Eubios Journal of Asian and International Bioethics 21 (May 2011)
will remain as redundant as they have been for the past
13 years. In this context, the concept proposed byThurber [15] of ‗organisational ethics‘ is key; sinceorganisational ethics aims at enhancing the overall ethicsof an organization with the goal of changing the climate
and then the culture of the organization [15]. In such an
ambience (thus in the ‗culture‘ of organisational ethics),
ethical assessment of care, along with (or on top of) any
kind of ‗legal‘ assessment of risk, could positively affecthospital environments; and most probably could do betternot only for the patients, but also for the hospitals (inIsrael and elsewhere).
Some conclusions
McLean warns HECs from becoming focused on
legal matters [6]. Indeed, the effects of the often massiveintervention of the legislation in Israeli PRECs suggest
she is right. The setting of PRECs has discouraged
ethical discussion in Israeli hospitals. Worse, doubt abouta ‗case‘, and possible error/s may remain undisclosed
within the system. This may undermine the useful, andnecessary, process of learning ethics.
The idea of hospital committees being legally required
has been followed in Croatia. In Israel, however, PRECs
remain ineffective. Therefore it is reasonable to change
the law. HECs, rather than ruling PRECs, should bepromoted. However, HECs should become budgeted,permanent consulting bodies; and provide advisory
assistance for HRMCs. As a result, the availability of
ethics consultation may lead to optimised patient care;and, work best for the management of hospitals as well.
Moreover, a culture of ‗organisational ethics‘ may
effectively improve the ‗management of risk‘ in hospitals.
Restructuring Israeli legislation of PRECs to a permanentadvisory bodies on ethics for HRMcs, and developing an‗ethical environment‘ may make ethics consultation moreworkable for patients and members of staff; and more
effective, not only in Israeli hospitals but also in otherparts of the world.
References

1. de Beaufort I. and Meulenberg F. ‗Eyewitness in Erewhon
academic Hospital‘ J Med Ethics 2010;36:326-327.
2. Tan S Y. Hospital Ethics Committees: Will America‘s Model
Work in Asia? Ann Acad Med Singapore 2002; 3: 808-12.
3. Borovecki A, ten Have H, Oresković S. Ethics committees
in Croatia in the healthcare institutions: the first study about
their structure and functions, and some reflections on the major
issues and problems. HEC Forum 2006;18(1):49-60.
4. Wenger NS, Golan O, Shalev C, Glick S. Hospital ethics
committees in Israel: structure, function and heterogeneity inthe setting of statutory ethics committees. J Med Ethics
2002;28(3):177-82.
5. Gonsoulin TP. A survey of Louisiana hospital ethics
committees. Laryngoscope 2009;119(2):330-40.
6. McLean Sheila A M. Editorial What and who are clinicalethics committees for? J Med Ethics 2007;33:497-500.
7. Gaudine A, Thorne L, LeFort M.S, Lamb M. Evolution of
hospital clinical ethics committees in Canada J Med Ethics
2010;36:132-137.
8. Vollmann J, Burchardi N, Weidtmann A. Health care ethics
committees in German university clinics. A survey of all medical
directors and directors of nursing. Dtsch Med Wochenschr
2004;129(22):1237-42.
9. Akabayashi A, Slingsby BT, Nagao N, Kai I, Sato H. Aneight-year follow-up national study of medical school andgeneral hospital ethics committees in Japan. BMC Med Ethics
2007;29(8):8.
10. Meulenbergs,T Vermylen J and Schotsmans P T ethics
committees in Belgium The current state of clinical ethics andhealthcare J Med Ethics 2005 31: 318-321.
11. Patient Rights Act. 5756 Sefer HaChukkim 1996: 327.
12.
BorovečkiA.
ten
Have
H.
Orešković
S.
http://jme.bmj.com/content/32/3/138.abstract?sid=ffcae16b-

91

07dc-4538-b82b-ffa8d2ed9818 - aff-3Education of ethics
committee members: experiences from Croatia J Med Ethics
2006;32:138-142.
13.HealthRiskassessment
Europeancommission
http://ec.europa.eu/health/ph_risk/risk_assess_en.htm.
Accessed 2.2.2010.
14. Beleveld D, Brownsword R, Wallace S. Clinical ethics
committees: clinical support or crisis management? HEC Forum
2002; 14:13–25.
15. Thurber CF. Assessing quality in the HCOs: a paradigm fororganizational ethics. HEC Forum 1999; 11:358-363.

How Should Ethics be Taught
to Medical, Nursing andOther Healthcare Students?
- Michio Miyasaka, Ph.D., Sayuri Sakai, M.S.N., Haruo
Yamanouchi, M.D., Ph.D.
School of Health Sciences, Niigata University
Asahimachi-dori 2-746, Niigata City 951-8518, Japan
Email: miyasaka@clg.niigata-u.ac.jp

Abstract
In the last three decades, formal ethics education has
become a common feature of medical curricula.
However, ethics teaching in medical schools has faceddifficulty justifying the allocation of substantial time in thebusy medical curriculum. The authors‘ primary goal is tosummarize the core approaches attempted in the healthcare ethics courses at our University and described in the
textbook written by one of the authors.
Our educational goals are: (1) to provide historicalinsights; (2) to provide a methodological guide foraddressing ethical issues in clinical and multidisciplinary
settings; and (3) to inspire students‘ introspection. In ourview, both the internal and external directions of moral
inquiry should be pursued. In history education, theknowledge of landmark events will be indispensable, but
not sufficient. Learners need to be motivated in theinternal direction by not letting them separate the pastand the present/future. In our experience, the internal
pursuit in learning the history of health care ethics can be
carried out by the student being aware of the possibilityof being on "the wrong side." In methodology education,
principles and the four-quadrant method are useful, butshould not be presented as simply a set of action guides
or checklists. Careful application of these "tools" to aparticular case requires not only their externalmanipulation, but also some approaches to intake
subjective viewpoints of each individual in the case. The
narrative approach might be useful for that purpose, butneeds to be grounded on basic principles not to place
excessive value on consensus.
Introduction
In the last three decades, formal ethics education has
gradually become a common feature of medical curricula.
The trend first appeared in the United Kingdom andUnited States, where systematic reviews on medical
ethics education were published in the 1980s. These
early documents shared a core premise that ethics
should be integrated into the formal curriculum
throughout medical teaching. The Institute of Medical
Ethics in the UK argued that medical ethics education

92

Eubios Journal of Asian and International Bioethics 21 (May 2011)

should recur at regular intervals throughout medical
training [1]. A 1989 review article from the U.S., entitled"Medical ethics education: coming of age," pointed outthat ethics education should be more clinically centeredthan human values education, and should be more
inclusive of philosophical, social, and legal issues thaninterpersonal skills training [2]. In Asia, the establishmentof medical ethics education apparently did not fall behindmuch. International surveys in 1990 showed that 89 of
100 medical schools in 14 countries (Japan, China, Hong
Kong, Taiwan, Korea, Mongolia, Philippines, Thailand,
Malaysia, Singapore, Indonesia, Sri Lanka, Australia, and
New Zealand) offered some courses in which ethical
topics were taught [3,4].
Despite ethics being frequently included in medical
training, ethics education in medical schools has
experienced difficulty in justifying the allocation ofsubstantial time within the busy medical curriculum. For
example, the 1990 Asian survey also showed that 87.5%
of Japanese medical schools offered ethics education,
but the majority taught it as a unit of other courses andallocated only a short time to ethical topics [4]. Empiricalstudies and theoretical arguments from around the world
suggest that on the one hand, ethics education has been
established as various types of courses in medical
curriculum, but on the other hand it has not yet been
established as an area of scholarship with definite goals,
and well-grounded contents and methods relevant to it[5-9].
Teaching Goal – Internal or External?
Some philosophical concerns have been addressed
regarding the development of ethics education in medical
schools. One criticism is of the ahistorical presentation ofstandard bioethics textbooks that respect the Hippocratic
Oath and the Nuremberg Code, but seldom engage inserious historical reflection [10]. In contrast to the role ofhistory in medical ethics education, it has been argued
that its goal should be primarily concerned with
inculcating medical professionalism, and that it should
give medical students the tools for navigating the
ethically charged terrain of clinical practice [11].
However, there are competing ideas even when there is
the shared goal of cultivating medical professionalism:
some regard this as creating virtuous physicians, whileothers perceive it as developing the skills for analyzing
and resolving ethical dilemmas [12].
The dichotomous argument over the goal of medical
education might be reflecting the controversy regarding
the direction of moral inquiry in contemporary medical
ethics – internal vs. external. Today‘s medical ethics (orbioethics) has converged on the external analysis ofhuman morality that is most evidently observed in anarrow conception of human autonomy [13]. While thetraditional quest for autonomy addressed internal moral
laws or self-awakening (for example, in Buddha's andImmanuel Kant‘s theories), bioethics focuses on an
external account of a patient‘s self-determination: how aperson can be judged autonomous by means of external
observation (for example, with some criteria to judge thathe or she is competent). This argument can be applied tothe controversy over the goal of medical ethics
education. If internal pursuit is at the core, we should

help students become good physicians and expect themto develop the virtues entailed by the profession.
According to Edmund Pellegrino, some of these virtues
are fidelity to trust, benevolence, intellectual honesty,
courage, compassion, and truthfulness [14]. He alsomentions the teachability of virtue, referring to ancient
Greek philosophers, and states: "He (Aristotle) said welearn by practice and that the best practice is to follow amodel of the virtuous person. In medicine this means weneed virtuous physicians as teachers." However, thisargument might be vulnerable to attacks on theestablishment of ethics courses in the busy medical
curriculum, because models of the virtuous physician canbe found during the clinical clerkship or in the workplace
after graduation. These concerns lead us to rely more on
pragmatic external approaches, with which teachers canconsider more concrete instruction on "skills" and "tools"
for analyzing ethical dilemmas.
Medical Ethics or Health Care Ethics?
Still another type of integration should be pointed out
with regard to the cultivation of professionalism. Ethics inclinical settings might not be best described as "medical
ethics" in its narrowest sense. In other words, theterminology needs to be questioned. In real clinicalsettings, ethics cannot be considered as the ethics of the"physician." Nurses and allied health professionals havetheir parts and therefore, ethics education in classrooms
should also be planned in a multidisciplinary context.
Preferably, students in medicine and various healthprofessional programs should be given the opportunity totalk about ethics in a classroom around a table. For thisreason, we used "health care ethics," rather than"medical ethics" in the title of our courses and the
textbook.
All these controversies over medical ethics education
might be attributed to its youth as an academic discipline.
Resolving these issues will require many more years oftrial and error in classrooms and clinical settings. In thisessay, we summarize the core approaches attempted inhealth care ethics education at our University anddescribed in the textbook written by one of the authors[15]. The first two of fifteen chapters in the textbook
present a review of the history of health care ethics,
followed by three chapters on methodology explicating
three approaches in the field: 1) principle-based, 2)
procedure-based, and 3) narrative. In the following
chapters, cases in "death and dying", "sexuality andreproduction", "patient's rights and public welfare","medical research and health care resources" arediscussed combining the three approaches. Our
educational goals are: (1) to provide historical insights,(2) to provide a methodological guide for addressing
ethical issues in clinical and multidisciplinary settings,
and (3) to inspire students‘ introspection.
Historical Insights
Japanese textbooks of medical ethics might be also
subject to the criticisms mentioned above regarding
ahistorical presentation. They tend to review bioethicalconcepts and history as a set of novel socio-academic
movements observed in the US during the last few
decades of 20th century. Theoretical arguments inEubios Journal of Asian and International Bioethics 21 (May 2011)
bioethics (e.g., "patient autonomy," "personhood theory,"and "slippery slope argument") are often described as aset of American artifacts in the context of landmark
developments in bioethics, such as the Nuremberg Code,Helsinki Declaration, Tuskegee syphilis scandal, and theAmerican Hospital Association‘s Patient's Bill of Rights
put an end to the long tradition of "medical paternalism"
since the Hippocratic Oath. Some Japanese critics haveclaimed that medical students should be taught important
events in which Japanese medical society played a keyrole [16].
A historical review of health care ethics can have a
deep impact on medical students, as it inevitably includes
reviewing how their predecessors failed or committed
inhumane acts. In our courses, we begin by illustrating
practices in ancient medicine in the East and West, andethical norms and codes of the time. Students learn thatmost of the important principles such as "nonmaleficence" and "beneficence," (or "benevolence" inEastern conceptualization), already existed at very earlystages of medicine not only in the West, but also in otherparts of the world. In contrast, they see that one of theessential principles in contemporary medical ethics,"respect for the patient's autonomy," is not seen in mostof the ancient medical norms and codes.
The knowledge of ancient medical ethics invites
students to consider when and why the principle ofpatient autonomy--one of the most important topics in thehistory of health care ethics—was established. Students
first learn the tragic history of Nazi medicine. Then they
are introduced to what was done by medical
professionals of Unit 731, a Japanese unit which
conducted human experimentation and vivisection,
primarily for the development of biological weapons,
using predominantly Chinese prisoners-of-war andcitizens. We also discuss how the American occupation
army exonerated Unit 731 leaders from the Tokyo War
Crimes Tribunal in 1946 in exchange for the data they
accumulated, leaving no renewal of the rules for humanexperimentation. This incident is contrasted with the
Nuremberg Medical Trial that sentenced seven of the
defendants to death and issued the Nuremberg Code,widely regarded as the first document to set out ethicalregulations for human experimentation based on
informed consent. In the last part of the historical review,
we discuss the history of the Japanese leprosy control
policy, which started in the late 19th century andcontinued until 1996 [17]. Students discuss the
responsibility of the medical profession for developmentof the control policy, which resulted in a mass humanrights violation.
In the history review in our health care ethics course,
we never guarantee that learners are safe from standingon "the wrong side." In other words, we do not adopt thesimplified dichotomy which lets learners think that thepast was wrong while the present is just, or that those in
the past demonstrated bad faith or thoughtlessness towhich the present students are unconnected or immune.
Instead, we expect them to engage in self-reflection
through the historical review and realize that the "banalityof evil" coined by Hannah Arendt can become their own,
if they are not prepared to think critically about the resultsof their actions or inaction.

93

Methodological Approaches
The underdevelopment of methods in health care
ethics represents the poor scholarship in medical schools
in Japan. Textbooks often utilize thematic descriptions ofheadline-grabbing contemporary issues such as organtransplantation, euthanasia, assisted reproduction, andhuman cloning. Theoretical foundations and grounding
concepts to bridge different issues and topics are lessfrequently discussed. In the English literature, casebased learning has been widely recognized as one of themost effective methods in health care ethics education.
Empirical studies conducted so far have reported on themethod of health care ethics education - how it should betaught. They focused on the material (videos, movies,
documents) [18, 19], the mode (lecture, small-group
discussion, role-playing) [20-22], and approach (moraltheory, literature/humanities, practical case discussions)[23, 24]. However, the theoretical basis for case studies
has received relatively little attention. We havedistinguished three different approaches in health care
ethics. Some of them are not necessarily proposed for
educational settings, but can be applied in a classroom
with either fictional or non-fictional cases.
1) Principle-based approach
The principle-based approach, which was ironicallycalled "principlism" or the "Georgetown mantra," hasdominated bioethics and attracted criticism from various
points of view. For example, Clouser and Gert claim thatthe principles lack any systematic relationship to eachother and the conflicts between them are unresolvablebecause they are not derived from a unified moral theory[25]. Others charge that the application of alreadyestablished principles to new situations "can do more
harm than good" [26], concerned that principles can beused as action guides or checklists in a shorthandmanner without promoting practitioners' deliberation.
Nevertheless, the advantages of a principle-based
approach, including its applicability to a wide range of
medico-ethical issues and its utility to people with great
differences in belief and ideology, are so evident that theapproach has survived criticism and been accepted
across the world. However, the weakness of thisapproach becomes obvious in educational settings wherecase studies are often attempted with only a short
description or "vignette" of a model case. Actually, it isdifficult for many students to analyze ethical problems inclinical cases using principles. As we reported previously,
students showed relatively poor performance and were
often not able to recognize conflicts between two or more
ethical principles [27]. This problem might be rooted in
the nature of the principle-based approach: principles are
abstract and do not indicate any concrete direction about
how to judge and act in a given situation. They requiredeliberate interpretation when being applied to realcases.
2) Procedure-based approach
Another category of methods in health care ethics iswhat we coined as "procedure-based" approaches. Thisis most vividly illustrated by Albert Jonsen's “Casuistry
and Clinical Ethics” [28]. In an attempt to bring casuistry

94

Eubios Journal of Asian and International Bioethics 21 (May 2011)(which had been harshly attacked by Pascal in the 17th
century) back into the limelight, Jonsen laid thefoundation for the methodology on case studies in healthcare ethics. Jonsen and colleagues claimed thatprinciples should be appreciated in the specific context of
the actual circumstances of a case, and formulated apractical method that integrates basic principles into a
healthcare provider's working procedures [29]. Theydeveloped a four-quadrant method for analyzing a casethat specifies four topics (―medical indications,‖ ―patient
preferences,‖ ―quality of life,‖ and ―contextual features‖),with which physicians can integrate ethical issues withthe other aspects of daily medical practice. Japanesephilosopher Tetsuro Shimizu noted that Jonsen's method
is based on the healthcare culture of the US, andproposed his version of clinical ethics that was intended
to integrate ethical considerations into the Japanesecontext of health care [30].
Procedure-based approaches are also friendly for
medical, nursing, and other healthcare students,
especially for those in clinical education. Once they
become familiar with factual discussions of clinical cases,
the four-quadrant method is much easier than a principlebased one. However, procedure-based approaches
hardly guide students to find a solution when there is a
conflict between moral points of view among players in acase. Teachers can facilitate the students‘ clarification of
the point of conflict in a case, but not illuminate how toproceed. This weakness might be attributed to the natureof the procedure-based approach, in which principles arecontextualized in actual circumstances, because no
single principle is privileged in these methods. This must
be decided in the context of each case, which is notpossible to demonstrate in a classroom.
3) Narrative approach
The narrative approach in health care ethics
educationwasdevelopedusing
linguistics/communication-basedmoralphilosophies(e.g., narrative ethics, ethics of care, and discourse
ethics) and social constructivist theory. We have applied
pragmatic narrative-based approaches in health care
ethics education for approximately ten years [27]. A caseis defined as a complex of multiple narratives and utilizes
the "Rashomon effect," the subjectivity of perception that
results in individuals producing substantially different but
equally plausible accounts of the same event [31]. Thisapproach requires students to carefully analyze how thecase is experienced by individuals in different positions
by means of collecting narratives.
In clinical settings, these narratives are collected via
interviews with each individual, focused on their history of
the experience using questions like: “What was it likewhen you first noticed the symptom?” and “How did you
think about your daughter's future life if she is dependent
on a ventilator?” The answers from each individual‘s
perspective are transcribed as ―the patient‘s narrative,‖―the mother‘s narrative,‖ ―the family doctor‘s narrative,‖―the nurse‘s narrative,‖ etc. In educational settings wheresuch interviews are impossible, a case must bepresented not in the form of vignette, but as a set of"narrative data" that includes what they have been told
up until the present situation.

The review of individuals' narratives allows for,although not perfectly, a deeper understanding of the―temporal wholes‖ of personal experiences of the parties
involved in the case. The knowledge of how the individual
has been led to his or her current state of moral belief will
promote participants to imagine further steps much moreeasily than in other approaches. Students can discuss
the future scenario and its options in the case withquestions such as: “What is the possible scenario(s), if
not best, that can be accepted by all parties in thiscase?" and “Who should talk to the patient's father on
this topic, and let him consider the options?”
The weakness of the narrative approach touches on
the debate concerning communication-based moral
philosophies in which human morality is regarded as
being established by means of a communicational
process. With these lines of conceptualization, thenarrative approach in health care ethics and its
education must overcome relativism, or the "anythinggoes" paradox, in which consensus is regarded as theultimate goal, and no rule or principle is referred to in
moral consideration. For this reason, the narrative
approach requires inspection with principle-based orprocedure-based approaches.
Conclusion
This essay has summarized the core approaches
attempted in the health care ethics courses at our
University and described in the textbook. We havepointed out that there are competing views regarding thegoal of health care ethics education, which reflect theinternal and external directions of moral inquiry incontemporary health care ethics. In our present view,
both directions should be pursued in education. The
external dimension is addressed with history education.
The knowledge of past landmark events will be
indispensable, but not sufficient. Learners need to be
motivated in the internal direction by not letting themseparate the past and the present/future. In our
experience, the internal pursuit in learning the history ofhealth care ethics can be carried out by the student being
aware of the possibility of being on "the wrong side," asillustrated by tragic events in the history of medicine.
We have distinguished three different approaches inhealth care ethics applicable in a classroom. At present it
is not clear whether all three approaches should be usedin parallel, or whether two of them should be combined.
Principles and the four-quadrant method are useful, butshould not be presented as simply a handy set of action
guides or checklists. Careful application of these "tools"
to a particular case requires not only their externalmanipulation, but also some approaches to intake
subjective viewpoints of each individual in the case. The
narrative approach might be useful to that end, but needs
to be grounded on basic principles not to place excessive
value on consensus.
Acknowledgment
This study was partly supported by a Grant-in-Aid for
Scientific Research No. 18320006 by the Ministry of
Education, Science, Sport, and Culture, Japan.

Eubios Journal of Asian and International Bioethics 21 (May 2011)
References
1. Institute of Medical Ethics. Report of a working party on
the teaching of medical ethics (the Pond Report). London, UK:
IME Publications; 1987.
2. Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK.
Medical ethics education: coming of age. Acad Med 1989; 64:705-714.
3. Miyasaka M, Akabayashi A, Kai I, Ohi G. An international
survey of medical ethics curricula in Asia. J Med Ethics 1999;
25: 514-521.
4. Akabayashi A, Miyasaka M, Kai I, Ohi G. Survey of
medical ethics education in Japanese medical schools. Med
Educ (Japan) 1999; 30: 47-53. (in Japanese)
5. Lehmann LS, Kasoff WS, Koch P, Federman DD. A
survey of medical ethics education at U.S. and Canadian
medical schools. Acad Med 2004; 79(7): 682-689.
6. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical
ethics education: where are we? Where should we be going? A
review. Acad Med 2005; 80(12): 1143-1152.
7. Mattick K, Bligh J. Teaching and assessing medical ethics:
where are we now? J Med Ethics 2006; 32(3): 181–185.
8. Shidfar F, Sadeghi S, and Kaviani A. A survey of medical
ethics education in Iran medical faculties. Iran J Allergy Asthma
Immunol 2007; 6 (Suppl. 5): 47-51.
9. Campbell AV, Chin J, Voo TC. How can we know that
ethics education produces ethical doctors? Med Teach 2007;
29(5): 431-436.
10. Baker R. Bioethics and history. J Med Phil 2002; 27(4):447-474.
11. Rhodes R. Two concepts of medical ethics and theirimplications for medical ethics education. J Med Phil 2002;
27(4): 493-508.
12. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical
ethics education: Where are we? Where should we be going? A
review. Acad Med 2005; 80: 1143–1152.
13. Miyasaka M. Resourcifying human bodies - Kant andbioethics. Med Health Care Phil 2005; 8: 19-27.
14. Pellegrino ED. Professionalism, Profession and the
Virtues of the Good Physician. Mt Sinai J Med 2002; 69(6): 378384.
15. Miyasaka M. Iryo-rinrigaku no houhou: gensoku, tejun,
narrative (Methods in healthcare ethics: Principles, procedures,
narratives). Tokyo, Japan: Igaku-Shoin; 2005. (in Japanese)
16. Omata W. Kensho jintaijikken: 731 butai, Nazi igaku (Astudy of human experimentation - Unit 731, Nazi medicine).
Tokyo, Japan: Daisanbunmei-sha; 2003. (in Japanese)
17. Miyasaka M. Punishing paternalism: An ethical analysis ofJapan's leprosy control policy. Eubios Journal of Asian andInternational Bioethics 2009; 19(4): 103-107.
18. Self DJ, Baldwin DC Jr, Olivarez M. Teaching medical
ethics to first-year students by using film discussion to develop
their moral reasoning. Acad Med 1993; 68(5): 383-385.
19. Leget C. Avoiding evasion: medical ethics education andemotion theory. J Med Ethics 2004; 30: 490-493.
20. Self DJ, Olivarez M, Baldwin DC Jr. The amount of smallgroup case-study discussion needed to improve moral
reasoning skills of medical students. Acad Med 1998; 73(5):521-523.
21. Fryer-Edwards K, Wilkins MD, Baernstein A, Braddock CH
3rd. Bringing ethics education to the clinical years: ward ethics
sessions at the University of Washington. Acad Med 2006;
81(7): 626-631.
22. Chung EK, Rhee JA, Baik YH, A OS. The effect of teambased learning in medical ethics education. Med Teach 2009;
22: 1-5.
23. Benatar D. Moral theories may have some role in teaching
applied ethics. J Med Ethics 2007; 33(11): 671-672.
24. Lawlor R. Moral theories in teaching applied ethics. J Med
Ethics 2007; 33(6): 370-372.
25. Clouser KD, Gert B. A critique of principlism. J Med Phil
1990; 15(2): 219-236.
26. Tony E. Adams. A review of narrative ethics. Qualitative
Inquiry 2008; 14: 175-194.
27. Miyasaka M, Yamanouchi H, Dewa K, Fukuda M, Sakurai
K. Narrative approach to ethics education for students withoutclinical experience. Forensic Sci Int 2000; 113: 515-518.
28. Jonsen AR. Casuistry and clinical ethics. Theoretical
Medicine 1986;7:65-74.
29. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A
practical approach to ethical decisions in clinical medicine. New
York, USA: McGraw-Hill; 1982.
30. Shimizu T. Clinical Ethics Project. Available fromhttp://www.l.u-tokyo.ac.jp/dls/cleth/index-j.html, date of access:November 12, 2009.
31. Heider KG. The Rashomon effect: when ethnographers
disagree. American Anthropologist 1988; 90: 73-7

95

An
ethicalandsocialexamination of the death
penalty as depicted in two
current films made in a “prodeath penalty society”- Atsushi Asai (corresponding author), Ph.D., M.D.,
Department of Bioethics, Department of Bioethics, Kumamoto
University Graduate School of Medical Science, Kumamoto, 11-1 Honjo, Kumamoto, 860-8556, Japan
Email: aasai@kumamoto-u.ac.jp- Sakiko Maki,
Department of Bioethics, Department of Bioethics, Kumamoto
University Graduate School of Medical Science, Kumamoto

Abstract
In Japan, although various arguments exist regarding
the appropriateness of the death penalty, nationwide
public opinion polls regarding the death penalty revealed
that 85.6% of respondents supported maintaining thedeath penalty in 2009. Under these circumstances, it isworthwhile to deliberate the ethical and social issues
surrounding the death penalty as depicted in Japanesefilms from medical humanities perspectives. In thepresent paper, we discuss two recent films concerning
the death penalty, 13 kaidan directed by Masahiro
Nagasawa, 2005 and Kyuka directed by Hajime Kadoi,
2007. The two films describe the impact of execution on
the executioners, secrecy of executions, rehearsal of theexecution, and voluntary participation in execution. They
depict the current situation surrounding the death penalty
and execution, as well as everyday life on death row, indetail. Serious concerns about current execution
procedures were also described. The two films seem totry to tell the audience that there is something strange inkilling people in perfect order with good will in the nameof law and justice. They show the officer‘s instinctive
aversion provoked by the execution and make us think
about what it means to kill a human.
Introduction
Variousarguments
exist
regardingtheappropriateness of the death penalty. Proponents argue
that we should take the murder victims‘ families wishes ofretribution into maximum consideration, social justicerequires death of the killer, and the death penalty works
as a deterrent to keep murder from happening. They also
argue that a life sentence without parole is moreinhumane than the death penalty, and we should
maintain it as a less cruel punishment for vicious
criminals. On the other hand, opponents argue that it is
not only the killer who should be blamed because society
as a whole is responsible for the occurrence of murders,which occur in part due to factors such as poor educationand severe poverty. They argue that we should stop thechain reaction of killing, cases of false accusation
undoubtedly exist, and many innocent individuals havebeen and will be executed in the name of justice. Other
opponents argue that the death penalty is an
infringement of fundamental human rights, particularly
the right to life. They also point out that the death penalty
is wrong because those who are in charge of executions