Vol. 50 No. 3 May-June 2007
Conferences and Lectures 42nd CMAAO Mid-Term Council Meeting: SYMPOSIUM —Continuing Development in Ethics and Professionalism— ...... 197
[Hong Kong] The Hong Kong Medical Association—Symposium paper for year 2005-2006 ...... 198
[Indonesia] Ethico—Legal System as Framing Tools to Enhance Professionalism in Indonesia ...... 207
[Japan] Challenges of Physicians and Medical Associations in Japan —Japan Medical Association playing a leadership role in child support activities— ...... 214
[Korea] The Development of Medical Ethics in Korea ...... 218
[Macau] Continuing Development in Ethics and Professionalism ...... 226
[Malaysia] Continuing Development in Ethics and Professionalism by Malaysian Medical Association ...... 228
[New Zealand] International Code of Medical Ethics ...... 234
[Philippines] Continuing Development in Ethics and Professionalism ...... 236
[Singapore] Continuous Professional Development (CPD) Programmes on Medical Ethics and Professionalism in Singapore ...... 238
[Taiwan] Ethics as Core Competence: Continuing development in ethics and professionalism on Taiwan ...... 243
[Thailand] Continuing Development in Ethics and Professionalism in Thailand (2006) ...... 254
[Sri Lanka] Development of Ethics and Professionalism in Sri Lanka ...... 255
Research and Reviews The Physician-Patient Relationship Desired by Society Hiroyasu GOAMI ...... 259 Contents
Local Medical Associations in Japan Activities of the Tochigi Medical Association Takeshi FUKUDA ...... 264
Activities of the Gunma Medical Association Toshiro IKEYA ...... 267
International Medical Community Presidential Address at the 57th WMA General Assembly (Summary) Nachiappan ARUMUGAM ...... 269
Healthcare System Reform in the United States —Analysis based on this year’s State of the Union Address and Budget Message— Kenya NISHIHIRA ...... 272
From the Editor’s Desk Masami ISHII ...... 276 Conferences and Lectures
42nd CMAAO Mid-Term Council Meeting: SYMPOSIUM —Continuing Development in Ethics and Professionalism—
Grand Copthorne Waterfront Hotel, Singapore November 24–26, 2006
The 42nd CMAAO (Confederation of Medical Associations in Asia and Oceania) Mid-Term Council Meeting was held from Fri. November 24 to Sun. 26, 2006 in Singapore and attended by a total of some 50 representatives of 13 medical associations (12 existing medical associations and Sri Lanka, whose membership has been newly approved). The following is a summary of the symposium that was held on November 26, on the theme of “Continuing Development in Ethics and Professionalism.”
CMAAO Meeting in Singapore
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[Hong Kong] The Hong Kong Medical Association— Symposium paper for year 2005–2006
CHAN Yee-shing Alvin*1
*1 Council Member, Hong Kong Medical Association, Hong Kong ([email protected]).
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[Indonesia] Ethico-Legal System as Framing Tools to Enhance Professionalism in Indonesia
Agus PURWADIANTO*1
Professionalism is a big issue towards Indonesian At the suprastructure level, there are two doctors nowadays. We have had “malpractice important regulation for medical practitioners’ fever” as a result of cumulative miscommunica- professionalism, i.e. Medical Practice Act 2004 tion gap between doctors/hospitals—patients. and National Social Security Act 2004. Indonesia The Indonesian people become more litigious. is now in a transition period to meet the mostly As a result, mostly Indonesian doctors become a international standard of health care system, by little bit defensive in doing their practice, giving focusing professionalism as an important para- the “out of pocket” health care system more digm of the medical profession. The Medical expensive. Council with it’s subordinate the Medical Disci- The competition between doctors become plinary Board as well as the Ministry of Health fiercer. There are a huge number of new Indone- with National Health Insurance and Indone- sian doctors—approximately about 2,000 first pro- sian Medical Association with it’s “subordinate” fessional degree doctors—come to the medical Medical Ethics Honorary Board will play a signifi- and health sector, as a product from 53 medical cant role to make “law as a social/medical prac- faculty through out Indonesia. But only a few— titioners engineering” to regulate and prescribe about less then 30% out of them—that do not the good competency, quality and professional have opportunity to entry residency as post- conduct of Indonesian doctors. graduate students. The Indonesian College of But professionalism can not stand alone. It Medical Specialist still has difficulties to develop should be packaged as a system. We call it: the “mass production” of specialist to fulfill the soci- ethicolegal system. ety’s existing demand.
*1 Secretary of Medical Ethics Honorary Board, Indonesian Medical Association, Jakarta, Indonesia ([email protected]).
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[Japan] Challenges of Physicians and Medical Associations in Japan —Japan Medical Association playing a leadership role in child support activities—
Sadaomi IMAMURA*1
school as well as at home is an extremely urgent Current State of Japan’s Declining issue. Birthrate Because child abuse has such a tremendous affect on the psychological well-being of children In Japan the total fertility rate is declining at a during their formative years, its early identifica- rapid pace; in fact Japan currently has one of the tion and early intervention are particularly impor- fastest falling birthrates in the world. As the tant; the role of physicians is thus extremely trend for women to continue working and marry significant. later has continued to grow, the birthrate has To enable parents to successfully balance fallen, with the total fertility rate dropping to a work and child-raising, child-raising support in record 1.25 in 2005. The government has been the local community is vital. Considering the putting forward various measures to counter this anxiety about child-raising felt by many women declining birthrate, but unfortunately we cannot and the incidence of child abuse by mothers, say that these have had sufficient effects. How there is a need for physicians—particularly to curb the declining birthrate is an extremely pediatricians—to not only supervise children’s important issue facing Japan today. health and medical treatment, but also act as The enhancement and strengthening of sup- children’s advocates. port activities for child-raising has been promoted as one countermeasure to the falling birthrate; JMA’s Child Support Activities however, in recent years the child-raising envi- ronment has changed tremendously with the rise The Japan Medical Association (JMA) believes of the nuclear family and changes in local com- that we have come to a time when we must take munities, leading to a notable increase in child- some form of action from a medical perspective raising anxiety and difficulties. An increase in to protect the medical and social environment the incidence of child abuse is also becoming a of children, who are the leaders of the next serious social problem. Numerous reports of child generation. abuse have appeared in the news, making this a The JMA has been proactively promoting mea- problem for the whole of society. The number of sures to support children through such activities child abuse cases reported to child counseling as the implementation of “Prenatal Visit Model centers has increased, with a record 34,472 cases Activities,” the compilation and distribution of reported in 2005—a 30-fold increase over the pamphlets such as “Child Health Support—Tem- 1,101 cases reported in 1990, the first year records porary Childcare Services Q&A” and “Prenatal were kept. Over 80% of child abuse is perpetrated Visiting Services Q&A,” compilation and distri- by the child’s parents—the mother in 61% of cases bution of “The Doctors’ Manual for the Early and the father in 32%—demonstrating a need Discovery and Prevention of Child Abuse,” imple- for support of parental education. In schools mentation of Child Immunization Week, and there are problems such as bullying, and thus the supervision and production of an anti-smoking improvement of the environment of children at DVD.
*1 Executive Board Member, Japan Medical Association, Tokyo, Japan ([email protected]).
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As a further measure to curb the declining With regard to the “Enhancement of sterility birthrate and protect the medical care environ- and infertility treatment,” the Ministry of Health, ment for the children who are to become the Labour and Welfare of Japan implemented Spe- leaders of the next generation, based on the cial Assistance for Fertility Treatment in 2004, but recommendations of the JMA Child Health because the nationwide performance and results Committee, the JMA in May 2005 issued a decla- of this system are unclear, the government is to ration. This is the “Japan Medical Association established the “Study Group on the Effective Declaration to Support Children” with regard and Efficient Management of Special Assistance to pregnancy, birth, and the child-raising years for Fertility Treatment” this year and delibera- in order to promote the improvement of the tions began recently. The Group intends to clarify medical care, health insurance, and welfare envi- the nationwide performance and results of the ronment for mothers and children so that the program as well as consider prerequisites for children who are to become the leaders of the such treatment, such as facilities and staff at next generation may grow healthy both physi- medical institutions in the program, and methods cally and psychologically. The Declaration has for validating the results and outcomes of fertility eight items with details of a total of 36 specific treatment. I will be participating in these delib- measures. erations as a member of this Study Group. The JMA has compiled a leaflet on the above The upper limit for Special Assistance for declaration which is being distributed to its mem- Fertility Treatment is US$830 per year, but from bers and local medical associations to spread and this year the benefit period will be extended from educate people about its principles. 2 to 5 years. For the Second item, “Enhancement of the JMA declaration to support children health care environment to enable greater safety The content of the Declaration to Support Chil- in pregnancy and birth,” there are five measures: dren is as follows. (1) Establishment of a perinatal stage network 1. We will endeavor to support those who desire to reduce maternal mortality and perinatal to become pregnant. mortality, 2. We will endeavor to enhance the health care (2) Establishment of a Community Health Care environment to enable greater safety in preg- System to identify and manage high risk nancy and birth. pregnancies, 3. We will endeavor to improve the social envi- (3) Enhancement of perinatal care staff at birth- ronment to enable mothers find satisfaction in ing facilities, pregnancy and birth. (4) Enhancement of measures to prevent mother/ 4. We will endeavor to enhance the health care child infection, and environment to make child-raising easier. (5) Establishment of a system of no-fault com- 5. We will endeavor to improve the social envi- pensation. ronment with regard to child-raising. With regard to a system of no-fault compensa- 6. We will endeavor to enhance school health. tion, the Japan Medical Association has established 7. We will endeavor to provide support for chil- a Project Committee to consider the systemization dren with special needs. of an “accident compensation system for cerebral 8. We will endeavor to lobby the government and paralysis related to childbirth” with the aims of other organizations responsible for the formu- providing an environment in which women can lation of policies concerning the support of give birth with a sense of security; removing the children and child-raising. temporal and psychological burden of childbirth Next I would like to talk about specific mea- accident lawsuits from obstetricians who are nei- sures for each item. ther negligent nor responsible for the accident; For the first item, “Support for those who de- and assure women of a healthy perinatal medical sire to become pregnant,” there are two mea- care environment based on a relationship of trust sures: between doctors and patients. The draft proposal (1) Enhancement of sterility and infertility treat- for this system was drawn up in August this year, ment; and and the JMA is working to see that systemiza- (2) Improvement of counseling organizations. tion is realized by presenting this proposal to the
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Minister for Health, Labour and Welfare for are eight measures: inclusion in the 2007 budget as an urgent issue (1) Improvement of care for children who are ill, with which the JMA is highly concerned. (2) Cooperation with childcare centers and kin- For the third item, “Improve the social envi- dergartens, ronment to enable mothers find satisfaction in (3) Support of coordination between social child- pregnancy and birth,” there are two measures: raising groups and child-raising salons, (1) Increase in the Lump Sum Birth Allowance, (4) Improvement of the work environment for and working parents raising children, (2) Support of younger and working pregnant (5) Support of parents concentrating on child- women. raising, From October of this year, the Lump Sum (6) Support for the development of environ- Birth Allowance has been raised from US$2,500 ments in which children of the same age can to US$2,900 and the application procedures have play together, also been improved. Previously the pregnant (7) Prevention of child abuse and early interven- woman (the insured person) paid the childbirth tion, and costs to the hospital, before receiving the Lump (8) Improvement of the environment based on Sum Birth Allowance; in order to lighten the conventions concerning the rights of children. burden of payment on the insured person, a In order to lighten the burden of balancing mechanism has been introduced whereby the work and child-raising, in 1994 the Ministry Lump Sum Birth Allowance is paid directly to of Health, Labour and Welfare implemented the medical institution rather than the insured “Child Health Support—Temporary Childcare” person. for children recovering from illness to be tempo- For the fourth item, “Enhancement of the rarily cared for at hospitals, clinics, and childcare health care environment to make child-raising centers. easier,” there are seven measures: In order to spread and teach people about this (1) Expansion of the Infant Medical Expense system, the JMA has produced a leaflet entitled Aid System, “Child Health Support—Temporary Childcare (2) Realization of a medical fee payment obliga- Services Q&A” and is working to ensure that tion of 10% for children aged 15 years and many more medical associations throughout younger, Japan become involved in these activities. (3) Improvement of the Emergency Pediatric For the sixth item, “Enhancement of school Care System, health,” there are five measures: (4) Enhancement of perinatal visitation (perina- (1) Efforts to nurture respect for life in children’s tal child health guidance), medical examina- mind, tions for infants, and child-raising counseling, (2) Enhancement of sex education and preven- (5) Enhancement of vaccination and increase in tative measures against sexually transmitted the immunization rate, disease, (6) Enhancement of health care for intractable (3) Promotion of anti-smoking education, diseases and cutting-edge medical care for (4) Preventative measures against lifestyle dis- children, and eases, and (7) Promotion of organ transplants for children. (5) Efforts to deal with psychological problems. The JMA has held “Child Immunization In recent years, the incidence of sexually trans- Week” since 2003 in an effort to raise the immu- mitted diseases has been growing due to such nization rate with the cooperation of local medi- factors as the diversification of sexual conduct, a cal institutions. lack of sexual knowledge, and people beginning The JMA aimed in particular to raise the immu- their sexual experience at younger ages. To help nization rate for rubella. The immunization rate as many people as possible to correctly under- was 70.4% in 2000, but had risen to 85.4% by 2005. stand sexually transmitted disease, the JMA Thus the “Child Immunization Week” initiative recently held a public forum on the theme “The has received much praise for its effectiveness. Current State of Sexually Transmitted Disease For the fifth item, “Improvement of the social and Countermeasures.” The forum was broad- environment with regard to child-raising,” there cast nationwide on November 18. Furthermore,
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because of the importance of sex education, the sored by the Ministry of Health, Labour and JMA intends to distribute a DVD of the forum to Welfare in the belief that this may help alleviate high schools throughout the nation to be used as the shortages of pediatricians and obstetricians material for sex education. which are becoming a serious problem in many With regard to the promotion of anti-smoking areas. In the future, we intend to expand the bank education, in March 2003 the JMA issued an to include all doctors to help alleviate the short- “Anti-smoking Day Declaration” and had been ages of doctors in remote areas. carrying out various activities to encourage With regard to doctors who care psychological people to quit or refrain from smoking. Because aspects of children, the number of children with a major problem is the increasingly young at psychological problems stemming from develop- which people begin smoking, the JMA is promot- mental disorders or abuse continues to increase ing anti-smoking measures aimed at young and measures to deal with this should be im- people, including the production and distribution proved. Because there are only limited doctors of an educational video. and medical institutions that can provide the For the seventh item, “Support for children specialized care required in this field, there is an with special needs,” there are three measures: urgent need to train and secure specialists in (1) Enhancement of medical care, child psychology. For this reason, the JMA is (2) Promotion of the securing of beds for chil- lobbying the government for funding for work- dren with special needs who require long- shops to train and secure child psychologists. term hospitalization, and Based on the “JMA Declaration to Support (3) Contribution to special support education. Children” and “Specific Measures,” in future And finally, for the eighth item, “Lobbying of the JMA intends to cooperate with all relevant the government and other bodies responsible for organizations in proactively undertake activities the formulation of policies concerning the sup- related to the support of children. Currently we port of children and child-raising,” there are four are developing a plan for broadly publicizing measures: the endeavors of the JMA as part of the “Love (1) Promotion of measures to resolve the short- Family” project by Asahi Newspaper Company. age and uneven distribution of obstetricians, In order to enhance support for children, there pediatricians, and midwives, is a need for various measures to be integrated (2) Promotion of measures to train doctors who and promoted comprehensively. To have most provide psychological care for children, effective results from each measure, the JMA (3) Formulation of a Child Health Law, and intends to spearhead support of children and (4) Tax benefits for pregnancy, birth, and child- with the support of members and related organi- raising. zations, proactively engage in activities to sup- As a measure to secure and improve the infra- port children. structure for reducing the uneven distribution of We believe that fulfillment of the “JMA Decla- doctors and providing quality care, this year the ration to Support Children” is an important social JMA is setting up a “Female Doctor Bank” spon- mission for physicians and medical associations.
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[Korea] The Development of Medical Ethics in Korea
Dong Chun SHIN,*1 Ilhak LEE*2
According to Hippocrates, the three elements that influenced changes in the declaration of that embody the field of medicine are sickness, medical ethics, this paper will show the changes patients and doctors. Medical ethics is formed that society demanded and how doctors were and developed through the relationships between able to cope with these demands. The examina- these three elements of medicine. In particular, tion of this process will also reveal the type of through the doctor’s relationship with the patient ethics-related mindset that a doctor requires. and the ethics that may arise from that relation- ship, the study of disorders and their treatments, The Function of the Declaration of and the various responsibilities that arise through Ethics a doctor’s relationship to the field of medicine and his colleagues. Of course, in today’s world As a profession, there are various characteristics there have been a diverse range of other parties that a doctor has or requires that sets it apart that have become involved in these relationships, from other occupations, such as the training such as with government, third party payer or required, specialized technical skills, professional future generations, making the relationships self-control, adherence to societal values and more complicated, but the relationships between ethical rules, particular motives for choosing the three basic elements remain to be essence this line of work, devotion to duties, a sense of and core of medical ethics. collaboration with colleagues, and so on. Doctors The source of medical ethics is primarily accept these features publicly as their own, so internal, namely through the beliefs that are that society can expect the manner doctors will acknowledged by the doctor and his associates. show during the medical service. The Latin origin In particular, the doctor’s oath comprises the of the word ‘professional’ means “to publicly basis of his ethics. However, as duties to society, acknowledge, to make a declaration, to make a particularly to the patient, became recognized, promise.” This sort of public promise became those beliefs and oaths gradually became prom- widely known through the Hippocratic Oath, ises to the general public that the doctor is “this which was written between the 4th and 1st Cen- kind of person” and the approval and granting tury B.C., as well as through more recent docu- of authority from society followed and the sub- ments such as the World Medical Association’s stance of medical ethics was formed. If that is “Declaration of Geneva.” After 1964, there have indeed the case, then a look into the ethics that been numerous medical ethics-related public doctors adhere to can reveal how the doctor’s declarations adopted and amended in Korea consciousness of ethics was formed. In particular, as well. if the course of transitions in the declaration of These ethics declarations commonly make medical ethics is examined, the transitions in pledges regarding the devotion to the relation- consciousness can be tracked as well. ships that a doctor makes with his patients and Through the transitions in the declaration of colleagues. Placing the patients’ interests before medical ethics, this paper will examine the their own, comradeship with fellow doctors, and changes that have taken place in the advice that the promise to provide care are the basis of those doctors give. Together with a number of cases pledges. Medical ethics declarations, particularly
*1 Executive Board Member, Korean Medical Association, Seoul, Korea. Professor, Department of Preventive Medicine, Yonsei University, Seoul, Korea ([email protected]). *2 Department of Medical Law and Bioethics, College of Medicine, Yonsei University, Seoul, Korea.
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to those just starting out in the medical profes- 6) A doctor should be satisfied with what patients sion, are accepted voluntarily and take on a dual give him or her as an expression of their grati- role as a promise to fellow medical professionals tude and should not be interested in compen- and to society. This concept of a dual role can be sation.1 explained further by saying that the primary The medical ethics presented in this medical value of having a grasp of society’s expectations encyclopedia stresses that high priority should be and knowing to what extent they should be placed on the interests of patients. It goes even accommodated, along with the medical commu- beyond humans and urges that attention be paid nity’s ability to rely on each other to conduct to animals and plants as well. This document themselves in a medically ethical manner are emphasizes that a doctor, as a specialist in treat- emphasized and reinforced. Furthermore, if these ing patients, should continually study medicine ethics declarations are looked at from a historical and goes so far as to say that a doctor is a profes- perspective, they have influenced the traditionally sional who recognizes that he should ignore his accepted roles of doctors, as well as the demands own personal gains and interests. However, this that present-day society places on doctors. type of thinking from the Chosun era lost signifi- How do these ethics declarations come to have cance, as modern Western medical systems began any binding force with doctors? Ethics declara- to be introduced. Other medical literature from tions are made with a backdrop of the consider- the Chosun era also refer to some essence of ations of the individuals and the communities medicine, a doctor’s behaviour, payments, basic that will be affected by them, and this creates mental attitudes, medical taboos, and so on. an ethical climate. Rather than seeing a doctor’s Although the traditional writings may not response to an individual’s ethical dilemma as an have direct impact thereafter, it can be said that isolated event, if it is seen from a perspective that public expectations about doctors and doctors’ encompasses societal and cultural views, the own perceptions have not changed so significantly. individual’s own experiences, and ethical norms, You can assume that the patient-focused ethics then ethics declarations can have the ability to then—alleviating suffering and not considering embody these norms. of their societal conditions—might have been carried on continuously combined by the works The Stages of Development in Korea’s of Western medical missionaries to introduce Declaration of Ethics Western medicine in Korea and the government’s poverty relief efforts. Literature referring to medical ethics can be However, sustainable development of medical found in any culture. In case of Korea, one of ethics in Korea was interrupted for a while by the the oldest documents that refers to the proper Japanese occupation. During the colonization era, conduct of doctors was written in the medical doctors were used by the imperial government as encyclopedia called Ui-Bang-Yu-Chui (醫方類聚; “medical police” to maintain surveillance of the A Collection of Medical Procedures) published Koreans, as well as for any other means the impe- in 1445. The following is the list of doctor’s duties rial government deemed necessary.2 compiled in it: Korea’s new declaration of medical ethics 1) A doctor has the duty to study sicknesses and was established in 1961, a number of years after treatments. regaining independence. Although this new dec- 2) A doctor exists to treat the patients’ illnesses. laration was not totally unrelated to the period Doctors should consider the best interest for of enlightenment, it did not reflect Korea’s par- patients only, regardless of their social status. ticular situation remaining simply as a translation 3) All lives including those of plants and animals of the Geneva Declaration enacted by the World should be respected and not be harmed sense- Medical Association in 1948. This declaration lessly in the process of medicine preparation. was composed of the general duties of doctors, 4) A doctor must do everything he can to treat duties to patients, and doctors’ duties to each other patients. and so forth. Although this declaration failed 5) A doctor should not put his or her personal to reflect the circumstances completely, it was interests over care for patients. He or she must accepted broadly and stands still valuable in that try to keep his or her dignity. the classification of doctors’ duties presented in it
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became a standard for discussions on medical 6) Rejecting unnecessary medical actions. ethics thereafter. The examination and amend- 7) Care and medical intervention for dying pa- ments to it began in 1970. At that time, the health tients. insurance system was just introduced in Korea 8) The protection of safety and autonomy for and access to medical services was still hard to medical research subjects.3 get among public. Especially when excessively These statements are a positive reflection of high health insurance claim fees became a soci- the demands of the past 20 years to guarantee etal problem in 1978, the Korean Medical Asso- patients’ rights and research test subjects’ rights. ciation began to review the ethical position of It can be said that to guarantee patient’s personal doctors and a new declaration of medical ethics rights does not have to be mentioned specifically was enacted in the following year as a result of as it is the very basic in medical conduct, but it the review. The changes are meaningful in that shows doctors’ strong resolution towards them they reflect contemporary realties and principles by stating it clearly and specifically. in order to truly deal with medical ethics issues So far, we have examined that Korea’s decla- and thus promoted a large number of medical ration of medical ethics have been revised to communities to join in the process of producing adjust to public demands and changes in doctors’ genuine agreement. perception shift towards their mission in commu- From 1980 to 1990, medicine in Korea expanded nity. What needs to be done from now on should both quantitatively and qualitatively. It can be be that the declarations be shared and accepted attributed to the advances in society and in medi- through diversified communication channels to cal technologies around the globe, increase in the public, so that they don’t merely remain as efforts of doctors and expand of medical expen- one-way declaration of doctors’ own. diture through health insurance system. During this time of change, patients and doctors became Events That Changed the Landscape of increasingly aware of human rights issues and Korea’s Medical Ethics this further influenced the development of medi- cal ethics. The declaration of medical ethics was If medical ethics should be developed through amended in February 1997 to reflect these changes. communication with society, a chaos brought The new declaration held on to the existing ideas forth by a medical scandal would be the time, of medical training and providing the best treat- when those communications take place the most. ment to patients (including the ethical duty to do There have been a number of eye-opening scan- everything possible), but it expanded the scope of dals in the Korean medical field. Among those, guidelines on cooperation among professionals two issues stand out: One is the “Boramae Hospi- into nurses and other medical staff. However, the tal Case” occurred in 1997, in which the courts most significant amendment was that this decla- called doctors to account regarding their duty on ration shaped the code of medical ethics (1997, the a patient’s discharge, who lost consciousness. 2006) and medical ethics guidelines separately, The other is “The Separation of Functions between thus having a more substantial and practical Prescription and Dispensary,” against which doc- influence. This was truly a turning point in that tors went on a general strike as an expression of the medical association recognized the society’s strong protest. The strike brought forth a lot of demand for a high level of ethics and made a real controversies over its righteousness. effort to meet them. From the code of ethics by the Korean Medical Association, the following The Boramae Hospital case can be found: On December 4 in 1997, a 58-year-old-man fell 1) A devotion to human dignity. on the floor at his house in a drunken state result- 2) Self-control in medical treatment and proper ing in an epidural hemorrhage in his head. He was conduct. taken to the Boramae Hospital in an emergency 3) The pursuit of awareness and public health. situation and received a 6-hour-long operation to 4) The protection of the patient’s right to decide remove the hematoma caused by the epidural for oneself. hemorrhage successfully. Although he was attached 5) The protection of the patient’s privacy, rights to a respirator because of difficulties in breathing and interests. resulted from cerebral edema from the brain sur-
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gery, he was recuperating little by little and interest. Beginning with a one-day strike, it went chances were for further recuperation. The on for five rounds, in addition to the nearly 4- patient’s wife learned from medical staff that months-long specialists’ strike. the hematoma was removed through surgery and Doctors focused on banning alternative filling that her husband’s condition would improve. of prescriptions by pharmacists. However, under However, she requested her husband to be dis- the circumstances in the medical field back then, charged due to financial burdens. The wife was it was hardly possible and they determined to told that he would die if he were to be discharged block the implementation of the system itself. without medical staff or a respirator. On Decem- Despite doctors’ strong opposition, the Govern- ber 5, she ignored the advice of the medical staff ment the system announced its stance to imple- and requested her husband to be discharged. In ment the system in September of 1998, with an less than 5 minutes after leaving the hospital, the exception of hospital in-patients and passed the bill patient began to have trouble breathing and died. in the following year. This brought forth strike The wife and the hospital staff in charge of the among primary care physicians first and expanded patient were charged with homicide and were into general strikes by doctors thereafter. prosecuted as joint offenders in this case. This event stemmed from the different views On June 24, 2004, the Supreme Court sentenced between the professionals’ interests and the gov- the doctor to 1 year and 6 month in prison and 2 ernment’s role over implementation of new policy. years probation. As grounds, the Court asserted The fact that physicians, who stand conservative that the doctor still followed the demands of towards social issues, initiated a strong action like the guardian and permitted the patient to be dis- general strike came to many people as a shock. charged although he knew that he would die It still remains to be seen whether this event without a respirator. This judgment imposed the will be seen by the society as a fair protest for the responsibility on the doctor. This judgement came justifiable rights of doctors or as an improper as a shock to most Korean doctors, as decisions of exercise of power. This provided a good opportu- patient’s family were generally accepted as an nity to debate society’s values regarding medi- important ground for doctors in making difficult cine and the medical workers’ role. However, decisions regarding treatment interruption. With doctors could not receive sympathy from the this judgement, doctors remind of their duties to public and failed to adhere to Article 8 of in the treat a patient as an autonomous individual and Declaration of Medical Ethics, thus bringing their best interest should be considered under down the level of trust invested in them by the any circumstances. There is a provision referring society. to this in the medical ethics guidelines, but no explicit written provisions in laws, causing confu- Conclusion sions. Although there formed an implicit ethical consent on the necessity of those provisions, We have examined how doctors are recognized measures for legislation. This shows an aspect of and perceived by the society and how changes lack of communication between medical profes- in the general principles of medical ethics have sional and the frame of the society.4 affected doctors’ own perception. We have also examined the events that increased awareness The separation of dispensing function from of the medical field and how that has affected prescribing society’s expectations in physicians. Physicians, Conflicts among doctors, pharmacists and the who doctors, who have the highest professional- government regarding the separation of dispens- ism which society grants, must positively accept ing function from prescribing provoked doctor’s their role in society and developments in ethics general strike of 2000 nationwide and became must continually be made so that they can a national issue that roused much conflict and present justifiable views and knowledge.
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References 3. From the website, 1. Shin DW. Medical theories during Chosun-Dynasty. Korean http://kma.org/General/intro/intro_declaration.asp (Korean) 4. Park J, et al. Legal considerations on discharge against medical Journal of Medical History. 2004;13:134–145. 2. Yeo I, et al. A history of medical license in Korea. Korean Journal advice—the case at Boramae Hospital. Proceeding Book of of Medical History. 2002;11:137–153. 2005 International Congress on Medical Law. 2005;1035–1042.
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JMAJ, May/June 2007 — Vol. 50, No. 3 225 Symposium Continuing Development in Ethics and Professionalism
[Macau] Continuing Development in Ethics and Professionalism
Nai Chi CHAN*1
*1 Director of the Macau Association of Medical Practitioners. President of the Macau Society of Hematology and Oncology ([email protected]).
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[Malaysia] Continuing Development in Ethics and Professionalism by Malaysian Medical Association
Siang Chin TEOH*1
18th century with John Gregory (1724–1773) a Introduction Scot who became Professor of Physic at Edin- burgh. He would lend his students his lecture A profession sets standards of competence and notes and one of them arranged their publication behaviour and is self-regulating. The adminis- in 1770. “Offices on the Duties and Offices of a tration of the Hippocratic Oath is the student’s Physician, and on the Method of Prosecuting introduction to the ethics and behaviour expected Enquiries in Philosophy.” of a physician. The public believes that the pro- In this, he advised on the moral qualities of a fession has the Oath as the ultimate guide for physician. The chief is humanity— physicians. Such codes of behaviour are charac- “that sensibility of heart which makes us feel for teristic of professions and over the centuries, the the distresses of our fellow creatures, and which, of Oath has been modified to reflect the changing consequence, incites us in the most powerful man- mores of society. ner to relieve them.” At the same time, the business of medicine He drew attention to sympathy, gentleness of has produced guidelines of behaviour between manners and compassion. He advised that the physicians and their patients that indicate how to physician develop a composure and firmness of practice medicine and these are used to govern mind so as not to be enervated. This was what was medical practice. These guidelines have often to be known as Osler’s Aequanamitas.1 been made into standards and regulations. The public has trusted that the profession applies The Profession of Medicine these standards and ensures the proper practice of medicine. Medicine is the branch of health science and the Legislation governing medical practice is noth- sector of public life concerned with maintaining ing new. The first example is seen in Mesopo- or restoring human health through the study, tamia, Babylon, whereby the ruler Hammurabi diagnosis, treatment and possible prevention of 1728–1686 B.C. had a code that applied to many disease and injury. It is both an area of knowl- legal matters including land-owning, divorce, boat edge—a science of body systems, their diseases building while a few deal with medical practice. and treatment—and the applied practice of that For instance, regulations set the fees for treat- knowledge. ment as well as the penalties for failure depend- The practice of medicine combines both sci- ing on the rank of the patient. This code is in the ences as the evidence base and art in the applica- Louvre, Paris. tion of this medical knowledge in combination “If a physician has performed a major opera- with intuition and clinical judgement to deter- tion on a lord with a bronze lancet and has saved mine the treatment plan for each patient. the lord’s life . . . he shall receive ten shekels of Central to medicine is the doctor-patient rela- silver; but if he caused the death of such a notable, tionship established when a person with a health his hand would be chopped off. A doctor causing concern seeks a physician’s help; the ‘medical the death of a slave would have to replace him.” encounter’. Other health professionals similarly The modern code of ethics emerged in the establish a relationship with a patient and may
*1 President, Malaysian Medical Association, Kuala Lumpur, Malaysia ([email protected]).
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perform various interventions, e.g. nurses, radio- graphers and therapists.2 Concern with clinical standards, outcomes, effectiveness and audit Values in a Doctor More and more of the care given to patients and the treatment offered will be based on proper High standard of ethics outcome based evidence. This is not to deny From the time of Hippocratic oath, medical innovation or to stifle research and development. practice has always had a very strong ethical Rather the opposite. Standards record where we foundation, and rightly so, as it is one of the key are now; research and innovation should take us features of a profession. More than ever, the to new levels of quality and care. It is clear from ethical principals associated with clinical practice many studies that there are variations in treat- need to be debated and clarified. New proce- ment and outcomes across Britain. Some of these dures and ethical dilemmas arise constantly. are understandable and explainable. Others are Greater public awareness of the issues means not. It is this aspect which from a public point of that the debates are no longer confined to profes- view requires resolution. Audit is a tool, which sional audiences and it is appropriate that the has value in measuring that quality of care pro- wider public is included. There is greater scrutiny vided. It is only one tool but an important one to of professional practice, and standards are now assure quality. As part of professional practice, all openly discussed in the media and public fora. doctors should be involved in auditing clinical The profession has nothing to fear from such work. debates as long as it is not defensive or secretive. Continuing professional development is an Ability to define outcomes issue, which is broader than continuing educa- Outcomes in some instances are not easy to tion. It is concerned with personal growth and define but are an important professional chal- satisfaction with professional work. It is an issue, lenge. The use of guidelines, which can be seen as which has been neglected, in recent years but, no more than the formalization and clarification with the changing role of the consultant, it is one, of good clinical practice, is part of the process which will need to be looked at afresh in the near of care and is not an end in itself. Guidelines need future. to be feasible, to encourage local involvement, and not to inhibit new methods of management. Ability to work in a team Rather, they should be a base from which to As medicine and health care increases in com- build. They should help us to understand and plexity so it becomes even more necessary to be explain variations in care. sure that all the skills of professions other than medicine are utilized to the full. This means Interest in change and improvement, working and learning in teams, but it does not research and development mean relinquishing the key patient-doctor rela- Medicine cannot and should not stand still. It is tionship, which is so central to the therapeutic continually evolving and improving. All doctors process. need to be involved in changing and improving Concern with health as well as illness is a key clinical practice. Indeed, they have an obligation issue. Are doctors to be concerned only with to be so, though this does not mean that all need those who are ill or do they have a wider role to be involved in “research.” This key value, how- in the community? ever, emphasizes the importance of academic input and of teaching. Patient and public focused The purpose of medicine is precisely to do with Ability to communicate serving the patient and the public. Perhaps we Of all complaints against doctors, problems of should be more willing to say this explicitly communication must be one of the greatest. Yet, it rather than implicitly. There is great energy is perhaps the key part of the function of the doctor and power in this process if it can be harnessed if you accept that making a diagnosis, assessing effectively. prognosis, and defining treatment are central roles for the doctors. Arrogance and discourtesy
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reflect badly on a profession whose primary pur- It is clear in these statements that professional- pose is to care for the patients. The importance of ism is above all an ethical concept. Its distinguish- communication (a two-way process) is increas- ing features are those of a profession: a strong ingly being recognized in medical schools, and commitment to the well being of others, high role models (Consultants and General Practitio- moral standards, mastery of a body of knowledge ners) must also recognize the effect of the “hid- and skills and a high degree of autonomy. These den agenda” (their attitudes and behaviour) on features clearly apply to the individual members medical students and post-graduates. of a profession. Their application to the group as a whole, including professional associations, is Definitions less evident.
Professionalism4 Ethics “The term professionalism is used to describe Put simply, ethics is the study of morality—care- those skills, attitudes and behaviours which we ful and systematic reflection on and analysis of have come to expect from individuals during moral decisions and behaviour, whether past, the practice of their profession and includes con- present or future. Morality is the value dimension cepts such as maintenance of competence, ethical of human decision-making and behaviour. The behaviour, integrity, honesty, altruism, service to language of morality includes nouns such as others, adherence to professional codes, justice, ‘rights’, ‘responsibilities’ and ‘virtues’ and adjec- respect for others, self-regulation, etc.” tives such as ‘good’ and ‘bad’ (or ‘evil’), ‘right’ “In Canada and the United States the social and ‘wrong’, ‘just’ and ‘unjust’. According to basis of the extraordinary grant of occupational these definitions, ethics is primarily a matter of authority and independence to professionalized knowing whereas morality is a matter of doing. occupations such as medicine and law has been a Their close relationship consists in the concern social contract between the profession and the of ethics to provide rational criteria for people public. Professionalism is the moral understand- to decide or behave in some ways rather than ing among professionals that gives concrete reality others. to this social contract. It is based on mutual trust. Since ethics deals with all aspects of human In exchange for a grant of authority to control key behaviour and decision-making, it is a very large aspects of their market and working conditions and complex field of study with many branches or through licensing and credentialing, professionals sub-divisions. Medical ethics is a branch of ethics are expected to maintain high standards of compe- that deals with moral issues in medical practice. tence and moral responsibility.” Medical ethics is closely related, but not identical “We think of professionalism as an activity that to, bioethics (biomedical ethics). Whereas medi- involves both the distribution of a commodity and cal ethics focuses primarily on issues arising out the fair allocation of a social good but that is of the practice of medicine, bioethics is a very uniquely defined according to moral relationships broad subject that is concerned with the moral . ..Three core elements of professionalism, each issues raised by developments in the biological different in nature, are necessary for it to work sciences more generally.5 properly. First, professionalism requires a moral commitment to the ethic of medical service, which Ethics and Professionalism in Medicine we will call devotion to medical service and its values. This devotion leads naturally to a public, Medical professionalism affects just about every- normative act: public profession of this ethic. Pub- body—physicians, patients, other health pro- lic profession of the ethic serves both to maintain viders, health care administrators, governments professionals’ devotion to medical service and to and the general public (as taxpayers, potential assert its values in societal discussion. These dis- patients, relatives of patients, etc.). Some of its cussions lead naturally to engagement in a politi- features may be good for some of these groups cal process of negotiation, in which professionals but not for others. For professionalism to be pre- advocate for health care values in the context served and enhanced, it will likely have to be seen of other important, perhaps competing, societal as serving the overall good of society, not just one values.” or two groups.
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patients or their families for inappropriate medi- Ethic of service cal services are arguably not in the best interests “Professionalism in medicine requires the physi- of either patients or society. cian to serve the interests of the patient above his or her self-interest. Professionalism aspires to Self-regulation altruism, accountability, excellence, duty, service, If there must be restrictions on their autonomy, honor, integrity and respect for others.” physicians prefer that they be imposed by their This fundamental characteristic of profession- peers rather than by non-physicians. They have alism is clearly in the interests of patients, who traditionally been granted this privilege by society are its primary beneficiaries. Society also benefits, on the grounds that only physicians know medi- by having those who control the knowledge and cine well enough to determine appropriate stan- skills for providing such an essential service as dards for its practice; they can be trusted to set medical care do so not primarily for their own and enforce appropriate standards of physician gain but for the good of others. The benefit of the behaviour; and this is the most effective way ethic of service to physicians is less direct but still for society to achieve the good it desires from of considerable importance. It entitles them to medicine. In this regard, it is important to note the trust, respect and gratitude of their patients that society has benefited from physician self- and of society (even if these are not actually regulation too, not least because relatively few bestowed). For the profession as a whole, the resources have to be devoted to the surveillance ethic of service contributes to the credibility of its of physicians. advocacy work. However, there have been many accusations that the profession has abused the privilege of Clinical autonomy self-regulation by failing to deal fairly with com- “Professional autonomy has been the highest plaints against physicians. If self-regulation is to ethic of the medical profession for much of the be seen as serving the overall good of society, twentieth century.” not just that of physicians, the profession has to This viewpoint is reflected in the World Medi- accept its burdens as well as its benefits, i.e., phy- cal Association Declaration on Physician Inde- sicians have to undertake the tasks required by pendence and Professional Freedom. Although self-regulation, including meting out penalties to the power of physicians to control their own their errant colleagues, and must also be seen to work and to direct others involved in the care do so. of their patients has diminished in recent times, William Sullivan, a prominent medical soci- it still exceeds that of many, if not most, other ologist: “Neither economic incentives nor tech- occupations. This is clearly a desirable feature of nology nor administrative control has proved an professionalism for physicians, in that it allows effective surrogate for the commitment to integrity them to act as medical expert and healer on evoked in the ideal of professionalism.” Without behalf of their patients. question, the medical profession itself wishes to This benefit is always obvious to others. Many function within a system dominated by a healthy patients want their physician to do what they and flourishing professionalism. As Sullivan and think best, not necessarily what the physician Friedson points out, there should also be substan- recommends. However, patients need their phy- tial advantages to society in preserving profes- sicians to exercise clinical autonomy in making sionalism as an effective value-based system. The recommendations about what is best for them, original reason for the use of the profession as whether or not they accept the recommenda- a means of organizing healthcare was because tions. Hospital administrators and third-party of the complexity of the knowledge base, the payers may consider physician autonomy to be difficulty in regulating it, and the presumption incompatible with prudent management of that the profession would be altruistic and health care costs. However, the restraints that devoted to the public good. We believe that noth- administrators and third-party payers attempt to ing in the past 150 years has altered that fact. place on clinical autonomy may not be in the best Thus, both society and the profession should wish interests of the patients. Furthermore, restraints for the same type of physician—competent, moral, on the ability of physicians to refuse demands by idealistic and altruistic. This is best guaranteed by
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a healer functioning as a respected professional.6 ism should include several components. The practice of medicine has a special charac- 1. Identifiable educational content in the under- teristic not found in so pronounced a manner in graduate medical school curriculum devoted other occupations. Doctors deal directly, and at to professionalism, which should be reinforced the time when a person is most vulnerable, with in postgraduate programmes and in continu- the immediate issues of life and death, health and ing medical education. The subject should be illness. The patient is heavily dependent upon the part of the evaluation of all students. technical knowledge and integrity of the doctor. 2. The concept that to be a professional is not a The doctor thus has a unique involvement with right but a privilege with a long history and the patient, but this relationship between doctor tradition of healing and service. and patient is not balanced. The patient’s attitude 3. The separate but linked concepts of the is a complex of trust (which comes from per- physician as healer, and the physician as ceived competence and integrity of doctor) and professional, and the fact that society uses paradoxically also that of distrust which comes professional status as a means of organizing from the state of uncertainty and vulnerability. the delivery of services. This ambivalence in doctor-patient relation- 4. A clear definition of professionalism and its ship is addressed by medical ethics, which tries to characteristics. guarantee the patient that the doctor will not 5. Professionalism as an ideal to be pursued, abuse his dominance in the relationship. Thus, emphasizing its inherent moral value. The medical ethics is essentially a regulatory mecha- concept of altruism and “calling” must be nism that makes the doctor commit publicly that highlighted as essential to professionalism. though medical practice is the source of his living, 6. An understanding that proper professional he will strive to the utmost for the benefit of the behaviour is essential for the healer to func- patient and not be driven by just for mere per- tion fully and to maintain the trust of patients sonal aggrandishment. and society. It is normally accepted as a rule that ethics is 7. Knowledge of codes of ethics governing the something more than law. The formulation of conduct of both the healer and the profes- various aspects of ethical code is based on ethical sional, as well as the philosophical and his- principles, which are in many ways different from torical derivations of these codes. legal principles. Ethics govern conduct. Principles 8. The essential nature of the autonomy of the based on it thus delve into fine aspects of the individual doctor, along with the legitimate conduct of doctors. Ethics and its principles also limitations that have always existed. The come into play to resolve recurrent ethical dilem- degree of autonomy will vary in different mas in medical practice. As the occurrence of a societies, but a minimum is required for a particular dilemma increases and as its resolution doctor to exercise the necessary independent in a certain manner gains general acceptance judgement to best serve the patient. within the profession, it gets integrated into the 9. The nature of collective autonomy of the pro- code itself. This creates a dynamic mode which fession, along with its legitimate and inherent makes the ethical code progressively more elabo- limitations. rate. Laws are circumscribed. Their elaboration 10. Relevant material drawn from sociology, by the judiciary is also greatly limited. Since the philosophy, economics, political science and profession acts as lawmaker as well as its imple- medical ethics as related to professionalism, menting agency, its elaboration is wider.7 including interpretations of both the histori- cal course of events and of doctors’ behaviour Teaching Ethics and Professionalism that are critical of the medical profession. The profession must not be allowed to build and Medical schools, teaching hospitals and those maintain its own myths while avoiding ideas responsible for continuing medical education challenging them. should teach professionalism as a subject for- 11. The link between professional status and the mally identified in the curriculum. The material obligations to society that must be fulfilled to be taught will change in different cultures and to maintain public trust. These obligations certainly with time. The teaching of professional- should be explicitly outlined and included in
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the teaching. They include obligations to Doctors are no longer alone in the clinical know and be guided by the applicable codes management of patients. Multi-professional team- of ethics and national and regional laws; to work, the philosophy behind modern shared care, participate in more effective and transparent has to be reconciled with the personal nature of self-regulation; to address health issues of doctor-patient relationship. concern to society; to maintain competence Doctors’ attitudes are also changing. For exam- throughout one’s medical career, to be pre- ple, more doctors attach as much importance to pared to be fully accountable for all decisions the quality of their lives outside medicine as to taken; to expand and ensure the integrity of their medical work. Part-time practice has become medicine’s knowledge base by supporting more common for both men and women. Such science in its broadest sense; to insist on the developments have major implications for conti- maintenance of sufficient individual and pro- nuity of care and the organization of medical fessional autonomy to enable the doctor to work.9 act in the best interests of the patient; and Doctors today are experiencing frustration as to be governed by professional standards of changes in the health care delivery systems in conduct no matter what role is being filled virtually all industrialized countries threaten the —private practitioner, employee of the state very nature and values of medical professional- or corporation, manager, administrator, or a ism. At present, the medical profession is con- mixture of roles. Finally, of course, the obliga- fronted by an explosion of technology, changing tion to put the welfare of the patient and of market forces, problems in health care delivery, society above one’s own is paramount.8 bioterrorism and globalization. As a result, physi- cians find it increasingly difficult to meet their Ethics and Professionalism in responsibilities to patients and society. In these a Changing World circumstances, reaffirming the fundamental and universal principles and values of medical profes- Our professionalism is shaped by the context in sionalism, which remain ideals to be pursued by which we work. First and foremost, medical all physicians, becomes all the more important. knowledge and skill have expanded at an unprec- The medical profession everywhere is embed- edented rate. This, together with the revolution in ded in diverse cultures and national traditions, information technology, has huge implications but its members share the role of healer, which for the profession. has roots extending back to Hippocrates. Indeed, People know more about health matters the medical profession must contend with compli- because they have independent access to clinical cated political, legal and market forces. More- information and because their interest has been over, there are wide variations in medical delivery stimulated by media attention. More patients and practice through which any general principles want an open relationship with their doctors; may be expressed in both complex and subtle they want to be well informed and involved in ways.10 decisions about their care.
References
1. Warren P. The development of a profession. Hippocrates on the 2002;177:208–211. Web. History of Medicine, Faculty of Medicine, University of 7. Jesani A. Law, ethics and medical council: evolution of their Manitoba. relationships. Medical Ethics. 1995;3:C-9–12. 2. Medicine. Wikipedia, free encyclopedia. 8. Cruess SR, Cruess RL. Professionalism must be taught. BMJ. 3. Calman K. The profession of medicine. BMJ. 1994;309:1140– 1997;315:1674–1677. 1143. 9. Irvine D. The performance of doctors: professionalism and self- 4. Canadian Medical Association. Professionalism in medicine. regulation in a changing world. BMJ. 1997;314:1540. CMA Series of Health Care Discussion Papers; 2001. 10. ABIM Foundation, ACP-ASIM Foundation, European Federation 5. World Medical Association. Medical Ethics Manual. of Internal Medicine. Medical professionalism in the new millen- 6. Cruess SR, Johnston S, Cruess RL. Professionalism for medi- nium: a physician charter. Ann Intern Med. 2002;136:243–246. cine: opportunities and obligations. Medical Journal of Australia.
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[New Zealand] International Code of Medical Ethics
Ross BOSWELL*1
At the 2006 General Assembly of the World permission of the patient except when the law Medical Association, a revision of the Inter- requires otherwise, or in those unusual circum- national Code of Medical Ethics was adopted. stances when it is clearly in the patient’s best The statement of the current version on confi- interests or there is an overriding public good. dentiality is: Patients should be made aware of the informa- “A PHYSICIAN SHALL respect a patient’s tion sharing which enables the delivery of good right to confidentiality. It is ethical to disclose quality medical care. Where a patient expressly confidential information when the patient con- limits possession of particular information to one sents to it or when there is a real and imminent practitioner, this must ordinarily be respected. threat of harm to the patient or to others and this Patients should be made aware in advance, if pos- threat can be only removed by a breach of sible, where there are limits to the confidentiality confidentiality.” which can be provided. When it is necessary to In New Zealand, there are a number of situa- divulge confidential patient information this tions where doctors are required by law to pro- must be done only to the proper authorities, and vide confidential patient information. Examples a record kept of when reporting occurred and its are: significance.” • Where the patient has some notifiable disease The draft of the International Code prepared such as meningococcal infection, campylobac- by the drafting committee and recommended by ter enteritis, syphilis, gonorrhoea etc. the Council to the WMA Assembly contained a • Where the police have the authority of a search further statement: warrant to seize records in the investigation of a “It is ethical to disclose confidential information crime when the law requires or allows it.” • Where cervical screening audit investigators This was struck out by the Assembly, because have authority to examine records of a woman of concern that in some countries, lawmakers who has developed cervical cancer. might inappropriately legislate to damage con- These circumstances fall far short of the very fidentiality. stringent requirement in the current Inter- The NZMA proposes that a middle ground, national Code for “real and imminent threat allowing for the possibility of reasonable disclo- of harm to the patient or to others and this sure without dire emergency and without explicit threat can be only removed by a breach of patient consent, could be reached by amending confidentiality.” the current version of the code by the addition of The current NZMA Code of Ethics has a the following: rather less stringent requirement: “It may be ethical to disclose confidential infor- “Protect the patient’s private information mation when the law requires it” throughout his/her lifetime and following death, so that the whole item reads: unless there are overriding public interest con- “A PHYSICIAN SHALL respect a patient’s siderations at stake, or a patient’s own safety right to confidentiality. It is ethical to disclose requires a breach of confidentiality.” confidential information when the patient con- and in the explanatory and advisory notes to the sents to it or when there is a real and imminent NZMA Code: threat of harm to the patient or to others and this “Doctors should keep in confidence informa- threat can be only removed by a breach of con- tion derived from a patient, or from a colleague fidentiality. It may be ethical to disclose confi- regarding a patient, and divulge it only with the dential information when the law requires it.”
*1 Chairman, New Zealand Medical Association, Wellington, New Zealand ([email protected]).
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Such a revision would allow for the reasonable to declare that some laws proposed or enacted in disclosure of information for public health needs, its country are against the principles of medical while allowing a National Medical Association ethics.
JMAJ, May/June 2007 — Vol. 50, No. 3 235 Symposium Continuing Development in Ethics and Professionalism
[Philippines] Continuing Development in Ethics and Professionalism
Jose Asa SABILI*1
*1 President, Philippine Medical Association, Manila, Philippines ([email protected]).
236 JMAJ, May/June 2007 — Vol. 50, No. 3 PHILIPPINE MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 237 Symposium Continuing Development in Ethics and Professionalism
[Singapore] Continuous Professional Development (CPD) Programmes on Medical Ethics and Professionalism in Singapore
CHONG Yeh Woei*1
*1 1st Vice President, Singapore Medical Association, Singapore ([email protected]).
238 JMAJ, May/June 2007 — Vol. 50, No. 3 SINGAPORE MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 239 Chong YW
240 JMAJ, May/June 2007 — Vol. 50, No. 3 SINGAPORE MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 241 Chong YW
242 JMAJ, May/June 2007 — Vol. 50, No. 3 Symposium Continuing Development in Ethics and Professionalism
[Taiwan] Ethics as Core Competence: Continuing development in ethics and professionalism on Taiwan
HUANG Ying-chia*1, LIU Peggy*2
*1 Taiwan Medical Association, Taipei, Taiwan, ROC ([email protected]). *2 Asia Unviersity.
JMAJ, May/June 2007 — Vol. 50, No. 3 243 Huang Y, Liu P
244 JMAJ, May/June 2007 — Vol. 50, No. 3 TAIWAN MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 245 Huang Y, Liu P
246 JMAJ, May/June 2007 — Vol. 50, No. 3 TAIWAN MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 247 Huang Y, Liu P
248 JMAJ, May/June 2007 — Vol. 50, No. 3 TAIWAN MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 249 Huang Y, Liu P
250 JMAJ, May/June 2007 — Vol. 50, No. 3 TAIWAN MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 251 Huang Y, Liu P
252 JMAJ, May/June 2007 — Vol. 50, No. 3 TAIWAN MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 253 Symposium Continuing Development in Ethics and Professionalism
[Thailand] Continuing Development in Ethics and Professionalism in Thailand (2006)
Wonchat SUBHACHATURAS*1
Amidst the Globalization and Economic Compe- tion, enforcement and professional penalties. tition nowadays, medical profession has received 3. The Medical Association, a professional non- a reflection in both positive and negative reac- governmental self controlled body, works as tions. In the positive arm, medical profession has a socially compromising and connecting peo- been making progressive and modernized devel- ple among health providers and health con- opment in both technical and educational areas. sumers. Stimulating all teaching bodies to New technologies have been developed to help educate undergraduates in ethical lessons and creating more precise and accurate diagnoses, professional responsibilities. Encourage and safer and more effective treatment resulting in boosting up the issue by insinuation the mat- the better quality of life. However on the other ter in professional meetings and publications. arm, the negative side, competition leads to a more The three-party committee has been set up advertisement, over usage of investments and in Thailand composing of the leading represen- more marketing in the field of medicine. Human tatives from the three organizations to work resources in health care services are inevitably together in the issue of medical ethics and pro- affected by the changes. Health industry was fessionalism. Meetings for discussion have been named and progressively replacing ideal health made 3–4 times a year to strengthen the good professionalism. and ethical medical practice and also to solve the Thailand, as a developing country, is unques- concern problems. tionably, also being affected by the said global Inequity and under payment for Medical Pro- development. Many newly graduated doctors put fessions are also the matters of concern these themselves dependent more on machines and days in Thailand. Health reform has been practic- technological equipments than mutual attitude ing for 5 years since 2001, aiming at the creation and relationship. It is true that competition is of universal coverage and equity of health care inherited deep in human midbrain as a natural services among Thai citizen in general. However instinct but it is also true that to have a person after a period of practice, some unpredictable living together with others in a community, dis- situations and problems were experienced and cipline is needed to be set. the newly reform system, the National Health The control of Medical Ethics in Thailand is Insurance, needs some corrections and tailoring under the care of three organizations. to fit the needs of the public and the spending of 1. The Government, via the Ministry of Public the country. Health, takes actions through legislation, law, More prevention leads to less need for cura- by-law and regulations. tive but more ethical providers in the field is still 2. The Medical Council, empowered by the law, the big challenges of the country. takes actions through professional registra-
*1 International Relation, Medical Association of Thailand, Bangkok, Thailand ([email protected]).
254 JMAJ, May/June 2007 — Vol. 50, No. 3 Symposium Continuing Development in Ethics and Professionalism
[Sri Lanka] Development of Ethics and Professionalism in Sri Lanka
Suriyakanthie AMARASEKERA F.R.C.A*1
A code of Ethics is one of the hallmarks of a rent year are profession. Prior to 1992, the Medical Ordinance • Complaints that inadequate time is spent on of Sri Lanka, laid down by an act of parliament consultations with specialists in 1927, was the only document that promulgated • Prevention of Medical Negligence a code of behavior for doctors. The Ceylon Medi- • Informed Consent cal Council performed the regulatory function • Broadcast Publicity of monitoring ethical behavior in the medical • Advertising by professionals and institutions profession. Other areas of activity In 1992 the Sri Lanka Medical Association • SLMA has representation in the Ethics Commit- formed an Ethics Committee with the objective tee of the Sri Lanka Medical Council which has of dealing with General Ethics relating to profes- produced a document on “Provisional Code of sional practice. An Ethical Review Committee was Practice for assisted Reproductive Technologies” formed a few years later, to deal with research • SLMA has representation in the National Bio ethics. Ethics Committee of the National Science Foun- Recognizing the importance of incorporating dation and is involved in drafting a Human good ethical principles in our day to day practice, Reproduction and Genetics Act the SLMA published the Declaration of Health • National Bio Ethics Committee which is chaired in 1995. by the Chairperson Ethical Review Committee The Committee also published Ethical Crite- of the SLMA is currently examining the defi- ria for the promotion of Medicinal Drugs and ciencies in the current regulations dealing with Devices in Sri Lanka in the same year. Human Genetic Data Collection The Ethics Committee, comprising of medical • Involved with the ERC of the Faculty of Medi- professionals representing the different specialist cine Colombo in the formulation of Uniform Colleges and Associations, representatives of the Guidelines for Ethics Research Committees legal profession and members of the public meets The Sri Lanka Medical Association is justly monthly. Various ethical issues that have been proud of its achievements so far in initiating, referred to the committee from the Council are monitoring and propagating high standards of taken up for discussion and appropriate action ethical behavior and professionalism in the taken. The committee also organizes Symposia medical profession in Sri Lanka. As the national and Workshops on ethical topics, and publishes medical association, we are committed to ensure articles in the monthly News Letter of the continued progress in this field by keeping up SLMA, drawing the attention of the medical pro- with emerging ethical issues in medical practice fession to current ethical problems. and research. Problems that have been dealt with in the cur-
*1 President, Sri Lanka Medical Association, Colombo, Sri Lanka ([email protected]).
JMAJ, May/June 2007 — Vol. 50, No. 3 255 Amarasekera S
256 JMAJ, May/June 2007 — Vol. 50, No. 3 SRI LANKA MEDICAL ASSOCIATION
JMAJ, May/June 2007 — Vol. 50, No. 3 257 Amarasekera S
258 JMAJ, May/June 2007 — Vol. 50, No. 3 Research and Reviews
The Physician-Patient Relationship Desired by Society
JMAJ 50(3): 259–263, 2007
Hiroyasu GOAMI*1
Abstract A physician-patient relationship based paternalism is still deeply rooted in today’s Japan. However, it is also true that “patient-oriented healthcare” is beginning to be emphasized in the clinical field here. Demand by patients for the disclosure of medical information is growing year by year. However, looking at the current situation in clinics in Japan, we are still far from receiving a pass score of “Good enough.” This may be due to the existence of a large communication gap between physicians and patients. Results of a questionnaire of physicians and patients indicate that physicians believe that they display an attitude of respect and consideration for patients, and provide patients with sufficient informed consent, but the patients themselves do not share this view. Thus, there is a large gap between the self-image of physicians and the image of physicians held by patients. In the first place, there is the wall of “information asymmetry” between physicians and patients. The optimum conditions for medical care are not achieved unless physicians polish up their communication skills and accom- pany their patients through the treatment process. At the same time, there is a strong need for patients to abandon the attitude of “leave-it to-the-doctor.”
Key words Patient rights, Communication gap, Information disclosure, Patient responsibility
“patient-oriented healthcare” have indeed become Introduction a pressing issue. Unfortunately, however, the medical environment in Japan is not sufficiently More than one million people die in Japan each prepared to respond to such changes. This paper year. In fact, a “rapidly aging society” is also a discusses the ideal form of healthcare in Japan “many-death society.” The number of people focusing on the relationship between physicians requiring healthcare will steadily continue to and patients. increase in the future, and the health standards demanded by society are always likely to increase, Communication Gap never decrease. Behind this are such factors as patients’ in- The phrase “informed consent” has become firmly creased awareness of their rights, spreading established in the clinical field, and it seems that awareness of self-determination manifested in the physicians spend more time than previously ex- desire of patients to “decide matters that concern plaining to patients about their health condition. them for themselves,” and spreading awareness This is a move that should be welcomed by of costs arising from increasing co-payment of patients, but the issue remains as to whether or medical expenses. Demand for information dis- not the physician’s explanation is truly getting closure is also growing stronger. through to the patient. A one-way explanation Changes in the medical environment toward peppered with medical jargon will not be easily
*1 Editor, City News Department, Yomiuri Shimbun, Tokyo, Japan ([email protected]). This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.135, No.7, 2006, pages 1538–1541).
JMAJ, May/June 2007 — Vol. 50, No. 3 259 Goami H
understood by the patient and will not dissipate and had some time to think and consult with their feelings of insecurity. people around them, various questions and con- One study has produced some thought-provoking cerns surface. When they bring these issues up findings. The Office of Pharmaceutical Industry with the physician, often the response is “I told Research conducted a questionnaire of 1,131 you that last time” or some other negative reac- medical consumers and 1,101 physicians on the tion. With such a response, it is difficult for the communication between physicians and patients patient to ask further questions even if they have during medical examinations, etc., and patient more they would like to ask. satisfaction levels. Patients very strongly “want to avoid being According to the survey results published in disliked by the physician.” It is therefore im- July 2005 (Research Paper No. 29),1 some 72% of perative that physicians are aware that there is physicians felt that they were “sufficiently provid- a large communication gap between physicians ing informed consent,” but only 45% of medical and patients. consumers felt that this was so. Although 81% of Conventional physician training is dedicated physicians said that they “made efforts to create to the acquisition of specialized knowledge and an atmosphere conducive to asking questions,” skills, but can not necessarily be said to be equally only 26% of medical consumers felt that this was dedicated to the acquisition of communication so; and although a very high proportion (83%) skills, which enable physicians to listen to their of physicians believed they “respected patients’ patients and understand their hearts and minds. wishes,” a mere 30% of medical consumers felt The website of the Shizuoka Cancer Center that this was so. states that, as part of “patients’ rights,” patients Moreover, 77% of physicians said that they may not only see their medical records but also “explained treatment procedures in an easy-to- tape-record the physician’s explanations as well understand manner,” but only 33% of medical as seek a second opinion, explaining the rights consumers felt that this was so; 76% of physicians of patients, including the right of patients and said that they “answered questions in detail and their families have to receive support in their respectfully,” but only a mere 32% of medical battle against the disease. With such consider- consumers felt this was so. ation taken, it becomes easy for patients to ask Analysis of the survey results shows that physicians questions about any doubts they may “physicians believe that they are highly skilled have or to request to see their medical records at interacting with patients and that they display or seek a second opinion. an attitude of respect and consideration for the The new advanced clinical training program, patient when they are interacting, but this is not which became compulsory in 2004, aims to estab- recognized to be the case by medical consumers; lish better relationships between physicians and in other words, there is a large gap between the patients and their families in addition to provid- self-image of physicians and the image of physi- ing necessary knowledge, skills, and attitudes for cians held by medical consumers.” basic medical examinations. It is hoped that the Patients are vulnerable when their bodies are entire medical field will pour its energies into weak from injury or illness and can be easily training physicians who really understand how wounded psychologically and discouraged by patients feel. an off-hand remark from a physician. The more Although it is true that there is “information serious the situation, such as when they are being asymmetry” between physicians, who have special- informed they have cancer, the more unsettled ized training, and patients, who know little about the patient will be and the more difficult it will be medicine, even prior to this there is a psychologi- for them to make decisions rationally. At such a cal wall lying between the two, and it is the task time, the patient will only become confused and of medical professionals to break down this wall will not be able to understand if “informed con- through day-to-day efforts. sent” is being given in a rapid string of medical jargon. Even so, if the physician asks, “Do you Understanding Patients’ Pain understand?” the patient almost automatically responds with, “Yes, I understand.” In Japanese, the kanji character for patient com- However, after the patient has returned home prises the character for “heart” being stabbed by
260 JMAJ, May/June 2007 — Vol. 50, No. 3 THE PHYSICIAN-PATIENT RELATIONSHIP DESIRED BY SOCIETY
the character for “skewer.” How far, I wonder, do psychological support such as counseling avail- physicians understand the pain in the skewered able for cancer patients and their families that hearts of patients? might lessen their fears. Even though use of the The writer Shusaku Endo, who proposed pain-relieving drug morphine has increased, the “warm-hearted healthcare” and strongly and con- dosage per patient in Japan is still said to be sistently called for “patient-oriented healthcare,” one-tenth of that in Canada. Although the rate included an essay entitled “Know Patients’ Pain” of palliative care being offered is more than in his essay collection “Nautical Table of the 30% in the United States, while in Japan it is less Heart.” 2 Although this was merely based on his than 10%. impressions upon seeing the film, the American It seems that in Japan the overwhelming belief film “The Doctor” (1991) provides much food is that the sole mission of physicians is to cure for thought when considering the relationship disease. Consequently, there appears to be a ten- between physicians and patients. dency for physicians to disregard the pain and “The Doctor” features an elite surgeon who discomfort patients experience during treatment develops laryngeal cancer. Until then he has only as inevitable and unavoidable. However, there encountered illness from the perspective of a are a number of diseases that cannot be cured, no physician, but after diagnosis, he must face his matter what efforts are made to do so. Medical illness from the perspective of the patient and care may be advancing in leaps and bounds, but for the first time notices various problems with there is a limit to human life. healthcare. Having himself experienced long I have often heard stories of physicians who periods in waiting rooms and physicians’ arro- had frequently visited their patient’s hospital room gant attitudes as well as the patient’s sense of until the patients were diagnosed with terminal isolation, the fully recovered surgeon returns to cancer, after which the physician avoided making his profession and insists that the interns under such visits. It may be that these physicians feel his supervision put on patients’ hospital gowns they should give priority to patients who can be and experience for themselves intravenous drips, cured with treatment over patients with terminal enemas, and various other tests. Using such slightly diseases. However, patients who cannot be cured rough methods, the surgeon teaches the young need even more psychological support than physicians the importance of understanding the patients who can be cured. If a patient knows patient’s perspective. that they will recover, they can better tolerate When Shusaku Endo himself underwent a bad-tempered physicians and unfriendly nurses. bronchial tube examination, the experience was In contrast, terminal patients with no hope for so uncomfortable he reflexively coughed. He the future may despair or lose the will to live at writes that the physician scolded him, saying, an offhand comment or gesture from a physician “Why did you cough when I told you not to?” or nurse. Endo also suggested that, like the protagonist in In the near future, the Ministry of Health, “The Doctor,” young physicians undergo as part Labour and Welfare intends to introduce a new of their qualifying examinations (1) a bronchos- medical system for the purpose of implementing copy, (2) drawing of blood from the back of the at all levels, from early-stage to terminal cancer hand, (3) a rectoscopy, and (4) an intravenous treatment, palliative care that relieves the physi- drip (for more than one hour). It is 10 years since cal pain and psychological strain experienced Endo passed away, but his deeply felt desire for by terminal cancer patients. Specifically, this will physicians to “understand patients’ pain” unfor- involve the establishment of medical teams com- tunately cannot yet be said to have sufficiently prising physicians, nurses, and medical psychology penetrated the clinical areas. specialists at core hospitals for cancer treatment For example, the spread of palliative care, in each region in 135 locations throughout the which relieves the pain of terminal cancer, is country, as well as the initiation of experimental lagging behind. In Japan, some 600,000 people medical treatments, including palliative care, for are diagnosed with cancer each year. Patients who 5,000 cancer patients selected from model areas. are told they have cancer must deal with fears of Applying the latest medical treatments and dying and the pain and discomfort of treatment proactively curing diseases is an important role with anticancer drugs. However, there is little of healthcare. Further improvement of ad-
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vanced medical technology and emergency care information and understanding, and that when is imperative. they do not receive this kind of response they tend Relieving patients’ pain and providing psycho- to feel distrust and dissatisfaction. An increasing logical support for terminal cancer patients and number of medical institutions are disclosing other patients whose diseases can no longer be their performance records for treatment, etc., but treated are also important tasks in healthcare. still there is a strong demand among patients for medical professionals to more thoroughly disclose Limitations of Medical Treatment and information and improve their communication Patient Responsibility skills. Behind the distrust of and dissatisfaction with What kind of physician do patients desire? A physicians is the reality that patients hold ex- national opinion poll published in the Yomiuri cessive expectations of medical care. Patients Newspaper in February 20063 provides some clues. tend to demand “perfection” from medical care, According to the poll results, of the 50% of which is by nature imperfect, and so clashes are respondents who said they “had a physician they inevitable. The larger the gap between the level could trust,” the reason given for this from among of expectations the patient holds and the reality multiple choice answers were “Because they of their medical care, the greater their distrust of explained properly about my illness and treat- and dissatisfaction with their medical care will be. ment methods” (82%), “Because their words and In order to realize patient-oriented healthcare, attitude encouraged me and gave me courage” good communication between physicians and pa- (30%), and “Because they respected my opinion tients is imperative. Physicians must make efforts and opinion of my family regarding treatment” to improve “accountability” and to “assure trans- (28%). parency,” but patients also must acknowledge In contrast, of the 42% of respondents who the limitations of medical care and not hold such said that they “distrusted their physician,” the excessive expectations. reasons given for this were “Because they did The Consumer Organization for Medicine and not properly explain my illness and treatment Law (COML) has compiled a list of “10 Points On methods” (55%), “Because their words and/or Consulting a Physician” for patients, which pre- attitude were hurtful and/or unpleasant” (41%), sents the kind of desirable relationship between “Because they misdiagnosed my illness” (26%), physicians and patients that not only patients but and “Because they did not respect my opinion physicians should also think about. and opinion of my family regarding treatment” (1) Prepare notes on what you want to say to (19%). the physician. The poll also found that people who “distrusted (2) Begin the exchange with a greeting. their physician” tended to feel that “the burden (3) As the patient, you also have responsibility of medical costs was heavy” more than people for creating a better relationship. who “had a physician they could trust.” (4) Subjective symptoms and clinical history are With regard to the kind of information patients important information that you must tell the wanted when choosing a hospital or physician, physician yourself. 43% of respondents wanted to know “If and how (5) Ask about the prognosis. informed consent was implemented,” 38% wanted (6) Make efforts to keep the physician informed to know “the hospital/physician’s medical care of any changes in your condition. policy,” 33% wanted to know “evaluations of the (7) Make notes of important things and check hospital or physician,” 29% wanted to know “the them. response and attitude of physicians and nurses (8) When you are not satisfied, keep asking to patients,” 29% wanted to know “the hospital/ questions until you are. physician’s performance record, such as the (9) Understand that medical care has limitations number of operations performed and recovery and is fallible. rate,” and 29% wanted to know “the hospital/ (10)You are the one who decides your treatment physician’s specialties.” method. The poll results show that patients want a The above 10 points require patients to “make response from physicians that provides sufficient efforts to understand” their medical condition,
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have the “will to make decisions for themselves,” training, and then continued education, so that a and “improve their skills of communicating with system for nurturing “good physicians” with ex- health professionals.” cellent communication as well as technical skills can be implemented as quickly as possible. Conclusion Revision of the nominal specialist program also cannot wait. Clarification of evaluation stan- The relationship between physicians and patients dards for treatment methods and results and the is not antagonistic and should not be so; it should standardization of medical care, as well as the be a three-legged race with the physician and pa- creation of a computerized database for medical tient battling the disease together hand-in-hand. information are all issues that must be addressed Recently in Japan, some medical institutions immediately. have begun to refer to patients not as “kanja The challenge is for us to see how far Japan’s (patient)” but “kanja-sama (respected patient).” healthcare—which has been described as a Simply adding the suffix “-sama,” though, will “black box”—can be made more transparent and not create patient-oriented healthcare. What is how much its quality can be improved. “Medicine important is that patients and physicians leave should begin with the patient, continue with the behind “paternalism” and “leave-it-to-the-doctor” patient, and end with the patient.” These are the attitudes about treatment, respectively, and build words of Sir William Osler, the man who built the a cooperative relationship based on mutual trust. foundation for modern medical education, and To achieve this, there needs to be a complete they should be deeply engraved on the hearts of revision of physician training, from entry to medi- all professionals involved in healthcare. cal school to post-graduate training, specialist
References
1. Yamauchi K, Shinno T, Tsukahara Y, et al. Iryo shohisha to 2. Endo S. Kokoro no Kohkaizu [Nautical Table of the Heart]. ishi tono komyunikeishon [Communications of the medical Tokyo: Bunshun Bunko; 1996. (in Japanese) consumer and the doctor]. Research Paper No. 29. Office of 3. National Opinion Poll. The Yomiuri Shimbun 2006 Feb 4. (in Pharmaceutical Industry Research; 2005. (in Japanese) Japanese)
JMAJ, May/June 2007 — Vol. 50, No. 3 263 Local Medical Associations in Japan
Activities of the Tochigi Medical Association
JMAJ 50(3): 264–266, 2007
Takeshi FUKUDA*1 Tochigi Pop. 2mil. Area 6,400km2 Located in the north of the Kanto Region, Tochigi Prefecture is a comfortable, convenient place to live that experiences few natural disasters. The Tochigi prefecture has a population of 2.01 million and 3,916 doctors, with Tochigi Medical Association membership at 2,058 (of which 2,019 are also members of the Japan Medical Association). Tokyo From among the many activities carried out by this association, in the following I will introduce the features of the rules of the Hospital Doctors Division which was established in 2006, the Shiobara Hospital which is now being renovated, internal and external promotional activities, and the association’s unique activities concerning rules include “items related to the participation health insurance. of the members of committees established by the prefectural medical association.” Rules of the Hospital Doctors Division 2. Rules were established enabling the establish- Established in 2006 ment of special committees that can intensively discuss items of interest. Three special com- Amongst medical associations in recent years mittees to consider the role of hospital doctors the role and responsibility of hospital doctors has and medical associations, to consider commu- become broadly recognized and each medical nity health care, and to consider the work association has been setting up their own hospital environment of hospital doctors are planned doctor division. The Tochigi Medical Association for the first year. established its Hospital Doctors Division in 2006, Doctors in private practice and hospital doc- and rules with the following features were tors working together as members of the medical adopted to ensure that the division’s activities association will ensure the association becomes would be fruitful. more assertive towards government authorities 1. Rules were established enabling the opinions and is also sure to raise the general public’s of hospital doctors to be reflected in appro- understanding of the association and its aims. priate sub-committees of the Tochigi Medical Association. As a first step in conveying the Construction of the New Shiobara opinions of hospital doctors to the Japan Medi- Hospital cal Association, an official route for conveying the details of decisions to appropriate sub- In 1972, the Tochigi Medical Association estab- committees within the prefectural medical lished the Tochigi Medical Association Hot association is necessary. For this reason, the Springs Research Institute Shiobara Hospital in terms of the activity description of the division Nasu-Shiobara City (formerly Shiobara Town).
*1 Executive Board Member in charge of Academic affairs, Tochigi Medical Association, Utsunomiya, Japan ([email protected]). This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.134, No.12, 2006, pages 2398–2399).
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In 1997 the hospital merged with the neighboring that the newspaper is issued thrice-monthly and National Shiobara Hot Springs Hospital follow- disseminates in a timely and swift manner. The ing transfer of administrative control, becoming e-mail magazine was started in 2002 and as of the New Shiobara Hospital (for general, recu- November 2005 had 559 registered subscribers. peration and treatment use with 199 beds). In general the e-mail magazine provides the The hospital is characterized by outdoor re- same content as the Tochigi Medical Newspaper habilitation that takes advantage of the beautiful but even more swiftly. natural environment and hot springs rehabili- tation that uses the plentiful and good quality External promotion hot springs of the area. However, because the The main media for external promotional activ- buildings had aged, the idea emerged in 2001 to ities are the Tochigi Medical Association website construct new hospital facilities. Based on the and public communications in the Shimotsuke recommendations of the Tochigi Medical Asso- Shimbun (local newspaper). On the website’s top ciation Committee on Future Hospital Ideas and page we have listed such headings as “Medical the New Hospital Construction Committee, the Institution Information Services” (1,014 medical Assembly of Delegates approved construction institutions in Tochigi) and “Medical Institutions of a new hospital, the Tochigi prefectural author- Providing Treatment for Quitting Smoking.” Re- ities included the project in a government plan cent publications such as “Emergency Treatment (Rehabilitation of Core Functions for Northern of Children Guidebook” and “Getting a Family Tochigi) and the construction of a new hospital Doctor” are listed on the Health Information was decided upon. Column and various other information services The new hospital is scheduled to open in July are provided for the convenience of prefecture 2007. With treatment centered on the rehabili- residents. In future, we hope to expand the tation center and recovery phase rehabilitation, website’s role and make it our main medium for the hospital will provide high-level, specialized external promotion targeting residents of the rehabilitation that other hospitals in the region prefecture and will make further improvements have difficulty in supplying, as well as extending based on an assessment of the informational support and guidance for other local medical needs of residents. institutions as a core hospital for rehabilitation Public communications are placed in the treatment in the region. The hospital is also to Shimotsuke Shimbun three to six times annually, provide sports medicine rehabilitation and hot providing health information and messages from springs rehabilitation. the medical association on a regular and timely basis. Promotional Activities The Tochigi Medical Association’s The Tochigi Medical Association undertakes pro- Unique Activities Concerning Health motional activities both internally and externally Insurance making use of the characteristics of various infor- mation propagation media, such as our Internet A major characteristic of the activities of the website, e-mail magazine, the Tochigi Medical association concerning health insurance is the Newspaper, local newspapers (the Shimotsuke existence of a forum called the “Five-Way Talks.” Shimbun), radio, and pocket tissue distribution. This forum comprises five members—the Social Insurance Bureau, Tochigi Prefecture National Internal promotion Health Insurance Department, Medical Fee Pay- The main media for internal promotion is the ment Fund, National Health Insurance Organi- Tochigi Medical Newspaper and the Tochigi zation and Prefectural Medical Association— Medical Association website and e-mail maga- and ensures that discrepancies between payment zine. The newspaper was first issued on July 5, amounts and national health insurance do not 1953 as the Tochigi Medical Association Bulletin arise in the processing of medical service fee and throughout the 47 years since then has been invoices. The forum has been meeting virtually the main organ for promotional activities aimed every month since its inception in 1972. Forum towards association members. Of special note is decisions are compiled in a booklet entitled
JMAJ, May/June 2007 — Vol. 50, No. 3 265 Fukuda T
“Results of the Five-Way Talks” and distributed to and important points in drawing up and submit- all forum members and related organizations as ting receipts. Training related to medical safety well as being posted on the association’s website. measures, such as the construction of medical In order to increase transparency, it has been safety systems at clinics, is also provided and possible for general members to participate in questions and requests from medical institutions forum meetings as observers since February 2005. are also answered as the need arises. Moreover, Another activity worthy of mention is the by the Social Insurance Bureau using the first 40 “Health Insurance Workshop” that was set up in minutes of these training workshops to provide 2004 with the aim of improving the understand- lectures classified as “collective individualized ing of members and medical institutions about instruction,” the association is also utilizing these the medical insurance system. Two Executive training workshops as an alternative to “collec- Board Members of the Tochigi Medical Asso- tive individualized instruction” for high-score ciation in charge of health insurance visit all the medical institutions. county and city medical associations throughout This concludes my brief description of some of the region and provide lectures on such topics as the activities of the Tochigi Medical Association the Medical Practitioners Law/healthcare regu- that may be somewhat unique and in which we lations, interpretation of medical fee schedule, are making special efforts.
266 JMAJ, May/June 2007 — Vol. 50, No. 3 Local Medical Associations in Japan
Activities of the Gunma Medical Association
JMAJ 50(3): 267–268, 2007
Toshiro IKEYA*1 Gunma Pop. 2mil. Area 6,400km2 This article outlines the activities of the Gunma Medical Association, focusing on the efforts that have been made in 3 specific areas.
Academic and Continuing Education Activities Tokyo Physicians at the forefront of healthcare services are continually required to keep apace with the latest medical knowledge and medical technology. The Gunma Medical Association, in cooperation with county and municipal medical associations, the Gunma University Doctors’ Association, and various specialty groups, has been providing op- great significance, setting a precedent for hands- portunities to attend lecture meetings and training on training seminars in Gunma Prefecture. The seminars on timely topics to learn such knowl- proceedings of the medical conferences have edge and skills. In addition, semiannual medical been published in the periodical journal “Gunma conferences are held jointly with the Gunma Igaku” so that the information is also available to Prefectural Government. The Spring Conference members who could not attend the conferences. features lectures on general topics in medicine, while the Fall Conference consists of study pre- Memory Loss Test Project sentations by members and special lectures on clinical themes. Senile dementia is emerging as a serious social Recently, emphasis has been placed on hands- problem, requiring an approach based on early on training seminars. During the 2004 Spring detection and early treatment. Starting from Conference, we held a training seminar on ACLS 2000, the Gunma Medical Association has been (advanced cardiovascular life support). The par- cooperating with the Health and Welfare Depart- ticipants of this seminar attended lectures on ment (the present Bureau of Health, Welfare and emergency life-saving procedures and treatment Food) of Gunma Prefecture and Gunma Univer- in the afternoon of the first day, and then spent sity Faculty of Medicine in conducting a memory the whole of the next day putting the actual loss test project. In this project, we identified procedures into practice. Despite the very tough various problems, such as citizens’ misunderstand- schedule, 41 members participated in this seminar. ings about senile dementia and reluctance to After this event, ACLS training seminars were seek medical advice, the insufficient responses of held one after another by county and municipal health, medical, and welfare organizations, and medical associations, and many members were the lack of cooperation between family doctors able to practice life support procedures. We are and specialists, and we started to introduce vari- convinced that the ACLS training seminar had ous measures to solve these problems effectively.
*1 Director, Gunma Medical Association, Maebashi, Japan ([email protected]). This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.135, No.1, 2006, pages 94–95).
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The memory loss test was conducted both in Given this situation, the Gunma Medical the forms of mass examination and individual Association concluded that the construction of a examination. First, a screening was performed database containing items shared across the pre- using a brain health checklist consisting of 20 fecture would facilitate the acquisition of health- items compiled by specialists in dementia, based care information, including that about human on their experience and data. A person who is resources, and stimulate referrals from clinics to positive for 5 or more items receives the MMSE hospitals and from hospitals to clinics. A project (mini-mental state examination). If the MMSE to build such a database was set up in April 2004. score is 24 or less, the family doctor evaluates the One of the purposes of this project was to make need for differential diagnosis and the need for some of the information available for use to treatment and care. If considered necessary, a support citizens seeking health care. Because the differential diagnosis can be made at a specialized database system contains personal information medical center. Thereafter, the patient is referred about doctors, ensuring its security was an essen- back, and starts to receive treatment and care tial requirement for this system to be operated provided through cooperation with care facilities. via the Internet. For this reason, information for In the case of mass examination, a checklist is doctors and information for citizens have been mailed from the local government agency. After separated in the system. The information for self-reporting of the checklist, an MMSE is con- doctors is protected by access restrictions with ducted by public health nurses and the patients authorization using the LDAP server, and the are handed over to their family doctor. security in daily data management is protected The examination was first conducted in 2001 by double authorization using an i-key and an ID. in 5 municipalities, covering 3,084 individuals in Because doctors working for large hospitals the first year. The examination was expanded to are frequently moved to different positions, the 8 municipalities in 2004, and is planned to cover maintenance of up-to-date information is a dif- the entire prefecture in the future. ficult task. This problem was solved by the use of a data entry tool, with which each medical Construction of Community Healthcare institution can update its relevant data fields. Information Network We also encountered the problem of differences in organizational size and capabilities among The Gunma Medical Association has been promot- county and municipal medical associations, but ing close networking among members through the we have been supporting the buildup of an IT biennial issuance of a member directory. Since environment through consultation and phased 1996, we have also been publishing a directory of explanatory meetings. doctors working for university, public, and private The system has been operated since July 1, hospitals to provide information on doctors to all 2005, and our achievement was reported in a healthcare-related facilities as well as members. national TV program and local newspapers. A However, because many of the doctors in hospi- questionnaire survey conducted 3 months after tals are working in positions with short tenures the start of the system indicated that local medi- at universities in Gunma Prefecture and those in cal associations had completed entry of about the Kanto region, the usefulness of these direc- 70% of their data. We intend to take further tories as a source of timely information has been measures to broaden the use of this database and limited. In addition, the announcement of health build an efficient and useful system to support services provided at each medical institution mutual linkage among the providers of regional has not been standardized, and the volume of healthcare. information varies from hospital to hospital.
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Presidential Address at the 57th WMA General Assembly (Summary)*1
JMAJ 50(3): 269–271, 2007
Nachiappan ARUMUGAM*2
It is a great honour and privilege to be elected as making the WMA more visible to the physicians the President of the World Medical Association of the world. (WMA). I would like to thank you for electing Ethics derived from a basic view of humanity, me and giving me the opportunity to serve as the has been a part of medical practice from the President of the Association. beginning. Ethical medical practise refers, to the The WMA in its mission statement clearly appropriate treatment of a patient maintaining a states the objective to provide a forum for its high standard of medical ability and skill with a member associations to communicate freely, to caring and moral obligation. Doctors are taught co-operate actively, to achieve consensus on high to be dedicated to the service of humanity and standards of medical ethics and professional subscribe to the caring spirit when entering the competence, and to promote the professional profession of medicine. freedom of physicians worldwide. Medical practice has attracted much criticism In any large organisation generally the bigger on unsympathetic personal, uncaring attitudes and more vocal members will tend to dominate and inappropriate treatments. That this probably discussion and influence. The establishment of the applies to a small minority of doctors, compared recent regional meetings should provide oppor- to the huge number of doctor-patient contacts tunities and impetus for the smaller member each day, gets overlooked and the profession as a national associations to play a more active role whole is discredited. The WMA has emphasized in the affairs of the WMA. As universal partici- the core values of the profession of caring, ethics, pation is a necessity for any healthy organisation, science, compassion and universal accessibility. in the coming year I will work with Council to Over the years the association has achieved rea- find ways to stimulate contribution of some of the sonable success in promoting these values not dormant and smaller members of the Association. only to the profession but also to the public and Many National Medical Associations are un- relevant authorities. able to allot sufficient time to the concerns and During the last two years under the Caring activities of the WMA as they have their own Physicians of the World initiatives doctors from demanding schedules and activities. Many indi- various countries were nominated, selected, and vidual physicians of National Medical Associa- recognised. A book published in conjunction with tions are not aware of the workings and the the initiative highlighted their contribution to significance of the WMA. Physicians nowadays society. This was a worthy project as it high- belong to many different medical societies, es- lighted the caring aspect of the profession. To pecially specialist/subspecialty societies, related continue this initiative and to motivate more directly to their work and they do not see the doctors to follow these exemplary footsteps and immediate relevance of the WMA. I therefore to recognise those who have dedicated their life strongly urge all of you to incorporate the acti- to the care of the needy it is time we institute vities of the WMA in as many ways as possible, a World Physicians/Doctors Day. On this day in the activities of your national associations, thus the WMA should honour a doctor from each of
*1 This Assembly was held in Pilanesberg in South Africa from October 11th to 14th, 2006. *2 President, World Medical Association. Malaysian Medical Association, Kuala Lumpur, Malaysia ([email protected]).
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the five regions of the world for their care, com- emphasize the necessity for change, as govern- passion and contribution to society. The day will ments are not doing enough as they have either help to emphasize, promote, develop and help not recognised the enormity of the problem or to maintain the tradition of caring. have been reluctant to face reality. Since the end of the Second World War, more The new millennium was awaited with eager- than half a century ago there have been remark- ness and globalisation was the buzz word of the able discoveries and inventions in medicine, which new century. Newer technologies especially elec- have led to unparalleled improvement in health tronic communication, the internet, the media of the population of the world. We are able to and air travel all have contributed to shrinking control and treat deadly infectious diseases the world at a staggering pace. Nations were which were causing fatalities and unthinkable being more connected and interdependent than suffering around the world with newly discovered ever before. International business was thriving medications. We are also through innovative and there was high expectation for improvement procedures and operations able to correct con- of international understanding, cooperation and genital abnormalities and acquired disabilities. unity in the world. Increasing pace of interna- The medications and treatment modalities have tional travel, liberalisation of national borders helped relieve suffering, improve the quality of and increasing changing migration patterns was life of the individual, the family and the nation. moving the world towards to a more homogenous Changes in the living standards of many coun- society. tries in the world further contributed to healthier Suddenly the world was shattered by events populations. Eradication of polio and the dis- never seen before and turmoil set in and now covery of medicines to treat deadly infections terror reigns. Ideological differences, religious gave hope and optimism to the people of the extremism, racial confrontations, economic dis- world that they were going to enjoy uninter- agreements have resulted in extreme provoca- rupted improving good health. tion and excessive retaliations. These actions These achievements and improvements seem have divided the world and ushered in an era of to have been short lived and the world is again anguish and unpredictability which has affected faced with new epidemics and challenges. The all of us in many ways. health of the population of the world seems South Africa, which has probably experienced more vulnerable and more hazardous than ever one of the most traumatic periods in modern before in recent history. The last decade has not history, under the apartheid regime was liber- only seen a resurgence of deadly infections like ated after a long and protracted struggle. The lib- Acquired Immunodeficiency Syndrome (AIDS) eration of South Africa and the transition to a and Severe Acute Respiratory Syndrome (SARS) prosperous and successful democracy gives hope but also a chronic serious epidemic commonly that old differences can be put aside and a new termed as life style diseases. beginning benefiting all can be established. The number of patients afflicted with Obesity, The Centenary celebration of the start of the Hypertension, Diabetes Mellitus, Dyslipidaemia civil rights struggle, started by one of the pio- and related diseases has been increasing at an neers in the liberation struggles in South Africa, alarming rate the world over. This surge in life Mohandas Karamchand Gandhi, was held a style diseases has not been confined to the few weeks ago here in South Africa. Mahatma wealthier and more developed countries but Gandhi as he has now come to be known was the has been spreading at an alarming rate in the pioneer of Satyagraha—resistance through mass developing and poorer countries. This current civil disobedience, strongly founded upon ahimsa epidemic, affecting people in their prime of life, —non-violence, becoming one of the strongest causes untold misery to individuals, families and philosophies of freedom struggles worldwide. It countries. The immense drain on the financial has been noted that Gandhi remained commit- resources of the families and the nations has ted to non-violence and truth even in the most jeopardised the development of sustainable extreme situations. healthcare systems in many countries. The WMA Numerous medical groups through the years should through its various member organisations have served in areas of disasters and conflicts to lobby relevant authorities and governments to help the needy and suffering irrespective of their
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allegiance to any political or religious grouping. growing disparity of medicine in populations, due The events of the last few years should make the to the staggering cost of new developments, all profession reflect on its role as curing the sick put the doctor in an unenviable position between and use its unique position to explore the greater the patient and systems. Increasing public de- possibility of helping to re-establish unity and mand for medical services, with counter demands harmony in the world and thus healing wounds by payers to control costs has put tremendous of the people both physical and mental. pressure on doctors the healthcare professional. Emergencies and crisis are a part of medical The patient’s quest for perfect results, often practice and intermittent outbreaks of epidemics not fathoming the unpredictability of medical has occurred throughout history. What is new in procedures, has put further tension on the doc- the recent emergencies was the scale and feroc- tors while escalating medical indemnity costs. ity. The world in general and the Asia Pacific re- The increasing control of the profession by gion in particular has experienced unprecedented administrators, regulatory authorities, govern- calamities, over the last five years. Many of these ments and third party payers has caused much have been caused by environmental degradation annoyance and uneasiness. Private hospitals are in the name of progress and must be halted generally managed by commercial interests and and health must be given the rightful priority it the difference between commercial values and deserves. professional values often leads to conflicts. It is These are challenging times to practice medi- important for doctors to be objective, balanced cine as the widening gap between what medi- and keep the interest of the patients foremost at cine can do today and what the individual or the all times. In spite of the uphill task and emerging society can afford has shaken up the fundamen- challenges the profession must stand and work tals of medical practice. The changes in the last together to achieve the best working conditions few decades especially on the mode of health for the profession while delivering efficient and delivery, commercialisation of medicine and the caring treatments to patients.
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Healthcare System Reform in the United States —Analysis based on this year’s State of the Union Address and Budget Message—
JMAJ 50(3): 272–275, 2007
Kenya NISHIHIRA*1
insurance) is 27.3%, and 15.9% of the popula- Introduction tion (approximately 45.6 million people) are not enrolled in any insurance plan; in other words, In his State of the Union Address on January they are uninsured.1,*2 23 this year, the 7th since he assumed office, With regard to outlay for medical services, President Bush announced the government’s healthcare expenditure in Japan in 2004 was agenda for healthcare tax reform and reform of approximately 320 billion dollars,2,*3 whereas the public healthcare system. He then announced healthcare expenditure in the United States for specific proposals for these policies in the Budget the same year was approximately 1.74 trillion Proposal for 2008 (Budget Message) released dollars—approximately 5.4 times the amount in on February 5. This paper first of all provides a Japan. In terms of a proportion of GDP, health- brief introduction to the differences between the care expenditure in the United States is 15.3% of healthcare systems in Japan and in the United GDP (2004), which is high compared to the level States, then based on this year’s State of the of healthcare expenditure in Japan, which is 8% Union Address and Budget Message, reports (2003), and high even compared to other OECD on the healthcare reforms that the United States member countries (average 8.9%).3 Moreover, is considering. medical expenditure per person in Japan is 2,249 dollars, while the average for OECD member Basic Comparison of Heath Care countries is 2,550 dollars. In comparison, medical in the United States and Japan expenditure per person in the United States is a very high 6,102 dollars—2.7 times the amount Unlike Japan, which has a universal healthcare in Japan (all figures are for 2004). system, public health insurance is limited to the If one compares the healthcare provision elderly and low-income earners and is not univer- systems in Japan and the United States, both sally available to all citizens in the United States. Japan and the Unites States have fewer doctors Consequently, 59.5% of citizens have health per 1,000 citizens (2 and 2.4, respectively) than insurance provided by their employers, with an the average for OECD member countries (3) (all additional 9.1% of citizens being individually figures are for 2004). Looking at the number of enrolled in private health insurance plans, so that nurses in both countries, Japan has 9 nurses per some 67.7% of the American people have some 1,000 citizens (2004), slightly more than the 7.9 forms of private health insurance. The proportion per 1,000 in the United States (2002) and the of citizens covered by Medicare (national health- average of 8.3 per 1,000 for OECD member care for the elderly), Medicaid (state healthcare countries. With regard to the number of hospital for low-income earners), and other public health beds, Japan has 8.4 beds per 1,000 citizens, insurance plans (including government employee whereas the United States has an extremely low
*1 Director, JETRO New York, Health and Welfare Dept. NY, USA ([email protected]). *2 Because there are people covered by multiple insurance plans, the figures for each of the groups do not add up to 100%. *3 Medicare (US national insurance for the elderly) benefits include expenditure for nursing care facilities and home services, and so nursing care .(yen 120סexpenditure (6.3 trillion yen) is included in healthcare expenditure for Japan (yen/dollar exchange rate 1 dollar
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2.8 beds per 1,000 citizens (the average for reforms of the Health Savings Account (HSA) OECD member countries is 4.1 beds per 1,000 system that was institutionalized in 2003. HSA is citizens). an income deduction that people who are insured receive when they enroll in a High Deductible Direction of Healthcare System Reform Health Plan (HDHP), which has a higher annual in the United States deductible than traditional health plans. Under existing laws, when the insured person is enrolled As mentioned above, the healthcare system in the in a health insurance plan under which the United States has two major problems: (1) nearly deductible amount is more than 1,100 dollars 16% of the population is uninsured, and (2) high and less than 5,500 dollars for an individual medical costs. The reform proposals have been insured person (or more than 2,200 dollars and made addresses these two problems. less than 11,000 dollars for insured person and their family), 2,850 dollars (or 5,650 dollars for Measures to reduce the number of insured person and their family) may be deducted uninsured annually from their taxable income and con- As part of measures to reduce the number of tributed to their HSA. Use of this contribution is uninsured people, a reform of the health insur- limited to expenses for specified medical treat- ance tax system has been proposed.4 Under the ments, and if used for any other purpose the current system, when an employer provides amount is regarded as income and therefore tax- health insurance to employees, the amounts of able, with a penalty tax of 10% also being added. insurance born by the employer and/or partly Under the current proposals, an insured by the employee are not regarded as part of the person would also be eligible to receive HSA income of that employee and thus are not subject tax benefits when they are enrolled in a health to taxation. In contrast, in the case of individual insurance plan, under which the insured person enrollment in health insurance, the insurance pays 50% or more of the cost at the time of the cost cannot be excluded from calculations of per- insurance payment instead of a high deductible sonal income, and tax is levied on the insurance setting. In addition to this proposal, the Bush cost paid. Administration has announced several other The current proposal seeks to change this proposals for revisions about HSA and tax cuts system so that regardless of the insured person’s of approximately 3.74 billion dollars have been income, their insurance provider, or the actual estimated with the next 5 years. amount of insurance paid, a fixed income deduc- Meanwhile, over the past few years states have tion is made for all insured people (of 7,500 also begun in rapid succession to implement their dollars for individuals and 15,000 dollars for own measures to reduce the number of unin- families; this amount is to be adjusted annually sured people, by passing laws aimed at uninsured with CPI). Furthermore, it is proposed that the people, beginning with Maine in 2003 then fol- unequal treatment of people insured by their lowed by Maryland and Massachusetts in 2006. employers and people insured privately under This year, California, the most populous state in the current system be remedied, by regarding the United States, announced policies aimed at the health insurance subsidies provided by reducing the number of uninsured people, and employers to employees who are not being New York and other state governments are also taxed on their health insurance as income for beginning to take similar action. those employees. Under these changes, both The national government is also planning people who are insured by their employers and budget proposals to support these state efforts. people who are privately insured will be eligible Concrete financing and aid methods are to be to receive the same deductions for healthcare, decided through negotiations between the head stimulating enrollment in health insurance plans of the Department of Health and Human Ser- in the private health insurance market. Accord- vices (HHS), Congress and each state governor. ing to government calculations, this is expected It is anticipated that states will, for example, to reduce the number of uninsured citizens by become eligible for aid toward (1) insurance pre- between 3 million and 5 million people. mium subsidies; (2) establishment of risk compen- The Bush Administration has also proposed sation for insured people with serious illnesses
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(risk pool, reinsurance, etc.); and (3) negotiations of the Department of Health, (a) the back-flow of between insurers and groups in coordinating funding from state hospitals to state govern- individuals and employers of small and medium ments is to be eradicated*5 and (b) Graduate businesses. The national government has yet to Medical Education (GME) is to be abolished. announce the specific details of this funding, but These are the proposals relating to contain- looking at the content of the proposals, it appears ing expenditure on Medicare and other public that part of the compensation of medical fees insurance plans, but the government has also provided by public insurance plans such as Medi- announced policies aimed at containing overall care and Medicaid to medical facilities will be cut. healthcare expenditure. For example, the afore- Regarding the State Children’s Health Insur- mentioned healthcare tax reforms are also ance Program (SCHIP), which is publicly-run expected to lead to the containment of medical like Medicare and Medicaid, the Bush Adminis- expenses. In other words, under the current tration has announced a year-on-year increase of system in which a third party (the employer) pro- approximately 18% (1.22 billion dollars) to 6.65 vides health insurance, incentives for an insured billion dollars in national government expendi- person (an employee) to enroll in inexpensive ture for the SCHIP budget as part of revisions for healthcare plans are weak. By changing the the 2008 fiscal year (5-year period; 3rd term). system so that people who are enrolled in less expensive insurance plans can receive greater Healthcare expenditure containment income tax deductions, it is anticipated that measures insured people will naturally become sensitive In addition to measures aimed at reducing the to health insurance costs, leading to the contain- number of uninsured people, the government ment of healthcare expenditure overall. also announced policies for containing health- care expenditure. Specifically, first of all, funding Summary of Medicare and Medicaid together is to be reduced by 101.6 billion dollars over the next 5 According to Center for Medicare and Medicaid years, aiming for growth rate reductions of 6.5% Services (CMS) estimations, the total amount to 5.6% and 7.3% to 7.1%, respectively.*4 spent on healthcare by Americans in 2006 was 2.1 In the case of Medicare, the government indi- trillion dollars, and is expected to reach 4.1 tril- cated a policy of containing compensation to lion dollars in 2016, representing 19.6% of GDP.5 healthcare facilities through the amendment of Moreover, over the next few years the number of indexes in compensation calculation. With regard uninsured people is expected to increase from to insurance expenditure paid out to recipients 15% to 16%. This is hardly a sharp increase, but (Part B), the government is considering raising is nonetheless a definite upward trend. the proportion of insurance expenses borne by In response to such trends in American health- the recipients by lowering in practical terms the care, President Bush appears to be aiming to baseline for the high health insurance burden achieve both the containment of national medi- borne by high income earners, and it plans to cal expenses and a reduction in the number of use the same mechanism for Part D insurance people who are uninsured through consumer-led expenses. cost-containment and consequent market com- In the case of Medicaid, through legal amend- petition stimulation. In other words, this could ments the government proposes (a) to standardize perhaps be called an experiment in stimulating national government expenditure on operational insured people’s (consumers’) cost orientation costs to a uniform 50% and (b) to lower the upper and consequently invigorating competition in the limit for the reimbursement price (FUL) for phar- medical insurance market through the enforce- maceuticals for which there are multiple products ment of healthcare tax reforms and promotion of with the same medicinal effects. Furthermore, HSA. Of course, implementing reforms in a mar- with regard to the executive powers of the head ket that opens up the healthcare system requires
*4 Total 2008 budget for Medicare, Medicaid, and SCHIP combined was 595.1 billion dollars. *5 Medicaid is financed jointly by funding from the national and state governments, with the national government matching the amount of funding by each state as a general rule. Under this system it is possible for state governments to increase national government contributions by increasing their own apparent contributions and then siphoning the increased amount from healthcare institutions under the pretext of tax.
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the disclosure of information about the quality of vidual policies, in general the vast majority of medical care and the computerization of health- Democrats are standing their ground against the care information, as well as the standardization president, and in such an atmosphere it will be of heath care fees by medical facilities, so that extremely difficult for President Bush to pro- consumers can choose healthcare services for mote the heath care policies outlined above. themselves. President Bush can be praised for Furthermore, the current budget proposal having proactively implemented reform relating contains much bad news for state governments. to healthcare information since assuming office. With regard to the tightening of income baselines Are these reform proposals likely to be for SCHIP in particular, the budget proposal accepted by the Democratic Party, which took indicates concern that the number of uninsured control of both legislative houses in the 2006 children will rise. However, with regard to the mid-term elections, and to be legislated some- national government funding of state measures time this year? In order to contain growth in to reduce the number of uninsured people that funding to Medicare and Medicaid, the Bush President Bush outlined in his State of the Union Administration’s 2008 budget proposal includes address, the government has yet to announce even stricter containment than that of last year, concrete methods or directions for debate on this when Congress was controlled by the Republican issue, and there remains concern over the rela- Party. Even if there are some slight differences of tionship between the national government and opinion within the Democratic Party over indi- the individual states.
References
1. DeNavas-Walt C, Proctor BD, Lee CH. Income, Poverty, and 4. General Explanations of the Administration’s Fiscal Year 2008 Health Insurance Coverage in the United States: 2005. Wash- Revenue Proposals (The Blue Book). ington, DC: US Census Bureau; 2006. 5. Poisal JA, Truffer C, Smith S, et al. Health spending projections 2. Ministry of Health, Labor and Welfare White Paper 2005. through 2016: modest changes obscure part D’s impact. Health 3. OECD Health Data 2006. Aff (Millwood). 2007;26(2):W242–W253.
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Quite some time has passed since the reuni- WMA Mid-term Council Meeting in Berlin fication of East and West Germany, but it seems The 176th WMA Council Meeting was held in that the reconstruction of Berlin amidst the Berlin, Germany, from May 10 to 12, 2007. As the disaster and destruction in the aftermath of demand for WMA activities has been increasing, World War II has taken place in a healing manner the number of representatives attending the using modern methods. It is deeply meaningful WMA Council Session grew from 14 at the for the WMA that this Council Session was previous Session to 21. The WMA Council, which held in Berlin with peaceful aims based on had been steered under the leadership of the humanitarianism. former Chair of Council, Dr. Blachar of the The Kaiser-Wilhelm-Gedächtniskirche, located Israeli Medical Association, is now being led by very close to the venue for the Council Session, the new Chair, Dr. Hill of the American Medical remains strong in my memory as a monument of Association. Under their leadership, the coop- a tragic era for mankind, as too are Hiroshima erative framework is being continued by WMA and Nagasaki. Secretary-General Dr. Kloiber of the German Medical Association, Vice-Chair of Council Dr. Masami ISHII, Executive Board Member, Japan Medical Association ([email protected]), Secretary General, Confederation of Iwasa of the Japan Medical Association, WMA Medical Associations in Asia and Oceania (CMAAO), Council Treasurer Dr. Hoppe of the German Medical Member, World Medical Association. Association, and other relevant WMA members and staff. Apart from official agenda items, several relevant issues that physicians currently face were addressed during the Session. These included the Introduction of JMA Journal Staff rising demand for IT progress and human rights The JMA Journal is prepared by the JMA’s as the proposed themes for the WMA General International Section. The staff members put Assembly in Copenhagen in 2007 and in Seoul in form to a broad diversity of ideas and broad- 2008, respectively. ranging visions of the JMA. It was an honor for us to have the recent renewal of the JMA Journal, reviving its original philosophy, highly praised by the NMAs during the discussion focused on the plan to revamp the World Medical Journal. There was also a heated discussion about such issues as the securing of sufficient human and monetary resources faced by many medical associations, and immigration problems involving physicians in some Latin American and Caribbean countries which contravene international medical (From left to right) Mahoko IMAMURA, Yoshie KONDO, Mieko HAMAMOTO ethics. Regarding the latter problem, the WMA (Senior Editor), Hisashi TSURUOKA (Managing Editor), Council urgently adopted a resolution at this Shusaku UCHIYAMA, and Nobuhide SAKUMA Session.
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