The word "bioethics" has different images for different people. Bioethics could be defined as the study of ethical issues associated with biology and medicine. It includes cultural, ethical and social issues rasied by agriculture, medicine,and use of the environment. In Introduction To The Study of Life (1) Morioka has argued that we could call bioethics the study of life. The word seime rinri (life ethics) is well known in Japan, where it is associated with the debate over brain death and organ transplantation. Some Japanese prefer to use the word bioethics in katakana. The relevance of culture to ethics should mean that any study of bioethics will involve study of culture. In this essay, I will also argue for the reverse - that bioethics offers much to studies of Japanese culture; and that the adoption of bioethical reasoning is set to transform modern Japanese culture.
It is difficult to gauge the success of bioethics research because it can have many goals, but some measures of the success are whether decisions by people, professions, society, government and companies become more "bioethical", whether all people become involved in making "bioethical" decisions, and whether bioethical principles are applied in the form of guidelines to influence behaviour.
Thirty years ago, the subject of bioethics began being popularised in North America, stimulated by at least three major forces. Theologians expanded catholic medical ethics to general bioethics adding emphasis from the concept of human rights (2). The civil right's movement lead to the recognition of patient rights and the practice of informed consent and truth-telling. The introduction of advanced technology into clinical practice presented questions like when someone in permanent vegetative state should be taken off life support. A third force was the growing awareness of environmental pollution and the limited resources of the planet Earth (3). In Europe, environmental concerns led to the politically important Green movement in the 1980's. Also there was much stimulation to medical ethics from the introduction of assisted reproductive technology into clinical practice, and from the pressure exerted by groups concerned that modern genetics might be abused like past racial eugenic policies. This is not to say that these topics, and other bioethical issues, had not been talked about before, but it was the impetus provided by new technology which catalysed a broader public discussion of these issues (4). In fact, we can trace many of the underlying questions, and approaches to solving them, to philosophers and religions that date from antiquity.
Cultural differences and individual similarities
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. However, this concern is only just beginning to give rise to public discussion of bioethics. This delay may be more related to the structure of Japanese society than to any difference between individual person's attitudes in Japan and Western countries. This can be shown from the results of opinion surveys, for example, when individuals were asked to give their reasoning for their opinions over bioethical issues such as genetic manipulation of humans or animals, there was at least as much variety in opinions expressed by members of the general public in Japan as there was in New Zealand (5). 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. At the same time, the overall statistical results of many of the questions in that survey were similar to results of surveys in New Zealand, Europe and the U.S.A.
Perhaps the most well known difference in bioethical policy between Japan and abroad is the policy regarding brain death. People have been told that Japanese people rejected organ transplanation from brain dead donors. However, in a 1990 opinion poll of 3,000 adults, 51% of the respondents agreed with donation of their brain dead relative's organs, while 31% said they did not know, and only 16% disagreed. In a similar 1984 survey, 20% said they would disagree, while 48% agreed to donation. There has been some trend towards further acceptance in this time, but about half the people have been willing to donate organs for about a decade. The consent rate in Western countries is only somewhat higher, as is the refusal rate, with the rate in practice being much lower than in theory.
Here we have a case of misinformation in the face of statistics. Various theories were proposed to explain what were claimed to be different attitudes to organ donation in Japan. The argument was that Japanese have special cultural barriers to such donations, which has been dismissed by Japanese sociologists and religious groups (6). 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. The conclusions of a 1992 Prime Minister's committee report on the subject was principally concerned about the process to ensure that consent is obtained from donors, although the meetings of that committee itself were closed to the public. This points us to the major problem of Japanese medicine, effective doctor-patient communication, and the idea of informed consent. Perhaps the awareness by some physicians that the era of consenting organ donors may herald the entrance of informed consent into more general areas of health care is one reason why some in the medical profession object to allowing willing physicians perform such operations with "willing" donors and recipients.
Bioethics can transform cultures
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 pseduo-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 (7).
This guiding ethic is in conflict with the principles of civil rights that lead to bioethics debate in Europe and North America, and it is unlikely that the bioethics process will succeed in Japan until enough individuals raise their voices. On the positive side, the bioethics debate may be the catalyst required to transform Japan from a "paternalistic democracy". Bioethics was part of the transformation of society that has occured in Western culture, removing much paternalism from medicine, and establishing organisations and ideas to aid environmental protection. One success of bioethics in Japan may be that by 1992, all 80 university medical schools in Japan had established medical ethics committees, though there are very few women or non-physicians, and perhaps no public representatives, on these committees. Thus, while the process of decision-making is being widened, it tends still to exclude the views of the public, and often the patient. Such bioethics is not the same as the American concept, though not so different from Western Europe. However, Japan is still to involve the public in decision-making at most levels of society, something intrinsically associated with bioethics at the social level.
It is understandable that there may be the feeling that it is good to maintain some character of traditional Japan as it continues to be Westernised. People of any country may resist the rapid change and globalisation of ethics, ideals and paradigms, as ethnic and national identities may be changed, or lost, especially countries with such a long history of culture. How countries approach globalisation is a fundamental question, but many individuals in countries with access to common news media have already answered the question by their converging lifestyles and values. To the extent that human rights are more respected, this trend is to be encouraged, providing that individuals recognise more their duties to other beings on the planet, and those to come in the future.
Concern about environmental pollution is the one area where government laws were introduced. The Japanese government has attempted to be seen to be involved in a global sense. However, it may not be due to bioethical concern, as companies are encouraged to seek new products for future "green" markets. The consumerism and energy consumption demanded by economic growth is fundamentally opposed to a bioethics of a sustainable environment and world, and until people's lives are directly inhibited and damaged by the environment there is little political force to bring about a change in policy. There are strict pollution standards for certain pollutants, but the environment is still not a politically important issue in Japan. More importantly, the countryside is filled with litter dumped by some people apparently lacking aesthetic concern about the external environment, though inside their houses and in their cuisine Japanese are reknowned for their aesthetic taste. Maybe we can relate this concern to another influence of Confucianist ethics; Japanese show much concern about family, but often indifference to the outside. Though, this is to be found to some degree in the more universal idea of "not in my backyard".
Universalism
When Japan opened its doors to Western society last century it lead to the introduction of a newly emerged science and scientific paradigm, only part of the fabric of Western society. Meanwhile Western society has continued to evolve, and bioethics has emerged. It is now time for bioethics to also be developed in Japan. The development of public discussion will affect many other aspects of culture, including politics and the hierarchy of society. In order to synthesise more cross-culturally applicable bioethics needs to be discussed in many countries. All cultures should be prepared to discuss these issues, and to 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..
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. This is a fundamental issue that any honest bioethicist must face. The fact that many basic bioethical principles grew out of Christian theology, makes this issue even more sensitive. Secular philosophy has basically failed to reach a logical defense of bioethical principles, it can probably only reach nihilism (8). There is no really sound secular defense of human rights - it rests on a common religious and cultural foundation among many major countries. Even to argue using consequences does not derive the ethical principle of love, also called beneficence. However, it does not necessary mean an exclusive Christian foundation. We can find common principles in different religious and cultural traditions that are consistent with bioethics. In this regard bioethics has a lot to offer cultural studies.@Bioethics generally holds that there can be absolute good or bad decisions, but in practice, many decisions lie between. "Absolute" bioethical decision-making would mean that the correct decision may not depend on the one supported by common morality in the virtue-style of ethics said to be characteristic of Japan.
The Council of Europe has drafted a bioethics convention, in the largest attempt so far to introduce a global set of ethical rules and principles. Even in Europe there are difficulties, as can be seen in a basic issue such as abortion - illegal in Ireland and Poland, yet otherwise legal to various degrees. The diversity of views on many bioethical questions in Europe would represent most of the diversity of views found around the world. Perhaps the diversity of laws based on bioethics, for example a law in Germany making human embryo research a criminal offense, while a law in Britain specifically permits it until 14 days of embryonic age, should warn us that the existence of a bioethics law does not mean it will be absolutely bioethical. The presence of a law does not mean that a country has considered bioethics, in fact, it may specifically decide that law should not regulate some decisions. Public opinion was cited above, in any culture we will find people who reject genetic screening and people who will accept it. For three thousand years philosophers and people have expressed pro- or anti- abortion ideas.
Bioethics should make cultures more tolerant towards people who hold diverse views - yet at the same time it would justify the restriction of individual autonomy when that threatens others. Bioethics will change the decision-making process; while cultural studies are a science of observation, bioethics has an active goal. Cultural studies are necessary to understand the current process, but bioethics will take this knowledge and use it to apply to social policy and changing culture. Cultural studies in many countries to identify useful bioethical principles for decision-making may aid the evolution of the framework for making bioethical decisions. Such principles would probably need to be universally found to be successfully applied, but it remains to be seen whether different countries will balance these in the same way. No matter how the synthesis is made, cultures are being changed by bioethics.
1. Morioka, M., Seimei Gaku eno Shotai (Invitation to the Study of Life) (Tokyo: Keiso Shobo, 1988).
2. L. Walters, "Religion and the Renaissance of Medical Ethics in the United States: 1965-1975", pp.3-16 in E. E. Shelp (ed.) Theology and Bioethics (Amsterdam: D. Reidel 1985).
3. V.R. Potter, Bioethics: A Bridge for the Future (1971).
4. D.R.J. Macer, Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture (Christchurch: Eubios Ethics Institute 1990).
5. D. Macer, Attitudes to Genetic Engineering: Japanese and International Comparisons (Christchurch: Ethics Institute 1992).
6. J. Nudeshima, Lancet 338: 1063-4 (1991).
7. D.Macer, "The Far East of Biological Ethics", Nature 359: 770 (1992).
8. H. Tristram Engelhardt Jr., The Foundations of Bioethics (Oxford Univ. Press 1986).
