Commentary on Asai et al.

- Todd S. Elwyn, J.D., M.D. Candidate

The University of Michigan Medical School
Fulbright Graduate Research Fellow, The University of Tokyo

Eubios Journal of Asian and International Bioethics 7 (1997), 165-6.

Relatively few physicians in Japan research and write about the ethical issues facing contemporary Japanese medicine. Accordingly, one is entitled to feel some excitement and anticipation upon finding this article, written by three Japanese physician-ethicists, describing research on the kinds and frequencies of ethical dilemmas commonly encountered by physicians in clinical settings in Japan. However, I have reservations with the design of the study and not all the results are relevant, which tends to obscure the study's very interesting findings.

To investigate the ethical dilemmas occurring in the general medical ward at Kyoto University Hospital, the researchers divided their project into two phases. In Phase 1, they conducted a chart review of patients seen over an 11 month period, and recorded all ethical dilemmas noted by the attending physician for each of the 61 patients treated, including the number of ethical problems per patient, the types of problems, and patient demographics. During Phase 2, the researchers spent 6 months questioning physicians in detail during the daily morning report about ethical dilemmas they were currently experiencing with their patients. A description of these ethical dilemmas is included in the results section.

To the surprise of no one, when the researchers compared the frequency of ethical dilemmas in the two phases they found the "prospective case findings", i.e., where the physicians were interviewed during morning report in Phase 2, identified a significantly higher frequency of ethical dilemmas (p<0.05) than did the retrospective chart reviews. Intuitively one would expect to find a difference in frequency when two such different methods are used to measure the same variable, and indeed, the authors admit that the higher frequency found in Phase 2 is most likely due to the use of a methodology having a "higher sensitivity." Perhaps their findings were not influenced by the way in which they asked the questions about ethical dilemmas. It is therefore not so very useful to compare the results of these two phases, except to suggest: 1) that prospective case findings are more likely to identify ethical dilemmas than retrospective chart reviews and, 2) that attending physicians in Japan probably do not chart every ethical dilemma they encounter.

One would have liked to see more discussion of the quantitative data and results of statistical analysis in the discussion section. Actually it is very difficult to know what to do with some of the results. The study found that 28% of patients had ethical dilemmas reported in their charts. What does this mean? Undoubtedly there exists no similar data from studies done in Japan or the rest of the world which might be useful in making comparisons. Two of the more interesting statistical findings-- that patients with a malignant disease had more ethical dilemmas than those without, and that patients who died had more ethical dilemmas than those who lived-- deserved discussion.

Instead, the authors devote most of the discussion section to commenting on the results obtained upon oral interview, the "qualitative" results. One cannot really object to this since the qualitative results are the most interesting part of the study. These data provide the reader with a window into the front lines of clinical medicine in Japan, where physicians regularly confront a variety of ethical dilemmas. Particularly interesting are the descriptions of how the family enters into the physician-patient relationship and modifies the decision-making algorithm. We read of a physician performing CPR on a dying patient since the family could not accept the death, despite a previous agreement with the family not to resuscitate; a mother who refuses to allow her child to undergo a needed psychiatric exam perhaps for fear of social stigma; physicians telling a patient he has cancer only because no competent family is available to tell in his place. Many of these dilemmas could be expanded into interesting case studies for a casebook on ethics in Japan, in the past few issues they have raised some case studies. The authors do not attempt to conclude whether these practices are ethically proper and, indeed, it is not needed, for the reader is stimulated by the descriptions and invited to contemplate for him or herself whether, in light of the circumstances, the act is appropriate or not.

One final quibble with this study is that the authors do not carefully distinguish that this study is an examination of the clinical ethical dilemmas in Japanese medicine as perceived by physicians themselves. It does not necessarily describe the range of ethical dilemmas which occur in patient care and one might get a very different view if one asked patients, nurses, family members, or others. This is a study of physicians' experiences conducted by physicians. The treating physicians primarily get to determine what constitutes an "ethical dilemma" (although the authors also include those "problems which are recognized as controversial in Japan", presumably whether or not physicians raise them) and in essence these dilemmas seem to be instances where the opinion of the doctor conflicted with the opinion of the patient or of the family. Perhaps we could more deeply examine the issue of ethical dilemmas more broadly to make efforts at triangulation during Phase 2, by inviting the opinions of others such as nurses or lay persons.

Upon reading this study one comes to conclude that the researchers should have stuck with using one research methodology, in this case, a qualitative one. While qualitative studies in the field of medicine may not have historically been as highly regarded as quantitative ones, they now have assumed important roles in exploring the dimensions of an issue and seem particularly well-suited for this study. The inclusion of some basic statistics, such as a breakdown of the frequency of the various dilemmas physicians feel they face, could be retained to give the reader some feel for the relative proportion of these dilemmas in clinical practice. But the spotlight should shine on the stories themselves and not on less (or un)important statistical comparisons. Ultimately these tales are what make this study worth reading.

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