In what follows, we focus on the discussions in the field of medical ethics/bioethics in Japan. We performed a database search using PubMed, Philpaper, and Philosopher’s index for English literature, Ichushi, J-stage, and Medical-online for Japanese literature. The search keywords used were autonomy, Japan, and relational autonomy. There were more than 500 hits, and we went through all abstracts. We then classified the papers and books according to the patterns in which autonomy is used. Although this search was not exhaustive, we think that it is sufficient to lead us to a meaningful conclusion.
In addition, there was discussion about when concept of autonomy and its centrality first emerged in Japanese bioethics. Some believed that that Japan did not need to embrace the concept of respecting autonomy at all, since it was a Western idea. This position is no longer popular.
‘Respect for Autonomy’: Beauchamp and Childress
The most popular and frequently used term, especially by healthcare professionals and in health-related papers, is ‘respect for autonomy’ as discussed by Beauchamp and Childress (2019), which is based upon the idea of ‘individual autonomy’. Beauchamp and Childress (2019, 99) do not define ‘autonomy’ itself but describe autonomous action thus: “The autonomous individual acts freely in accordance with a self-chosen plan, analogous to the way an autonomous government manages its territories and sets its policies”.
In Japan, the word autonomy is frequently used without definition. Because only the concept of Beauchamp and Childress’s autonomy was imported into Japan in the 1990s, most Japanese people do not know that there are other types of autonomy.
Therefore, if the author of a paper uses autonomy or Jiritsu without any specific commentary referring to the English or Japanese literature, it is assumed that the version of autonomy being referred to is that developed by Beauchamp and Childress (Ruhnke et al. 2000; Tsuruwaka et al. 2020; Tanaka and Kodama 2020). In the field of psychology, this trend seems to be the same (Yu et al. 2018; Tan et al. 2021).
This formulation of autonomy has engendered much criticism in Japan as well as in Western scholarship. The authors who formulated these theories have responded in defence of their definition. For example, Childress (1990, 12) states that one of the reasons is misdirected criticism. He claims: “In several ways, the principle of respect for autonomy has been misunderstood and misinterpreted, in part as a result of flawed formulations and defenses by its supporters”. Childress (1990, 17) concludes:
Yes, we should go beyond the principle of respect for autonomy - in the sense of going beyond its misconceptions and distortions and in the sense of incorporating other relevant moral principles. But going beyond should not mean abandoning. Despite its complexity in application, despite its limits in scope or range and in weight or strength, and despite social changes, the principle of respect for personal autonomy has a critical role to play in biomedical ethics in the 1990s. But that role requires a sense of limits; we must not overextend or overweight respect for autonomy.
Japan is no exception in its use of this formulation, and even official bodies such as the Ministry of Health, Labor, and Welfare and the Japan Medical Association use this version of autonomy without defining it.
In order to understand Japan further in this context, we want to introduce an article by Asai et al. (2022), which discusses obstacles to clinical shared decision-making. Asai et al. (2022, 138) state that “The situation is complicated further by differences in the various understanding of personal autonomy […]. At least two kinds of autonomy are at play—individualistic autonomy and relational autonomy.” Although their focus is ‘shared decision-making,’ the paper introduces many crucial issues which Japan’s medical ethics/bioethics faces at present. It may be also informative to look at the article by Childress and Childress (2020) regarding shared decision-making in the USA.
Relational autonomy (translated as Kankeiteki-Jiritsu) is the second most popular term used in papers by Japanese scholars. Since Japan is regarded as a family-oriented society, proponents of relational autonomy often emphasise that autonomy created by individualistic Western countries fits poorly with issues related to medical ethics and bioethics in Japan. Thus, in the fields of nursing, medical treatment and care, palliative care, and other end-of-life issues such as advance care planning (ACP), relational autonomy is highly relevant and used commonly (Brandi and Naito 2006; Morita et al. 2020; Akiba 2021). However, as in the case of Beauchamp and Childress’s respect for autonomy, in the discussion of relational autonomy, too, no working definition is usually given.
We found one recent philosophical paper related to relational autonomy in Japan, written by a Japanese researcher (Asagumo 2021, 57). In her abstract, she suggests that “the concept of relational autonomy might have some practical and valuable implications in a country where individual autonomy is considered incompatible with societal values.”
As Asagumo (2021, 61) correctly states, “[R]elational autonomy denotes various perspectives that understand autonomy from a relational standpoint”. However, Asagumo uses the definition of relational autonomy proposed by Gomez-Virseda et al. (2020) as follows (Asagumo 2021, 61):
Based on this systematic review, Gomez-Virseda et al. (2020, 3–5) identify four shortcomings of the traditional understanding of autonomy from which a key understanding of relational autonomy can be developed: autonomy entails more than merely possessing cognitive capacity; autonomy is not exercised by patients existing in a social and cultural void; autonomy is not a binary ‘all-or-nothing’ condition; autonomy is not exercised in terms of isolated discrete discussions. Autonomy is a multidimensional capacity which consists of emotions and bodily mediated experiences besides rationality; autonomy is exercised in a sociocultural context that shapes us, and the relationships between patients, family, and personal relationships, and healthcare professionals are able to enhance or undermine autonomy; for these reasons, autonomy manifests itself in a scale, and we can be more or less autonomous rather than be or not be autonomous; therefore, autonomy is a temporal perspective evolving and unfolding over time through interactions with others. I argue that it would be beneficial to introduce this analysis of autonomy into clinical practice in Japan. I defend my view in relation to the second, third, and fourth points of the shortcomings of individual autonomy suggested by Gomez-Virseda et al.
Thus, Asagumo uses the almost same definition proposed by researchers in a Western country (i.e., Belgium). Asagumo (2021, 61) argues that it would be beneficial to introduce this analysis of autonomy into clinical practice in Japan.
As Japan is a family-oriented society, we presume that the relational character of clinical decision-making already prevails. Asagumo’s (2021, 67) conclusion, “[A] change in the understanding of autonomy in medicine could pave the way for fulfilling patients’ wishes in Japan”, is somewhat confusing to us. We ask the question: are patients’ wishes not fulfilled in Japan?
The Japanese philosopher, Seisuke Hayakawa, who teaches relational autonomy at the University of Tokyo, Faculty of Literature says, ‘I have laid more emphasis on empathic interaction necessary for the development of relational autonomy (or agency) and its attendant trusting relationship.’ (Personal communication).
We move to Asagumo’s discussion on advance directives (ADs). She (Asagumo 2021, 61) states “a more fundamental rethinking of autonomy with greater attention given to the concept of relationality might help to facilitate better understanding and realization of AD in Japan”. ADs are not legally binding in Japan. Questionnaire surveys in Japan in 1996 and in 1998 (Akabayashi et al. 1997, 2003) and articles produced by international collaborations on ADs (Sass et al. 1996; Voltz et al. 1998) may be useful to understand why this is so. Many Japanese respondents to the survey did not like written forms of ADs. Japanese respondents also preferred entrusting decision-making to their families in case of an emergency (see also Sehgal et al. 1992). After 25 years, ADs remain uncommon in Japan. Moreover, there are three or four types of ADs. The Japan Society for Dying with Dignity has created a form for AD (Living Will). This is the first of its kind, but it does not seem sufficient for use in the clinical setting. The AD consists of two components, namely ‘designation of durable power of attorney’ and ‘direction to healthcare professionals.’ From a relational autonomy perspective, which component is suitable for the Japanese context? Or are they both suitable? In addition, as Asagumo correctly points out, it is difficult to predict the future or imagine when one is dying; that is, there is a theoretical limitation in ADs. Proxies also have limitations to predict patients’ real wishes (Akabayashi et al. 1997, 2003; Emanuel 1993).
Recently, the Ministry of Health, Labour, and Welfare in Japan has been promoting the Advanced Care Plan (ACP), a concept proposed in the late twentieth century in the USA (Prendergast 2001; Teno et al. 1994). Despite several efforts to evolve new ACP styles (Martin et al. 2000; Johnstone and Kanitsaki 2009), the ACP has not been easily implemented in Japanese clinical settings. Although it has been reported that the ACP is now prevalent in Asian countries (Cheng et al. 2020), it is unclear whether rethinking autonomy will facilitate ADs or the ACP in Japan because it is absolutely socio-cultural reasons as stated above. Many Japanese did not like written forms of ADs. Japanese also preferred entrusting decision-making to their families in case of an emergency. This expression of autonomy in Japan will not change easily.
In what follows we would like to discuss articles that explain why it is still not a common practice to withdraw ventilators from end-of-life patients in Japan, and why physicians still fear being sued (Nakazawa et al. 2019a, b). In these articles, the authors explain the related concepts of dependency (amae) and village society and critically argue that Japanese people are hesitant to make decisions on this matter. We believe that amae is one of the factors. Amae, which means dependency, is closely associated to the idea of relationality.
Onora O’Neill’s Conception of Autonomy
Onora O’Neill’s (2002) criticises the contemporary conception of autonomy in medical ethics/bioethics and proposes an alternative interpretation derived from Immanuel Kant, which she calls ‘principled autonomy’. In the first chapter of her book titled ‘Gaining autonomy and losing trust?’, O'Neill (2002, 2-4) writes as follows:
During these years no themes have become more central in large parts of bioethics, and especially in medical ethics, than the importance of respecting individual rights and individual autonomy. [...] Yet [...] public trust in medicine, science and biotechnology has seemingly faltered. [...] Is some loss of trustworthiness and of trust an acceptable price for achieving greater respect for autonomy? Do we have to choose between respect for individual autonomy and relations of trust? None of these prospects would be particularly welcome: we prize both autonomy and trust. Yet can we have both?
As mentioned above, O’Neil touched on the mistrust of medicine, which was also prevalent in Japan during the time that she was writing. This ‘mistrust of medicine’ may be one of the factors for philosophers in Japan to engage with O’Neil’s (2002) concept of autonomy. As well, O’Neill (2003) and Japanese philosophers alike were not satisfied with the way informed consent was both discussed and utilised.
This is exemplified by Enzo et al. (2021, 41) who refer to O’Neill in their public prenatal screening paper, stating, “we will focus on O’Neill’s argument about rights and obligations. Drawing on her position, we will show that it is important to change our normative perspective to obligations and to explore government obligations concerning respect for autonomy”. It is also worth noting that they also state (Enzo et al. 2021, 44), “Therefore, in addressing our research questions, we need to change our normative perspective from rights (in particular that of autonomy) to obligations, and to explore government obligations concerning the promotion of autonomy.”
Finally, we introduce three more papers written in Japanese. These draw on the stream of philosophy known as communitarianism. As Miller (2014, 306) notes, criticism of autonomy was also launched from a communitarian perspective (Sandel 1982; Callahan 1984). Communitarians object to liberal individualism on several grounds. Central is the claim that the socialisation process determines or shapes the value and preferences of individuals (Miller 2014, 306). Sasaki’s position is close to this. Sasaki (1998) argues for a concept known as ‘collective autonomy’ (authors’ translation of Kyodouteki Jiritsu). Another one is Hoshikawa’s (1994) ‘die autonome Offentlichkeit’ (autonomous publicity: the authors’ translation of Jiritsuteki Kyodousei), relying mainly on Jürgen Habermas’s idea. Judai (2014) argues that for a dying person, it is more important for caretakers to share the suffering with the patient than for the patient to be ‘autonomous’. This argument is drawn from the work of Lois Shepherd (1996) and Daryl Pullman (2002).