IV. JAPAN. B. CONTEMPORARY JAPAN

Due to Japanese society and its distinctive historical understanding of medicine and the role and responsibilities of the physician, it was not until the 1960s that the bioethical and sociolegal concerns about the practice of medicine began to be deliberately reflected, and only during the 1980s that the notions of autonomy and rights in medicine, and of bioethics in general, became gradually influential (Kimura, 1979, 1987a, 1987b).

In the long tradition of Japanese medical practice, the Confucian notion of jin (benevolence) has been one of the most important ethical elements; medicine itself is known as jinjyutsu (the art of jin). Physicians, as conduits of jin, were required to act with benevolence toward their patients and were responsible for the welfare of patients in a fiduciary (trust) relationship (Kimura, 1991a). It was obligatory to use medicine, a gift of benevolence, for the good of others even without payment. Physicians fulfilled their responsibility toward their patients and the patients' family members by acting in a paternalistic and authoritative way; the Japanese, nurtured in the Confucian ethos to respect law, order, authority, and social status, acquiesced without murmur to the superior knowledge of the physician.

Traditionally, the socially reinforced mentality of thinking of oneself as a member of a group rather than as an individual could be seen as one key element to understanding the sense of "related-ness" in the Japanese society (Doi; Mitchell; Johnson). This unique character can be interpreted in the framework of "related-autonomy" or the making of autonomous decisions in relationship striving for harmony (wa) with other people in the Japanese cultural bioethics. The sense of relatedness and codependence extend to all living beings and to one's bond with the environment.

In keeping these twin notions of related-autonomy and harmony (wa) in mind, this entry will discuss the contemporary Japanese approach to various issues and problems of bioethics, in light of the social, cultural, and historical milieu in three stages of chronological development.

Confucian Virtues in a Paternalistic Medical Tradition (1868–1937)

In 1868, feudal samurai in particular han (local provinces), such as Satsuma, Choshu, 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 (jiyuu-minkin undo) 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).

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 medicine (waho) and Chinese medicine (kanpo) 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).

As capitalism became established in Japan, 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 though 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).

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 Koseisho, the Ministry of Health and Welfare, in 1938. The National Health Act and additional laws protecting factory workers were promulgated that 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 Koseisho was to strengthen the health of the nation to wage war. Similarly, the National Eugenic Law of 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. 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.

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. But 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; Williams and Wallace).

Official documents exchanged between the United States and U.S. General Headquarters in Japan, now declassified and 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 the corps chief, on the condition that all related medical records and specimens be handed over to the United States (Kimura, 1997). 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).

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 Shusaku Endo, titled Umi to dokuyaku (1960), in which he dramatically depicts 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 (Kimura, 1997).

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 terms 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."

After the defeat of Japan, one of the first pieces of legislation implemented was the Eugenic Protection Law of 1948. Unlike the National Eugenic Law that it abolished and the Japanese Criminal Code, which since 1907 had held abortion illegal, the 1948 law permitted abortion for medical, and later for social and economic, reasons. Under the Japanese Criminal Code, abortion for other reasons remained a prosecutable offense. Nevertheless, because of vigorous opposition from advocates for the disabled, the new law 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, 1987a, 1987b). MacArthur defended the policy, saying that it had arisen from and was implemented by the Japanese Diet.

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 that were stored at the U.S. Atomic Energy Commission (AEC). 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 AEC is in fact the forerunner of the U.S. Energy Department, which initiated the Human Genome Project in the early 1980s on the basis of the voluminous data from the survivors of Hiroshima and Nagasaki (Cook-Deegan).

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 in medical practice of the ancient principle of jin, the benevolence of Confucian teaching, 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 the 1960s Japanese society felt the effects of the worldwide trend 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 (1969–2000s)

Toward the end of the 1960s, numerous social issues competed for attention in Japan. Health-related issues that drew increasing notice included air and water pollution, food additives, iatrogenic diseases (diseases caused by physicians), and the revival of kanpo (traditional Chinese medicine). There was also an increased emphasis on health. The growing number of older people focused attention on the need for healthcare for the elderly. Japan has been one of the most successful countries in decreasing the birthrate, and life expectancy in 2001 was the longest in the world, nearly eighty-five years for women and just over seventy-eight years for men (Minstry of Health, Labour, and Welfare). In 1997 the Long-term Health Care Insurance Law for the Elderly was enacted to create national mutual support systems for the elderly, who were traditionally cared for mainly by the family in the community. Advances in medical technology and healthcare have raised additional issues for the Japanese medical profession and society in general. The period from the late 1960s to the early 2000s has seen increased 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; it was combined with a law governing kidney transplantation in 1979.

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 with heart failure. The patient died after eighty-three days. A surgeon at Sapporo Medical College, Juro 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. The aftermath of this case, however, 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 for the benefit of the patient.

This incident spawned the Patients' Rights Declaration in 1970 (Owatari et al.). 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.

In 1997 the Law on Transplantion went into effect. This law, reflecting the legal and ethical uniqueness of the Japanese situation, makes harvesting organs difficult because of two rigid consent provisions. The first provision is the requirement for advanced consent in accepting brain death. The "brain death criteria for death" box must be checked on the donor card, expressing the intention of the organ donor when alive. The second provision is the requirement for the consent of the family for harvesting organs from a brain-dead body. Article 6, Section 1, allows organ donation "in the event that a deceased person had during his lifetime expressed in writing his intent to donate organs to be used for organ transplants." Section 3 of the same article also states that "when the donor during his lifetime had expressed in writing his consent to the diagnosis—made based upon the provisions—and his family, informed of the removal, did not object to the diagnosis," organ transplants can be legally permitted (Kimura, 1998).

This law is supposed to promote—by endorsement—organ transplantation. From enactment through early 2003, however, Japan has had an only a small number (twenty-three) of organ transplants. Furthermore, these two elements of ethical and legal rigidness have made the enactment of more relaxed applications—such as allowing organ transplants involving infants—almost impossible to perform.

CRITERIA FOR DEATH. Leading objections to brain-death criteria are the fears 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 (those born without a brain or without a major part of the brain) 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. Nevertheless, the use of organs from anencephalics has not been officially reported since 1981, because of clinical concerns about the condition of the organs from such donors and public concerns about the appropriateness of such practices (Kimura, 1989a).

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 as being composed of distinct and separate units of mind, body, and spirit. This mind–body unit, according to the Japanese, 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). 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 regard the extension of life by accepting organs from another individual's body as unnatural and unethical, because 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 (Tamaki; Fujii). The basis for the uneasiness in accepting brain criteria for death and organ transplantation thus comes from both Confucian and Buddhist thought, which incorporate some ideas from Japanese traditional folk religions and Shintoism.

EUTHANASIA. Media coverage has made euthanasia one of the most debated topics in Japanese bioethics. The Japanese Euthanasia Society was established in 1976 (and was later renamed the Japan Society for Dying with Dignity [JSDD]), and the first international conference on euthanasia was held in Tokyo that same year. The Ninth International Conference of the World Federation of Right to Die Societies was organized by the JSDD and held in Kyoto in 1992. No legally established procedure for euthanasia 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. 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).

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, the court's ruling 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 sole purpose of the act must be to relieve the patient's suffering;
4. a sincere request and permission are required from competent patients;
5. in general, the act should be performed only by physicians; and
6. an ethically acceptable method must be used.

The Nagoya High Court ruled that, although the first four criteria had been met, the final two conditions had not. The son was sentenced to four years' imprisonment with three years' suspended sentence.

In the light of medical and technological advances, the conditions once considered fatal can now be treated effectively or even cured. Better methods of pain control have been developed, and new centers for palliative care have been developed.

The ruling of Yokohama District Court on March 28th, 1995 is significant for its clear statement of the principle of individual autonomy based on the patient's own intention to stop treatment. In this case, the physician prosecuted for murder claimed he had a clear request from the patient's son to alleviate his father's suffering. Later, the son denied, when questioned, any intention to end his father's life. The ruling does not endorse familial decision making based on the presumed wishes of the patient, however, if the patient has communicated openly enough with family members about his or her view of life, character, and values, the family will be able to make a conjectural decision to end his or her life in a natural way without aggressive over treatment (Kimura, 1998).

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. In the 1980s, however, 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 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, Switzerland. The amendment enacted 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. 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, Kyoto, and Nagoya. By the 1980s, members of these groups participated as bioethics volunteers in medical service organizations. The nationwide concern with health and medical services in Japan led to a new declaration of patients' rights, which was issued in 1984 by a group of patients, lawyers, physicians, and journalists. 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 (Seikyo). 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 FOR ADVANCED MEDICAL RESEARCH. The first medical ethics committee in Japan was established at the Tokushima University School of Medicine in 1982 in order to review in vitro fertilization (IVF) technology and its application to infertile women. As of 2003, each of the eighty medical schools and major hospitals had its own medical ethics committee reviewing cases such as segmental liver transplantation, gene therapy, and embryonic stem cell research. Due to a lack of national legislation regarding these review committees for the advanced medical research, each has a different composition. With the exception of a few lawyers and ethicists, the majority of the committees are composed of the same medical faculty and are male.

In 1991 the Greater Tokyo Metropolitan Government established the first hospital ethics committee with membership of nonmedical practitioners, and the committee opened all its meetings to the public. This committee serves as a policymaking body for the fourteen hospitals operated by the Tokyo Metropolitan Government. One of the epoch-making outcomes of the committee was the adoption of the "Patients' Bill of Rights for the Hospitals of Tokyo Metropolitan Government" in 2001.

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 Japan Medical Association 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 800 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 the early 2000s, the Bioethics Committee of the Science and Technology Council (part of the Ministry of Education, Culture, Sports, Science and Technology) has been active on bioethical issues relating to biomedical research, such as cloning. The Health and Welfare Council of the Ministry of Health, Labour and Welfare is also dealing with bioethical issues, mainly relating to clinical medicine. These two ministries worked with the Ministry of Economy, Trade and Industry to prepare a document titled "Ethics Guidelines for Human Genome/Gene Analysis Research," which was released in 2001. They jointly made an official announcement of the Guideline in 2001 for the first time as a result of cooperative work in bioethics public policy in Japan.

BIOETHICAL TRENDS IN COURT DECISIONS, CODE OF ETHICS, AND LEGISLATION. One of the most controversial legal issues relating to bioethics in the 1990s was the revelation that HIV-contaminated blood products were used for hemophiliac patients without heat processing, resulting in around 1,600 people being infected with HIV. After more than seven years of legal struggle, the Ministry of Health and Welfare, pharmaceutical corporations, and the plaintiffs in the case agreed to a settlement involving a compensation fee of about 400,000 U.S. dollars per person.

In 1996 the Eugenic Protection Law was amended, and its name was changed to the Maternal Protection Law. In addition to deleting the word eugenic from the name, the new law eliminated all provisions related to eugenic operations, including the lists of genetic diseases that were the subject of eugenic operations, such as Hansen's disease (leprosy). The discriminatory Law for the Prevention of Leprosy, in effect since 1907, was abolished in 1996 following the initiation of legal action against the government of Japan. Later, in 2001, the Kumanoto District Court ruled against the Ministry for its responsibility and the government gave up the appeal. Diet members adapted an unanimous resolution on the issue of Hansen's disease expressing sincere remorse and apologized for committing human rights violations for over 90 years.

The bioethical principle of autonomy was strongly affirmed by a 1997 decision of the Tokyo High Court relating to a Jehovah's Witness who had been given a blood transfusion, a medical treatment forbidden by his religion. The decision was made in favor of the plaintiff, as he had not been told that he might be given a blood transfusion under certain circumstances. The notion of "informed consent" was thus taken seriously in legal terms in the context of religious beliefs and bioethical conflicts of decision making when life is at stake (Kimura, 2000).

In 2000, the Japan Medical Association adopted the "Code of Medical Ethics" in six provisions in simplified form. The emphasis on the public role of medical service and contribution to the society through medical works can be seen in provision five (JMA, 2000).

The social concerns facing the increasing number of elderly population and the need of mutual support systems by the local and state and government has led to the realization of "The Long Term Care Insurance Law " in 2000. This was the reflection of the shift in values from traditional ethos of family support to the mutual, societal support mainly to be managed by the community (Kimura, 2002; Ministry of Health, Labour and Welfare, 2003).

Toward Bioethics of Cultural Harmony: The Cloning Prohibition Law in Japan

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 in all areas of daily 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 traditional Japanese cultural practices. Bioethics has been proposed and developed in Japan as a supra-interdisciplinary endeavor embracing all traditional academic disciplines in equal partnership, for the valuable exchange of ideas and criticism each field has to offer (Kimura, 1986)

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 in Japan. 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.

The notion of harmony is reflected in Article 1 of the Law concerning the Regulation of Cloning Technologies and Other Similar Technologies Relating to Humans, which went into effect in June 2001. This article states that one purpose of the law is to "harmonize the society and peoples' lives with the development of science and technology."

In the international community of the twenty-first century, with the 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, it is useful to emphasize the twin notion of "related-autonomy" and the Japanese principle of harmony (wa) in cultural bioethics.

rihito kimura (1995)

revised by author

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