- Kenzo Hamano, Ph.D. Professor , Department of Philosophy, Kwansei Gakuin University, Nishinomiya, Japan
It goes without saying that bioethical issues do not exist in a vacuum. They are always surrounded by a particular socio-economic and political environment. For example, some features of important institutions in a society constitute the background of the bioethical issues and hence, influence the way to deal properly with such issues. Bioethical discussion must always take into consideration the socio-economic and political context of the issues in question. Otherwise, a bioethical discussion loses its connection with the real life situation, and may lead to results opposite to it aims. The situation is similar to that in which an idealized mathematical economic model that loses the connection with the messy, political-economic reality can make false economic forecasts and lead to disastrous policy decisions. Bioethics, which deals literally with matter of life and death, must make every effort to avoid as much as possible this kind of serious mistake by paying attention to the socio-economic and political context of the issues.
This socio-economic context becomes all the more important when we realize that bioethics is an expression of a society's attitude towards life. Bioethics also aspires to contribute to the society's effort to develop a proper attitude towards life. Hence, bioethics is both a reflection and a maker of the society's attitudes. Therefore, bioethicists must always remind themselves that they are handling something which is of extreme importance and fragility, that is, easily degradable. They must discuss bioethical issues with great caution.
What bioethicists must take into consideration is the attitude towards life of their society embedded in its socio-economic context. What I mean by "attitude towards life" of a particular society is not a general and invariant feature of the culture, but rather the attitude concretely manifested by major governmental policies especially social security policy, by the mores shaped by those policies, and by the characteristics of the major institutions, such as medical institutions, which are created in part by governmental policies. Accordingly, the attitude towards life of a society can change, that is, improve or deteriorate in accordance with economic and political factors, for example the economic situation and the hegemonic ideology. Finally, bioethicists also must make their best effort to contribute to the creation of the proper attitude towards life, which will orientate a society's deliberation of bioethical issues and produce concrete policy proposals with a clear understanding of the practical implications of their proposals in their own society.
The issue of whether euthanasia should be legalized in Japan requires exactly these considerations and precautions, especially because in Japan the concepts of self-determination and autonomy tend to be used to cover up the explicit and implicit socio-economic and political pressures upon individuals' decision-making processes. With the actors pretending those pressures do not exist; people's decisions are then treated as if they are in fact free and autonomous ones.
At first glance a person's autonomous decision must be respected and, if a person decides to seek for euthanasia or physician-assisted suicide, that decision certainly has a moral power. With that kind of moral power an autonomous decision of a person could be used as trump against any kind of the opposition to euthanasia. People may say a person himself said "yes", and who are you to try to overturn the person's autonomous decision concerning an extremely personal issue. Nevertheless, a person's 'autonomous decision' should not be accepted at face value without the examining the authenticity of that person's autonomy. Not all seemingly autonomous decisions are in fact authentically autonomous; there are many features of contemporary Japanese society that put significant pressures upon an individual to make a particular choice. In other words, those external pressures tend to make the other alternatives unrealistic or unacceptable and so constricts choice. Under certain circumstances, the presence of choice may be an illusion. As will be shown, there are realistic and serious reasons for being skeptical about the authenticity of a person's autonomous decision about the end of life in the Japanese medical system. Without this kind of a thorough examination of bioethical discussions become alienated from the real life situation of Japanese people.
The problematic features of Japanese society which put pressure upon people's end-of-life decisions are the persistence of doctors' paternalism in the Japanese medical system, the inadequacy of the nursing care system and the underdevelopment of hospice care. Doctors' paternalism leads to further problems such as the lack of sufficient communication between doctors and patients, especially about cancer diagnosis, the underdevelopment of pain control, and a dysfunctional team approach to patient care. In the following sections I will discuss these issues in this order. First, I will discuss the legally accepted view of euthanasia in Japan.
First, one should review a few basic facts about euthanasia in Japan. There is no law that recognizes passive or active euthanasia. However, there is an influential court decision (Yokohama District Court in 1995 on a mercy killing case at Tokai University) part of which contains a legal test under which active euthanasia is tolerated. Active euthanasia requires the following four conditions: 1) the patient's death is inevitable and imminent; 2) the patient is suffering from unbearable physical pain; 3) the doctor has already done everything possible to remove the pain; and finally 4) the wish of the patient to die has been made clear. Even in the abstract, these four conditions are problematic. For example, the rapid improvement of drugs to control pain has made unbearable physical pain very rare. If we focus on physicians' willingness to strictly comply with these conditions for active euthanasia, the situation is more worrisome. One major factor is paternalism.
In spite of the fact that the words such as "autonomy," "self-determination" and "informed consent" are often mentioned in a discussion of the doctor-patient relationship in Japan, the reality is far from what the frequent invocation of the words would suggest. Furthermore, after hearing these buzz words so often, some people tend to yield to the illusion that the values of autonomy, self-determination and informed consent are actually incorporated into and have became part of the Japanese medical system. In the Japanese medical system, doctors' paternalistic attitudes towards patients still persist and create many problems.
A) You cannot rely on your doctor to tell the truth about a diagnosis of cancer.
Doctors still often do not tell cancer patients the true nature of the patient's disease. Sometimes the doctor is inhibited by family members, who do not want the doctor to tell the patient the truth. The doctor, however, has significant discretionary authority to decide whether or not to the patient to tell the truth. Often doctors do not. The reason usually cited is that if informed, the patient would lose hope and die sooner than if kept ignorant. One hospice doctor stated that the rate of truth telling to the cancer patients in Hyogo Prefecture is about 30 %.
The revelation of the truth to the cancer patient is called "kokuchi" in Japanese. The word has an inescapably condescending tone built in it: a socially superior person does "kokuchi" to a person below. "Kokuchi" is not used to describe an action done between people on the equal footing. Hence, some people who push the cause of the democratization of the Japanese medical system urge discarding the word and adopting a better one. The persistence of the use of this word shows the true status of autonomy and self-determination in the Japanese medical system, and shows the danger of the uncritical use of those words.
B) You cannot easily extract sufficient information from your doctor.
Because of the prevalence of the paternalistic attitude of doctors and of the over-crowding in the hospitals and clinics, it is not easy to talk with your doctor for a long enough period of time in order to make an informed decision on the matters of life and death. For example, sixty-three percent of outpatients and fifty-four percent of in-patients wish to know the contents of their medical records, and out of them twenty-one percent of outpatients and the twenty-five of in-patients say that the reason is that they wish to know the true diagnosis of their disease, the state of their disease, and the nature of their treatment. The crucial condition for proper decision-making at the end of one's life, the flow of information between doctor and patient, is clearly not being met in the present Japanese medical system. There are admirable doctors, however, who try their best to change the status quo and to realize patient autonomy and self-determination in their own practice.
C) The Doctors' paternalistic attitude makes it difficult to create a real team approach to patient care.
Due to the rigid social structure in the Japanese medical system, another crucial channel of communication between patient and doctor via nurses and other health care providers does not work well. In the Japanese medical system, nurses are still undervalued and treated as second-class citizens in the medical community. Hence, conferences on individual cases are an occasion for doctors to convey their opinions to other staff members and there is no real, mutual consultation. As a result, crucial information can be lost. In fact, the lack of close communication among doctors and other medical staff often leads to the medical accidents, which, frequently covered by news media, feed people's skeptical attitude towards the medical system.
Hierarchy in the medical system prevents setting up a smooth communication channel among health care deliverers through which nurses can convey what they learned from daily contact with the patients. There is no ethos among doctors that encourages doctors to listen to what patients tell them with humane and professional humility. Such attitude must be inculcated in doctors during medical education; manifestly, it is not. Medical paternalism and the flaws of the medical education produce many serious problems in the Japanese medical system. The features of the Japanese medical system that are due to doctors' paternalism make it difficult for patients to make a reasonable and truly informed decision concerning the end-of-life treatment.
D) Japanese doctors are reluctant to use morphine to reduce the pain of terminally ill patients.
According to 1997 the International Narcotics Control Board (INCB) statistics with respect to the amount of the therapeutic morphine used per million people per day, Japanese doctors are clearly much more reluctant to use morphine to alleviate the pain of their patients in comparison with their counterparts in other developed nation, using on average 12.9 gram in comparison with Australia (101.9), Canada (92.8), UK (86.0), US (64.2), France (64.2) and Germany (16.8). The reluctance to use pain killers leads to unnecessary suffering and amplifies the patient's fear of the supposedly unendurable pain during the dying process. Paternalism and ignorance on the part of doctors are a deadly combination that gives the wrong reason for the legalization of euthanasia. In Japan, people think that one of the major reasons for euthanasia is an inevitable and unendurable pain as the accompaniment of dying process. This situation in Japan is in a striking contrast with the Dutch situation, illustrated by the fact that one survey shows only 5% of Dutch respondents cited pain as the possible reason for euthanasia.
Some people claim that doctors in Japan shy away from administering pain relievers because they are trained to prolong the patient's life as long as possible and try to avoid treatments which sabotage that purpose. The same fact, however, can be interpreted to show that Japanese doctors are not ready and concerned to know the feelings, opinions and preferences of their patients in order to accommodate those preferences as much as possible in their treatment. The ideal state summarized by the phrase that a "patient's will is a doctor's command" is far from the reality in the Japanese medical system.
Until now, the focus has been the persistence of the doctors' paternalism and the harm it causes. In the following I will discuss the socio-economic and political contexts surrounding the issue of euthanasia in Japan, which are shaped by the governmental policies. The key point is that the prospect for long-term care of the elderly is so bad that patients may "voluntarily" choose euthanasia or suicide.
A) Murder because of the burden of the nursing care (kaigo satsujin)
In Japan from time to time people read small articles in the newspaper on the murder of a nursing care recipient, often a bed-ridden person, by the nursing care giver and, sometimes, an article about double suicide of both the care giver and the nursing care recipient. The articles are short, because people have got so used to these kinds of incidents; they are not big news any more. This mundane quality to such tragedies is certainly not a healthy development. These avoidable human tragedies have not been dealt with seriously by the society as a whole. The government has not exerted itself to eliminate it by deploying proper resources in adequate amounts. Hence, the phrase "nursing care hell" (kaigo jigoku) is a part of contemporary Japanese language. The phrase expresses how difficult, exhausting and overwhelming is the nursing care of the elderly sick at home. That means that elderly sick could be treated inhumanly as commodities without human dignity. It can also mean that the care giver in a home-setting is exhausted physically and mentally, eventually destroying him or herself.
Unfortunately, because of the lack of publicly available statistics I cannot give a precise account of the scale of this problem with respect to elderly care, but the frequency of news items on these tragic cases suggests the number of cases is not negligible. I would point out that the fact that there are not any reliable statistics concerning this important problem shows the lack of concern on the part of public authorities, their attitude towards the life of people in trouble.
B) The new nursing care insurance system, which was supposed to deal with the distressing situations with respect to the elderly care, did not keep its promise.
The Japanese welfare system has traditionally relied on the mutual support of the family members, especially the unpaid labor of women. But the emergence of the nuclear family, the reduction of the family size due to the drop in the number of children, and the increase of women into the labor market have made the tradition of home care almost impossible. In post-war era, however, the western idea of welfare state was partially adopted by the Japanese government. That is, still the mutual support of family members is expected, but significant amount of public support started to be provided. As for the care of the elderly, the welfare of the elderly law was enacted in1963, and in 1973 the revision of that law made the medical care for the elderly (older than seventy) free. Thus, even if the policy of making the medical care for the elderly free was discarded eventually in1982, the post-war welfare system, although insufficient to say the least, gave an indispensable support to the family.
Nevertheless, the change of the structure of the Japanese family advanced more in 1980s and 1990s. As a consequence, the problem of the care of the elderly became large social issue. Nursing care insurance, which was introduced in April 2000, is the government's answer to this problem through what the government called "the socialization of the nursing care." The basic idea is that nursing care must be born not by the family but by the society as a whole. Two years after the start of this new system, however, a variety of problems showed up. In addition to operational problems (discussed below), a certain number of the critics of the system dispute the true motivation of the government in introducing the new system; they claim it was not "the socialization of the nursing care" but the reduction of the government's responsibility with respect to the welfare of people who need nursing care. That is, because of a chronic budget deficit, the government wanted to slash welfare expenses. By imposing cost sharing upon people in the form of the payment of insurance premium ("user pays" approach), the government succeeded in the cost cutting.
In the nursing care insurance system, the recipient must pay according to the benefits they enjoy, not according to their ability to pay as in the old social welfare system. Even a recipient who has such a low income that he obtains a waiver for residential tax still has to pay premiums in the new nursing care insurance system. Furthermore, the recipient has to pay 10% of the price of the services used. In Fukuoka Prefecture, for example, a recipient now has to pay two or three times more than before. Hence, people in need of care with low income are pressed not to use services more than under the old, social welfare system. Because recipients have to carry more burdens of the costs, poor people tend to hold back from using the services. So there is a retrogressive character in nursing care insurance system. An article in the Asahi Shinbun on January 17 of 2002 claimed that the government's new nursing care system is not tailored to the needs of its elderly users, of whom half use only one of its fourteen services.
As a consequence, nursing care has not really been socialized: the family still has to cope with the care of the elderly sick. The partial withdrawal of the government from the welfare means the continuation of the traditional reliance upon the family members, especially women. Nevertheless, as mentioned above, the structure of the Japanese family has irrevocably changed. The family whose size shrunk and whose women work outside cannot cope with the pressure of the nursing care of its elderly on its own. Tragedies are all too predictable. In fact, immediately after the start of the new system, on the very first day when the new system started actually, a woman in her nineties committed suicide because she knew she would become a greater burden on her family under the new system. That is, since the amount of the outside help would actually decrease in the new system, there would have been more work for the family. Even before the start of the new system, a man at the age of 72 committed suicide because he was afraid that he couldn't stay in the nursing home in the new system. Although their reactions may seem extreme, there is in such cases a real basis for these concerns. Two years after the start, complaints about the flaws in the new system are harsh and cannot be ignored.@
The attitude towards the life of the elderly who needs care, which is built into this new system, is not life-affirming and life-enhancing. On the contrary, people who need care are forced to perceive themselves as burdens to their families and society. In some instances they could feel guilty about being alive, that is, they feel like selfish parasites demanding self-sacrifice from other people. Not surprisingly, they feel they ought to sacrifice themselves and end their wretched lives. Without societal support people turn to self-sacrifice in this situation. This acquiescence to euthanasia and suicide should not be confused with an autonomous decision to end one's life. Rather, the range of rational choices of the sick has been unnecessarily narrowed by bad governmental policy and values. Within the artificially created narrow range of options, the elderly sick, falling back on an old cultural notion of self-sacrifice, which justifies and reinforces their forced choice, may hasten the end of their lives. But such decisions, springing essentially from the meager social context created by the government, cannot in any true sense be called "autonomous."
Japanese politicians, bureaucrats and executives, by the way, do not often show the so-called Japanese virtue of self-sacrifice. Their obstinateness and tough refusal when caught up in a scandal not to voluntarily reveal incriminating evidence, is born out of a ruthlessness of self-preservation, not so different from the tenacity of Enron executives. In Japan, all too often socially powerful miscreants can get away with their wrongdoings into prosperous old age. Only people who cannot get away with their bad behavior due to a lack of resources resort to the desperate action of self-sacrifice. I do not think that those tough Japanese politicians, bureaucrats and business executive are Americanized or non-Japanese; they just have enough power and privilege to keep their tough hides intact.
Furthermore, it should be never forgotten that the origin of the so-called Japanese virtue of self-sacrifice, the inculcation of this "traditional" virtue, arose as one of the main pillar of Japanese educational system during the Meiji era (1868-1912) and it was nurtured by successive authoritarian governments until the end of the Second World War. The Meiji government needed a populace, which are willing to sacrifice their lives for the state in order to realize quickly a country with much hard currency due to exports and a strong military. That is, this so-called traditional virtue is partly a consciously invented tradition. Even after the World WarUthe Japanese government never stopped fostering elements of the pre-war educational system in order to cultivate a nationalistic mentality complete with the virtue of self-sacrifice. Rather than permitting the present day government to play on this "tradition" to coerce "autonomous" decisions of the sick to remove themselves from society, Japanese society must do its best to change the situation in which socially weak Japanese are forced to express "the Japanese traditional virtue of self-sacrifice." That kind of self-sacrifice should be understood as the manifestation of the low quality of the Japanese attitude towards life, something to be ashamed of, not to be praised.
In the next section I will discuss in detail a case, which epitomizes the points that I try to make. In 1998 a mercy killing incident took place in Kawasaki City in Kanagawa Prefecture that showed that the flaws mentioned above could cause unnecessary tragedy.
In November 1998 " a fifty-eight year-old man suffered an asthma attack and was admitted to the hospital, where he remained in a coma after fifteen days, the attending physician removed an oxygen tube from the trachea of the man, who had difficulty breathing, and injected him with a tranquilizer and a muscle relaxant. The man promptly died.
Speaking through a lawyer, the attending physician said she removed the tube at the request of the patient's wife and children, to whom she had explained in advance that removal of the tube would cause the patient to die. The patient's oldest son, however, claims he had not been properly informed of the consequences of the removal. The doctor had injected muscle relaxant allegedly to liberate the patient from agonizing pain. An investigation of the incident disclosed that the doctor's behavior did not meet the four conditions for active euthanasia. The patient could in fact breathe without the help of the respirator. That is, his death was neither imminent nor inevitable. The hospital record stated that he could have lived at least six more months. Furthermore, while the patient was in coma for fifteen days, he did not suffer from the unendurable pain. Finally, the patient had not given his consent to the withdrawal of life-support. This case illustrates starkly the problematic aspects of the Japanese medical system pointed out above. Obviously, the doctor did not communicate with the family very well. She did not give full and explicit information about the condition of the patient and about the basic plan for the treatment of the patient. Nor was her explanation to them accurate.
As the doctor's disregard of the four conditions for active euthanasia shows, the doctor was not trained well in the end-of-life care. In addition, she allegedly said that the patient was 99% brain-dead when in fact the patient could breathe autonomously. The doctor also said that the patient was in the worst vegetative condition and should eventually be moved from the hospital, since hospital services would not be needed. According to the lawyer for the doctor, because the patient's family consulted with doctor about the economic aspects of the difficulty of caring the patient outside the hospital, the doctor thought the family did not wish the treatment to continue if the patient would become the burden on the family. This is exactly the feared, adverse effect of the legalization of euthanasia in Japan, that is, the difficulty of taking care of the patient who needs extensive help can make possible the collusion of the doctor and the patient, or the doctor and the family to eliminate the problem by euthanasia.
In this particular case the patient did not have opportunity to express his opinion and the family denied that they wished to terminate the treatment. According to the family's version of the case, the doctor misunderstood the real intention of the family. But the doctor, thinking her inference was valid, reasonable and acceptable, acted accordingly. Alas, such a doctor's understanding is not always mistaken: some family member want by authorizing euthanasia to avoid taking on their shoulders care made very burdensome due to governmental policies.
It is also significant in this case that the doctor made a decision to euthanise the patient single-handedly without input from the rest of the medical team. She did not consult with other doctors nor with the nurses about the overall plan of the end-of-life care of this particular patient. The nurse involved in the termination of treatment did what was ordered by the doctor without raising any question on the spot concerning the validity of the doctor's actions. Moreover, the doctor did not communicate to the family of the patient her intention and the meaning of her actions. Apparently, there was no informed consent. The fact that this problematic case was made public only three years after the actual event also shows the secretive and self-protective attitude of the doctors and hospital. These facts indicate the enormity of the power of doctors in the Japanese medical system. No effective counter force operates in the system. Hence, it can be said that doctors' paternalistic attitude is still predominant and accepted as the rule in the Japanese medical system.
Finally, I will discuss the underdevelopment of hospice care in Japan. Hospice care which is supposed to focus upon the quality of life of a patient during the end-life days can give a concrete alternative to euthanasia, but in fact in Japan it does not do so.
In Japan the population of which is 127 million, the number of hospices is 60 and the number of beds is about one thousand. Because the average stay in hospice is two months, the number of people who die in hospice is 6,000-7,000 per year. Contrast that tiny number with the fact that each year about one million people die in Japan, more than 250,000 of them dying of cancer. It is truly difficult for an ordinary Japanese person to take advantage of hospice care at the end of life. Moreover, the need of spiritual care has not been understood in Japan yet. Moreover, the basic purpose of hospice care, which is to help dying patients live comfortably and meaningfully to the end of their lives, has not been understood by many doctors. They regard hospice as the place for the patients to go to die a sort of warehouse. When the prognosis of patients is not good and there is nothing to do for them, doctors started to suggest the transfer of patients to hospice. The suggestion by doctors to go to hospice, without a sufficient explanation of what hospice care means, tends to be taken by patients merely as the declaration of imminent death. Consequently, the image of hospice in Japan tends to be very dark. In addition, home hospice care is truly insufficient: the inadequate nursing care insurance fails to deal with the sick elderly; all the more it fails people in need of hospice care in their homes. The Japanese hospice movement still has a long way to go.
Real choice is not yet possible in the Japanese medical system. Doctors' paternalism, which allows them not to learn and practice pain control, also stands in the way of effective communication with patients, their relatives, and other medical workers. These flaws in the Japanese medical system tend to make patients feel their lives not properly valued and respected. Hospice care, which could be a better alternative, is not easily available to the vast majority of people who desperately need it. Furthermore, flaws in the social welfare system lower the self-esteem of care recipients and can make the life of care recipients and their relatives miserable. This kind of environment produces guilt-feelings in the mind of care recipients and can lead to despair and ultimately the emergence of suicidal intentions. Under these circumstances, suicidal intentions must not be taken at face value. They may not be autonomous decisions but ones coerced by the misery of their environment. Therefore, life-affirming and life-enhancing environment must be created before euthanasia is legalized in Japan. At the very least, the government and society as a whole should make a great effort to promote the affirmative, enhancing attitude towards life that must be realized in concrete policies and the reform of major institutions, such as medical institutions. It is unrealistic and hypocritical to pretend that people can die peacefully at the end of their lives while people's lives at other stages and other aspects of their lives are treated without sufficient respect and consideration. Bioethicists must be very careful not to make a proposal that are reasonable in the abstract but disastrous in the reality, and must try to contribute to the establishment of the proper life-affirming and enhancing attitude towards life.
 Kenji Yamagata M.D., "The Human Rights of Patients: From the Viewpoint of Hospice Care" Lecture at Kwansei Gakuin University, June 28, 2000
 "The Outline of the 1999 Inquiry into the Use of Medical Services" (Heisei Jyuichi Nen Jyuryo Kodo Chosa no Gaiyo), The Ministry of Welfare and Labor http://www.mhlw.go.jp/toukei/saikin/hw/jyuryo/00/kekka-7.html
 "The Report the External Evaluation Committee on 'the Case of the Death Due to the Removal of the Oxygen Tube and to the Administration of Medication'" at Kawasaki Kyodo Hospital " (Kawasaki Kyodo Byoin ni okeru Kikan Chubu Bakkyo, Yakuzai Toyo Sibo Jiken ni Kansuru Gaibu Hyoka Iinkai Hokoku) , the External Evaluation Committee on 'the Case of the Death Due to the Removal of the Oxygen Tube and to the Administration of Medication' at Kawasaki Kyodo Hospital " 2002
 Kenji Yamagata M. D., "The Human Rights of Patients: From the Viewpoint of Hospice Care" Lecture at Kwansei Gakuin University, June 28, 2000
 "Euthanasia: Looking at life and Death" (Anrakushi: Sei to Shi o Mitsumeru), ed. by NHK Human Body Project, NHK Publishing Company (Nihon Hoso Shuppan Kyokai)1996
 As for the content and problems of Nursing Care Insurance, the following two books give a perceptive and critical evaluation. Shuhei Ito, "Reviewing Nursing Care Insurance" (Kaigo Hoken o Toinaosu), Chikuma Shobo Publishing Company, 2001 and Ryu Niki, Medical Care and Nursing Care at the Beginning of the Twenty First Century" (21 Seiki Syoto no Iryou to Kaigo) Keiso Shobo Publishing Company, 2001
 Shuhei Ito, "Reviewing Nursing Care Insurance" (Kaigo Hoken o Toinaosu), Chikuma Shobo Publishing Company, 2001, p.10
 Asahi Shinbun, April 25, 2002
 Asahi Shinbun, April 22,2002
 Terumi Shimizu "Kawasaki Kyodo Hospital 'Euthanasia' Case: Questioning the Attitude Towards Life" (Kwasaki Kyodo Byoin Anrakushi Jiken: Towareru Seimei eno Shisei) Nurse Education (Kango Kyoiku), Vol. 43, no. 6, 2002, p. 480
 As for the present situation of hospice care in Japan, see History of Patients in Post-War Japan" (Sengo Nihon Byonin Shi) ed. by Takeshi Kawakami in Cooperation with Shiro Sakaguchi and Hiroyuki Fujii, Nobunkyo Publishing Company, 2002, pp. 707-718