IV. JAPAN. A. JAPAN THROUGH THE NINETEENTH CENTURY

The following is a revision of the first-edition articles on (1) the same subject by the same author, and (2) "Traditional Professional Ethics in Japanese Medicine" by Takemi Taro. Portions of the first-edition articles appear in the revised article.

The history of Japanese medical ethics must be seen in the context of the stratified development of Japanese culture. In each of the four layers discussed here, particular attention will be paid to medicine and ethics and the ways they were constituted with respect to changes in law, religion, custom, tradition, and social and political institutions.

Early Japan

The earliest layer of Japanese cultural stratification is the magico-religious universe of the ancient Japanese people, which persisted in subsequent periods (often submerged under later cultural layers and foreign traditions). From archaeological evidence, early mythic narratives, and poetry, we surmise that the ancient Japanese worldview was based on a mythic mode of apprehending the origin and nature of human beings, kami (usually translated as "deities"), the world, and the cosmos. This indigenous Japanese religion was later called Shintō or the "way of the kami." Early Shintō understood life to be essentially good and beautiful; evil was simply that which was unclean, ill omened, or inferior. Even the term tsumi (often translated as "sin") meant defilement or lack of beauty—for example, sickness, disaster, and error, all due to the influence of evil spirits and removable by ablution and lustration. The early Japanese believed that there were numerous kami and mono ("spirits," especially those of the fox, snake, badger, and other animals), which could possess humans and cause sickness. As a result, people depended on diviners, shamans, healers, and magicians to deal with physical and mental problems, to prevent disasters or sicknesses, and to avoid pollution. For example, early writings refer to medicinal fruits and plants as well as to common practices to avoid pollution, such as avoiding contact with sick people, menstruating women, and death. The early Japanese resorted to herbal infusions, hot-spring baths, frequent bathing, or gargling for prevention and healing. These practices are mentioned in the eighth-century Kojiki, a compilation of Japanese mythology, and even in fourth-century Chinese chronicles that describe Japan.

Socially, early Japan was organized by uji (a lineage group often translated as "clan"); the Yamato kingdom, an old designation for Japan, which emerged around the third or fourth century, was in effect a confederation of semiautonomous uji-groups under the nominal political authority of the chieftain of the leading uji, later known as the imperial household.

The Ritsuryo System

In the wake of the political changes on the Asian continent in the sixth and seventh centuries, Japan acquired a second cultural layer, with the heavy influx of Chinese civilization through Sinified Korea, including Confucianism, Taoism, and the Yin-Yang school, as well as law, medicine, philosophy, ethics, and various sciences and technologies and Buddhism. Stimulated by the unification of China, Japanese leaders made a serious attempt to unify Japanese culture and society. The Ritsuryo system—an important and early synthesis of religious, cultural, social, and political ideas—is the concrete embodiment of this second layer of Japanese culture. Its basic principles, especially the doctrine of the mutual interdependence of Shintō-, Confucian-, and Taoist-inspired imperial ideology and Buddhism, survived until the sixteenth century. Thanks to the emerging synthetic cultural matrix, the Japanese learned that it was possible to apprehend a universal structure governing the world of nature and the human body. Especially noteworthy was the popularization of an East Asian tradition of medicine much later called kampō-i, or "Chinese-style medicine." As early as 602, a prominent Korean Buddhist monk, Kwalluk, brought to Japan a series of books on diverse subjects, including astronomy, medicine, and magic. From that time on, with active support from the Yamato court, Chinese medicine was spread rapidly throughout Japan by émigré Korean and Chinese physicians, pharmacologists, and Buddhist priests, who utilized their medical knowledge for healing as a part of their religious activities. Many Japanese physicians were especially attracted by the medical theories of the Chinese scholar Sun Ssu-mo (581–682?).

In the main, Chinese medicine combined an emphasis on the prevention and healing of disease with a concern for ethical behavior, in the belief that the body is not an individual's own possession but a gift from one's parents, and that one's health depends on the harmonious interaction of the negative (yin) and the positive (yang) principles. Thus it was one's filial duty to maintain one's health by maintaining harmony with the environment, inasmuch as sickness was believed to arise from imbalance at the physiological, psychological, or cosmological level. Chinese medicine also encouraged acupuncture (hari), massage (amma), moxa treatments (akyu or moxibustion, the application of plants as counterirritants, set on key acupuncture points and burned slowly), and herbal medicine. Chinese medicine did not stress anatomical studies and surgery, largely because of the Confucian emphasis on the sacredness of the human body.

Significantly, Buddhist leaders in Japan affirmed that what one learned from the Chinese medical-ethical tradition was in complete harmony with the fundamental Buddhist principle of compassion. In keeping with this principle, when Prince Regent Shōtoku (573–621) built a temple in what is today Osaka, he provided an asylum, a hospital, and a dispensary on the temple grounds. Following his example, pious monarchs and aristocrats sponsored medical and philanthropic works. Buddhism introduced to Japan not only the savior deity Amida (Amitâbha), and the bodhisattva of great compassion, Kannon (Avalokitesvara), but also the Buddha of Healing, Yakushi-nyorai (Bhaisajya-guru). The Chinese-inspired Taihō Code, promulgated in 702, stipulated the establishment of a Ministry of Health, to be staffed by ten physicians, who were massage specialists, herbalists, and magicians. Judging from the records of the imperial storehouse, the Shōsō-in, built in the mid-eighth century in the capital city of Nara, the Yamato court imported a variety of continental herbal medicines. Another subdivision of the government, the Onmyō-ryo ("Yin-Yang bureau") was staffed by specialists in divination, astrology, and calendar making; its main task was to combine magico-religious features (e.g., geomancy, divination techniques, fortune-telling, and exorcism) and the semiscientific art of observing planetary movements.

During the seventh and eighth centuries the imperial government supported the officially sanctioned Buddhist schools but also strictly controlled the activities of their clerics by enforcing the Sōni-ryo ("law governing monks and nuns"). The government also made a serious effort to (1) discourage the popularity of the unauthorized Buddhist clerics—the rustic shamans, magicians, and healers who came under the nominal influence of Buddhism and wandered from village to village, offering divination, magic and healing; and (2) confine legitimate monks and nuns to monastic quarters, keeping them from exercising black magic and practicing medicine. On both accounts, the government failed miserably. The unauthorized clerics, called ubasoku, continued their preaching, philanthropic, magical, and healing activities among the lower strata of society, which were all too often ignored by official Buddhist schools. On the other hand, some of the officially sanctioned Buddhist monks, notably Genbō (d. 746) and Dōkyō(d. 772), were reputed to have miraculous healing and incantational powers, and they wielded great influence in court circles.

During the Heian period (781–1191), two new Buddhist schools, Tendai and Shingon, were introduced from China, bringing with them new forms of magic, incantations, and cosmological speculation, all of which greatly facilitated the blending of indigenous Japanese (Shintō), Chinese, and Buddhist traditions. Similar eclectic tendencies appeared in medicine and ethics, as exemplified by the thirty-volume medical work Ishimpo, compiled in 984 by Tanba Yasuyori. This work integrated native Japanese insights into the T'ang Chinese medical framework and coupled this with ethical exhortations. From the Heian period on, the term kampō-i ("Chinese-style medicine") was used in Japan to refer to this hybrid system comprising Buddhist, Confucian, Yin-Yang, and Japanese beliefs and practices, and covering a wide range of subjects: acupuncture, herbalism, moxibustion, massage, cures for the diseases of various internal organs, nutrition, dermatology, hygiene, pediatrics, obstetrics, and so forth. It was also during the Heian period that the government actively promoted its health service and the training of physicians.

For the most part, however, medical services were monopolized by the upper strata of society. The masses had no recourse except to traditional, indigenous folk or popular practices, for example, moxibustion and massage coupled with talismans and incantations. Ironically, the Heian period also witnessed, among both the elites and the masses, the popularity of native as well as Chinese forms of omen lore, demon lore, directional taboos, and exorcism. In this situation, even though learned Buddhist leaders expounded the lofty themes of the compassionate Buddha Amida, their teaching was easily transformed into a "nembutsu [recitation of Amida's holy name] magic" by the peasantry.

During the Kamakura period (1192–1333), the Japanese polity was split between the courtier-based Kyoto court and the samurai-based feudal regime (bafuku or shogunate) in Kamakura, not far from present-day Tokyo. Understandably, the Ritsuryō ideology declined, as did the Heian government-inspired health service. In its place a new class of professional physicians emerged who charged fees for their services. The thirteenth century witnessed an unusual heightening of Buddhist spirituality, which added luster to outstanding medical and philanthropic activities by saintly Buddhist monks. One monk, named Ninshō, of the Ritsu school, is credited with having cared for 46,800 patients in his medical relief station in Kamakura, and with having established a leprosy sanatorium in Nara. Among the many dedicated priest-physicians of the Kamakura period, mention must be made of Kajiwara Shozen, the compiler of two important medical works—the Tan-i-shō, a fifty-volume work in Chinese, and the Man-an-pō, a sixty-volume Japanese work.

During the Muromachi period (1338–1578), a semblance of the feudal regime under the Ashikaga dynasty was maintained even as the social order steadily broke down. Toward the end of this period, three strongmen—Oda Nobunaga (d. 1582), Toyotomi Hideyoshi (d. 1598), and Tokugawa Ieyasu (d. 1616)—terminated the moribund Ritsuryō religious, cultural, social, and political synthesis. During the later Muromachi period, the various schools of Buddhism were unable to exert significant spiritual influence, the only exception being Zen, which inspired art, culture, and learning, and was instrumental in transmitting the syncretistic Neo-Confucianism of Sung Dynasty China (960–1279), as well as legal, philosophical, and medical classics of the Yüan (1276–1368) and Ming (1368–1644) dynasties. During the Muromachi period a number of Japanese physicians (both secular and clerical) studied in China, and able Chinese physicians migrated to Japan. Warfare among warrior families, especially the devastating Onin War of 1467–1477, promoted interest in surgery. Many prominent surgeons of this period were military men who combined medicine, Zen, and the martial arts.

The Muromachi period is also uniquely important in the history of Japanese medicine because of the coming of European medicine with the arrival of Portuguese traders and Roman Catholic missionaries. In the mid-sixteenth century, Jesuit missionaries established clinics, hospitals, dispensaries, and leprosy sanatoriums in Japan. One of the famous medical missionaries was Luis de Alameida, a successful surgeon-turned-Jesuit. For the most part, the European missionary-physicians admired the high quality of kampō-ijutsu (Chinese-style, mostly internal medicine) then available in Japan, and they contributed new knowledge and techniques in surgery, which were badly needed in the war-torn nation. After 1560, when the Society of Jesus terminated its medical activities, Japanese physicians who had been trained by European missionary-physicians carried on their work until the feudal regime decided to exterminate all traces of Catholic missionary influence from Japan in the mid-seventeenth century. Although the tradition of Namban (literally, "Southern Barbarian") medicine was short-lived, its scientific approach, coupled with an altruistic spirit and ethical imperative, left a significant imprint on the history of Japanese medicine and medical ethics.

The Tokugawa Era

In 1603, Tokugawa Ieyasu, one of the three strongmen mentioned above, inaugurated a shogunate that lasted until 1867, when the last Tokugawa shogun returned the prerogative of ruling the nation to the young Emperor Meiji. A different synthesis of religious, cultural, social, and political elements developed during the Tokugawa period. The Ritsuryō system discussed above tried to subsume two universalistic principles—tao ("the way"; michi in Japanese) of Confucianism and dharma ("the law"; hō in Japanese) of Buddhism—under the indigenous tradition represented by Shintō and the imperial system. The Tokugawa synthesis of religious, cultural, social, and political elements (the third layer of Japanese stratification) was based on universalistic Neo-Confucian principles of immutable natural laws and natural norms implicit in the human social and political order, grounded in the Will of Heaven (t'ien; ten in Japanese). Ironically, it was the Confucian thrust that stimulated the nativist kokugaku ("national learning") movement, which in turn fostered the resurgence of Shintō as the guiding principle for restoration of an imperial regime in 1868, inaugurating Japan's modern period.

From the perspective of medical history, the Tokugawa period was rich in variety, propelling the development of Chinese (classical Confucian and Neo-Confucian) and nativistic Japanese medicine, and the return of Western medical science. During the Tokugawa period, following the regime's policy in favor of Neo-Confucianism, Japanese medicine separated from its Buddhist underpinning and sought a new foundation in Neo-Confucian metaphysics, physics, psychology, and ethics. Under Neo-Confucian influence, idō (the "way or ethics of medicine") was summed up in the phrase i wa jin nari ("the practice of medicine is a benevolent art"). Significantly, the first systematic treatises on medical ethics written in Japan, the Ibyo-ryogan and the Byoi-mando, by Takenaka Tsuan, as well as the Yojo-kun ("Instruction on Hygiene"), by Kaibara Ekken (d. 1714), were published in the early Tokugawa period. About that time, among the physicians of kampō-i ("Chinese style medicine"), a group called gosei-ha ("school of later centuries") taught an intricate fusion of medicine and Neo-Confucian philosophy and became quite influential.

One of the most influential works on healthcare was the Yojo-kun ("how to live well"), by the samurai and physician Kaibara Ekken. A Neo-Confucianist scholar, Kaibara wrote widely on various subjects for the edification of people in all walks of life. His lifelong dedication to the cause of healthcare is summarized thus: "Medicine is the practice of humanitarianism. Its purpose should be to help others with benevolence and love. One must not think of one's own interests but should save and help the people who were created by Heaven and Earth." This represents the view that human beings are created by the union of Heaven and Earth, that is, the parents. Since medicine is an art that can make the difference between life and death, it is a profession of utmost importance. This means that physicians must be culturally and intellectually accomplished. Kaibara urged physicians to be conversant with the best medical books, to think logically and precisely, and to acquire important theories, practicing lifelong education. He proposed an ideal image of the physician, who excels in qualities of character and scholarship, in contrast to the inferior physician, who serves his own interests rather than saving others. At the end of his treatise Kaibara lists eight requirements for the physician: (1) to have a high goal in life; (2) to be cautious; (3) to acquire scholarship of broad knowledge; (4) to make the medical profession a full-time pursuit; (5) to be thirsty for new and ever greater knowledge; (6) to be humble; (7) to be clean at all times; and(8) to be magnanimous.

Meanwhile, in the latter part of the seventeenth century two interesting phenomena developed: (1) the emergence of "ancient studies" (kogaku) within the Japanese Confucian tradition, which encouraged kampō-i ("Chinese-style medicine") physicians to react against the Neo-Confucian orientation and to return to classical Chinese medicine; and (2) the emergence of the Japanese "national learning" school (kokugaku), inspired by Confucian kogaku.

Clearly, the ancient studies school was a reaction among Japanese Confucianists against the regime-sponsored Neo-Confucian orthodoxy that involved advocating a return to ancient Confucian sages. Ancient studies precipitated the rise of a school of medicine called koihō-ha ("school of ancient medicine") among Japanese kampō-i physicians, who advocated a return to ancient (i.e., Han dynasty, 206 b.c.e.—220 c.e.) Chinese medicine and, more specifically, tried to retrieve the medical work of a Han physician, Chan Chingchung. For example, Chan's book on fevers and their remedies, the Shokan-ron, became widely read in Japan.

Paradoxically, the philological-philosophical approaches of kogaku inspired some nativists to apply its scholarly method to the study of ancient Japanese classics, thus developing the school of "national learning" (kokugaku), which soon grew into an influential movement and eventually joined with other nativists in the anti-Tokugawa and pro-royalist movement. One of the leading theoreticians of this school, Motoori Norinaga (1730–1801), was a physician. We are told that in his youth he studied both Neo-Confucianism and the Neo-Confucian-inspired goseiha tradition of medicine, but gradually discarded Neo-Confucianism in favor of national learning and repudiated the gosei-ha medical orientation, turning to the koihō-ha tradition. Other "national learning" scholars, such as Ueda Akinari (1734–1809) and Hirata Atsutane (1776–1843), were also physicians. Hirata attached great importance to mental therapy and excelled in taking his patients' psychosomatic conditions into account.

Western medicine, briefly introduced by the Jesuits, returned to Japan under Dutch influence. In order to exterminate Catholic influence, the Tokugawa feudal regime had proclaimed the policy of national seclusion in 1639, terminating all contacts with Western powers. It had allowed only non-Catholic Holland to maintain a small trading post in Nagasaki. Through this minimal contact, Dutch medical supplies and surgical methods continued to influence the Japanese medical profession. As early as the mid-seventeenth century a Dutch physician, Casper Schambergen, spent nearly a year at Nagasaki, teaching Dutch medicine. His influence greatly enhanced cosmopolitan (Westernized) medicine, especially surgery, then called the aranda-ryu geka ("Dutch surgical school"). This school became popular through a translation of the Tavel Anatomia (Kaitai-shinsho) by Mayeno Ryotaku, Sugita Gempaku, Nakagawa Jun'an, and Katsuragawa Hoshu in 1774. In 1823–1828, Philip Franz von Siebold, a German physician and scientist attached to the Dutch trading post in Nagasaki, was permitted to operate a clinic and an academy that attracted a number of able Japanese medical students. He revisited Japan in 1859–1862. Those Japanese students who studied Dutch learning had been well grounded in Confucian learning, which to them was essential for moral cultivation, whereas Dutch (and later, other Western learning in general) was considered practical learning. Hence the famous motto "Eastern ethics and Western science."

The Meiji Synthesis and Modern Japan

The once powerful Tokugawa feudal regime was exhausted politically when the last Tokugawa shogun surrendered feudal power in 1867. It was succeeded by the Meiji-era synthesis of religious, cultural, social, and political ideas that survived until the end of World War II in 1945. Unlike the Tokugawa regime, which authenticated its policy and culture in terms of universalistic Neo-Confucian principles, the Meiji regime reverted to particularistic Shintø and imperial traditions reminiscent of the Ritsuryō synthesis of the seventh century, notwithstanding the Meiji emperor's Charter Oath to the effect that "uncivilized customs of former times shall be abolished" and "knowledge shall be sought throughout the world." (Understandably, the basic contradictions of the Meiji synthesis have haunted modern Japan until our own time.)

In the modern period Japan welcomed Western knowledge and technology, which inspired, among other things, modern Westernized law, philosophy, ethics, and medicine. In medicine, the Japanese government officially adopted the German system of medical education in 1869. In 1873, there were slightly over five hundred Westernized physicians and twenty-three thousand traditional kampō doctors (or kampō-i). From 1876 on, the government required all physicians to study Westernized medicine, although kampō medicine, which never lost its official recognition, continued to flourish throughout the nineteenth century and into the twentieth. In retrospect it becomes evident that from early times to the modern period, through all the cultural layers, Japanese medicine and ethics—nurtured by Sino-Korean culture, Buddhism, and Western influences—never completely lost its ancient, indigenous orientations, including magico-religious beliefs and practices.

joseph mitsuo kitagawa (1995)

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