1. Shizen -- 2. Chisei -- 3. Chitsujo -- 4. Jikan -- 5. Bi.

In Japan, where a prominent gap exists in what is considered a patient’s best interest between the medical and patient sides, appropriate decision-making can be difficult to achieve. In Japanese clinical settings, decision-making is considered an act of choice-making from multiple potential options. With many ethical dilemmas still remaining, establishing an appropriate decision-making process is an urgent task in modern Japanese healthcare. This paper examines ethical issues related to shared decision-making (SDM) in clinical settings in modern Japan from the psychocultural-social (...) perspective and discusses the ideal decision-making process in present Japan. Specifically, we discuss how five psychocultural-social tendencies – “surmise (Sontaku),” “self-restraint (Jishuku),” “air (atmosphere or mood, Kuuki),” “peer pressure (or tuning pressure, Docho-Atsuryoku),” and “community (Seken)”—which have often been referred to as characteristics of present-day Japanese people, may affect the ideal practice of SDM in Japanese clinical settings. We conclude that health care professionals must be aware of the possible adverse effects of the above Japanese psychocultural-social tendencies on the implementation of SDM and attempt to promote autonomous decision-making, thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life, experiences, goals, preferences, and values. (shrink)

Microautophagy is originally defined as lysosomal (vacuolar) membrane dynamics to directly enwrap and transport cytosolic components into the lumen of the lytic organelle. Molecular details of microautophagy had remained unknown until genetic studies in yeast identified a set of proteins required for the process. Subsequent studies with other experimental model organisms resulted in a series of discoveries that accompanied an expansion of the definition of microautophagy to also encompass endosomal membrane dynamics. These findings, however, still impose puzzling, non‐integrated images as (...) to the molecular mechanism of microautophagy. By reviewing recent studies on microautophagy in various experimental systems, we propose the classification of microautophagy into three types, as the basis for developing a comprehensive view of the process. (shrink)

Background Evidence concerning how Japanese physicians think and behave in specific clinical situations that involve withholding or withdrawal of medical interventions for end-of-life or frail elderly patients is yet insufficient. Methods To analyze decisions and actions concerning the withholding/withdrawal of life-support care by Japanese physicians, we conducted cross-sectional web-based internet survey presenting three scenarios involving an elderly comatose patient following a severe stroke. Volunteer physicians were recruited for the survey through mailing lists and medical journals. The respondents answered questions concerning (...) attitudes and behaviors regarding decision-making for the withholding/withdrawal of life-support care, namely, the initiation/withdrawal of tube feeding and respirator attachment. Results Of the 304 responses analyzed, a majority felt that tube feeding should be initiated in these scenarios. Only 18% felt that a respirator should be attached when the patient had severe pneumonia and respiratory failure. Over half the respondents felt that tube feeding should not be withdrawn when the coma extended beyond 6 months. Only 11% responded that they actually withdrew tube feeding. Half the respondents perceived tube feeding in such a patient as a "life-sustaining treatment," whereas the other half disagreed. Physicians seeking clinical ethics consultation supported the withdrawal of tube feeding (OR, 6.4; 95% CI, 2.5–16.3; P < 0.001). Conclusion Physicians tend to harbor greater negative attitudes toward the withdrawal of life-support care than its withholding. On the other hand, they favor withholding invasive life-sustaining treatments such as the attachment of a respirator over less invasive and long-term treatments such as tube feeding. Discrepancies were demonstrated between attitudes and actual behaviors. Physicians may need systematic support for appropriate decision-making for end-of-life care. (shrink)

Variation in decision-making about end-of-life care among ethnic groups creates clinical conflicts. In order to understand changes in preferences for end-of-life care among Japanese who immigrate to the United States, we conducted 18 focus groups with 122 participants: 65 English-speaking Japanese Americans, 29 Japanese-speaking Japanese Americans and 28 Japanese living in Japan.Negative feelings toward living in adverse health states and receiving life-sustaining treatment in such states permeated all three groups. Fear of being meiwaku, a physical, psychological or financial caregiving burden (...) on loved ones, was a prominent concern. They preferred to die pokkuri (popping off) before they become end stage or physically frail. All groups preferred group-oriented decision-making with family. Although advance directives were generally accepted, Japanese participants saw written directives as intrusive whereas Japanese Americans viewed them mainly as tools to reduce conflict created by dying person's wishes and a family's kazoku no jo– responsibility to sustain the dying patient. These findings suggest that in the United States Japanese cultural values concerning end-of-life care and decision-making process are largely preserved. (shrink)

ここで議論される“身体知”は、本選集6巻連結の先に見えている新知平を示す。それは、ホモ・ファベル(道具を有する存在)からホモ・アルターエゴ(他我を有する存在)への人間存在の転換といえる。生産物(ロボッ トやコンピュータ)を道具と見なしている主客二元的次元から、それらを“もう一人の対なる自己(アルターエゴ)”と見なす間主観的あるいは共同主観的知平の再構築である。.

Empirical surveys about medical futility are scarce relative to its theoretical assumptions. We aimed to evaluate the difference of attitudes between laypeople and physicians towards the issue. A questionnaire survey was designed. Japanese laypeople (via Internet) and physicians with various specialties (via paper-and-pencil questionnaire) were asked about whether they would provide potentially futile treatments for end-of-life patients in vignettes, important factors for judging a certain treatment futile, and threshold of quantitative futility which reflects the numerical probability that an act will (...) produce the desired physiological effect. Also, the physicians were asked about their practical frequency and important reasons for futile treatments. 1134 laypeople and 401 (80%) physicians responded. In all vignettes, the laypeople were more affirmative in providing treatments in question significantly. As the factors for judging futility, medical information and quality of life (QOL) of the patient were rather stressed by the physicians. Treatment wish of the family of the patient and psychological impact on patient side due to the treatment were rather stressed by laypeople. There were wide variations in the threshold of judging quantitative futility in both groups. 88.3% of the physicians had practical experience of providing futile treatment. Important reasons for it were communication problem with patient side and lack of systems regarding futility or foregoing such treatment. Laypeople are more supportive of providing potentially futile treatments than physicians. The difference is explained by the importance of medical information, the patient family’s influence to decision-making and QOL of the patient. The threshold of qualitative futility is suggested to be arbitrary. (shrink)

In Japan, people are negative towards life-prolonging treatments. Laws that regulate withholding or discontinuing life-prolonging treatments and advance directives do not exist. Physicians, however, view discontinuing life-prolonging treatments negatively due to fears of police investigations. Although ministerial guidelines were announced regarding the decision process for end-of-life care in 2007, a consensus could not be reached on the definition of end-of-life and conditions for withholding treatment. We established a forum for extended discussions and consensus building on this topic.

Clinical ethics support, including ethics consultation, has become established in the field of medical practice throughout the world. This practice has been regarded as useful, most notably in the UK and the USA, in solving ethical problems encountered by both medical practitioners and those who receive medical treatment. In Japan, however, few services are available to respond to everyday clinical ethical issues, although a variety of difficult ethical problems arise daily in the medical field: termination of life support, euthanasia and (...) questions about patient autonomy. In light of these conditions, a group of 17 volunteer educators and researchers from the area of biomedical ethics, including the authors, have formed the Clinical Ethics Support and Education Project, and began providing Japan’s first small team clinical ethics consultation service in October, 2006. Members include scholars of biomedical ethics, scholars of philosophy and ethics, legal professionals and legal scholars, nurses and doctors, consisting of five women and 12 men. Consultation teams, made up of a small number of members, were organised each time a request for consultation was received. Over approximately 15 months (October 2006–December 2007), the programme received 22 consultation requests from medical practitioners and medical institutions, and three from the families of patients. In this paper, we will discuss the status of our consultation service and examples of consultation cases we have handled. In addition, we will examine the process of evaluating small team clinical ethics consultation services, as well as the strengths and weakness of such programmes. (shrink)

To consider whether or not we should aim to create a perfect healthy utopia on Earth, we focus on the SF novel Harmony, written by Japanese writer Project Ito, and analyze various issues in the world established in the novel from a bioethical standpoint. In the world depicted in Harmony, preserving health and life is a top priority. Super-medicine is realized through highly advanced medical technologies. Citizens in Harmony are required to strictly control themselves to achieve perfect health and must (...) always disclose their health information to the public and continuously prove their health. From a bioethical standpoint, the world in Harmony is governed by a “healthy longevity supremacy” principle, with being healthy equated to being good and right. Privacy no longer exists, as it is perceived ethical for citizens to openly communicate health-related information to establish one’s credibility. Moreover, there is no room for self-determination concerning healthcare because medical interventions and care are completely routinized, automated, centralized, and instantly provided. This is a situation where the community exhibits extremely powerful and effective paternalism. One can argue that healthy longevity is highly preferred. But is it right to aim for a perfectly healthy society at all costs? Should we sacrifice freedom, privacy, vivid feelings, and personal dignity to achieve such a world? In our view, the answer is no, as this would require the loss of many essential values. We conclude by proposing an alternative governing principle for future healthcare, and refer to it as the “do-everything-in-moderation” principle. (shrink)

Progress in artificial intelligence technological innovation raises questions about the role of medical staff and the meaning of medical specialization. This study involved a qualitative survey of medical professionals and ordinary citizens to expand knowledge of this topic. A combination of Neo-Socratic Dialogue and Transfer Dialogue techniques, was used to acquire knowledge related to emerging forms of medical care and changing work demands after the implementation of AI, qualitatively analyzing the TD transcript only. Eleven subjects participated in two surveys. The (...) main points raised during TD were classified into five categories: i) Functions which AI could perform/would find difficult to perform, ii) Changes in medicine caused by AI, iii) Necessary preparations for the application of AI to medicine, iv) Concerns about AI, and v) Others. The survey findings suggest that initiatives to promote the acceptance of each individual in society and appropriate technological development are essential to the process of preparing for the changes in medicine following the implementation of AI. These preparatory conditions cannot be limited to medical professionals, and must extend to workers across all disciplines and to society as a whole. (shrink)

In Japan, few studies and ethical debates have addressed medical futility, but articles suggesting the practice of such treatment exist. The present study aimed to explore attitudes about this by examining personal practical experiences of those who have been involved in judging treatments as futile. We employed a qualitative descriptive design with content analysis of semi-structured and focus group interviews with 11 Japanese physicians and 9 nurses of a university hospital in Japan. The interviews mined their practical experience to identify (...) why they provided treatment that was regarded futile, factors for determining futility, and attitudes toward foregoing futile treatments. All participants had provided treatments judged as futile for various reasons, such as patient request, inadequate decision-making processes, request from another physician, and the lack of standards with which to judge futility, among others. In addition to medical science factors , participants also considered non-medical science factors to determine if a treatment was futile. Almost all participants agreed that futility should be defined and that such treatments should be foregone, but they did not take a proactive stance towards this due to factors related to the healthcare worker‟s situation or the patient. Although the implications of the present study are somewhat limited, our results indicate that futile treatments are provided at multiple treatment departments. Health-care workers employ a variety of factors to determine futility, including non-medical science factors. As provision of such treatment is not always performed for reasons of patient autonomy, diverse approaches should be employed to cope with situations regarding futile treatments. (shrink)

Background: The introduction of healthcare AI to society as well as the clinical setting will improve individual health statuses and increase the possible medical choices. AI can be, however, regarded as a double-edged sword that might cause medically and socially undesirable situations. In this paper, we attempt to predict several negative situations that may be faced by healthcare professionals, patients and citizens in the healthcare setting, and our society as a whole. Discussion: We would argue that physicians abuse healthcare AI (...) through their excessive and dependent use of it, and they will focus only on the AI services in their office and patient medical data and information, and forget to observe the patient in their clinical encounters. In the era of AI introduction, data from the wearable terminal or AI advice will become the primary target of the physician’s interest, and could be regarded as a patient surrogate. Paternalism would be paradoxically resurrected by the introduction of state-of-the-art AI. A physician’s conflict of interest related to AI as a commercial product could strongly influence his or her actions in clinical settings. We also worry that the general public will become uneasy and hypersensitive slaves to information, compulsively and uninterruptedly requesting healthcare information concerning their own health and advice from AI. An AI system capable of expressing proper and timely empathy to suffering patients could deprive healthcare professionals of their roles in terms of hospitality and emotional exchange. Finally, entire societies would soon share and consolidate healthcare sensitive information from all in the general public as part of a totalitarian healthcontrolled society where individual privacy and personal secrets could be neglected. The advent of the healthcontrolled society could lead to the metamorphosis of the concept of privacy itself into something completely different. Conclusion: Although AI which surpasses human healthcare professionals may never appear, hoping for the best and preparing for the worst is the best approach to take. To this end, we present some potential countermeasures including conducting clinical research and social investigations concerning problems surrounding the introduction of AI and developing guidelines for its appropriate use. (shrink)

In everyday medical settings in Japan, physicians occasionally tell an elderly patient that their symptoms are “due to old age,” and there is some concern that patient care might be negatively impacted as a result. That said, as this phrase can have multiple connotations and meanings, there are certain instances in which the use of this phrase may not necessarily be indicative of ageism, or prejudice against the elderly. One of the goals in medical care is to address pain and (...) suffering that develops with age in elderly individuals, and whether or not aging is a disease is inconsequential. However, assuming that an individualized and thorough examination has been performed, there are some conditions that can be attributed only to age. Accordingly, physicians must acknowledge the merits and drawbacks of using the phrase “due to old age,” and exercise caution when using it. Both physicians and their elderly patients must share a common awareness of the incomplete and limited nature of modern medicine and its scope, and physicians must help their elderly patients accept and live with the aging phenomenon. (shrink)

BackgroundInstances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan.MethodsA cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors (...) and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process.ResultsOf the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates’ considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings.ConclusionsSurrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning. (shrink)

The objective of this study was to reveal the problems related to interpersonal relationships which patients with obstinate diseases face, and consider the behavior, attitude and medical intervention that healthcare and healthcare-related professions should take in regards to these problems. Semi-structured individual interviews were conducted with patients with obstinate neurological diseases and observation of outpatient care was also conducted. Data were analyzed by qualitative content analysis. Patient diseases included Parkinson Disease , Amyotrophic Lateral Sclerosis , myasthenia gravis, spinocerebellar ataxia , (...) and progressive supranuclear palsy . Findings highlighted that patients’ disease and suffering was not understood fully by patients’ families, that patients feel a lack of family support and cooperation, and that society’s level of understanding of their disease was also insufficient. Again, findings revealed that patients recognized their inability to perform personal activities and to behave competently within the contexts of family and society. This lowered their self evaluation. These findings highlight three needs: “the need for empathy,” “the need for self the “the need for empathy” and “the need for self esteem.”This study was supported by a great-in-aid by Ministry of Health, Labor and Welfare in Japan, “Outcomes Research of Specific Diseases”（PI:S.Fukuhara）（Grand no: H14-44）. (shrink)

Tanto en su Iǧāza como en su Fihrist, Ibn al-ʿArabī se refirió a Risāla ilà aṣḥāb al-Šayḫ ʿAbd al-ʿAzīz al-Mahdawī como a una obra separada. Este documento es una carta escrita a los discípulos del Šayḫ ʿAbd al-ʿAzīz al-Mahdawī de Túnez por el propio Ibn al-ʿArabī, y recientemente se ha determinado que también sirve como una especie de prólogo de Mašāhid al-asrār. Este prólogo cubre temas tales como quién debe estudiar el Mašāhid y cómo debe hacerlo, las explicaciones de las (...) palabras difíciles que se encuentran en él y las defensas de posibles críticas contra él. La carta de Ibn al-ʿArabī es importante por derecho propio: desarrolla los conceptos de ḫatmiyya, walāya, nubuwwa y wirāṯa en sus formas originales y hace referencia a discusiones en los círculos académicos de al-Andalus y el norte de África. Este artículo mostrará cómo debe entenderse la Risāla con los Mašāhid y explorará su contenido a la luz de las obras de Ibn al-ʿArabī y su medio social e intelectual. (shrink)

Este artigo explora a dialogicidade do objeto da Estética Peirciana. Seguindo Herbart, o pragmaticista americano, em seu relato mais maduro (1911), concebe a Estética como uma ciência que lida com os dois tipos de τὸ καλόν, a saber, com a nobreza da conduta (realizada na ação) e com a beleza sensual (experimentada na arte natureza), embora predilete sistematicamente pela primeira, isto é, pelo estudo das condições da imaginação de um fim último admirável em si mesmo (considerando assim o fim esteticamente (...) em sua primeiridade, como uma qualidade possível) e que é pressuposto no estudo das condições de sua atualização como summum bonum (considerando assim o fim eticamente em sua segundidade, como norma que fundamenta relações diádicas de conformidade de conduta autocontrolada a ele). Como a (des)aprovação estética dos fins revela o fundamento último de imaginar a unidade de uma possível identidade prática, a Estética revela as condições de uma liberdade interior que torna a conduta autogovernada possível em primeiro lugar; não, porém, como dado transcendental, mas como resultado de práticas pedagógicas (Seção I). Em seguida, analisamos como a dialogicidade estética se origina da postura de primeira pessoa da questão fundamental que ela faz: “[O] que estou procurando?” (II.1); diferenciamos os partidos, fases e pressupostos dessa dialogicidade (II.2), e analisamos o papel de um ideal – em sua concretização metodológica como hábito de se sentir “crescido sob a influência de um curso de autocrítica e de heterocríticas” – joga pela causalidade semiótica envolvida na formação da conduta (II.3). (shrink)

Hay que entender que los cambios súbitos de todo tipo que nos están afectando globalmente, demuestran claramente que los modelos puramente racionales resultan ser insuficientes para dar respuesta a las complejidades de este mundo. Pero también, hay que entender que los modelos no puramente racionales han sido de difícil lectura y de poca aceptación. Pienso que este es el caso de la Crítica del Juicio. La falta de sensibilidad respecto de la apreciación de esta obra puede deberse a que la (...) misma ha sido calificada en nuestros días como el trabajo arquetípico del postmodernismo, revelando las contradicciones inherentes a toda idea de conocimiento, racionalidad, cultura y arte... “Ya no es el paradigma del clasicismo, ni del formalismo, la última del trio de las tres grandes Críticas se ha convertido de pronto, en el símbolo del deconstruccionismo”. También consideraremos a esta obra, como centro del sistema kantiano, un modelo para los sistemas complejos. Así que luego de señalar I- las discrepancias de Bauman con la Crítica del Juicio, veremos II- las correspondencias de esta obra con los axiomas del postmodernismo, y III- con los sistemas complejos. Luego IV- presentaremos un proyecto de rehabilitación de esta obra, y en V- ‘proyecciones sobre el presente’, expondremos el pensamiento de Bauman y Jonas señalando que no es el futuro, sino el presente de las condiciones globales de la vida humana y la existencia misma de la especie lo que está en peligro inminente. La metafísica de la moral de Jonas, aplicada a una ‘Moralidad sin Concepto,’ cierra el circulo de la nueva moralidad propuesta. Incluímos al final un apéndice sobre el supremo bien. (shrink)