pp. 146-150 in Bioethics for the People by the People, Darryl R. J. Macer, Ph.D., Eubios Ethics Institute 1994.

Copyright 1994, Darryl R. J. Macer. All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with Eubios Ethics Institute.

Bioethical reasoning in Japan

Yuko Kato & Darryl Macer
Institute of Biological Sciences, University of Tsukuba, Ibaraki 305, Japan

1. Country Background

Japan is economically among the most developed countries in Asia and its population is over 120 million. The birth rate is at replacement level, with a gradually aging population. The economic wealth makes it one of the two largest donors of foreign aid, making the policies and values of the country important globally. In 1991 a survey of different population groups was conducted with some similar questions (Macer, 1992a), which forms a background for the current survey. A review of most relevant survey data on Japan is found in the previous book.

There are concerns about the lack of public involvement in the development of policy in Japan, as expressed before (Macer, 1992a-c). Soon after the survey was conducted in 1993 there was a political change. The Liberal Democratic Party had been majority in the Diet since after the War, but with the defection of members to form the Japan Renewal Party, and the subsequent election saw a coalition formed with the Japan New Party and other former opposition parties (excepting the Japan Communist Party). Political realignment and party changes continue in 1994, but the general view of the public is to question whether there is real change.

Compared to most industrialised countries the application of agricultural biotechnology, human gene therapy, organ transplantation and informed consent in general has been slow. However, these techniques are being introduced with some bioethical debate, and in vitro fertilisation has been practised for a number of years and is spread over 100 clinics across the country. The health care system is nationalised, providing coverage to all the population, which is a more positive sign of bioethical maturity.

2. Sample characteristics

The International Bioethics Survey was conducted in Japanese among the public and medical students. The previous survey used in 1991 (Macer, 1992a; 1993) was also conducted among nurses and nurse training students in Fukui in early 1993 with the kind assistance of Prof. Norio Fujiki and Dr Mikio Hirayama. In the nurses sample (N=301) there were 86% females; with 20% less than 21 years old, and 58% less than 31 years; 76% single, 20% married; 81% no child; 60% high school education and 33% a two year college. The education survey was conducted among high school teachers as is described in another paper in this book.

The public was very mixed with all ages represented, from 33 prefectures of the 47 in Japan. 105 requested result summaries. The students were from 29 prefectures, studying in Fukui or Tsukuba. There was higher response rate from the younger medical students in Tsukuba than theose further educated, suggesting that time rather than knowledge was a key factor in determining questionnaire response. Many in the Fukui medical student sample were from rural areas, and overall, there was quite a reasonable rural response, representing the sampling strategy.

Religion in Japan is interesting, with the number of people registered to different religions over double the total population, suggesting many claim to follow several. A few respondents put many, for example one said they were "Buddhist, Shinto, and I could agree with the idea of Muslims and Christians"! The survey options did not include Shinto, and a few marked this in the "other" response. Religion is not very important in daily life, as seen in the survey results and in everyday life. Younger people tended to be more indifferent, as seen in medical students. The Christians were significantly more religious than the Buddhists.

3. Knowledge of science and attitudes to it

More than 80% of public and medical students agreed that science contributed to their life (Q1a). They are apt to reserve clear judgement, though, the trend is similar to other countries. In Q1a and Q1e, the percentage which answered "neither" is highest in Japan. Attitudes to the application of technology seem to be similar to Australia and New Zealand, other countries with advanced economic systems. Their interests in science and technology shows us that more than three quarters are at least somewhat interested in it (Q3,5).

Nurses were not very interested in science, with 7% saying they were very or extremely interest, 29% saying they were interested, 56% saying they were not very interested and 7% saying they were not at all interested. They are a special group in this survey, and their attitudes were very different from other samples in Japan this time, or previously (Macer, 1992a). 56% agreed that science made an important contribution to the quality of life, with 7% opposed. 10% saw science as doing more harm, 19% as doing more good, and 70% as doing the same of each. 76% were positive about in vitro fertilisation, considerably higher than the public samples - suggesting medical therapy was considered worthwhile. 90% were positive about biotechnology, and 87% were positive about genetic engineering, so they did support specific examples of technology even though they expressed little interest in the general questions (Macer, 1993). There major information source was television.

In the specific examples of environmental release of genetically modified organisms (Q31) the nurses were somewhat less willing compared to the public, but the feature was the high proportions who said they did not know (for example, 45% said they didn't know about "sports fish, 39% rejected it and 16% accepted; and 55% accepted disease resistant crops, but 34% said "don't know"). In the set of questions on the use of genetic manipulation on humans, animals, plants and microbes (Q7abcd, Macer, 1992ab), about 17% had not heard of genetic manipulation, with 35% saying they had not heard of it with microbes - despite the use of recombinant DNA products such as insulin in medical practice. They showed a similar level of acceptability to the past surveys, with less benefit and less risk being perceived. The range of reasons was similar to the 1991 survey.

Among the International Bioethics Survey samples of public and students, human gene therapy is not so familiar to the public, and 23% of them answered they had not heard of it. Many people regarded scientific research as worthy, however, they also expressed worries about its impact. There are some differences between countries in Q8 about the sources of information, which could result from word usage. However, in Japan the people understood the meaning, and half said both newspaper and television, with 31% saying magazines, and 16% citing books as sources. The media could have a very strong effect on people, and the Japanese are among the highest readers of newspapers in the world.

The results of the patenting question (Q30) revealed similar results to the 1991 survey (Macer, 1992a), with rejection of patenting human genes remaining high. The 60% support for a patent on an AIDS cure was the same as Australasia. The nurses sample gave similar answers in value terms to the public, with support being 82% for inventions, 56% for books, 55% new plant varieties, 42% new animal breeds, 37% genes from plants and animals, and 34% support for genes from humans.

4. Environmental concerns

Most of the respondents agreed with the idea of that there is some value in the natural environment (Q1c), and also they agreed with animal rights (Q1i), more highly than other countries. However, environment concern in practice (Q2) was less than most other countries. Students seem to be more passive than public. And less people said Yes to Q2d compared with others. They might not realize such things in daily life or these idea might not be common in Japan, or they answer the question in a different way.

Less people included the idea of harmony in Q15 (nature), though, they might imagine scenery such as forest, mountain, ocean. In Japan, for life we asked about "inochi" using the same question as Morioka (1991), which has only partial overlap with the English word "life". Inochi usually doesn't mean daily life or lifestyle, so some differences in usage are seen (Q32, life), there are other words in Japanese that may correspond to the other meanings of the very broad term "life". Some answers like "life is mysterious" were included in the category of "God" together with some who were clearly religious. The translated comments to both these questions allow for detailed reader examination. There were a number of meanings associated with the word that can be seen from the responses.

5. Biotechnology - nonhuman

More people answered that they don't know in Q1d, Q9-12, and Q31, as in most questions compared to other countries. Among the public and nurses the proportion of people who were not aware of the use of genetically modified organisms was higher (Q13). They also have some uneasiness about products from genetically modified organisms (Q14). The nurses gave the same degree of concern as the public in 1991 for all four items (Macer, 1992a).

An interesting result is the amount of trust that people had in authorities who were making a statement about the safety of a product of biotechnology, for example a new drug (Q29). In Japan, it seems that they have no trust, especially in doctors. In fact it appears Japanese do not trust anyone very much, but the biggest difference with the other countries was that doctors and university professors were mistrusted, especially so by medical students. The general lack of trust may be a linguistic problem, but the comparison among the different groups suggests a problem in medical authority. The low trust in dieticians and nutritionists may also be related to less familiarity with these professions.

6. Genetic diseases and AIDS

Abortion of a 4 month old fetus was supported from one third of the public and more students (Q1f). Internationally, the abortion rate in Japan is very high, above that of China, and several times Australasia, in reality the people may be open to abortion if some reasons are given. Abortion of a fetus with congenital abnormalities (Q1g) was supported by 51%, with only 12% against it. There were more people saying "either" than in the other countries, which was also seen in the high school teachers.

Approval of prenatal genetic testing is high (Q16,17). The results were consistent with the 1991 survey, and continue to suggest there is no difference in Japan between public and academics as seen in the data from 1991 (1). The frequency of risk perceived was widely varied (Q18), suggesting the need for varied genetic counseling depending upon the perceptions of the individual. The genetic screening questions used in the 1991 survey (Q9-12, Macer, 1992a), found the nurses more willing by about 5% for each question, with 5% less opposition to the screening, than the public in 1991. The personal use question gave the same as last time, and this time, 57% being willing to screen their fetus - confirming that these questions seem independent of sample.

In Japan many said they knew someone with colour blindness, as a genetic disease, but few Australasians or other samples said so. The incidence of all types of colour blindness in total in Japan is about 5% of men, whereas it is 8% in Caucasians. Colour blindness is a school example of a genetic disease in Japan, and it appears that this stays in people's minds. This should make us think carefully about the way that genetic disease is discussed in schools. It is only in the last year or so that medical schools have accepted people with colour blindness.

In the open comments about people suffering with disease, most people expressed sadness or compassion, but in Japan more included a comment like "they would be happy about therapy". This may be only a matter of language, and all these comments are sympathetic. For mental disease, such as depression, more people considered the diseases their own fault, as in all countries. People were more afraid of people with neurosis.

Respect for privacy of genetic information was similar to Australasians, differing from those in the USA (Q21). People in Japan (like the Philippines) may share information more with the immediate family than in Singapore, Thailand or Hong Kong, and less in India and Australasia or the USA. Less people in Japan think that information about genetic disease or HIV should be shared with insurers and employers. Currently some employers do secretly screen for HIV, and people may be "strongly encouraged to resign".

7. Gene therapy

There was a high level of support for personal and children's use of gene therapy (Q26, 27). The overall support as measured in Q26 and Q27 significantly increased between 1993 and 1991. This we suspect is due to increased media attention, particularly during the last year. The acceptance increased over the period 1986-1992, unlike the USA. The nurses sample showed intermediate approval with the 1991 and 1993 public samples (Macer, 1992ab). The major reasons were to save life and increase the quality of life. Few people gave a reasons like "improving genes". The respondents showed significant discretion over therapeutic and cosmetic applications of gene therapy, and the support for specific therapeutic applications of gene therapy in Japan may be higher than in other countries (Q28).

8. Conclusion


The overall results were consistent with the previous survey in 1991, and with past surveys. The open questions allowed a better understanding of the reasoning of the respondents and these were generally similar to other countries. Japanese still have a positive view towards science and technology, but are also able to appreciate many of the risks that are associated. They tended to give more cautious approval to general or broad questions, and stronger approval for specific questions, compared to other countries.

The meanings of questions may differ a little because of the linguistic differences, especially in Q29 (trust) and Q32 (life). It might be character of Japanese not to express stronger attitudes or ideas, but Russians were found to express "don't know" even more. The "don't know" response does not necessarily mean they don't think anything, rather they may just like to suspend judgement. As a trend, there were not any big difference to other countries and there was most similarity with Australasia in most questions.

We need to think why the social policies on some issues are different in Japan (Macer, 1992c), and what is meaning of "international" and becoming "international", as is discussed elsewhere in this book. There is a need to bring new technologies, such as gene therapy, to the Japanese medicine, and there is positive support for this. The question is now at the infrastructure stage, and at establishing these therapies and screening programs into the national health insurance schemes. There is the need for continued bioethical education, but at least some aspects of individual decision-making, such as balancing benefit and risks, are already found in Japanese people. The problem lies in the expression of these choices.

9. Acknowledgements

We would like to thank various people for their assistance. For general assistance throughout we thank Mr Shiro Akiyama, Ms. Yukiko Asada, Mrs Nobuko Macer, and Ms. Miho Tsuzuki. For advice on the questionnaire and translation we also thank Dr Masahiro Morioka, Dr Yuzuru Oguma and Dr Yasuko Shirai. For aid with the distribution of surveys we thank Tetsuya Adachi, Keigi Hayashi, Kazumi Kaihotsu, Suzuyo Kawabe, Michiko Komatsu, Masataka Okada, Chiyoko Okamura, Shusei Sato, Maki Tsujimoto, Junko Umeki. We also thank Shiro Akiyama, Yukiko Asada, Sawako Suzuki, Minako Teramoto, Miho Tsuzuki, Keiko Wakao, and Mihoko Yamanishi for assistance with the preparation of the surveys. For preparation and distribution of the nurse sample in Fukui, and distribution of the Fukui Medical School students sample we thank Prof. Norio Fujiki and Dr Mikio Hirayama. For the distribution of the Tsukuba University Medical School student surveys we thank Prof. Hideo Hayashi.

10. References

Macer, D.R.J. (1992a). Attitudes to Genetic Engineering: Japanese and International Comparisons. Christchurch: Eubios Ethics Institute.
Macer, D. (1992b). "Public acceptance of human gene therapy and perceptions of human genetic manipulation." Human Gene Therapy 3(5): 511-8.
Macer, D. (1992c) The 'far east' of biological ethics. Nature 359: 770.
Macer, D. (1994). "Perception of risks and benefits of in vitro fertilization, genetic engineering and biotechnology", Social Science and Medicine 39: 23-33.
Morioka, M. (1991) "The concept of Inochi: A philosophical perspective on the study of life", Nichibunken Japan Review 2: 83-115.
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