Commentary on Asai

- Masahiro Morioka

International Research Center for Japanese Studies
3-2 Oeyama-cho, Goryo, Nishikyo-ku, Kyoto 610-11, JAPAN

Eubios Journal of Asian and International Bioethics 6 (1996), 94.
Atsushi Asai's paper "Barriers to Informed Consent in Japan" gives us a precise and up-to-date analysis on the practice of informed consent in contemporary Japan. As Asai states in his paper, the concept of informed consent was introduced to Japan a decade ago, and several recommendations have been published by official committees and citizen groups. Nevertheless, many physicians even now do not give their patients enough and adequate information and obtain voluntary consent in everyday clinical settings. As for truth telling to terminal cancer patients, almost 80% physicians withhold crucial information to their patients. This situation looks very similar to that of the US in the 1950s and 60s, which BG. Glaser and AL. Strauss vividly described in their classic Awareness of Dying (Aldine Pub, 1965).

Asai points out that barriers to informed consent reside not only in physicians but also in the family and the patient. I have the impression that many Japanese physicians have strong consideration and compassion to their patients especially when they rely on their doctors, but these sentiments sometimes lead the physicians to problematically paternalistic attitudes. And these attitudes easily create the one-sided power relationship between the physician and the patient. In many cases physicians are unconscious of the existence of this power relationship while patients know this one-sided power and flatter their doctors to protect their own future benefits.

Not a few Japanese physicians feel uneasy when hearing the words "patients' rights" and "informed consent" because they know that these concepts have potential power of destroying the one-sided power relationship in clinical settings, and that they may lose the paternal status that has provided them the authority to manage and control the patient-physician relationship.

However, one of the reasons that Japanese physicians have been keeping this kind of paternalistic attitudes in clinical practices, as Asai writes in his paper, is that the patient and the family themselves have been willing for their physician to be paternalistic, almighty to resolve every difficult situation with their professional hands only. In this sense, patients and/or the family leave their rights and the responsibility to their doctor, and as a reward, they get comfort and relief in the process of a battle with illness. This is a type of mutual accomplishment among physician, patient, and family.

Honestly speaking, I am very pessimistic. I cannot find anywhere where a breakthrough that may destroy this inadequate relationship can be made, which would lead us to a more individualistic society where everyone's life belongs to themselves, and where everyone freely expresses their own opinion and ideas in their workplace, home, and hospitals. For example, when I expressed my personal ideas and proposals openly in the staff meeting of our research institute, one of my bosses came to me afterwards and gave me a piece of warning saying that here is Japan, not the US. Even in a staff meeting it is very hard to express one's opinion and ideas freely in this country. How can it be possible to speak out in clinical settings before an "authoritative" physician?

But as Asai says in his paper, Japanese "attitudes toward authority and self-determination are gradually changing," hence I hope younger Japanese in the 21st century will change the situation step by step in the hospital and Japanese society as a whole. Then, the "shared decision making among a patient, physician, and family members" will be functioning well in this half-Asian, half-Western country.

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