SUMMARY OF THE REPORT ON INFORMATION FROM DOCTORS AND CONSENT OF PATIENTS

Japan Medical Association

1991

In 1951, the Japan Medical Association (JMA) issued a Physician's Code of Ethics, which is of historic interest for its emphasis on the Confucian concept of jin, "loving kindness," in the practice of medicine. Medicine is considered a jin-jyutsu, "humanitarian art." Traditionally, in Japanese medical practice, the combination of jin with the concept of shinrai-kankei, "fiduciary relationship," which is a positive value between people, correlated with a tendency for patients to trust and adhere to professional advice without question and a predilection toward medical paternalism. Since the 1960s, a gradual trend has emerged in Japan toward reassessing the nature of the patient–physician relationship. Exposure to contemporary Western bioethics and greater recognition of patients' rights is reflected in a movement among Japanese medical professionals to redefine the formerly paternalistic fiduciary relationship in light of a new emphasis on shared information and decision making with their patients. Although the JMA has never technically rescinded its 1951 code, the code has been superseded in practice by more recent documents from the JMA Bioethics Council that reflect the trend away from medical paternalism. One such document is the 1991 Summary of the Report on Information from Doctors and Consent of Patients, which follows.

• 1. The Definition of Informed Consent
  In strict terms, informed consent refers to the system of determining of the selection of medical procedures, which is carried out once the physician, as obliged, provides the patient with thorough explanations regarding feasible procedures within the course of medical treatment activities.
  Informed consent is a concept which originated in U.S.A. as the principal statement of the rights of a patient and came to incorporate a specific content as a result of courtroom judicial precedents and so forth in connection with mishaps during medical treatment.
  It would seem necessary in the case of Japan, however, to examine its content independently and thereupon, with the opportunity offered by the informed consent, proceed with the structuring of a new relationship between physician and patient in the context of medical treatment.
• 2. The Relationship between the Physician's Explanation and Patient's Consent
  As a general rule, the patient's consent is obtained on the occasion of direct or indirect invasions of the patient's body; carrying out such invasions without consent could, legally speaking, entail the possible occurrence of problems of the criminal infliction of bodily harm or those of civil justice involving injury compensation.
  Thus, the consent of the patient is premised on explanations by the physician; the physician must provide thorough explanations to the patient necessary to allow the patient to make judgments or selections.
• 3. The Current Meaning of Informed Consent
  In Japan up to the present, there has been a tendency on the part of the patient to leave everything up to the physician. However, more and more we are seeing an increase in the comprehension of patients relating to medical treatments, changes in the structure of present-day illnesses, together with subdivision and specialization taking place in treatment methods, resulting in an increased emphasis on the frank and open interaction between physician and patient. There has also been a deeper concern for the problem of informed consent.
  At this point, instead of simply adopting the American style of informed consent intact, it is more reasonable that we should embrace one which is relevant to our own society, one which sufficiently takes into account the sentiments of the people, the history of medical treatment, cultural background, the character of the nation and so forth.
• 4. Specific Content of Informed Consent and Its Configuration

THE PHYSICIAN'S EXPLANATION AND THE PATIENT'S CONSENT

The physician's explanations to the patient must be expressed in words which are easily understood, allowing effortless comprehension by the patient, with the minimum use of specialized terminology.

The patient's consent indicates that the patient has comprehended, is satisfied with and consents to the procedures which the physician proposes to take.

• 5. The Physician's Obligation to Explain and Its Limits
  Explanations within the limits indicated below can be considered necessary under normal circumstances:
• 1. The disease name and its present condition>
• 2. Proposed treatment methods for the disease
• 3. The degree of risk involved in such treatment methods (the presence and extent of risk)
• 4. Other possible choices of treatment methods and their relative advantages and disadvantages.
• 5. Prognosis, that is, future assumptions relating to the patient's illness Emergencies or cases in which the patient does not have the capacity to make judgments him or herself regarding consent after having been given explanations can be cited as exceptions to the general rule.

Cases in which the patient does not have the capacity to make judgments regarding consent after having been given explanations require that explanations be provided to the most appropriate next of kin and the patient's consent received by proxy. However, since the procedures in question are directed specifically to the patient, the inclinations of the patient should be taken into consideration when it is recognized that the patient does have judgmental capacity, though it may be impaired.

• 6. Informed Consent in Routine Diagnoses and Treatment
• (1) Notification of Cancer
  The following should be given thorough consideration as prior conditions upon the notification of cancer:
• 1. The purpose of notification must be explicit.
• 2. The family of the patient must be receptive.
• 3. Physician or others in the practice of medicine must have a satisfactory relationship with the family of the patient.
• 4. Mental care and support of the patient must be possible subsequent to notification.
• (2) Living Wills
• When a patient in terminal treatment has prepared a living will in advance and there is no hope of recovery, it is considered reasonable to respect the wishes of the patient not to engage in life-prolonging procedures, when such have been clearly stated.
• (3) Others
• If there is a necessity for blood transfusions in a patient who refuses such for religious reasons, the patient should be persuaded and then consent for transfusions obtained. However, if the patient persistently refuses, the will of the patient should be respected even though the outcome of not doing so would be disadvantageous to the patient. In such cases, it is considered that the physician does not assume any legal liability.
  When the patient is a child, transfusions given contrary to the will of the parent can be considered permissible, even though the parent, as a follower of a religion, has refused such, since the child and the child's parents are fundamentally separate beings.
• 7. Informed Consent in Medical and Treatment Education
  It cannot be denied that concern regarding informed consent among young physicians is lacking. It is of extreme importance that instruction regarding informed consent be promoted in the future both prior to graduation and thereafter through continuing education.