References to Japanese / Asian traditions in the Japanese bioethical debate. Some Examples and Methodological Reflections


Introduction
Ladies and Gentlemen,
I am very proud an happy to be able to speak to you today. The topic of my paper is: References to Japanese and Asian traditions in the Japanese bioethical debate. Some Examples and Methodological Reflections.

Accordingly, in the following, I will The main material of my investigation will be introductory works on Bioethics in Japan. I chose this kind of material, because it also teaches us in respect to which subjects Japanese cultural traditions are invoked in the Japanese literature.
Before I jump right into the subject, let me make two clarifications on terminology:
By Japanese literature I refer to what is written in Japan, or by people who are permanent residents or citizens of Japan, or descendants from Japanese who identify themselves as Japanese and relate to a Japanese environment; thus, Japanese translations or adaptations of European or Angloamerican sources are part of Japanese bioethics, as are bioethical initiatives or reflections by permanent residents of Japan without a Japanese passport, if they are part of the public discourse in Japan – Carl Becker at Kyoto University would be one example.
Secondly, by tradition I refer to a distinct way of doing things with normative implications that is being passed on between a plural number of individuals in a mode of inter-generational transmission. That is, any form of culture or sub-culture goes into the stage of tradition when it is passed on to a second generation of followers. Thus, as we have now in Japan a generation that studied bioethics with the pioneers of Japanese bioethics, and is now publishing and teaching - examples would be Morioka Masahiro, or Tsuchiya Takashi - we can, and should, speak of a Japanese tradition of bioethics.
So much by way of introduction. Let me now proceed to the main issue of my talk, and present you with some of my findings concerning the topic of Japanese culture and traditions from introductory works on bioethics.

Japanese culture and traditions in introductory texts on bioethics
As I said, in this section I will briefly summarize, how „Japanese culture" and „Japanese traditions" are treated in various introductory works on bioethics from Japan. I will follow these works in a chronological order, so that we may derive an understanding also of continuities and discontinuities within the past two decades.
One of the first general introductions on bioethics in Japan was Yonemoto Shôhei‘s Baioeshikkusu, first published in 1985 and still a classic. In 1985, Yonemoto Shôhei was a science journalist. He later became a member of the Cabinet Commission for Inquiry into Clinical Brain Death and Organ Transplantation, and today is director of the Mitsubishi Center of Life Sciences and Society.
The major part of his book is dedicated to an introduction of the US-American bioethical debate.  The issue of a specific Japanese culture only emerges around page 200, when Yonemoto turns to the subject of brain death.  Here, he firstly mentions that scientific research is to some extent dependent on culture, which influences interest in certain fields or excludes others. He specifically points to the inexistence of sexology in Japan (1985: 199). From there, he goes on to explain that there is a specific cultural background to the different ways brain death and organ transplantation are treated in Japan and in the West. In his opinion, in Western countries the human body tends to be perceived as a machine, whereas in Japan, it is seen as a person.  These „tendencies" (keikô) lead to different perceptions of transplantational surgery: While in the West, there is a powerful rhetoric that equates transplantation with the exchange of spare parts, in Japan, it is seen as a way to continue the life of  a person byond death (Yonemoto 1985: 200). Yonemoto also mentions that the strong resistance in Japan against organ donation from brain-dead patients may have something to do with the Japanese folk Buddhist mythology of death: According to this myth, the departed have to cross the river of death,"Sanzu no kawa éOìrÇÃêÏ", in a state of integrity, before they receive their judgment, pass through the death-world and finally ascend to Buddhahood. (Yonemoto 1985: 202; Bukkyôgo daijiten:  478-2).
Another classic of Japanese bioethics is Kimura Rihito‘s Inochi o kangaeru. Baioeshikkusu no susume („Thinking about Life. Recommending Bioethics"), first published in 1987. Kimura, a Japanese Christian who is a Professor both at Waseda University in Tokyo and at the Kennedy Institute in Washington,  championed the cause of patients‘ rights in Japan. In his view, every country has its own, distinct culture, morals, and ethics. These have to be respected. Still, to Kimura these specific traditions cannot demand absolute respect. Kimura sees a conflict between the older Japanese traditions and the respect for human dignity and human rights that informs his version of bioethics. He demands that in such cases, where traditional culture clashes with universal values, it has to be reevaluated in the light of international standards (Kimura 1987: 123-124).
While in the case of Yonemoto and Kimura, the issue of Japanese traditions does not receive more than occasional attention, Morioka Masahiro in his 1988 „Invitation to Life Studies", a bold  attempt by a then still very young author, dedicated a whole chapter to the specifically "Japanese transformation" of bioethics.  
The first point Morioka mentions is the Japanese tradition of importing and adapting ethical systems - for example Buddhism and Confucianism, which goes along with a tendency to "deuniversalize" them (152). Morioka, relating a book on „The Heart of the Japanese" by Sagara Tôru (1984), says that in Japanese culture, principles (dôri ìπóù) are interpreted not as tools to systematize theories with a claim to universality, but as something which lives naturally in the feeling heart (Morioka 1988: 153). In Japanese bioethics, this traditional tendency shows in various ways. One is the conspicuous absence of critical discussions: opinions may contend, but there is rarely an attempt to mediate opposing viewpoints in order to achieve a new synthesis (Morioka 1988: 156-157). There is also a tendency in Japanese bioethics to move from universal principles towards emphasis on human relations and human feelings (157-161; examples from Iida Nobuyuki (1985), Nakamura Keiko et al). This tendency is also connected to a preference for the "natural" , as evidenced in much of the bioethical literature (Morioka quotes Nakajima Michi ( and Sagara Tôru, Morioka 1988: 163). What is "natural" is also the object of an unanimous consensus, because it does not provoke any resistance (164-165). This goes along with "group thinking" (165).
Finally, Morioka critically reflects on references to Japanese culture. In his opinion, these tend to foster authoritarianism (167-168). In other words, references to „the" Japanese tradition in bioethics tend to obliterate self-determination and human rights. Here, he explicitly refers to Kimura Rihito‘s above mentioned statement (170-171). Still, Morioka sees that a "Japanese transformation" of Bioethics, if it is seen in line with other local adaptations, may help to test claims to universality, which are made by traditional Bioethics with its roots in US-American society and culture (172).
The physician Hoshino Kazumasa, formerly Chairman of the Kyoto University‘s Medical School Bioethics Committee and another leading figure in Japanese bioethics, has often referred to a distinctly Japanese way of thinking in his international publications. In his introductory work on „Medical Ethics" (Iryô no rinri), written for the general Japanese public, he points to an aversion against formal regulation of ethical matters as a general cultural trait of Japanese society. He therefore argues in favour of a  transformation of "informed consent", which in his opinion should be regarded as a moral rule guiding subjective behaviour rather than a formal or legal provision (a point refuted by Katô Hisatake, see below). In Hoshino‘s view, the weak standpoint of the patient makes the standard procedure of "informed consent", through the filling in of forms  counterproductive (1991: 97-98; 101),
The points made by Hoshino recur in a more elaborate fashion in a book by one of present-day Japan‘s most renowned philosophers, Nakamura Yûjirô, which I quote here although it is not exactly written as an introduction to bioethics proper. The main issue of the book (Nakamura 1992) is „clinical knowledge" (rinshô no chi ó’è∞ÇÃím), which according to Nakamura is a paradigm of knowledge in its own right, with a high significance far beyond the scope of clinical medicine. However, the book does have a lengthy chapter on bioethical matters.
Nakamura makes several references to specifically Japanese traditions. He first mentions differences in the legal and social institutions between Japan and the US, which necessitate an adaptation of concepts developed for the framework of American society. But these differences are also related to common social practices, including ways of perception and moral argumentation. Nakamura explicitly refers to the fact that in Japan there is no strong tradition of legal contention as a manner of conflict resolution. Other elements of difference are a lack of rhetorical force of the references to „humanity" and other abstract notions, and an aversion against clear-cut utilitarian calculations (175). Nakamura admits that Japan has a modern formalized legal system, meaning that there are interpersonal relations based on legal contracts, but, he says, there is still a strong substratum where people relate to each other on the basis of an emotional sense of community (184). Discursive public arguments, which  would pinpoint opposing viewpoints against one another, are generally avoided (189).
Referring to the problem of brain death, Nakamura mentions a strong emotional attachment to mortal remnants in Japan as a specific cultural trait, giving the example of victims of plane crashes, where relatives go out of their way to bring the relics back to Japan (184). He also makes a very interesting observation, which leaves the framework of „national culture": in his opinion, the contesting views on brain death are in part due to a cultural differences between occupational groups, such as specialists in private or criminal law, or pathologists and clinicians, which may be more important than differences in religious traditions and the like. In his view, pathologists and experts in criminal law tend to favour brain death criteria because of a professional preference for clear-cut distinctions and universally applicable concepts. On the other hand, specialists in private law and clinical physicians professionally have to pay more attention to individual characteristics of a given situation, and rather avoid either-or decisions, which makes them favour a view of death in terms of a process.
However, when he turns to the aversion within the Japanese lay population against the brain death concept, Nakamura reverts to an explanation in terms of national traditions: He assumes that this aversion is nurtured by a traditionally monistic view of body and mind (194), although this may also be a convenient tool used to avoid a thorough exploration of the problems at hand (191).
With reference to the concept of informed consent, Nakamura points out that Japan has a medical system which is strongly informed by European and American influences. Modernization and technicization of medicine lead to a more anonymous relationship between doctors and patients everywhere on the globe. Likewise, paternalism is the hallmark of the more traditional modern medicine in many countries, including Japan as well as the USA (197-198), the concept of patient autonomy being a rather recent invention. As Nakamura points out, the „natural" prevalence of paternalism conforms with the exemplary situation that brings patients and physicians together: patients consult doctors, because they suffer, and that is, they are weak; they also lack the knowledge that physicians possess. Still, Nakamura sees specific Japanese traits concerning the question of informed consent. The general ethos does not encourage explicit formulation of individualistic goals. Rather, people choose indirect ways to express their wishes, which is a way to avoid open confrontation. Nakamura even assumes that the Japanese lack a conscious individual ego, and tend to fuse with their environment (206-207). Even within a paternalistic structure, there is no clear polarity between those who make decisions, and those who are taken care of. Thus, Nakamura thinks that in Japan, we should rather speak of „maternalism" than of „paternalism", and he points to the fact that such a maternalistic atmoshphere makes it difficult to accept the formal practices that come with the legal concept of informed consent, i.e., the filling in of forms etc. (207-208). Therefore, he argues in favour of a personal encounter between physicians and patients, where the physician has to translate his specialist knowledge into everyday Japanese, which would put both sides on a more equal footing and foster a feeling of empathy and commonality (208-209).
This relegation of informed consent to the sphere of personal relations between patients and physicians, sponsored by Hoshino or Nakamura, is expressly refuted by the philosopher and ethicist Katô Hisatake in his book on „Exemplary problems of bioethics" (Katô 1999). Katô notes that reservations against the concept of informed consent often refer to the absence of individualistic traditions in Japan (172). However, "informed consent" is not a matter of discretion, but already a part of legal provisions in Japan (on this matter, see also Kanagawa 1998). It is part and parcel of modern, formalized and technicized medicine, and as such has already been incorporated into the medical tradition of Japan. On the other hand, Katô states that the concept of „informed consent" is open to an interpretation that does not require explicit consent for every single medical intervention by the patient. In other words, the patient can give "comprehensive consent" (hôkatsuteki na dôi ïÔäáìIÇ»ìØà") by asking the physician to choose the treatment he deems most appropriate (173). This may be termed a cultural adaptation of the norm of informed consent, which is in accord with older traditional mores of Japan.
Katô also refers to Japanese traditional thought when he discusses the question of brain death. He questions the assumption that the traditional Japanese understanding runs contrary to an equation of brain death with death. In his opinion, traditionally to die means to become an inhabitant of the „Land of the Yellow Springs" (yomi no kuni â©êÚÇÃçë), from which one does not return (yomigaeranai ÇÊǛǙǶÇÁǻǢ).(1999: 54-55) In this respect, he also adduces ancient Japanese notions, mentioned in Kojiki, of an invisible substance (= soul) that leaves the body at the point of death to go to this land of the "Yellow Sources" (57-58). Thus, the traditional criterion of death to Katô is the irreversible loss of conscious or spiritual presence in the body, which can be matched with brain death criteria. Katô also insists that there is already a Japanese / Asian tradition of modern science; thus, it will not do to pinpoint „Western" scientific concepts against „Eastern" traditional religions.
I have somewhat extensively related references to culture and tradition within six representative examples of introductory literature on bioethics from Japan. Let me now briefly summarize what we found, and add some methodological reflections.
Analysis and critical reflections
First of all, the issue of culture and tradition seems to receive only passing attention. Only one of the six works quoted devotes extensive deliberations to the subject. In all the others, „culture" and „tradition" come into play as a form of auxiliary explanatory tool. They serve to explain specific difficulties that arise in relation to individual bioethical topics, most exemplary the issues of informed consent and brain death. In these cases, tacit assumptions about the existence of a distinctively Japanese culture come into play. This concept of a unified „Japanese culture" is used by all authors, and critically reflected upon only by two of them, Morioka and Nakamura, who nonetheless employ it.  The specific traits associated with „Japanese culture" vary to some extent. Recurring features are:
– A preference for tacit consent, empathy and indirect communication, the other side of which is an aversion against explicit confrontation of opposing interests and opinions, and against thinking in terms of abstract, universalist notions.
– The preference for empathy over rational understanding and mediation concurs with an optimistic outlook on the possibility of harmonizing interests within a community; formal regulation and legal contention are avoided as much as possible.
– Japanese culture is seen as discouraging individualism and embracing a form of authoritarianism, which resorts to a tacit manufacturing of consent through promotion of harmony, rather than the explicit use of forceful measures. Only Nakamura to some extent criticizes the equation of „authoritarianism" with „Japanese tradition", and „equality" with „Western thinking" in mentioning the streak of paternalism that is still operative in Western medicine as well. On the other hand, he does not feel compelled to seek for an ideal of equality within any of the older Japanese traditions, and he reinstates the model of a specific Japanese culture of paternalism in theorizing about a „soft" Japanese authoritarianism, and an ego-less Japanese psyche.
– A preference for harmony and unity is also seen to govern Japanese traditional thought on the relation between body and mind. A strict form of dualism between mind and matter, body and psyche etc. is seen as something exclusively „Western". This assumption is only contested by Katô Hisatake, who points to a dualism of body and soul in ancient Japanese sources. Katô is also the only one who explicitly refers to modern science as part and parcel of contemporary Japanese traditions.
All these characteristics are well-known features of modern day „theories of Japaneseness" (nihonron), a very popular genre seeking after the essence of Japanese culture, which generally mingles descriptive and normative traits (see Aoki 1996). Those authors who described traditional Japanese culture as emotional, communitarian, hierarchical, harmony-oriented, monistic and not rational, principle-oriented, confrontational, democratic, egalitarian, or individualistic,  in all probability were only repeating what they regarded to be well-established facts and perceptions.
In this respect, it is worth noting what we do not find in our texts when they speak of Japanese culture. Two things are conspicuously absent: Neither do we find any evidence adduced to substantiate the claims made about Japanese culture in terms of social science, nor are there elaborations on specific traditions or sources.
As regards the lack of facts and figures to substantiate what is regarded as self-evident, it seems that the general idea of Japanese culture tends to supersede other insights that would contradict its main features. Even authors like Nakamura or Katô, who accept modern science and technology as a part of present-day Japanese culture, and who point towards differences in professional cultures, do not question their view of a unified Japanese tradition when it comes to other points.
This conforms to the superficial way in which tradition itself - especially pre-modern tradition - is treated. Only in two cases, both of which refer to older Japanese notions of death, specific and clearly identifiable traditions are mentioned:  Yonemoto refers to the myth of a river of the dead, Sanzu no kawa; and Katô refers to Kojiki when he speaks of an ancient notion of a dualism of body and soul. However, even in these cases the references remain very general. There is no detailed discussion of the source adduced, its origins, its contents, its possible interpretations. Yonemoto does not even care to explain how the myth of Sanzu no kawa, which he deems responsible for the lack of post-mortem donors for organ transplantation in Japan, connects to the aversion against the cutting up of corpses; and Katô equates Kojiki, an 8th century effort by the imperial court to streamline  mythology according to its political needs, with „ancient Japanese thought" without any mention of historical circumstances. He also quite straightforwardly identifies the ancient „soul" with the modern concept of „consciousness", an interpretation that is, to say the least, creative. In all other cases, we do not even learn where those traits identified with Japanese culture supposedly come from, which makes it hard to discuss the descriptive value of the arguments involved.
In fact, what we learn from this literature is more about a certain image of Japanese culture and its import on bioethics, than a critical assessment of this thorny issue. Still, if we turn to some of the more detailed arguments rather than to the general image, there are some insights to be gained:
— In this respect, I would first like to return to Nakamura Yûjirô‘s remarks on professional cultures that may shape attitudes towards bioethical issues. I think this is an important point that deserves further elaboration, not the least, because it implicitly transcends the boundaries of the discourse of  national, or ethnic, cultures. As Nakamura explicitly states, there are structural exigiencies inherent to certain professions, which foster a certain frame of mind. As the problems of modern bioethics exist within a field of highly organized division of labour and professional specialization, the implicit world-views of  professional traditions are bound to make their impact on the conceptualization of problems, and on preferred solutions. The interaction of such profession-specific world-views with other traditions, be they religious, ethical or political, should be a topic worthy of thorough investigation. On a more general note, the issue of professional cultures also leads us to the question, whether bioethical conflicts are conflicts of more general, encompassing traditions and attitudes, or conflicts between specialists of different professions, or between specialists and lay persons.
— Secondly, I would like to reiterate Katô Hisatake‘s point that there is already an Asian tradition of modern, experimental natural science that has a history of more than hundred years, and that the Japanese legal system should also be regarded as a part of Japanese culture relevant to bioethical discussions. In other words, and with reference to the example of informed consent used by Katô, if Japanese doctors or patients feel a certain alienation when confronted with the procedural regulations governed by the principle of informed consent, this is not an alienation in terms of „Japanese" versus „Western" culture, but of Japanese popular or Japanese medical professional culture versus Japanese legal culture. This of course leads back to the question, whether similar conflicts exist in other societies.
— Thirdly, there is the issue of local adaptation and transformation as a test-case for bioethical principles and concepts mentioned by Morioka Masahiro. Whether we assume that the majority of the Japanese in fact shares a predilection for emotional argumentation and a rhetoric of empathy and has little taste for rational discussion and the appeal to abstract ethical norms, or whether we regard this as a typical modern Japanese myth: criticisms of the notion of informed consent according to the norms embedded in this tradition or attempts at adaptation may reveal the limits of a concept that, in another context, was believed to express a universal norm. The positive attitude towards non-verbal and indirect communication can serve to subdue the dissent of powerless individuals or minorities. However, as can be learned from Nakamura, Hoshino and Katô, it can also lead to a greater sensitivity for the situation of patients who are in physical pain and emotional distress, and feel simply overwhelmed if presented with highly formalized information and paperwork. In this respect, we should cherish the potential of plural traditions, be they modern or ancient, to test our current assumptions.

Conclusions
In the following, I shall draw some more general conclusions from our findings, relating to the main issue of my paper: what is the import of culture and tradition on bioethical discussions, and how should we go about in our research on this matter.
1) My first conclusion refers to the object of such research. Here, I think it is extremely important to open our eyes to the full scope of traditions, which are almost by definition relevant to bioethical problems. This includes: the tradition of the sciences and the medical profession, including subtraditions due to specialization; the legal tradition, including national as well as international regulations; ethical and ideological traditions, which are bound to be plural in any modernized society; traditions of folk lore and every day pragmatics; traditions of administration and policy. Not every tradition may be equally relevant to a specific problem, and some may be distinctly „national", others „regional" and many of them will clearly be „international".
2) This leads directly to a second conclusion, which is on the plurality of methods necessary for such research. It simply says that the variety of traditions involved requires a plurality of research methods. While all talk of „tradition" will first bring classical methods of the humanities to mind, such as historiology, philology or hermeneutics, we cannot expect all the relevant traditions to be neatly laid down in written documents. Or, what exists in written sources may be less important than oral or pragmatic traditions. Thus, it is important to include methods from cultural anthropology, the social and political sciences etc., in addition to philology, historiography and hermeneutics.
3) My third conclusion goes back to the question of the „grand traditions", such as religion, philosophy, literature and the like, and their part in bioethical discussions. Here, I would propose to make a clear distinction between a),  the production of normative texts from the point of view of such a tradition - be it Buddhism, Kantianism, Catholicism, Liberalism, Marxism or whatever we may think of - and b), the analysis of such normative texts. As the production of normative texts can be seen as an act not only of passing on, but also of creatively shaping a tradition, it is for the traditions to decide what is an appropriate argumentation, and what is heresy. As for analytical texts, methodological stringency is certainly required. Of course I cannot even give an abbreviated account of what that means here. But I would like to single out one issue that is, however elemental, neglected in many cases - including most of those analysed in the previous sections of my talk. It seems a basic necessity to me that, when treating grand traditions, we at least make the attempt to identify the relevant sources  in a specific matter, and that we clarify their proper context. Only then can we assess, whether some reference to a presumed time honoured tradition can claim to be correct, or whether it is a creative invention, which may then lead to another modern tradition.
4) Let me deviate from the Occidental tradition of summing up in three, and add a fourth conclusion, which is a kind of closing remark. As you will have noticed, all my conclusions make things more complicated rather than more simple. If this be madness, there is still a method to it. I think that the problems we face in the field of bioethics are complex by their very nature. They are created by the mutual interaction of science, technology, a form of economy that manages to concentrate massive ressources, a cost-intensive medical infrastructure, and the eternal, and essentially non-resolvable problems of human existence: illness, affliction, old age, death - and these are not all the factors involved. In the face of this, I think it is our duty as researchers in this field to resist the drive toward simple and quick solutions. This, of course, can only be successful if we do it on an international level, and with a spirit of mutual solidarity. I am therefore particularly grateful for being invited to give a talk at this conference, and for the fact that all of you were ready to sit through my talk. Thank you very much.

References Cited

Aoki Tamotsu: Der Japandiskurs im Wandel. München: Iudicium, 1996. (Monographien aus dem Deutschen Institut für Japanstudien der Philipp-Franz-von-Siebold-Stiftung; 14).  [Übersetzt von Robert Horres, Marc Löhr, Stephan Biedermann und Annette Schad-Seifert].
Hoshino Kazumasa: Iryô no rinri. Tokyo: Iwanami shoten, 1991
Hoshino Kazumasa : Bioethics in Japan: 1989-1991. In: Regional Developments in Bioethics 1989-1991. 1992. S. 379-387.
Hoshino Kazumasa: Why many Japanese do not accept `Brain Death` as a Definition of Death. In: Bioethics 7 (1993), S. 234-238.
Hoshino Kazumasa: Bioethics in Japan: 1991-1993. In: Regional Developments in Bioethics: 1991-1993. 1995. S. 367-376.
Hoshino Kazumasa  (ed.): Japanese and Western bioethics: studies in moral diversity. Dordrecht: Kluwer Academic Publishers, 1997. (Philosophy and medicine; 54).
Iida Nobuyuki: Kanô na koto to nozomashii koto. In: Risô12/ 1985.
Kanagawa Takuo: Infômudo konsento. Hô to hanrei riron kara no kenshô. In: Saitô Takao; Kôyama Arifumi (ed.): Seimei rinri gaku kôgi. Igaku, iryô ni nani ga towareteiruka. Tokyo: Nihon hyôron sha 1998, S. 53-70.
Katô Hisatake: Nôshi, kuron, idenshi chiryô: baioeshikkusu no renshûmondai. Tokyo: PHP Shinsho, 1999.
Kimura Rihito: Inochi o kangaeru. Baioeshikkusu no susume. Tokyo: Nihon hyôron sha, 1987
Morioka Masahiro: Seimei gaku e no shôtai. Tokyo: Keisô shobô, 1988.
Nakajima Michi: Mienai shi: Nôshi to zôki ishoku. Tokyo: Bungei shunju, 1985.
Nakamura Hajime: Bukkyôgo daijiten. Tôkyô shoseki, 1976.
Nakamura, Yûjirô: Rinshô no chi to wa nani ka. Tokyo: Iwanami Shoten, 1992.
Sagara Tôru: Nihonjin no kokoro. Tokyo: Tôkyô daigaku shuppankai, 1984.
Yonemoto Shôhei: Baioeshikkusu. Tôkyô: Kôdansha, 1985. (Kôdansha gendai shinsho; 759).