Commentary on Asai

- Prof. Susan O. Long

Department of Sociology
John Carroll University, University Hts., Ohio 44118, U.S.A.

Currently in Japan: c/o International House, Osaka University, Machikaneyama-cho 1-18, Toyonaka-shi, Osaka 560

Eubios Journal of Asian and International Bioethics 6 (1996), 93.

Returning from studying bioethics in the United States for two years, Dr. Asai is struck by cultural differences between the US and Japan which limit the applicability of informed consent in Japanese clinical practice. In particular, he notes the historical absence of a concept of personal autonomy, the current rejection of attempts to establish legal standards of informed consent, and cultural differences in family and in doctor-patient relationships. He begins by expressing concern for Japanese medicine: "And why do some patients never complain about their physicians, who virtually ignore a basic ethical principle from which all might benefit?" But later in the article, he comes to question, although still from within a bioethics framework, whether insisting that all patients have full knowledge of their disease is not also a violation of some patients' right to choose autonomously. He thus raises the question of whether bioethical principles have cross-cultural validity. This question is a difficult one. Ishiwata and Sakai have argued that paternalism is inappropriate for contemporary Japan for both physicians and patients. Doctors, they believe, can no longer take full responsibility for complex choices. Patients need information to be active participants in the decision making process. They urge a reconsideration of "what is the 'natural' behavior... in the modern setting," a setting which includes human rights concerns and malpractice lawsuits as part of the cultural landscape (Ishiwata & Sakai 1994). Yet I would agree with Dr. Asai that the cross-cultural validity of bioethical principles cannot be assumed. American bioethical theory has developed out of Western philosophical and Judeo-Christian religious traditions and is a product of late 20th century America.

In taking principles such as justice and autonomy from this context, we need to ask empirically not if there is a Japanese equivalent, but how such concepts are understood, not understood, and differently understood not only between the US and Japan, but within Japan as well. Dr. Asai has asked whether informed consent in Japan should perhaps not be called informed consent (p. 2, par. 1). What does it mean to Japanese patients and physicians? What is the history, however recent, of the term, and why is it referred to as "infamudokasento" rather than by a Sino-Japanese term?

Dr. Asai's article also raises the important issue of the gap between conceptual understanding and practical application. He points out that a number of surveys have suggested that Japanese patients do in fact want information about and participation in decisions about their medical care. Rather than seeing these value's as counter to Japanese culture, it may be useful to see them as in potential conflict with other deeply held beliefs, such as the importance of family relationships or of conflict avoidance. We need to consider how incompatible values are prioritized in specific situations, and how economic and political factors at the micro and macro levels influence this process. In short, explaining the gap between what people say and what they do will involve further analysis of complex relations among values, interpersonal relations, and the context of Japanese medical care delivery.

In a recent article, legal scholar Robert Laaflar (1996) agrees that cultural explanations for the current status of informed consent in Japan are more powerful than strictly economic or legal ones. He also stresses that Japanese society is undergoing significant changes that are affecting the beliefs and practices described by Dr. Asai and others, changes that are intertwined with the political and the economic changes.

The recent adoption of reimbursement for informed consent discussions in the insurance fee schedule can be expected to lead to greater consideration of "infamudokasento" and new cultural practices may develop as a result. Yet as I recently heard one Japanese physician say, "If it is done for money, is it really informed consent?" Questions of meaning and of political economy cannot be easily divorced.

References

Ishiwata, R and Sakai 1994 "The Physician-Patient Relationship and Medical Ethics in Japan" CQHE 3 (1994), 60-66.
Laflar, RB, "Informed Consent and Patients' Rights in Japan. Houston Law Review 33 (1996), 1-112.

Go to commentary by Morioka
Go back to EJAIB July 1996
Go back to EJAIB
The Eubios Ethics Institute is on the world wide web of Internet:
http://eubios.info/index.html