Sole clinical ethicist always has full plate

Koichiro Itai runs a “cafe” in a Miyazaki Prefecture hospital whose main dish is anything but ordinary: ethics.

Ethicist Koichiro Itai –

speaks with hospital staff at his Kissa Rinri (Ethics Cafe) at Miyazakihigashi National Hospital in late June.
TOMOKO OTAKE PHOTO

Clad in blue apron, he actually does serve customers. But they are by and large medical professionals who seek his counsel on life and death issues, ranging from whether to switch off the artificial respirator of a baby with no chance to recover, to dealing with a family who wants their mother, in a vegetative state, kept alive so they can continue to receive her pension income.

Since May 2005, Itai, an associate professor of biomedical ethics at Miyazaki University’s faculty of medicine, has been counseling visitors to his Kissa Rinri (Ethics Cafe) in a lounge at Miyazakihigashi National Hospital.

Although they are common in the West, Itai is the only ethics consultant in Japan.

His work is becoming more and more important, because, while new medical technologies have made the border between life and death murkier, Japan is ill-equipped to answer the ethical questions raised by such technologies, as seen in the recent controversy over the removal of respirators at a hospital in Imizu, Toyama Prefecture.

Doctors there were found to have ended the lives of seven terminal patients between 2000 and 2005.

“Ethics are in real life, not in academia,” Itai said. “What happened in Imizu is symbolic of what’s happening all across the country.”

In the West, ethics consultants, or clinical ethicists, offer mediation to patients, families, doctors, nurses and other professionals whenever they run into emotionally charged situations, such as over when to take someone off life support or how to ensure the autonomy of patients.

There is no qualification system or training courses for clinical ethicists in Japan.

Itai, who has studied philosophy but doesn’t have a medical degree, focuses mostly on counseling doctors, even taking midnight phone calls from them, saying they are the most in need of help from ethicists.

“Doctors have been taught not to rely on others when they make treatment decisions,” Itai said. “They are also taught how to save lives, but not how to communicate with patients or their families.”

While many patients express their wish to “die with dignity,” a choice of treatment is much more complex than what they can specify on paper, Itai said, adding that his job involves helping families and doctors determine what “dying with dignity” means to individual patients in critical condition.

During a recent visit, Dr. Keiichi Shioya, deputy director of the hospital, dropped by along with other hospital staff.

Shioya said it was difficult at first for doctors to seek the opinions of nonmedical professionals such as Itai, as they have been taught to decide everything on their own. But over time, Shioya said, he has come to realize the importance of getting an ethicist’s help on how to deal with patients.

“We doctors can be narrow-minded,” Shioya said. “We have a policy to confirm patients’ preferences (mostly on end-of-life choices) in writing. One time, when professor Itai and I were talking, he said I shouldn’t force answers out of people. Then I said, ‘OK, so I just need to wait for patients to speak to me, right?’ He said ‘No! You have to keep searching for opportunities to hear their opinions.’ When we are busy running around, such considerations come last.

“Most doctors have good intentions, but they often don’t realize that they can be self-righteous,” Itai said, adding that ethicists shouldn’t confront doctors, but make them stop and think.

“Many doctors, especially surgeons and ER doctors, are on call 24 hours a day, often unable even to go home for three days. Then they are told by their bosses that they are not caring enough for their patients. Without support, doctors can burn out any time.”