This paper has two aims, to summarise recent domestic and international events related to medicoethical-legal decisions in the clinical setting and to discuss the ethical implications of these events. Domestic issues include brain death and organ transplantation, refusal of treatment for religious reasons, disclosure required for legitimate informed consent, surrogate motherhood, prenatal diagnosis and selective abortion, issues pertaining to HIV/AIDS, concealment of medical mistakes, truth telling, public trust in physicians and in health care, and medical research. International issues include voluntary euthanasia and assisted suicide, the imposed separation of conjoined twins, problems pertaining to wrongful life, fetal surgery, the Icelandic database, homosexuality, resource allocation and global justice, and the death of participants in medical research.
It is hoped that this review of recent events related to clinical ethics may serve as a basis for ethical considerations in daily practice.

Clinical ethics education aims to provide medical students and residents with adequate knowledge and skills to cope with ethical problems encountered in patient care. It is essential for students to study the historical background of biomedical ethics, normative ethical theories, and qualitative and quantitative data relevant to descriptive ethics in Japan. The significance of critical case analysis from an ethical point of view should also be addressed. Informed consent, truth-telling, and medical end-of-life decisions have been gradually gaining recognition as the most important topics in clinical ethics education. Controversial issues, such as medical futility, fair resource allocation, and family involvement in medical decision in our culture, should also be studied.

Medical ethics is taught as a principle of medicine at medical schools in Japan. However, the best way to teach medical students about decision-making in ethical dilemmas in unclear. Therefore, we conducted a survey of 80 medical schools in Japan to identify the current issues in the teaching of medical ethics. We asked how and when students learned about medical ethics at medical school and asked about the objectives, achievement goals, contents, and curricula for the first to sixth years and postgraduate studies.1) A preliminary study of educational affairs at faculties of medicine (response rate, 99%) showed that medical ethics is most likely to be taught in the earliest year (first year, 61%) and is less likely to be taught in later years (fifth or sixth year, 11%). 2) Only 28% of lecturers who teach medical ethics are familiar with the whole curriculum of medical ethics, and only 15 medical schools had cross-faculty teaching.3) Lecturers' satisfaction with the system of teaching medical ethics at medical schools was related with the introduction of the elements of medical ethics at bedside teaching (odds ratio=7.4, p<0.01).4) A logistic regression model adjusted for lecturers' specialties indicated that sufficient content for teaching medical ethics was associated with classroom discussions with clinicians (odds ratio=9.3, p<0.05).5) Despite the recently increased recognition of the importance of teaching medical ethics, the human resources for teaching medical ethics at medical schools are scarce and insufficient. Urgent responses are needed to address current shortcomings in the teaching system and the advanced training of teachers.

We reviewed essays on clinical ethics written by 94 5th and 6th-year medical students on rotation at the Department of General Internal Medicine of Kyoto University Hospital. Issues regarding brain death, medical decisions concerning the end of life, and informed consent and truth telling were each identified as ethically important by one-third of the students. Approximately 90% of the students expressed a desire to learn more about ethical issues, including actual ethical decisions made by physicians in Japan, cross-cultural differences, medical decisions concerning the end of life, and informed consent. Most students were extremely sensitive to issues of informed consent and truth telling relevant to the patients they cared for.

BACKGROUND : In Japan, clinical ethics support services are only available at certain institutions. The actual conditions surrounding ethics consultation are unclear with few resources available for determining its efficacy. The object of this study is to clarify the expected outcome of ethics consultation and identify the appropriate mode. We also aim to elucidate the ideal consultant and the obstacles to achieving full utilization of ethics consultation.
METHODS : Eighteen medical practitioners participated in the study. We held semi-structured interviews and analyzed these interviews by qualitative content-analysis technique.
RESULTS : This study suggests that specific advice, new insights from outside parties, emotional support, and an appropriate process based on a division of labor between medicine and ethics all contribute to a team-based practice of medicine that avoids the arbitrariness and dogmatism of single practitioners. It is also indicated that timeliness and swift answers are required. Knowledge of medicine and ethics, communication skills, a close familiarity with actual conditions in medical practice, and empathy toward the medical staff were found to be as important as the qualifications of consultants. Contrarily, the participants suggested that the busy pace, lack of psychological breathing room, medical practitioners' pride, lack of awareness of ethical issues, and the negative image of the word “ethics” were significant impediments to achieving full utilization of ethics consultation.
CONCLUSIONS : The present study is the first of its kind to reveal the views of medical professionals regarding clinical ethics consultation in Japan. Further research is required to identify the features of a consultation system that can be easily accessed and effectively utilized in Japan.

A 62-year-old woman with idiopathic thrombocytopenic purpura (ITP) was admitted to undergo cardiac surgery for aortic stenosis, angina pectoris, and paroxysmal atrial fibrillation. A bleeding tendency was expected due to the dramatic decrease in platelets during cardiopulmonary bypass. We performed high-dose transvenous gammaglobulin infusion (400mg/kg/day) for 5 consecutive days immediately before surgery. The gammaglobulin therapy caused steady increase of thrombocytes from 4 days after surgery, even though the platelet count showed no significant change preoperatively. The postoperative course was satisfactory with neither a bleeding tendency nor wound infection. High-dose transvenous gammaglobulin therapy is thus useful for perioperative patients with accompanying ITP, who are often under medication with steroids. This therapy is also effective for prevention of infection.

In the presence of Leriche syndrome, the lower extremities are perfused by collateral flow from internal mammary arteries. If an internal mammary artery graft is used in coronary artery surgery, an acute ischemic limb will develop postoperatively. A 52-year-old man was admitted to our department with bilateral claudication. Multidetector row computed tomography with contrast showed total occlusion of the infrarenal abdominal aorta and rich collateral flow to the lower extremities from internal mammary arteries. Cardiac angiography revealed three-vessel disease. Simultaneous coronary artery bypass grafting and an ascending aorto-bifemoral bypass were performed without cardiopulmonary bypass. Postoperative computed tomography angiography showed that grafts to the coronary and bifemoral arteries were patent. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease. This procedure without cardiopulmonary bypass has not previously been reported.

The left atrium and left atrial appendage have unique genetic anatomical and physiological features. Recently, advances in diagnostic imaging technology have provided much new knowledge. Clinically, the risk of developing atrial fibrillation increases with age. In order to reduce the public health burden such as cerebral infarction caused by atrial fibrillation, we need to find some predictive risk factors and preventive strategies for cerebral infarction and more effective treatments. The new concept of atrial myopathy has emerged, and animal models and human studies have revealed close interactions between atrial myopathy, atrial fibrillation, and stroke through various mechanisms. Structural and electrical remodeling such as fibrosis and deterioration of the balance of autonomic nerves and complicated interactions between these mechanisms lead to deterioration of atrial fibrillation and a continuous vicious cycle, and finally thrombosis in the left atrial appendage. Although anticoagulant therapy for patients with atrial fibrillation is strongly recommended, it is difficult for many patients to continue optimal treatment. In the nearly future, it will be important to understand the anatomy and physiology of the left atrial appendage and to understand the shape changes, size and the changes of autonomic function, and thrombus formation conditions associated with LAA remodeling during atrial fibrillation, and then we should provide early therapeutic intervention.

1)Professionalism should be explicitly introduced as a fundamental content into curricula/programs of undergraduate medical education, postgraduate clinical training, and of continuing medical education provided by professional societies and the Japan Medical Association.
2)We need to enhance our research activities on goals and objectives which should be accomplished through professionalism education, effective learning strategies, appropriate assessment methods, as well as the impact of informal and hidden curricula.
3)We propose that the medical profession should collaboratively develop various activities to win the trust of the general society in tandem with the introduction of professionalism education.

A 2-month-old boy developed Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after bidirectional Glenn anastomosis for hypoplastic left heart syndrome. After reexploration, only the skin was closed but the sternum left open, and continuous mediastinal irrigation using saline containing isodine was commenced at an infusion rate of 20-40ml/h. The sternum was closed on day 7 and irrigation was stopped on day 21. The patient was weaned from the ventilator 4 days later, and is currently in a good condition awaiting a Fontan operation.