第 23 号 - 浜松医科大学

ISSN 0914-0174
浜松医科大学紀要
一 般 教 育
第 23 号
2009 年 3 月
浜松医科大学
目 次
ある漸化式から生じる数の集合について（1）平均値とメディアン … 野田 明男 ……………… 1
狩猟採集民バカの病対処行動：コンゴ共和国北西部の事例
………… 佐藤 弘明 …………… 11
An Examination of the Human Soul that Dwells within the Machine
as Exemplified by The Ghost in the Shell …………………………………… 遠藤 幸英 …………… 33
医師養成における教育と訓練の役割に関する検討
…… グレゴリー・オーダゥド …………… 45
付録：浜松医科大学紀要一般教育の編集，発刊に関する申し合わせ
…………………………… 70
浜松医科大学紀要 一般教育 第 23 号（2009）
ある漸化式から生じる数の集合について （1）平均値とメディアン
野田 明男
（総合人間科学講座・数学）
On the Set of Numbers Derived from Some Recurrence
Formula (1) Mean and Median
Akio NODA
(Integrated Human Sciences · Mathematics)
Abstract: Let a sequence fn(t) of polynomials be defined by the following recurrence formula:
The author is interested in the set Sk consisting of natural numbers n such that the degree of fn (t) is
equal to k (k =1,2,3,·····), and investigates its structure from a statistical point of view. Indeed, the various
statistics of Sk such as the minimal and maximal values, the mean and the variance, admit closed-form
expressions (see §2). For the median Mk of Sk , however, it is not easy to obtain its exact formula of k ,
although the values of Mk for all k ≦19 are computed and listed in §1. In the present paper, we are content
to apply Paulson’s approximation formula ([1]) concerning the Beta distribution to the study of an
asymptotic estimate of Mk (see §3), which implies that
to be smaller than the mean value
as
and hence that Mk turns out
.
Key words: Recurrence formula, Mean, Median, Beta distribution, Paulson’s approximation formula.
1
On the Set of Numbers Derived from Some Recurrence Formula (1) Mean and Median
§ 1. 問題と結果（定理 1，定理 2）の陳述
次の漸化式によって定まる多項式列 fn(t) を考える。
これら fn(t) の列を追うとき，k 次多項式がどこで現れるかという問題に興味をもったのが，この研
究の始まりである。すなわち， fn(t) の次数を dn とし， dn が満たす漸化式
を使って，数の集合
を統計的観点に立って考察する。
,
,
, ……となっている。
この論文では Sk のいくつかの統計量−最小値 min (Sk)，最大値 max (Sk )，メディアン Mk ，平均
値 µk ，分散 σk 等を調べる。
2
で Sk の要素の個数を表わすと，得られた結果は以下の定理1と定
理2にまとめられる。
定理1．（1）
（4）
（2）
（3）
（5）
この結果は，集合 Sk が3つの写像
によって完全に記述される事実から，比較
的容易に証明される
（§2参照）。しかしながら， Sk の順序構造は少し複雑であり，中央の位置を示
すメディアン Mk を k の式として閉じた形に表わすことは容易ではない。2項分布の上側確率
（これ
がベータ分布の分布関数 Ix( α , β ) で表わされることは周知の事実である）を調べて， Mk の値を含
み，相対的に小さな幅の区間をわれわれは見出したい。事実，上記 Ix( α , β ) に関するPaulsonの近
似式（［1］）
を応用して，次の結果に到達する。（定理2の証明は§3で詳述する。）
定理2. 十分大きな m に対し，次の不等式が成り立つ。
定理2の Mk の評価式は，
を教える。従って，
に留意して定理1
（4）を使えば，
十分大きな k に対し， Mk < µk が成り立つことがわかる。この不等式は，「右裾の長い分布」が示す
諸特徴の中でも第一に挙げられる性質である（［3］）。
2
浜松医科大学紀要 一般教育 第 23 号（2009）
注意1. 3 ≦ k ≦ 19 のとき，2項分布の上側確率に関し，2項係数を含む式を具体的に計算して，
定理2の正しさを確かめるとともに， Mk の正確な値を求めた。 M1 = 3, M2 = 10 は明らか。以下，
M3 =35, M4 = 101, M 5 =326, M 6 =1114, M7 = 3235, M8 = 10469,
M9 = 35609, M10 = 103589,
M11 = 336473, M12 = 1137962, M13 = 3315667, M14 = 10783637, M15 = 36397987, M16 = 106122664,
M17 = 345351896, M18 = 1164505706, M19 = 3396507003 となっている。20 ≦ k ≦ 36 の範囲の k に対
しては，ベータ函数表（［2］）を利用して，定理2の主張を確認した。なお，k ≧ 37 の場合にも定理2
は成り立つであろうと予想する。しかし，証明する手立てが今，著者にあるわけではない。
3
On the Set of Numbers Derived from Some Recurrence Formula (1) Mean and Median
§ 2. 数の集合 Sk の構造と平均値（定理 1 の証明）
われわれの集合 Sk の構造は，3種類の写像
によって完全に記述される。すなわち，
は S k から S k+1 への1対1写像である
（ k = 0,1,2,……）。
補題1.（1）
ならば，
（2）
ならば，
である。
である。
（証明）
（1）n に関する数学的帰納法で示す。
である。帰納法の仮定により，
ならば，
は
,
と高々 1 しか違わないので，
が成り立つ。また，
ならば，
から同様にして，
（2）
ならば，
故
して，
が従う。
は明らか。また，
に留意
を得て，
が示される。
も同様に示される。
補題1によって，
からスタートして，
,
という風に，高次の
集合 Sk が順々に構成される。すなわち， Sk の任意の要素 n は，
の形に， k 個の重複順列
と 1 対 1 に対応する。こうして，
れる。また， Sk の最小値は，
，最大値は，
（2）と（3））。記法を簡略にするため，
補題2.（1）
（3）
（証明）
（1）
4
なので，定理1
（1）が示さ
で与えられる（定理1
とおく。
（2）
（4）
に留意して，
を得，
から
が従う。
浜松医科大学紀要 一般教育 第 23 号（2009）
（2）
から，
ば，
が従う。ここで，
となり，
とおけ
つまり，
が示される。
（3）
（4）の結果は，上記（2）と同じ論法で示される。
さて， Sk の平均値 µk は，
と計算される。分散
は，
で求められる（定理1の（4）と（5））。
補題2
（3）と（4）により， Sk の歪度 αk(3) と尖度 αk(4)（［3］）を求めて，この節を終えよう。
標準偏差
を導く。
に留意して，
のとき，
そして変動係数
はい
ずれも +∞ に発散することがわかる。こうして k が大きくなるとともに，「右裾の長い分布」という
Sk の統計的性格がもたらす諸特徴が一層目立つことになる。
5
On the Set of Numbers Derived from Some Recurrence Formula (1) Mean and Median
§ 3. メディアン Mk の漸近挙動（定理 2 の証明）
Sk の要素を記述する合成写像
の間の順序構造を調べ
るために，重複順列の空間 V k を， k 回の選択のうち，0の選ばれた回数 によって分割することか
ら始める。
とすれば，
補題3. となる番号 i は 個ある
である。
は任意の自然数とする。
（1）
（2）
（3）
（4）
（5）
（6）
以上，（1）
から（6）までの数値は単調に大きくなって行く。
（7）
補題3の計算は容易であり，くわしい証明は省略したい。
の順序構造は，
に対応する最小値
から
始まり，
に対応するもの，
き，最後
に対応する 2k 通りの数
（
方，同じ
内では，v1 から順にみて行き，初めて同じ値でなくなる成分 vi に着目する。その
6
に対応するもの，……と移るごとに大きくなって行
からの最大値
にわたる）に至る。他
浜松医科大学紀要 一般教育 第 23 号（2009）
値を比べて，–1,0,1の順序で定まる辞書式順序になっている。こうして，メディアン Mk を求めるに
は，
を同時に満たす整数 m を，まず定める必要がある。そ
して，
順列
の中で，小さい順にみて，
を探さなければならない（
番目の数に対応する重複
）。
このために，上記の不等式をそれぞれ 3k で割って，成功の確率1/3の2項分布に移行する。そして，
2つの上側確率
を評価する。
はべータ分布の分布関数を表わす。α, β がともに大きい
ここで，
とき，次の近似式が有用である（［1］p.99参照）。
Paulsonの近似式 で標準正規分布の分布関数を表わすとき，次式が成り立つ。
さて，自然数 m と
によって，
とかくと，逆に m と v は k から一意的に求まる。
このとき，十分大きな m に対し，Paulsonの近似式を適用すれば，下記の補題4を得て，
が成り立つことがわかる。次に，
とおき，3–k の項は無視して，比
の漸近挙動（補題5）を調べる。このように，この節の後半は，探求すべき
のおよその在
り処を見出す仕事に費される。
補題4. 十分大きな m に対し，
とおくと次式が成り立つ。
（1）
7
On the Set of Numbers Derived from Some Recurrence Formula (1) Mean and Median
（2）
補題4の式はすべて，Paulsonの近似式に
の冪級数展開を適用して，近似計算した結果に他
ならない。
補題5. のとき，次式が成り立つ。
ここで，
である。
（証明） x > 0 が十分小さいとき，
とかける。従って，v = –1 のとき，
となる。比をとれば，
を得る。 v = 0,1 の場合も，同じ手法で結果が示される。
8
浜松医科大学紀要 一般教育 第 23 号（2009）
今や定理2の Mk の評価式へと進む用意が整った。( v3, v 2, v 1 ) の値を指定することによって，Wk (m)
を27個の部分集合 Wk (m ; v3, v2, v1 ) に分割しよう。それらの間の順序関係は，補題3によって，以下
のようにかける。
Wk(m ; –1, –1, –1) < Wk(m ; 0, –1, –1) < Wk(m ; 1, –1, –1) < Wk(m ; –1, 0, –1) < Wk (m ; 0, 0, –1) <
Wk(m ; 1, 0, –1) < Wk(m ; –1, 1, –1) < Wk(m ; 0, 1, –1) < Wk(m ; 1, 1, –1) < Wk (m ; –1, –1, 0) <
Wk(m ; 0, –1, 0) < Wk(m ; 1, –1, 0) < Wk(m ; –1, 0, 0) < Wk(m ; 0, 0, 0) < Wk (m ; 1, 0, 0) <
Wk(m ; –1, 1, 0) < Wk(m ; 0, 1, 0) < Wk(m ; 1, 1, 0) < Wk(m ; –1, –1, 1) < Wk (m ; 0, –1, 1) <
Wk(m ; 1, –1, 1) < Wk(m ; –1, 0, 1) < Wk(m ; 0, 0, 1) < Wk(m ; 1, 0, 1) < Wk (m ; –1, 1, 1) <
Wk(m ; 0, 1, 1) < Wk(m ; 1, 1, 1)
( v3, v2, v1 ) の3つの成分に出現する0の回数を i とすれば，
k = 3m + v として，
を得る。
との比を計算すれば，i = 0 のとき
,
i = 1 のとき
のとき
i = 3 のとき
と結論できる。補題5に留意して，メディアンを与える
を探すと，「 v = –1 なら
,
なら
」という風に，27個ある部分集合のうち，特定の1つに
ことに成功する。こうして特定された部分集合に対応する数
なら
の在り処をしぼり込む
の中で，最小値と最大値を補題
3から算出した結果が，定理2の不等式に他ならない。
最後に，大学行事で出会った確率問題を1つ取りあげて，よく知られた中心極限定理とわれわれが
依拠したPaulsonの近似式とを比較する。
注意2. 浜松医科大学では，入学ガイダンスの一貫として新入生の合宿研修を毎年実施している。
その開始をつげる「アイス・ブレイキング」は，山本清二准教授（光量子医学研究センター）の担当。
壇上に立つ山本先生は，n = 155 人の新入生を相手にじゃんけんを行って，場の雰囲気をやわらげ
る。これは，先生に勝った者のみ生き残って，次回のじゃんけんに進むゲームである。生き残る人
がいなくなった時点でゲームは終了し，昼食の席に全員移ることになる。ここでは初回のじゃんけ
んの結果，生き残った人数 X の95% 信頼区間を構成する課題に取り組む。（ゲーム終了までの待ち
時間 T も興味深いテーマであるが，T の確率解析は機会を改めて考察したい。）
通常用いられる中心極限定理は，確率変数 X が成功の確率1/3の2項分布に従うので，
，つまり n = 155 の場合，40.16≦ X ≦63.17という範囲を与え，
整数値の X
に 対 し ， 端 点 の 決 め 方 に 苦 し む こ と に な る 。P a u l s o n の 近 似 式 に よ れ ば ，
9
On the Set of Numbers Derived from Some Recurrence Formula (1) Mean and Median
で，期待される2 . 5 % よりも小さく，
は満足できるレベルとなる。また，
は期待される97.5%よりも大きいが，
となる。このよう
に Paulson の近似式は，適切な範囲 41≦ X ≦63
（それが実現する確率は，約95.01%）
をわれわれに
恵む。
謝辞
レフェリーの指摘を受けて，理解のしやすい記述に改めることができました。レフェリーに深く
感謝申しあげます。資料の整理に加えて，原稿の清書をお願いした鴨藤江利子さんに，心から御礼
申しあげます。
参考文献
［1］山内二郎（編）：統計数値表 JSA-1972．日本規格協会，1972．
［2］春日屋伸昌（編）：実用数表大系15 ガンマ函数表・ベータ函数表．技報堂，1972．
［3］東京大学教養学部統計学教室（編）：統計学入門．東京大学出版会，1991．
10
浜松医科大学紀要 一般教育 第 23 号（2009）
狩猟採集民バカの病対処行動：
コンゴ共和国北西部の事例
佐藤 弘明
（浜松医科大学・総合人間科学講座・人類学）
Coping behavior for illnesses among the Baka
hunter-gatherers: a case study
in northwestern Republic of Congo
Hiroaki SATO
Anthropology
Abstract
Examining the role of folk medicine in a regional health care system, and the distribution of folk
medical knowledge among the Baka people, the author observed the coping behavior for illness among
the Baka hunter-gatherers with limited access to modern medicine. The data was collected by a daily
interviewing method: visiting all families (a total population of 129) every day in a settlement in the
Soanke District of northwestern Republic of Congo for 66 days from October 1990 to January 1991 and
interviewing the main members of each family about their health condition and their coping behavior
when family members become ill. The findings are as follows:
1. Thirty-nine various terms for illness or symptoms were recorded in 304 cases of illness.
2. The illness composition of the 304 cases were similar to the disease composition of diagnosis
records for outpatients in the hospital of Soanke town.
3. Some treatments were given in more than half of the cases, the most of which were home remedies.
4. Almost all of the home remedies were self-medication using some raw materials as medicines.
5. Most of the raw materials used for medicines were tree bark, roots, and leaves of plants, identified
by 71 vernacular names, including 56 wild kinds.
6. Self-medication methods given for each illness or symptom were very diverse.
7. The reason for such diverse self-medication methods was probably that each inhabitant had a large
stock of knowledge of medicinal plants and folk medical knowledge which he or she had was not
common, but personal.
キーワード：Baka hunter-gatherers, folk medicine, coping behavior for illness, home remedy, self-medication
11
Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
はじめに
北西コンゴから南東カメルーン一帯の熱帯雨林地帯に住む狩猟採集民Bakaはいわゆるピグミーと
して知られてきた人々で，およそ3,3000人の人口を有し
（Cavalli-Sforza, 1986）
，アダマワ・ウバンギ
アン
（1A6）に属する言語を話す（Greenberg, 1970）
。現在，その多くが定住集落を築き，焼畑農耕に従
事しているが，今なお，狩猟採集活動は生業の柱であり，近隣の農耕民とは異なる独特の社会・文
化を維持し，熱帯雨林に強く依存した生活を送っている
（佐藤, 1991; Sato, 1992）
。
筆者はこれまで彼らの民俗医学，とくに民俗病因論（佐藤, 1998; Sato, 1998）や病観（佐藤，2001），
治療痕（佐藤，2005）について報告してきた。民俗病因論や病観の報告においては，病や薬について
該博な知識を有する専門家からの聴取により，Bakaの病認識に熱帯雨林環境，とくに，多種多様な
動物の存在が深く関わっていることを明らかにした。治療痕の報告においては，30名を越える男女
の観察から彼らの身体には湿潤な熱帯雨林環境ゆえと思わせる種々の傷病が文字通り刻印されてい
ることを明らかにした。これらの報告はBakaの人々が実際にどのような病に罹患し，それらに対し
てどのように対処しているかという実体的側面を取り扱うものではなかった。しかし，民俗医学を
いかなる立場から扱おうとも，この実体的側面を知らぬままでは済まされない。ところが，現実に
は，小集団を対象にした民俗医学研究では，観察できる症例数に限りがあること，罹患している病
の診断が民俗医学，現代医学のどちらにしても難しいこと，治療法，とくに薬に関する情報が秘匿
されがちであることなどから，実体的側面の正確な把握は難しい。民俗医学の研究者自身が医師で
あれば
（Lewis, 1975）
，あるいは，呪医のような当該地の専門家の助手の立場につければ（掛谷，
1977）
，長期の観察調査によってこの問題は解決できるかもしれない。しかし，筆者のように医師で
も呪医でもなく，長い調査期間が望めない者にとってこれは難題である。そこで，筆者は短い期間
ではあるが対象集団全員を毎日訪問し，病の罹患状況，病の対処行動について聴取するという調査
を計画した。この調査で得られる資料は，その多くが民俗医学の素人である対象者自身が診断する
病であり，対処行動に関しても多くはいわば素人療法である。したがって民俗医学の専門家による
診断や治療とは異なるおそれがある。しかし，一般住民が訴える病や症状であってもその内容を吟
味すれば，彼らの疾病構造の概要を明らかにできるであろうし，その対処行動も民俗医学の一端，
すなわち民衆レベルにおける民俗医学の実践が現れていると考えることができよう。
本稿は，Bakaの人々が日常実践している病の対処行動について報告する。この報告の目的の一つ
は，現代医学にアクセスできない熱帯雨林住民が日常的にどのような病の脅威にさらされ，それに
対してどのような対処手段を実施しているかを明らかにし，熱帯雨林の地域医療における民俗医学
の役割を検証すること，もう一つは，彼らがどのような民俗医学の知識を有しているか，それをど
のように実践しているかを記載し，Bakaの民俗医学の実践的側面の特徴を民族科学の観点から明ら
かにすることである。
12
浜松医科大学紀要 一般教育 第 23 号（2009）
調査対象と方法
1．調査地と対象集団
病対処行動の観察調査は，1990年10月から1991年1月まで北西コンゴのソアンケ郡の郡都ソアンケ
市から約2キロメートルのゴマニ集落でおこなった（図1）。ゴマニ集落の住民はすべてBaka人であっ
た。ソアンケ市およびその周辺にはBakwele，Fan，Djemの農耕民諸族が居住していた。1991年1月
当時，ゴマニ集落の人口は110∼130人であった。
当時，ソアンケ市には，1名の医師と7∼8名のパラメディカルスタッフで運営される国営病院が
あった。医療費は無料であったが，医薬品をほとんど欠いていたためスタッフのすることは外来患
者の処方箋を書くことだけで，事実上開店休業状態であった。薬はキリスト教伝道教会が経営する
薬局で購入することができる。しかし，社会的経済的地位が低く，貧しいBakaの人々にとって薬は
高価であり，処方箋しかもらえない病院を訪れることはほとんどない。ごく少数の敬虔なキリスト
教信者以外，ゴマニ集落住民が近代医薬品を利用する機会は限られていた。
Baka社会にはンガンガと呼ばれる呪医がいる。病気や他の不幸，とくに深刻なものについてその
原因を探しだし，診断をし，多様な特効薬を処方するンガンガはBakaの民俗医学体系のなかで重要
な役割を果たす。高名なンガンガともなるとそれを生業にするものもいるが，通常は，一般人と変
わらぬ生活をおくる。調査当時，ゴマニ集落にはンガンガと呼ばれる呪医はいなかったが，それに
類するものが男性2名，女性1名いた。彼らはいずれも50歳を超えていると思われる高齢者で，病や
民俗薬に関する博学な知識を有し，ときに住民の相談に乗ることもあった。彼らは病の名称，薬，
病因論（佐藤, 1998；Sato, 1998；佐藤，2001）
に関する筆者のインフォーマント（言語資料提供者）で
あったが，本調査ではそれぞれ聞き取り対象者の一人とした。
図1 調査地
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Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
2．方法
調査方法は以下の通りである。当時ゴマニ集落にあった33戸の家を毎日1回夕刻に訪問し，その家
の住人にその日の体調を聞き，不調ならば，病名，もしくは症状を聞き，さらに，それに対して採っ
た行動を聞き，記録した。聞き取り対象者は，原則本人としたが，本人が不在の場合や子どもなど
聞き取り不能の場合は，配偶者や親など本人の近親者から聴取した。結果的に聞き取り対象者はほ
とんど各世帯の成人の男女，すなわち，世帯構成の中心となる夫婦であった。調査期間は，1990年
10月31日から1991年1月24日までであったが，途中筆者のマラリア罹患で12月15日から1月3日まで一
時中断したため，聞き取りが実施できた調査日数は66日間であった。調査対象者総数は129名
（男性
61名，女性68名）
であった。この中には，本来住民ではないが，長期に滞在している者も含まれてい
る。また，対象者であっても，他村や森，畑に出かけて外泊した日は調査日数から除外した。対象
者の年齢については，Baka社会には年齢を数える習慣はないので，外見，長幼の順序，絶対年齢が
判る者との対照から推測できる年齢，出産歴，子どもの年齢などを総合して推定した。表1に調査対
象者の性，年齢階層構成，および調査日数を示した。
表1 対象
病や症状を区分する名称は，聞き取り対象者から申告された病名，症状名を原則そのまま採用し
た。これについては説明を要するので以下に述べる。まず，申告された病の名称は，大別して二つ
のタイプに分けられる。一つは，固有の名称で，もう一つは，kònà○○○と表現されるタイプであ
る。前者は特定の病を指すので問題ないが，後者の場合，複数の病を包含する表現なので前者とは
本来カテゴリーレベルが異なる。kònàbuboを例にすると，kòは病を意味し，buboは腹を意味するの
で，kònàbuboとは腹の病全般を意味することになる。しかし，kònàbuboの個々のケースを識別し，
特定することは不可能なのでここでは，kònàbuboという名称を固有の病名称と同列に扱った。症状
も病名称とは異なるカテゴリーレベルにあるが，これもその症状を引き起こした病があったとして
もそれを特定することはできない
（筆者はもちろん特定できないし，申告者も特定できないからこそ
症状だけを訴えたはずである）ので病名称と同列に扱った。結果として，本稿で取り扱われる病や症
状の名称は異なるカテゴリーレベルが混在する名称群となったが，調査対象者の病構造，および，
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浜松医科大学紀要 一般教育 第 23 号（2009）
病対処行動を知る上で大きな障害にはならないと判断した。 次に，本稿の記述，分析に際して使う用語について説明する。
ケース：ある調査対象者が，ある日，ある病を得たとき，その病が続く限り1日で終わろうと，10
日で終わろうと一つのケースとする。あるケースが続いている途中，その病とは異なる別の病，あ
るいは症状が訴えられるとき，二つ目の異なるケースが開始したとする。したがって，一人が同時
に二つのケースを抱えるという事態もあり得る。
罹患日数：あるケースが記録された日数を罹患日数とする。
病日数：ある調査対象者が何かの病を得た日を病日とし，その合計日数をその対象者の病日数と
する。病日数と罹患日数の関係は以下のごとくである。ある対象者が異なる二つの病を10日間に渡っ
て得たとすると，その病日数は10日であるが，罹患日数は二つのケースでそれぞれ10日となる。
病の対処行動：各ケースの対処行動を実施された治療法にしたがって4タイプに分けた。一つは，
友人や呪医（呪医に準ずる民俗医学の専門的知識をもった知人も含める）による治療法，二つ目は，
病院や薬局，あるいは筆者から入手した医薬品の使用，三つ目は，病者本人，もしくは近親が施療
するか，あるいは，薬を収集し投薬する自家治療，最後は，以上の治療行為をまったくしない場合
である。Soankeの商店で購入した民間薬を使用する場合については，その個性的な使用方法が自家
治療に相応しいと判断し，自家治療に含めた。なお，本調査の期間中は筆者が持参している医薬品
は原則として使えないことを調査実施前にあらかじめ住民に伝えていたのでそれを要求する対象者
は少なく，筆者の医薬品が投薬された例は数例だけであった。
投薬療法：自家治療において民俗薬を使用した療法を指す。
投薬療法の種類：投薬療法は，投薬された薬材の種類とその使用部位，投薬方法によって様々な
種類に区分される。
投薬療法の例数の取り扱い：あるケースにおいて同じ種類の投薬療法が複数回実施されてもその
投薬療法の例数は1とする。同じ投薬療法が異なるケースで実施された場合，それぞれのケースで例
数を1とする。
ゴマニ集落住民の多くはBaka語とともにアフリカ中央部の共通言語であるLingala語を話す。本調
査は主としてLingala語を使用しておこなったが，病，植物などの名称はBaka語で表記した。また，
Baka語には高，中，低の三音調があるので中調子は無符とし，高調子は揚音符（´），低調子は抑音
符（`）で表記した。
植物の同定はコンゴ人民共和国（当時）の首都ブラザビルのORSTOMに依頼した。
結果と考察
1．病と症状
調査期間中に記録された病名，症状名は全部で39名称であった。以下に病番号，名称，概説の順
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Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
で記述する。
S1．bìbà：大きなできもの。腫れて，熱をもつ。時間が経つと，口が開き，膿が出る。どこにでも
できるが，大腿部に多い。nguso（後述）よりも大きい。
S2．bíbìli：全身がたまらなくかゆくなる。2，3日でなおる。蚊，吸血蝿，南京虫などに刺されると
毒が入ってかかる。
S3．bimba：身体の部位の腫れを指す。腫れもの。
S4．bulebàkè：腹（bubo）の痛み（bàkè）を指す。
S5．gobulebàkè：全身の疲れやだるさを訴えるときこのように表現する。
S6．golebàkè：首の後部（gobo）の痛み。
S7．ìndàyà：はじめに頭痛，次いで，発熱，最後に肛門に赤い丸い傷ができる。腹の病と考えられ
ている。この病が村にくると，皆かかると信じられている。
S8．jiò：頭痛，高熱，悪寒をともなうとき（マラリアであろう），この病名が使われるが，熱がある
という症状を指す場合にも使われる。
S9．jolebàkè：頭（jobo）痛。
S10．ka：傷全般を指す。
S11．kòàkàlu：発熱。目の上が白くふちどられたkàlu（白黒コロブス）
のように目の上が木で打たれた
ように痛み，涙が出る。 S12．kònàbebo：腕（bebo）の病全般を指す。
S13．kònàbubo：腹（臍の周辺部分：bubo）の病全般を指す。
S14．kònàbúmábo：胸下部（bumabo）の病全般を指す。
S15．kònàfebo：背中
（febo）の病全般を指す。
S16．kònàgábo：脇腹（gabo）の病全般を指す。
S17．kònàgobobo：身体全体（gobobo）の病。全身が痛むとき，疲れたときこのように表現する。
S18．kònàjobebo：ひざ（jobebo）が痛むときにこのように表現する。
S19．kònàjòbo：頭（jòbo）の病全般を指す。
S20．kònàjobubo：下腹部（jobubo）の病全般を指す。
S21．kònàkábo：乳房（kabo）の病全般を指す。
S22．kònàlábo：目（labo）の病全般を指す。
S23．kònàlo：森や畑の樹木（lo）による怪我を指す。
S24．kònàlutubo：脊骨（lutubo）の病を指すが，背中が痛むときにこのように表現する。
S25．kònànobo：足（nobo）の病全般を指す。
S26．kònàtobo：胸上部
（tobo）の病全般を指すが，胸が痛むときにもこのように表現する。
S27．liboko：左脇腹や右脇腹が腫れて固くなる。死ぬこともある。小児の病。母親が獲物の肝，脾
臓を食うとかかる。両親の婚外交渉によってもかかる。
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浜松医科大学紀要 一般教育 第 23 号（2009）
S28．manda：血便。
S29．mèngòmedè：眼病。目が充血する。痩せて，下痢をすることもある。村民一人が罹患すると村
人が皆罹患する。
S30．ndíkangòlò：そけい部のリンパ腺が腫れ，痛みと熱がある。
S31．ngúsò：できもの。熱はない。
S32．nyángalí：歯に穴があき，痛む。ハチミツとトーモロコシを食べるとかかる。虫歯。
S33．pholo：腹の中に巣くう虫，および，それによる腹具合の変調も意味する。
S34．sàkakòto：脇にできるできもの。膿をもつ。
S35．sàsà：発疹。
S36．sende：下痢。
S37．songo：発熱。胸から背に針が貫くように痛む。
S38．ti：とげ（ti）が身体に刺さって痛む。
S39．tulanga：熱はないが，咳やのどの痛みがあるときこのように表現する。風邪に相当するもの。
以上の39の病・症状名は，固有の病名称13，kònà○○○と表現される病の一般名称15，症状の名
称13に分けられる。同じゴマニ集落に住む病や薬に詳しい二人の男性インフォーマントから聞き取っ
た固有の病名称は89（佐藤，1998）を数えたが，本調査で記録されたそれは13にとどまった。これは
調査期間が短いこともあるが，聞き取り対象者のほとんどが一般住民であったことも関連している
のであろう。
なお，tulanga
（風邪）と同時に，あるいは，少し遅れてjiò
（熱）
や，jolebàkè
（頭痛）が訴えられること
も少なくなかった。これはtulangaが悪化してjiòや，jolebàkèを引き起こしたと思われるが，このよう
な場合でもケースは別として扱っている。すなわち，tulangaが3日間続いた後，4日目はjiòだけを訴
えたような場合，tulanga 3日とjiò 1日のケースとして記載した。また，4日目にjiòが訴えられたとき，
tulangaもまだ続いているなら，tulanga 4日，jiò 1日のケースとして記載した。そうした理由は，因
果関係を確かめる術がないこと，また，聞き取り対象者の申告をそのまま記載することで病態把握
が容易になると考えたからである。
2．病対処行動
1）病・症状の構成
表2に記録された病・症状のケース数を年齢階層別に示した。全ケース数の8割弱を占めている上
位11の病・症状名を相応する日本語の病・症状名を付して表記すると，上位からtulanga（風邪）
，jiò
（熱），sende（下痢）
，nyángalí（虫歯）
，ka（外傷）
，jolebàkè
（頭痛）
，bimba
（腫れ）
，kònàfebo
（背中の病：
痛み），ìndàyà
（日本語の病名は不詳），kònànobo
（足の病：痛み），gobulebàkè
（疲れ）の順であった。
これは，筆者がソアンケの病院の協力を得て2年間の外来診療記録から作成した傷病構成（佐藤，
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Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
表2 年齢階層別病ケース数
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浜松医科大学紀要 一般教育 第 23 号（2009）
1993）に類似している。その診療記録における記載数上位11位を順に挙げると，マラリア，咳，発
熱，感冒，下痢，腹痛，気管支炎，腰背痛，掻痒，頭痛，多発疼痛であった。マラリアを表すBaka
語はないので本調査の病構成にマラリアは出現しないが，2番目に多かった発熱，悪寒を意味するjiò
のケースの中にはマラリアによる症状も含んでいると考えられる。すでに述べたようにBakaの人々
は病院を訪れることはほとんどないので，診療記録の傷病構成はBaka以外の住民のそれを表してい
るが，民族の違い，生活様式（農耕への依存度がBakaの方が低い）
の違い，社会経済的地位の違いを
越えてこの地域の住民がさらされている病の脅威は共通していることが伺える。
調査日数100日当たりのケース数
（罹患率とする）は年齢階層によって異なっていた。全体でケース
数が1位のtulangaは，全年齢階層でほぼ同様の罹患率を示しているが，2位のjiòは高年齢層ほど高い
罹患率を示す一方，3位のsendeは低年齢層の罹患率が高い。4位のnyángalíは高い年齢層に限られて
いる。なお，14位のlibokoは4ケースとも5歳未満であるが，これはクワシオルコール症として知られ
る熱帯地域に多い小児の蛋白欠乏症と思われる。クワシオルコール症は2歳前後の離乳期の小児が罹
患しやすい栄養障害で，慢性的経過をたどる（Robson, 1972：55-63）。本調査のlibokoの場合も4ケー
スで罹患日数が63日を示し，ケース当たりの罹患日数がもっとも多くなっていた。全ての病・症状
を合わせたケースの罹患率は15歳以上の中・高齢層に高くなっていた。これは中・高齢層が15歳未
満の若年層より病に罹りやすいことを示しているとも考えられる。しかし，聞き取り対象者にとっ
ては家族
（ほとんどは子ども）の体調より自身の体調の方が筆者に訴え易いであろうから，聞き取り
対象者のほとんどすべてが中・高齢層に属していたことも高い罹患率に結びついたのかも知れない。
2）対処行動
病・症状ごとに採られた対処行動を見ると（表3），全ケース304のうちまったく治療行動が採られ
なかったケースは144
（47.4％）
で，半数以上は何らかの治療行動がとられていた。しかし，その様相
は病・症状によって異なっていた。ケース数の上位11位について見ると，sende，bimba，ìndàyàの施
療率（何らかの治療がなされたケースの割合）は非常に高く，nyángalíは低く，ケース数の多かった
tulanga，jiòは40∼50パーセントであった。nyángalíの訴えの内容はほとんどすべて虫歯の痛みであ
る。Bakaの民俗医学も耐え難い虫歯の痛みには為す術がないことを示しているのであろう。一方，
治療手段が数多くあるtulanga，jiòとsende，ìndàyàの間の施療率の差は，各病が病者に与える深刻さ
の違いか，あるいは，住民が各病に感じる重大さの違いが反映しているのかも知れない。tulangaは
いわゆる風邪であるが，jiòは何らかの熱病，たとえば，マラリアなど深刻な病の可能性もある。し
かし，Baka住民は腹の病であるsende，ìndàyàにより脅威を感じるのであろう。治療手段について見
ると，友人・呪医による治療や病院・医薬品による治療はきわめて少なく，何らかの治療がおこな
われた160ケースのうち132ケース（82.5％）で自家治療が施されていた。彼らの施療手段はほとんど
自家治療に依存していると言えよう。
表4に病の対処行動を年齢階層別に示した。何らかの治療行為をしたケース数は15歳未満の年齢層
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Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
表3 病別対処行動
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浜松医科大学紀要 一般教育 第 23 号（2009）
表4 年齢階層別対処行動
は65パーセントを超え，15歳以上の年齢層の43パーセントに比べ有意に多かった。これは，もっと
もケース数の多かったtulangaは年齢層による施療率の差異はなく，施療率の高いsende，Ìndàyà，
libokoなどの病は若年層において罹患率が高く，一方，施療率の低いnyángalíやjiòは高年齢層におい
て罹患率が高かったことが反映しているのであろう。
3．自家治療
1）投薬療法
自家治療をした132ケースで実施された治療法は，1例の瀉血療法を除いてすべて投薬療法で，そ
の例数は186例であった。なお，病対処行動タイプの一つである友人や呪医による治療方法もすべて
投薬療法であり，Bakaの民俗医療における投薬療法の重要性が判る。投薬療法で使われた薬材は，
植物が166例，植物とミント入り軟膏が2例，植物と土が1例，土が1例，灰が1例，家の中のすすが6
例，屋根を葺いている植物材が1例，タバコが2例，石けんが2例，ミント入り軟膏が4例であった。
薬材として多様なものが利用されているが，植物が圧倒的に多い（90.9パーセント）
。薬材としての
植物はほとんどの場合，生草，生木が利用される。186例の投薬療法で記録された薬材の投薬方法は
多様であったが，①薬液の服用，②加熱した薬液の服用，③摂食，④塗布
（薬で患部を洗うことも含
める），⑤薬材を炭にして患部に塗布（患部に傷を付け，塗布する場合も含める）
，⑥薬材を炭にして
服用，⑦浣腸（薬液を肛門に垂らすことも含める）
，⑧湿布，⑨身体の穴への液体の滴下，⑩装着，
の10方法に区分した。もっとも適用例の多かった方法は，植物の茎や樹皮をそのままかじり，滲み
出る樹液を飲む，樹皮を水で煮てその汁を飲む，あるいは，葉をもみしだき，水を混ぜて飲む，な
ど薬液の服用（①，②）がもっとも多く，40パーセントを超えている（表5）。次いで，炭にした薬材の
患部への塗布（⑤），薬液の塗布（④），薬材の装着
（⑩）
の順で多かった。薬材
（ほとんどは植物の根や
樹皮）を炭にして患部に塗布する投薬方法の場合，多くは患部にカミソリで小さな傷を付け，そこに
21
Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
表5 実施された投薬方法
炭を塗布する。多少の出血を伴うこの療法はBaka社会でもっともポピュラーな療法の一つで，ほと
んどすべての成人は身体のそこかしこにその瘢痕を残している（佐藤，2005）。薬材の装着とは，蔓
や植物の繊維を患部に巻くというもので，いわゆるまじないの類であるが，施療例は少なくない。
小さな子どもの身体には病の防御，健康維持，無事な成長を願っていろいろな種類の薬材（お守り）
が首や腰に必ずくくりつけられている。
2）薬用植物
投薬療法で薬として使われた植物は，71方名種
（他に植物薬が投薬された例が8例あるが，方名を
確認することができなかったのでここでは除外している。また，屋根をふいている椰子の葉柄の使
用例も除外している。）を数えた。これらの詳細な民族薬学的検討は別稿にゆずり，本稿では，投薬
例の観察から植物を使用するBakaの投薬療法の特徴について検討する。表6に71方名種の学名，使用
部位，投薬形態，適用した病・症状などを示した。科名，種名とも同定できなかった3方名種を除い
た68方名種は，41科，63属，55種
（他の13方名種は，種名が不詳であった。）から構成されていた。
71方名種のうち56種が野生植物，15種が栽培植物
（油椰子など自生的なものも含む）であった。短期
間の調査で薬としてこれだけの植物，とくに野生植物の利用が確認されたことはBakaの人々がもつ
並々ならぬ植物の知識を示すものであろう。薬とする利用部位は，樹皮と葉と根で大半を占める。
薬材の投薬形態は，単材投薬が一般的で，混合投薬は一部を除いて少ない。混合投薬される傾向の
強い植物薬はálamba（とうがらし）
で，34の投薬例のうち16例が他の薬材との混合投薬であった。
álambaはもっとも投薬例の多かった薬材でもあった。殺菌作用のあるカプサイシンを含むálambaは
アフリカ（Neuwinger, 1994: 829-35）
のみならず世界でもっとも多用される植物（ナージ，1997）として
知られている。Bakaの人々にとってもálambaは料理に不可欠な調味料であるが，薬材としても欠か
せない植物のようである。álambaに次いで投薬例が多かった植物はgángelangéである。これはtulanga
の薬としてもっともポピュラーなもので，調査期間中，甘酸っぱい水分を含んだ茎をかじる住民の
22
表6 薬に使用された植物
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浜松医科大学紀要 一般教育 第 23 号（2009）
23
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Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
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浜松医科大学紀要 一般教育 第 23 号（2009）
25
Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
姿がしばしば見かけられた。これらに次いで投薬例の多かったyomboを加えたこれら3方名種の投薬
例は60例であった。植物薬の全投薬例169例のおよそ4割近くに達している。いずれも適用される
病・症状が多数で，しかも，栽培植物（álamba）や，道端や庭の二次林に多い野生植物（gángelangéと
yombo）であるためいつでも容易に手に入れることができる薬材である。これらはBakaの民俗薬の中
でもっとも有用なものであると言えよう。
3）投薬療法における多様性
前述したように，álamba，gángelangé，yomboの植物薬3方名種は多用されていたが，残り68方名
種の投薬例は合計で122例，1方名種当たり平均1.8回と少なかった。言い換えれば，投薬例数の割に
は多様な種類の植物薬が利用されていた。このような現象を引き起こした要因としては，ある特定
の植物しか薬として適用されない病・症状が多数存在しているか，逆に，一つ一つの病・症状に対
してそれぞれ多様な植物が適用されているかのどちらか，あるいは，両方が考えられる。しかし，
前者に該当する病・症状はkònàgábo，kònàlábo，nyángalí，tiの四つにしかすぎず，実際に起きたこと
は，後者であった。多様な植物薬が適用された主な病・症状名とその自家治療例数，および，投薬
された植物薬の種数を挙げると，tulanga：34例，30方名種，jiò：22例，15方名種，sende：15例，12
方名種，kònàtobo：4例，5方名種，liboko：4例，6方名種であった。kònàtobo，libokoでは，投薬療法
例すべてにおいて異なる植物薬が使用されていた。多様な植物薬材に加え，それらの投薬方法もま
た多彩であるのでBakaの投薬療法の種類の多様さには目を見張るものがある。表7に例としてケース
数の多かったtulanga，sende，jiòの投薬療法例を示した。58例の投薬例が記録されたtulangaでは，薬
材，あるいは，投薬方法の異なる38種類にも上る投薬療法が記録された
（表7-1）
。このうちgángelangé
とálambaだけを薬材とする3種類の投薬例が16例と多数を占め，tulangaの投薬療法における両薬材の
一般性が伺われる。その一方，30種類もの投薬療法は適用例がわずか1例であった。jiòについてみる
と，32例の投薬例中álambaだけを薬材とする投薬療法が9例を占めていた
（表7-2）。ここでもálambaが
jiòの一般的な薬材であることが判るが，適用例が1例のみの投薬療法も15種類を数えた。sendeの投
薬療法には，一般的な薬材は見あたらず23例の投薬例中19種類もの異なる投薬療法が記録された
（表
7-3）。
これほどまでに多様な投薬療法をどのように考えればいいのであろうか。一つは，これらの投薬
療法の実施者が一般住民であったことが理由として考えられる。いわゆる素人療法を大勢が実施し
たために不統一でさまざまな治療法が見られたと考えるのである。とはいえ，Bakaの民俗医学体系
が現代医学のようにBaka社会に通ずる普遍的なものであれば，たとえ，素人療法であってもそれを
示唆するような投薬行動があってもよいように思えるが，実際には一部の病にわずかな種類の植物
薬が一般的薬材として適用されるぐらいで，体系的と思われる投薬行動はなかった。すなわち，そ
もそもBakaの民俗医学自体が専門家であるンガンガ（呪医）によっても，地域によっても異なる個性
的なものではないか。これが二つ目の考えられる理由である。Baka社会においてンガンガはそう珍
26
浜松医科大学紀要 一般教育 第 23 号（2009）
表7-1 tulangaの投薬方法
27
Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
表7-2 jiòの投薬方法
しい存在ではない。たいていのBaka集落には一人や二人のンガンガ，あるいはそれに類する人がい
る。Bakaのンガンガは専門家と言ってもそれを職業とするものはほとんどいない。Baka人イン
フォーマントによれば，ンガンガは素質のあるものが身近なンガンガの手伝いや見習いを経てなる
というケースが多いようである。このようなンガンガによって維持される民俗医学知識は体系的と
いうより個人的なものであるだろう。病因論のような理念的側面については，Baka社会に共通する
ものが見られるであろうが（佐藤，1998），病の診断，病の治療という実践面については，各地域集
団を取り巻く自然・社会環境，さらにはそこに住むンガンガの個人的条件によって変異するのでは
ないだろうか。もし，そうだとすれば，一集落であっても一般住民のもつ民俗医学知識もまた多様
なものであることは容易に想像がつく。同じクラン
（伝説や神話上の始祖を共通にもつ父系出自集団）
28
浜松医科大学紀要 一般教育 第 23 号（2009）
表7-3 sendeの投薬方法
同士の婚姻が禁じられるクラン外婚制を維持し，もともと狩猟採集民で可動性の高いBaka社会で
は，小さな集落にも出身を異にする住民が入り混じって住む。彼ら一人一人が民俗医学の知識を身
近な親や知人やンガンガから学んできたとすると，その集落における民俗医学も多様にならざるを
得ないであろう。ただ，そうであったとしても聞き取り対象者自身が豊富な知識をもっていなけれ
ばその多様性はこうまで広がらなかったであろう。短期間に記録された植物薬は71種以上にのぼり，
そのうち56種は野生種であった。なぜBaka人一般住民がこれほどまでに豊かな植物薬の知識をもっ
ていたのであろうか。おそらくそれは病の脅威に対するほとんど唯一の対抗手段が自家療法であり，
しかも，彼らが森の植物薬に絶大な信頼を寄せているからと思われる（佐藤，2001）。二人の男性イ
ンフォーマントと病の話をしているときしばしば聞かされたことは，
“この病は重いが，薬があるか
29
Coping behavior for illnesses among the Baka hunter-gatherers: a case study in northwestern Republic of Congo
ら問題ない”と言うことであった。彼らの言う薬は森の植物である。ごく少数の病を除いてほとんど
の病には薬があると信じられている。薬の効果に寄せる信頼と，どんな病にも必ず森には薬がある
という確信は，Bakaの人々の関心を森の植物に向ける原動力となっているのであろう。これが本調
査で多様な投薬療法が記録された三つ目の理由であろう。服部（2007）は，カメルーン東部州に居住
するBakaの一小集団において，森の植物に関する豊かな知識をもっている住民が，食物や道具に利
用される植物の知識は共有しているが，薬の知識については共有していなかったと報告している。
おそらくBakaの投薬療法はどこでも多様なのであろう。
まとめ
1990年当時，コンゴ人民共和国（現コンゴ共和国）西北部ソアンケ地区に住むBakaの人々にとって
現代医療資源はほとんどあってなきがごとくの状態であった。1950年代のフランス統治時代，キリ
スト教伝道教会経営の病院があった。1960年の独立後，その病院は国営病院となって無料の診療が
行われてきた。ソアンケ市に永く住んできたBakwele人インフォーマントによれば，病院は独立後も
しばらくはそれなりに機能していたが，80年代になってその機能は急速に低下したと言う。一方，
Baka人インフォーマントによれば，伝道教会経営当時は病院を受診するBaka人は多かったが，国営
になってからはその機会は少なくなったとのことであった。いずれにしても90年頃には病院は開店
休業状態であった。一時的にせよこの地方で現代医学が医療資源として機能していたのは間違いな
い。しかし，アフリカの奥地ではどこでもあり得ることであるが，昨日まで機能していた病院が今
日にはもう無力になることはそう珍しいことではない。また，病院が機能したとしても，その数は
きわめて少なく，徒歩しか交通手段がない多くの住民にとって病院へのアクセスは容易でない。こ
のような地域の人々にとって，とくにBakaのように社会的・経済的地位が低位に置かれた人々に
とって，病院はあまりに遠く，今なお自身の伝統的民俗医学がほとんど唯一の医療資源なのである。
本調査のゴマニ集落のBaka住民はそれを如実に体現していた。
本調査の聞き取り対象者は一般住民であった。しかし，彼らの病や症状の訴えは決していい加減
なものではなかった。確かに，特定の病名が言及されたのは13例にすぎなかったが，訴えられた病
や症状は概ねソアンケ市の病院の診察記録による疾病構成と類似した構成を示していた。2ヶ月とい
う短い調査期間であったが，悉皆調査をすることで実相に近づくことができたのかもしれない。さ
らに，特筆すべきことは，病・症状への対処行動であった。施療行動はほとんど自家治療に限られ
たが，その内容は実に多様であった。71方名種にもおよぶ植物を薬材とし，さまざまな投薬方法を
組み合わせて行われた投薬療法の多様さは驚異的ですらあった。この多様性はBakaの民俗医療その
ものが個性的，地域的であるゆえと考えられたが，それに加えて，Bakaの人々が薬材としての森の
植物に注ぐ大いなる関心も要因として考えられた。これはある意味合理的である。熱帯雨林の多様
な植物は多様な化学物質の宝庫である。もちろん有毒なものもあろうが，薬効成分を含むものも少
30
浜松医科大学紀要 一般教育 第 23 号（2009）
なくないだろう。試してみる価値はある。
従来の民族科学で明らかになったことの一つに，関心の強いものほど精緻な分類の対象となると
いうことが挙げられる（Conklin, 1955; Frake，1961）。Bakaの一般住民が投薬療法に示した知識の豊
かさは，彼らが病や医療に強い関心をもってきた証であろう。熱帯雨林は必ずしも人類にとって生
存するに楽な環境ではないという見解もある（Hart and Hart, 1986; Headland, 1987）。熱帯雨林は，
干魃のおそれがなく，飢饉に見舞われる危険は少ないが，クワシオルコール症のような栄養障害は
一般的である。また，その湿潤な環境はウイルスやバクテリア，カビなどの微小生物にとって良好
な環境を提供する。このような熱帯雨林環境で，いわゆるピグミーは長ければ，数万年，短くても
1万年にわたって生存し続けてきた可能性がある
（Mercader, 2003a; 2003b）
。もし，Bakaの人々が彼ら
の末裔だとすると，彼らには，病とその対策への強い関心が脈々と引き継がれてきたのではないだ
ろうか。現代医学からBakaの民俗医学の有効性を疑問視することは簡単である。中には，首をかし
げたくなるような治療法，病の解釈もあることは間違いない。しかし，彼らが示した植物薬に関す
る多様で豊かな知識は，現代医薬品の多くが植物由来のものであることを考えると，科学的にも耐
えうる効果的な薬材を探し求める上での試行錯誤の結果と見ることも可能である。そして彼らがこ
れまで生存し得たことは彼らの民俗医学が効を奏してきたことを示唆しているのではないだろうか。
謝辞
本研究は，昭和62年度文部省科学研究費補助金
（海外学術調査：代表・伊谷純一郎）
，および平成
2年度文部省科学研究費補助金
（海外学術調査：代表・寺嶋秀明）の支援の下に実施された調査に基づ
いている。Baka研究の道に誘っていただいた故伊谷純一郎先生，ならびに寺嶋秀明神戸学院大学教
授に心から感謝したい。 病や薬の知識を惜しげもなく私に教えてくれたゴマニ集落のゾア氏とグソ氏に，そして，一貫し
てソアンケ地区の筆者の調査を手伝ってくれたBakwele人のノエ氏に深甚の謝意を申し述べたい。最
後に，いつもあたたかく親切だったゴマニ集落のすべてのBaka住民に心からお礼を述べたい。
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University Press, pp.64-92, 2003b.
Neuwinger, H. D.: African Ethnobotany: Poisons and Drugs. Chapman & Hall, Weinheim, 1994.
Robson, J. R. K.: Malnutrition: its causation and control. Gordon and Breach, New York, 1972.
佐藤弘明：定住した狩猟採集民バカピグミー．田中二郎，掛谷誠
（編）ヒトの自然誌．平凡社，544566，1991．
Sato, H.: Notes on the distribution and settlement pattern of hunter-gatherers in northwestern Congo. African
Study Monographs 13(4): 203-216, 1992.
佐藤弘明：アフリカコンゴ熱帯雨林地帯における医療と傷病．公衆衛生57（5）：361-365，1993．
佐藤弘明：病気と動物：アフリカ熱帯雨林狩猟採集民Bakaの民俗病因論．浜松医科大学紀要12：3555，1998
Sato, H.: Folk etiology among the Baka, a group of hunter-gatherers in the African rainforest. African Study
Monographs, Suppl. 25: 33-46, 1998.
佐藤弘明：森と病い―バカ・ピグミーの民俗医学．市川光雄・佐藤弘明
（編）講座生態人類学2，森と
人の共存世界．京都大学出版会，187-222，2001．
佐藤弘明：病歴を物語るBakaピグミーの治療痕．浜松医科大学紀要19：9-24，2005．
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浜松医科大学紀要 一般教育 第 23 号（2009）
An Examination of the Human Soul that
Dwells within the Machine as Exemplified by
The Ghost in the Shell
Yukihide Endo
English
Abstract:
Since the 1980s Japanese anime — a.k.a. Japanimation — for TV and movies has rapidly been a
movement growing worldwide with widespread, significant, and diverse effects. Among other anime
filmmakers, Hayao Miyazaki (b. 1941) and Mamoru Oshii (b. 1951) have internationally been considered
the most prominent and ingenious. While Miyazaki chooses to focus on either foreign or domestic
mythological themes, Oshii prefers to explore the theme of futuristic cyborgization.
Oshii’s 1995 anime Ghost in the Shell adapted from Shirow Masamune’s manga gained critical
acclaim in the global arena and still remains popular with international anime viewers. My research will
focus on the significance of humanness in a cybernetworked society of the future. It is worth considering
how full cyborgization of the human body and even mind will turn out. What does the ghost in the
machine, or the ghost in the shell, suggest?
Key words:
ghost, cyborg, cybernetic body, infinity, mirror images, alterity
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An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
Despite the advent of Darwinian materialism, Cartesian body-mind dualism has been embedded in
our consciousness for over three hundred years. Among other disagreements, the emerging discipline of
biosemiotics has begun to pave the way for a new constructive, insightful approach to the life processes
living organisms carry out in order to survive and evolve on Earth. Indeed, biosemiotics provides us a
scientific perspective on the complexity of life processes so much so that we can understand how
components of the body interact and communicate at the molecular level. The living organism,
biosemiotics argues, is much more than a mere machine, the fact of which is perhaps most relevant
concerning human beings. The relatively new concept of “body-mind” serves as a guideline for the
exploration of life and humanity. In his article, “The Semiosic Body-Mind”, the Danish biochemist and
semitotician Jesper Hoffmeyer notes:
The semiotisation of nature has as a consequence that body-mind dualism falters and that the
obstinately guarded borderline between human and natural sciences become riddled. Just as
organisms cannot be understood as if they were just sophisticated computers, the human mind
cannot be understood as if it had no body. All bodies are minded and all minds are embodied
(Cruzeiro Semiótico 22-25).
This emphasis on the interconnectedness of body and mind strongly suggests that the classical
body-mind distinction is irrevocably collapsing.
For clarity’s sake, the term “semiosic” -not semiotic- in the title of Hoffmeyer’s article should be
defined. It can simply be interpreted as “sign-producing”. The word is derived from another Greekorigined word “semiosis”. In “Pragmatism” (1907) Charles Sanders Peirce (1839-1914), an American
scientist and philosopher, introduced semiosis into the academic language of cognitive science, in which
this term plays a crucial role in his theory of cognition. Merriam-Webster defines it as:
Semiosis: a process in which something functions as a sign to an organism (circa 1907): New
Latin, from Greek sēmeiōsis observation of signs, from sēmioun to observe signs, from
sēmeion.
This term has extensively been introduced into related academic areas such as semiotics and, later,
biosemiotics.
In this paper, I will examine the way in which this body-mind interrelatedness is illustrated by
emerging popular perceptions and views of both cyborgs and cyborgization of humans. In so doing, I will
focus on the groundbreaking and internationally acclaimed Japanese anime film, Ghost in the Shell
(1995) directed by Mamoru Oshii. The film centers around a character called Motoko Kusanagi, a female
cyborg with an implant made of human brain cells who, while being recognized as a highly competent
warrior fighting terrorism, begins to feel encouraged or urged, by an entity unknown to her, to dive into
her mind or inner world. The most crucial issues in this film are whether cyborgs possess souls, and if so,
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浜松医科大学紀要 一般教育 第 23 号（2009）
how they are aware of their souls. In other words, does the ghost exist in the machine, or rather, as the
film’s title suggests, does it in “the shell (inorganic body)”? And how are they interrelated?
Hoffmeyer’s insightful description of bodies as “minded” and of minds as “embodied” opens up a
new, exciting avenue for examining how mind and body invariably and inextricably interact with and
interpenetrate one another. Although this analysis primarily refers to the nature of human existence, both
corporeal and incorporeal, it can also be applied to the possible cyborg nature that will come into being in
the not so distant future. Indeed, it is most likely that biocybernetics will make it possible to overcome
existing clearly identifiable boundaries between human and machine.
Traditionally there is a clear division between mind and body or human and machine as typified by
Cartesian dualism. On the other hand, humanist scholars of the Twentieth century such as Gilbert Ryle,
an Oxford philosopher who harshly criticized Cartesian dualism because of its simplistic and materialistic separation between the two, emphatically argued for their inseparability. One of his major works, The
Concept of Mind (1949), is a critique of the notion that the mind is distinct from the body. He also
accused the American psychologists B. F. Skinner’s and John B. Watson’s behaviorism of disregarding
consciousness, while paying too much attention to observable behavior. Ryle opposed to this kind of
naive materialism. He asserts:
. . . one person could in principle never recognise the difference between the rational and the
irrational utterances issuing from other human bodies, since he could never get access to the
postulated immaterial causes of some of their utterances. Save for the doubtful exception of
himself, he could never tell the difference between a man and a Robot. . . . According to the
theory, external observers could never know how the overt behaviour of others is correlated
with their mental powers and processes and so they could never know or even plausibly
conjecture whether their applications of mental-conduct concepts to these other people were
correct or incorrect (The Concept of Mind 22).
He derogatively described Cartesian dualism as “the Ghost in the Machine” (17). For him Cartesians and
behaviorists view the human mind as an imaginary entity incarcerated in the physical body and thus
disregard the interrelatedness of mind and body, which he argued serves as the foundation of human
existence.
Ryle is not said to have denounced his contemporary, mathematician Norbert Wiener, whose theory
of cybernetics was coming into fruition at that time. Yet Ryle would show disapproval of artificial
intelligence theorized by the cybernetician and state that Wiener put the ghost in the machine. Interestingly, the same wording appeared some fifty years after in Pete Barlas’ book review of a biography of
Wiener, Dark Hero of the Information Age: In Search of Norbert Wiener, the Father of Cybernetics,
coauthored by F. Conway and J. Siegelman. Barlas was so impressed with Wiener’s extraordinary
35
An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
intelligence in a slightly negative or critical way that he chose that title for his review.
Interestingly again, Ryle’s concept of the ghost in the machine evolved to take a different tone after
two decades. Receiving inspiration from his book, the Hungarian-British writer and journalist Arthur
Koestler wrote The Ghost in the Machine (1967) but, unlike Ryle, he adopted a neither negative nor
positive but rather realistic stance. In the 1960s when the Cold War was turning hot again in Vietnam after
the Korean War, he envisioned the threat of nuclear war. He believed that despite the continuing
development of science and technology, the human world naturally possesses both the potential to
advance and regress. By emphasizing the idea of infinity he argued that it is necessary for human beings
to be aware of the unlimited multiplicity of the human world. He observes:
Consciousness has been compared to a mirror in which the body contemplates its own
activities. It would perhaps be a closer approximation to compare it to the kind of Hall of
Mirrors where one mirror reflects one’s reflection in another mirror, and so on. We cannot get
away from the infinite. It stares us in the face whether we look at atoms or stars, or at the
becauses behind the becauses, stretching back through eternity. Flat-earth science has no more
use for it than the flat-earth theologians had in the Dark Ages; but a true science of life must let
infinity in, and never lose sight of it. In two earlier books I have tried to show that throughout
the ages the great innovators in the history of science had always been aware of the transparency of phenomena towards a different order of reality, of the ubiquitous presence of the ghost
in the machine—even such a simple machine as a magnetic compass or a Leyden jar. Once a
scientist loses this sense of mystery, he can be an excellent technician, but he ceases to be a
savant (underline mine, The Ghost in the Machine 219-220).
His view of the ghost in the machine is open to the world beyond physical reality, that is, “a different
order of reality” in which the mysteries of life and existence abound so productively that both nature and
society may develop with a mixture of apparent progress and regression. More important, the notions of
infinity and mirror in relation to the ghost in the machine in this excerpt play a key role in my subsequent
analysis of the anime The Ghost in the Shell.
While writers, critics and scholars have philosophically argued about the relationship between mind
and body and where soul and matter meet, scientists have successfully developed cybernetics and
bioengineering. In fact, science and technology have yet to develop in order to produce cyborgs that are
as physically and intellectually capable as humans, or even superior to them. Nevertheless, emerging
sciences such as biological cybernetics and biological nanotechnology promise the possibility of creating
super-powered cyborgs and of cyborgizing humans. The British cyberneticist Kevin Warwick’s recent
surgically invasive human enhancement experiments known as Project Cyborg that began in 1998 has
demonstrated that by implanting a microchip in the body humans can be cyborgized, at least partially.
Although his scientific adventure was extremely risky, it is in line with the posthumanist conception of
cyborgs as a radical form of body metaphor. His experiments predict the emergence of a new kind of
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浜松医科大学紀要 一般教育 第 23 号（2009）
human body and ontology and perhaps transformation of the traditional concept of humanity
posthumanism seems to seek. It is likely that poshumanism will provide the point of intersection between
philosophy and science so that the cyborg as a technologically enhanced human represents a new state of
being, which remains debatable and even controversial. But sci-fi novels, manga and anime have already
begun to explore this state of being.
The Ghost in the Shell, an anime canon applauded by international viewers, exemplifies the cyborg
as a product of the best possible human intelligence, creativity and imagination. The narrative begins with
sudden and unexpected attacks by cyberterrorists against Japan in the year 2029. Consequently, a series
of investigations are initiated by the Internal Affairs section of the Public Security Bureau. A squad leader
of the Bureau is the physically and intellectually high-powered female cyborg called Kusanagi, who is
almost fully cyborgized with only a small chunk of organic brain cells left intact. Her squad pursues the
cyberterrorist group with unexpected consequences. Subsequent investigations gradually reveal that the
cyberterrorists’ ringleader, the Puppet Master, who masterminded the attacks is in fact a virtual entity
born in the vast sea of the cybernetwork. It also becomes apparent that both the Japanese government and
military are involved in these crimes; their top secret project to develop cyber control systems has gone
very wrong, resulting in the emergence of a maladjusted mastermind hacker known as The Puppet
Master. Moreover, it turns out that another section of the Bureau dealing with foreign affairs has been
obstructing her team’s investigations in order to cover up for the government and military. This results in
the investigations by Kusanagi’s squad becoming more complex and extremely difficult.
Most surprisingly, but crucially, Ghost in the Shell, whilst appearing to highlight cyber warfare and
cyberterrorism, centers around the theme of the cyborg’s unexpected encounter with its hidden soul. The
final sequence of the film unexpectedly suggests that the protagonist, while portrayed as the technologically idealized cyborg, feels compelled to begin a new journey in order to touch her own soul lurking
inside a chunk of brain tissue of her full cyborg body. Therefore, the title Ghost in the Shell suggests that
her ontological status is spiritually delicate and mysterous. On the other hand, the Puppet Master claims
that their ghosts have something in common and wants to merge. Despite her resistance, the protagonist
herself feels that their fusion is inevitable. In the film’s conclusion, these two irreconcilable opponents
unite their ghosts. The film’s foregrounding of her internal journey toward her own spirituality and the
amalgamation of both ghosts encourages the viewer to perceive the cybernetwork as a visual
externalization of the mysterious cyborg mind with its growing thirst for spiritual identity. Near the end of
the film, the fierce battle between the two ghosts with disposable bodies results in the loss of her original
cyborg identity. Having merged with the Puppet Master’s ghost, she leaves her colleagues behind and
disappears into the vast sea of the network. This implies the beginning of her initiation into a spiritual
world.
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An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
In an era of biotechnological and technoscientific possibilities, when a cybernetwork permeates the
entire world, communication seldom occurs on an interpersonal basis. This is because by plugging
themselves into nearby input/output terminals every communication participant can be readily connected
to the worldwide network. Their selfhood and subjectivity are destabilized and lost into a world of panglobal cyber-connectivity. For the posthumanist cleansed of selfhood and subjectivity, communication
can be unlimitedly enhanced and supported by the use of advanced technologies. But this technologized
future is likely to come with a great cost; the demise of interpersonal interaction and denial of the soul.
The posthumanist may consider the protagonist of the film, Kusanagi, an ideal posthuman since among
other characters, she is able to successfully interact with her rapidly changing network environment
through environmental sensing. In truth, she represents the successful embodiment of the biotechnological concept of “data made flesh” which has been explored by such scholars as Eugene Thacker, Robert
Mitchell and Phillip Thurtle. Thacker describes this concept as,
[a] primary moment that characterize[s] this intersection between biotech and infotech [which]
has to do with the “translatability” between flesh and data, or between genetic codes and
computer codes (“Data Made Flesh: Biotechnology and the Discourse of the Posthuman” 90).
The research of this area effectively essentializes and reduces the body to a mass of digitalized biological
data which matches the posthumanist description of the body. As a result, a cyborg’s communication in
cyberspace can be conducted succinctly and effectively.
But is Kusanagi satisfied with her cyborgized body and mind? If yes, why does she look so sullen
and unhappy throughout the film narrative? Her constantly brooding appearance strongly suggests that
she is dissatisfied with the sterility of excessive productivity and ultimate convenience of the electronically networked environment of which she is a part. When talking to Togusa, a male squad colleague on a
terrorists search mission, she laments her extreme adaptability to this environment.
If we all reacted the same way, we’d be predictable. And there’s always more than one way to
view a situation. . . . It’s simple. Overspecialize and you breed in weakness. It’s slow death (Ch.
3 of the DVD version of The Ghost in the Shell).
And she even appears to envy his lack of cyborgazation, saying:
. . . except for the slight brain augmentation, your body’s almost completely human (Ch. 3).
As early as this stage of the film’s narrative, she begins to question -whether inadvertently or not- her own
identiy.
Cyborgs could be considered “posthumans” who are usually defined as a symbiosis of human and
artificial intelligence. Posthumanists such as Danna Haraway argue that the cyborg is liberated from the
institutionalized concept of subjectivity and that they are able to demonstrate autonomy without being
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浜松医科大学紀要 一般教育 第 23 号（2009）
subjugated in any way and interact freely with others, including animals, in dynamic environments.
But it is doubtful that Kusanagi enjoys being a posthuman in her present environment, for while
being an acclaimed squad leader, she persistently isolates herself from the outside world in her private
life; even in her public life she remains much less sociable than her colleagues. Her communication
environment does not allow semiosis-the processes of sign-based meaning production-to evolve on its
own. She always feels isolated and alone and thus gets more and more depressed. She moans about her
cyborg identity.
There are countless ingriedients that make up human body and mind. Like all the components
that make up me as an individual with my own personality. Sure, I have a face and voice to
distinguish myself from others. But my thoughts and memories are unique only to me. And I
carry a sense of my own destiny. Each of those things are just a small part of it. I collect
information to use in my own way. All of that blends to create a mixture that forms me . . . and
gives rise to my conscience (Ch. 7).
After a moment’s pause, however, she continues:
I feel confined, only free to expand myself within boundaries.
To her disappointment, an inescapable sense of confinement permeates her inner world.
The nature of her claustrophobic situation stands in stark contrast to what Marshall McLuhan sees
as a dominant characteristic of communication environments. In his analysis of communication dynamics he writes:
[Communication] environments are not passive wrappings, but are, rather, active processes
which are invisible. (The Medium is the Message 68)
The ways in which communication dynamics operates in McLuhan’s communication theory correspond
to those in which semiosis operates. What illustrates their similarities is the significant characteristics of
semiosis which include great flexibility, spontaneity and creativity in responding to the situation of the
moment. The Estonian semiotician Kalevi Kull notes:
Since all components of semiosis are repeatedly rewritten, both the creation of new and the
forgetting of old becomes possible (Semiotica 120.3-4: 303).
The communication environment in which Kusanagi is engaged is not as flexible and creative as both
McLuhan and Kull argue. Apart from other cyborg characters, the protagonist alone appears to continue
to be in a pensive mood because she feels compelled to struggle with the question of her own ghost, i.e.
her soul or, plainly speaking, her identity-a new mode of her identity-that can support her so as to live and
survive in the posthuman environment. But her present environment provided by the futuristic networked
society in the film has deprived her of the opportunity to establish her own identity because in this
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An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
environment, semiosis does not operate in a way that helps her communicate actively with her own ghost.
In other words, she struggles with her identity crisis and feels driven to search for a new, deeper identity
in the posthuman environment that is unfavorable and even hostile to her. But once she has become aware
of an insuppressible spiritual drive toward communion with her ghost, she seeks to undergo a radical
identity metamorphosis.
Susan Napier sees Kusnagi’s identity metamorphosis as a key theme of the film. She writes:
. . . Ghost in the shell . . . turns inward in its exploration of the possibilities of transcending
corporeal and individual identity (Anime: from Akira to Princess Mononoke 104)
Here Napier intuitively senses an undertone of spirituality in the film and perceives what is happening
inside Kusanagi’s cybernetic body and mind.
Although outwardly unconcerned with origins, Kusanagi is profoundly concerned about
whether she possesses something that she and the film call her “ghost,” the spirit or soul that
animates her being (107).
This spiritual quest serves as the leitmotif for the film. It should be noted that throughout the film, even in
such scenes that display violence as entertainment, Kusanagi’s almost obsessive determination to search
for her ghost, her deeper soul, remains intact. While trying to seek out and destroy the enemy of society,
i.e. the cyberterrorist group, Kusanagi, a leading member of the counter terrorism task force, inadvertently pursues an encounter with her ghost in the guise of the Puppet Master.
There is a deep connection between the Kusanagi and the Puppet Master. While the cyborg
Kusanagi has a tiny amount of human brain cells implanted in her body, the Puppet Master is a purely
digital entity created in the sea of digitalized information. In fact, this entity was initially a product of the
latest computer technology manipulated by a government-led secret organization, but something went
wrong and the entity became autonomous so as to develop, even evolve, by itself. And as the story
unfolds, it turns out that these two characters are closely related to each other so much so that they end up
merging.
How and why do they attract each other? The film’s title implies that a creature made of inorganic
materials can possess a soul in which his or her spiritual identity and dignity are embedded. Yet the search
for the soul’s abode necessitates a certain kind of awakening to the truth of humanity in the cyborgized
body. Thus, it is necessary for her to face the extremely severe challenge to her status as a cyborg
exlusively incarcerated in the networked society. This challenge is posed by the hacker Puppet Master
since this criminal in the eyes of non-cyborg society has the intent of merging with her ghost, which the
film refers to as “ghost hacking.” Needless to say, this tyrannical act can be seen as spiritual usurpation. If
the Puppet Master’s ghost fuses with hers, it seems, his will dominate hers. In fact, as noted earlier, she
needs the Puppet Master’s ghost in order to seek out her own ghost. In other words, the Puppet Master
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represents not a total stranger and enemy but one closely related to her own ghost, or even an integral part
of her ghost itself.
There is something more important than this apparent interconnection between these two cybernetic
and digital entities. It is the theme of infinity that unites them not externally but internally as they have
chosen to live in a cybernetically structured society that is destined to expand itself without limit. Taking
into account this unlimitedness, it appears that they both endlessly float in a sea of information. As
Kusanagi, who has found a home temporarily in a child cybernetic body which her closest colleague,
Bateau, bought her at a black market, says at the very end of the film, “The net is vast and infinite” (Ch.
14). In the previous chapter of the film in which subsequent to a fierce battle between them their merger
takes place, the Puppet Master affirms their affinity and kinship to Kusanagi by asserting:
We are more alike than you realize. We resemble each other’s essence, mirror images of one
another’s psyche (Ch. 13).
Crucial to the theme of infinity are these mirror images that face each other, since this series of mirror
images repeat themselves infinitely and endlessly in all parts and all scales. Just as consciousness in the
earlier quote from Koestler is infinite and endlessly self-generating, so too are mirror images. Koestler
likens consciousness to a “Hall of Mirrors where one mirror reflects one’s reflection in another mirror”
(219). In the film Kusanagi and the Puppet Master are depicted as being identical in appearance but also
feeling an immediate, mysterious affinity with each other. Their internal connection the film revels can be
seen as a metaphorical mirror image. Thus, the themes of infinity and mirror images are closely
connected to each other.
In addition, realistic mirror images intensify the theme of infinity. Chapter 7 of the film depicts
Kusanagi as enjoying scuba diving not just for fun but rather for spiritual healing as she is stressed out
and desperately wants to find an answer. After exploring the ocean depths she returns to the surface and
encounters the mirror image of herself. This mirror image shown on the screen does not represent a
realistic mirror reflection but rather her yearning for her own ghost. By using another mirror image,
Chapter 8 also graphically reveals this unquenchable yearning. She is going on a canal boat cruise and
after a while finds her look-alike sitting at a cafe table inside the restaurant located along the shore.
Kusanagi looks at her look-alike, or the other way around. In fact, the looker turns out to be the looked at,
and both cannot be distinguished. The theme of a mirror image underlies the film so that it helps
emphasize Kusanagi’s compelling search for her ghost.
For clarity’s sake, it needs to be noted that the apparent merger between Kusanagi and the Puppet
Master merely predicts that both “ghosts” will find a home in the vast and infinite digital network. Yet it at
least suggests hope exists for cybernetic bodies, or future humans in the posthuman era.
Initially, the endless self-generation of mirror reflections brings out the theme of infinity that sheds
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An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
light on the infinity of cyberspace in which finally Kusanagi has launched herself on a journey of
discovery, into her own being. Furthermore, what the mirrors continuously reflect are the ghost images of
the cybernetic and digital entities. These ghost images illustrate what Jean Baudrillard and Marc
Guillaume describe as the figures of “radical alterity” whom the early 19th century West-led modernization marginalized through alienation. Consequently a new type of figure of alterity emerged with
modernization. It is a product of modern exoticism that deprived them of their traditional fierceness and
destructiveness. Guillaume notes that:
the 19th century saw the first widespread expansion of exotic inspiration in literature and art. I
see it as a terminal sign of the decline of the presence of the Other (Radial Alterity 47).
It was inevitable that in the modern world commercial tourism would begin to seek figures of artificial
alterity that had replaced radical alterity. Since figures of radical alterity are gone, Baudrillard argues, the
modern world has continued to produce counterfeits of a quality fit for use. He states:
Starting with modernity, we have entered an era of production of the Other. It is no longer a
question of killing, of devouring or seducing the Other, of facing him, of competing with him,
of loving or hating the Other. It is first of all a matter of producing the Other. The Other is no
longer an object of passion but an object of production. Maybe it is because the Other, in his
radical otherness [alterite], or in his irreducible singularity, has become dangerous or unbearable. And so, we have to conjure up his seduction. Or perhaps, more simply, otherness and dual
relationships gradually disappear with the rise of individual values and with the destruction of
the symbolic ones (“Plastic Surgery for the Other”, Radical Alterity).
Thus, the film seeks to depict the future resurrection of radical alterity figures in the belief that the
posthumanist quest for identity and dignity necessitates such a figure who confronts and challenges the
posthuman. For the posthuman Kusanagi, the Puppet Master epitomizes this figure of alterity. Traditional
anthropology theorizes that to secure one’s position in the community, one has to undergo an initiation
rite such as a series of demanding, even life-threatening, tasks in preparation to achieve a higher state of
mental and spiritual development. This ordeal is still applicable in the electronically wired world of
Kusanagi.
Those who seek to live, thrive and survive in this futuristic world have yet to face the challenge of
encountering a figure of radical alterity. The protagonist of the film who represents both a posthuman and
a posthumanist constantly broods about her ghost because she acutely feels the need to ascertain her
identity in the ubiquitously networked world which is too vast and expansive to adapt herself to. While
other cyborgs are unaware of the mythic complexity of the network, the protagonist is repulsed by the
idea of behaving like an artificial brain-equipped robot. She refuses to adopt the materialist view of the
world and tries to look into the abode of her ghost and chooses to become aware of her connectedness
with it.
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Having undergone the ordeal of encountering the Other, Kusanagi deserves to be reborn into a new
life. Near the end of the film (Ch. 13) in which she awakes as a child cyborg, she recites biblical sayings,
which are a paraphrase of 1 Corinthians 13:11:
When I was a child, my speech, feelings, and thinking were all those of a child. Now that I am
a man I have no more use for childish ways.
Charles Solomon, a critic and historian of animation argues:
Kusanagi’s final quote from I Corinthians suggests that electronic evolution may compliment
and eventually supplant organic evolution <http://www.amazon.com/Ghost-Shell-AtsukoTanaka/dp/6304493681>.
Obviously Kusanagi does not want to grow up to become a mature being in an ordinary sense. Rather, she
is completely reborn into a new child-like cybernetic body, which symbolically demonstrates her
commitment to the quest for higher spirituality.
In conclusion, Ghost in the Shell subtly portrays the complexity of mythology centered around the
theme of human identity and existence. Beneath the surface glitter of digital imaging, there lies a deep
mythic plane where the mythological and mysterious figure of radical alterity is anxious to confront and
dominate the protagonist who embodies the conflict of the awakening of the soul. Confrontation with this
figure of otherness awakens the inner pull towards a higher form of life that lies submerged in the
protagonist’s cyborgized body, which one might describe as a “ghost in the machine.”
Technology does not simply imitate nature, but it is capable of helping posthumans and cyborgs
perceive subliminally the mysteries of life and nature without the confines of the material world and
beyond the confines of their disciplinary thinking. Although these posthumans are reinforced and
enhanced by technologies, they may not be completely satisfied with their situation. This dissatisfaction
is epitomized by the film protagonist's obsession with her “ghost,” i.e. her thirst for spirituality. For her
the vast cybernetwork, which the film depicts as a fathomless ocean, is no longer a static, lifeless system
of organized electronic structures. It is as creative, dynamic and evolving as the life processes in nature
that have been critically described and illustrated by biosemioticians. At the end of the film the
protagonist adopts the new body and mind and thus ascends into a new state of being. Ready to go in
quest of her own ghost, she courageously dives into the unknown, already aware of the fresh and hopeful
perspective on the meaning of life the cyber environment will provide her. In other words, the representation of the cybernetwork ocean serves as a perceptual framework in which the cybernetic or cyborgized
body with a thirst for spirituality will seek spiritual revelation or spiritual revival as the cyborg still
possesses some remnant of humanity.
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An Examination of the Human Soul that Dwells within the Machine as Exemplified by The Ghost in the Shell
The cybernetwork the film depicts was pervaded by policing and disciplining by social control
agencies, but at the end of the film it begins to symbolically represent the semiotic space where the image
of a ghost in the machine inspires a subtle spirituality that will create a space for a lively, stimulating and
productive semiosis and thus enable the achievement of a meaningful life in the cyborgized world of the
future.
WORKS CITED.
Barlas, Pete. Put The Ghost In The Machine. 5 Jan. 2005 Investor's Business Daily.
<http://www.accessmylibrary.com/coms2/summary_0286-7770071_ITM>.
Baudrillard, Jean and Marc G uillaume..Figures de l'alterite (Paris: Descartes & Cie.), 1994. English
trans. Ames Hodges as Radical Alterity (Semiotext(e), 2008. This translation lacks the book’s
last chapter “Plastic Surgery for the Other”, but Francois Debrix’s rendition of this chapter is
available online.
http://www.egs.edu/faculty/baudrillard/baudrillard-plastic-surgery-for-the-other.html
Conway, F. and J. Siegelman. Dark Hero of the Information Age: In Search of Norbert Wiener, the Father
of Cybernetics. New York: Basic Books, 2005.
Hoffmeyer, Jesper. Cruzeiro Semiotico, 22-25 (1995): 367-383.
<http://www.imbf.ku.dk/MolBioPages/abk/PersonalPages/Jesper/Semiosic.html>.
Koestler, Arthur. The Ghost in the Machine. London: Hutchinson, 1967.
Kull, Kalevi. Semiotica 120.3-4 (1998): 303.
McLuhan, M. and Q. Fiore. The Medium is the Message. New York: Random House, 1967.
Mitchell, Robert and Phillip Thurtle. Data Made Flesh: Embodying Information. New York: Routledge,
2004.
Napier, Susan. Anime: from Akira to Prince Mononoke. New York: Palgrave, 2001.
Oshii, Mamoru, dir. 1995. Ghost in the Shell. DVD with English subtitles. Kodansha, Bandai Visual,
Manga Entertainment, 1995.
Ryle, Gilbert. 1949. The Concept of Mind. 1963, Harmondsworth: Penguin, 1963.
Solomon, Charles. Editorial Reviews.
http://www.amazon.com/Ghost-Shell-Atsuko-Tanaka/dp/6304493681.
Thacker, Eugene. “Data Made Flesh: Biotechnology and the Discourse of the Posthuman”, Cultural
Critique 53 (Winter 2003), 72-97.
44
浜松医科大学紀要 一般教育 第 23 号（2009）
An examination of the roles of education and
training in the making of a doctor
医師養成における教育と訓練の役割に関する検討
Gregory V. G. O’Dowd
English
Abstract: The aim of this paper is to provide some important insights into the roles of education and
training of medical students at medical universities and outline some possible innovations to promote the
evolution of the medical education system and hopefully graduate better medical practitioners.
Key words: doctor, education, training, change
Introduction
The purpose of medical education is to build knowledge, train necessary skills, develop a spirit of enquiry
and foster the values of physicians in a balanced and integrated approach to produce good doctors. As
teachers in the Japanese medical education system, our focus should be on the quality of education we
provide to medical students and how we can improve their education to fulfill the stated purpose and
objectives of our university. But how can we know if those goals are being met? What does the current
crisis in Japanese health care tell us about the changes needed in the training of new doctors and nurses?
Is the current curriculum designed to meet all the set objectives at a time when the medical health care
system in Japan is groaning under the weight of ever-increasing problems? It appears that the status quo
is no longer functioning well enough to warrant saving and that change is needed, but before change can
be enacted, it is first necessary to understand what needs to be addressed.
In this paper, I will (1) introduce some opinions about what a “good doctor” is, (2) briefly describe how
medical curriculums have evolved over time, (3) look at some of the broad objectives of medical schools
for making a “good” doctor, (4) define the roles of education and training for medical students, (5) note
some of the recent changes that have taken place in medical education generally and their implications,
(6) report some of the feedback received from an informal survey of doctors and students, and (7) outline
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An examination of the roles of education and training in the making of a doctor
some possible innovations to promote the evolution of our medical education system and hopefully
graduate better medical practitioners.
What is a “good doctor”
When people are sick and in need of medical assistance, they entrust the care of their health and life to a
doctor, and hope that the doctor is a good one. But what is a “good doctor” and how are they made? The
Cambridge International Dictionary of English (1995) defines “doctor” as “a person with a medical
degree whose job is to treat people who are ill or hurt”, and “good” as “very satisfactory because of
being pleasant, enjoyable, of high quality, effective or suitable; morally right; behaving well; kind and
helpful”. Putting these two definitions together actually comes very close to the mark in defining what a
good doctor is for most people. However, there is no agreed-upon exact measure for determining whether
a doctor is good or bad; it is entirely subjective. There is, nevertheless, a vast array of different opinions as
to what desirable characteristics such a doctor needs to possess or display in order to win this label. For
example, the British Medical Journal1 asked its readers to respond to the question “what makes a good
doctor?” and collated a listing of more than 70 qualities a good doctor should have from 102 responses;
these included compassion, understanding, empathy, honesty, competence, commitment, humanity,
courage, creativity, a sense of justice, respect, optimism, and grace. A survey of other lists11 of desirable
doctor traits and professional values would add accountability, advocacy, altruism, caring, confident,
confidentiality, efficient, ethical, a good communicator, a good listener, integrity, knowledgeable, a
lifelong learner, possessing the spirit of enquiry, proficient, responsible, self-regulation, self-improvement, and serious.
That any one person should possess all these characteristics opined would be nothing short of miraculous
and verging on the divine. In elevating the status of doctors to such exalted levels, patients and their
families expect nothing less than perfection from their doctors. Doctors themselves are just as human as
their patients, possessing similar faults and foibles, but having had the benefit of six years of medical
education and training to be able to perform their job. And considering that the vast majority of medical
students don’t graduate their courses with full slates of “A” grades, the pedestal that doctors stand upon is
actually quite shaky. There is indeed dark humor in the old joke: “What do you call the least talented
medical student who graduates at the bottom of the class? You call them ’Doctor’”. Newly graduated
doctors should understand that their learning curve is just starting with their entry into general practice
and that it will take a lifetime of commitment to learning just to keep apace with medical developments.
The term “good doctor” is therefore quite relative.
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浜松医科大学紀要 一般教育 第 23 号（2009）
In order to make something “good”, the starting point should be good materials to work with, to which
good ingredients are added, and molding in an appropriate manner to produce the desired outcome. In
other words, to make a good doctor, medical schools first need to select good candidates and then educate
them with the necessary blend of knowledge, skills development, critical thinking for problem solving,
and medical techniques to produce a doctor who reflects the medical school’s stated objectives and,
hopefully, society’s needs.
The evolution of medical curriculums
The history of medical education stretches back to long before there were any medical schools and even
before the time of the ancient Greek physician Hippocrates2 (ca. 460BC – ca. 370BC) who is widely
regarded as the “father of medicine”. As humans developed and accumulated knowledge related to health
care and treatments, this earliest medical knowledge was treasured and passed down from father to son,
mother to daughter, and those belonging to the inner circles of traditional healers, usually be word of
mouth and imitation. Then, starting in ancient Greece and then flowing through the rest of the civilized
world, Hippocrates made a great impact on the teaching and practice of medicine, being credited with
many milestone contributions. For example, he developed a systematic approach to the study of medicine, assembled his medical writings and case studies in a Corpus that became a standard reference for
doctors to follow, and identified the practice of medicine a distinct profession. Of course, one of his
greatest contributions was his prescribing of the professional responsibilities of physicians called the
Hippocratic Oath3. In it, the Hippocratic Oath stated that medical knowledge should be solemnly
protected and passed along to those selected for the physicians’ inner circles. This apprenticeship model
of medical training persisted for many centuries until the nineteenth century. As industrial society rapidly
modernized and more doctors were needed, these circles of instruction grew and developed into formalized lecture-style teaching of groups as medical knowledge was increasingly collected, recorded and
disseminated. As formal medical training developed, human dissection for anatomy studies was included
and in the last one hundred years laboratory studies became standard. Progress was nevertheless slow,
piecemeal and without commonality until the beginning of the twentieth century.
The first major change to modern medical education began with the release of the Flexner Report4 in
1910. Until this time, medical schools were mainly small business ventures that awarded medical degrees
after only one or two years study to anyone who could pay the fees and run by private doctors to
supplement their incomes; these courses offered patchwork curriculums, inadequate facilities, and
unscientific approaches to both medicine and education. Then in 1904, the American Medical Council set
up the Council on Medical Education (CME) to determine how medical education in North America
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An examination of the roles of education and training in the making of a doctor
should be reformed. Two basic standards were proposed; the first was a standard for the minimum
necessary education level for admission into a medical school, and the other set out parameters for a basic
four-year medical program split between education and clinical hospital training. It was the CME who
directed the Carnegie Foundation for the Advancement of Teaching to examine the state of medical
education based on its reformist agenda; the Carnegie Foundation in turn commissioned research scholar
Abraham Flexner to visit all 155 medical schools in the USA and Canada to assess and report on his
findings of medical education. Flexner generalized about the medical schools he visited as seen in this
comment:
“Each day students were subjected to interminable lectures and recitations. After a long morning of
dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even
five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading
and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more
than participated.”4
In Flexner’s view, intellectual medical training based on a scientific foundation was the ideal for modern
medical schools. In particular, he regarded the educational program of John Hopkins University as the
ideal model for all other schools to emulate; a few years of scientific education followed by several years
clinical training in a teaching hospital where research interests would be stimulated by interactions
during patient care. A major repercussion of Flexner’s Report was the ensuing closure of the majority of
schools that did not meet the high standards set, resulting in medical education becoming much more
expensive and fewer doctors being produced. Nearly one hundred year later, the Flexner Report is still
chiefly remembered for its achievement in enabling a single model for medical education to become the
standard, not only in North America but the world over, that has lasted up to the present day with many of
its recommendations still relevant. Nevertheless, Flexner himself, fifteen years after the release of his
report, lamented the over-emphasis of the scientific education approach and the exclusion of social and
humanistic aspects in doctor training5.
The current medical school system in Japan owes much to the foundation created by Flexner’s report,
being reconstituted after World War II using the American system as its template. Undergraduate medical
programs, such as that at HUSM and other Japanese universities, are generally 6 years long with
admission based on an entrance examination taken at the end of high school. Admission to medical
school is considered to be the most competitive of university entrance exams; successful candidates are
considered an elite group. Medical studies commence with a four year pre-clinical program; students
study Liberal Arts for the first one and a half years, which include physics, mathematics, chemistry, and
foreign languages, followed by two and a half years of Basic Medicine covering anatomy, physiology,
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浜松医科大学紀要 一般教育 第 23 号（2009）
pharmacology, and immunology. The final two years are concentrated on clinical medicine in a hospital
setting. After successful completion of the graduation examination, the graduates sit for the National
Medical License examination, and should they pass it, are awarded a Doctor of Medicine (M.D., from the
Latin Medicinae Doctor) degree (IGAKU-SHI in Japanese) and registered with the Ministry of Health,
Labor and Welfare, thereby becoming licensed to practice medicine as a physician. Graduates wishing to
undertake further studies can enroll in a four-year Ph.D. program and emerge with an IGAKU-HAKASEI
doctoral degree.
Of course, change continues unabated. Recent reforms to medical curriculums in Japan have seen a
directional shift away from conventional teacher-centered education towards more student-centered
practices that mimic real-world clinical environments such as problem-based learning, organ-based
curricula and Objective Structured Clinical Examinations (OSCE). Even so, not all these reforms have
been greeted as positive as implementation subsequently proved to be more problematic than first
expected. Despite such teething problems, the momentum of change and evolution of medical curricula
in Japan will continue in the years ahead.
Medical school objectives
The natural goal of every medical school should be to produce “good doctors”. Indeed, a reading of the
stated goals and objectives of the Hamamatsu University School of Medicine (HUSM) confirms this to be
one of its primary tasks:
“The university seeks to achieve three chief objectives; firstly, to grow up excellent clinicians and
highly creative researchers...” (see Appendix 1)6.
In addition, the university educational objectives for educating and training individuals who successfully
enter the university after passing its entrance examination requirement are as follows:
Educational objectives for students of the Medical Faculty:
1. to acquire essential knowledge and skills of medicine to solve problems.
2. to learn how to accurately evaluate oneself and how to continue to educate oneself independently.
3. to create a desire for scientific exploration that is essential for those engaged in medicine.
4. to cultivate themselves in ways that enable them to take an active part in the international arena.
5. to learn to be humane and sincere doctors.6
However, the very broad nature of these objectives does not provide a firm enough foundation for the
development of a curriculum that meets society’s changing needs and expectations. In addition, attaining
such objectives has become ever more difficult to fulfill due to numerous factors such as the rapid pace of
medical knowledge expansion, failed reforms of the compulsory education system, demographic changes,
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An examination of the roles of education and training in the making of a doctor
society’s heightened expectations of health care providers, bureaucratic mismanagement of the health
care system, doctor burnout and time lags in responding to change. The questions that need to be
addressed are how should the University identify and quantify its educational objectives and then
evaluate if these are being met? How will these objectives be integrated into the curriculum and
syllabuses? Does simply passing courses mean that students have satisfied all objectives set for them?
These are questions that need to be addressed in a far larger study than this one here.
Other universities are taking a different approach to setting their goals and objectives; they are setting for
themselves more detailed points that are easier to assess than the broad brush-stroke approach taken in
the past. A good example can be found in the detailed objectives set out by the Queensland University
School of Medicine (QUSM)7 in Brisbane, Australia (see Appendix 2). QUSM includes many goals and
objectives in point-form detail for the various aspects of its medical program, making it easier to
implement, monitor and assess. Indeed, it outlines in specific detail how implementation of various
objectives is to be carried out, making it clear to administrators, teachers, students and community
stakeholders alike. Shiga University of Medical Science in Shiga prefecture, Japan, has also followed this
example by more clearly outlining in greater detail their objectives and elements of their curriculum 8,9.
Indeed, the actual objectives of many medical universities in Japan have changed significantly since
2004, when the Japanese government changed the status of National Universities to “semiautonomous
corporations”, as research and funding pursuits have overpowered teaching and medical education as the
prime focus of doctors and administrators’ activities. Indeed, the “publish or perish” academic culture is
de rigueur at medical universities now, often to the detriment of educational programs. Nevertheless,
society still expects medical universities to graduate good doctors. And the only way to graduate good
doctors is to have appropriate educational and training programs in place that make up for any prior
deficiencies and that can instill the needed knowledge, training and values expected in medical school
graduates.
The roles of education and training
Education and training are often easily be mistaken for each other; for example, the Oxford Advanced
Learner’s Dictionary defines education as “a process of teaching, training and learning, especially in
schools or colleges, to improve knowledge and develop skills.” But the distinction between these two
learning activities, although subtle, is nevertheless an important one. In very simple terms, education can
be considered as the imparting of knowledge (book learning), while training involves the acquisition of
skills (doing). And even though both are an essential part of learning, the greatest distinction can be made
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浜松医科大学紀要 一般教育 第 23 号（2009）
from their purpose. It can be argued that the main purpose of education is the enhancement of an
individual’s ability to think and understand and improve their mind so they can achieve their personal life
goals; training, on the other hand, is rather a means to developing skills that will be used for practical,
developmental, or more economic purposes. Applying this to medicine, the purpose of medical education
can be said to be the acquisition of knowledge, building a solid medical knowledge base, and developing
analytical thinking skills, while the purpose of medical training would be to master all those tasks
relevant to doctors in actual clinical practice. And so the conventional model for medical studies has
developed where education naturally occurs in academic university classrooms while training takes place
in the hospital wards, with education usually coming first, training after. However, a broader idea of both
as well as a deeper consideration of the balance between the two is needed to better fit the needs of
making a modern professional doctor.
In my capacity as a medical university teacher, educational activities of both types fall clearly within my
purview even though my teaching environment is the university classroom. It is my job to develop
curricula, syllabuses, and materials both to teach my own students as well as to integrate with other
educators and doctors to produce students with basic knowledge, intellectual curiosity, communication
skills and appropriate study skills, as required by the HUSM principles and objectives, upon which they
will build their future medical careers. Achieving all this in only the first one and a half years of the
students’ time at the university, where the English courses are concentrated, is indeed a challenge.
Naturally, this knowledge-building phase is well suited to the typical classroom environment, where
textbooks, lectures, tutorials, group work, homework, report writing and the internet are excellent
educational tools. In addition, my concentration on skills development such as study skills, communication skills, thinking and reasoning skills, research skills, and presentation skills, requires students to be
less desk-bound and more interactive to develop the social skills needed for cooperation, coordination
and collaboration skills. An important consideration is how to balance these competing needs and keep
students positively engaged in their learning processes as they are trained in these new skills.
Nevertheless, the current trend in medical education is away from staid lectures and towards the taskoriented nature of medical training that most often occurs in clinical settings as this will be the future
working environment for most doctors. Indeed, as Flexner observed in his visits to medical schools,
boring lecture-style education was of little value in medical education, especially when combined with an
absence of practical hands-on experience with patients in hospitals; “An education in medicine,” wrote
Flexner, “involves both learning and learning how; the student cannot effectively know, unless he knows
how.5 ” Of course, there are many practical skills that students can be trained for in the classroom; taking
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An examination of the roles of education and training in the making of a doctor
a medical history, interviewing patients, group discussion skills, collaboration, research methodologies
and so on. The competencies that result from teaching vocational or practical skills and knowledge in the
classroom environment can be carried forward to specific useful skills in the students hospital programs.
Thus, there is a lot of overlap between these two distinct areas, so our educational and training missions
should be cooperative in nature. And after graduation, it is expected that they will continue their medical
education and training as professional development to keep their knowledge and skills up-to-date.
Indeed, no one ever learns all they need to know at school or university. An additional problem that has
arisen recently is that the many students’ experience of 12 years of education prior to entering medical
school in Japan, e.g. “yutori kyoiku” (relaxed education) and emphasis primarily on tests and cramming
for tests, is now being discovered to have little prepared freshmen for the academic rigors and intellectual
challenges of their six-year medical study programs (O’Dowd, 2006). Indeed, the Japanese Ministry of
Education, Culture, Sports, Science and Technology (Monbukagakusho) clearly articulates this trouble in
their own 2005 White Paper on the state of Japanese education:
“There are challenges with regard to children’s Academic Ability, as children are not always sufficiently
equipped with the ability to apply knowledge and skills they have learned, such as reading comprehension. In addition, it is especially concerning that Japanese children have a poor desire to learn and have
not mastered good learning habits. We must foster Academic Ability for the children to master the basics
so that they can learn to educate themselves, think for themselves, and have the ability to solve problems
even better.” (MECSST, 2005, p.2)10
Not surprisingly, in a previous study on students’ initial expectations of university life (O’Dowd, 2006) I
found a clash of lax expectations with the academic demands of the medical university curriculum,
making the adjustment period difficult for many. In addition, although students do manage to pass their
courses, many students fail to adequately learn or absorb course content or forget what they learn in a
relatively short time (i.e. after the examination is over). Students typically do not know how to engage in
the types of learning that makes syllabus content a permanent acquisition to their knowledge base. Thus,
it is difficult to say that students now are more “educated” in practical terms than in the past as the
learning goal posts have moved significantly as medical knowledge is expanding exponentially. These
days, graduates who aren’t making the effort to keep up with the times are falling behind rapidly as their
knowledge and skills atrophy, even making themselves a danger to their patients. It is therefore clear that
we are now in an age where lifelong learning is a necessary requirement for all doctors.
Another factor strongly influencing medical education now, not only in Japan but the world over, is the
establishment of the Global Minimum Essential Requirements (GMER) in medical education established
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浜松医科大学紀要 一般教育 第 23 号（2009）
by the Core Committee of the Institute for International Medical Education (IIME)11. This committee has
developed a set of minimum learning outcomes that should be common to all medical school graduates,
with the goal of developing “global physicians” with a common high standard of medical competencies.
The four basic competencies required are Clinical Skills, Population Health, Professional Values and
Attitudes, and Scientific Foundations. Within these four competencies, three core skills are centered:
Communication Skills, Critical Thinking and Information Skills. By placing the focus on medical student
outcomes the IIME intends to influence medical school curriculums as well as the educational processes
currently in practice:
“In defining the essential competencies that all physicians must have, an increasing emphasis needs to be
placed on professionalism, social sciences, health economics and the management of information and the
health care system. This must be done in the context of social and cultural characteristics of the different
regions of the world. The exact methods and format for teaching may vary from school to school but the
competencies required must be the same”11.
The main elements of the GMER can be seen in Appendix 3.
Recent changes in medical education and some implications
Since 1990, Japanese medical education has undergone a number of significant changes. Many medical
schools have now implemented integrated curricula, problem-based learning in tutorial settings, and
clinical clerkships. In particular, problem-based learning (PBL) is now a very common program in
medical education around the globe. However, how PBL is applied in regards to educational methods and
innovation may not resemble what PBL should actually be. This is because the implementation of PBL in
different educational cultures does not undergo a similar evolutionary process; each implementation is
different, each experience is unique, and “success” can be defined in many ways. It is also regrettable that
some doctors and students have based their negative opinion of PBL and what it is able to accomplish on
their experience or observations of poorly delivered units, unaware of the fact that they were not seeing
the true potential problem-based learning has as a more effective learning method.
In 2005, a nationwide common achievement test was instituted that students must pass to qualify for preclinical medical education, similar to the United States Medical Licensing Examination (USMLE) Step
1, although the Japanese test is not a licensing examination. The National Examination for Physicians is a
500-item multiple-choice examination that is administered once a year. This test has impacted on the way
medical students are studying; rather than studying to build their knowledge base for their future careers,
they are merely cramming for the test. Both students and teachers have commented that students narrow
concentration on test preparation guides rather than their text books has left them without the basic
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An examination of the roles of education and training in the making of a doctor
knowledge that their teachers in the hospital expect them to have. Nevertheless, in 200612, 8,602
applicants sat for the examination and 90.0% passed. It appears many medical students are better at
taking tests than learning.
Another new law now requires postgraduate training for two years after graduation with improved
conditions for residents. Residents are paid reasonably well (compared to the past), and their work hours
are limited to 40 hours a week; although this has reduced the burden on them, it has in fact resulted in a
greater burden falling on existing doctors as well as reducing residents exposure to practical experience
that they sorely need. Unfortunately, although well-intentioned, not all changes have been for the better;
the new matching placement system introduced in 2004 was intended to give graduates more freedom,
however, significant problems have resulted as many hospitals in regional areas can’t get enough new
doctors to fill positions, resulting in critical staffing shortages, department closures, and even hospital
closures. It appears the medical system in Japan still faces a number of crisis issues, with no easy
solutions on the horizon.
Comments on the current system
In order to better understand the impact of these recent changes to medical education, I undertook an
informal survey that included several third-year medical students, doctors who are teaching medical
students, and doctors who are training medical students in the hospital. Feedback was limited, with
eleven oral replies and three pieces of written feedback. These replies still illuminate some of the
problems currently being experienced as well as suggesting what they think should be done to improve
the situation for all concerned. The following is a summary of the feedback received.
# We need to be able to adjust our medical school admissions based upon realistic projections of doctor
needs for small towns, regional areas and specialities like pediatrics.
# Training in professional behavior is needed in the hospital.
# I think we need to base our curriculum more on the feedback from hospitals and doctors in practice
about what needs to be learnt in the universities and training in the hospitals.
# Students should be ranked earlier, and streamed for medical education & training to bring below
average and poor students up to a decent level in line with the university’s objectives.
# Doctors are currently burdened with an unsustainable level of teaching, administration and hospital
workloads.
# There is too much emphasis on research (and winning grants and funding), and not enough emphasis on
education & training.
# About the performance of current students, some are good, some are acceptable (as I was), and some
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浜松医科大学紀要 一般教育 第 23 号（2009）
are terrible as medical students. I feel awful to think of them as becoming a doctor in the future. Indeed,
you can see some “MONSTER trainee” in this hospital. Selfish, ill-mannered, dirty, poor hand and poor
knowledge, and wasting university money. They are not refined as an adult much less as a clinician.
# PBL? Most of the students do not think the problems are realistic, and neither do some tutors. Reality
and seriousness are lacking.
# Before allowing students to be put in front of patients, basic medical knowledge is necessary, of course.
Better screening out of students who lack this basic knowledge is required. Their knowledge should not
only be focused to pass exams. Useless knowledge is nothing in front of a patient. Motivation may not be
a skill but it is an essential component.
# Reality, motivation, practicality and a tough standard; these may be more desired in our curriculum.
# Role play and lectures by upper-class students could be helpful.
# The current situation in medical education is not good. Too many teachers are lukewarm in teaching;
and the students are lukewarm about learning!
# The evaluation system for teachers and for students isn’t working. How did some of these students pass
their courses and enter the hospital??
# Teachers need to sift out the poor students earlier. Poor students passing classes sets a bad example for
other students and lowers their motivation. Then the standard falls lower too.
# The curriculum should re-emphasize the prime role of preparation of doctors who will serve in the
community.
# Too many multiple-choice question tests. It would be better to have students show what they know and
understand by writing short answers or essays as well as giving oral responses.
# Students need to read more books, not just test preparation guides.
As can be surmised by these comments, a considerable degree of frustration exists in the current medical
education and training system. Some of the recurring themes from doctor teachers were the lack of
student preparedness and motivation, poor knowledge base due to inadequate study habits, and a need to
change the curriculum to better reflect real world needs although some do not see the value in some of the
recent changes in medical education made at HUSM. In addition, some doctors commented that they did
not see current students as being as serious or motivated as they themselves were at the same time in their
training. Students expressed disappointment in some of the courses they were required to take, citing lack
of perceived relevance, boring classes, sub-par teaching, lack of structure, time wasting, and incomprehensible evaluations. Nevertheless, every doctor and student interviewed had some constructive comments to make about how to improve the medical education system here.
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An examination of the roles of education and training in the making of a doctor
Innovations for evolution
Giving due consideration to the opinions expressed above, I would like to outline some possible
innovations that could positively promote the evolution of our medical education system and hopefully
graduate better medical practitioners. Firstly, with regards to the objectives of HUSM, (1) update and
expand the objectives to promote a more focused vision for the university and its students and graduates,
(2) create a greater awareness of these objectives amongst the teachers and students so these become
more significant in both education and training, (3) have teachers consider how to promote these
objectives in the course syllabuses and programs they develop, and (4) implement some checkpoints or
methods for determining success in attaining these objectives.
Secondly, more emphasis should be placed on students taking responsibility for their own learning and
performance (or lack of) and quality control. Ideally, medical universities should continually monitor
both their inputs and outputs of the education and training provided. This would require a more intense
scrutiny of individual students in order to help any under-performing students to get back on track; early
exit mechanisms should be put in place to deal with students who are found to be unsuitable to continue
in the university program.
Thirdly, a range of assessment methods should be employed that promote the building of the students
knowledge base, encourage students to develop their own learning skills and abilities, enable assessors to
better determine what students actually know and understand, provide fairness to all students, and that
show how the objectives of the university are being met.
Fourthly, the heavy workload of many of the doctors means less efficient education, training and
evaluations, e.g. juggling classes, PBL tutorials and meetings with their hospital duties, patient loads and
research. In addition, many doctors are not trained as professional teachers and are subsequently limited
in their approaches to education and classroom instruction; greater recognition and support should be
provided to doctor-teachers which in turn would provide better support for the students and their
academic success.
Finally, that all implemented innovations are monitored closely to ensure that they are on track to achieve
what they are meant to achieve. Changes to a program can often raise unforeseen problems that dilute
effectiveness, derail intentions and seriously impact on student performance. Mechanisms therefore need
to be put in place so timely feedback is provided that allow adjustments or modifications to be made as
efficiently and effectively as possible. Indeed, change is a constant element in the educational equation
56
浜松医科大学紀要 一般教育 第 23 号（2009）
and it is how administrators and teachers manage change that determines whether it is positive or
detrimental to the outcomes desired.
Conclusion
The critical question still facing medical educators and institutions today, as it has done in the past, is
what is the best way to make a good doctor. Many changes have occurred in the long history of medical
education and training, and more changes are taking place or are being considered at this very time. But
although medical universities continually turn out a wide variety of good, poor and bad doctors, this does
not mean that the goal of making students into good doctors is unattainable. This paper has endeavored to
explore some of the elements in play in the ongoing debate about where medical institutions like HUSM
should go from here. My starting point was looking at the vast array of qualities that good doctors are
thought to possess and then looking at the objectives of medical universities whose quest it is to produce
such individuals. I also looked at the past history of medical education before looking at the changes that
are currently taking place and the direction these changes are leading towards. Finally, I listened to the
voices of doctors and students already in the midst of these changes and looked for innovations that could
help our medical education and training system become more focuses on its primary tasks as well as
promoting its evolution. Achieving the goals and objectives of medical universities requires that they
continually take a critical view of both medical education and training and the balance of both. For only
when doctors are well educated and trained can they uphold the high ideals and standards that society
expects of them.
Notes
1. Rizo, C.A., et al., What’s a good doctor and how do you make one? Retrieved from <http://
www.bmj.com/cgi/content/full/325/7366/711>
2. Retrieved from <http://en.wikipedia.org/wiki/Hippocrates>
3. Retrieved from <http://en.wikipedia.org/wiki/Hippocratic_Oath>
4. Retrieved from <http://en.wikipedia.org/wiki/Flexner_Report>
5. Molly Cooke, David M. Irby, William Sullivan, and Kenneth M. Ludmerer, American Medical
Education 100 Years after the Flexner Report, The New England Journal Of Medicine, Retrieved
from <http://content.nejm.org/cgi/content/full/355/13/1339>
6. Retrieved from <http://www.hama-med.ac.jp/university_e/university_guide/philosophy/index.html>
7. Retrieved from <http://www.som.uq.edu.au/som/about/mission.htm>
8. Retrieved from <http://www.shiga-med.ac.jp/e/profile/philosophy.html>
9. Retrieved from <http://www.shiga-med.ac.jp/e/curriculum/characteristics.html>
57
An examination of the roles of education and training in the making of a doctor
10. Ministry of Education, Culture, Sports, Science and Technology (Japan). FY2005 White Paper on
Education, Culture, Sports, Science and Technology. Retrieved from <http://www.mext.go.jp/
b_menu/hakusho/html/06101913.htm>
11. Retrieved from <http://www.iime.org/documents/gmer.htm>
12. Kozu, T., Medical Education in Japan. Retrieved from
<http://www.ncbi.nlm.nih.gov/pubmed/17122471>
References
Cambridge International Dictionary of English, 1995, Cambridge University Press.
O’Dowd, G.V.G. An Introduction to Life Long Learning Skills. JALT Proceedings 2004.
O’Dowd, G.V.G. Student Expectations of Medical School and the Ripple Effect.
Reports of Liberal Arts. Hamamatsu University School of Medicine, 20, 2006.
Oxford Advanced Learner’s Dictionary, 2000, 6th edition, Oxford University Press.
国立大学法人 浜松医科大学概要 2008 Hamamatsu University School of Medicine, Hamamatsu,
Japan.
58
浜松医科大学紀要 一般教育 第 23 号（2009）
Appendix 1
Hamamatsu University School of Medicine (HUSM)6
Philosophy and objectives of HUSM at its establishment:
The university seeks to achieve three chief objectives; firstly, to grow up excellent clinicians and highly
creative researchers; secondly, to promote original researches and the innovation of medical techniques;
and thirdly, to play a leading role in local medical treatments by practicing medicine for the greatest
benefits of patients. These goals should contribute to the health and welfare of all mankind.
Mission Statement:
The main task of Hamamatsu University School of Medicine is to actively promote the mankind’s health,
happiness and prosperity through its educational and academic activities. The school, which serves as an
educational and research institution for medicine and nursing, aims at teaching and researches on the
newest theories and practical applications of them. The school continuously seeks to grow up expert
clinicians and nurses and their researchers who are not only highly academic and skilled but also well
trained and versed in medical ethics. By doing so, the university plays a leading role in local medicine
and health care and helps them develop.
Educational objectives for students of the Medical Faculty:
1. to acquire essential knowledge and skills of medicine to solve problems.
2. to learn how to accurately evaluate oneself and how to continue to educate oneself independently.
3. to create a desire for scientific exploration that is essential for those engaged in medicine.
4. to cultivate themselves in ways that enable them to take an active part in the international arena.
5. to learn to be humane and sincere doctors.
Educational objectives for Graduate students of the Doctoral Program in Medicine:
1. to gain the ability to carry out research based on highly professional knowledge and skills.
2. to develop their ability to write well organized and eloquent theses.
3. to make efforts to explore and discover a mystery of humans by approaching it from their individual
and unique perspectives, thereby learning by themselves to pursue lifelong academic achievement.
4. to build personality composed of severity and sincerity being appropriate to a scientist.
5. to utilize their international perspective, thereby sharpening the intelligence and cultivating themselves.
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An examination of the roles of education and training in the making of a doctor
Appendix 2
University of Queensland School of Medicine - Objectives
http://www.som.uq.edu.au/som/about/mission.htm
At our School the broad aim of medical education to produce competent, caring, scientific doctors who
are life long self directed learners, continues as the focus, but with emphasis on the ongoing challenge to
anticipate and respond to the increasing pace of change in:
Community needs and attitudes,
Medical science and technology, and
The need to provide sustainable health care of the highest standard.
The enthusiasm and dedication of UQ medical educators and practitioners keeps the School at the
forefront of worldwide trends in medical education and research, with ongoing evaluation of educational
programs and an emphasis on critical appraisal and current best practice. Historically, the medical school
dates back to 1936 when it was founded. Incorporated within the Faculty of Health Science it provides
the majority of medical training places in the State of Queensland.
Vision: The University of Queensland School of Medicine aims to maintain its ranking as the top medical
school in Queensland, to be among the top 3 in Australia, and among the top 20 in the world within the
next 5 years.
Mission: The University of Queensland School of Medicine works in partnership with the health system
to provide world class accredited medical education, underpinned by lifelong learning skills, our leading
researchers, and our contribution to innovative best practice in clinical services. We do this for the benefit
of all members of our community in Queensland, Australia, and the world.
The Bachelor of Medicine/Bachelor of Surgery (MBBS) Program
The University of Queensland (UQ) conducts a four year graduate entry medical program, the Bachelor
of Medicine/Bachelor of Surgery (MBBS). Designed to produce doctors able to meet the challenges of
the new century, the curriculum has been planned to capture the enthusiasm and maturity of its graduate
entrants and help them develop into highly skilled medical graduates capable of entering the wide variety
of career options open to them.
Key features of the program are:
The simultaneous learning of basic, clinical, biological and social sciences,
The improved teaching of communication skills,
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浜松医科大学紀要 一般教育 第 23 号（2009）
The use of learning approaches that encourage lifelong learning skills,
The incorporation of ethics and professional development as an integral part of the program, and
The incorporation of modern information technology and computing skills to ensure that graduates are
able to utilise the advances in technology to improve their learning skill and knowledge acquisition.
Graduates of the School of Medicine Fulfill the Community’s Requirements for Competent and
Professional Practitioners
Implementation: Students are selected, educated and assessed according to:
A model of clinical reasoning consisting of the ability to integrate knowledge, skills and attitudes from
the four domains of learning in the MBBS program, which are:
Clinical Sciences
Biomedical Sciences
Population Health and
Ethics and Professional Practice
The needs of Queensland’s urban, rural, remote and indigenous communities.
The University of Queensland’s commitment to graduate attributes and
The community’s, the School’s and the medical profession’s requirements for personal and professional
attributes.
Graduating students must satisfy the School’s academic standards and be prepared to commit themselves
to lifelong education.
Graduating students must demonstrate that they can practice safely and are clinically and professionally
fit to practice at intern level.
The MBBS Program’s Curriculum Emphasises the Factors Required to Equip Graduates to be
Responsive to the Changing Health Needs of the Community
Implementation: Community representatives participate in admissions committee meetings.
Students from a range of backgrounds, including rural and indigenous communities, are encouraged and
supported in seeking admission to the program.
Instruction in the sciences and clinical practice is informed by the principles of evidence-based medicine.
The curriculum accurately reflects the burden of disease affecting the communities served by the School
and its graduates.
The domain structure of the course links clinical practice to its social, legal and political contexts.
Students develop the capacity of critical self-awareness, which enables them to constructively respond to
their own personal and health problems, and learning needs.
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An examination of the roles of education and training in the making of a doctor
Students, the medical profession, Queensland Health, allied health practitioners, community groups, and
other individual and institutional stakeholders participate in curriculum development, review and delivery.
The School Serves the Community through Education, Research, Provision of Clinical Services
and Specific Links with the Wider University, the Medical Profession and the Public
Implementation: The School prepares competent graduates who enter the medical profession and
provide health services to the Queensland, Australian and international communities.
The MBBS program provides learning opportunities for students and familiarity with health service
delivery through partnerships with individual health practitioners and private and public health institutions.
The School supports the medical profession and the health of the community by providing postgraduate
degree courses and training, and through continuing medical education.
Members of the School serve the university through participation on and leadership of faculty and
university committees.
Members of the School serve the Queensland community by providing high quality clinical services
through a variety of the state’s health institutions.
Members of the School serve the community through participation in government and non-government
committees, consultancy and secondments.
The School Encourages and Supports its Staff in their Participation in Relevant and High Quality
Clinical, Scientific and Educational Research
Implementation: The School offers opportunities for staff members to engage in important research
projects to extend the knowledge base concerning health and disease, and to disseminate the results
through national and international peer-reviewed journals.
Clinical academics inform their teaching in the MBBS program and postgraduate courses with the results
of their research.
Clinical and scientific research undertaken within the School reflects the burden of disease affecting the
communities served by the School and its graduates.
Clinical and scientific research undertaken within the School is subject to peer and community review
and monitoring, through the University’s Human Research Ethics Committee system, in accordance with
the NHMRC’s National Statement on Ethical Conduct in Research Involving Humans (1999).
Research into educational methods is conducted within the MBBS program, with publication of the
results in national and international journals.
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浜松医科大学紀要 一般教育 第 23 号（2009）
The School Encourages and Provides a Collegial and Supportive Culture for Staff and Students
Implementation: The School values the contributions made by its staff to the implementation of the
MBBS program in the areas of curriculum design and delivery, assessment, teaching and learning
development, pastoral care, and evaluation.
Students are active members of School committees.
Students are regularly involved in the evaluation of curriculum content, structure and delivery, and
assessment.
Senior students provide pastoral care for junior students, and new graduates participate in tutorial
teaching in year two of the course.
The School provides a suite of support and pastoral care processes, with particular attention to the
specific needs of indigenous and international students and students with special needs.
The School Regularly Evaluates, and Invites External Evaluation of its Educational, Research and
Service Activities
Implementation: The School provides detailed and timely reports to the Australian Medical Council,
which accredits Australasian medical programs.
The School undertakes outcomes evaluation of the MBBS program.
Annual curriculum conferences critically review curriculum, teaching and assessment policies and
processes.
National and international medical education authorities regularly participate in Curriculum. Conferences and workshops, and provide critical appraisal and advice on the program.
The School attracts medical and related research grants at a high rate.
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An examination of the roles of education and training in the making of a doctor
Appendix 3
Global minimum essential requirements in medical education
Source: http://www.iime.org/documents/gmer.htm
The Core Committee of the Institute for International Medical Education has grouped the ’essentials’
under following seven, broad educational outcome-competence domains:
Professional Values, Attitudes, Behavior and Ethics
Professionalism and ethical behavior are essential to the practice of medicine. Professionalism includes
not only medical knowledge and skills but also the commitment to a set of shared values, the autonomy to
set and enforce these values, and responsibilities to uphold them. The medical graduate must demonstrate:
· recognition of the essential elements of the medical profession, including moral and ethical principles
and legal responsibilities underlying the profession;
· professional values which include excellence, altruism, responsibility, compassion, empathy, accountability, honesty and integrity, and a commitment to scientific methods,
· an understanding that each physician has an obligation to promote, protect, and enhance these
elements for the benefit of patients, the profession and society at large;
· recognition that good medical practice depends on mutual understanding and relationship between the
doctor, the patient and the family with respect for patient’s welfare, cultural diversity, beliefs and
autonomy;
· an ability to apply the principles of moral reasoning and decision-making to conflicts within and
between ethical, legal and professional issues including those raised by economic constrains, commercialization of health care, and scientific advances;
· self-regulation and a recognition of the need for continuous self-improvement with an awareness of
personal limitations including limitations of one’s medical knowledge;
· respect for colleagues and other health care professionals and the ability to foster a positive collabora-
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浜松医科大学紀要 一般教育 第 23 号（2009）
tive relationship with them;
· recognition of the moral obligation to provide end-of-life care, including palliation of symptoms;
· recognition of ethical and medical issues in patient documentation, plagiarism, confidentiality and
ownership of intellectual property;
· ability to effectively plan and efficiently manage one’s own time and activities to cope with uncertainty, and the ability to adapt to change;
· personal responsibility for the care of individual patients.
Scientific Foundation of Medicine
The graduate must possess the knowledge required for the solidscientific foundation of medicine and be
able to apply this knowledge to solve medical problems. The graduate must understand the principles
underlying medical decisions and actions, and be able to adapt to change with time and the context of his/
her practice. In order to achieve these outcomes, the graduate must demonstrate a knowledge and
understanding of:
· the normal structure and function of the body as a complex of adaptive biological system;
· abnormalities in body structure and function which occur in diseases;
· the normal and abnormal human behavior;
· important determinants and risk factors of health and illnesses and of interaction between man and his
physical and social environment;
· the molecular, cellular, biochemical and physiological mechanisms that maintain the body’s homeostasis;
· the human life cycle and effects of growth, development and aging upon the individual, family and
community;
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An examination of the roles of education and training in the making of a doctor
· the etiology and natural history of acute illnesses and chronic diseases;
· epidemiology, health economics and health management;
· the principles of drug action and it use, and efficacy of varies therapies;
· relevant biochemical, pharmacological, surgical, psychological, social and other interventions in acute
and chronic illness, in rehabilitation, and end-of-life care.
Communication skills
The physician should create an environment in which mutual learning occurs with and among patients,
their relatives, members of the healthcare team and colleagues, and the public through effective communication. To increase the likelihood of more appropriate medical decision making and patient satisfaction,
the graduates must be able to:
· listen attentively to elicit and synthesize relevant information about all problems and understanding of
their content;
· apply communication skills to facilitate understanding with patients and their families and to enable
them to undertake decisions as equal partners;
· communicate effectively with colleagues, faculty, the community, other sectors and the media;
· interact with other professionals involved in patient care through effective teamwork;
· demonstrate basic skills and positive attitudes towards teaching others;
· demonstrate sensitivity to cultural and personal factors that improve interactions with patients and the
community;
· communicate effectively both orally and in writing;
· create and maintain good medical records;
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浜松医科大学紀要 一般教育 第 23 号（2009）
· synthesize and present information appropriate to the needs of the audience, and discuss achievable
and acceptable plans of action that address issues of priority to the individual and community.
Clinical Skills
The graduates must diagnose and manage the care of patients in an effective and efficient way. In order to
do so, he/she must be able to:
· take an appropriate history including social issues such as occupational health;
· perform a physical and mental status examination;
· apply basic diagnostic and technical procedures, to analyze and interpret findings, and to define the
nature of a problem;
· perform appropriate diagnostic and therapeutic strategies with the focus on life-saving procedures and
applying principles of best evidence medicine;
· exercise clinical judgment to establish diagnoses and therapies;
· recognize immediate life-threatening conditions;
· manage common medical emergencies;
· manage patients in an effective, efficient and ethical manner including health promotion and disease
prevention;
· evaluate health problems and advise patients taking intoaccount physical, psychological, social and
cultural factors;
· understand the appropriate utilization of human resources, diagnostic interventions, therapeutic modalities and health care facilities.
Population Health and Health Systems
Medical graduates should understand their role in protecting and promoting the health of a whole
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An examination of the roles of education and training in the making of a doctor
population and be able to take appropriate action. They should understand the principles of health
systems organization and their economic and legislative foundations. They should also have a basic
understanding of the efficient and effective management of the health care system. The graduates should
be able to demonstrate:
· knowledge of important life-style, genetic, demographic, environmental, social, economic, psychological, and cultural determinants of health and illness of a population as a whole;
· knowledge of their role and ability to take appropriate action in disease, injury and accident prevention
and protecting, maintaining and promoting the health of individuals, families and community;
· knowledge of international health status, of global trends in morbidity and mortality of chronic
diseases of social significance, the impact of migration, trade, and environmental factors on health and
the role of international health organizations;
· acceptance of the roles and responsibilities of other health and health related personnel in providing
health care to individuals, populations and communities;
· an understanding of the need for collective responsibility for health promoting interventions which
requires partnerships with the population served, and a multidisciplinary approach including the health
care professions as well as intersectoral collaboration;
· an understanding of the basics of health systems including policies, organization, financing, costcontainment measures of rising health care costs, and principles of effective management of health
care delivery;
· an understanding of the mechanisms that determine equity in access to health care, effectiveness, and
quality of care;
· use of national, regional and local surveillance data as well as demography and epidemiology in health
decisions;
· a willingness to accept leadership when needed and as appropriate in health issues.
Management of Information
The practice of medicine and management of a health system depends on the effective flow of knowledge
and information. Advances in computing and communication technology have resulted in powerful tools
for education and for information analysis and management. Therefore, graduates have to understand the
capabilities and limitations of information technology and the management of knowledge, and be able to
use it for medical problem solving and decision-making. The graduate should be able to:
· search, collect, organize and interpret health and biomedical information from different databases and
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浜松医科大学紀要 一般教育 第 23 号（2009）
sources;
· retrieve patient-specific information from a clinical data system;
· use information and communication technology to assist in diagnostic, therapeutic and preventive
measures, and for surveillance and monitoring health status;
· understand the application and limitations of information technology;
· maintain records of his/her practice for analysis and improvement.
Critical thinking and research
The ability to critically evaluate existing knowledge, technology and information is necessary for solving
problems, since physicians must continually acquire new scientific information and new skills if they are
to remain competent. Good medical practice requires the ability to think scientifically and use scientific
methods. The medical graduate should therefore be able to:
· demonstrate a critical approach, constructive skepticism, creativity and a research-oriented attitude in
professional activities;
· understand the power and limitations of the scientific thinking based on information obtained from
different sources in establishing the causation, treatment and prevention of disease;
· use personal judgments for analytical and critical problem solving and seek out information rather than
to wait for it to be given;
· identify, formulate and solve patients’ problems using scientific thinking and based on obtained and
correlated information from different sources;
· understand the roles of complexity, uncertainty and probability in decisions in medical practice;
· formulate hypotheses, collect and critically evaluate data, for the solution of problems.
69
浜松医科大学紀要一般教育の編集，刊行に関する申し合わせ
（平成15年3月3日改訂）
※平成15年度から適用
一部改正 平成17年1月27日
一部改正 平成17年7月19日
Ⅰ．紀要の発行
1．名称は「浜松医科大学紀要一般教育」とする。英語の名称は Bulletin of Liberal Arts Hamamatsu
University School of Medicine とする。
2．発行者は浜松医科大学とする。
3．編集は研究成果等刊行物編集専門委員会（以下「編集委員会」という。）が行う。
4．投稿資格者は，本学の教官，非常勤講師（他に本務を有さない者に限る。
）並びに共同研究者又
は研究協力者とし，投稿論文は未公刊のものに限る。
5．収録範囲は一般教育科目等及び関連諸学科領域とする。但し，非実験系科目を優先的に収録す
るものとする。
6．発行回数は原則として年 1 回とする。
Ⅱ．紀要の体裁
1. 誌面の大きさはA4判，組版は横1段とする。
2. 表紙には日本語で，裏表紙には英語で，次の事項を記す。
1）紀要名 2）号数 3）発行年月 4）大学名
3. 背表紙には日本語で次の事項を記す。
1）紀要名 2）号数 3）発行年月
4. 巻頭のページには目次を記す。
5. ページ数は，次のとおりとする。
1）ページは白紙を含めた通しページとすること。
2）白紙ページはページ数を記さないこと。
3）記す位置はページ下外側とすること。
4）横書き論文は巻頭から始めてアラビア数字とすること。
6. 論文は，奇数ページから始まるものとする。
7. 各論文の体裁は以下のとおりとする。
1）表題，著者名，所属
2）和文の場合は，1）の欧文訳
70
浜松医科大学紀要 一般教育 第 23 号（2009）
3）欧文の要約
4）欧文のキーワード
5）本文
6）文献
8. 本文の組版は次のとおりとする。 和文 42字×34行×1段（1,428字）
欧文 84字×34行×1段（2,856字）
9. ランニング・タイトルは，奇数ページに紀要名と号数と発行年，偶数ページに論文題名を記す。
論文題名は，著者が短縮して，和文の場合は30字以内，欧文の場合は60字以内とする。
10. 奥付には次の事項を記す。
1）紀要名 2）号数 3）印刷年月日 4）発行年月日
5）編集者 6）発行者 7）印刷所
11. 別刷の表紙には，論文題名と著者名を上部中央に，紀要名，号数，
「別刷」，発行年月を下部中
央に記す。
Ⅲ．投稿の手引き
1. 原稿の体裁
原則として，ワープロによるものとし，和文原稿はA4版明朝体11ポイント42字×34行とし，欧
文原稿はA4 版Times New Roman 11ポイント84字×34行とする。
2. 表題，著者名，所属
1）原稿1枚日に記す。
2）表題は冒頭中央に書き，末尾にピリオドをつけない。サブタイトルを必要とする場合は次の
行に記す。
3）欧文表題は，第1語，名詞，形容詞，副詞の頭文字は大文字とする。
4） 著者名は1行あけて，行の中央に記す。ローマ字の場合は，名は頭だけ大文字であとは小文
字，姓はすべて大文字とする。
5）共著のときは和文ならばナカグロ
「・」で連ね，欧文ならばandで連ねる。3名以上の場合はコ
ンマとandで連ねる。
6）所属は，和文ならば学科目名を書いて（ ）
でくくり，欧文ならばイタリック体で書いて（ ）
でくくらない。
共著で各著者の所属が異なる場合は，それぞれの著者名の右肩に［＊］，［＊＊］をつけ，所属
名の左肩に同じ印を入れ，間を和文ならばナカグロ
［・］，欧文ならばセミコロン［；］で切る。
7）和文の場合には，原稿1枚日の下半分に，かさねて欧文で，表題，著者名，所属を記す。
3. 要 約
71
1）和文の場合も，欧文の場合も，欧文の要約を付ける。
2）原稿2枚日に要約を記載する。
3）見出しはゴシックで Abstract，Résuméなどとする。
4. 欧文のキーワード
キーワードは，要約の次に改行し，最適な4∼5語を記載する。
5. 本 文
1）原稿3枚目以下に記す。
2）和文の場合，
① 段落の始まりは1字分あけて書きはじめる。
② 句読点はコンマと句点（。）とする。
③ 句読点，カッコ等は1字分に書く。
④ 欧文文字及びアラビア数字は2字を1字分とする。
⑤ 外国の固有名詞は原則としてカタカナで表記し、特に明示する必要のある場合を除いて
欧文文字を用いない。
3）欧文の場合，段落の始まりは3字あける。コンマ，セミコロン，コロンなどの文中の読点の
後は1字分をあけ，ピリオド，疑問符，感嘆符などの文末の句点の後は2字あける。
4）数 式
① 数式の上下にはスペースをとる。
② 文章中の簡単な分数式には／を用いる。
6. その他
1）注
① 原則として巻末注とする。
② 注の見出しは，本文該当箇所の右肩に，
（ ）を付し，その中に番号を順番に記入する。
③ 特に脚注を必要とする場合は，本文該当箇所に＊）
を付し，本文中そのすぐ下に，上下を
横線ではさんで注を記入する。その冒頭に＊）を付し，その左欄外に脚注と表記する。
2）文 献
① 引用文献を指示する場合には，原則として本文該当筒所の右肩に ）を付し，その左に通
し番号をアラビア数字で記入する。
② 文献は一括して末尾の文献欄に列記する。
③ 記載の形式は，次のとおりとする。
A．雑誌論文の場合
著者名：論文題名，雑誌名 巻（号）：最初のページ−最後のページ，発行年．
（和文例） 半田 肇，長沢史朗：脳死の診断とその問題点：脳神経外科医の立場から，臨成
人病14（4）：30−31，2002．
72
浜松医科大学紀要 一般教育 第 23 号（2009）
（欧文例）Cranford RE, Jackson DL: Neurolongists and the hospital ethics commitee. Semin Neuro 4
(1) :15–22, 2002.
注 1．著者多数の場合は，鈴木二郎（他），Youngner SJ, et al.等としてもよい。
2．雑誌名の略記は慣行に従う。なお，欧文雑誌名はイタリックとする。
3．ページ数は通巻ページを記入する。各号ページの場合は14（4）：30−31のように巻数
の後に号数を（ ）に入れて表示する。なお，巻数はゴシックとする。
B．図書の場合
a．図書全体を引用する場合
著（編）者名：書名．［出版地：］出版者，出版年．
（和文例）河野友信，河野博臣（編）：生と死の医療，朝倉書店，2002．
（欧文例）Bondeson WB, et al, eds: New Knowledge in the Biomedical Science. Boston: D.Reidel,
2002.
注 1．編者名には（編），ed［s］を付記する。
2．洋書の場合は書名をイタリックとし，出版地と出版著名をBoston: D.Reidelのように記
載する。
b．図書の一部分を引用する場合
分担著者名：論文題名．［In］
編者名：書名．［出版地：］出版者，出版年，引用ページ
（和文例）浜松太郎：現代医学と倫理．日本倫理学会（編）：技術と倫理．以文社，2002，P173
−193．
（欧文例）Cassell EJ: Heart disease; the ethical quandaries of treated the aged. In Reiser SJ, Anbar M,
eds: The Machine at the Bedside. New York: Cambridge University Press, 2002, P327–331.
3）表，図，写真
① 表，図については可能な限り本文中に取込むものとするが，これによりがたい場合は，下
記のとおりとする。
② 写真については，A4版の台紙に1枚ずつ貼り，別紙とした表または図はA4版の用紙に，そ
れぞれ作成または貼るものとし，表は
表Ⅰ（TableⅠ）
，表Ⅱ（TableⅡ）
……………
図及び写真は
図Ⅰ（FigⅠ），図Ⅱ（FigⅡ）……………
と表記する。
③ 1枚ごとに著者名を表記する。
④ 本文中のおおよその該当箇所の枠取りをし，表Ⅰ，図Ⅰ・・・・・と表記する。
7．原稿の提出，受理
1） 原稿はフロッピーディスクとプリントアウトしたもの（2部）
を提出するものとし，次の順序に
73
並べて通し番号を付ける。
表題，要約，本文，注，文献，表，図，写真
2）原稿の枚数制限は，図表，写真等を含めてA4版40枚以内とする。
なお出来上がり1ページの体裁は，
和文 42字×34行＝1,428字
欧文 84字×34行＝2,856字
3） 原稿が制限ページを越える場合，あるいは特別の印刷（多色刷，別添図等）を要する場合な
ど，差額を著者負担とすることがある。
4） 提出された原稿は査読者に提出し，掲載の是非，修正の必要性及びその箇所を指摘した査読
意見書の提出を求める。査読者は編集委員長（図書館長）が定める。査読意見書の書式は別に定
める。
5） 受理年月日は，完成原稿を編集委員会に提出した日をReceived，査読者の同意を得て編集委
員長が掲載を決定した日をAcceptedとし，原稿の末尾に記入する。
6） 印刷の形式等で特例を必要とする場合は，原稿提出時に編集委員会にその旨連絡するものと
する。
8. 校 正
1）論文の著者校正は初枚のみとする。
2）別刷を実費著者負担において，要求する場合は第1校返却のとき，編集委員会にその旨連絡す
るものとする
9．論文の公開
1）掲載された論文は，浜松医科大学ホームページ並びに国立情報学研究所が実施している
「研究
紀要ポータルシステム」及び「電子図書館サービス」により公開するものとする。
2）著者は，このことを了解したうえで原稿を提出するものとする。
74
Contents
On the Set of Numbers Derived from Some Recurrence Formula
(1) Mean and Median
……………………………………………………… AKIO NODA ……………… 1
Coping behavior for illnesses among the Baka hunter-gatherers:
a case study in northwestern Republic of Congo ………………………… HIROAKI SATO …………… 11
An Examination of the Human Soul that Dwells within the Machine
as Exemplified by The Ghost in the Shell ………………………………
YUKIHIDE E NDO …………… 33
An examination of the roles of education and training in the
making of a doctor ……………………………………………… GREGORY V.G. O’DOWD …………… 45
Appendix; Editorial Policy and Instructions to Authors …………………………………………………… 70
浜松医科大学紀要 一般教育 第 23 号
平成 21 年 2 月 20 日 印刷
平成 21 年 2 月 27 日 発行
編集者 浜 松 医 科 大 学
研究成果等刊行物編集専門委員会
発行者 浜 松 医 科 大 学
〒431-3192 浜松市東区半田山一丁目 20番1 号
TEL.（053）435 − 2169
印刷所 有限会社 ケーエス企画
BULLETIN OF LIBERAL ARTS
HAMAMATSU UNIVERSITY
SCHOOL OF MEDICINE
NO.23
MARCH
2009
HAMAMATSU UNIVERSITY
SCHOOL OF MEDICINE