The title of this article asks to whom should we look when developing bioethics - to the public or to philosophers? Of course, "philosophers" refers to the broad meaning - academics, or professionals (including medical workers or any other group that claims to be able to define bioethics). The title is related to my recent book, Bioethics for the People by the People (2), which included the results of an International Bioethics Survey conducted in 1993 in a number of countries (including Australia, Hong Kong, India, Israel, Japan, New Zealand, The Philippines, Russia, Singapore, Thailand). This does not mean that bioethics can be defined by surveys (in case someone should misinterpret that), but these surveys included many open questions and the reasoning in different countries was compared, with additional comparisons to North America and Europe. The key point of this approach is that we must ask the public, and people from many countries, what they think, in order to develop bioethics.
Japanese bioethics: Responses to Dr Becker
I will go through the criticisms of my earlier article by Dr Becker, which should clarify what I mean. As I said in the introduction to my previous paper (1), it is obvious that cultural studies contribute much to bioethics, and I was making the point that thinking about bioethical issues will also change culture, a two way interaction. Most of his criticism is based on a false and very misleading assumption that I refer to "Western" bioethics - yet it should be clear from the broad definitions that I used ("bioethics is the study of ethical issues associated with life") that I do not refer to what "Westerners", or in particular Americans (in the narrow meaning of the USA), may like to consider bioethics. Often they restrict the use to medical ethics issues, and autonomy dominates everything. It is unfortunate, as I am sure we agree, that bioethics (and many other aspects of life) in Japan is so dominated by the introduction of ideas from the United States (what I referred to as a type of cultural imperialism) that Japanese have not generally developed their own approach (a point which Carl Becker was also making in his paper "Japanese traditional world-view and science" that accompanied my paper last year). It is sad that the word "bioethics" becomes immediately, and falsely, associated with recent trends in the United States, and at the end of my introduction last year I said we could trace these debates back to antiquity.
It is an unfortunate fact that few papers and books representing any indigenous modern and practical approach to bioethical debates in Japan are published, and there is very little original research if we compare to overseas. I sympathise with those in Japan who which to preserve cultural identity, as I said in that paper, and I have been attempting to develop bioethics in an international perspective over the last few years. These activities are published in several books from the Eubios Ethics Institute (3, 4), including many papers from Japanese contributors about bioethical dilemmas. In efforts to stimulate debate I also publish and distribute the Eubios Ethics Institute Newsletter, in about 70 countries of the world, and it recently has included the International Association of Bioethics Genetics Network, and is a forum of debate between other people both inside and outside of the UNESCO Bioethics Committee.
Above all, however, I consider the best approach to develop Japanese bioethics is to go to the Japanese people and ask them what they think, see how they reason, and look at the culture of today and the past. Hence the title of this paper, and the recent book (2). I also value the approach of those who study older traditions and literature, and from these combined approaches we can develop bioethics. Unfortunately most Japanese bioethicists are looking to North America, and a few to Europe, while most of those who do not are trying to oppose these views based on presumed cultural differences. This leaves very few to examine, or represent, what modern Japanese people think - and perhaps this is why this debate is between two people living in Japan who many Japanese would not consider to be Japanese.
I find the extent to which Dr Becker's criticisms are misinterpreting my earlier paper disturbing, especially if the references were read. In attempting to paint me as a bioethical "missionary" that has come to preach American autonomy he should realise that I do not agree with such views, as may be seen clearly in my writings. He also says I have "a Greco-Roman and Judeo-Christian antiquity", having "little respect for Buddhist, Taoist, Shinto or classical Japanese philosophies". Yet I wrote we should learn from antiquity with no such restrictions given, and I was referring to studies of the Japanese public. Considering New Zealand, as a part of Polynesia has a few additional roots beside Europe, and is at the opposite extreme from the USA in the spectrum of social welfare and community solidarity in health problems (Japan would lie in between), it is misleading. In fact, I am not Maori and genetically have European roots, but do share aspects of New Zealand culture which have emerged following interaction between Polynesian and European roots. Rather than criticising the authority and race of a person, an academic debate should be centred on the defense of ideas, and on consistency between observations and ideas.
Brain death
As I am writing this, it is suggested that by the time this is published there will be a law enabling organ transplantation in Japan from brain dead donors. I consider published and reviewed public opinion polls to be more reliable than student surveys, and our experience differs even with students. I agree they are not everything, but those who ignore the data and say they "think" Japanese don't really believe what they say need to provide solid data to support this. I seem to read different sociologists to Becker, and the real answer is that these is diversity. As I said before, in every culture some people reject organ donation, and in fact in a recent Swedish survey only 62% accepted donation of their own organ and 39% accepted donation of a relative's organ (5) - less than Japan! The December 1993 an opinion poll of 2116 interviews conducted nation-wide(6). Agreement that brain death is human death is rising, to 54%, with 18% saying no, and 28% saying they are not sure. The support for heart and liver transplants was high, with 74-76% supporting them and 12-14% against. This agreement is in the same range as general opinion across Western countries.
The brain death debate is a very sad episode in Japanese medicine, and people who continue to prevent willing donors and recipients from exchanging organs need to count the deaths they indirectly cause (it is measured in thousands per year if we compare to other industrialised countries) by what is quite routine technology for heart transplantation (not counting kidneys and livers and other organs). They try to say they are heroically protecting Japanese - yet in fact they are prolonging the days that people do not have access to many transplants - some heroes! Even if transplants are expensive, if we compare this to the days lost and other hospital treatment, these considerations also fail. I do understand the negative side of transplants, mistrust in doctors, and economic costs, and I have suggested elsewhere that the introduction of organ transplants and the question of consent that this raises, has the potential to speed the introduction of informed consent into general medicine (7).
Patient choice
I am afraid that when Becker says "Most Japanese patients do not want to be given choices", he is wrong. The data against this includes: opinion survey data, radio or television talk back programmes, a wide range of woman's magazines, the experience of doctors and in the number of patients who already choose what doctor or hospital to visit. It is true, like most countries, that some patients do not debate treatment details with the doctor, and that the concept of informed consent may become presumed consent - or paternalism. Some patients have chosen their doctor - and once in the hands of the doctor, so to speak, they do not challenge the doctor. Some of this is actually because they are afraid to challenge the doctor - as interviews with patients has found - they are afraid. It was therefore not surprising that the least trust in medical doctors among the International Bioethics Survey was seen in Japan (2), and especially among medical students - they don't even trust themselves!
In Western countries the family is also involved with medical decisions, like Japan, and this should remain so. However, the ultimate decision should be made by the patient. In some areas of medicine, such as genetic counseling the person seeking treatment is not sick but seeks medical services, and so some call them a client. Medical services are already open to some market choice, like shopping, and this trend has a positive impact on raising the patient above the doctor in their relationship, as in other commercial sectors. Informed choice is a phrase more appropriate than informed consent. Even in Japanese tradition the idea of taking control of one's own life is seen in the various forms of suicide, and chosing somewhere to die, so that the autonomy of writing a living will is a return to the past - before advanced technology took these decisions away from the person themselves.
Nature and harmony
If anyone should claim that Japanese have a special respect for nature, and value harmony, and that Western traditions do not, we should judge by data - what we see and what we can read in literature. In both Western and Asian traditions there is literature that supports a closeness with nature. However, sadly, in both we also see in practice disregard for nature. Japan, whether we like it or not, has a bad environmental record. Not only do we see the countryside littered with rubbish, and vending machines, and advertising signs, they have also a poor record of consumption of nature in other countries, for example, tropical timber, and use of common assets such as international fishing water. People are selfish in any culture - and everywhere economic policies have under or not valued the environment. Even the claims that native tribes in South American rain forest have a sustainable harvesting method has recently been refuted and lifestyle observations have shown that they show little respect for sustainability. Their survival depended on low population density more than stewardship.
Even the image that Japan is a harmonious society is misleading. It is true that disagreement is discouraged and a group consensus is desired, however, to avoid voicing dissent a group may split rather than debate. Which is more harmonious, somewhere where there is division inside one association but it remains intact, or somewhere where division results in two or three associations who split from one.
As I said in the past paper, and just above, we should develop a bioethics that is culturally appropriate, and tolerant. Becker claims that "Christians" are intolerant and lack harmony - whereas Japanese are supposedly so? Many old Asians would not agree, after the Second World War and occupations of Korea and China, and South Eastern Asia. It is a dangerous comparison to make - but it suggests harmony or humility is not a special virtue of Asia. Neither would one call communist China, North Korea or some other governments in Asia tolerant - their way to reach harmony is to remove opponents. I consider Asia has a lot to offer to bioethics, Asia was the home of most major religions in the world, and represents half of the world's population. The point is that all countries have a bloody past - and comparisons are therefore very limited.
Cross-cultural bioethics
One of the key issues here is whether people in different countries are different as groups from each other. Here we have data of several types to suggest that they are actually similar, and I refer readers to look through the reasons expressed and reproduced in recent books (2, 8). Analysis of the comments reveals more similarity than difference, and it also clearly shows the total diversity in any one country is as great as the whole. The data is consistent with common reasoning - and rather than opinions and desires let us see data to the opposite.
Becker claims that we can formulate bioethics from secular principles, which is quite debatable. Yet let us look at the list and defense he proposed (I will use his numbers). What is the basis of principle (1, 4 (cultural), and 5)? These are based on respect for human "rights" - and deriving human rights, or respect for other people, from secular philosophy is based on their possession of some character. People who do not possess this character (the word often used is autonomy!) do not deserve such rights, according to that approach. Inside philosophy the question of whether future nonexistent persons can have any "rights" is not yet defensible, and is a common philosophical debate. (2, 4 (biological diversity)) Respect for nature does not come from secular philosophy, rather it is inside every person as a value. (3) Population control implies responsibility, again based on protection of the future, and economic sense. Quality of life is desirable, and could be defended by utilitarianism. (6) Decision-making including the wisdom of elders and history is a value choice, that their wisdom was useful to apply to today's world - it is hardly secular philosophy. This certainly does not mean I disagree with the value of such principles, but rigorous thinking in published bioethics literature shows they are based on religious and cultural values, and they include values shared in the Christian West or Japan, and certainly in the emerging common bioethical framework (2).
The dangers of views that Japan is special are twofold. One is that it is counter to the data and thus represents a theory inconsistent with observations. The second is that it is nationalism, and such nationalism is a basis that may be misused by people for future attempts at domination. In the bioethics world, the most nationalistic country is the United States - however, other countries are also approaching nationalistic views. It is nice to say that it is up to each country to decide their own policies, however, no country is an Island. Both Japan and the United States are major supporters of international aid by virtue of their wealth, and such aid has been made conditional upon agreement with the policies of the donor country, as seen in the restrictions on family planning funding in the Reagan-Bush presidency. The mass media does much to internationalise thinking, though they are often misused. Japan is no longer an Island, it cannot turn the clock back and remove "Western medicine" - and Japanese people are generally educated well enough to think for themselves.
In conclusion I would share Becker's final sentence, "Japan's rich intellectual heritage offers much to any serious scholar of bioethics", and add that any study of Japanese bioethics should start with what Japanese people think, look at the traditions elsewhere and develop an approach that can be used from now for the future. Unfortunately, and but often fortunately, we cannot return to the past - we must proceed from now with the development of society. I also agree that technology is a powerful agent of cultural change, but add that how society deals with technology (including bioethics) is another moulder of culture. We must look forward, and in my opinion this requires people to be able to judge benefits and risks for themselves, and to have choice.
1. D. Macer, "What can bioethics offer to Japanese culture", Nichibunken Newsletter 15 (August 1993), 3-6.
2. D.R.J. Macer, Bioethics for the People by the People (Eubios Ethics Institute, 1994).
3. N. Fujiki & D. Macer, eds., Human Genome Research and Society (Eubios Ethics Institute, 1992).
4. N. Fujiki & D. Macer, eds., Intractable Neurological Disorders, Human Genome Research and Society (Eubios Ethics Institute, 1994).
5. M. Santer, "A comparison of public attitudes toward autopsy, organ donation, and anatomic dissection", J. Amer. Med. Assoc. 271: 284-8 (1994).
6. Yomiuri Shimbun (12 Jan), 1, 20-21.
7. D. Macer, "The 'far east' of biological ethics", Nature 359: 770 (1992).
8. D.R.J. Macer, Attitudes to Genetic Engineering: Japanese and International Comparisons (Eubios Ethics Institute, 1994).
