Yasuhiro Kadooka

Reexamination of the Ethics of Placebo Use in Clinical Practice

A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth-telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision-making and mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient-provider relationships, the publics trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception.

ARGUMENTS AGAINST PROMOTING ORGAN TRANSPLANTS FROM BRAIN-DEAD DONORS, AND VIEWS OF CONTEMPORARY JAPANESE ON LIFE AND DEATH

As of 2009, the number of donors in Japan is the lowest among developed countries. On July 13, 2009, Japans Organ Transplant Law was revised for the first time in 12 years. The revised and old laws differ greatly on four primary points: the definition of death, age requirements for donors, requirements for brain-death determination and organ extraction, and the appropriateness of priority transplants for relatives. In the four months of deliberations in the National Diet before the new law was established, various arguments regarding brain death and organ transplantation were offered. An amazing variety of opinions continue to be offered, even after more than 40 years have elapsed since the first heart organ transplant in Japan. Some are of the opinion that with the passage of the revised law, Japan will finally become capable of performing transplants according to global standards. Contrarily, there are assertions that organ transplants from brain-dead donors are unacceptable because they result in organs being taken from living human beings. Considering the current conditions, we will organize and introduce the arguments for and against organ transplants from brain-dead donors in contemporary Japan. Subsequently, we will discuss the primary arguments against organ transplants from brain-dead donors from the perspective of contemporary Japanese views on life and death. After introducing the recent view that brain death should not be regarded as equivalent to the death of a human being, we would like to probe the deeply-rooted views on life and death upon which it is based.

Can physicians’ judgments of futility be accepted by patients?: A comparative survey of Japanese physicians and laypeople

Back groundEmpirical surveys about medical futility are scarce relative to its theoretical assumptions. We aimed to evaluate the difference of attitudes between laypeople and physicians towards the issue.MethodsA questionnaire survey was designed. Japanese laypeople (via Internet) and physicians with various specialties (via paper-and-pencil questionnaire) were asked about whether they would provide potentially futile treatments for end-of-life patients in vignettes, important factors for judging a certain treatment futile, and threshold of quantitative futility which reflects the numerical probability that an act will produce the desired physiological effect. Also, the physicians were asked about their practical frequency and important reasons for futile treatments.Results1134 laypeople and 401 (80%) physicians responded. In all vignettes, the laypeople were more affirmative in providing treatments in question significantly. As the factors for judging futility, medical information and quality of life (QOL) of the patient were rather stressed by the physicians. Treatment wish of the family of the patient and psychological impact on patient side due to the treatment were rather stressed by laypeople. There were wide variations in the threshold of judging quantitative futility in both groups. 88.3% of the physicians had practical experience of providing futile treatment. Important reasons for it were communication problem with patient side and lack of systems regarding futility or foregoing such treatment.ConclusionLaypeople are more supportive of providing potentially futile treatments than physicians. The difference is explained by the importance of medical information, the patient family’s influence to decision-making and QOL of the patient. The threshold of qualitative futility is suggested to be arbitrary.

A comparative survey on potentially futile treatments between Japanese nurses and laypeople

In the issue of futile treatments, patients and healthcare professionals tend to disagree. We conducted an Internet questionnaire survey and explored the Japanese nurses’ attitude toward this topic, comparing with that of laypeople. In total, 522 nurses and 1134 laypeople completed the questionnaire. Nurse respondents were significantly less in favor of providing potentially futile treatments in hypothetical vignettes and stressed quality of life of the patient for judging the futility of a certain treatment. Of them, 85.4% reported having experienced providing such treatments. Reasons for providing them included factors related to not only patients but also healthcare teams. Our results indicate that attitudes among Japanese nurses toward the issue of futile treatments are different from patients and that their actual practice is influenced by several situational factors.

Matters to address prior to introducing new life support technology in Japan: three serious ethical concerns related to the use of left ventricular assist devices as destination therapy and suggested policies to deal with them

BackgroundDestination therapy (DT) is the permanent implantation of a left ventricular assist device (LVAD) in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering.Main textWestern ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment.ConclusionThere is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation.

Misuse of emergent healthcare in contemporary Japan

BackgroundMedical care is obviously an important public service to ensure the health of a nation; however, medical resources are not always used appropriately. ‘Convenience-store consultations’ and inappropriate ambulance transportation represent instances of such improper use by contemporary Japanese citizens in recent years. This article illustrates two examples of misuse and discusses potential countermeasures by considering factors contributing to these behaviours.Main bodyFrom both public and medical perspectives, these patient behaviours are problematic, causing potential harm to others, negative consequences to such patients themselves, exhaustion of healthcare staff, and breakdown of emergency medical services. Although citizens need to recognize the public nature and scarcity of medical care, the more immediate need may be to identify and to remove personal and social causes inducing such misuse. In addition, healthcare professionals should become more trustworthy. To combat these issues, one-sided penalties such as accusations or sanctions for patients who misuse the system cannot be justified in principle. If measures taken to prevent misuse are ineffective, imposing surcharges or restricting consultations may be considered official policy, but these are not acceptable for several reasons.ConclusionFor now, we conclude that we must rely on the spontaneous motivation of patients who engage in ‘convenience-store consultations’ and ambulance transportation instead of taking a taxi.

Comparison of ethical judgments exhibited by clients and ethics consultants in Japan

BackgroundHealthcare professionals must make decisions for patients based on ethical considerations. However, they rely on clinical ethics consultations (CEC) to review ethical justifications of their decisions. CEC consultants support the cases reviewed and guide medical care. When both healthcare professionals and CEC consultants face ethical problems in medical care, how is their judgment derived? How do medical judgments differ from the ethical considerations of CECs? This study examines CECs in Japan to identify differences in the ethical judgment of clients and CEC consultants.MethodsThe CEC request and response documents of all 60 cases reviewed across Japan between October 2006 and the end of October 2011 were classified in terms of the presence of decisional capacity in the patient. We conducted a qualitative content analysis of the differences in reasoning between client and CEC consultants. Reasoned judgments were verified in individual cases to classify the similarities or differences of opinion between CEC clients and teams.ResultsAs the result of classification of the decisional capacity and the difference of opinion regarding medical care, the most frequent category was 25 cases (41.7%) of “uncertain decisional capacity,” and 23 cases (38.3%) of “withholding of decision-making.” A chi-square analysis was performed on presence of decisional capacity and agreement in decision-making, yielding a statistically significant difference (p < 0.05). The CEC consultants’ reasoning was based on “patient’s preference was ambiguous,” “validity of family as a surrogate,” “estimation of patient preference,” and “patient’s best interest,” whereas the CEC client’s reasoning was based on “consistent family preference was shown/not shown” and “appropriate therapeutic methods to manage patient safety.”ConclusionDifferences in opinions were found in cases classified according to decisional capacity. Furthermore, the reasoning behind judgments differed between CEC clients and CEC consultants. The reasoning of CEC consultants was critical and reflective, while for clients it was situational and pragmatic.

Ethical reflections on the thoughts and lives of Kurosawa's doctors

The year 2010 marked the centenary of the birth of Akira Kurosawa (1910–1998), whose works have been reassessed favourably in the last couple of years in Japan. During his lifetime, Kurosawa directed and produced three films whose chief characters are medical doctors: Drunken Angel (1948), The Quiet Duel (1949) and Red Beard (1965). This paper discusses these three films and examines the thoughts and lives of the three protagonists from the perspective of modern medical ethics. The films depict contemporary ethical and social problems, and deal with paternalism, a healthy professional life and the proper place for human reason in medicine, all of which still give rise to debate in modern medical settings. They are very impressive in their portrayal of extreme paternalism, excessively professional lives and disproportionate reliance on rationality. The doctors are role models in certain situations and are examples of how not to behave in other situations. On the one hand, they are devoted to helping their patients, with their self-sacrifice firmly based on humanity and medical ethics. On the other hand, they perform unwelcome favours and are unhealthy role models who might harm others through narrow-minded attitudes about human beings, a fixed view of life and inflexible ideas about medicine. In this sense, they can be regarded as a rather mixed blessing. These films provide us with an opportunity to simultaneously recognise the importance of modern ethical principles and the significance of ‘old’ ethical values.