pp. 144-147 in Bioethics in Asia

Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 2000, Eubios Ethics Institute All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

4.3. Medical Education and Japanese Bioethics

Michio Miyasaka,* Haruo Yamanouchi, Koji Dewa (Department of Legal Medicine,

Niigata University School of Medicine), Koji Sakurai (College of Biomedical

Technology, Niigata University), Niigata City 951, Japan.

1. Present situation of bioethics education in Japanese medical schools

1) Independent medical ethics course

Many Japanese medical schools are not teaching bioethics or medical ethics as an independent subject. Hoshino et al. conducted a national survey on ethics education at medical schools in 1987, and found that only 7 out of 80 schools had independent medical ethics courses. Eighteen schools were offering medical ethics in other courses, and 54 schools did not have any formal medical ethics program. An international survey, conducted by Miyasaka et al. between 1994 and 1995, found that the proportion of Japanese medical schools offering independent medical ethics courses had increased to 20% (19/64). But they also reported that the proportion was remarkably low compared to Asian countries, such as Taiwan, Philippines, Thailand, Indonesia, and Sri Lanka. In these countries, more than 60% of medical schools offered independent medical ethics courses.

2) Introduction to medicine

Some Japanese medical schools are dealing with ethics in an introductory medical course (Table 1), which is called IGAKU GAIRON (IG) in Japanese. IG is literally translated in English as [Introduction to Medicine], or [Medical Outline]. IG was recently lectured at 89% of Japanese medical schools, according to Professor Mori and colleague's report in 1994. Their survey also found that it is covering only limited subjects in medical ethics. Topics that seem to be related to medical ethics such as [on death], and [on doctor-patient relationship] were allocated only 15 to 20% of lecture time within IG. These three reports show that medical ethics in Japanese medical curriculum is underdeveloped.

Table 1: Present situation of bioethics education at Japanese medical schools

A. Independent ME (medical ethics) course

Hoshino, et. al. (1987)

Independent ME courses 7 ( 8.8%)

Teaching ME in other courses 18 (22.5%)

No formal ME program 54 (67.5%)

Total 80 medical schools

Miyasaka, et. al. (1994 ~ 1995)

Independent ME (Japan) 20%

Independent ME (Taiwan, Philippines, Thailand, Indonesia, Sri Lanka, etc.) >60%

B. Introductory medicine (igaku gairon; IG) course (Mori et. al. 1994)

Offering IG 89%

Teaching gon deathh, gon doctor-patient relationshiph in IG 15 - 20% (respectively)

2. Weakness of Japanese Medical Education and Bioethics Education

1) General problems that relate to Japanese medical education

(a) Too much stress on acquisition of knowledge

If we look at the desktop of some students attending the bioethics course in our school, which we just started in September 1997 for 5th year students, we found they opened a textbook of pediatrics, for example, and put the handout of bioethics on a workbook of internal medicine. One student was reading the textbook of pediatrics, and once in a while, looking up at the handout and lecturer. He had already completed the attendance card; he had filled his name, student's ID number, and a brief comment on today's lecture, in spite that the lecture was still ongoing. The topic of the lecture was euthanasia and the death with dignity. The student commented on the card, geuthanasia is very important for medical students, we need to think of it seriously.h To make this comment, he didnft have to listen to the lecture to the end. One of the authors noticed some students were doing exactly the same thing. In our school, the 5th year students usually start to prepare for the national examination of medical license, which is notorious for too much stress on acquisition of knowledge. If a student takes bioethics as a collection of knowledge; philosophical terms or concepts, guidelines or recommendations, they donft have to spend much time in bioethics, because the examination will ask them only one or two questions about it.

We believe bioethics needs discussion, and it should not be a one-way lecture without interpersonal communication between lecturers and students, or among students. But students are often accustomed to lectures without discussion.

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Figure 1: Attitudes of students regarding the balance of time allocation to lecture and discussion

L >> D; lecture should be allocated more time than discussion

L > D; lecture should be allocated moderately more time than discussion

L = D; lecture and discussion should be allocated equal time

L < D; discussion should be allocated more time than lecture

L << D; discussion should be allocated moderately more time than lecture

This is a result of a simple questionnaire survey, which we conducted before our bioethics course started. The question was ewhich proportion of lecture and discussion do you think is appropriate in a bioethics course?f This was a disappointing result for us, but many students expected lecture rather than discussion.

Discussion is, with no doubt, indispensable for learning bioethics, anywhere in the world. We have no automatic system anywhere in the world to reach the gright answerh for ethical dilemmas in medical practice. In the course, he was in charge of a lecture on ethical issues in organ transplantation, and he took a classic case of a Japanese heart transplantation, (which is called gWada (Heart) Transplantationh), and facilitated their discussion. No one raised hands and expressed their opinions, until the lecturer pointed a microphone to each student. However, most of them wrote down long comments on the report pad which was distributed during the case discussion, and quite often we found their comments impressive and sharply grasping the ethical nature of the case.

Therefore, students are not prepared for oral presentation, even though they have their own moral viewpoints in their mind. The lack of discussion in the bioethics classroom is probably due to the lack of the opportunity to express their moral viewpoints in front of others, before they came to the bioethics course. We think this is the basic weakness of current medical education not only at our school, but also at many schools in this country. Most students do not have any opportunities to exercise discussion at any stage in medical schools, and even before entering medical schools. Under the present environment, lecturers in bioethics course must actively facilitate the discussion.

(b) A lack of theoretical and organizational basis of interdisciplinary fields extending over medicine, humanities, and the social sciences

The second weakness has its root in the gap between the structure of Japanese academic activity and the interdisciplinary character of Bioethics. In Japan, some medical school are organized as a faculty of a university, and some medical schools are standing alone without other faculties. But even in the university which have many faculties, different departments, and many teachers specialized in diverse academic fields, medical schools are often standing alone like an island. Medical students have no contact with other students in the classroom except for the first or second years. Also, quite a few medical schools, including our school, are standing in the different place from university main campus, because they need to provide medical care service at university hospitals located in the convenient city area. Students spend their first year at main campus, and come to the medical school campus from the second year. And since then, they can not attend courses of other faculties.

Table 2 gives the topics lectured in the bioethics course in our school, and faculties of the teachers. Many lecturers from main campus participated in the course. But this is quite new to our medical schools. Interdisciplinary teaching has seldom been tried before in the formal curriculum. This was possible because a professor of legal medicine played the coordinator, moving his personal human network, and the dean and the faculty members appreciated the interdisciplinary teaching. So, it is suggested that organizing teachers from different faculties can be achieved if you have human network and some understanding teachers in each relating faculty.

We think the weakness of our strategy should be addressed in the lack of theoretical basis rather than organizational basis required for interdisciplinary collaboration in the bioethics teaching. This might be deeply rooted in the characters in the scholarship of Japanese philosophy.

Table 2: Topics of course

Topics Faculty of teacher

Introduction Humanities

What is bioethics? Kyoto university

Organ transplantation and bioethics Medicine

Psychiatry and bioethics Medical college

Handling life in the human history Humanities

Euthanasia and the death with dignity Law

Woman, citizen, and bioethics Medical college

Informed consent and bioethics Law

Bioethics from a perspective of botany Agriculture

Human dignity and human right Humanities

Medicine and bioethics Medicine (dean)

2) the specific problem for Japanese bioethics as epistemological knowledge rather than practical knowledge.

Teaching bioethics requires practical knowledge by which you can relate different cases, and extract hidden ethical dilemmas. This process essentially requires the methods in applied ethics and social sciences. However, the tradition of Japanese philosophy is attached to epistemology, and has kept its distance from applied ethics and social sciences.

For example, in the class of informed consent, you can compare the Willowbrook case and a Japanese case, in which a nurse was not informed that she had a cancer. To address ethical dilemmas regarding informed consent, you must carefully compare the two cases using some moral concepts or principles. But this kind of gpracticalh discussion is actually dealt with most likely by jurists, not by philosophers in our country.

Let us think about another case; the brain death issues. A lot of Japanese philosophers actively objected to the acceptance of brain death as a personfs death, because it will drastically change the nature of death. But it was seldom discussed whether a children of age under 15 has a right to donate organs or not. We believe this is also an important philosophical issue, but it was actually discussed by jurists or politicians, not by philosophers.

We didnft find any Japanese philosophical or religious textbook to facilitate discussion on the three cases, we took the well-known textbook by Tom Beauchamp and James Childress, even though this might be a gcultural invasionh of America, as someone advocate. The "four principles" was very useful to let students illustrate moral dilemmas in the cases, and students appreciated this method. But it was again disappointing for me that some students asked the lecturer gafter all, what is the right judgment?h This may be a fundamental dilemma in the moral education.

We think analytical methods in Western bioethics can be a cue to methodological reformation of Japanese bioethics education, but a refinement of the theoretical system should be essential. We have to address every possible practical ethical dilemmas in our country. In the bioethics teaching for students at clinical stage, philosophical discussion should also be started from the bed side. The encounter with real patients and heath care givers will provide students real cases from which they can learn bioethics. Epistemological thinking is important, but it should be promoted at earlier stage. And the preparation should be indispensable to learn bioethics from the real cases at clinical stage.

3. Conclusion

We would like to address three strategies for curricular reformation at Japanese medical schools, and one for qualitative refinement of bioethics education. We think every possible ways to develop bioethics education at Japanese medical schools will require the communication between the classroom and the bed side.

Table 3: Strategies to integrate medical ethics education into Japanese medical curriculum

The formation of a core organization of study and information exchange

The formation of an academic network extending over medical fields, humanities, social sciences, and natural sciences

The promotion of understanding and support for bioethics education of the dean and the college.

Development of practical medical ethics mediating between medical practice and philosophical epistemology.

References

Hoshino, et. al. (1987) Hoshino, K. (chief researcher) Report of a Basic Study on Bioethics Education in Japan (in Japanese)[wagakuni ni okeru seimeirinri kyoiku ni kansuru kisoteki kenkyu]. 1987. 4, p.12. Japan Medical Education Foundation

Miyasaka, M., Akabayashi, A., Kai, I., and Ohi, G., Ethics Education in Medical Schools in 15 Asian Countries ----- An Overview Questionnaire Survey. presented at East Asian Conference on Bioethics (EACB' 95), Beijing, China, 1995.

Mori, C., Nishio, T. Survey of Curriculum in the Medical Humanities at Japanese Medical Schools - A Comparative Study between an Initial Survey in 1988 and a Second Survey in 1994. (in Japanese) Medical Education (Japan). 1996; 27: 155-159.


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