- Clinical Ethics Consultation in Japan:The University of Tokyo Model
The use of clinical ethics consultation (CEC) is expanding throughout the world. Across disparate countries and regions, medical practitioners struggle with ethical issues involving clashes of values and difficult diagnoses. These situations are challenging for clinicians, as well as patients and their families. Japan is no exception. This article discusses the history of CEC services in Japan and the characteristics of the University of Tokyo model, including the possibility of applying this model in other regions.
History of CEC Services in Japan
CEC services began to become available in Japan between the late 1980s and early 1990s. In 1982, the first ethics committee in Japan was created at the Faculty of Medicine, the University of Tokushima. This ethics committee functioned as both research ethics committee and hospital ethics committee (HEC). By 1992, all 80 medical school-affiliated hospitals throughout Japan had established similar ethics committees. By about 1995, the primary responsibility of these groups was the review of research protocols and the drafting of hospital policy; however, 18% were already providing CEC services for individual clinical cases. 1 Ethics committees were gradually established in general hospitals; according to a 1996 questionnaire survey of general hospitals with 300 or more beds (N = 1457), 24% had ethics committees, and 36% offered CEC services. 1 Thus, by the mid-1990s, both general hospitals and university hospitals were providing CEC services. We could call this the dawn of CEC in Japan. [End Page 283]
One factor driving the increase in CEC was the demand from clinical practice. In a 1996 survey, 72% of institutions indicated a need for CEC services, 1 and a 2005 survey of clinical training hospitals found that the number of facilities that needed this service had increased to 89%. 2 These figures demonstrate that Japan has the same CEC needs as countries such as the US and the UK, 3 and that demand for CEC services is rising in Japan. The need for a standing mechanism to address ethical issues in clinical practice is thus an important factor driving the establishment of ethics consultation services.
In addition to this internal demand for advice and support for ethical issues, other factors have also encouraged the development of CEC-providing systems. For example, the Guidelines for Terminal Stage Medical Care (2007) set forth by the Ministry of Health, Labor and Welfare mention the "establishment and support of a committee composed of experts that can provide advice" when it is not possible to reach a consensus on medical policymaking among caregivers, patients, and family members. In addition, the Japan Council for Quality Health Care, which is the Japanese version of The Joint Commission on the Accreditation of Healthcare Organizations, called for "clarification of policies on clinical ethics" in version 5 of its evaluation categories (July 2004) and "an investigative framework on clinical ethics" in version 6 (July 2009). Thus, external factors have also increased the need for CEC services at medical institutions.
However, despite this rise in CEC needs, a system for providing this service has not yet been fully realised. Although 89% of the facilities surveyed in 2005 2 indicated that CEC services were necessary, only 25% offered them. This finding suggests that the system for providing CEC has changed little since the 1996 survey was carried out. Although ethics committees were initially responsible for providing CEC services in Japan, as of 2005, hospital organisations were unable to accommodate the increasing demand.
It has been reported that clinical ethics committees responsible for providing CEC services are common in general hospitals, but these are isolated reports at individual facilities. As of 2011, no accurate statistical reports describe the extent to which CEC services are provided in Japan.
History of CEC Services at the University of Tokyo Hospital
The University of Tokyo Medical School established its ethics committee in 1985. At this time, the ethics committee possessed HEC functions, such as formulating hospital guidelines, in addition to research protocol review. The ethics committee was also active in clinical case consultation. For example, the [End Page 284] ethics committee handled cases in which patients refused blood transfusions...