- Atsushi Asai, MD.
Department of General Medicine and Clinical Epidemiology
Kyoto University School of Medicine, Kyoto 606, JAPAN
(Email : firstname.lastname@example.org)
Patients and physicians have confronted many ethical dilemmas in Japan and more complete medical ethics education should be developed to cope with them. We have to be cautious, however, when adopting ethical guidelines and decision-making priorities utilized in Western countries and expert ethicists' opinions without critical deliberation. Accepting them as absolute norms would fail to resolve ethical problems deeply rooted in the idiosyncratic Japanese human relationship and value system. Traditional ethical attitudes in Japan should be also criticized because they have apparently failed to deal with present ethically difficult situations.
We have to, therefore, start our
consideration regarding appropriate medical ethics education by
asking the following questions: What is an ethical problem in
Japan, what kind of decision-making process should be used, and
what is ethically right in this country? We would obtain valid
answers only through recognition of present situation in this
In 1990s, researchers have conducted several clinical studies about ethical issues in Japan. These demonstrated that we have many unresolved ethical dilemmas with regard to issues like truth telling, informed consent, medical decisions concerning the end of life, and the physician-patient relationship. Under these circumstances, advocates and educators of biomedical ethics have emphasized the significance and importance of new medical ethics education in medical schools and postgraduate residency programs (1,2). Undoubtedly, current situations of medical care in Japan requires us to develop more comprehensive and practical medical ethics education for students and physicians to help them make clinical decisions in favor of the best interest of patients.
There are, however, many questions
to be answered before we begin to build teaching formats and systems
of medical ethics education in Japan. Such education can be stereotypic,
useless, and sometimes harmful unless these unanswered questions
are considered. In this brief essay, I would discuss potential
questions and propose how to think through them. First, what
is an ethical problem in Japan and who should decide it? Second,
what kind of decision-making process is suitable and what decision-making
priority we should follow? Third, what is an ethically appropriate
answer for controversial ethical judgment?
2. Unanswered questions of medical ethics education
What is an ethical problem in Japan?
We have to start our analysis by
asking a very primitive question: What is an ethical problem in
Japan? This question may include how to define an "ethical
problem" and who should do so. In Western countries, definitions
have been developed and many ethical dilemmas have been identified
and discussed (3-6). On the other hand, there is no universally
accepted definition of an "ethical problem" in a clinical
setting in Japan. Many would agree that disclosure of a diagnosis
of cancer to a patient and euthanasia involves ethical issues.
However, is discontinuation of artificial food and hydration
(AFH) of patients with persistent vegetative state (PVS) an ethical
problem, or is it problematic for physicians to undertake computed
tomography for a patient with tension headache solely because
of request of the patient to do so? Is receiving a gift or money
from a grateful patient regarded an ethical problem in Japan?
Among the problems being discussed in Western countries as ethical
ones, there might be some that are not regarded as ethical problems
or actually are not ethical problems in Japan. Some Japanese
would find no room to think or discuss about the ethical implications
of discontinuation of patients with PVS because it is nothing
but a brutal murder, and others might think that a patient with
PVS is no longer human and there is no reason to support their
life. Some also would argue that a gift from patient is just
a matter of custom and no one may have problems. A prolonged
hospitalization based on "social" indications rather
than medical ones might also be good example in Japan. Some would
point out problems of resource allocation and others find it acceptable
and no problem in Japan. Given there is no consensus in this
regard, what problems should be educated as ethical ones to medical
students or physicians? It should be also noted that there may
be some ethical dilemmas that western ethical thinking fails to
identify. Furthermore, who should decide what is ethical problems
may be a more serious problem in a country where its structured
paternalism of the society is built upon the idea that only the
view of so-called experts should be heard (7). If so-called authorities
including physicians, nurses, and ethicists decide and select
what an ethical problem to teach is , such selection could be
highly biased and fail to represent "ordinary" Japanese
whose best interest is the final goal of medical ethics education.
Preferred decision-making process and priority
The second question is whether both Japanese physicians and patients prefer medical decisions that rely on universal prescriptive ethical guidelines or on case-by-case basis. Although no published data is available, my overriding impression is that some Japanese physicians, even young residents under training, prefer case-by-case medical decisions relying on physicians' professional discretion rather than universal guidelines. I am unaware of any study on Japanese patients in this matter. It is certain that there are merits and demerits in both type of decision-making. Medical decisions that rely on prescriptive ethics guidelines may become too rigid to deal with subtle personal issues and exceptional situations. The reality could be so complicated that any guidelines might fail to help decision-making. The process of developing such guidelines per se should be questioned in terms of fairness and generalizability. The validity of them should also be challenged. On the other hand, excessive emphasis on case-by-case decisions may be followed by arbitrary judgment biased by emotion and personal fear and desire. It is unlikely that physicians involved in individual patient care can make rational decisions free from emotional reaction. We also have to ask patients whether it is acceptable for them to have utterly different medical care even in totally identical situations beaches of idiosyncratic physicians' belief. If a physician made a decision solely on personal opinion, any consistency and standard would be lost. Diverse attitudes and actual practice of physicians toward truth telling and terminal care have provided good examples. Medical care each patient has can depend on chance. However, it might be acceptable if Japanese patients do not think it problematic and regarded medical decision as a matter of human relationships between an individual patient and his or her physician.
We should also ask what kind of
decision-making priority should be applied. In the US, for example,
an adult competent patient's decision is by far highly prioritized
in almost all medical decisions and their advance directives and
family's decisions follow in the case when the patient becomes
incompetent (8). On the other hand, no explicit guidelines exist
in Japan. The traditional process usually prioritizes decisions
made by physicians or the patient's family rather than these of
patients when they have serious medical problems. A Japanese
physician argues that the majority of Japanese people are still
notably less individualistic than are most Westerners and the
personality of Japanese is not something that belongs to an individual,
but rather something which belongs to the family or society (9).
If this was true for every Japanese patient, the current decision-making
process might have no problems. If Japanese patients found no
problem when their physicians prioritize family preferences rather
than theirs, the decision-making priority established in Western
countries would be irreverent. The patient's decision should
be, however, prioritized if their self determination is regarded
to be the most important in Japan. Who should decide it?
What is ethically right in Japan?
A major purpose of ethics education is to facilitate people to think through ethical issues by themselves based on valid logic. Medical ethics, especially clinical ethics, in addition to facilitation of philosophical consideration, is supposed to help medical students and physicians make a decision-making in favor of the best interest of patients. In this purpose, medical ethics education used in clinical settings is required to provide them with some kind of "right" answers. In a clinical setting, physicians and patients have to make a choice in relatively short time even though they are uncertain that such choice is exclusively ethically right among alternatives.
In Holland and Northern Territory in Australia, physician-assisted-death is acceptable. In the USA and UK, discontinuation of life support of patients with PVS has been supported by a majority of people and courts. AMA clearly declares that there is no distinction between withholding and withdrawing of life support and law supports it (10). At present, however, it seems that Japanese medicine does not have distinctive right answer and fair approach for many controversial ethical dilemmas. We have not concluded on the appropriateness of truth telling in the real clinical situations after decades of lengthy discussion yet. Discussion regarding informed consent failed to build effective procedure in clinical setting. Intellectuals and experts in ethics have recently started discussing euthanasia and death with dignity, but it is doubtful that many physicians and patients are concerned with this agenda.
Even if discussion regarding what is ethically right becomes rigorous among expert ethicists or physicians and they reach the "ethically right" answers, it would not necessarily mean that it is really right to every Japanese person. People have diverse opinions in bioethical issues, but such various attitudes might fail to attract attention and effect the conclusion because of structured paternalism and ostracism of this society (7, 9). In addition, unfortunately, there is insufficient evidence that what is ethically right in western bioethics and applied ethics guidelines are equally correct in our culture.
Given such circumstances, it is
very difficult to provide ethically correct answers when medical
education is given. For example, we cannot teach medical students
that there is no ethical distinction between withholding and withdrawing
of life support if a majority of Japanese patients judge that
withholding of life support is acceptable but withdrawing is murder.
3. How can we answer the unanswered problems ?
In the previous section, I discussed several potential questions in medical ethics education in Japan. I do not have immediate answers, but have same proposals in order to build useful medical ethics medication. First, we should abandon "ethical problems and its right answers" which rely on traditional beliefs of Japanese medicine, or predominant opinions made by expert ethicists and intellectuals, and even norms of western medical ethics to answer these questions. What is left in our hand to decide and what would give us fundamental evidence to decide what we teach medical ethics in Japan? I believe that reasonable patient's satisfaction, not patient self-determination per se, is the one and only thing that we can start from to answer these questions.
With the purpose to reveal patient's satisfaction, we must investigate whether patients are satisfied with current medical situations, and if they are not, we have to reveal what they want to change. We must not forget to ask them their desire to meet family's satisfaction even at the mercy of their own satisfaction because Japanese patients sometimes want to make the final decision in favor of their family. There are some other important questions to be asked: What role would Japanese patients want their physicians to play, friend, teacher, or guardian, or technician? Would they want their physicians to guess their wishes without explicit communication? Would they want their physicians to evaluate their capacity to endure the burden of bad news, and in that case, what patient's character would they want to be used?
It is also important to ask physicians and residents under training what ethical dilemmas they have and what they want to learn about ethical issues in clinical settings. We also ask them about their opinions to what extent they want their patients to be responsible for decisions made.
Neither a patient nor physician can be completely rational or responsible when they have a difficult problem, and relying on either one when we develop an educational program in ethics is problematic. Therefore, we have to ask both of them about what is ethically problematic, how to decide, and what is the correct answer for ethical problems.
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