session 3

Changes in Public Opinion over Brain Death and Heart Transplant. A Validation from Science Journalism in Japan since 1967.

Ren INO, Waseda University

 In Japan, public opinion over brain death and heart transplant has some notable changes since the first successful heart transplant by C. Barnard in South Africa in Dec. 1967.Here is the outline of relevant cases:

1. Barnard’s first transplant in Dec. 1967

2. Barnard’s second transplant in Jan. 1968 (so-called “Blaiberg-transplant”)

3. First success in Japan in Aug. 1968 (“Wada-transplant”)

4. Establishment of criteria for diagnosis of brain death (“Takeuchi-criteria”) by Ministry of Health and Welfare study group in Dec. 1985

5. Special investigation committee of the Prime Minister about brain death (1990-1991)

6. Establishment of Act on Organ Transplantation in Jul. 1997

7. First heart transplant from brain-dead donor under Act in Feb. 1999

8. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul in May 2008

9. Revised Act on Organ Transplantation in Jul.2009

Barnard’s second transplant for P. Blaiberg, who had survived about 19 months, was regarded as a success at the time. Unfortunately, the first heart transplant in Japan (Wada-transplant) was made only 7 months after the Blaiberg’s, so the public opinion in Japan had missed its fraud. Japanese first recipient died two and a half months later, in Oct. 1968. After Blaiberg’s death in Aug. 1969, the attending physician Wada was accused of murder.

Although he dropped charges because of insufficient evidence, the public opinion has lost confidence in heart transplant. This distrust had continued for three decades surprisingly. Meanwhile, efforts to legislate organ transplantation and brain death certification continued, and the most decisive effect was the Istanbul declaration in 2008.

Currently, as a member in the international community, Japan keeps on making efforts to realize a positive attitude to organ transplantation and brain death with the aim of expansion of organ offer and the eradication of transplant tourism.



Exchanging the Incommensurable: An Anthropological Exploration of Commercial Kidney Transplantation in the Philippines

Yosuke SHIMAZONO, Global Collaboration Center, Osaka University

   Kidney trade has been a topic of much heated debate for a past few decades. While it has been banned in many countries, it continues to flourish in some places in the world. Those who condemn the kidney trade consider the commodification of human body parts to be exploitative of the poor and the disenfranchised. It is also seen as a degradation of human dignity, delegating what belongs to a person to a category of things. However, many physicians and ethicists have criticized the ban on the kidney trade as undue paternalism. A legalized market for live donor kidneys, they say, enhances the autonomy of the poor, providing them with a choice. The notion of self-ownership is also invoked to support this view. The fact that the debate drags on seems to suggest that it touches on an inherent tension in the “Western” conception of personhood. A question raised in this article is: What do paid kidney donors have to say about this issue? Based on fieldwork and interviews conducted with paid kidney donors in the Philippines, I examine how the voices of paid kidney donors fit in with bioethical debate. I seek to demonstrate that some paid kidney donors’ accounts of exchange are at odds with the bioethical discourse concerning the kidney trade as a “field of opinions.”



An Ethical Consideration of Low-Dose Radiation Exposure after 3.11

Fumika YAMAMOTO, Tokyo City University

 The 3.11 disaster in Japan, that is, the Great East Japan Earthquake and the nuclear meltdown and radiation leakage at Fukushima Daiichi Plant, claimed some 20,000 lives and still now a lot of people are facing risk. The scale of this disaster was so large that it was regarded as a catastrophe especially in Europe and United States. However, in contrast, it was not taken as seriously in Japan until continuation of the radiation leakage catastrophe.

In any case, it is obvious that life is at stake. Most of the problems caused by a disaster of 3.11 are, as matter of course, surely not irrelevant to the issue of bioethics. The purpose of this presentation is to make a case for investigating these problems from the perspective of bioethics.

First, analyzing the intellectual confusion caused by 3.11 disaster, I examine the reason that bioethics is failing to handle this new catastrophe (i.e. low-dose radiation exposure risk). Then, considering the causes, damage situation, range of damage, and measures that we should take, I clarify the differences between new catastrophes and old ones.

Furthermore, I consider whether we have effective ethical principles for such new catastrophes. To give an example, is the precautionary principle, which is familiar to environmental ethics, really effective? The inhabitants of Fukushima are virtually made to undergo a clinical trial. So from the viewpoint of four biomedical principles and the toxicological point of view, does it have validity?

Finally, I show what bioethics should do under conditions of medical uncertainty. A randomized controlled trial (RCT) of local inhabitants is not conducted ethically, which means essentially that we do not know enough about low-dose radiation risk; nevertheless, daily life must go on.



How Can We Justify “Moderate Paternalism” ?

Yasushi ISHIDA, Ochanomizu University

 Recently, when obtaining an informed consent in medicine, the so-called “conversation model” is endorsed to promote the patient’s autonomy.  It has been pointed out, however, that the model has many problems, in particular in terms of its practical efficacy and legal practicality. To address these problems, Howard Brody proposes to add to the model what he calls “transparency standard,” which requires a doctor to make his decision on the patient’s medical treatment adequately revealed (“transparent”) to the patient. Though this standard enhances the practicality of the model, it introduces a sort of paternalism (“moderate paternalism”). Paternalism is taken to be the interference with a person’s autonomous action, being supported by reasons that refer to the person’s welfare, benefits, and needs. But given the legitimacy of autonomy, is this version, considered to be hard paternalism that arguably violates a patient’s autonomy, justifiable? To investigate, this paper proposes to distinguish two levels of patients’ commitment for treatment: one in which patients accept that they are willing to receive some type of treatment; the other in which the patients choose to consent to a specific treatment. Most patients are willing to make the first commitment as long as they choose to see a doctor.

Patients can be competent to a certain degree in understanding any technical sense of a proposed treatment, yet irrational due to the contents of their choices and undue pressure. Although patients giving consent are considered to be ordinary adults, their situation normally meets the conditions of the lack of knowledge, the lack of (psychological) control and undue influence, all of which provide the ground for justification of weak paternalism.  Distinguishing the two types of commitment allows us to interpret that our paternalism (moderate paternalism) is in fact a weak version, which is more widely accepted. As is often claimed for weak paternalism, the intervention in the case of moderate paternalism can actually support patients’ autonomy, rather than suppress it.


A New Model of Medical Communication: Who is the Third Person both Observing and Communicating?

Naoki MORISHITA, Hamamatsu University School of Medicine

A medical communication consists of two different side communications. The one is the deciding side communication (doctor’s professional risk management). The other one is the influenced side communication (patient’s danger-fear conversation). There is a large gap between the two. And this kind of gap could not be crossed over, because the deciding side does not stand on the influenced side at the same time.

As is commonly known, in order to cross that gap, two models of communication have been advocated in medical ethics. The one is the doctor-based one-way model, which contains in itself two types: the traditional healing-medicine type and the 19th century’s modern acute disease-medicine type. And the other is the patient-based two-way model, which bioethics has recommended.

Nowadays, the second model is dominant and implies two patterns. The first one is to softly induce patients to receive professional risk decisions (by means of persuasion or enlightenment), and the second one is to aim at any just and best consensus (by the name of “shared decision”). Indeed, this second pattern seems to be more recommendable. But, in fact, it imposes a certain idea of humanity on individual human beings. In this respect of framing, this second pattern is fundamentally the same as the first one of the patient-based two-way model. And furthermore, that applies also to the doctor-based one-way model because of imposing any professional scientific frame.

Now we need the third new model, that is, as it were, the side-based parallel model. In this model, both side communications never converse and any self-changes of each side occur under the influence of outside others. However, this influencing-outside other is required to be in medical communication, as the third person both observing and communicating. In this case, who should the third person be? A possible candidate would be a nurse (strictly speaking, a pair of nurses because of the one nurse could observe the other nurse).



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