●　「東 THE EAST」 に三好春樹紹介記事！

Vol.39, No.6, MARCH/APRIL 2004
Reportage MIYOSHI HARUKI
A New Idea and the Practice of Elderly Care in Japan
【 日本における老人介護の新しい思想と実践 】
（和訳）　（英語原文）

日本における老人介護の新しい思想と実践（和訳）

高齢化社会のかかえる様々な問題の中でも、最も深刻なのが痴呆老人である。国立精神神経センターの推計によると、日本の65歳以上の痴呆性老人は、2000年に155万7700人。10年前に比べ55万人増えた。世界中の医学関係者の多大な努力にも関わらず、痴呆の原因に関してはまだ定説が確立されておらず、これといった治療法もない。また世界中の製薬会社が抗痴呆薬の開発に積極的に取り組んではいるが、まだ決定的な新薬の開発には到っていない。そのため病院、福祉施設、そして家庭で、正体の見えない相手との厄介な手探りの戦いが行われているのが現状である。

ものもらいが眼の病気であるのと同じ意味で、痴呆は脳の病気であると、普通は考えられている。後天的な脳の器質的疾患のために知的能力が著しい低下をきたす状態、それが痴呆の医学的定義である。痴呆は大きく脳血管性痴呆-脳卒中、脳硬塞などの脳血管障害によって起こる-と、アルツハイマー型痴呆-主として脳の萎縮や変性によって起こる-の２種類に分類される。しかし上記のようにまだ痴呆の治療法が確立されていないため、痴呆老人にとっては治療と同じくらい、あるいは治療以上に、心身両面での介護が重要になる。

その介護の現場から痴呆の常識的理解に異議を唱えている日本人がいる。「痴呆は脳の病気ではない」と端的に主張するその日本人とは、三好春樹である。「かつてヒステリーは子宮に原因のある女性特有の病気だと考えられていました」三好は言う。「いま私たちがその誤解を笑っているように、あと10年もすれば『痴呆は脳の病気である』という今日の通念は笑いの対象になっているでしょう」。

三好によれば、痴呆＝脳の病気という医学の考え方は原因と結果を取り違えている点で間違っている。脳の萎縮や変性は医学者が言うように痴呆の原因なのではなく、むしろ痴呆の結果なのだと三好は考える。「ピック病、アルツハイマー病など、明らかに脳の器質的欠陥に原因のある痴呆が存在することは確かです」三好はそう認めたうえで言う。「しかしそうした脳器質性の痴呆の割合は一般に考えられているよりもずっと小さく、また脳の萎縮や脳血管障害があっても痴呆にならない人や、その逆のケースが意外に多いことから見ても、脳の機能低下と痴呆の間に単純な因果関係を想定するのは無理があります」。

さてしかし、脳の病気でないとすれば、痴呆とは一体何なのか？　それは、三好の言葉で言えば、「関係障害」である。「人間を取り巻く関係については、大きく家族的関係と社会的関係に分けて考えられることが多いわけです。前者は血縁や愛情、友情といった情緒的な関係であるのに対し、後者は契約的で合理的な関係であると。しかし、この２つに加えて《自分自身との関係》という視点が痴呆老人を考えるうえで特に重要です」。三好はそう言う。

自分自身との関係とは、老人の場合で具体的に言えば、物忘れする自分、失禁する自分、老いて弱った屈辱的な自分とどう心理的に折り合いをつけるかということである。もしなんらかの理由で老人が老いた自分自身と折り合いをつけることに失敗し、老いた自分を自分で否定し疎外するようになると、そこに自分自身との関係における障害が生まれる。その障害が社会的関係や家族的関係をも壊して行く過程で痴呆が始まる。三好はそう考える。

具体的に言えば、老いた自分を恥ずかしく思うあまり外出や人付き合いを嫌い、家に閉じこもり、家族との関係も次第に悪化して毎日の生活が煮詰まっていき、やがて孤独の苦しみの中で心に異常をきたし、脳の変性や萎縮が起こる・・それが多くの痴呆老人の実態であり、決してはじめに脳の異常があるわけではない。痴呆の本質は関係的存在である人間だけが経験する関係障害である。従って痴呆老人には治療ではなくその人自身の関係性の修復を助けるような介護が必要である。それが三好の考えである。

三好のそういう考えは自身の長年にわたる介護現場での体験に基づいている。つまり、病院では廃人同然だった痴呆老人が老人ホームでの人間的な介護によって不思議なくらい生気を取り戻す例をいくつも見てきた、そして彼自身も介護によってそのような回復を実現してきた実体験が彼に医学的常識を真っ向から否定する勇気を与えている。

三好が介護の仕事を始めたのは1974年、彼が24歳のときであった。広島県呉市に生まれ、警察官の父を持つ一人っ子として広島県内のいくつかの街を移り住みながら育った三好は、県内で最も優秀な子供が集まる中高一貫制の私立修道学園へ進んだ。知的に早熟だった三好は当時盛んだった学生運動に先頭に立ってコミットした。生徒会会長としてベトナム反戦デモの先導などを繰り返した彼は学校側から睨まれる存在となり、高校卒業を目前に控えた1969年1月、過度の政治活動を理由に強制退学させられた。

その後は新左翼系のセクトに属し、職を転々としながら、地元や隣の山口県で政治活動を続けた。やがて1970年代に入り、新左翼セクト同士の内部闘争が激化してくると、三好は政治活動の第一線から身を引き、当時の新左翼にとっての指導的思想家であった吉本隆明の影響で、日常生活の場から《生活者》として社会改革運動の再建を志すようになった。

そんなとき彼は、特に老人介護への関心もないまま、たまたま知人の依頼で広島県内の特別養護老人ホームの職員になった。特別養護老人ホームは65歳以上で身体もしくは精神に著しい障害を持ち常時介護を必要とする老人を対象とする公の施設で、多くの痴呆老人も在所している。俗っぽいものが嫌いで世間に背を向けていた三好青年はここで《もう一つの世間》に出会う。

「一般的に老人ホームに入ってるのはかわいそうな老人たちと思われていて、私もそう思い込んでいたのですが、とんでもない思い違いでした」三好は語る。
「寮母を召し使いと思い込んでいる84歳の元お嬢様をはじめ、主任指導員に見事なくずし文字のラブレターを渡すじいさんや、マヒで全身硬直しながらも１日中ベッドの上で赤旗を読む元活動家など、個性全開といった面々が実にマイペースに暮らしていた。
人間、最後にこんなに個性的になるなら、若いときから個性的に生きればいいんだと思えて、ホッとできた。世間で理想とされるコースからはずれてしまった自分にとって、老人と出会えたことで開き直りができて、どの人生にもレールなんてないこと、行き着く先も過程もみんな違うことを教えられたんです」。

救うはずの老人たちとの出会いによって却って救われた三好は、日々の老人たちとの接触を通じて、老人介護と老人医療の現実に直面することになった。老人病院で点滴のために手を縛られ、オムツをつけ、表情をなくしてやって来た女性が、ベッドの脚を切って低くしただけで、立ってトイレに行けるようにもなった。逆に、特養では自立できていたおばあさんが、疾患があるため病院に１週間検査入院したところ、車椅子に乗せられ、尿意も分からなくなってオムツをつけて帰ってきた。

「病院＝専門家集団＝頼りになる」という自分の中の常識の壁がいつしか崩れていった。「ベッドを低くして足が床につけば、立てるようになる。歩いてトイレに行ければ尿意が回復し、目の輝きも戻ってくる。介護現場には専門書には書いてないことばかり。介護は自分たちの日常体験の中にあるんだと分かった」三好はそう語る。

28歳から３年間、三好は九州リハビリテーション大学校に通い、理学療法士の資格を取得した。その後再び特別養護老人ホームに戻り、従来の禁欲的に努力するリハビリが思うような成果をあげないことに悩み、遊びやゲームの要素を取り入れた新しいリハビリを考え出して実施し、それらが老人をイキイキさせるのに非常に有効なのを知った。

そうした現場での試行錯誤の積み重ねの中で、三好の中に、自分の守備範囲、つまり自分が人よりうまくやれる仕事は何なのかについての見極めが生まれてきた。と同時に、従来の介護の意味や方法を考え直し、新しい介護のあり方をもっと広い場で作り出していきたいという志向が生まれてきた。
1985年、三好は老人ホームを辞めて、東京に「生活とリハビリ研究所」を設立した。これ以後彼は全国各地で介護職員を対象にした講演や介護講座を開くことと介護に関する著作の発表を中心に活動することになる。

現場での介護体験に基づいた、徹底して具体的な三好のレクチャーや著作は介護現場で働く職員たちから強い支持を集めた。オムツではなくトイレで排せつすることで老人を元気にする方法を検討する「オムツはずし学会」やチューブからの栄養注入ではなく口で食べることを推奨する「チューブはずし学会」といったユニークな活動（「学会」と言っても実際は介護現場の職員による勉強会である）の運営などを通じて、三好は徐々に介護の世界のオピニオンリーダーとして注目される存在になっていく。

介護される老人の立場に立った徹底した具体性と実用性が三好が介護現場から大きな支持を集めた第一の理由であるが、三好がオピニオンリーダーたりえているもう一つの理由として、三好が介護の意味を深く考察しているということがある。
「どんな介護職でも大なり小なり哲学者になるっていうのが現場の面白いところ」三好は言う。「この人はボケちゃって生きている意味は何だろう、それに関わることの意味って何だろう、この人の一生は何だったんだろう。具体的な方法論も必要だけど、そうした思想、哲学も手に入れないとやっていけない」。

哲学という点では、三好は学生時代から私淑していた吉本隆明のほか、ミシェル・フーコー、クロード・レヴィストロースといったフランスの構造主義哲学者から多くを学んでいる。「レヴィストロースの『野生の思考』を読んで、いわゆる未開社会の人々の思考方法や生産方法が介護の世界のそれに非常に近いことに気付きました」三好は語る。

「ブリコラージュと呼ばれるそうした方法はサイエンスにはなりえないがアートにはなりうる。そんなレヴィストロースの文章を読んだ夜は、自分のしてきた介護の実践と現代思想が重なり合うように感じて興奮し、朝まで眠れませんでした」。実際、三好の介護に関する透徹した思考は、単に福祉の世界だけでなく、哲学や文学を含めた周辺領域へも徐々にその影響を及ぼしつつある。

それでも、三好はあくまで現場の人間である。ここ数年は年に170回以上の講演をこなす。それほどの引っ張りだこぶりには理由がある。三好の講演は上等の話芸なのである。暗くなりがちな介護の話を、痴呆老人の意表をつく実話を交えながら彼はまるで落語家のような軽妙な口調で面白おかしく語って聞かせる。聴衆は何度も爆笑させてもらえる。そうして笑いながら聞いていても三好の考えは分かりやすく頭に入ってくる。それは単に三好が話し上手ということではなく、彼が痴呆老人というコミュニケーションの難しい人間を相手にする日々の中でコミュニケーションの方法論について深く考えてきた結果である。

三好の講演の主眼は、「痴呆は脳の病気ではない。関係障害だ」という視点から、では実際どうやって痴呆老人の介護を行えばよいのか、その説明にある。痴呆が社会・家族・自分自身との関係障害であるということは、痴呆の対処法は少なくとも痴呆老人の数と同じだけあるということになる。１人ひとりの老人について、その人が受け入れ可能な人間関係を老人と一緒に作っていくこと。

三好によれば、それが介護という仕事の重要部分である。例えば、元芸者で８０歳になるお婆さんが訪問介護ヘルパーを泥棒扱いするようになった。痴呆老人に典型的な被害妄想である。
さてどう対処したらよいか？　三好はそう聴衆に問いかける。
聴衆に考える時間を与えた後で、実際にうまくいった解決策を紹介した。家事の世話を終えたあと、ヘルパーがそのお婆さんから彼女お得意の小唄と都々逸を教えてもらう。それだけで妄想は消えた。

どういうことか？　そのお婆さんはもともと自立心の強い人で、一方的に介護を受けることに心理的苦痛を感じていた。自分がヘルパーに対して加害者の立場にあるような罪悪感を打ち消すために、自分がものを盗まれているという被害妄想が必要だった。しかし音楽を教えるようになり、依存関係が双方向的になったことで心理的負担はなくなり、妄想も消えた。へぇ?。思わず感嘆の声があがる。

しかしこの種の面白い話だけだったら三好の講演に年間７万人もの介護職員が集まってきはしないだろう。介護の難しさに日々直面している彼ら現場の職員が三好の話に共感するのは、そこに自分たちの実感と一致するリアリティのある言葉があるからだ。入浴を拒否する老人をどうやって風呂に入れるか、夜不安で寝つけず廊下でおしゃべりしている老人をどうやって寝かしつけるか、老人を便秘にさせないためにはどうすればいいのか・・そうした下世話な、しかし介護現場では切実な問題の一つ一つに、三好は対処の考え方を述べ、解答例を示す。

「入浴を嫌がる人も本当は風呂に入りたいんです。でも、嫌がるのを無理に入れさせられた、という形で入りたいと思ってるんです」「便秘を防ぐにはとにかく朝食の後、トイレに座らせることが大切。便秘が直っただけで問題行動が消える例がたくさんあります」。そんな具体的で説得力のある言葉が次々と語られる。いずれも聞き手である介護現場の職員たちが翌日から自分たちの仕事の中で活かしていける言葉である。

「講座は、自分の知っていることを人に教えていくという啓蒙的なかたちじゃなくて、自分がなぜそういう考え方になったか、こういう方法論を手に入れたのか、その認識の過程を語るというやり方。現場で経験、実感したことから離れないで、それを言葉にしていくという方法です」三好は言う。

「介護というのはまったく新しい世界ですから、教科書がない。それを何かに頼るのではなく、現場の実感から言葉をつくっていく作業です。だから、参加者は真似するんじゃなくて、それに追体験しててもらえればいい」。
痴呆を人間関係の障害と見る三好は、一方では、痴呆を近代的自我が崩壊して人間が自然に還って行く過程と認識してもいる。自立した個人を基礎とする市民社会は、痴呆老人という、人間の形をした自然にうまく対処できない。だから医療や従来の介護は薬を飲ませたりリハビリをさせたりして老人をもう一度自立した個人に戻そうとするわけだが、三好によればこれは根本的に間違ったやり方である。

「80過ぎたら生き仏」という言い方を三好は好んでする。要は、老人の生活を改善しようとするのではなく、老人の現在のありのままの姿を尊重して、彼らが少しでも楽しく元気に生きられるよう生活上の手助けをすること。そこに介護の本質があると三好は考える。そしてこうした考え方が日本的な考え方であることも意識している。

自著『老人介護　常識の誤り』の中で三好は次のように述べている。 「近代個人主義の側から言えば、「自分自身との関係」は、社会からも家族からも独立していて、社会が相手にしてくれず家族は冷たくても、「自分は自分だ」となるはずなのだが、日本人にはそんな自我の強い人はめったにおらず、特に老人は、世間（社会）と身内（家族）の中で自分を感じとれることで自己の確認をしているようである。それが、日本人は個人として成熟していない、などと批判されるのだが、私はそれは文化の違いに過ぎないと思っている」 「日本には老いの固有の文化がある。老人に似合った年相応の格好というものがある。それは、自立してなくたって人間のうちだという相互依存の文化が作り出したものである」。

老人介護が日本で切実な問題になってきたのは、単に日本が高齢社会になってきたからではなく、「年寄りは家族が面倒を見る」という日本の伝統的な慣習が、戦後の個人主義的教育を受けて育った日本人の増加によってもはや成り立たなくなってきたことが大きな理由である。
自我を持ち自己決定力のある個人は、自我の崩壊した痴呆老人をいわば異人と見なして排除する形で処理してきたわけだが、これからはそうして排除してきた側の自立した個人主義者たちが排除される側に回る時代が来る。自我に信頼する彼らこそが最も激しい関係障害を体験することになる可能性は十分に考えられる。
それは悲惨な痴呆老人がこの先ますます増える可能性があるというのと同じである。そうなる前に、痴呆や老人に関する考え方そのものを変えてはどうか。三好はそう問題提起しているように見える。

とはいえ、誰もが悲観に傾きがちな中で、誰よりも楽観しているのも三好である。その楽観もまた彼自身の現場での経験から来ている。それは髪を茶色に染め、耳やそれ以外の部分にピアスをつけた一見日本人らしくない若い介護職が、老人介護の仕事にみずから積極的に就き、老人たちと心を通わせ、老人の死に涙する場面を幾度も見ているからだ。

「今の若い人たちには『近代』への幻想がありません」三好は言う。「核家族も個人主義も自己責任原則も、生まれた時から所与としてあった彼らにとって『近代』はむしろ桎梏なのです。そんな彼らにとっては昔の日本のような大家族が憧れの的だったりするわけです。自立や個人主義といった近代的幻想から覚めている分、彼らはスッと老人たちの心に入っていけるんですね。それは頼もしいことです。ただし、そういう若者はたいてい僕の本を読んでくれませんが」。

三好が介護の世界に足を踏み入れてから今年で30年になる。いま彼は介護を見つめてきた眼で介護の周辺にある問題をより精細に見つめようとしているように見える。その問題の一つは「死」である。講演では自らの判断ミスによって老人を死に至らしめてしまった経験を軽い口調で話す三好であるが、幾多の老人の死をみとってきた彼には今の日本の死をめぐる状況がどこか危うく感じられるようだ。

「イラクに自衛隊を派遣するときに、小泉首相が『たとえ死者が出てもそれは名誉ある死だ』というようなことを言いましたが、あれはおかしいですよね」三好は言う。「死は個人の問題であって共同体の側から意味付けをするのはウソでしょう」。
そしてかつて若い頃老人ホームでみとった１人の老人のことを語った。「性格の悪い爺さんでね。死んでも家族も友人も誰ひとり葬式に来ない。ひどい最期だなあ、とその時は思いました。でも、今考えてみると、彼の死は他人を誰も悲しませなかったんですよね。その意味ではあれが一番立派な死だったのかもしれない」。
誰も悲しませない死が一番良い死。その観点から見た時、介護は、死は、そして生はどんな意味を持つのだろうか。三好が答えを出すのはまだ先になるだろう。確かに言えることは、三好が日本社会にこれまでなかった新しい共同性を創り出す野心を捨てていないことだ。その野心がこれからも彼を介護現場と現代哲学の間を忙しく往復させるだろう。（了）

Kobayashi Motoki　　

日本における老人介護の新しい思想と実践（原文）

There are various problems with the graying of our society. The most serious are the problems involving senile dementia. According to estimates by the National Center of Neurology and Psychiatry, Japan, of the Japanese aged sixty-five and over, 1,557,700 were suffering from senile dementia in 2000, which showed an increase of 550,000 people from a decade ago. Regarding the cause of dementia, there is not yet an established theory despite the strenuous efforts of medical experts around the world. And there is no specific cure for this disease, either. Besides, an effective medicine for the disease has not yet been found, although pharmaceutical companies are trying hard to develop one. Under these circumstances, hospitals, welfare homes, and households are fighting a hard battle against the disease through trial and error methods.

A sty is an eye disease. Likewise, dementia is generally considered a brain disease. In medicine dementia is defined as severe deterioration of mental faculties due to an organic disease of the brain in the course of lifetime. Roughly speaking, there are two types of dementia. One type is caused by injuries in the cerebral blood vessels, such as cerebral apoplexy and cerebral infarction. The other type, which is exemplified by Alzheimer’s disease, is mainly attributable to the contraction or degeneration of the brain. As mentioned above however there is not yet an established cure for dementia. In the case of those suffering from senile dementia, it is of great importance to care for them not only physically but also spiritually,

There is a Japanese who is opposed to the common idea of dementia. It is Miyoshi Haruki, who is himself engaged in the care of elderly people affected with dementia. "Dementia is no brain disease," he said positively "Hysteria used to be considered a disease unique to women who had trouble with their wombs. Today, however, we laugh at such a misunderstanding. Similarly, in ten years or so today's popular idea that dementia is a brain disease will become a laughingstock."

According to Miyoshi, the medical circles' claim that dementia is a brain disease is incorrect in that they mistake the cause for the effect. He thinks that the contraction or degeneration of the brain, which doctors say is the cause of dementia, is the effect of that disease. "Indeed there really exists dementia caused by an organic disease of the brain, such as Alzheimer's disease and Pick's disease." he said. "But the proportion of this type of dementia is much smaller than expected. Besides, contrary to expectation, there are quite a few people who escape from dementia even though they are suffering from the contraction of the brain or injuries in the cerebral blood vessels. And there are also a lot of cases in which it is the other way around. Considering these facts, I should say that it is unreasonable to simply ascribe dementia to the deterioration of brain functions."

If dementia is not a brain disease, what is it then? It is "relationship trouble," according to Miyoshi's wording. He explained as follows, "Human relationships can be broadly classified into family and social relationships. While the former is an emotional relationship involving kinship, affection, or friendship, the latter is contract-1ike and rational. In addition, there is the relationship with oneself, which is the key to senile dementia. "

Regarding an elderly person's relationship with himself, he should try to come to terms with the humiliating fact that he is forgetful, incontinent about urine, or weakened with age. Suppose he fails to come to terms with his senile self for some reason. He will try to deny and estrange his senile self. Then he will start to have trouble with the relationship with himself. As a result, his family relationship and social relationship will be destroyed, too. In the meantime he will contract dementia. "

To be specific, ashamed of his senile self, he will abhor going out and seeing others. As he confines himself to his room, his family relationship will be getting worse and worse. Before long amid the agonies of solitude he will fall into an abnormal state of mind. In the end, he will start to suffer from the contraction or degeneration of the brain. ... Such is often the case with a sufferer of senile dementia. It is not that he has brain trouble from the beginning. "

Dementia is relationship trouble unique to human beings, who are involved in various relationships. Therefore, what is necessary to an elderly person suffering from dementia is not treatment but care to help him regain his relationships."

Miyoshi's idea is based upon his long experience. He has seen many wonderful cases in which elderly people ruined by dementia regained a vivid life as they moved from hospitals to old people's homes, namely, places where they could receive humane care. And he himself has helped such people recover by caring for them. It is his firsthand experience that encourages him to reject doctors' common idea of the disease.

Miyoshi began to care for the elderly in 1974, when he was twenty-four years of age. Born in Kure City, Hiroshima Prefecture, he grew up as a policeman's only child. In his boyhood his family moved from place to place. He studied at Shudo Gakuen, a private junior and senior high school attracting the cream of the children of the prefecture. This intellectually precocious boy committed himself to a student movement, which was active at the time. As the president of the student council, he took the lead in staging demonstrations against the Vietnam War time after time. The school authorities considered him a dangerous student. In January 1969, when he was about to graduate, they forced him to leave the school on the grounds of his excessive political activity,

After leaving the school, he belonged to a radical left-wing sect. While hopping from job to job, he continued with his political activity in the two adjacent prefectures of Hiroshima and Yamaguchi. In the 1970s, when domestic strife among the radical left-wing sects was intensifying, he withdrew from the forefront of political activity. As a citizen he started to direct his efforts toward the reconstruction of social reforms under the influence of Yoshimoto Takaaki, a leading thinker for the radical left wing of the time.

One day an acquaintance of his requested him to work for a special elderly nursing home in Hiroshima Prefecture. (A special elderly nursing home refers to a public institution meant for physically or mentally handicapped people aged sixty-five and over who require nursing around the clock. Among the residents of the home are many who are suffering from dementia.) Although Miyoshi was not particularly interested in the care of the elderly, he accepted the request. As he began to work for that special old people's home, he saw a world different from the one he had turned his back on because of his aversion to worldly things.

"The public has the idea that those living in an old people's home are piteous. And I was myself imbued with that idea, too. But I found it totally wrong." he said. "The residents of the home I worked for were living at their own pace, displaying their individuality to the full. For example, an eighty-four-year-old woman who came of a good family firmly believed a female staffer to be her own maid. And an old man would write a love letter in an admirably cursive hand and give it to a chief female staffer. Besides them, a former political activist made it a rule to read the newspaper of Aka-Hata (the Red Flag) on his bed all day long, although he was suffering from general paralysis. Seeing them, I thought that if we are to live the rest of our lives in so many different ways, we should live in our own ways from youth. I felt relieved at that thought. In the eyes of the public, I am the one who strayed from the ideal course. As I met the residents of the home, however, I learned to reconsider my life from a fresh angle. They taught me that there are no rails in our lives, and that we differ from one another in course and destination."

Miyoshi was rescued by the elderly people he was to rescue. While working for the home day after day, he was confronted with the realities of the care and medical treatment of the elderly. For example, there was no expression on the face of a woman from an old people's hospital, where she had been diapered and given intravenous drip injections with her hands tied. To encourage her to go to the toilet in the home, he shortened the feet of her bed. As a result, she became able to walk to the toilet by herself. On the other hand, a woman who had been on her feet in the home became unable to walk while she was hospitalized for an examination of her disease. After a week's stay in the hospital she returned to the home, confined to a wheelchair. Even unable to answer the call of nature, she was diapered.

Such cases shook his belief in hospitals as a group of reliable experts. He observed as follows, "To encourage a bedridden person to find his feet, it is necessary to cut short the feet of his bed so that his feet can reach the floor. If his feet can reach the floor, he will become able to get up on his feet. And if he can walk to the toilet, he will become able to answer the call of nature again. In the meantime his eyes will start to shine as before. Technical books cover none of the things we, the staff of the home, are going through. I've found that the key to the care of the elderly lies in our daily experience."

When Miyoshi was twenty-eight, he entered Kyushu Rehabilitation College, where he studied for three years. After obtaining a physical therapist's license, he returned to the home. It worried him that conventional stoical rehabilitation was not as effective as expected. Before long he devised a new rehabilitation method adopting the idea of play or a game. As he applied the new rehabilitation to the people of the home, he found that it was considerably instrumental in animating them.

While undergoing such trial and error in the home, he came to realize where his strength lay, that is, what kind of work to do. And at the same time he determined to seek a new way of caring for the elderly while reconsidering the significance and methods of conventional care.

In 1985 he left the special old people's home and founded, in Tokyo, the Research Institute of Life and Rehabilitation. He devoted himself to publishing books about elderly-care and to giving lectures to the staff of old people's homes throughout the country. His books and lectures, which were based upon his own experience with elderly-care, were so lucid that they won the enthusiastic support of those working for the elderly. He also established the "Society to Remove Diapers," which is aimed to encourage the bedridden to go to the toilet instead of depending on diapers, and the "Society to Remove Tubes," which is intended to prompt the bedridden to eat food instead of getting injections of nourishment through tubes. (Actually, the members of each society meet together to learn how to achieve their purpose.) Through these unique activities he has gradually pushed his way to the position of a world opinion leader on elderly-care.

The main reason for his rise to such a preeminent place is that he has brought an exhaustively concrete and practical approach to the care of the elderly while respecting their situation. However, there is another reason for that, too. It is that he has given considerable thought to the meaning of elderly-care. "Whoever is engaged in the care of the elderly can be a philosopher more or less. It is the zest of this job," he said. "While I was caring for a man suffering from senile dementia, I wondered for what he was living. I asked myself the meaning of my involvement in his life. And I pondered over the meaning of his life. Such thought and philosophy are essential for elderly-care just as a concrete methodology is."

Regarding philosophy, Miyoshi has adored Yoshimoto Takaaki since his school days. In addition, Miyoshi has learned a lot from French structuralist philosophers, such as Michel Foucault and Claude Levi-Strauss. "As I read 'The Savage Mind' written by Levi-Strauss, I was impressed by primitive people's ways of thinking and production, which seemed to have much to do with the world of elderly-care," he said. "In the book Levi-Strauss said that primitive people's methods of doing things, which was called Bricolage, could be art, not science. On the night when I read that book of the modern philosopher's, I was excited, feeling that modern thought overlapped my way of caring for the elderly. I was wide awake all the night through."

As a matter of fact, Miyoshi's lucid idea of elderly-care is gradually exerting an influence not only on the world of welfare but also on its surrounding areas, including the worlds of philosophy and literature.

An active man, Miyoshi has given a lecture more than 170 times a year for the past several years. There is good reason for his great popularity as a lecturer. It is that he is a master storyteller. Although stories of the care of the elderly tend to be gloomy, he tells them very humorously, quoting surprising behavior of those suffering from senile dementia. As often as not, he moves the audience to laughter as if he were rakugo-ka (a professional raconteur who is supposed to make the audience laugh). His words are easy, even for the laughing audience, to understand. It is not merely because he has the gift of the gab. Behind it is also the fact that he has thought over the method of communication while taking care of the demented elderly, who are hard to communicate with.

He delivers his lectures in the belief that dementia is not a brain disease but relationship trouble. And the point of his lectures lies in the explanation of the care of the elderly suffering from dementia. He said to the audience as follows, "Dementia is trouble with relationships with society, family, and oneself. This means that there are at least as many cures as the cases of dementia. We should help each patient establish relationships with people he can accept. This is an essential part of the care of the sufferers from dementia.

"For example, a former geisha aged eighty began to treat her visiting helper as a thief. This was a delusion of persecution typical of senile dementia. How do you think the helper should cope with it?"

After having had the audience think it over for a while, he resumed the story as follows, "As the helper finished doing domestic chores for the old woman, she learned from this former geisha ko-uta (Japanese ballads) and dodoitsu (Japanese ditties), which were in her line. As a result, the woman was cured of her delusion. Why? Well, she was such an independent woman that she felt uneasy about being cared for by the helper. To wipe out her guilty feelings toward the helper, the woman had to have the delusion that the helper stole things from her. However, as she began to teach the helper ko-uta and dodoitsu, they got to depend on each other. Then the woman was relieved of her mental anguish. And she was also freed of her delusion of persecution." Hearing this, the audience gave an exclamation of surprise.

His lectures are not limited to these kinds of stories, though. Otherwise it would not attract as many as 70,000 professional carers of the elderly a year. His audience is daily confronted with the difficulty of taking care of the elderly, They feel sympathy toward his lecture because it is based upon realities familiar to them.

His audience wonders, for example, how to bathe the elderly who refuse to take a bath, how to keep the elderly from constipation, or how to bed down those who are chattering in the corridor because they cannot go to sleep because of anxiety. He is ready to help them solve these vulgar but pressing problems. Regarding their questions related to these kinds of problems, he answered as follows, "Even those who seem to be reluctant to take a bath actually want to do so. However, keep in mind that they do want to make believe they are forced to take a bath. And as for the means of keeping the elderly from constipation, it is of great importance to have them sit on toilet stools after breakfast. I have seem quite a few cases in which those cured of constipation got to refrain from problem behavior."

Miyoshi's words were that concrete and convincing. His audience could apply his advice to their work from the next day on.

"I give a course of lectures not for the purpose of enlightening the participants by conveying my knowledge to them," he said. "I want to deliver the kind of lecture in which I can recount the process I have gone through. I would like the participant to understand what is behind my thought or methodology, I make it a rule to stick to what I experienced or felt while tending the elderly, And I put such experience or feeling into words. The world of elderly-care is quite a new world without a manual. Having nothing to rely on, I should verbalize my own experience. The participants do not have to imitate my ways. They should just experience for themselves what I have undergone."

While viewing dementia as trouble with human relationships, Miyoshi also thinks that dementia is representative of a ruined modern self on the way back to nature. Civil society, which is founded upon independent individuals, is not good at dealing with the elderly suffering from dementia, or nature in the form of human beings. Doctors and carers try to rehabilitate them while administering medicine. Miyoshi says, however, that such doctors and carers are utterly wrong.

He has a habit of saying, "Whoever turns eighty is a living Buddha." According to him, elderly-care is meant not to improve their lives but to help them enjoy their present lives as much as possible. He is aware that there is something Japanese about such an idea of elderly-care.

In his book Rojin Kaigo Joshiki no Ayamari (Mistakes about Common Knowledge of Elderly-care) he observed as follows, "Viewed from the standpoint of modern individualism, one's relationship with himself is independent of society and his family. Consequently, even if society and his family give him the cold shoulder, he should remain himself.

"Among the Japanese, however, are very few with such strong selves. Particularly, the elderly seem to have a tendency to identify themselves with society and family This lays the Japanese open to the criticism that they are immature as individuals. I think, though, that Japan just has a culture different from any other country.

"Japan has a unique culture of the elderly. The elderly of Japan have ways befitting their age. Such ways were born of the culture of mutual dependence, which tolerates those not able to stand by themselves."

The care of the elderly is an urgent problem in Japan. It is not simply that Japanese society is aging. The main reason is the collapse of the Japanese families' long-standing custom to take care of their old folks in the wake of an increase in the population of those imbued with an individualistic education since the end of the Second World War. People who maintain their selves and have the power of self-determination dismiss sufferers from senile dementia, or those whose selves have been ruined, as aliens. However, a day may come when these individualists themselves will fall victim to dementia and be estranged from others. There is a possibility that the individualists, who place confidence in themselves, will undergo the severest relationship trouble. In other words, it is possible that the number of piteous senile-dementia victims will be further on the increase in the future. Miyoshi seems to suggest that we change our ideas of dementia and the elderly before the situation becomes that serious.

Although we tend to be pessimistic about the care of the elderly, Miyoshi sees in it something encouraging. Among the professional carers of the elderly are young people. At first sight they appear as if they are not Japanese. They dye their black hair brown. And they have their ears and other regions of the body pierced to wear rings. When it comes to work, however, they are very eager to help the elderly, trying hard to communicate with them. Miyoshi has often seen them tearfully weep over the death of those they had taken care of. "Young people of today have no illusions about 'modernity,"' he said. "Since birth they have taken for granted the existence of nuclear families, individualism, and the self-responsibility principle. To them 'modernity' is rather a burden. They have a strong yearning for, say, the extended family system of old Japan. Because they are free from the illusions about modern things, such as independence and individualism, they have no difficulty entering into the hearts of the elderly. This is encouraging. Most of these young people read none of my books, though."

It is three decades since Miyoshi entered into the world of elderly-care. This old hand is closely examining the issues surrounding it. Among these issues is death. In his lecture he says, in gentle tones, that he once caused an elderly person to die because of his own misjudgment. And apart from that case, he has attended the deathbed of quite a few elderly people.

He seems to see something dangerous about the perception of death in today's Japan. "Concerning Japan's dispatch of the Self-Defense Force troops to Iraq, Prime Minister Koizumi said, 'If an SDF official should die in Iraq, it would be an honorable death.' But I think it ridiculous," he said. "Death is a private matter. So the death of an SDF official should be above the evaluation of the government."

He also told of the death of an old man he had looked after in the old people's home many years ago. "He was such an ill-natured man that his funeral was attended by none of his family and acquaintances. At the time I thought that he met a miserable end. Now I think, though, that it may have been the most respectable death because it caused sorrow to none."

If dying unwept is the best form of death, what is the meaning of elderly-care, death or life? It will take Miyoshi some time to find an answer to that. It is certain, however, that he never forgets his ambition to establish collaboration new to Japanese society, This ambition will oblige him to frequently travel between the two worlds of elderly-care and modern philosophy.

Kobayashi Motoki