The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens.

BACKGROUND: According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment. METHODS: Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment. RESULTS: In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%). CONCLUSIONS: A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

Cross-cultural differences in prefrontal cortex activity in moral judgment: A functional near-infrared spectroscopy (fNIRS) study based on the CNI model.

BACKGROUND: In the past, comparative cultural neurological studies of moral judgments have mainly focused on Eastern and Western groups. We initially examined Japanese and Chinese groups, both East Asian cultures. We utilized a recently proposed polynomial model known as the "consequences, norms, and generalized inaction" (CNI) model to investigate the variations in the overall prefrontal cortex activity between these two groups during moral judgment. METHODS: We employed functional near-infrared spectroscopy (fNIRS) to analyze the prefrontal cortex (PFC) activity within a CNI model of moral judgment among 23 healthy Japanese and 26 healthy Chinese adults. RESULTS AND CONCLUSIONS: Our study revealed significant differences in the PFC activation between Japanese and Chinese individuals in the CNI moral judgment task context. Specifically, during the CNI task, Chinese men exhibited higher right dorsolateral prefrontal cortex (R-DLPFC) activity than Chinese women. In contrast, Japanese women showed greater left dorsolateral prefrontal cortex (L-DLPFC) activity than Japanese men. In an international comparison, R-DLPFC activity was higher in Chinese men than in Japanese men. Conversely, the left ventrolateral prefrontal cortex activity was higher in Japanese men compared to Chinese men. Additionally, among women, the right ventromedial prefrontal cortex activity was higher in Japanese women than in Chinese women. In conclusion, our findings support the perspective of cultural psychology and identify cultural and sex differences in PFC activity between Japanese and Chinese individuals.

Clinical Ethics Consultation in Japan: What does it Mean to have a Functioning Ethics Consultation?

This research examines the current status of clinical ethics consultation (CEC) in Japan through a nationwide study conducted with chairs of ethics committees and clinical ethics committees among 1028 post-graduate clinical teaching hospitals. We also qualitatively analyzed their viewpoints of the CEC's benefits and problems related to hospital consultation services to identify the critical points for CEC and inform the development of a correctly functioning system. The questionnaire included structured questions about hospital CEC organization and service purpose and operation and open-ended questions about the benefits and problems of initiating CEC. The questionnaire comprised the presence/absence of an ethics committee, CEC services and membership when services were implemented, users, and the number of cases handled since inception. In addition, the respondents also provided their impressions of the CEC system's impact on their hospital by describing (a) the benefits of CEC services and (b) the ineffectual or harmful aspects of the CEC system. Qualitative data were examined using qualitative content analysis to determine the impact of establishing a CEC and the difficulties of practice. One hundred twenty-five questionnaires were returned from either the chair of the ethics committee or clinical ethics committee in teaching hospitals. Of these, 90 (72%) reported they provided CEC services. Additionally, 36 respondents (34.6%) reported that their existing research and clinical ethics committees had conducted CEC services, and 35 (33.7%) reported having a newly established clinical ethics committee conducting CEC services. Three positive effects of establishing and four challenges in managing CEC were also identified.

Perceptions of Psychosocial and Ethical Issues and the Psychological Characteristics of Donors in the Clinical Setting of Living Kidney Donors: A Qualitative Study.

BACKGROUND: There are several psychosocial and ethical issues surrounding the decision to be a living kidney donor. The present study aimed to determine the perceptions of psychosocial and ethical issues that living kidney donors may have, and analyze their psychological characteristics. METHODS: Face-to-face semi-structured interviews were conducted with 15 donors. Thematic analysis was then performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board. RESULTS: Four main categories were identified: Awareness of family dynamics, barriers to a proper understanding, contrasting psychological effects of recipient presence in clinical practice, insufficient information explained in informed consent. CONCLUSION: Donors felt that they took on the "role as a care giver" for the recipient and were less aware of themselves as patients. This is a new concept that has not been shown in previous studies. Donors exist within the recipient and family, and the range of their autonomy may go beyond the traditional concept of autonomy and be rooted in relational autonomy. This study suggested that medical treatment in the presence of the recipient promotes the relational autonomy of the donor.

Should Physicians Be Permitted to Refuse Follow-Up Care to Patients Who Have Received an Organ Transplant Through Organ Trafficking?

In 2018, the Istanbul Declaration stated that organ transplantation via organ trafficking is a crime. Since then, the number of medical institutions in Japan who refuse follow-up care to patients who have undergone unethical organ transplantation overseas has been gradually increasing. Deterring transplant tourism involving organ trafficking is an issue that must be addressed by the government, medical institutions, and individual physicians. The refusal of medical institutions and individual physicians to provide follow-up care after organ transplantation may challenge the idea of the incompatibility thesis; moreover, it may be ethically justified in the context of conscientious objection if it is based on the belief of deterring transplant tourism instead of punitive motives or a reluctance to support a criminal activity. However, conscientious objection based on a belief in fair transplantation care is conditional; according to the compromise approach, it is limited to particular conditions, such as that the patient's medical state does not require urgent care and that the patient is reasonably able to receive follow-up care at another institution.

Ethics Guideline Development for Neuroscience Research involving Patients with Mental Illness in Japan.

This study aims to develop guidelines of key concepts and specific considerations to make the research more ethical when conducting neurological examinations and treatment interventions in mentally ill patients. We analyzed guideline development theory and literature, previous issues, and discussions with specialists of philosophy, medicine, sociology, and bioethics. The selection of research participants, drafting of intervention plans, and informed consent process were examined with reference to the dual burden; the minimal risk as a general rule of ethical allowance levels, assent and dissent to assess the individual's judgment capacity for consent, relational autonomy for personal consent with assistance by the proxy, and risk/benefit assessments. When conducting studies, this guideline requires that these three processes be set up appropriately on a case-by-case basis. Supplementary Information: The online version contains supplementary material available at 10.1007/s41649-023-00240-x.

Exploring cultural and gender differences in moral judgment: A cross-cultural study based on the CNI model.

Recently, researchers have proposed a polynomial model called the "consequences, norms, generalized inaction" (CNI) model for researching moral judgment. However, it is unclear whether the model can be used to explore cultural differences in moral judgment. In this study, we investigated the applicability of the CNI model of moral judgment to East Asian groups, and subsequently explored cultural and gender differences in moral judgment between East Asian (i.e., Japan, n = 211; China, n = 200) and Western (i.e., USA, n = 201) groups. The CNI model was proposed by Gawronski et al., and it can quantify individuals' sensitivity to moral consequence, sensitivity to moral norms, and their general preference for inaction or action in moral dilemmas. Our results indicate that the CNI model fits well for Japanese and Chinese individuals. Both East Asian women and Western women were significantly more sensitive to moral norms than men in their respective countries. In the international comparison, Westerners were more sensitive to moral norms. The Japanese groups, for both men and women, were most biased towards inaction. Regarding sensitivity towards consequences, no differences were observed in the comparison between Eastern and Western male groups, whereas poor sensitivity was observed among women. By using this new model, this study provides new insights into the differences of cultural and gender in moral judgment. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-023-04662-6.

Identifying practical clinical problems in active euthanasia: A systematic literature review of the findings in countries where euthanasia is legal.

OBJECTIVES: Currently, active euthanasia is legalized in only 7 countries worldwide. These countries have encountered problems in its implementation. The study aims to summarize the practical clinical problems in the literature on active euthanasia. METHODS: A systematic literature review was conducted using 140 works consisting of 130 articles from PubMed and EthxWeb and data from 10 euthanasia laws. RESULTS: After reviewing the specific problems reported to be associated with euthanasia in each country, 5 problems were extracted: many ambiguous conditions with room for interpretation, insufficient assurance of voluntariness, response to requests for euthanasia due to psychological distress, conscientious objection, and noncompliance by medical professionals. SIGNIFICANCE OF RESULTS: Multiple ambiguous conditions that are open to interpretation can result in a "slippery slope phenomenon." An insufficient guarantee of voluntariness violates the principle of respect for autonomy, which is the underlying justification for euthanasia. In cases of euthanasia due to mental anguish, a distinction between a desire for death caused by psychological pain alone prompted by mental illness and a desire for death caused by mental symptoms prompted by physical illness is essential. Conscientious objection should remain an option because of the heavy burden placed on doctors who perform euthanasia. Noncompliance by medical professionals due to ignorance and conflicts regarding euthanasia is contrary to procedural justice.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND: In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined. METHODS: Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes. RESULTS: Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions. CONCLUSIONS: In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

Attitudes of the Public Toward Consent for Biobank Research in Japan.

Background: Parallel to the rapid advancement of biological and information technologies, the role and forms of biobank research have been constantly changing. The ethical, legal, and social implications of consent in biobank research are in a state of flux. This study aimed to clarify current Japanese public preferences regarding the consent model and explore how public attitudes are determined. Methods: We conducted an online, population-based quantitative survey among Japanese residents aged between 20 and 69 years. Statistical analyses consisted of univariate and multivariate logistic regression. Results: Of the 1580 respondents, 60.9% preferred autonomy-based consent (specific or dynamic consent) and 23.9% preferred broad-type consent (opt-out or broad consent). Marital status, gender, and privacy concerns were significantly associated with the preference for a consent model. Conclusions: Our results demonstrated the public's current preference for autonomy-based consent, including dynamic consent. However, our findings also revealed that approximately half of the respondents considered broad consent as somewhat preferable.

Practical training using immersive roleplay and an intensive course on clinical ethics consultation in Japan.

BACKGROUND: Clinical ethics consultation (CEC) is not sufficiently widespread in Japan. A possible reason is that a practical training system for CEC has not been established. Hence, we have developed "immersive role-play (IR)" as a practical training program that applies a new theatrical technique, immersive theater, to role-play learning. Its characteristics include high fidelity in the use of a studio and actors and dynamic realism in the progression of the scenario to immerse learners in role-play learning. METHODS: We offered an intensive course on CEC for healthcare professionals from 2016 to 2019, with IR as part of the course curriculum. A questionnaire survey was administered to the participants regarding the educational effectiveness of IR. The questionnaire was anonymous, and participants responded on a 4-point Likert scale regarding their satisfaction with IR and their perception of its learning effects. An open-ended section at the end of the questionnaire asked about the effectiveness and areas for improvement of IR. RESULTS: The questionnaire survey showed good results in all categories: usefulness, satisfaction, understanding, and interest. In the questions that compared the learning to traditional role-play learning, the participants gave significantly high ratings, specifically for "realism," "seriousness," "understanding the importance of communication skills," and "understanding the diversity of the narratives." In the free-text responses, the most frequent response was that they learned a lot about the practical procedures for participation. CONCLUSION: IR is sufficiently effective as a practical educational program, but not for everyone. It is suitable for those who are or will soon work as consultants. Conversely, beginners and intermediates who have not fully mastered the CEC theory and skills will need a stage-specific educational program separate from the IR.

Facts and Recommendations regarding When Medical Institutions Report Potential Abuse to Child Guidance Centers: A Cross-Sectional Study.

BACKGROUND: Medical institutions are required to report suspected cases of child abuse to administrative agencies, such as child guidance centers in Japan. It is left to the discretion of the medical institutions whether to notify the family of the child or the center. However, it is unclear what kinds of measures are being taken to ensure a robust policy of notification versus non-notification and how notifying the family will affect the child. METHODS: An unregistered questionnaire survey on reporting suspected child abuse cases to child consultation centers and notifying families was conducted by mail across 518 pediatric specialist training facility hospitals designated by the Japanese Pediatric Society. RESULTS: Responses were received from 323 facilities (62.4% response rate), of which 5 facilities were excluded because of incomplete responses. Therefore, in all, 318 facilities were included in the analysis. The results showed that 59.8% of the facilities had a policy of notifying the family, 33.7% said the decision varies from case to case, and 6.6% did not have a policy of notifying the family. The facilities that had a policy of either notifying or not notifying the family were less likely to experience problems than those with a policy of deciding on a case-by-case basis. The proportion of cases in which some problems occurred was higher in the cases where families were notified than in the cases where they were not, with 51.4% of the children experiencing worsening of relationships with family members. In the cases where the families were not notified, the children were twice as likely to experience further abuse than in cases where the families were notified. CONCLUSION: Problems arise in the case of both notification and non-notification. It is necessary to examine background factors and specific methods of notification in the cases where problems arise.

Indications for involuntary hospitalization for refusal of treatment in severe anorexia nervosa: a survey of physicians and mental health care review board members in Japan.

BACKGROUND: When a patient with anorexia nervosa refuses treatment despite a physically critical condition, the therapist considers involuntary inpatient treatment under the Mental Health Law. However, ethical and practical problems arise from its application. In this study, a survey of treatment providers for eating disorders and psychiatric review board members was conducted regarding indications for involuntary hospitalization under the Mental Health Act for refusal of treatment for anorexia nervosa. METHODS: A survey of 212 physicians affiliated with the Japanese Society for Eating Disorders and 180 members of Mental Health Care Review Boards across Japan was conducted using six vignette cases of patients with anorexia nervosa refusing treatment. RESULTS: Regardless of the duration of illness or age of the patient, few physicians chose compulsory hospitalization with or without the consent of the family, while the largest number of physicians chose hospitalization for medical care and protection when there was family consent. Among committee members, only hospitalization for medical care and protection was determined to be appropriate when there was family consent. Both hospitalization for medical care and protection, and compulsory hospitalization were deemed appropriate in the absence of family consent. Committee members who adjudged refusal of treatment for anorexia nervosa as self-injurious behavior suggested that compulsory hospitalization was indicated. CONCLUSIONS: When a patient with life-threatening anorexia nervosa refuses inpatient treatment, hospitalization for medical care and protection is actively chosen if the patient's family consents. Mental Health Care Review Board members considered this acceptable. However, if the family does not consent, the physicians did not choose compulsory hospitalization, and the psychiatric review board was divided on this. Consensus was not achieved in this regard.

When a patient with anorexia nervosa refuses treatment despite a physically critical condition, it raises an ethical dilemma. If the patient in a life-threatening condition refuses treatment, physicians consider involuntary hospitalization for treatment as per the law. To date, there is no uniform decision in this regard. Therefore, in this study, a survey of treatment providers for eating disorders and psychiatric review board members was conducted regarding indications for involuntary hospitalization under the Mental Health Act for refusal of treatment for anorexia nervosa. When family members consented to treatment, the physicians considered hospitalization for medical care and protection, and the members also agreed that this was indicated. However, when the family did not consent, the physicians did not choose compulsory hospitalization, and the members were divided on the indications for compulsory hospitalization. Therefore, the handling of cases wherein patients with anorexia nervosa refuse inpatient treatment despite a life-threatening condition, in addition to their families not providing consent for treatment, will be extremely difficult.

Report on the Establishment of the Consortium for Hospital Ethics Committees in Japan and the First Collaboration Conference of Hospital Ethics Committees.

Hospital ethics committees (HECs) are expected to play extremely broad and pivotal roles such as case consultation, education of staffs on healthcare ethics, and institutional policy formation. Despite the growing importance of HECs, there are no standards for setup and operation of HECs, and composition and activities of HECs at each institution are rarely disclosed in Japan. In addition, there is also a lack of information sharing and collaboration among HECs. Therefore, the authors established the Consortium of Hospital Ethics Committees (CHEC) in October 2020, which has been regularly hosting a couple of core activities. One is the Healthcare Ethics Forum, held monthly online for CHEC members to freely discuss HECs and healthcare ethics consultation. The other is the Collaboration Conference of Hospital Ethics Committees, intended to provide a place for HEC members and administrative officers from across Japan to exchange information of their HECs, learn from each other, and cooperate to operate HECs appropriately. In this paper, the authors introduced CHEC as well as reported the results of a questionnaire survey conducted at the first conference among participating facilities, suggesting the diverse structures and activities of HECs in Japan.

Disclosing a diagnosis of autism spectrum disorder without intellectual disability to pediatric patients in Japan in early diagnostic stages and associated factors: a cross-sectional study.

BACKGROUND: With a recent increase in the prevalence of autism spectrum disorder (ASD), an important issue has emerged in clinical practice regarding when and how patients themselves should be given explanations following a diagnosis of ASD. The clinical guidelines of the UK National Institute for Health and Care Excellence state that children diagnosed with ASD should receive an explanation about what ASD is and how it affects their development and functioning-"if appropriate". However, the guidelines do not provide any specifics regarding what constitutes "appropriate" situations METHODS: We conducted an anonymous self-administered postal questionnaire survey targeting all members of the Japanese Society for Child and Adolescent Psychiatry (n=1,995). The analysis included only physicians who had newly diagnosed pediatric patients with ASD in the past year. We imposed a limit of one year because diagnoses further back than that are difficult to recall; in other words, this would enhance the recall bias RESULTS: The recovery rate was 30.8%, and the rate of diagnosis disclosure to patients themselves without intellectual disability was 15.3%. We asked 361 physicians who responded that "deciding on a case-by-case basis" was the ideal way to disclose an ASD diagnosis about 20 items prioritized by physicians at the time of diagnosis disclosure and extracted three factors through exploratory factor analysis. Multiple logistic regression analysis was performed with physician attributes, awareness of ASD as a disorder or personality, and the three extracted factors as explanatory variables; diagnosis disclosure was the dependent variable. The patient age group and only one of the three factors (i.e., "factor related to readiness to accept diagnosis") showed a significant association with disclosure of the diagnosis to the individual. Items included in the "factor related to readiness to accept diagnosis" were as follows: the degree of parental understanding, relationship of the patient with their parents/physician, agreement in opinion between parents, parental consent, "sufficient" patient understanding, symptom stabilization, and a guarantee of sufficient time required to explain the diagnosis to the patient CONCLUSION: In clinical settings, disclosing an ASD diagnosis with the consideration of patient/parent readiness toward accepting the diagnosis could help to guide physicians in determining an ideal timing for disclosure. Future studies are needed to establish detailed and concrete guidelines regarding disclosure of an ASD diagnosis to patients.

Psychosocial and Ethical Behaviors and Attitudes of Health Care Professionals in the Clinical Setting of Living Kidney Donors: A Qualitative Study.

BACKGROUND: There are several psychosocial and ethical issues surrounding the decision making of living kidney transplant donors. This study aimed to determine what health care professionals (HPs) consider in their clinical practice and their attitudes toward donors' decision-making processes. METHODS: Face-to-face semistructured interviews were conducted with 15 HPs. A thematic analysis was performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board and conducted in accordance with the Declaration of Helsinki. RESULTS: Six main categories-maintaining family relationships, improving donor understanding, supporting voluntary decision making, setting the environment for the examination, having different attitudes toward the donor's intentions, and resisting confirmation of intent-were identified. The HPs provided diverse considerations to respect the donors' autonomy. CONCLUSION: In clinical practice, there is a lack of practical methods to confirm living donors' levels of understanding and spontaneity, suggesting that these methods need to be established. Factors related to family functioning may reflect the unique culture of Japan, and this may be indicative of the need to consider treatment based on cultural values.

Key components of the mental capacity assessment of patients with anorexia nervosa: a study of three countries.

BACKGROUND: Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment. METHODS: A questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders. RESULTS: A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference. CONCLUSIONS: It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.

This study investigated the method of assessing the mental capacity of anorexia nervosa (AN) patients who refuse treatment in Japan, the United Kingdom, and the United States. Approximately one-third of clinicians who assessed patients with AN declared that those patients showed impaired decision-making capacity when refusing treatment. Clinicians who considered patients with AN to have impaired decision-making ability tended to focus on the level of psychopathological values when assessing their mental capacity.

International comparison of physicians' attitudes toward refusal of treatment by patients with anorexia nervosa: a case-based vignette study.

BACKGROUND: This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa. METHODS: A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa. RESULTS: For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient. CONCLUSIONS: Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment.

This study aimed to investigate the attitudes of physicians in Japan, the UK, and the US toward refusal of treatment for anorexia nervosa. Physicians in all three countries received an anonymous questionnaire comprising four fictitious cases for which they had to respond whether they would choose compulsory inpatient treatment or not. The study revealed that in all three countries, compulsory treatment tended to be the prevalent choice in cases of life-threatening malnutrition, regardless of the patient's age or duration of illness. Moreover, in all the three countries, treatment tended to be forced if a family member requested treatment, and this trend was particularly strong in Japan. The influence of family request was stronger for acute AN in the U.K. and the U.S., and for SE-AN in Japan.

Stroke Survivors' Experiences and Needs during the Decision-making Process Considering Rehabilitation Options: A Pilot Descriptive Study in Japan.

Objectives: The purposes of the present study were to describe stroke survivors' experiences and to identify their support needs when faced with decisions about rehabilitation. Methods: Based on the Ottawa Decision Support Framework needs assessment, semi-structured interviews were conducted with 15 stroke survivors. The degree of participation in decision-making and anxiety were assessed quantitatively. All interview transcripts describing their experiences and emotions were qualitatively analyzed. Results: All participants had hemiplegia but could perform their daily activities unassisted. Most participants played an active role in decision-making, but 13 patients felt some anxiety when choosing chronic-phase rehabilitation programs. Qualitative analysis identified 19 codes, of which 13 were categorized into the four factors of knowledge, values, certainty, and support. The codes related to patient feelings of anxiety and insecurity about making decisions were "lack of information about options," difficulty in "selecting appropriate information," and "lack of support" from medical staff. Trustworthy specialist support and prior knowledge of rehabilitation were identified as factors that could help patients feel more secure about making decisions. Conclusions: To support stroke survivors in their decision-making about rehabilitation, each patient should be given a long-term perspective on stroke rehabilitation and sufficient information on rehabilitation options tailored to their individual needs. Decision aids for stroke survivors built on these findings will be used in clinical practice, and their efficacy will be verified in future studies.