"Washington-Japan Journal", 2-4, 1994. 3.

Bioethics and Japanese Health Care

The following is a text of a talk by Professor Kimura at The Japan-America Society of Washington, D.C. February 9, 1994.
Prof. Rihito Kimura wearing a smile

Prof. Rihito Kimura
About the author...

Professor Rihito kimura, originally a law professor, became interested in bioethics long before the word was coined. When he was a visiting professor of Asian Studies at Saigon University, Vietnam 1970-1972, a student came to his home and asked about Prof. Kimura's daily diet. After Prof. Kimura detailed his diet of fish, rice and tea, the student told him not to eat the fish or drink the water and, perhaps, he ought not eat the rice. Curious at this directive, Prof. Kimura asked why. The student showed him pictures of deformed infants and sick people who, he said, suffered from the results of the defoliant U.S. troops were using in the war. This "Agent Orange" was being washed into the river, contaminating the fish and into the ground, contaminating both the drinking water and the rice crops. Shorty after this event, Prof. Kimura said, the Japanese Embassy in Saigon issued a directive to Japanese in Vietnam not to eat the fish or drink the water. Japanese experts of fish genetics had discovered that the dioxin in the chemical affected the DNA structure of fish exposed to the dioxin. Medical ethics are required of physicians but bioethics has a wider scope, encompassing the doctor, the patient, the ecology and is an area of widening impact on everyone.

Today, Prof. Kimura divides his time between his position as Visiting Professor and Director, International Bioethics Project at the Kennedy Institute of Ethics, Georgetown University and as Professor of Bioethics and Law, Department of Health Science, School of Human Sciences, Waseda University in Tokyo. Prof. Kimura said bioethics is still not widely taught but Waseda has a two week mandatory course for freshmen and a full term mandatory course for upperclassmen. Prof. Kimura lectures to a full house of 300 students and, unlike many university level courses in Japan, he requires full participation by his students in the discussion of bioethics.

In October, our family had a very sad event because of the sudden death of my mother-in-law and we, all our family members in the States, went back to Japan for the funeral service. She was on the way to Sunday morning Church services when she had a heart attack at the bus station. Some passers-by called emergency for an ambulance, but despite the prompt attention, emergency treatment was carried out without hope of recovery.
My mother-in-law had always said that was they way she wanted to go on to the other world-- suddenly. In the U.S., the ambulance and emergency service given my mother-in-law might have been expensive but in Japan the total bill we received was only 1700 yen which is about $15 US. The fee for an ambulance is always paid by the local government. In her case, there were some additional benefits as she was a senior citizen and a fair amount of the hospital expenses were covered.
It is a well known fact that dying in Japan is usually a very expensive process and one of the most serious issues in the Japanese health care system is the large expenses at the end stages of illness. A great amount of medical resources are consumed in giving expensive medication and/or surgery along with intensive care services of the hospital personnel.
End-stage care is, of course, a good chance for many hospitals in Japan to make a profit.
This rather sad personal story represents my opening point. Japanese medical services are inexpensive and this feature is rather unusual and one of the positive elements of the Japanese health care system from the patient's and health consumer's point of view. Above all, our system covers all Japanese nationals and temporary official residents equally and provides access to any clinic or hospital wherever we live, whenever we need it, at a charge of only ten percent of the total medical fee for the Insured or thirty percent of the total medical fee for family members or those not covered by the National Health Insurance System. It is almost like socialized medicine in the otherwise industrialized, capitalistic society of Japan.
Why is this possible? Who pays? What kind of philosophy exists behind the unique system of Japanese health care? Is the system good? Who created it and what will happen to it in the future as we are faced with an enormous increase in the number of elderly in our population? In the 2025, only 31 years from now, those over the age of 65 will represent one-quarter of the total population. Is there any financial guarantee for medical and welfare services in Japan?
I think it would take almost a day-long seminar to answer these very important questions in detail. Due to time constraints, however, I will give you only a very brief analysis of these issues based on my, perhaps limited, experiences. I hope to provide what may be a unique insight by using the framework of bioethics to look at Japan's health care system.
My presentation has three parts. First, I will provide a quick look at the roots of the Japanese health care system very briefly. Secondly, I would like to invite you to take a hospital visit with me. Finally, I would like to assess the future of Japan's health care system in a global context.

The Roots of Japanese Health Care

What are the roots of Japanese health care? Originally, medicine in Japan was deeply rooted in Japanese soil, probably as early as the Jomon era, several thousand years ago. In the year 992 AD, rather recently compared to the Jomon era, one of the medical experts of that time, Dr. Yasuyori Tamba, presented the Emperor with 30 volumes of a medical encyclopedia known as Ishinpo that he had written. In his preface, he mentioned that the spirit of medicine comes from the great mercy of Buddha and the loving kindness of Confucian teaching. Since that time, medicine in Japan has been regarded as Jinzyutsu, or the Art of Jin.
From the Middle Ages to the End of the Yedo era, around 1860s, there was also a slight influence of Western medicine brought by Dutch officers who were allowed to stay on the small island of Deshima in Kyushuu, Southern Japan.
There are numerous medical documents and books written by Japanese Confucian physicians and some of them still have quite a number of readers thanks to modern Japanese editions. I had an opportunity to read some original copies of the Japanese classical medical books for the first time in my life -- in Washington, D.C. where they are kept at the Library of Congress. In Japan, it is almost impossible to have access to original copies of these very valuable books but in the U.S. both the National Library of Medicine and the Library of Congress allow public access to many books, including these rare editions.
A reprint of the Ishinpo, originally published in 992 was made by the Tokugawa government in the 1850s. This Ansei era edition is kept in the East Asia section of the Library of Congress in Washington, and one of the most well read and best-selling health education textbooks, Yojokun or Teaching of Health by Kaibara Ekiken and published in 1713, is located at the National Library of Medicine at Bethesda's National Institute of Health campus. It is fascinating and a bit ironic to read all kinds of Japanese and Chinese classical medical books here in Washington. In these texts, the Japanese physician's paternalistic attitude nurtured in our cultural context is clear. The traditional way of regarding the peoples' health as a state concern is particularly embedded in the process of modernization of Japan and its health care system.
A great influence on Japanese medicine came from Prussian Germany, as there was a strong tendency to look to and imitate what was best in the world in the middle of the 19th century as is the case at present. Many medical experts were trained in Germany and did excellent research of the highest academic standards -- some of the individuals enjoy an international reputation such as Kitasato, Shiga, Hata, Takamine, and so on. Some of the influence of German medicine are still apparent today in the Japanese medical system.
With increasing urbanization in Japan, tuberculosis became one of the most disabling diseases for many Japanese and the government's concern about the health of the Japanese population became serious. One of the most important driving factors behind the government's agenda for health was the demand for healthy young Japanese for recruitment as soldiers. As a matter of fact, the Koseisho (the Ministry of Health and Welfare, Japan) was established in 1938 for this reason to control and promote the good health of the Japanese to ensure a healthy fighting force.
On the other hand, the influence of socialized medicine also came into Japan and some unique movement to establish "medical cooperatives" was formed in the 1920s in urban areas such as Tokyo, Osaka, and Kobe etc. In the face of peoples' concern about health issues and the governmental need for health policy, the Health Insurance Law was enacted in 1922 just before the devastating Kanto Earthquake in 1923. There were also several thousand Health Insurance Associations formed before World War II. However, because of the disastrous quake and the continuing policy of expansion and waging war under the militaristic government, the National Health Insurance System did not become integrated until 1961. Since 1961, all Japanese should be covered by some health insurance system closely affiliated with the Government Health Insurance Policy.
Now, one of the most important shifts in cultural, political, economic and medical influence occurred during the Japanese Occupation by the Allied Forces. Drastic change was introduced particularly in the areas of health care, medical services and medical and nursing education. It may be that, without the enormous efforts and great contribution by U.S. public health officers under Brigadier General Sams, we Japanese would not even have the present system of Japanese Health Insurance.
As you may know, Japan's "Peace Constitution" was drafted by General Headquarters (GHQ) and Japan's Health Insurance System was also drafted by GHQ experts, many of them known as "New Dealers" who had fresh hope for new ideas which were to be applied to Japan. interestingly enough, some of the radical ideas such as "National Health Insurance" and a "Minimum Support System for the Poor" are currently causing quite a debate in U.S. Congress as the Clinton Health Care Plan is discussed.
Ironically, a heated discussion of this similar health policy went on in Japan around 47 years ago. During this discussion a group of delegates from the American Medical Association (AMA) even came to Japan to investigate the situation in Japan regarding coercion in the Japanese health plan. There was concern even then by the AMA that if bureaucrats in Japan were in charge of health care, it might also happen in the U.S., a precedent the AMA was more than likely reluctant to encourage.
The Occupation of Japan ended in 1951 and the Japanese bureaucracy, with its unique ability to "Japanize" everything, made a kind of amalgam, borrowing some ideas from health care in advanced countries such as Britain, Germany and the U.S. and using others derived from worldwide research comparing the pluses and minuses of various system. The result developed into a Japanese-style patchwork health care system with the resulting Japanese health care and its underlying system being a unique combination of many elements from various cultural roots in Asia, Europe and America. However, in this strange mixture of its system, the Japanese-ness remains as the keystone and that includes the belief in equal access to health care for everybody. (The World Health Organization's "Health for All in the year 2000" has been accomplished in Japan in a distorted way for many years.) Our history lesson finished, let us experience this equality of access principle first hand as it functions in our Japanese health Care institutions.

Let's Go to the Hospital

We Japanese have a tendency to go to the hospital even when we have only minor ailments such as the flu, headaches, or stomach aches. If medical expenses are not high and we do not feel well, then why not go see a doctor and get some medication. Let us see what happens when many people think that way.

The Waiting Room, With Emphasis on Waiting

The result, of course, is that waiting rooms of clinics and hospitals are full of people. Everyone is welcome and there are, in fact, regular customers. Sometimes elderly people come to see a friend and the hospital waiting room become as sort of salon. Actually, this phenomenon has happened in the specialized hospitals for the elderly. When I go to the hospital, I have to join the line to secure a consultation with a physician by picking up a numbered card or by putting my health care into the box at the reception desk. Then I have to wait to be called by name or number. There are very few hospitals which practice the "appointment" system. Waiting at least one hour is definite, according to a recent Kyodo News agency nationwide opinion poll taken in December 1993. The Poll reported that 5.2% of Those polled waited more than two hours to be seen while 60% of those polled waited between 30 minutes and two hours.

At Last - Seeing the Physician

Then we see a physician. Again, the poll found that 42% of patients polled saw a physician for about five minutes, while 25% reported only a two-to-three minute visit. These figures mean that 75% of those patients polled had a consultation with their physician of five minutes or less.
On the one hand, this five minute screening session weeds out the patients with minor problems who, after one trip with hours of waiting, will think twice or perhaps more before making a second journey to the hospital. The patient with serious problems, if he returns two or three times, will be referred to another physician for a closer look.
Physicians have an incentive to see as many patients as possible because the Japanese health care system provides no compensation for consultation time with a patient. Our system is "fee for service" and depends on a report of some medical treatment such as injection, technical exams such as CAT scans, X-rays, etc. and also on the provision of medication from a physician's or hospital's dispensary. After a few minutes of examination, the physician usually says to the patient that he or she will give you some medicine that will heal you and then immediately calls for the nurse to send in the next patient. By the way, the doctor gets money directly for the medication he prescribes.
The examination areas are very small and no privacy is guaranteed in the consultation room as there is only a cloth curtain between the other waiting patients in the outer room. As a patient, I can usually hear, without intention, any comments by the physician from the next curtained booth. If my physician decides some tests or examination are necessary, I must again wait in line. Finally, I have to wait again for the medication for many hours. The waiting areas are very crowded as you might guess and we have to listen carefully to hear our name or number called or check frequently to see whether it has been posted on a special wall board.
As you can see, going to the hospital is quite an exhausting exercise for the patient alone and that is the reason why there are also many healthy people such as parents, spouse, sisters and brothers waiting together with the patient. Few people would go to the hospital for "fun".
When we receive medication we usually pay cash. The charge is always less than $10 US and sometimes the payment will be reimbursed by the patient's particular health association.
How do Japanese feel about this system? According to a survey, only 28% of Japanese expressed confidence in their physician and 31% are thinking about changing their present visiting hospital. Out of this 31%, 69% say that the reason is due to the unsatisfactory attitude of medical staff members and the poor content and quality of medical services at their particular hospital.

Informed Consent and Patient's Rights

Medical care, medical education of our doctors and the cost of medical research are paid for through our contribution of tax money. Japanese patient's right to get informed consent, the idea of bioethics, had quite an impact on the Japanese health care system in terms of changing and restructuring the whole medical system since the end of the 1970s. As a pioneer of bioethics in Japan, I have been working in teaching, lecturing, and holding dialogues with people of the Japan Medical Association, the Ministry of Health and Welfare, the Japan Hospital Association and other groups. Although the system will not change instantly, there are now various recognizable changes happening at the local and national level in Japan's medical community.
One example is the recent decision of the Japan Hospital Association to accept the "Patient's Bill of Rights". There are also many bioethics committees in Japanese medical school hospitals and the notion of informed consent has broader acceptance. But change takes time. Several weeks ago, I was invited to speak on an NHK Radio talk show about the issue of informed consent.
The response by telephone and fax to my Waseda University office asking for more detailed information and offering both agreement and opposition to my comments was surprising. One physician wrote to say that our health care system could not allow more time for informed consent. He also felt the level of patient intelligence and understanding was so low that informed consent would not work effectively in Japan. It is really a shame to have these kinds of comments.
In one case, a grandmother was hospitalized with a terminal illness (about which she was not informed) but, perhaps sensing all was not well, asked that no artificial means be used to prolong her life. The physician said it would be against his code of ethics not to do everything possible. The truth was slightly different. He was, in fact, using experimental treatment on the woman without her knowledge or consent. This reflects back on the influence of German medicine in Japan where the patient was treated as material, not a human being, and the doctor held an authoritative approach to his patient.
One question facing doctors and health insurance companies in the U.S. is the degree to which a patient is entitled to expensive and sometimes extraordinary medical treatment to increase chances of survival. In Japan, doctors operate on a points system with guidelines laid out by the Ministry of Health and Welfare, Instituting medical procedures based on a number of criteria assigned points which are not necessarily diagnosis-related.

The global Context of Japanese Health Care and Quo Vadis?

We reviewed the roots of the Japanese Health Care System, spent some time in a very crowded Japanese hospital and exercised the hope that some change in the status quo will happen, in particular relating to the practice of informed consent and a transformation in the traditional paternalistic attitude of medical staff members towards patients.
Let us conclude this discussion by looking at the effectiveness and performance of our Japanese health care system in the global context.
Despite the concerns of patient dissatisfaction with the less tangible aspects of Japanese health care, this system is able to produce good results from a macro point of view. As you may know, Japanese longevity is number one in the world at 82.22 years for women, and 76 for men compared to 81.81 and 75.86 respectively in the U.S. The infant mortality rate is extremely small at one 4.4 out of 1000 live births compared to 9.8 in the U.S.
Total expenditures in health care as a percentage of Gross National Product is six percent in Japan compared to eleven percent in the U.S., even though the average Japanese visits a hospital seven times annually at an average cost per visit of approximately 7000 yen of which the patient pays 700-2100 yen.
What is this secret? Why from the macro point of view dies the Japanese health care system work so well?
Of course, there is no simple answer to this question. There are many factors that play a part in the success of Japanese health care system. However, as a bioethics-lawer I trace this rather positive performance to the traditional Japanese sense or mentality of homogeneity and related-ness which provides the foundation for the desire for equal access to health care for all and an effect to work for the welfare of all regardless of age, sex, income or residential area.
Particularly, during the process of the Koudo Seichou era, or era of high economic growth, from the middle of the 1960s to the middle of the 1980s, concern for health for many Japanese increased enormously as income of the average Japanese became much larger. (For comparison purposes, the average income per person based on Japan's GNP is $28,120 according to World Bank data complied in December 1993, the third highest after Switzerland and Luxembourg while the U.S. is ranked eighth at $23,120 and Germany is ranked ninth at $23,030.)
Japanese corporations and big businesses are eager to protect the health of their personnel to the point that they require an almost compulsory annual check-up (there has been some concern in major companies of the phenomenon of Karoushi, or death by overwork) and provide their own well endowed health care organizations, funded in part by worker contributions. Conversely, the National Health Insurance system always lacks funds to support its members as this system usually includes independent professionals, retired persons, farmers, fishermen and small business people.
Health-related business is booming in Japan as more people are concerned about their health. Widespread savings for future health and life is a dominant phenomenon as in some cases there is a cap or limit to reimbursement of expenses, or gaps in coverage occur when there is a significant difference between the official fee (reimbursable) and the fee for additional amenities such as a private room, protection or extra expenses incurred related to terminal illness.
These gaps still exist despite Japan's unique system for the coverage of expensive medical treatment fees called the "High Cost Medical Treatment Assistance System". This system provides financial assistance when the amount owed for medical care is high. At present many U.S. health insurance companies are coming to Japan because they view Japan as one of the most promising markets in the future. Japanese have money in hand and want to be healthy in order to enjoy their later years.
The notion of private insurance for individual health care is quite new to Japan but now, almost every day we see many advertisements by American health insurance companies appealing to the need to prepare for unexpected illness or terminal care. These advertisements focus on cancer treatment at the hospital and expenses related to long term hospital care and other expensive treatment not covered by the Japanese Health Care Insurance mechanism.
Japanese are also beginning to change the way they look at health benefits, not from the State or Health Ministry alone but focusing on patient's rights, a movement which began around the end of the 1970s and is now socially acceptable. In addition, a number of health related volunteer activities in the community, such as hospice, are expanding. This represents a dramatic change for a society that did not speak about illness, cancer or death.
A recent case of publicity concerns a Japanese newscaster, Mr. Itsumi, whose doctor informed him he had cancer but who also offered Itsumi hope for recovery when, in fact, the cancer for incurable. Mr. Itsumi later went to a second doctor who informed him the illness was incurable. Itsumi went public with his criticism of the doctor who misinformed him. This is not an usual situation. Often, a patient will be told to leave the room by the doctor who will then proceed to tell family members the truth about the patient's condition while the patient himself is not informed. Doctors feel that to tell the patient the truth will disturb the harmony of the universe. There is a combined Shinto/Confucian/Buddhist attitude which regards the body as a gift from one's parents that is to be treated with respect, a philosophy which perhaps changes the discussion when one looks at issues such as organ transplants and suicides by the terminally ill. In Japan, for instance, the definition of death is when the heart stops beating whereas in the U.S. "brain-death" often is the accepted moment when a physician may remove organs designated or donated for transplant.
In more cases now, patients are issuing an "advanced directive", a dying with dignity declaration or living will which asks that doctors and family avoid futile attempts to prolong life but the number of people opting for this still remains small.
Finally, looking to the future, the Japanese government's "Ten Years Gold Plan" for the welfare of the aged has been announced and in the publication outlining the plan, there is the following statement:

"In order to make the aged society of the coming 21st century a society where everyone is healthy, has something to live for and is able to live with assurance, Japan will have to urgently develop the necessary infrastructure especially in the field of health care and welfare services for the aged during the last decade of the 20th century when Japan will rapidly become an aged society like today's Northern European countries. Under these circumstances, this 'Ten Year Strategy' has been developed to set the goal for the measures to be urgently carried out during the last decade before the 21st century and to promote the project."

The government plans to have more home helpers, community based health activities, including establishing welfare centers, etc and it has started to implement this Gold plan already. My friend, a former health attaché at the Embassy of Japan from the Ministry of Health and Welfare is now back in Tokyo and in charge of this program. He is very confident that the plan to accomplish these goals by securing the financial resources set aside from every fiscal year's budget will be successful. I am certain that this type of government plan, conceived in a policy vacuum, would fail if there was a lack of support from the grassroots level. This is what bioethics is all about. Peoples' health concerns to respect the "sense of autonomy" needed to make "public policy" based on the people's right to health care cannot be accomplished without the mechanism of peoples' input on health issues as tax payers.
The mission to achieve equality in health care for whoever, whenever, wherever has been somehow accomplished as we have seen. However, we need more quality in the aspect of real human care and sharing more time with each other, and supporting each other by giving time, energy, and resources to each other. These will become more and more important bio-ethical issues as we are faced with scarce resources, decreasing economic activity and pressures from outside of Japan to change the course of Japan toward more global participation. I hope the philosophy of health and health policies of the Japanese people enrich the nation of Japan as well as the global community.

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Please send your opinion to rihito@human.waseda.ac.jp

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