This survey reveals the latest status of HCEC, an ethics support in clinical practice in Japan. It found that in 2004, about 25% of hospitals designated for clinical training had HCECs. In 2016, 71.6% had this system. Furthermore, HCEC was a function not only of existing ethics committees but also of newly established clinical ethics committees. The number of committees established began to increase from 2013 onward. The presence of HCEC was not significantly different between hospitals with more than 400 beds and those with less than 400 beds, indicating that hospitals had this mechanism regardless of their size. However, the largest number of requests for HCEC was 1–10 per year, with some respondents reporting zero requests. This finding indicates that although HCEC has been established in Japan, it is not yet fully functional. This section discusses the background that has influenced the development of HCEC.
One of the factors that may have led hospitals designated for clinical training to develop a HCEC system may be an external factor, that is, the accreditation of hospital functionality evaluation. The Japan Council for Quality Health Care (JCQH) started evaluating hospital functions in 1996 to assess the quality and safety of medical care. Since then, JCQH has revised the evaluation items every five years. Each time, the items related to clinical ethics have been revised to evaluate the actual performance of the hospital, from the establishment of a clinical ethics system to the way it deals with ethical issues that arise in the hospital, as well as the hospital's understanding of ethical issues. The results of this study also indicate that the number of teaching hospitals that established HCEC services increased in 2007 and 2015 in response to these revisions. The external evaluation of hospitals may motivate the establishment and organization of new systems, such as HCEC. However, this survey reports numbers of consultations ranging from 1–10. Some hospitals have had no consultations since their inception, suggesting that although the mechanisms have been established, they may not function properly. As the results of the semi-structured document analysis indicate, the reasons for the lack of functionality include issues related to the operation of the HCEC system, such as "difficulty in coordinating HCEC time," "problems related to cases handled by the HCEC system," and "immaturity of the HCEC system" in which the person in charge is not identified. The following issues were identified in the operation of the HCEC system. In addition, there are issues on the consulting side, such as "misunderstanding of the function of HCEC on the part of medical professionals.
First, one solution to the problems associated with the operation of HCEC, such as the need to ensure coordination of dates and times, the speed of response, and the immaturity of the consultation system, is to appoint a full-time person to clarify who is in charge and to centralize the contact points. However, even in the U.S., a leading HCEC country, few professionals have formal education in HCEC. Furthermore, it is reported that there are difficulties in assigning a full-time person to this task due to operational difficulties. It is reported that HCEC is conducted by a team of people with various educational backgrounds.3 (FOX) In Japan, where HCEC has just started, it is difficult to assign a full-time ethics consultant, although training of ethics support personnel has begun. In such a situation, it would be possible to operate HCEC in Japan with a banking system that pools about 20 people who can provide HCEC and respond to problems as they arise. However, educating those in charge on the knowledge and skills required for HCEC is necessary. There are short educational programs for the education of ethics consultants in Japan. In addition, graduate education programs have begun to provide the knowledge necessary for HCEC. However, education and certification in Japan are still in their infancy compared to the U.S. Currently, a need exists to build the knowledge and skills required for those who practice HCEC to resolve ethical issues in clinical practice in Japan. At this point in time, when the certification of ethics consultants is still in its infancy, one solution is peer education, in which those who are currently active work together and build on each other's knowledge and skills. In Japan, the Hospital and Clinical Ethics Committee Collaboration Conference was launched in 2019, and efforts to share clinical ethics support activities among hospitals with specific functions began voluntarily. In addition, the Clinical Ethics Consortium was launched to create a forum for those responsible for HCEC in clinical settings to collaborate, exchange information, and discuss. The accumulation of opinions and discussions on HCEC activities at each facility in the future will help improve each other's knowledge and skills.
Next, "misunderstanding of the function of HCEC" was identified as a problem for those who requested a HCEC. The first problem, "seeking the hospital's judgment and throwing the decision to the hospital," can be said to be a mismatch between the expectations of the consulting healthcare professionals for HCEC and the functions of the ethics consulting practitioners. Conflicts of values that arise in clinical practice require an adjustment of values that is acceptable for both parties. However, some healthcare professionals are sometimes affected by feelings of exhaustion from conflicts with patients and their families and want HCEC to decide. Especially in Japan, the discontinuation of life support equipment is not accompanied by a legal basis for the patient's advance directive, unlike in Europe and the U.S. In some cases, the risk of criminal prosecution is considered to be a psychological defense, making it easy to harbor such feelings of exhaustion and emotion. A change in mindset is needed to address these problems. Discussing the issue from a domestic legal and ethical perspective may also protect healthcare professionals. Furthermore, opportunities to introduce ethical support and educate about ethical considerations are needed.
The other problem is that of 'confusion of functions and roles’ with other hospital organizations. The problem may stem from steps taken by hospitals to increase the number of HCEC requests, as inferred from the scarce number of these. Hospitals consult with frontline patients about managing medical care problems and difficult cases. Moreover, they also consult with patients about difficult cases when responding to their complaints. Of course, patient complaints may also include ethical issues requiring assistance, such as HCEC. However, given the current state of HCEC in Japan, it is necessary to provide a wide range of consultation services, including various types of consultation, to make the HCEC system function. However, it is also true that some people may be uncertain about what they need, so they may decide to seek advice in any case, which may lead to problems in making distinctions.
In addition to the challenges of HCEC, the survey also revealed the positive impact of the establishment of this service. In particular, the findings indicate that they “feel safe and secure by having gone through an organized procedure,” and that it “provided a mechanism for hospitals to support policies and responses based on legal, ethical considerations.” Requests for HCEC are often accompanied by conflicting values between the healthcare professional and the patient/family, resulting in emotional communication, an inability to dialogue, and a relationship in which trust is undermined. Therefore, it is hoped that the presence of an ethics consultant as an objective party to the case and the parties involved will neutralize the situation. In addition, a positive impact was extracted from the fact that “the ethics support system improves staff awareness and control of medical care in the hospital.” It has been reported that consulting a HCEC can lead to reassurance in resolving conflicts over medical care with patients and their families and confidence in basing the medical care options being contemplated on ethical considerations. It has also been reported to have a positive impact in that it can be a control of medical care within the hospital and help ensure the appropriateness and fairness of medical care.13,
Limitations
This survey focused exclusively on teaching hospitals. Since the response rate was low, only hospitals with a strong interest in clinical ethics support structures may have responded. Consequently, it cannot be inferred that the results represent all Japanese teaching hospitals. Further, while this survey targeted teaching hospitals, these comprise only 13.9% of all hospitals in Japan (1,028/7,379 as of December 2016). Hence, the current status of HCEC systems in all Japanese hospitals deserves further study. As this survey is an overview of current HCEC mechanisms and their activities, the topics of outcome assessment and quality assurance remain for future investigation.
Given that only a small number of medical institutions answered and those who did were interested in HCEC, the findings obtained in this study cannot be regarded as typical for hospitals designated for clinical training in Japan. The number and type of hospitals answering in 2004 and 2016 differed. However, these studies are the first ones that give some insights into changes in HCEC services over the last decade in Japan.
Because respondents to the semi-structured questions were active in the development and activities of HCEC, their answers cannot be generalized. However, it can be said that they objectively described the positive impacts and difficulties associated with the establishment of HCEC at each facility. Future work includes conducting a qualitative study of those involved in HCEC to determine the process of organizing the service and the skills required of those responsible for HCEC.