Rebirthing Bioethics Akira Akabayashi Bioethics Across the Globe Bioethics Across the Globe Akira Akabayashi Bioethics Across the Globe Rebirthing Bioethics This book is an open access publication. ISBN 978-981-15-3571-0 ISBN 978-981-15-3572-7 (eBook) https://doi.org/10.1007/978-981-15-3572-7 © The Editor(s) (if applicable) and The Author(s) 2020 Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this book are included in the book's Creative Commons license, unless indicated otherwise in a credit line to the material. 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This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Akira Akabayashi Department of Biomedical Ethics University of Tokyo, Faculty of Medicine Tokyo Japan To Aru, the only one who will inherit my genes. vii Acknowledgments I offer my sincere thanks to the many who offered scholarly insight at various points in preparing this book. Specifically, I thank Drs. Deborah Zion, Victoria University, and Eisuke Nakazawa, the University of Tokyo. I also thank Mr. Katsumi Mori, Ms. Fumiko Kan, and Ms. Asuka Naramoto of the University of Tokyo for their technical assistance. In addition, I really appreciate the con- tinuous support of my family while I was writing this book: Aru, Mahoko, Noriko, and Kan. The publication of this book was partly supported by grants from Pfizer Health Research Foundation and Mitsubishi Foundation. Copyright: Images on pages, 116, 117, Getty Images; Images on pages 28, 95, Chinatsu Hagino; Images on pages, 102, 103, Asahi Shimbun Photo Archive. viii Acknowledgments ix Global bioethics has a short history. Van Rensselaer Potter was the first person who coined the term bioethics back in 1970, using it to describe the global “science of survival” [1, 2]. The term global bioethics has a shorter history and is now used widely in academic journals, such as the Journal of Global Bioethics, as well as in many books, including the Encyclopedia of Global Bioethics [3] and the Handbook of Global Bioethics [4]. The term is also used by nonprofit organizations such as the Global Bioethics Initiative . Notably, most of the conceptual frameworks used within this field such as “human rights,” “human dignity,” and “distributive justice” are all part of a Western ethical paradigm. In their foundational paper, Potter and Potter [5] note that the goal of global bioethics is “acceptable survival.” They state that “(a) acceptable survival is a long-term concept with a moral constraint: worldwide human dignity, human rights, human health, and a moral constraint on human fertil- ity.” Human dignity and human rights are two key terms used in Western thinking, but it is unclear whether these concepts will be relevant in the future. In the preface to The Future of Bioethics: International Dialogues [6], I wrote the following: Most studies in bioethics advocating East-West dialogue have either attempted cross-cul- tural comparison or proposed Eastern philosophical paradigms as a counter to Western ideas. The tacit premise of previous writing on East-West dialogue is therefore a strain of relativism. From the Eastern perspective, Western views are treated as a cultural construct that should be referenced as models, but are not appropriate to be utilized in their existing form. To Westerners, Eastern interpretation represents ways of thinking that should be rec- ognized but can never truly be understood in their complexity within Western cultures. For this reason, Asians place Western conceptions of bioethics on the critical chopping block, and approach them as something to be overcome. In contrast, although Westerners occa- sionally comment on current conditions in Asian countries, they rarely fully engage with bioethical discussions led by Asian researchers, and neither express agreement nor fully critique such views. In a globalized world, simply maintaining a respectful distance from other cultures is no longer sufficient. Furthermore, as stated by the former president of International Association of Bioethics (Campbell AV) [7], “(b)ioethics is not merely a Western philosophical pastime, but is a discipline that unites East and West, North and South in a common Introduction x quest for solutions to the countless moral dilemmas of modern medicine and evolv- ing biological sciences.” Thus “global bioethics recognizes the importance of the local while thinking globally” [8]. It is therefore imperative to begin to listen more intently to the thoughts and perspectives about the values of those in other countries, regions, and cultures. The time has come for us to engage in an active discussion of our different cultural perspectives, in which attentive listening, rather than simply hearing, is the main objective. One scholar of Japanese cultural studies wrote the following [9]: Ever since Japan formed its own civilization..., it has consistently been plagued by the fate of comparing and scrutinizing its own civilization with those of other continents... Beginning with literature, and ranging through policies, philosophy and religion, Japan has borrowed from other countries ..... in such a way that its own customs and cultures are often changed, and its own frameworks are processed so that they can coexist or fuse with oth- ers.... After the Meiji era, the target against which Japan compared itself simply changed from China to the West; the exact same process was adapted and has been applied continu- ously to this day. (Translated by the author) Bioethics was born in the West—more accurately, the United States—during the second half of the twentieth century. The present text shares with the reader Japan’s encounter with this Western concept of bioethics and its cohort of ethical issues, and how it has found its position as it decides where it stands, what it should accept, and what it has rejected (either openly or silently). Beginning with a brief history of bioethics in Japan, I introduce a variety of topics. I use my own writings and weave specific experiences from Japan into the narrative. This book may become a valu- able source of information for those specializing in Asian or Japanese research, but it is in no way meant to be an introductory text about Japan itself. In the last chapter, I present my own views on current global bioethics discus- sion. I go so far as to propose discarding the overarching term of Global Bioethics. Instead, I propose a more challenging term to accommodate future discussion. True Global Bioethics has yet to be born, and the longer we continue to limit ourselves to the use of concepts and methodologies from the West alone, the longer Global Bioethics will remain in stasis. As many scholars have proposed, a dialogue that encourages both local and global thinking is needed. I believe that such a dialogue must be enabled by mutual understanding or, at the very least, a healthy attitude and sincere effort toward obtaining it. This book is intended to serve as a tool to promote this. Once the book has been read, the reader’s understanding of Japan will be deeper than when he or she began. Lastly, but most importantly, this book is open access. Many of the articles cited in this text are also open access. Thus, readers from LMICs (low to middle income countries) as well as students and laypersons can read them for free. I urge all who read this book to write their own story for their own country to add to this dialogue. In this regard, this is not an introductory book on Japan, but rather the beginning of the series comprising many other narratives to come which will serve as tools that will facilitate the international and mutual understanding we require to initiate genuine dialogue. Introduction xi • As noted above, I cite many of my own papers in the text. Many of them are open access, which means that they are available for free on the Internet. I have tried to high- light the essence of those papers in this text. I recommend that readers read the book before reading the open-access articles in depth, as this will facilitate a much better understanding of the overall narrative. To read open-access papers, from Google, go into “PubMed” and search for “Akabayashi.” The free articles will be marked in orange. Clicking on the title will present the Abstract, and the full text can be read by clicking on “free article.” PDF files can be downloaded if necessary. References 1. Potter VR. Global bioethics: building on the Leopold legacy. Michigan University Press: Michigan; 1988. 2. Potter VR. Getting to the year 3000: can global bioethics overcome evolutions fatal flaw? Perspect Biol Med. 1990; 34:89–97. 3. Encyclopedia of Global Bioethics ten Have H ed. Switzerland: Springer International Publishing; 2016. 4. Handbook of Global Bioethics ten Have H, Gordijn B eds. Dordrecht: Springer Science + Business Media; 2014. 5. Potter VR, Potter L. Global bioethics: converting sustainable development to global survival. Med Glob Surv. 1995; 2:185–90. 6. Akabayashi A. Preface. In Akabayashi A, editor. The future of bioethics: interna- tional dialogues, Oxford: Oxford University Press; 2014. pp. v–vi. 7. Campbell AV. Presidential address: global bioethics – dream or nightmare? Bioethics 1999; 13:183–190. 8. Widdows H, Dickenson D, Hellstein S. Global bioethics. New Rev Bioeth. 2003; 1:101–116. 9. Okubo T. Genealogy of theory of Japanese culture. Chuo-Kohronsha, Tokyo, 2003, pp. i–ii. (in Japanese). Introduction xiii Contents 1 A Brief History of Bioethics in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Phase I: Introduction (1980–1999) . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1.1 Brain-Death and Organ Transplantation . . . . . . . . . . . . . . . 2 1.1.2 Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1.3 Issues with End-of-Life Medical Care and Euthanasia . . . . 3 1.2 Phase II: Development (2000–2010) . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2.1 On the Moral Status of the Embryo . . . . . . . . . . . . . . . . . . . 4 1.2.2 Systematization of the Enactment Processes for the Life Sciences and Medical Care . . . . . . . . . . . . . . . . 4 1.2.3 Ethics Education in Medicine and in Research . . . . . . . . . . 5 1.3 Phase III: The Recent Past (2011–Present) . . . . . . . . . . . . . . . . . . . 5 1.3.1 Enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.3.2 Neuroethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.3.3 Ethical Issues Surrounding Regenerative Medicine . . . . . . 7 1.3.4 Public Health Ethics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.3.5 Precision Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.4 The Future of Bioethics in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5 Before Moving on to the Main Chapters . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2 Brain-Death and Organ Transplantation: The First Japanese Path . . . 13 2.1 Enactment of the Organ Transplantation Law (OTL) . . . . . . . . . . . 13 2.2 The First Organ Transplant from a Brain-Dead Donor . . . . . . . . . . 15 2.3 Twenty years After the 1997 OTL Enactment . . . . . . . . . . . . . . . . . 16 2.4 Is Japan Moving in the Right Direction? . . . . . . . . . . . . . . . . . . . . . 19 2.5 Living Donor Organ Transplantation . . . . . . . . . . . . . . . . . . . . . . . . 21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3 Informed Consent, Familism, and the Nature of Autonomy . . . . . . . . 27 3.1 Nature of Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.2 Prognosis Disclosure: An Unresolved Issue . . . . . . . . . . . . . . . . . . 32 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 xiv 4 End-of-Life Care, Advance Directives, Withholding and Withdrawing Life-Sustaining Treatment, and the Goals of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.1 Advance Directives (AD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4.1.1 AD: A Global Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.2 Withholding and Withdrawing Life-Sustaining Treatment (Especially Artificial Ventilation). . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.2.1 Legal Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.2.2 Cultural Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.3 Subtle Changes in the Goals of Medicine . . . . . . . . . . . . . . . . . . . . 41 Original Article . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 The Goals of Medicine: Time to Take Another Look . . . . . . . . . . . . . 42 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5 The Moral Status of the Embryo: The Second Japanese Path . . . . . . 47 5.1 Neither a “Person” nor a “Thing”: The Controversy Concerning the Moral and Legal Status of the Human Embryo in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5.1.1 The Bioethics Committee of the Council for Science and Technology . . . . . . . . . . . . . . . . . . . . . . . . . 48 5.1.2 The Subcommittee on Human Embryo Research . . . . . . . . 49 5.1.3 “The Sprout of Human Life” . . . . . . . . . . . . . . . . . . . . . . . . 50 5.1.4 Consequences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.2 The Issue of Abortion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 6 The Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant Accident . . . . . . . . . . . . . . . . . . . . . . . . . 55 6.1 Lack of Transparency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 6.1.1 Closedmindedness, Impenetrability and Secrecy Are Significant Characteristics of Japanese Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 6.2 The Fukushima Thyroid Screening Study . . . . . . . . . . . . . . . . . . . . 57 6.3 Why Less Scientifically Meaningful Data? What About the Victims? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 6.3.1 Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 6.4 Animal Ethics and Intergenerational Ethics. . . . . . . . . . . . . . . . . . . 60 Original Article . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 7 Outcome Egalitarianism and Opportunity Egalitarianism . . . . . . . . 69 7.1 Medical Care and the Social Welfare System . . . . . . . . . . . . . . . . . 69 7.1.1 Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 7.1.2 Social Welfare: Public Livelihood Assistance and Pensions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Contents xv 7.2 The Education System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 7.3 Taxation, Salaries, a Stimulation Policy, and Equal Burden on Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . 71 7.3.1 Income Tax and Salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 7.3.2 Restoration Tax Following the Great East Japan Earthquake and Fukushima Nuclear Power Plant Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 7.3.3 A Stimulation Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 7.4 Japanese Socialism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 8 Research Regulations, Ethics Committees, and Confronting Global Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 8.1 Governmental Guidelines or Legislation? . . . . . . . . . . . . . . . . . . . . 75 8.2 Ethics Committees in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 8.2.1 Number and Status of Ethics Committees . . . . . . . . . . . . . . 76 8.2.2 Ethics Committee Members and Their Roles . . . . . . . . . . . 78 8.3 Enforcement of the Clinical Research Act . . . . . . . . . . . . . . . . . . . . 80 8.4 Scientific Misconduct in Research: Cultural Perspectives on Criteria for Authorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 8.5 Conflict of Interest in a Society Supported by Fiduciary Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 8.6 An Addendum: Hospital Ethics Committee and Clinical Ethics Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 8.6.1 Clinical Ethics Consultation . . . . . . . . . . . . . . . . . . . . . . . . 83 8.6.2 University of Tokyo Model: Patient Relations and Clinical Ethics Center (PRCEC) . . . . . . . . . . . . . . . . . . 85 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 9 Modern Medical Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 9.1 The Diversity of Medical Professionalism. . . . . . . . . . . . . . . . . . . . 89 9.2 Difficulties in Teaching Medical Professionalism to Young Students and Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 9.3 Emerging Issues in Medical Professionalism . . . . . . . . . . . . . . . . . 94 9.4 On the Happiness of Medical Caregivers. . . . . . . . . . . . . . . . . . . . . 95 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 10 What Does It Means to be Truly “Interdisciplinary”? . . . . . . . . . . . . 99 Original Article . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Do Professional Athletes Have the Right to Dispute a Referee’s Judgment? An Ethical Analysis of Sumo Wrestling in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 The Yokozuna Hakuho Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Contents xvi 11 Rebirthing Bioethics: Going Global . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 11.1 The UNESCO International Bioethics Committee . . . . . . . . . . . . 114 11.2 International Health (Global Health) . . . . . . . . . . . . . . . . . . . . . . . 115 11.3 Van Rensselaer Potter, Inventor of Bioethics, his Acceptable Survival, and Anthropocentrism . . . . . . . . . . . . . . 118 11.4 Universalism Versus Relativism . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 11.5 Bioethics Across the Globe (BAG) . . . . . . . . . . . . . . . . . . . . . . . . 121 11.6 What Can Japan Contribute to BAG? . . . . . . . . . . . . . . . . . . . . . . 122 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Case I: A Japanese Patient in the Late 1980s . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Case 2: An American Patient in the 1990s . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Case 3: Mr. K, a Japanese Patient in 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 In What Sense Is the Family-Facilitated Approach Consistent or Inconsistent With Patient Autonomy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Relational Autonomy and the Family-Facilitated Approach. . . . . . . . . . . . . . . 140 Informed Consent Revised: A Global Perspective . . . . . . . . . . . . . . . . . . . . . . 143 Contents xvii About the Author Akira Akabayashi, MD, PhD, is a Professor in the Department of Biomedical Ethics at the University of Tokyo, Faculty of Medicine, Tokyo, Japan, and an Adjunct Professor of the Division of Medical Ethics at New York University School of Medicine, New York, NY, USA. His research interests span cross-cultural bioeth- ics, global bioethics, medical/clinical ethics such as informed consent, organ trans- plantation, end-of-life issues, medical humanities, including professionalism, public health ethics, research ethics, and bioethics policy making. As an academic researcher, he has published more than 200 original articles and more than 20 books/textbooks or chapters in English, in addition to many Japanese publications. These include the English textbook Biomedical Ethics in Asia: A Casebook for Multicultural Learners , McGraw-Hill Education, 2010. As an educa- tor, Professor Akabayashi has taught bioethics/medical ethics for over 25 years. Professor Akabayashi has served as the chair of the Research Ethics Committee at the Kyoto University Faculty of Medicine and the University of Tokyo Faculty of Medicine for more than 15 years. He is also the Founding Director of Office for Human Research Studies where he conducts research ethics consultation at the University of Tokyo. Professor Akabayashi has also been engaged in clinical ethics consultation as the Founding Director of the Clinical Ethics Center at the University of Tokyo Hospital. A part-time physician, he has worked in hospice care for ten years. Outside Japan, he has served as a member of UNESCO’s International Bioethics Committee and was a board member of the International Association of Bioethics. He is currently a member of the International Advisory Board, Oxford Centre for Practical Ethics, Oxford. Professor Akabayashi serves as an editorial advisor for several international bioethics journals such as Journal of Medical Ethics, Cambridge Quarterly of Healthcare Ethics, BMC Medical Ethics , and Asian Bioethics Review and is a founding editor of the CBEL Report Professor Akabayashi established the first Bioethics Center in Asia (University of Tokyo Center of Biomedical Ethics and Law: CBEL, www.cbel.jp) in 2003. This center was acknowledged as a Global Center of Excellence in Japan, highlighting his strong leadership. This leadership is also reflected internationally, through xviii Professor Akabayashi’s establishment of the Global Alliance of Biomedical Ethics Centers (GABEX) that comprises world-class bioethics centers including The Hastings Center, USA, and the Ethox Center, Oxford University, UK. Work done by this network has resulted in a book The Future of Bioethics: International Dialogues, edited by Professor Akabayashi (Oxford University Press, Oxford, 2014). His cur- rent interest focuses on global bioethics, expanding dialogues among bioethics researchers throughout the world. He has also been honored as a Fellow of The Hastings Center (USA) in 2008. He was elected as the President of Japan Association for Bioethics in 2017. Disclaimer: Professor Akabayashi is President of the Japan Association for Bioethics (JAB); however, this book reflects the author’s personal academic analy- ses and opinions. It does not represent JAB’s official position. About the Author 1 © The Author(s) 2020 A. Akabayashi, Bioethics Across the Globe , https://doi.org/10.1007/978-981-15-3572-7_1 Chapter 1 A Brief History of Bioethics in Japan Abstract In this chapter I look back at the history of bioethics in Japan, which can be divided into three phases: Phase I, Introduction (1980–1999); Phase II, Development (2000–2010); and Phase III, the Recent Past (2011–present). Phase I marks the period when the concept of bioethics that originated in the West came to Japan. It was also when Japanese society faced its first difficult bioethical issues: namely brain-death and organ transplantation. Other issues emerged during this period, particularly pertaining to death, such as end-of-life medical care and eutha- nasia. In Phase II, the problems shifted to those pertaining to the beginning of life, such as the moral status of the human embryo. As well, during this period the gov- ernment implemented ethical guidelines for research ethics. During this period, social awareness of bioethics increased, and bioethics education began to appear not only medical education, but also within high school curricula. In Phase III, Japan began to tackle its own ethical issues, such as enhancement, regenerative medicine, neuroethics, public health ethics, and precision medicine. Some of my thoughts concerning projections for the future are discussed at the end of this chapter. In this introductory chapter, I consider the current period (ca. 2020), look back on the history of bioethics in Japan over the past 40 years, and finally, look briefly toward the future. First, I present an overview of the types of problems that have been handled in the fields of bioethics and medical ethics in Japan since the 1980s. I begin my discussion in this era because modern bioethics began its development in Japan in the early 1980s. I divide this time period (beginning in the early 1980s until around 2020) into three parts, corresponding to Phase I, Introduction: 1980–1999; Phase II, Development: 2000–2010; and Phase III: the Recent Past (2011-present). No significant distinction is intended between use of the terms “bio- ethics” and “medical ethics.” For full description, refer to references [1–3]. This chapter is a brief summary of those three papers and some further considerations. 2 1.1 Phase I: Introduction (1980–1999) Bioethics is said to have been born in the USA in the 1960s. In the early 1980s in Japan, bioethics literature was introduced and texts were translated from English, primarily at universities and other academic institutions. My own interest in issues such as euthanasia, dying with dignity, disclosing a cancer diagnosis, abortion, and genetic manipulation developed when I was a medical student in the 1970s. I did my best to learn about these subjects, but at the time, Japan had no academic field equipped to handle these types of problems. While attending an exchange event at the Japan-America Student Conference, an American student informed me, “You are interested in a field called bioethics.” This was the first time I heard the term “bioethics.” In 1979, Beauchamp and Childress published their first edition of the Principles of Biomedical Ethics ; this was concurrent with bioethics being estab- lished as an academic field in the USA. 1.1.1 Brain-Death and Organ Transplantation In Japan, the issue of brain-death and organ transplantation was highly influential to the development of bioethics (see Chap. 2). Beginning in the 1980s, nationwide debates began as to whether brain-death constituted human death, and whether organ transplantation from a brain-dead body should be permissible. These issues were discussed in medical circles, religious groups, political groups, the media, and among the general population. With the establishment of a commission on brain- death, and the 1997 enactment of the Organ Transplantation Law, organ transplanta- tion from a brain-dead body was finally deemed permissible, with strict conditions. Specifically, the clear and written expression of the intent to donate from the organ donor (15 years or older) as well as the family’s consent were both required. Politically, this marked a major milestone. Several positive outcomes were achieved, including discussion on the definition of death and Japanese views on life and death; this set a healthy tone for how bioethical arguments should be handled in Japan from that point forward. 1.1.2 Informed Consent At about the same time, the idea of informed consent began to emerge as an issue in clinical settings (see Chap. 3). Informed consent in the clinical context entails an act in which “medical caregivers provide sufficient explanation to those with sound judgment capacity and ensure that the patient understands, while the patient then offers consent of their own volition.” Today this is considered common protocol, but such was not always the case in Japan. There was even extensive debate on how to 1 A Brief History offiBioethics infiJapan 3 translate the English term “informed consent” into Japanese; today, the term “ info- mudo konsento ” is used, but is presented in katakana , the phonetic alphabet used for foreign terms and names. In the course of this discussion, those arguing to protect patient autonomy, basing their arguments on self-determination and the right to know, were in a dominant position. Others countered that argument, stating that prioritizing individual autonomy so heavily is unsuited for Japan. However, an explanation of the patient’s condition has now been systematically added to the treatment plan at the time of hospital admission and discharge, such that it is cov- ered by health insurance [4]. Informed consent is therefore a common theme that has been integrated into medical care. This flow of events necessitated a change in paternalism among physicians. It also led to the medical record disclosure system based on the Private Information Protection Law in 2003. 1.1.3 Issues with End-of-Life Medical Care and Euthanasia One other major event during Phase I was the 1991 Tokai University Euthanasia Incident. In this case, a physician, in response to a clear request from the patient’s family, administered potassium chloride (KCl) to a terminal cancer patient [5]. He was found guilty of murder and given a suspended sentence by the Yokohama District Court in 1995. The trial was an unprecedented case in which a doctor per- formed euthanasia. As the court decision presented the conditions that would allow for active euthanasia in the obiter dictum, it was erroneously relayed to other coun- tries that active euthanasia was legally permissible in Japan. Reports of physician- assisted suicide emerged from abroad, and terms such as euthanasia, mercy killing, and dying with dignity were used without clarity. Currently in Japan, the act of a medical caregiver administering muscle relaxants or KCl to a patient, leading to the latter’s death, carries with it a high probability that the medical caregiver will be placed on trial for murder. Notably, unlike several other countries, Japan has not legalized active voluntary euthanasia. In addition, with the increased popularity of hospice or palliative care, fewer cases of “withholding treatment” requested ahead of time by patients are legally problematic. However, the issue of “treatment with- drawal” (removal of an artificial respirator) from a terminal patient has yet to be subject to legal resolution (see Chap. 4). 1.2 Phase II: Development (2000–2010) There are three characteristics of Phase II. First, the topics of discussion shifted from issues pertaining to the end of life (brain-death, end-of-life medical care, and euthanasia) to those dealing with the beginning of life, particularly the moral status of the embryo and problems related to reproductive medicine. Second, numerous policy guidelines and legislation were produced in the fields of life sciences and 1.2 Phase II: Development (2000–2010) 4 medical care, paving the way for the establishment of a framework for policy deci- sions. Third, bioethics came to be socially acknowledged in the fields of medical education and research. 1.2.1 On the Moral Status of the Embryo In the second phase, topics in medical ethics shifted to issues pertaining to the beginning of life. Among them, the heightened discussion surrounding the moral status of the human embryo became particularly significant. At this time, research on embryonic stem cells (hereafter, ESCs) had become widespread. Human ESCs have the capacity to differentiate into all kind of tissues and all cell types, and there was great hope for these cells in the field of regenerative medicine. However, in order to create human ESCs, one must destroy a fertilized egg (embryo) that has the capacity to become a human individual in the future. If one perceives that human life is present in an embryo, then this type of use of embryos cannot be approved. In 2004, the Council for Science and Technology Policy and the Experts Panel on Bioethics compiled the document “Basic Principles Concerning the Handling of Human Embryos.” This document stated that the human embryo is not a person per se, but it is also not an object. The document instead uses the phrase, “sprout of human life.” The writers conclude that a human embryo is worthy of respect and requires careful handling (see Chap. 5). Fundamentally, “The Guidelines for Derivation and Utilization of Human Embryonic Stem Cells” and “The Act on Regulation of Human Cloning Techniques” take the same stance as “The Basic Principles Concerning the Handling of Human Embryos.” Given that the moral sta- tus of the human embryo is a topic of deep religious and political debate in other countries, it seems that Japan has actually handled this issue with relative ease. However, it remains a mystery as to why abortion—another debate that should be begging many questions about the moral status of an individual prior to birth—did not gain as much momentum as that surrounding the human embryo. 1.2.2 Systematization of the Enactment Processes for the Life Sciences and Medical Care At the end of the twentieth century, numerous governmental ethical guidelines (Ethical guidelines for human genome/gene analysis research, Ethical guidelines for epidemiological research, and Ethical guidelines for clinical research) as well as a number of laws (The Organ Transplant Law, The Act on Regulation of Human Cloning Techniques) came into the fields of life science and medical care. Many of these were drafted by governmental review boards or committees. These drafting sessions came to include medical and legal specialists as well as ethicists, and representatives from the general public such as journalists. By this time, a new 1 A Brief History offiBioethics infiJapan