tradition (Kampo); this has developed in Japan since the last thousand years. Originating in China, oriental medicine has more than a four thousand year history. Usually Kampo is known for (1) placing emphasis on the patient rather than the disease (i.e., a "holistic" approach); (2) revealing a tendency toward naturalism in health; (3) producing almost no side effects from its pharmacopoeia; and (4) attention to chronic and so-called "geriatric" diseases, those which most frequently accompany old age. During the Seventeenth International Congress of Internal Medicine, which convened in Kyoto in 1984, at a symposium on traditional oriental medicine, a positive evaluation of traditional Japanese medicine that originated in China was presented; it included a detailed clinical report regarding its application as well as a report on acupuncture (International Congress for Internal Medicine, 1984).
In the context of worldwide growing concerns and interests in cross-cultural aspects of bioethical studies, the first Asian bioethics program affiliated with Georgetown University within the Joseph and Rose Kennedy Institute of Ethics was formally established in 1980 (Kimura, 1984a). The first and the second Japan-U.S. Bioethics Symposium convened in Tokyo and Kanagawa in August 1985 and 1986, with the support of the Institute of Medical Humanities of the Medical School at Kitasato University, Japan. Kitasato Medical School, since the mid-1970s, has been the pioneering institution in Japan for the study of the philosophy and ethics of medicine (Sakanoue, 1983).

II. BIOETHICS AS CIVIC ACTION

According to the author's interpretation, a unique characteristic of bioethics is its bearing on a "civic action movement". In the U.S., the concern for life, death, and the environment has been affected by civic and community activities opposed to social, economic, racial, and political injustice ¹. In this sense, bioethics is a result of these human rights movements and various expressions of civic action; some of these include the women's liberation movement, access to equal opportunity, patients' rights, informed consent of an entire community for the opening of gene-manipulating laboratories, and campus protest groups who question the meaning of academic neutrality ². All of these movements have spread to various nations of the world, including Japan (Kimura, 1980).
Since 1980, the lay public and scholars called attention to the serious implications of bio- and medical-technological developments in Japan. Of course, we should acknowledge some of the very positive and commercial applications of bio-medical technology; however, we should also consider the negative effects that include the failure to adequately protect the welfare of the people; this is particularly true in Japan, where the Japanese suffered the tragedy of Minamata disease that was caused by one of the leading nitrogen fertilizer companies in southern Japan ³.
Japan's lay public still has negative feelings toward a too hasty advance of science and growth of technology. Perhaps this is due to Japan's first national experience in the world - having monumentally suffered from the extraordinarily "successful achievement" of science and technology in Hiroshima and Nagasaki in 1945!
Since the early 1980s, a bioethics network has been formed in Tokyo, Hamamatsu, Nagoya, and Kyoto; it is composed of some one hundred nurses, housewives, students, and physicians, some of whom have become very active as volunteer workers in the psychiatric department of Azumi Hospital in Nagano Prefecture in central Japan. Based on the notion of patient-centered services, volunteers work together with the medical and nursing staffs of the hospital in order to "humanize" the milieu of the psychiatric section (Kurimoto, 1986; Kimura, 1983). Licensed acupuncture specialists are also quite active as volunteers and serve this purpose successfully ⁴.
One of the more interesting experiences for these volunteers, as well as patients and professionals who conduct this bioethical activity in the hospital setting, is the newly rediscovered importance of natural rhythms and the feeling of being within nature. Washing and cleaning the feet of the patient, followed by a barefoot walk outdoors have an extraordinary and positive effect on the patients' mental state (Okamura, 1987). "Bioethical acts" such as these have been developing in local community hospitals, but are still in the beginning stage in Japan. However, it might be useful to note that more and more holistic approaches to health, environment, life, and nature have become evident, and the notion of "bioethics" itself has been interpreted within a totally new holistic approach to life, death, and virtually all health issues ⁵.
Given this continuous concern of the lay public, which involves issues bearing on the own lives, environment, and community, one very important dimension of bioethics has been developing; the very distinctive difference between "medical ethics" for physicians and professional ethics for professional people and the lay public; the latter group must depend on a fair amount of information from experts and professionals, but it is not necessary that they follow the opinions or decisions made by physicians from the perspective of their own value systems.
The lay public's concern in democratic decision-making calls out to be respected, and reflects a newly formed public policy that should help deprofessionalize clearly value-laden (and often prejudicial) decisions by health professionals.

III. PATIENTS' RIGHTS IN JAPAN

Until quite recently, the medical profession has enjoyed enormous power and professional discretion with regard to medical treatment. The Japanese are accustomed to authoritative structures and paternalistic attitudes, due in part to the fact that physicians have been nurtured in a traditional Confucian ethos - "Jin", traditionally developed in China. Medicine was regarded as "an art of Jin", and is viewed as an expression of loving kindness (Jin) by the physician, which is given to people who are not to ask any sort of questions. Although the Japanese have developed socialized medical service and social insurance medicine, and physicians work within this system even in their private medical practices, they still abide by the traditional notion of "Jin" as the basis for their services (Nakano, 1976).
However, bioethics, which is "supra-interdisciplinary", goes beyond the traditional closed realms of the academic disciplines in order to accomplish its task (Kimura, 1986a). For example, in the quasi-didactic, traditional, paternalistic relationship between physician and patient, the notion of "patients' rights" could not be meaningfully formed. Bioethical concerns have altered the image of the patient by applying the notion of "rights" from the legal traditions that might be rejected as indifferent notion in medicine according to its logic of health and medical care. "On behalf of the patient", and "for the patient's benefit" are phrases that emerge according to criteria set by the attending physician. However, this has gradually been changing in Japan, especially with respect to the new bioethical emphasis on the patient's framework of values in making final decisions concerning medical treatment. The principle of "informed consent" applied in clinical medicine is also a recent development in bioethical decision-making ⁶.
An earlier series of articles on Bioethics and Patients' Rights, which appeared in the Japanese Journal of Hospitals, were the first of their kind, and had a significant impact on physicians as well as on patients (Kimura, 1981). The Japanese Hospital Association, in 1983, took the issue seriously and announced its version of the principle of patients' rights in their official handbook for hospital physicians. The first national conference on "Patients' Rights Declaration" took place in December, 1984, in Tokyo. Bioethical decision-making has given greater emphasis to each patient's right to make particular decisions based on his/her own values and moral standards. Of course, this has been viewed by lawyers and bioethicists as an expression of the principle of autonomy and the patient's moral right to make his or her own treatment decisions.
However, the concept of "right" (Kenri) can be traced to the Dutch word "regt" and later found in Japanese by using a Chinese character; this occurred around one hundred years ago. It is originally an alien notion for the Japanese, and hence not only the notion of "patients' rights", but also the notion of "sharing information" and "shared decision-making" between patients and physicians is still quite radical for many Japanese patients and particularly for many paternalistic Japanese physicians (Kimura, 1986b).
The notion of autonomy, one of the fundamental principles of Western-oriented bioethics, does not apply suitably to the Japanese socio-cultural tradition, particularly within the paternalistic medical tradition. In Japan, each human being as well as all living beings is dependent in that every person has to suppress his egoistic self.
A more delicate sense of "relatedness" is thus the key element in the recovery of one's true humanity within nature, including the entire living being. The Japanese are influenced by the important traditional Buddhist teaching of "En" (relatedness). All fellow beings are related to one another as well as to nature (Fujiyoshi, 1984).
The Japanese thus need to change their profoundly paternalistic attitude, which is reflected in their medical tradition into more positive ways of "sharing" information, trust, treatment between medical professionals and patients. This is the importance of the bioethical principle of "sharing" in Japan - sharing life with others, including all living beings who suffer, are sick, or aged. This positive, creative, living principle is critical to human empathy and grounded on "En" (relatedness) (Tamaki, 1982).
The lay public in Japan is becoming more and more interested in all areas of the life sciences, which are increasing the boundaries of medicine, science, and technology. By sharing information and working together, they hope to protect and develop their lives as we progress toward the twenty-first Century.

IV. CONCLUDING WORD

In reviewing the development of civic action and interest in bioethics in Japan, one cannot yet claim that bioethics is an established academic discipline in any traditional or classical sense. It is a totally new discipline for the Japanese lay public, if not for the medical profession in general. But the development of bioethics as a civic action will provide enormous help, of course, to health care professionals, as well as government policy makers since this set of problems has been of central concern for some years in Japan ⁷.
It is quite natural, then, that bioethics as a civic action movement is now in the process of incorporating itself into Japan's cultural value system (Kimura, 1981; Kimura, 1982; Kimura and Steslicke, 1985; Kimura, 1984b; Kimura, 1985).

NOTES

REFERENCES

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