In Japan, there has been concern about bioethical issues such as environmental pollution, suspicion of the medical profession and its paternalism, and the question of brain death. Public discussion of bioethics has only begun in the last few years. The delay is more related to the structure of Japanese society than to any difference between individual person's attitudes in Japan and Western countries. When individuals are asked to give their reasoning for their opinions over bioethical issues such as genetic manipulation of humans or animals, there is as much variety in opinions expressed by members of the general public in Japan as in Australia or New Zealand (Macer, 1992a, 1994). Many people perceive simultaneously both benefits and risks from science and technology. The diversity of reasoning exposed in the survey was independent of education or age, and similar diversity of reasoning was found among members of the public, high school biology teachers, and scientists. The overall statistical results of many of the questions in surveys conducted in 1991 and 1993 are similar to results of surveys in Australasia, Europe, India, Russia, Thailand and the U.S.A. (Macer, 1994).
Perhaps the most well known difference in bioethical policy between Japan and abroad is the policy regarding brain death. People are still told that Japanese people reject organ transplantation from brain dead donors. However, about half the people have been willing to donate organs for about a decade (Macer, 1992b). The consent rate in Western countries is only somewhat higher, as is the refusal rate, with the rate in practice being lower. The argument was that Japanese have special cultural barriers to such donations, which has been dismissed by Japanese sociologists and religious groups (Nudeshima, 1991). In every culture one can find people who reject removing organs from bodies, of their own or family members, and their views should be respected.
A more serious doubt in the minds of some people is whether they can trust the doctors who make the decisions about transplantation. Japanese show less trust in medical doctors than people in New Zealand, Australia or the U.K (Macer, 1994). Even in the most widely respected of Japan's attempts at providing a national forum, The Prime Minister's ad hoc Committee on Brain Death and Orgna Transplantation, which reported in January 1992, had closed meetings which were in conflict with the purpose of a forum in which public views should be heard. It was unusual for Japanese committees because it did have a minority opinion, not being unanimous, though this is not always in itself a sign of logical discussion. This points us to the major problem of Japanese medicine, effective doctor-patient communication, and the idea of informed consent. A long awaited law to allow transplants is expected soon, but it will not define death as brain death. It may herald the entrance of informed consent into more general areas of health care. The delay in accepting brain death may also be related to an attempt for power in medicine by some in the law profession. The Japanese health care system has many other ethical and scientific problems (Imamura, 1993).
Bioethical decision-making involves recognition of the autonomy of all individuals to make free and informed decisions providing that they do not prevent others from making such decisions. This is consistent with democratic principles, and the extent to which a society has accepted this is one criteria of the success of bioethics. However, the structured paternalism of Japanese society is built on the idea that only the views of so-called experts (sensei) should be heard. It also means that their views should not be questioned, in accordance with the traditional paternalistic Confucian, or pseudo-Confucian, ethos. Medicine is "an art of Jin", the expression of loving kindness (Jin) by the health care professional. The main theme of Confucianist ethics was the maintenance of moral discipline for the nation, society and the home; and it was to the benefit of rulers and family leaders. Therefore, it is not suprising that many of the authorities in Japanese society share this ideal because it means respect for them, and hence reject autonomy-centred bioethics. They may promulgate the idea that Japanese are different as an attempt to prolong the Confucian ethic. They also believe that medical ethics can be determined within the profession, and there is little need for a wider forum.
This guiding ethic is in conflict with the principles of civil rights that lead to bioethics debate and the establishment of some national forums in Europe and North America. The bioethics debate may be the catalyst required to transform Japan from a "paternalistic democracy" (Macer, 1992b). Japan looks to the U.S.A. for ideas on many issues, so if the U.S. re-establishes a national forum on bioethics, Japan may think it needs one too. However, another barrier to possible establishment is the divided power sharing of each Ministry associated with health care or environmental issues. At University Hospitals both Ministry of Education, Science and Culture, and Ministry of Health and Welfare, approval is required for all therapy. There needs to be two sets of guidelines for human gene therapy to be possible in University medical schools, which were released in the last year. Public opinion does support gene therapy (Macer, 1992c). New reproductive technologies are offered in over 100 clinics nationwide, regulated by Association guidelines, and have had no public forum, despite the high level of individual concern over in vitro fertilisation seen in Japan (Macer, 1993). There are no signs of a public forum being initiated for any issue.
The development of public discussion affects many aspects of culture in any country, including politics and the hierarchy of society. Hanna et al. (1993) say that there is no longer any single voice such as the church so people look to the government. However, public trust of authorities in any country are rather low. Japanese have little faith in any authority, and authorities that are little trusted are not likely to be willing to establish independent bodies (which are usually more trusted) if such bodies are going to have different conclusions from the government. Some bioethical issues, like brain death, do not run along political party lines, but in some countries some issues involving value questions of human life and human intervention in life (e.g. embryo status, abortion, euthanasia) do, but not in Japan. Politicians show little interest in making new laws or policies on these issues, it is left to Ministries, professional medical associations, law courts, or individual consumers.
The time has come I believe for more than many national bioethical forums, but international forum, such as the Council of Europe and United Nations bodies. Countries are forming alliances economically and legally. Some bioethical issues, such as patenting the human genome, germline gene therapy, health care system treatment of non-citizens, are international. The forward step to make is to establish international policy, however, nationalism will attempt to maintain national policy. Although claims that there are universal bioethical principles that all people should observe can be criticised as a type of cultural imperalism, already in the UN Declaration of Human Rights and the International legal codes protecting individual rights, we can see recognition of some universal principles. Also, as countries become more multicultural there is a need to develop universal bioethical solutions to the perpual dilemmas of decision-making. In order to synthesise more cross-culturally applicable guidelines, bioethics needs to be discussed in many countries and at international forum. All people should discuss these issues, and change to the degree that is consistent with the recognition of our duties to all others on this planet and to aid the sustainability of human society and the environment in a global age.
Hanna, K.E., Cook-Deegan, R.M. & Nishimi, R.Y. (1993). "Finding a forum for bioethics in U.S. Public Policy", Politics & Life Sciences 12, 205-19.
Imamura, K. (1993). "A critical look at health research in Japan." Lancet 342: 279-82.
Macer, D. (1992a). Attitudes to Genetic Engineering: Japanese and International Comparisons. Christchurch: Eubios Ethics Institute.
Macer, D. (1992b). "The 'far east' of biological ethics." Nature 359: 770.
Macer, D. (1992c). "Public acceptance of human gene theray and perceptions of human genetic manipulation." Human Gene Therapy 3: 511-8.
Macer, D. (1994). "Perception of risks and benefits of in vitro fertilization, genetic engineering and biotechnology", Social Science and Medicine 38: 23-33.
Macer, D. (1994). Bioethics for the People by the People. Christchurch: Eubios Ethics Institute.
Nudeshima, J. (1991). "Obstacles to brain death and organ transplantation in Japan." Lancet 338: 1063-4.
Please send comments to Email < Macer@sakura.cc.tsukuba.ac.jp >.