メイサーダリル（大会長）庄司進一、手嶋豊（大会副会長）
赤林朗 青木清 江藤肇 藤木典生 藤井正雄 藤本隆志
浜口秀夫 林英生 紙屋克子 小松奈美子 宮田登 村上和雄
小原信 大井玄 大林雅之 坂本百大 玉井真理子 山田卓生

賛助組織

筑波大学
ユウバイオス倫理研究会
文部省
三共（株）筑波研究所
藤沢薬品工業（株）筑波研究所
日本油脂（株）筑波研究所
武田薬品工業（株）開拓第一研究所

年次大会　　　　　　会期　　　　　　　大会長　　　　　　所属　　　　　　場所

第１回 1989年11月25〜26日 坂本　百大 青山学院大学 東京
第２回 1990年11月 3〜 4日 古川　俊之 国立大阪病院 大阪
第３回 1991年11月 8〜 9日 瀬在　幸安 日本大学 東京
第４回 1992年11月19〜20日 糸川　嘉則 京都大学 東京
第５回 1993年11月13〜14日 藤井　正雄 大正大学 東京
第６回 1994年10月 1〜 2日 木村　利人 早稲田大学 東京
第７回 1995年10月28〜29日 中谷　瑾子 大東文化大学 東京
第８回 1996年10月23〜29日 竹内　一夫 杏林大学 東京
第９回 1997年11月 1〜 2日 メイサーダリル 筑波大学 つくば

Abstracts

Nenad Hlaca Fax: +385-51-226689
Law School of Rijeka, University Rijecka, Hahlic 6, CROATIA

In some scientific circles bioethical dilemmas in the former state were imported with the new medical technology in the last decades. In the same time there was strong impact of the socialist regime in which collective rights were more important and in which there was no place for what in that time was called ﾒliberalistic and individualisticﾓ approach in the protection of human rights. Historically an important step in the development of the bioethical approach was the first Course ﾒHuman Rights and Medicineﾓ organized at the Inter-University Center for Postgraduate Studies in Dubrovnik in 1984. In the last thirteen years, even during the war, the Courses in Dubrovnik were dealing with human rights issues in medicine and health care. In the multidisciplinary approach, participants from Croatia and aborad discussed ethical dilemmas and protection of human rights. The Hastings Center from New York organized the first East-West Bioethics Conference in 1989 in Dubrovnik. Tragic events in the former state during the war focused the interests of the participants on the problems of the war victims, displaced persons and refugees as well on the ethical and legal aspects of the family dysfunction, in the 1994 Course. This year's Course was oriented to the new European reality: on the Convention on Human Rights and Biomedicine. As a tragic war experience it will be stressed the problem of forced pregnancy as a serious violation of the rights to reproductive choice. Forced pregnancy through rape during the armed conflicts is treated as a war crime (UN doc.E/CN.4/1994/5). In the war in former Yugoslavia rape is expressly considered as a breach of international humanitarian law and a crime against humanity in certain circumstances. In the same time during the war there was investigated serious examples of the male sexual abuse. The problem of abortion of sexually abused Bosnian citizen refugees in Croatia was treated according to Croatian law. But the problem was that the raped women reached Croatia usually too late for the medically acceptable abortion.

Anne Boyd, Hood College, USA Email: boyd@NIMUE.HOOD.EDU

Pinit Ratanakul and Attajenda Deepudong, Mahidol University, THAILAND

The Acquired Immunodeficiency Syndrome (AIDS) global epidemic is an opportunity for pluralistic dialogue and academic debate about ethical standards and principles in an international context. Ethics attempts to guide decisions in which priority is given to the principles of autonomy over paternalism, truth telling over deception, social justice over consumerism, and beneficence over inertia. There is a dialectic between theory and application in every culture where the AIDS epidemic is threatening health care resources, national economy, and political stability. No universal agreement exists about how myriad cultures ought to evaluate the decisions that this epidemic imposes. The AIDS epidemic in Thailand provides a case study for ethical analysis. The Ministry of Public Health must decide how to allocate money and human resources to curtail the AIDS epidemic and to care for those already infected and dying. What ethical standard or principles provide the best formula for public policies?

Buddhism is the fundamental basis of moral education in Thailand and directly influences individual and collective ethical analysis. Ethics, defined as an individual reasoned response to a situating in which a person seeks to do the good thing, means that priori values with ethical reasoning. The assertion is that moral philosophy and ethics philosophy are convergent at the existential level.

The Buddhist concept of compassion is one of loving kindness which embraces the ethical principles of beneficence, nonmaleficence, and justice. Justice is the social form of compassion. Compassion exceeds justice in basic equality and human rights to the point of self-sacrifice voluntarily, equal treatment, giving to each their due. Although people differ in circumstances, they are equal as moral agents. Justice means providing available health care for all, poor and rich. Wat Phrabatnampu illustrates the concept of compassion as the largest AIDS hospice in Thailand.

Compassion as a principle prescribes a prima facie duty as an ethical response to a compelling human need. Buddhist philosophy is ethical, metaphysical, and epistemological. The ancient Greek Sophists proposed ethics as useful to human relationships because it would establish customs and conventions to enhance social existence. Kantian ethicists place a premium on individual human worth and dignity. The debates about what is the philosophical good and how human beings decide what action to take in a given circumstance extend the conversations of ancient philosophy into contemporary topics.

Given the wide variety of opinion about ethics that exist within and among different cultures and different epochs of the same culture, the meta-ethics question of the human capacity for morality remains unanswered. What moral or ethical code has better common ground in the world of human beings than compassion?

Frank J. Leavitt, Hadas David-Gabizon & Vered Yeflach-Wishkerman
The Jakobovits Center for Jewish Medical Ethics, Faculty of Health Sciences,
Ben Gurion University of the Negev, Beer Sheva, ISRAEL Email: yeruham@bgumail.bgu.ac.il

School bioethics education is important not only because of the ethical questions raised by medicine, nursing, biotechnology and the environment but also as an attempt at an antidote to the moral problems of post-modern society: crime, corruption, violence, etc. Ethics is not taught by preaching but by free and open inquiry into the moral issues, including their scientific background. This requires faith that when young people investigate an issue freely they will certainly come to the ethical conclusion. This article of faith requires examination.

Our school bioethics experience in Beer Sheva began with voluntary enrichment sessions for high school biology students, taught by some of our medical students who had previously studied bioethics as part of their medical education. These medical students gained further experience by teaching bioethics sessions to religious girls doing National Service (an alternative to army duty) by working in the hospital.

More recently, Vered Yeflach-Wishkerman, a Ph.D. student in biology specializing in radiation medicine is teaching bioethics in one high school, concentrating on ethics in genetics and the environment. In another school, Hadas David-Gabizon a philosophy student who emphasizes the philosophical basic of bioethics has been surprisingly successful at teaching bioethics in the lower grades.

Bioethics is a big field with a wide range of sub-topics (medical ethics, environmental ethics, animal rights, etc.) and of approaches to foundations (philosophy, religion, sociology, etc.) We hypothesize that choice of sub-topics and of approaches is best determined by the teachers personal interests and a feel for what excites the pupils. We also hypothesize that success is more a matter of the teachers personality than of a properly planned syllabus.

We try to maintain close communication with similar projects elsewhere in Israel as well as in the Hope Flowers School near Bethlehem, which is under the Palestinian Autonomy. In June 1997 we held a one-day workshop on Israel in Asian Bioethics, part of which was devoted to bioethics in the schools. We hope to devote a full day's workshop to this subject, with our South Asian and East Asian friends, in Israel in June, 1998.

Richard Weisburd Email: Weisburd@biol.tsukuba.ac.jp

Institute of Biological Sciences, University of Tsukuba, Tsukuba Science City 305

The current status of the biosphere and trends in anthropogenic activities and their biogeochemical impacts have some sobering implications for the ability of future generations to meet their basic needs. Indeed, the trends raise some troubling ethical concerns about behavior and lifestyle choices being made today. Whereas most people seem to use ethical principles to govern their behavior and choices, long-term environmental degradation is generally regarded as either not being an ethical issue or being beyond the scope of ethical issues deemed worthy of serious consideration. That irreversible environmental degradation is a bona fide ethical concern can be demonstrated by exploration of a series of scenarios, in each of which, personal gain is achieved at the cost of an ethical violation; these violations progress from direct and intentional causation of grievous bodily harm to a neighbor, to those that increase the probability that the health and welfare of future generations will be impaired. Does knowledge of the ethical implications of environmental degradation impose any obligation to act and/or educate? Would a population more aware of the ethical implications of their actions, alter their behavior by foregoing some level of convenience in return for a more sustainable lifestyle?

Jayapaul Azariah and C. Thomson Jacob Email: jazariah@unimad.ernet.in

Department of Zoology, University of Madras, Madras 600 025, INDIA

The rapid growth of industrialization and excessive mining of ground water threaten the very availability and quality of ground water. The depletion of ground water resources and ground water pollution has brought about a scarcity in ground water resources in Tiruppur. Tiruppur is a special grade municipality in the Coimbatore district, Tamil Nadu, India with 400,000 inhabitants. It extends to a total area of 27.19 sq.km. The main industries of the town are hosiery and knitting garments. There are about 187 bleaching and 526 dyeing units making a total of 713 water intensive industrial units which consume a total amount of 91.7 mld of water. Phenomenal industrial growth has generated a huge annual foreign exchange of more than 30 billion Rs per year.

As members of the current generation we may wish to brighten our own welfare, improving during our own lifetime, and treating the needs of the future as less important. As the extent of the general damage increases the question of water rights becomes more urgent. Should future people be treated as if they were already dead? Should this generation care about its actions that will result in a degraded environment in the distant future? If we do care then what should be done? A great deal of thinking and research need to be done to come up with appropriate legal measures with regard to mining and the use of available ground water.

Ground water was not mentioned in any of the lists in the seventh schedule of the constitution of India. This could be because the farmers in their infinite wisdom did not envisage such a water crisis as we are facing today. The fact remains that we are faced with this water crisis. Furthermore all the attempts at action made by the various legislators have only tried to address extraction. None of the bills or acts have sought to deal with the inequity and inequality inherent in the very conceptualisation of ground water. Water should not have been handed out to the regulatory states at the time of the framing of our constitution. The reason why these bills and acts have failed is because the focus of regulation was merely extraction, and the authority vested with this power was based on a political or linguistic divisions of the state.

For an efficient regulatory regime, perhaps we require ecological, and more specifically aquifer-based divisions. The question of rights, those of the landed and those of the landless, need to be addressed within this framework. All attempts that ignore this question remain inadequate, and perhaps we need to look at water and water management more holistically: understanding surface water, ground water and rain water as a common pool of resource or a common world heritage. Segregating/dissecting does not make water management efficient. There is a need to develop a universal bioethics regarding the abstraction of ground water.

地下水法と工業用水汲み上げにおける倫理の必要性

　インドの急激な工業化と大量の地下水汲み上げは、地下水の利用と量そのものを危機に追いやっています。水源の枯渇と水質汚染により、ティルプールの地下水が減少しています。ティルプールは、タミール・ナドゥ州コインバトール市の人口40万人、総面積27.19平方キロメートルの特別自治区です。主要産業は靴下やメリヤス／ニット製品の製造販売です。同地区にはさらし工場187棟、染色工場526棟の計713の、水を大量に使用する工場があり、合わせて91.7mldを消費しています。脅威的な産業の成長は、年間300億ルピー以上の莫大な外国為替取引を生んでいます。

　現世代の人間として、私たちは生きている間により明るい繁栄を望み、未来のニーズを軽視して危機にさらしています。ダメージの範囲が広がれば広がるほど、一般に水の使用権の問題の切迫感は増します。未来の人を既に死んだかのように扱っていいのでしょうか？　私たちの世代は、遠い未来の環境を破壊する行動を意識すべきでしょうか？　意識するとしたら、何をしたらいいのでしょうか？　今ある地下水の汲み上げと利用に関する適切な法的措置を打ち出すには、多くの思考と調査が必要です。

　地下水は、インド国憲法の第7付帯条項のどこにも触れられていませんでした。農民たちの英知をもってしても、私たちが現在直面している水問題を予見できなかったからかもしれません。私たちが水の危機に直面している事実は動かせません。どの自治体も汲み上げに取り組んだだけでした。法案も条令も、地下水の概念化そのものが内包する不公平と不平等を扱おうとはしません。水は、憲法立案時に中央政府に委ねられるべきではありませんでした。これらの法案と条令が失敗に終わったのは、規制の焦点が汲み上げだけにあり、管轄当局が政治や言語で分裂していたからです。

　効率的な管理体制のためには、環境にやさしく、とくに帯水層を扱う部署が必要かもしれません。土地を持てる者と持たざる者の権利の問題は、この枠組みで捉えるべきでしょう。権利問題を無視した試みはすべて不適切です。私たちは水と水の管理について、もっと歴史的に見るべきかもしれません。地表水、地下水、雨水を共有資源または世界の共有財産として理解するのです。分裂と分断があっては、水管理は効率的に進みません。地下水汲み上げに関する世界的な生命倫理を作り上げるべきなのです。

C.Thomson Jacob and Dr. Jayapaul Azariah Email: jazariah@unimad.ernet.in

Department of Zoology, University of Madras, Madras 600 025, INDIA

The Coimbatore-Tiruppur-Erode belt is one of the fastest growing industrial regions in Tamil Nadu, India. Coimbatore and Tiruppur are major industrial towns in Tamil Nadu. The major constraint on the development of this area is the non-availability of fresh water, both for drinking and for industrial use. Improper disposal of sewage and industrial effluent damage the whole ecology of Tiruppur. The untreated effluent from bleaching and dyeing units is released into the Noyyal river, and thus has created major environmental problems, particularly with regards to ground water depletion and deterioration of water-quality. The export of T-shirts fetches a revenue in foreign exchange to the turn of 30 billion Rupees a year, but who will pay for the ecological degradation of this town? Demands placed by the textile industry and individual households have led to the conversion of agricultural wells to commercial use for selling water. There is a flourishing private water-market involving transport of water by tankers and bullock carts to users in the Tiruppur area. All users, including the poor, have to pay if they wish to use this source of water. In Tiruppur 30-60 million liters of water are transported to and sold in the private markets daily. The private supply accounts for 50-70% of water used.

The fast depleting water table in the Coimbatore district has forced some farmers to quit agriculture and become either farm or non-farm laborers. They have been pushed to this extreme step because their efforts to deepen wells or change the crop pattern have failed. There was a steep rise in the number of abandoned wells from 4000 in 1960 to 20,000 in 1996. A conservative estimate has put the cost of digging wells at Rs.50,000 a well and hence, the capital loss amount to Rs. 100 crores. In Coimbatore a large number of open wells have become dry and recently the drilling of borewells upto a depth of 750 feet has become a common feature. The heavy withdrawal of ground water for irrigation purposes has resulted in a marked lowering of the water table.

It has been reported that in many parts of the Coimbatore district the water table had fallen to nearly 200 ft during the last 20 years. In the last 10 years the mean water table has declined significantly. The figures(in meters) are as follows. Avanashi(9), Coimbatore (6), Palladam (5), Pollachi (4) and Vdamalpet (3). The number of wells has doubled from 9 lakhs in 1996. The area under well-irrigation had increased from 600,000 ha. to 1.4 million ha. during the same period. Owing to competition for water among irrigators by the year 2025, it is predicted that 34 countries will face water scarcity and reduction in per-capita water availability between 1990 and 2025, and that for a country like India, this will reach about 39%. This paper discusses certain remedial measures for the preservation of this ecosystem.

Tシャツの環境倫理コスト−タミール・ナドゥ州ティルプールの場合

　コインバトール、ティルプール、エロードを結ぶ一帯は、タミール・ナドゥ州でも有数のスピードで工業化が進んでいます。コインバトールとティルプールは、同州の主要工業都市です。この地域の発展を妨げる大きな要因として、飲料／工業用の新鮮な水がないことが挙げられます。汚物と工場廃水の勝手な投棄は、ティルプールの生態系全体を悪化させています。さらしや染色の工場からの未処理廃水はノヤル川にそのまま流され、大きな環境問題、とくに地下水の枯渇と水質悪化を引き起こします。Tシャツ輸出は年間300億ルピーもの外国為替取引収入をもたらしますが、生態系悪化のコストは誰が負担するのでしょうか？　繊維産業や家庭からの需要のせいで、農業用井戸は水を売る商業利用に転換されました。民間水市場は活気づき、タンカーや牛の荷車がティルプール地区の利用者に水を輸送しています。貧困層も含めてすべての利用者は、水が欲しければお金を払わなければなりません。ティルプールの場合、1日に3,000万から6,000万リットルの水が民間市場に輸送され、売られています。民間供給は、ティルプールで消費される水の50から70%を占めます。コインバトール地区の急速な地下水面の枯渇により、農民は農業を捨て、畜産その他の仕事に就かざるをえなくなっています。井戸を深く掘ったり耕作物を変える努力が実らなかったため、ここまで追いつめられたのです。放棄された井戸は1960年には4,000基だったのが、1996年には2万基と急増しています。井戸を1本掘るには控えめに見ても5万ルピーかかるので、資本損失は10億ルピーにも上ります。コインバトールでは数多くの蓋なし井戸が干上がり、深いもので200メートルも掘り下げるのが当たり前になっています。潅漑用に地下水を大量に汲み上げるため、地下水面が著しく下がっています。

　コインバトール地区のあちこちで、地下水面がこの20年間で60メートル近くも下がっていることが報告されています。過去10年間で、地下水面の平均は大幅に低下しています。以下に数字を挙げます（単位メートル）。アヴァナシ（9）、コインバトール（6）、パラダム（5）、ポラチ（4）、ヴダマルペット（3）。井戸の数は1996年の90万基から倍増しています。井戸を利用した潅漑用地は、同時期に60万ヘクタールから140万ヘクタールに拡大しました。潅漑耕作農は競って水を使うため、国民1人当たりが使える水は、1990年から2025年の間に34ヶ国で減少し、インドの場合、39%減ることが予想されます。本論文では、生態系保護のための改善措置をいくつか取り上げます。

Humitake Seki Email: seki@biol.tsukuba.ac.jp

Institute of Biological Sciences, University of Tsukuba, 305 JAPAN

It was about 2 billion years ago when the rise of oxygen from the primordial atmosphere was brought about by photosynthetic activity of newly evolved autotrophic cyanobacters such as stromatolites. One reason for the emergence of these photosynthetic organisms is speculated as a nutrient shortage because the enzyme-mediated consumption rate of organic nutrients by primitive microorganisms is much higher than their physico-chemical production rate. Hence, at this period of the biosphere history, primitive organisms inhabiting the anoxic biosphere faced a great crisis of nutrient shortage, but found the resolution of producing nutrients by themselves through the biological evolution at the hands of God. Although the nutrient shortage was relieved by the photosynthetic activity, the activity caused the rise of oxygen in the primordial atmosphere above the Pasteur point (0.01 PAL), that is the lethal threshold for anaeobic primitive microorganisms. Just like the God rained buring sulfur on the cities of Sodom and Gomorrah and destroyed all the people there, except the survivors Lot and his two daughters. These microorganisms that were tolerant to oxygen eventually acquired respiratory metabolism.

An equivalent great crisis in biological phenomenon in the history of our planet is exactly what we have forced upon ourselves (and all others) to face at present! It must be one of few choices that human acceleration of the Noosphere evolution relieves this forthcoming Biosphere crisis with Great Will, as Sir Alister Hardy has described as "it is God working through men". There, upon anthropogenic acts beyond any purely Scientific reflections in the Domain of God, none can deny the apparent need for interventions of the philosopher and theologian.

David Shapiro Fax: +44-171-323-4877

UNESCO IBC Rapporteur; Nuffield Council of Bioethics, 28 Bedford Square, London WC1B 3EG, UK

The UK is presented as a case study in the development of national policy strategies for the application and regulation of the new genetics. The UK may well be a special case for two reasons: First, the UK has a National Health Service. The public therefore expects that, in health matters, the Government will take a lead. Secondly, professional self-regulation has long been a feature of medical law and ethics in the UK. The development of policy strategies in the UK began with a series of reports from the Royal College of Physicians in the early 1990s. Ethical, social and legal issues were set out in 1993 in the report of the Nuffield Council on Bioethics, Genetic Screening: Ethical Issues. This report was taken up by the House of Commons Select Committee on Science and Technology in its report Human Genetics: the science and its consequences (4 vols, 1995). The UK Government has responded by establishing in January 1996 the Department of Healthﾕs Advisory Committee on Genetic Testing and in December 1996 an overview body, the Human Genetics Advisory Commission.

英国における新遺伝学とその規制

　新遺伝学の応用と規制の国家政策の発展におけるケーススタディとして、英国の事例を発表します。英国が特殊なケースなのは、2つの理由から見て当然と言えます。

1　国民健康保険がある。したがって国民は保健問題については政府主導を期待する。

2　英国の医療法と倫理の特色は、長い間、専門家の自主規制だった。

　英国の政策は1990年代初め、王立外科医師会の一連の報告書によって立案されだしました。1993年にはナフィールド評議会の生命倫理報告書「遺伝子スクリーニング：倫理的問題」が、倫理的社会的法的問題に触れています。この報告書は下院の科学技術特別委員会の報告書「ヒト遺伝学：科学とその意義」（全4巻、1995年）で取り上げられました。

　これに応えて英国政府は、1996年1月には保健省遺伝子テスト諮問委員会を、1996年12には調査団体、ヒト遺伝学諮問委員会を設立しました。

Ole Doering Email: ODring@aol.com

Institute for Asian Studies, Univ. Hamburg; Ahornsteg 8, D-37079 Goettingen, GERMANY

Progress in ethics has nowhere reached a degree of maturity which would entitle to straightforwardly abandon eugenics and Chinese medical politics. What are the criteria for such a mature ethical discussion of eugenics? At first we have to define the problem of eugenics, which is twofold: Its descriptive dimension, 'What can we expect to achieve in health care with our biotechnological skills, and what is mere science fiction or ineffective if we balance costs and merits?' The second dimension is prescriptive, 'What shall we do with our (assumed) medical knowledge and skills, and should we encourage bioscientific progress as such?" Hans Jonas in his popular book on 'Technology, Medicine and Ethics' holds that the very new quality of technological accomplishments is permanently creating new ends of the same new quality we do not quite comprehend. Jonas arguments rely substantially on the notion of a historical Great Leap towards Modernity. This New Age makes him worry whether we might finally end up in a catastrophe due to the exhaustion of our limited capacities, which leave us unprepared for our new challenges. Darryl Macer, on the other hand, reminds us that in principle biotechnology and eugenic ideas are not new but as old as human cultures. Macer still acknowledges the limits of our understanding that some express as the belief in a 'god of the gaps', but encourages us that ethical progress is possible.

I frankly confess that I feel more attracted to the view of Macer which is at least based on a decent reading of the history of medical concepts and sciences, and ready to take the challenge. Though I still have some concern about a new quality of problems which I regard as effects of quantity and complexity. I hold that neither claiming a New Age nor quoting the historical evidence of biotechnological engagement does provide a strong argument. It appears like we are now forced to pay as much attention to empirical facts as we philosophers have seldom done before. I may remind you that even in mainstream ethics it is very often regarded odd to become involved in matters of trivial life as an ethicist. Some colleagues prefer to engage in most abstract conceptual analyses or game theories, disregarding the old tradition of associating the philosopher with the physician.

Eugenics is not simply good or bad. For example eugenics can indicate an attempt to improve the quality of our bodily constitution, which is fine if we think of hygiene or antibiotics. Interference is inevitable for a natural being. It makes a considerable difference to kill a population of bacteria, to reanimate a gene-sequence in charge of health, or to try to design a germline. Obviously, all of these bear a different impact on the concerned persons and society, with the latter also effecting on future generations. But there is no general innate ethical value in any of these.

For an ethical statement we require additional conditions. Track one is to explore the ethical quality of our proclaimed intentions. James Buchanan has suggested a revised spelling of this device for the context of biotechnology, putting it into a paradox: 'Act so that the effects of your actions reflect the fact that you cannot predict the effects'. A concrete specification would be, 'In order to gain a more healthy population, can we wish that sterilization of handicapped persons becomes the regular procedure under all circumstances, at any time, and for every person?'. Track number two is to explore the practical coherence of our applied maxims. We have to look for so-called hypothetical imperatives, which are defined by having not an aim in themselves and also consisting of empirical elements. In light of the sterilization example it may be formulated like this: 'In order to gain a more healthy population, is it effective at all to perform sterilization of handicapped people? And if 'Yes', for which particular cases would this be true. And, subsequently, can we be sure that the respective medical system is effective enough to provide the measure for the whole population? Finally, can the risks and shortcomings outweigh the costs of the respective measure?'.

If one or more of the answers is negative, as we know it is true for our example, we have reason to revise the questioned means. This double track method provides mere evidence for the value of one maxim. There occur cases of a lethal collision of maxims, which have been found to be consistent within themselves, like the clash between legitime interests of individuals and of society. Still it is possible to solve these problems if we again go through the enlightened double track process, but this requires lengthier explanations than I may perform here.

This ethical approach can be very promising but it also requires a very high level of interdisciplinary sophistication, at least some skills in systematics and a high degree of social and psychological sensitivity. We are far from educational systems and scientific practice which would encourage this sufficiently, not to mention the very poor back up in society and politics.

Historical experience teaches every European that eugenics is a very dangerous approach, at least under the guidance of narrow minded interests, and it has almost every time been abused for ill purposes. Even recently it was revealed that Sweden among others has been following a eugenics policy of coercive sterilization adopted in the thirties. The more the eugenic's proponents urged that a 'better race' required stern means for a few the worse the effects on more and more people turned out, with no countable gain left in the end. This is an insight the whole mankind will profit to share, and hopefully this convinces others, in China and elsewhere, to avoid trapping into the same pitfall of human hybris, of reshaping what does not seem to fit, instead of showing humaneness and understanding. Asia also has had its 1984 Singapore experience of social engineering, which is a relatively mild form of eugenics but still influenced by some naive biologism which raises concern. The shaping of genes by biotechnological, social and even legal force should be held away from the toolbox of politics, where we cannot expect pure ethical arguments to be too influencial.

A general welcome to technological improvement and innovation, which has often be ascribed to Asian societies, should not hamper us to be extremely careful and open to face, name and calculate risks, and, in case, to accept the modest conservative course of interference into peoples lives, which is an advice of an ethical understanding Asian traditions are proud of.

All of this has a massive impact on present day's China with its practice of sterilization, selected abortion, underdeveloped infrastructure, education and a widespread poorly sophisticated body thinking. The eugenics issues have neither been thoroughly discussed nor embedded in proper practical and legal frameworks yet. The problem appears not to be a special one for China, but again a challenge for humanity. Eugenics in China is primarily a political problem. This entails at the same time an ethical concern, but this ethical concern is neither restricted to China nor to politics. We ought not to confuse these two levels of discussion.

Hideyuki Nakazawa Email: hideyuki@health.shinshu-u.ac.jp

Mariko Tamai Email: mtamai@gipac.shinshu-u.ac.jp Fax: 0263-39-1140 Department of Psychology, School of Allied Medical Sciences, Shinshu University

Asahi 3-1-1, Matsumato Nagano 390

Keywords ：Medical genetic services, Guidelines, Common disease, Primary care

The aims of medical genetic services have been clearly extended to multifactorial or common diseases. Single gene disorders are now considered as the objects of the narrow sense of medical genetic services. The current medical genetic services appear to be a part of primary care.

PS. Harper said, "until very recently, most concerns and applications were focused on genetic tests for rare, although important, disorders with Mendelian inheritance patterns. The emphasis is now shifting to the common chronic diseases that make up the major health burden in most Western countries", suggesting that all of the diseases are now practically within the command of growing medical genetic services as their objects. Medical services have dealt with genetic and environmental factors, both of which interact and create sick conditions. Recently, however, greater efforts are being made to analyze genetically the epidemiology of common diseases.

With the recognition of such a crisis, the ethical, legal, and social issues of medical services are growing more controversial these days. In the worldwide perspectives, the Declaration on the Protection of the Human Genome of UNESCO and Guidelines on ethical issues in medical genetics and the provision of genetic services (draft) of WHO are prominent examples.

The social and ethical implications of these guidelines are identical. These guidelines: 1) presuppose that genetic information is so special that it belongs to all of the family members regardless of their generation; 2) include particular consideration of the human rights, so that any social discrimination shall not be derived from the genetic information; 3) guarantee an adequate informed consent process, a process to provide sufficient information and to support self-decision either to agree, to deny, or to choose; 4) improve facilities to support patients including a system to provide genetic counseling; and 5) keep any discussion about formulation of such guidelines cross-sectional and wide-open to supporting groups for patients.

Medical genetics tends to aim at common diseases and to play a role in primary care and public health services. This tendency should encourage Japanese society to formulate ethical guidelines and, for this reason, interdisciplinary discussion should be provided openly. The ethical guidelines (draft) of the Japanese Society of Familial Oncology was released in May 1997. This shall provide a model of such guidelines, including its developing process in Japan.

Shinryo N. Shinagawa Fax: 0172-32-8053

Institute on Public Issues Relating to Health Care and Medicine; Hirosaki University, Hirosaki

From a viewpoint of a Japanese who experienced Pre-War Japanﾕs education and World War II, seven topics relating to Post-War Japanﾕs philosophy will be presented. They are:

1. Idealistic pacifism which desires peace (and disarmed society and international relationship) for all time. (Preamble and Article 9, Constitution of Japan, 1946)

2. All people shall be respected as individuals. (Article 13 Ibid.); From a country of ﾒHuman Torpedo and Kamikazeﾓ to a country of ﾒHuman life is heavier than the globe.ﾓ

3. All of the people are equal under the law. (Article 14, Ibid.)

4. From a country of Nationalistic Shintoism to a country of a Museum of Religions: Freedom of religion is guaranteed to all, and at the same time, no religious organization can receive any privileges from the State nor exercise any political authority. (Article 20, Ibid.)

5. Protection of socially and economically disadvantaged persons: All people shall have the right to maintain the minimum standards for wholesome and cultural living. (Article 25, Ibid.)

6. Elevation of the living standard; From a country of ﾒSaving is a virtueﾓ to a country of ﾒAffluence is a virtue.ﾓ

7. Peaceful and harmonious coexistence with the Emperor and His family minimizing their privileges: The Emperor shall be (no more the ruler but) the symbol of the State and of the unity of the people. (Article 1, Ibid.)

Darryl Macer Email: asianbioethics@yahoo.co.nz

Institute of Biological Sciences, University of Tsukuba, Tsukuba Science City 305, JAPAN

I wish to share a few thoughts about Japan. I am not a historian but it is obvious that bioethics did not start when the word was made, but the ideals of doing good and avoiding harm, and of choices from autonomy versus social justice, have been with us since the beginning of civilisation. Yet it seems we have to reinvent the wheel very often. Let me give a few examples from Japan.

I think the concept of "informed choice", should replace the concept of "informed consent". Both concepts are found early in Japan. Last century Hanaoka Seishu records informed consent for breast cancer operations in Japan. Why do we use Informed Consent in katakana, not kanji? Japanese like to introduce new words which can be a positive trait, but why are new ideas better than the same idea in an old name? Of course, if it really is the same idea is a question for us to examine.

It is said that death is a taboo in Japan, but actually more elderly people live at home with the family in the sometimes depressing years of fragility that old age brings, than in the West. The daily experience of death and futility may be more common in Japan, yet discussion of death is said to be less common than overseas. Maybe in America they talk about futility but put the elderly in separate care. In independent care they can pretend that they are young, and on the positive side keep a cheerful active life. However, this is also avoiding to see death by the family.

If we look for bioethics in literature we can find stories of the beauty of dying in nature, as in many countries. We can also see stories like "Ubasuteyama", which could be translated as "Grand-mother throwing mountain". This practice was relatively well known before the Meiji era, and involves the son carrying the mother up to the mountain to leave her there to die. It was made famous in a film "Narayama bushiko" which won a Cannes film prize. The reason was usually the shortage of food. This unpleasant practice is reported to still occur in Korea, and is also shared with Siberian tribes such as the Yakuits and Mongolians, who are close to the Koreans and Japanese in origins.

Mabiki is another practice that involved pulling out extra rice seedlings, used for killing of unwanted babies. This we can see more broadly across cultures, and it also relates to the dilemmas of prenatal testing. We also see a very interesting practice of Mizuko statutes, water-children, which is a griefing process for remembrance of aborted fetuses, miscarried children, and babies who died very young. It is a Japanese response to a universal dilemma.

Japan is a country where you may get a warning time before a parking ticket is given. There is less involvement of law in medicine, and more consensus then confrontation. This I believe to be a plus of Japan, as long as individuals can be protected if this harmonic system fails.

There are good and bad points of all cultures, the neighbourﾕs grass can be refreshing but it is not always greener. All societies are a mixture of opinions, and survey data show there is not one view of any culture on one issue. We should build societies that respect diversity and tolerate choices that people make.

国際生命倫理に日本が貢献出来ること

　私は歴史家ではありませんが、生命倫理は名前がつけられたときに始まったのではなく、善いことを行ない悪いことを避けることや、社会正義に対して自発的に選ぶことといった理想が、文明の始まった時からずっとあったことは明らかです。どうして新しい言葉が必要なのでしょう。日本の例を幾つかあげてみます。

　私は「インフォームド・コンセント」の代わりに「インフォームド・チョイス（説明を受けての選択）」という概念を使うべきだと考えます。両方とも、かなり以前から日本にありました。１９世紀に、華岡青洲が乳癌の手術のインフォームド・コンセントを記録しています。どうして私達はインフォームド・コンセントをカタカナで書き、漢字を使わないのでしょうか？日本人は新しい言葉を使うのが好きです。それはいいことでもあるのですが、どうして同じことを表わすのに古い名前より新しい方がいいのでしょうか？もちろん、本当に同じことであるのかどうかは、これから研究しなければなりませんが。

　日本では死はタブーとされていると言われますが、西洋よりも多くの高齢者が、家族とともに自宅で、高齢からくる体の弱さで時には気のめいるような日々を送っています。死や無益な医療といったことを日常的に経験することは、日本での方が多いかもしれないのですが、死について話すことは外国にくらべて少ないと言われます。おそらくアメリカでは無益な医療について話しあうのでしょうが、高齢者は高齢者だけの施設に入れられます。別々の施設なら、高齢者達は若いつもりでいられますし、陽気で元気な生活が送れるという利点もあります。しかし、これは家族の死を看取ることを避けるということでもあるのです。

　文学のなかで生命倫理を捜すと、諸外国と同じように、自然に死ぬことの美しさといった話がたくさんあります。しかし同時に「姥捨て山」のような話もあります。こういった習慣は明治以前にはよくあったことで、息子が年老いた母を背負って山に置き去りにして、そこで死ぬのを待つということです。カンヌ映画祭で賞を取った「楢山節考」で有名になりました。原因は大抵の場合、食料の不足です。この悲しい慣習は現在でも朝鮮半島で行われていると報告されています。韓国・朝鮮人や日本人に近い人種だと言われている、シベリアに住むヤクート族やモンゴル人などの間にも同じような慣例が見られます。

　間引きという望まれない子供を殺すために行われる慣習もあります。これは、元々は、丈夫な稲の苗を育てるためにじゃまになる苗を抜いてしまうことを指すものでした。この慣習は、より広くいろいろな文化にわたって見られます。これは、出生前診断の問題にも関連しています。また、水子のための地蔵という興味深い例もあります。中絶されたり流産で死んだりした胎児や生まれて間もなく死んだ赤ん坊を供養するためのものです。これは、普遍的な問題に対する日本流の解決法なのです。

　日本は、駐車違反で切符を切られる前に、警告してくれる国です。また、この国では医学に法律が関わることは少なく、衝突よりは合意が多く見られます。このことは、日本の長所と思いますが、この調和的な仕組が上手く働かない場合には個人の保護が必要となります。

　どの文化にも良い所と悪い所がありますし、隣の芝生は清々しく見えても、必ずしもより青い訳ではありません。どの社会でも雑多な意見があるのであり、世論調査をすれば、どの文化でも１つの問題について１つの考え方があるだけではないということが分かります。多様性を尊重し他人の選択を受け入れることができるような社会を、私達は作らなければなりません。

Karl Friday Email: kfriday@uga.cc.uga.edu

Dept. of History, University of Georgia, Athens, GA 30602, USA

That responsibility for the bulk of the world's ecology and environment-related problems can be laid at the feet of something called "Western Culture" has become almost an article of faith for the political and academic left. Taken at face value, this charge is, of course, tautological, in as much as "Western Culture" can be defined such that it includes--or does not include--virtually anything the accuser has in mind. Nevertheless, the accusation itself raises an intriguing set of questions: Is modern man's unrepentant rape of the world's ecology an accidental artifact of history, of the emergence of a particular society or civilization? Have human interactions with the environment, in particular the use or overuse of natural resources, been significantly determined by elements of culture, such as religious or philosophical worldviews? Are there worldviews alternative to those underlying modern European civilization that are intrinsically healthier for the environment? And would the more prominent ascendency on the world historical stage of one of these alternative worldviews have left us with a better ecological legacy today? The answer to the third question, at least, would seem to be a qualified yes. The answers to the others, however, are far less clear.

This paper briefly contrasts the ecological implications of the "Western," Judeo-Christian worldview with that of traditional Japan. It then tests the latter against the historical record, in an effort to draw some preliminary conclusions about the relationship between human environment- related philosophies and human environment-related behavior.

Anne J. Davis Email: Davis@mbox.nagano-nurs.ac.jp

(University of California, San Francisco) Fax: 0265-81-5156

Nagano College of Nursing, 1694 Akaho, Komagane, Nagano 399-41

In the USA, there is now more cultural diversity than at any time in the country's history. Furthermore , this diversity has reached into most regions of the country and not just in large coastal cities. In California, where this research took place over a three year period , the so-called minorities now constitute the majority and in San Francisco every third citizen is Asian while there is also a large Spanish speaking population.

Despite these demographic realities in California and other states, ethical issues associated with cultural diversity have been mostly ignored in health care. Those in the bioethics field as well as the health care field have assumed the universal applicability of bioethical principles that have been drawn from the Wwestern philosophical tradition.

The bioethically constructed ideal dying patient is self-governing, future oriented, and willing to engage in open and frank discussions about his/her own death. From these research data it is clear that the implications of cultural differences for bioethics practices at the end of life are significant. This research report, with a sample of dying cancer patients and their families from four ethnic groups living in San Francisco, provides some examples of this fact.

The American and Japanese Responses to Perinatal HIV Transmission: Ethics, Values, and Policy in Context

中島理暁 (Toshiaki Nakashima) Email: masaaki@m.u-tokyo.ac.jp Fax: 03-3980-2373

東京大学国際保健学講座, 〒113　東京都文京区本郷7-3-1

Dept. Community Health, School Int. Health, Univ. Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113

キーワード：HIV母子感染，保健医療政策，倫理，日本，米国

Keywords ：Perinatal HIV transmission, Public Health Policy, Ethics, USA

This paper will compare and contrast the reactions to perinatal HIV transmission in Japan to those in the United States, relating variations to both differences in social and cultural values and in the history of public health policy in the two nations. In a democratic culture, public welfare and individual liberties are often in a state of tension in public health policy. The communal public health goal of preventing the birth of HIV-infected newborns comes into conflict with the reproductive freedom of HIV-infected individuals. Although both Japan and the United States are industrialized democracies, the difference in their initial responses to the issue of perinatal HIV transmission is striking. Due to the lack of controversy over abortion and the historical absence of women's need to struggle for reproductive rights, reproductive freedom of an HIV-infected pregnant woman was seriously challenged in Japan. By locating public health and medical authorities' responses to the issue of perinatal HIV transmission in the broader historical and sociocultural context of public health, this paper will address how social and cultural values have significantly shaped the response to this ethical dilemma posed by the AIDS epidemic.

Pitak Chaichareon, Pinit Ratanakul Fax: +66-2-246-2123

Mahidol University, 45/3 Ladphrao 92 Bangkapi, Bangkok 10310, THAILAND

Euthanasia is an agonizing problem of Thai society as more and more high-tech treatments are being used by doctors. It has raised many unresolved ethical problems as witnessed by the case of Venerable Buddhadasa. The issue is further complicated because of the increased practice of organ transplantation. The question being raised now is whether Buddhist compassion as practiced by doctors should go beyond their concern for their own immediate patients to those patients whose lives could be saved by their own dying patients' organs, as Buddhist compassion is impartial and is directed to all involved in a given situation. There should be extensive dialogue between members of the public and medical profession about this issue. Doctors' patients and the public alike will be benefited by this discussion of the reality and possibility of organ transplantation.

It is clear that active euthanasia including assisted suicide is against Buddhist teaching. But passive euthanasia presents a complex ethical challenge to Buddhist morality. Doctors cannot prolong the use of life-support systems indefinitely because of complicated factors involved such as medical cost for family members, scarce medical resources, medical uncertainty, and the resulting quality of patients' lives saved or sustained. Contemporary emphasis upon patients' autonomy, that the patient should have the right to choose and refuse treatment, and the possibility of conflicts between patients and doctors, doctors and family members are the other factors that complicated the issue. But the situation is even more aggravated when cases involve incompetent patients such as seriously defective infant (e.g. spina bifida babies, and anencephalics) who may be spared the agony of short but futile life by stopping life-sustaining treatments. In this case it is not the length of life that is really significant in making life and death decision it is the infants' own agony and the futility of treatment that matter.

Suggestions are given by some Thai Buddhists that one can draw a distinction between "killing" and "letting-go-of-life" is worthy of serious consideration because in Buddhist ethics the motivation and intention behind actions are morally significant factors not simply the end result. If there really is such distinction, Thai Buddhists may feel that letting-go-of-life does not constitute a breach of the Buddhist first precept, and Buddhism can offer a "middle way" between the two extremes, i.e. active euthanasia including assisted suicide and the position of sustaining life at all costs and under all circumstances. However for the general public there is still uncertainty about distinguishing between "killing" and "letting-go-of-life", and passive euthanasia remains problematic for them. It is even more problematic for the doctors who strongly believe that sustaining the lives of their patients is their primary duty and obligation. Therefore the question of to save or let-go-of-life is a continuing ethical issue as Thai Buddhists grapple with the reality of existence in the modern world and the need to be faithful to Buddhist teachings. Like Venerable Buddhadasa more and more elderly Buddhists, monks and lay people alike, express their wishes to be allowed to die in the last stage of their lives accepting death as a natural end simply because, they believe, this is the Buddhist way of facing the inevitable death.

Atsushi Asai Email: atsushi@kuhp.kyoto-u.ac.jp

Dept General Med. & Clinical Epidemiology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-01

Co-reseachers: Yasuhiko Miura , Shunichi Fukuhara, Noboru Tanabe, Minoru Kurihara

Medical decisions concerning the end of life (MDEL) have been the subjects of sustained ethical debate recently in Japan. However, no study has provided us with a picture of what kind of ethical dilemmas Japanese physicians have in their care for the terminally ill. We therefore conducted a national survey on Japanese physicians who are involved in medical care for terminally ill patients in everyday practice in this regard.

A postal questionnaire was sent to 500 physicians who are members of the Japan Society of Cancer Therapy. Their experiences were sought on ethical dilemmas at the end of life. 339 (68%) physicians participated. Of these, 11% answered that they were always perplexed, 26% often, 39% sometimes perplexed by ethical dilemmas in MDEL. A total of 386 dilemmas were reported by 267 respondents as the most perplexing. They included decisons about life-sustaining treatment, patient's family's demand or request about medical care, patient's refusal or demand of medical care, truth telling to a terminal cancer patient including requests of patient's family not to inform a true diagnosis and prognosis to patients. Many respondents asked whether cardiopulmonary resuscitation should be performed for a terminal patient, in what situation should be life-sustaining treatment withheld, and whose wishes for medical care should be prioritized in the face of disagreement between a patient and family.

Our study revealed Japanese physicians are facing various perplexing ethical dilemmas and alternative ethical norms replacing traditonal ones should be considered.

Carl B. Becker Fax: 075-753-6647

Integrated Human Sciences, Kyoto University, Yoshida Nihon-Matsu-cho, Sakyo-ku, Kyoto 606-01

"Informed Consent" has been touted in the States as a way to strengthen patients' rights, to improve patient-physician communication, and to reduce the crippling costs of medical litigation. Now Japan's Ministry of Health is about to impose informed consent procedures on Japanese medical practitioners. This paper proposes that in the absence of other Western cultural presuppositions, informed consent will become a formal but largely meaningless procedure. Indeed, the re-revaluation of informed consent from a Japanese perspective demonstrates that (a) even where it is widely practiced, informed consent fails to provide the information and understanding that it seems to promise, (b) in order to be effective, physicians' re-education in communication skills as well as medical techniques would be required, and (c) if this re-education were possible, the need for formal informed consent procedures in Japan would be obviated.

Yaman Ors Fax: +90-312-310-6370

Unit of Medical Deontology, Ankara Medical Faculty, Sihhiye 06100, Ankara, TURKEY

Whether within the state machinery or in a private enterprise, bureaucracy has apparently two main or basic characteristics which would be worth mentioning in general terms: a hierarchical order and the preparation and circulation of written texts within its structure. To be sure, all the inter-human relationships in a bureaucratic order do not solely depend on hierarchy, and what we might call the paper exchange is certainly not limited to the interior of a bureaucratic institution.

The quality I would like to mention as regards bureaucracy in the present context may be due to a recent development - as so many aspects of human life, the bureaucracy of our time has apparently been under the impact of internationalization. Add to this the advance specialization in our time, possibly in the case of every main profession and/or academic field, and we have such a high number of knowledgeable people, whom you would possibly meet in every corner of the world. And in addition to the national and regional or local institutions, above all the states, there exists basically political international organizations such as UN, EC, UNESCO, WHO, and the multinational companies as gigantic economic powers, all of which are full of "technocrats".

The already highly internationalized field of bioethics appears to be a good example whereby you would definitely witness a variety of technical bureaucrats - a variety represented by nationalities, creed, ideologies, professions, and so on. Their approach to bioethical issues, however, an so far I have been able of observe, do have certain common aspects - seemingly moralism... as the case may be. And a confusion seems to underlie such an attitude - a confusion worth considering, and involving the concepts and activities of deontology, law preparation of regulations, establishing standards, and ethical debate.

Sahin Aksoy Email: sahin.aksoy@man.ac.uk

Centre for Social Ethics & Policy, Manchester University, Oxford Road, Manchester, M13 9PL, UK

The moral status of the prenate is one of the central issues in bioethics, which is extremely relevant to the moral assessment of in vitro fertilization (IVF), embryo research, prenatal testing and abortion. This issue has been explained from different perspectives, and various criteria have been employed. In this article I will examine this issue in Islamic texts and compare them with other major philosophical understandings and religious teachings.

One of these criteria maintains that the human person is more than a mere physical entity, and several inquiries have been made to define his metaphysical nature. From the time of Pythagoras (c. 580-497 BC) onwards many philosophers, including Aristotle, believe that the human individual consists of body and soul. When divinely revealed religions are examined it will be observed that there are similar arguments concerning the human individual.

Although in Jewish law, full human status is not acquired until birth, several distinct stages in the evolving status of embryo are mentioned which have some common features with other religious teachings and philosophical understandings. In Christianity due to the lack of relevant information in the scriptures concerned with animation (the relation of the soul to the human person), there is an uncertainty about it. However the arguments of some prominent Christian theologians are similar to ancient philosophers' understandings and the teachings of other monotheistic religions.

In Islamic texts the creating of human individual, and fetal development are referred to in various contexts, and in this paper these texts will be examined to find out whether they can help to resolve the problem of moral status of the prenate.

Maria Cristina Rosamond Pinto Email: cpinto@fml.fm.ul.pt

Faculdade medicina de Lisboa, Rua Amilcar Cabral No. 21-R/C ﾒHﾓ, 1700 Lisbon, PORTUGAL

A National wide survey to analyze the attitudes of the Health Staff regarding Advances in Biotechnology and attitudes towards Science was conducted in Portugal from late 1996 to early 1997, based on questions from the International Bioethics Survey of Macer (1994).

The survey was conducted through the medical magazine ANAMNESIS, freely distributed to the 12,000 general practitioners listed in the Portugal Medical Boards files. The magazine was also displayed at the Primary and Secondary Health Centers making the survey accessible to other specialized physicians as well as nurses and paramedics. The survey was published at a monthly rate and in separate magazine numbers. The issues focused on various subjects such as Attitudes towards Diseases, Prenatal Diagnosis, Genetic Engineering, Patenting in Biotechnology, Human Genome Project, Gene Therapy, among other topics. The first issue displayed an Editorial about the purposes of the questionnaire, emphasizing advantages and disadvantages of these types of surveys with a general positive feedback obtained in other countries where the survey was conducted.

The majority of answers were from physicians ranging from 30-66 years of age and with no experience with genetic pathology. The vast majority was not familiar or less familiar with the topics of focus although most favoured Reproductive Genetics and Genetic Engineering applied to Agriculture, Industry and Medicine. There was a high degree of agreement regarding concerns on ethical and moral issues raising from Biotechnology approaches to Medicine.

The Survey on "Medical Attitudes Towards Advances in Biotechnology and Sciences" displayed consistency of opinions referring to topics like Genetic Engineering, Prenatal Diagnosis, Attitudes towards Diseases. Disagreements or disapproval concerning Gene Therapy, progresses in the Human Genome Project and Eugenics are discussed within age, religious and other factors of the participants.

Chee Heng Leng Email: hengleng@eco2.upm.edu.my

Fakulti Ekilogi Manusia, Univ. Pertanian Malaysia, 43400 UPM Serdang, Selangor Darul Ehsa, MALAYSIA

In the strongly patriarchal cultures of Asian societies, women's position is low in many respects; although some communities, particularly those in Southeast Asia, have more egalitarian folk traditions. In many countries, women's subjugation is reinforced by state policies and practices. State population policies, backed by international aid programmes, have viewed women as pawns, whose fertility rates are to be manipulated in order to achieve some state-defined objectives. The histories of abuse have been varied: from the dumping of unsafe contraceptive technology to the practice of deception and lack of informed consent in the sterilisation of women. The availability of reproductive technologies have not necessarily led to greater choices for women. In the case of amniocentesis, for example, it has been argued that women feel pressured to use the test even though they may not want to. Women's weak position means that their interests are often subsumed by the interests of the state, community, or simply, by the more dominant groups in society. In the current AIDS crisis, for example, researchers have warned that Asian women are particularly vulnerable because of their centuries-old subjugated position. Yet there is evidence of women's agency, women having notions of entitlement, and women exercising reproductive decision-making power. This paper explores these issues; as well as whether or not bioethics addresses them, and if so, how may Asian women's position be strengthened.

Ken R. Daniels Email: K.Daniels@sowk.canterbury.ac.nz

Dept. Social Work, University of Canterbury, P.O. Box 4800, Christchurch, NEW ZEALAND

All government or government appointed committees set up to review and advise on developments in assisted human reproduction (AHR) devote attention to the consideration of the children/offspring of AHR. Reports from professional bodies and independent organisations have adopted a similar approach. This paper will review the different ways in which children's interests are presented in these reports, focusing particularly on the "rights" based and "needs" based arguments. In this respect, this area reflects the interplay of ethical, policy and legal thinking. It will be shown that the membership of the report teams and the time at which the reports were published have an impact on the way the arguments are constructed and presented. One particular area impacting on children/offspring - the sharing of information when donated gametes have been utilised - will be examined to show how children's rights and needs, although espoused in most reports, is not reflected in recommendations concerning access to information concerning their genetic backgrounds or the possibility of meeting the donor.

Maurizio Salvi Email: m.salvi@philosophy.unimaas.nl

Dept. Philosophy, Univ. Maastricht, P.O. Box 616, 6200 MD Maastrichit, THE NETHERLANDS

In 1996 the International Bioethics Committee (IBC) of UNESCO ﾒPresentation of the Preliminary Draft of a Universal Declaration on the Human Genome and Human Rightsﾓ defined ﾒhuman dignityﾓ as a fundamental element for evaluating the moral meaning of human genetic. The purpose of my talk is to examine the philosophical implications of Human Dignity -HD- as ﾒthe principle by that it should be possible to clarify the moral meaning of genetic therapies. I shall present an analysis of the philosophical implications linked to the HD view in Bioethics. If we accept this principle we have a whole of problem to clarify as: Which relationship exists between th HD and the gene transformations of a patient who has a genetic disease? Which relationship exists between the HD and Human Health? Which value may we tribute to HD: an intrinsic or a ﾒinstrumentalﾓ value? Which ethical problems are involved in the HD acceptance? My talk is focused on the examination of these questions, and has as purpose to analyse the relationship between Human Dignity and Human Health.

Christian Byk Fax: +33-1-4337-4710

General Secretary, Int. Ass. Law, Ethics & Science, 62 Bvd. de Port-Royal, 75005 Paris, FRANCE

"AIDS bring us back to the most radical spects of men and women in their bodies: blood, sperm, vaginal secretions...": the bishops of France did not hesitate to problain this in a document in which they ask themselves - and they ask us- "how can we unite in one word the highest meaning of life and the most original realities?".

Biotechnology also refer us back to original realities: genes, genetic code, the species, which although primary, were long unknown to humans because we had no science to understand them (genetics) and no technique to identify them and analyse them (molecular biology). Today, while these realities make their mark on the unfolding of all life, including human life, individuals and collective, they are also the essential elements of the boom in genetic engineering techniques used for industrial purposes. How then can we unite in one sense this human economic activity with the nature, which is sometimes equally human, of these original realities?

This question is not only philosophical. It is also legal and topical. At a time when French legislation has thought it good to introduce into the Civil Code "a status of the human body", at a time when the Council of Europe has introduced the convention on bioethics, the European Union is thinking of having a text of harmonization concerning the patentability of biotechnology adopted.

So it seems more difficult to agree to engage the human body in new legal relations when these relations are situated outside the framework of medical activity. It is no doubt because the legal nature of the body seems different here: invented and no longer discovered, but also because some people see an opportunity to assert the primacy of the ethical order over the legal order.

Anwar Nasim Email: nasim@constech.sdnpk.undp.org

Advisor on Science, COMSTECH Secretariat, 3 Constitution Ave, G-5/2, Islamabad, PAKISTAN

Revolutionary breakthroughs in genetic engineering, molecular biology and bioetchnology have led to novel ways of manipulating the genetic material. These advances have also led to the construction of transgenic plants, genetically engineered microorganisms and food items. The envionmental impact and the associated risks to human health are both complex ad challenging. One very important consideration in this whole debate is that each society will deal with these issues in the specific cultural, social and religious background, with the prevalent values and moral considerations. The present paper will examine these issues from the point of view of a Muslim society and discuss how patent laws, sequencing of the human genome, production of pharmaceutical products and hormones using transgenic animals, cloning of Dolly and the potential for experiments using human material will be viewed in the light of Islamic principles. This is certainly an added and relatively new dimension to the discussions which will provide an opportunity for sharing these views with researchers representing other societal makeups.

Kazuo Murakami Fax: 0298-53-4605

Institute of Applied Biochemistry, University of Tsukuba, Tsukuba Science City 305

I have been engaged in life science research using new biotehcnology including genetic engineering, cellular engineering, transgenic- and knockout- techniques. At first, I will summarize some of our results. Secondly, I speak about my impression of DNA and Life (Something Great). The entire DNA sequence of some bacteria have been completely decoded and the human entire DNA sequence will be in the near future. The speed of sequencing is much faster than expected in the past. The genetic aspects of disease will be understood more clearly after the complete sequesnce of human DNA is known.

However, the amazing thing is that about three billion base codes are lined up in order in a submicroscopic human DNA which weighs only 0.00000000002 grams. Moreover, from the human DNA 50,000-70,000 proteins can be produced in a beautiful harmony. The imput of all human genetic information in such a small place and the work of all the genes in the harmony had not been brought about by human being but by the (great) nature.

So, what is nature? It is a kind of ﾒNatureﾓ that shifts from chaos, disorder and diffusion to one of a unifird system and works together with other system in a concerted manner, keeping its organic relationship intact. This suggests a scientifically unimaginable great power, a kind of will may exist which I call ﾒSomething Greatﾓ.

Leonardo D. de Castro Email: Idecastr@cssp.upd.edu.ph

Dept. Philosophy, University of the Philippines, Diliman, Quezon City 1104, PHILIPPINES

Notwithstanding the existence of controversy regarding what some have called the "Georgetown Mantra," universal principles provide a shared mechanism for rational communication and debate among peoples coming from different nations on matters of bioethics. Agreement concerning such universal principles makes it possible for peoples of varying cultures to discuss common concerns using the same instrument for evaluating situations, justifying decisions and resolving conflicts. Aside from providing a tool for rational communication, universally accepted principles also serve as a catalyst for integrating culturally-rooted values and norms, mainly through the use of a common language. But the process of integration could be costly as it poses a challenge to the integrity of cultures.

Universal principles do not have universal interpretations. They take their meanings from particular cultural contexts. Outside the unique context that gives it a meaning, a principle may have no more than nominal significance. Hence, bioethicists must make an honest effort to understand the meanings of principles within their natural setting. Principles are made meaningful not by their being held in common but by their being understood in their uniqueness."

Hasna Begum Email: gulfam@dhaka.agni.com

Dept. Philosophy, Dhaka University, 6 Dhanmondi R/A, Rd. 9, Dhaka-1205, BANGLADESH

Bangladesh, like most other third world countries in Asia, is tradition oriented. It is hence not easy to infiltrate new ideas among its people. Only the survival instincts can prompt them to accept new ideas. People generally are tempted to adopt reproductive technologies to control reproduction through free distribution of food and money as incentives. In this way the ethical dilemma becomes a reality. In the case of infertility technologies can be implemented as in Islam adopt is not allowed even though there are many undernourished and uncared for children available for adoption. The scenario of bioethics is very different compared to Western developed countries due to cultural and religious traditions as economic backwardness, e.g. the bioethical problem of genome mapping and health insurance policies does not exist as there is no health insurance system in Bangladesh.

V. Manickavel Fax: +977-56-21527

Immunology Dept, College of Medical Sciences, Post Box 23 Bharatpur, Chitwan District, NEPAL

There is a lot of confusion in the synonymous use of the term moral and ethics. Here, and attempt is being made why a distinction is necessary and also it is shown, how it can be done? In all the societies to regulate the kinship certain values are established and followed. There values were concerned only about that particular society. Thus these intersocietal values were restrictive in their application and regulative immediate benefits only and understood at a particular time and space. Because of this limitation, their currency becomes valueless whenever intersocietal interaction are met with. Hence, there is a need for values which regulate intersocietal relationship and accepted by other societies at all times. This difference in the value system has to be recognized in all of the ethical discussions. Also, in the discussions of modern medical technology applications and in the resource intensive industrial developmental projects the differences between the transcendental and immediate effects should be acknowledged. It is proposed here, that, morals refer to the values of limited nature restricted by time and space and regulative of immediate benefits. In contrast ethics is about the values of transcendence. To illustrate, so case studies are discussed here, arguments are also given that technology transfers should have the appropriate ethical value consideration of that particular technology rather than the moral value consideration.

R.N. Sharma Email: sharma@ems.ncl.res.in

Deputy Director, National Chemical Laboratory, Pune-411008, INDIA

The genesis of God in human cultures seems to be undeniably linked to fear of uncontrollable forces of Nature, and uncertainity of individual destiny, which have been innate to the human ethos ever since the very emergence of modern man. Two opposite concepts of poly and mono-theism exemplified by Hinduism and Christianity are analysed. Search for enduring and Universal values and truisms through history of the two systems is deployed to identify commonalities. How far is plurality fissiparous, and partisan singularity unifying, is also compared. It is argued that progressive transcension must form the goal of all spiritual systems irrespective of regional or ethnic backgrounds. Realities of the one world concept dictated by the inescapable Space ship Earth paradigm unequivocally lead to one species, one people, and one kind, how-so-ever anomalous the current trends. This inevitability must necessarily entail a unifying, single ethicality, with or without notion of Godhead. In essence, all spirituality stems from the need for individual or personal salvation and satisfaction. Group or species obligations come next, although it may be expected that with further human evolution these may supersede the selfish propensities predominant hitherto. It is concluded that the evolutionarily transcendent human suscribe to a universal ethical force which must necessarily belong to the genre of a singularity embracing the whole human kind.

Lessons for Asia

R.R. Kishore Fax: Int+91-11-6876621

Ministry of Health and Family Welfare, Government of India; Indian Society for Health Laws and Ethics (Ishle), D-II/198 Kidwai Nagar (West), New Delhi-110023, INDIA

The world has always been under transition but it was never as fast as it is today. Fast advancing biotechnology has turned fiction into reality and the humanity is on the verge of losing its identity. The erosion of individual's autonomy and the possibilities of biological exploitation of human species have created new ethical dilemmas. This is because we can understand Nature at a much deeper level, and it means we should develop matching ethical formulations. The biological link between the past, present and the future was always present but in the contemporary milieu it has assumed new dimensions as a part of "Common Heritage of Humanity". Genetics, in its attempt to understand biology in molecular terms has led to objectification of human subjects. Fortunately (!), till today we have not been able to synthesize life and the capability is limited to synthesizing and putting together the twenty amino-acids present in living matter. What will be the scenario when we learn the art of imparting vitality to those amino-acids? Who will control whom? The Creator or the Created?

At the same time there is enormous therapeutic promise of biotechnology. The genetic knowledge carries vast potential for ameliorating human suffering and improving quality of life by diagnostic, therapeutic and preventive measures. Nearly 5000 different diseases are already known or suspected to result from defects in single genes and the screening of defective genes has become a practical possibility. Transplantation technology holds the promise of producing persons out of unborn mothers, besides replacing the disease organs.

Advancement breeds controversy. Achievements in genetic science and technology have generated controversies relating to individual's identity, autonomy, liberty and equality; commodification of the human body; humanization of animals; damage to biosphere; patentability; alteration of priorities; economic impairment; and a host of other issues. Humankind face the third form, not only life or death but PVS (Persistent Vegetative State). The rights of the mother and the embryo/fetus interfere with each other increasingly. Utility has a vast potential of making the life worthless and misconceived, compelling one to search for new meaning in objects and phenomena. Thus today's medicine is not just a clinical science. It embraces far greater meaning and expectation than the earlier times when it was confined to somatic intervention. It includes subtle appreciation of social, economic, cultural, and religious aspects of individual and societal life.

The Indian panorama presents a blend of variable trends and expectations. The country's large population of nearly 960 million, racial heterogeneity, geographical diversity, rich biosphere, economic disparities, cultural, linguistic and religious differentiation, plurality of therapeutic systems, and demographic transition, call for evolution of multi-faceted and indigenous policies in order to ensure adequate medical care to all sections of the society. Owing to the Government's limitations private enterprise has entered the health sector in a big way. This has created an urgent need for protecting the people's rights against commercialization of their medical needs. In the view of these realities, inspite of the federal system of Governance with complete autonomy to states in the matter of human health, the countries central legislature (Parliament) is case with a de-facto responsibility to set guidelines for regulation the health care and related activities. Consequently, there is perceptible attempt to streamline the country's laws by means of fresh enactment and by updating the existing laws. The international experiences are being monitored in order to assess their suitability in the Indian conditions and in certain areas there has been positive legislative crystallization.

Although there has been no statutory enactment in India in the area of human genetics, the perceptions seem to be quite clear i.e., genetic medicine should go hand in hand with conventional medicine and research in human genetics should be confined, for the time being, to specific areas which pose major health hazard to the population and in which the genetic intervention carries definite preventive or therapeutic potential, and the development of genetic medicine should not be encouraged at the cost of primary health care. As regards genetic patentability, there is distinct concern to safeguard the country's rich biodiversity against possible attempts at its exploitation by foreign entrepreneurs and the need is being increasingly felt to enact suitable statutory provisions in this regard. But this should not in any manner cause obstruction in the scientific interaction or positive exchange of information with the developed countries. It must however be remembered that the Indian responses have not been uniform and the issue of bioethics legislation in India is an open question contemplation appreciation of immediate and long-term national perspectives.

The oriental philosophy is blessed with a deep sense of universality and holism, necessary to evolve ethical paradigms on fundamental issues. For this reason I think the Asian approaches, particularly the Indian perception, can provide conceptual clarity and erectness on the emerging ethical intricacies. In this context two important statutes, recently enacted in India can be cited, namely, "The Transplantation of Human Organs Act, 1994" and "The Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994". Both the statutes reflect country's legislative wisdom and maturity by aptly reconciling the intrinsic sense of values as enshrined in the Indian cultural thought and the emerging imperatives of fast advancing biotechnology and globalisation.

In the current paper I have endeavored to analyze the Indian legislative responses in the field of advising biotechnology from different perspectives and to evaluate their merit in the wider Asian context.

Dua Kamal Kumar Fax: +91-562-351845

Department of Zoology, Dayalbagh Educational Institute, Dayalbagh, Agra 282005, INDIA

Biological resources provide the basis of life on earth. The fundamental social, ethical, cultural and economic values of these resources have been recognised in religion. The latter has not only also advanced the remedy which includes the application of ethics to protect these from further decimation. Ethics provides the basis to know what is good or bad, right or wrong. The importance in helping to make good choices concerning nature is well recognised. The World Charter for Nature, adopted by UN in 1982 states, ﾒEvery form of life is unique, warranting respect regardless of its worth to man, and, to accord other organisms such recognition, must be guided by the moral code of action. The Earth Summit is also one such step in this regard.

Bhagavad Gita (BG) has not only identified the cause for the loss of biodiversity but also put forward the solution. Further, it exhorts the decision makers to take up the challenge and act in a righteous manner. They have a great responsibility (BG II-31). They to act in a right direction and righteous war has to be launched against the demoniac persons (BG-XVI 4 to 16). The action line includes the path of knowledge. ﾒYour right is to work only, but never to the fruit thereof. Be not instrumental in making your actions bear fruit, nor let your attachment be to inactionﾓ (BG II-47).

Noritoshi Tanida Email: CZN03166@niftyserve.or.jp 　 Fax: 0798-45-6661

Dept. Internal Medicine 4, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663

Discussion regarding euthanasia has begun openly since the Tokai University and Keihoku Hospital euthanasia cases and disclosures of non-voluntary passive euthanasia in nursing homes. However, the discussions on these issues are rather confusing. End-of-life issues including euthanasia primarily stem from patient's autonomy in Western countries. On the contrary, the survey of Japanese people has indicated that the acceptance of euthanasia is not from autonomy principle but from cultural backgrounds. Japan has a long history of practicing euthanasia. The Bioethics Counsel of the Japanese Medical Association put it "there is no way other than allowance of euthanasia in very exceptional occasions as it is practiced currently". The autonomy principle has been gaining an important position in Japanese medical practice. Presumably, confusion in euthanasia issues derives from the process of introducing the autonomy principle in Japanese life and death.

Frank J. Leavitt Email: yeruham@bgumail.bgu.ac.il

Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, ISRAEL

The Israeli Sabbath, a day when we are to refrain from work and remember Gods work of creation is not just a lazy day but means of achieving a detached concern with respect to the world just as a good physician will take a detached concern with respect to a patient. As pollution, modern warfare, noise and perhaps also recombinatury genetics are changing the world beyond recognition, bioethics will have to teach us not only what we ought or ought not do but perhaps more importantly how to live sanely and morally in a world which is not as it ought to be. A cross cultural Asian bioethics will encourage a dialogue seeking the common ground of West and East Asian spirituality - Israeli Sabbath rest, Zen and Tao meditation - to work together to learn how to live in the new world.

The reason why I did not want to talk today is my attempt to observe the Israeli Sabbath, resting on the seventh day as Holy Scripture, the Bible, commands us to do: not lighting a fire, not cooking, not traveling, not manufacturing any products, not even writing. This day of rest might seem to you like taking a day off from bioethics, being a little lazy. But actually the opposite is true because I think that Sabbath rest can be a much truer devotion to the ethic of life than is all the running around which we do during the week to compete for professional promotion or to publicize our egos. But in order to explain what I mean, Ill first ask your permission to explain two different approaches to bioethics.

Medicine, nursing and biotechnology are making the world change very fast. Bioethics is supposed to talk about morals and meaning in this changing world. One approach to this is to do what Darryl Macer often calls descriptive and prescriptive bioethics. In descriptive bioethics we conduct surveys to find out what people think and how they act. And then in prescriptive bioethics we try to tell people what to do or what not to do. During the coming week in Kobe and Fukui we shall probably do a lot of prescriptive bioethics, meeting with important people from around the world and perhaps voting on some declarations about human cloning or germ line gene therapy or who has the right to do research into the genomes of indigenous peoples.

But there is another approach altogether. I think we have to be humble enough to admit that our well meaning ethical declarations might not have all that much effect anyway. One example is that five years after vast resources were spent to fly all sorts of distinguished people to Rio de Janeiro, breaking up who knows how much ozone on their way, many still refuse to reduce emissions of greenhouse gases or to set quantitative goals for emissions of carbon dioxide (BMJ (1997) 315: 3-4). I think we have to learn how to live with the fact that whether we like it or not the world is getting horribly polluted, and unbearably noisy, and bizarre genetic experiments will be performed, and researchers will pry into the genomes of innocent people with barely a pretense at informed consent, and governments will pressure less-favored citizens to have fewer or no children. It is the job of bioethics to teach us how to live meaningfully, deeply meaningfully, in this crazy new world. This is what I mean by the second approach to bioethics.

But I promised and shall now try to discuss specifically Asian bioethics. I live in Israel, the Far West of Asia. You have deeply honored me to allow me to speak at this meeting of the Japan Association

of Bioethics here in the Far East of Asia. Many people think of Israel as western, and American influence is so great that Prof. Shinryo Shinagawa, after a recent visit, wrote me that he was writing an article in Japanese calling us an American made country. And Judaism is thought of as a western religion, primarily because of the efforts of Jews who lived in Germany and tried, with tragic failure, to appear the same as their hosts. But we Israelis are really only a West Asian Semitic tribe. And our mystical, prophetic tradition has a lot more in common with East Asian mysticism than many people think. Our awareness of this fact is largely due to the scholarly researches of the late Rabbi Aryeh Kaplan ( Meditation and Kabbalah.York Beach, Maine, Samuel Weiser Inc., 1982).

I would like to dwell for a moment on a point of Asian mysticism, and then try to apply it to bioethics. I do not pretend to know much about East Asian mysticism but I have been reading books for several years about Buddhism and Zen and the Tao, and I have even started to try to learn Aikido, and even though I always feel like a total ignoramus, I think we have to risk making mistakes and try to understand one-anothers traditions if there ever is to be cross-cultural understanding in Asian bioethics.

In books on Asian mysticism I keep seeing references to non-being and emptiness. In a book called Kyudo: The Art of Zen Archery, Hans Joachim Stein discusses Tao and wu-wei. He says that Tao is the creative principle of life out of which all things are generated and that wu-wei is non-doing. (pp. 24-26). But he explains that this non-doing is not laziness or sluggish passivity or laissez-faire (just as, I might add, the Israeli Sabbath is not a lazy day), but a spontaneous activity with no craftiness or egotistical ambition, natural action without reflection. I will talk about this and other examples.

If this simplicity, this virtual separation from the world of getting and spending, could be brought to some degree into our weekday lives, if we had fewer desire for material luxuries, then mightn't our temptation to be dishonest in order to obtain these luxuries be correspondingly reduced ? Might the need for research ethics not be reduced in direct proportion to our learning to live simply ? Of course I have been discussing an ideal, which is far from our reality. And this ideal is hard enough to realize perfectly even on the Sabbath, not to mention our weekday lives. But sometimes if we keep our ideals and dreams in mind, then even if we cannot make our daily lives perfect at least we can make them a little better.

Self-Determination upon Death

五十子　敬子 (Keiko Irako) Email: irako@ff.iij4u.or.jp

〒241　神奈川県横浜市旭区中沢3-48-8

Nakazawa 3-48-8, Asahi-ward, Yokohama-city, Kanagawa 241

キーワード：安楽死，自己決定，尊厳死，パリアティブ・ケア，死ぬ権利

Keywords ：Euthanasia, Self-Determination, Death with dignity, Paliative care, Right to die

　今や二一世紀を目前にして，先進諸国においては，自然死（Natural Death），尊厳死（Death with Dignity），臨死介助（Sterbehilfe），安楽死（Euthanasia, Euthanasie）という概念構成をもって，生きている自己に自己の死をかかわらせて，死が論じられる様になった。勿論そこでの「死」は死に方の選択という態様をとるが，それはまた「死」を自己主体の領域内にかかえこむということにつながる。「死ぬ権利（Right to die）」という概念は最も端的にそれを示している。死に方の選択あるいは死ぬ権利を論ずることに対しては，「死」から神聖を奪うものという反発も起きているが，自己の死に自己決定を関わらせることは生の拡充を意味するものとなり，そこから生命の尊重に新しい地平が開けてくるとも言い得るのである。こうした基本の認識の上で，主として比較法的視座から概観し，死をめぐる自己決定についての歴史及び現状を考察する。

　積極的安楽死論についての先駆は英国で既に１９世紀末に論じられている。ひるがえって英国の現状をみると，１９９４年の上院の医の倫理特別委員会は積極的安楽死を法制化することは提言せず，ホスピス，病院，地域でのパリアティブ・ケアの推進と充実を推奨する旨報告し，政府もそれを歓迎する旨回答した。この間における歴史的経緯を軸にアメリカ，ドイツ，オランダ，オーストラリアなどの国における展開，あわせて日本近代において提起された問題点を考察し，現状を比較した上で，安楽死法立法の是非，治療の中止及び差し止めにおける説明と同意，さらに説明された上での自己決定など末期医療の諸問題についても付言したい。

With the 21st century almost upon us, concepts such as natural death, death with dignity, sterbehilfe (assisted death), and euthanasia are being discussed throughout developed countries. These concepts involve matters related to death in our lives. The death being discussed is not death itself but rather the concept of choice in dying. There is recognition of the fact that we may have control over our death as a part of our life. The concept of the right to die highlights this recognition most directly. Some may refuse to accept such ideas as the choice of dying or right to die because they deprive a person of the sanctity surrounding death. But choice in dying by self-determination may also mean extension of life. According this concept, I am researching the history and the present situation from the view of comparative law.

Voluntary euthanasia was already discussed in United Kingdom at the end of the 19th century. In that country, the Select Committee of the House of Lords recommended that there be no change in the law to permit euthanasia, and strongly commended the development and growth of palliative care services in January 1994. The government approved the Committee's findings in May 1994. I also am researching four other countries, Germany, the Netherlands, Australia, and the United States of America, from viewpoints of historical development and comparative law.

Moreover I have investigated the problems in our current world which surround the concept of self-determination in relation to artificial prolongation and termination of life, in an attempt to answer the question of whether euthanasia should be legalised.

Persistent vs. Permanent Vegetative State

塚本泰司　(Yasushi Tsukamoto) Fax: 03-3420-3829 関東中央病院　脳神経外科, 〒154　東京都世田谷区新町２ー３５ー２４　　

Dept. Neurosurgery, Kanto Shuo Hospital, 2-35-24, Aramachi, Setagaya-ku, Tokyo 154

キーワード：遷延性植物状態，permanent vegetative state，不可逆性，リビングウイル

Keywords ：persistent vegetative state, permanent vegetative state, irreversibility, living will

　1972年，JennetとPlumは，外的刺激に対する反応の欠除する状態の継続する脳障害の患者について，PVS (persistent vegetative state)と命名した。彼等はこの状態は継続するが，永続性（permanent)であるか，不可逆性（irreversible)であるかは，断言できないとして，遷延性 （persistent)という語をもちいた。しかし今日，意識障害が１２ｹ月継続したものについて，その障害は不可逆的であるとして（Bland 事件etc.)， PVS にたいしpermanentを用いる識者がおり，PVSにおいては大脳皮質の機能はpermanentに喪失している（Institute of medical ethics)などの記述が見られる。また，そのことが脳死問題における大脳死説や，植物状態からの栄養補給停止の論拠とされることがある （Truog 1997)。

　日本においては日本脳波学会が1974年，遷延性植物状態の定義をし，意識障害の継続が６ｹ月以上続いたものとしている。またPVSの訳語としては遷延性植物状態が一般的ではあるが，｀持続性｀植物状態，｀不可逆的遷延性｀植物的生存状態（生命倫理懇談会）などの用語もみられ統一がとれていない。persistentも permanentも P で始まるため，PVS　の解釈に混乱があるものと思われ る。

　米国のMulti-society task force　によると，意識障害が１２ｹ月つづけば不可逆であるとする。が、その不可逆性は経験的，確率的なものであり，科学的に証明されたものではない。例えば Higashi 他（1981)は１１０名の脳波学会の基準を満たすPVS患者について，５名の意識回復患者があり，そのうち１名は３年後，他の一名は５.５年後に徐々に意識の回復が始まった症例を報告している。

　もちろん，不可逆性が担保されていないからといって，正確な知識に基づいた living will や，医療資源の問題からの医療中止の議論は成り立たぬことはなかろう。しかし今日の新聞報道などにみる植物状態に関する議論をみるとき，permanentという用語の使用は不適切で誤解を招き， living will などを不正確な知識で作成させる心配があると憂慮する。

In 1974, Jennet and Plum proposed the name "persistent vegetative state" to describe the patient's condition with severe brain damage due to trauma or ischemia and with prolonged unresponsiveness. They used the term "persistent" instead of "permanent" or "irreversible" as they are not sure about the irreversibility of consciousness. Recently, the term "permanent vegetative state" appeared, when the unresponsive state continues more than 12 months (BLAND case in England). Some author dares to discuss the possibility of using a "permanent vegetative state" patient as a donor of heart transplantation (Truog,1997).

American multi-society task force on PVS also uses "permanent vegetative state" to describe patients whose unresponsiveness continues more than a year, and says "permanent means irreversible, though it is empirically based".

We believe that the irreversibility of PVS patient is still not assured yet, and that the term of permanent vegetative state is misleading. As Japanese doctors reported PVS patients who gradually recovered consciousness, one after 3 years and another after 5.5 years among 110 PVS patients. Moreover,"persistent" and "permanent" both start with "p" and I wonder some people take PVS means "permanent" vegetative state.

Japanese EEG society defined PVS in 1974, in which the duration of unconsciousness should be more than 6 months. Obviously it can not be taken to be permanent.

Even though PVS is not assured to be irreversible, there may exist the possibility of withdrawing food from such a patient upon his or her "living will" or upon financial bases, we must be careful in discussion of PVS, as the irreversibility is only empirically based, not scientifically assured, even when the unconsciousness continued more than 12 months.

立石彰男，福本陽平，東玲子 Email: atate-ygc@umin.u-tokyo.ac.jp (Akio Takeishi)
(Akio Tateishi, Yohei Fukumoto, Reiko Azuma) Fax: 0836-22-2687

山口大学医学部附属病院総合診療部，医療技術短期大学部, 〒755　山口県宇部市小串1144

Department of Integrated Medicine, Yamaguchi University Hospital, Yamaguchi University,
The School of Health Allied Sciences, 1144 Kogushi, Ube, Yamaguchi 755

研究協力者：山口大学付属病院総合治療センタ−　石井はるみ，吉若知英子，羽嶋則子

Cooperators of the study: Harumi Ishii, Chieko Yoshiwaka, Noriko Hajima

キーワード：集中治療，終末期，自己決定，事前指示

Keywords ：Intensive care, Terminal stage, Autonomy, Advanced directive

　ICUでの治療を必要とするような病態の終末期には，疾患そのものによる脳機能の低下や鎮静薬の使用（持続的に行われる処置から受けるストレスを和らげる目的）により，患者自身の意思表明は困難なことが多い。このような自己決定主体の不在という条件の下で，医師および近親者はどのように決定を下しているか分析を試みた。

【調査方法と結果】1)全国大学病院ICU医師にアンケート調査を行なった。改善傾向のない肝不全を含む多臓器不全の症例を示し，医師の対応を質問した。「治癒困難な状態での延命処置の中止を希望する」という患者の事前指示を想定した。約80％の医師が事前指示にいう状態に相当するとしながらも，その70％は事前指示に従うのではなく，近親者の死の受容を優先すると答えた。2）ICU で死を迎えた患者の遺族に対しアンケート調査を行なった。漠然としたものであれ，終末期に関する事前の意思表示があったものは約20％で，大多数は近親者が家族などと相談して治療方針を決定した。「医師の意見を重視した」，「患者自身の元来の意思に沿った」のはそれぞれ10％であった。

【考察】ICUでの終末期という自己決定の主体が不在な条件の下で，医療者と近親者の態度は，死を個人のものとするよりも，残される近親者にとっての意味を重視する点で符合する。リビングウイルなどの自己決定意識の昂揚によって，決定代行にまつわる心理的負担が軽減される側面と，喪失感とのジレンマを生じる側面がともに考えられる。

In the terminal stage of a critical illness which has neccesitated treatment in an intensive care unit, it is difficult for patients to express their own will because of the involvement of cerebral function and/or administration of sedative drugs (in order to relieve stress response to uninterrupted therapeutic interventions). We tried to analyze how physicians and patients' families make decisions regarding withdrawal and withholding of life-sustaining treatments in such occasions, where patients themselves cannot make autonomous decision.

1. Questionaires were sent to staff ICU physicians in 81 Japanese University Hospitals. Their attitude in decision-making was asked for an imaginary patient who had received mechanical support for multiple organ failure including intractable liver failure. The patient's advance directive was assumed, which said "I wish discontinuation of life-sustaining measures in the case my illness is revealed incurable". Although 80% of physicians answered that the patient's condition was equivalent to that mentioned in the advance directive, 70% of them attached greater importance to the families' intention than to termination of the patient's undesired life.

2. Questionaires were sent to 51 bereaved families of patients who had died in our ICU. Only 20% of patients had in advance expressed his/her thoughts on life-sustaining treatments for terminal illness to family members. In most occasions the key person in his/her family, with or without other members, had made decision. Only 10%, respectively, "followed physicians' view" or "met the patient's own wish".

In the terminal stage of intensive care, patients themselves cannot make autonomous decision on withdrawal and withholding of life-sustaining treatments. In such occasions, attitudes of physicians and patients' families agree in considering meaning of patients' death for other family members rather than regarding it as the entirely personal event. Increasing popularity of the idea of autonomy in Japan, such as the spread of living will, may reduce the mental burden of other members of patients' family accompanying playing the role of a surrogate. On the other hand, a dilemma may arise about a loss of the patient when they would obey his/her directive.

意識調査 / Survey Research on Terminal Care and Death with Dignity of Chronic Kidney Disease/Dialysis Patients

三浦靖彦(国立佐倉病院　内科) Email:ymiura@hosp.sakura-nh.go.jp(Yasuhiko Miura)

浅井篤(京都大学　医学部　総合診療部) Fax: 043-486-8696

福原俊一(東京大学　医学部　国際交流室)

田邉昇(京都大学　法学部)　　

〒285　千葉県佐倉市江原台2-36-2　国立佐倉病院　　

Yasuhiko Miura (Internal Medicine, National Sakura Hospital)*, Atsushi Asai (Kyoto University), Shunichi Hukuhara (Tokyo University), Noboru Tanabe (Kyoto University)

*National Sakura Hospital, 2-36-2, Eharadai, Sakura, Chiba 285

キーワード：慢性腎不全，透析，終末期医療，尊厳死，事前指示 　

Keywords ：Chronic renal failure, Dialysis, Terminal care, Death with dignity, Advance Directive

【目的】延命治療の一種である透析医療を受けている患者の，終末期医療に対する意識を調査し，わが国の終末期医療の現状と将来の展望を考察する。

【対象及び方法】通院中の血液透析患者500名（千葉県腎臓病患者連絡協議会の会員）および連続携行式腹膜透析（以下CAPD）施行中の100名（国立佐倉病院，東京慈恵会医科大学，東海大学，日立総合病院のCAPD患者）に，自己 記入式無記名アンケートを施行した。

【結果】余命1年の重症疾患に罹患し，呼吸器につながったまま，激しい痛 み，寝たきり，ぼけ，昏睡，の各状態が続くと仮定すると，60％以上の者が延命治療を希望しないと回答した。また，延命治療に対する事前指示（Advance Directive）を必要だと考える者は81％で，実際に何らかの形で意思表明している者が36％だった。しかし，事前指示の利点はという問に対しては，自己決定を尊重するためよりも，家族の負担を軽減するためと回答した者の方が多 かった。

【考察】昨年施行した透析医の意識調査で，患者から事前指示を受けた医師は 非常に少なかったが，患者側は，かなりの高率で事前指示を行っていること， また，終末期医療において，自己決定を尊重する欧米に対し，残される家族を重んじる傾向があることが明らかとな�