jma policies jma activities research and reviewsjmaj, july/august 2008 — vol. 51, no. 4 219 jma...

JMA Policies

The Continuing Medical Education Program of the Japan Medical Association

Masami ISHII ......................................................................................................................................................... 219

JMA Activities

School and Community Health Project: Part 1:A community development and health project in Nepal

Masamine JIMBA, Kalpana POUDEL-TANDUKAR, Krishna C. POUDEL .......................................... 225

Report

A Healthcare Crisis in Japan: Criminalizing medical malpractice

Rintaro SAWA ...................................................................................................................................................... 235

Research and Reviews

What Maternity Clinics Can Do for More Reliable Perinatal Care

Isamu ISHIWATA ................................................................................................................................................ 242

Present Status of Obstetric and Perinatal Care and the Action Plan Issuedby the Japan Society of Obstetrics and Gynecology

Nobuya UNNO ...................................................................................................................................................... 247

Current Status and Future Prospects of Hospital Midwifery Departments

Kyoko YOKOO, Mayumi OKANAGA, Masayo AWANO .......................................................................... 255

Article 21 of the Medical Practitioners Law

Norio HIGUCHI ................................................................................................................................................... 258

A Model Project for Survey Analysis of Deaths Related to Medical Treatment

Masashi FUKAYAMA ......................................................................................................................................... 262

Medical Malpractice in Obstetrics—A look into the practice under South Korean law

Sanghan WANG .................................................................................................................................................... 267

From the Japanese Association of Medical Sciences

Management of the Open Abdomen—Usefulness of the bilateral anterior rectusabdominis sheath turnover flap method for early fascial closure

Shigeki KUSHIMOTO, Hiroyuki YOKOTA, Makoto KAWAI, Yasuhiro YAMAMOTO..................... 272

Current Status of Musculoskeletal Disorder Care in Japan

Kazuo YONENOBU ............................................................................................................................................ 278

Vol. 51 No. 4 July-August 2008

Contents

Local Medical Associations in Japan

A Regional Medical Association That Works

Hidenori TORIZAWA ......................................................................................................................................... 281

The Aichi Medical Association and Community Healthcare Provision System

Akio FUJINO ........................................................................................................................................................ 283

Osaka Medical Association Activities

Yasuyuki TAKAI .................................................................................................................................................. 285

International Medical Community

Task Shifting: Necessary practice or dangerous precedent?

Yoram BLACHAR ............................................................................................................................................... 287

Ethics at the World Medical Association: From policy to practice

John R. WILLIAMS ............................................................................................................................................. 290

From the Editor’s DeskMasami ISHII ......................................................................................................................................................... 294

219JMAJ, July /August 2008 — Vol. 51, No. 4

JMA Policies

*1 Executive Board Member, Japan Medical Association, Tokyo, Japan ([email protected]). Secretary General, Confederation of MedicalAssociations in Asia and Oceania (CMAAO). Council Member, World Medical Association.

The Continuing Medical Education Program ofthe Japan Medical Association

JMAJ 51(4): 219–224, 2008

Masami ISHII*1

university medical departments in Japan at thepresent, admitting approximately 7,500 studentsevery year. Reflecting the shortage of physicians,the annual admission capacity is expected toincrease gradually. After the 6-year medical edu-cation, students must pass the National Examina-tion for Medical Practitioners, be registered withthe Ministry of Health, Labour and Welfare, andcomplete 2-year postgraduate training. While thispostgraduate training was voluntary in the past, itwas made compulsory in 2004. In this way, newphysicians are trained and allowed to performmedical acts in Japan

Outline of JMA

JMA is a private organization with a membershipof 165,000 (as of December 1, 2006). It was estab-lished in 1916 by Dr. Shibasaburo Kitasato andcolleagues, and was legally authorized as a non-profit organization in 1947.

There are approximately 270,000 physicians inJapan at the present, and about 60% of them areaffiliated with JMA on a voluntary basis. Almostall self-employed hospital-based physicians areJMA members. The membership includes self-employed physicians and employed physicians atthe ratio of approximately 1:1. Figure 1 shows thetrends in JMA membership. It has been growingyear after year from the 50,000 at the time of es-tablishment in 1947. Figure 2 represents the over-all organizational chart of JMA. There are regionalbranch organizations covering various regionsin Japan, which include 47 prefectural medicalassociations and approximately 900 municipalmedical associations. Each of these associationsis an independent incorporated organization.

Introduction

In 1987, the same year as the publication of theWorld Medical Association (WMA) Declarationof Madrid on Professional Autonomy and Self-Regulation, the Japan Medical Association (JMA)started systematized continuing medical educa-tion (CME) programs to provide systematic sup-port to the broad-based, effective engagementof physicians in CME under the philosophy ofprofessional autonomy based on self-regulation.

In this system, physicians voluntarily andautonomously endeavor to improve their clinicalcapabilities and study basic healthcare problemsshared by all colleagues, so that they can buildtrust relationships between physicians and patients,provide high-quality health care prioritizing patientsafety, and contribute to health of the people. Theprogram is also open to non-member physicians.This article outlines this CME program, alongwith introductory descriptions of the school edu-cation system in Japan and the activities of JMA.

School Education System in Japan

The compulsory education in Japan consists of9 years from elementary school to junior highschool. After compulsory education, studentsmust undergo 3-year high school education andthen complete a university medical course to beeligible for qualification as physicians. The univer-sity medical education comprises 6 years, includ-ing basic and clinical education. The courses up tothis point are under the supervision of the Minis-try of Education, Culture, Sports, Science andTechnology. There are 80 medical colleges and

220 JMAJ, July /August 2008 — Vol. 51, No. 4

Ishii M

To be eligible for membership in JMA, a physi-cian first needs to join a municipal medical asso-ciation and then a prefectural medical association.

Decisions at the level of JMA are made by theBoard of Trustees, and the House of Delegates isthe highest decision-making body.

Main Activities of JMA

Shaping national health policiesPreparing for future amendment of medical legis-lation and revision of medical fees, JMA is con-

Japanese Association of Medical Sciences JMA Membership of JMA:

164,110

House of DelegatesGeneral Assembly Membership of

Prefectural Medical Associations

President Board of Trustees Council of Arbitration

Vice-PresidentsExecutive Board of

Trustees

Membership of County, City, and Ward

Medical Associations

Board MembersExecutive Board Members

Auditors Committees

Physicians

Woman Doctor Bank Medical Library Secretariat JMA Research Institute

JMA Center for Clinical Trials

Fig. 2 Organizational chart of JMA and member physicians

170

1947 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2006

160150140130120110100

908070604030302010

0 0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Number of members (left)

Percentage of female members (right)

Fig. 1 Trends in the membership of JMA


THE CONTINUING MEDICAL EDUCATION PROGRAM OF THE JAPAN MEDICAL ASSOCIATION

stantly constructing the theoretical foundationfor its basic, long-term policies and announcingits position in the Grand Design published byJMA. The Council on Health Policy has beenestablished as an advisory body reporting to thepresident to materialize comprehensive measuresin communities and making proposals from thestandpoint of citizens.

Ethical issuesIn the field of medical ethics including bioethics,JMA has the Bioethics Council and other mecha-nisms to study important issues relating to medi-cal ethics, such as the attitude problems towardsadvanced medical technologies, end-of-life care,and informed consent, and is making proposals inthese areas. In 2007, JMA published the Japaneseversion of the WMA Medical Ethics Manual anddistributed about 220,000 copies to JMA mem-bers, medical students, lawyers, etc. at no charge.

Academic activitiesIn the field of academic activities, JMA is playinga leading role in the discussion of how universitymedical education and CME should be organized,positioning the CME system as the central axis ofeducation. The monthly publication, the Journalof the JMA, and the radio and TV programs onmedical topics produced by JMA are utilized bya wide range of people. The JMA Library, hous-ing 71,000 books and journals, is supporting theresearch activities of members.

Medicine, healthcare, and welfareThis field pertains to all aspects of communityhealthcare, and JMA believes that enrichment inthis field should be central to healthcare in Japan.Some issues in this field, such as the response tothe aging population and patient safety policy,are extremely important, and JMA is now mak-ing great efforts in addressing these issues.

International activitiesJMA is a member of WMA, and is also playingan active role as the secretariat office of theConfederation of Medical Associations in Asiaand Oceania (CMAAO), which is an organiza-tion made up of 17 national medical associations.In addition, JMA is promoting interaction withmedical associations in various other countries.

Public relationsPublic relations as part of advocacy activities isimportant to spread the policies and opinions ofJMA. With increased staffing, public relations areexpected to play increasingly important parts asa core part of the activities of JMA.

JMA Research InstituteJMA Research Institute was established in 1997as an internal body for studying medical policies.This Institute is a think tank supporting the JMA’sgoal of “the development of health policies forthe people” through various research activities,information collection, and survey analysis. JMAcarefully examines the study results and incorpo-rates them into policy development. The Instituteis currently staffed by about 50 persons, includingresearchers and support personnel.

CME Program of JMA

Basic policyThe CME Promotion Committee of JMA hasbeen established to promote and support theCME of members. Local associations also havesimilar committees for physicians in respectiveregions, and JMA is working in close cooperationwith these committees. The CME Committee ofeach local association is supporting the learningof members with programs incorporating thepolicies and regional characteristics. The contentof learning covers not only medical science butalso various fundamental issues physicians mustunderstand in their daily practice, such as medi-cal ethics. Respecting the self-determination ofphysicians, the CME activities performed byindividual physicians are evaluated based onself-declaration in principle, and no penalty isimposed on physicians who fail to declare. “TheCME Certificate” is awarded to physicians whodeclare that they have completed 10 credit unitsor more in a year. Physicians achieving thiscertificate in 3 successive years are granted “theCertificate of Recognition for Completion ofCME.”

CurriculumsThe curriculums set the goals and show the learn-ing directions of the physicians. The study topicsin the curriculums are divided into basic health-care topics and medical topics.


Basic healthcare topicsThese include the 106 basic healthcare topics thatall physicians should know irrespective of thefields in which they specialize. Examples of suchtopics are medical ethics, laws, welfare, socialsecurity, and health economy. This part of thecurriculum is intended for the acquirement ofbroad knowledge related to healthcare.Medical topicsThese are the learning of medical science, com-prising the 2 parts covering “important mattersin medical practice” and “important diseases,”respectively. The former part, “important mattersin medical practice,” assesses the acquirementof the knowledge, skills, and attitude related tothe important matters in the process of medicalpractice. The latter part, “important diseases,”is a curriculum that assesses the acquirementof sufficient knowledge and treatment skills fordiseases commonly seen in daily practice anddiseases of clinical importance.

JMA recommends the following ways of uti-lizing these curriculums.1) The CME Committee of a local medical asso-

ciation may plan a CME workshop, featuringsome of the themes in the curriculums.

2) The curriculums may be used in self-directedhome learning and group learning.

3) It is recommended to select study topics refer-ring to the curriculum of experience-based learn-ing in a hospital-clinic cooperative program.

Main learning mediaMain learning media include the Journal of JMApublished in Japanese by JMA. The Journal,produced by its Editorial Committee of JMA,is published in 12 regular issues and 2 specialissues every year. The JMA CME Courses refercollectively to the CME courses supported bycollaborating companies reflecting the diversifi-cation of learning media. These courses are alsoplanned by the Editorial Committee.1) The JMA website allows visitors to search and

read papers in the Journal of JMA, to searchtitles in the video library, to view video-streamed medical TV programs, and to viewInternet-based CME courses.

2) In addition, journals and websites of localmedical associations are also used as learningmedia.

Learning methodsLearners may obtain credit units defined asfollows.

A learner attending a lecture meeting or aworkshop receives a certificate (card, sticker,etc.) from the host organization and submits itwith the declaration to acquire 3 to 5 credit units.In the case of experience-based learning (learn-ing in a hospital-clinic or clinic-clinic cooper-ative program), the learner submits the theme,

Ishii M

Table 1 Specialty societies offering interchangeabilitywith JMA CME programs

1. The Japanese Society of Internal Medicine

2. Japanese Ophthalmological Society

3. Japanese Pediatric Society

4. The Japanese Association of Rehabilitation Medicine

5. The Japanese Orthopaedic Association

6. Japan Radiological Society

7. The Japanese Urological Association

8. Japan Society of Obstetrics and Gynecology

9. The Japanese Society of Psychiatry and Neurology

10. The Japan Geriatrics Society

11. The Japanese Society of GastroenterologicalSurgery

12. The Japanese Society of Gastroenterology

13. The Oto-rhino-laryngological Society of Japan

14. Japan Society of Plastic and Reconstructive Surgery

15. Japan College of Rheumatology

16. Japanese Dermatological Association

17. The Japanese Society of Balneology, Climatologyand Physical Medicine

18. Japanese Society of Psychosomatic Medicine

19. The Japanese Society of Pathology

20. Japanese Society of Laboratory Medicine

21. Japan Diabetes Society

22. The Japan Society of Colo Proctology

23. Japanese Society of Pediatric Surgeons

24. The Japan Society of Transfusion Medicine andCell Therapy

25. The Japan Society of Hepatology

26. The Japanese Association for Infectious Disease

27. Japan Gastroenterological Endoscopy Society


THE CONTINUING MEDICAL EDUCATION PROGRAM OF THE JAPAN MEDICAL ASSOCIATION

the name of facility, and other details with thereport form, and receives 5 credit units. Someprofessional achieve-ments may be recognizedas credit units. A learner making an academicpresentation or publishing a paper attaches therecords of presentation title, author name, etc. tothe declaration and receives 3 to 10 credit units.Home learning, such as sending an answer to aquestion in the Journal of JMA via mail or theInternet or answering the self-assessment in theInternet-based CME courses, is worth 1 creditunit each time.

Self-declaration practiceThe acquisition of credit units is based on self-declaration in principle. Some local medical asso-ciations collect declarations from the memberssend them to JMA. The report form is distributedas a supplement to the March issue of the Journalof JMA every year. A person making a declara-tion fills in the report form, attaches the certifi-cates of attendance to seminars and other eventsand records of achievements, and submits the com-pleted form to the county, city, or ward medicalassociation or the university medical associationto which he or she belongs by the end of Aprilevery year. The submitted declaration forms aresent to JMA via prefectural medical associationsand processed and managed by computer.

Interchangeability of credit unitsThe certificates of attendance obtained from theparticipation in the JMA CME Courses areinterchangeable with the credit units needed forthe renewal of specialist certification in severalspecialty societies. In the CME system of JMA,attendance to a lecture meeting or other eventsof a specialty society is counted as 3 credit units.As of 2008, arrangement for credit interchange-ability has been made with the specialist physi-cian/certificate physician systems of 27 specialtysocieties listed in Table 1.

Awarding of “the CME Certificate” and“the Certificate of Recognition forCompletion of CME”“The CME Certificate” (Fig. 3) is awarded tophysicians submitting the CME declaration anddocumented (by certificates of attendance, records,etc.) to have achieved 10 credit units or more ina year. Physicians achieving this certificate in 3successive years are granted “the Certificate ofRecognition for Completion of CME” (Fig. 4).

Although these certificates of completion andcertificates of recognition do not signify anyqualification, the proof of participation in CMEas indicated by the declaration rate provides ayardstick for measuring the attitude of a physi-

Fig. 3 CME Certificate Fig. 4 Certificate of Recognition for Completion of CME


Ishii M

cian towards CME. The physician may displaythese certificates in the clinic, for example, asa means of building the trust relationship withpatients.

Conclusion

The medical care system of Japan faces a crisisas a result of the government’s policy of cuttingexpenditure and curtailing social security mea-sures. In this difficult situation, JMA is doingeverything in its power to enrich community healthensuring patient safety and to build a reliablefoundation for social security. The CME programis one of the most reliable means of improvingthe quality and ability of individual physicians,and the importance of CME is undoubtedly goingto increase in the future.

In addition, JMA has been engaged in inter-national works through participation in WMA,

and continuing the interactions with the medicalassociations of various countries to exchangeopinions regarding world healthcare problems.The enrichment of community health in Japandirectly means a contribution to the health ofpeople in the world. From this perspective, JMAis committed to continue its efforts to improvethe health standard of the world from the stand-point of patients. JMA intends to compile recordsof successful cases in the solution of variousproblems of community health, and share theexperience with the physicians of the world, sothat it may be of help to physicians working invarious environments.

Acknowledgements

Dr. Ishii wishes to thank for Ms. Mieko Hamamoto,editorial staff of the JMA Journal for her assistance indeveloping the draft.


JMA Activities

Introduction

The Japan Medical Association (JMA) imple-mented a School and Community Health Project(SCHP) in Nepal from 1992 to 2006. Althoughseveral articles have been published on SCHPactivities both in Japanese and English, no Englishpaper has yet been published that summarizesSCHP’s activities as a whole, in particular, as acommunity development and health project. Thispaper has two major objectives. The first is toshow the background to why a community devel-opment approach was needed in Nepal after the

*1 Department of International Community Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan([email protected]).

School and Community Health Project: Part 1:A community development and healthproject in Nepal

JMAJ 51(4): 225–234, 2008

Masamine JIMBA,*1 Kalpana POUDEL-TANDUKAR,*1 Krishna C. POUDEL*1

AbstractThis article first gives information on the School and Community Health Project (SCHP) by His Majesty’sGovernment of Nepal, the Japan Medical Association, and the Japan International Cooperation Agency, whichtried to improve the living conditions and health of the rural population in Nepal. Secondly, it describes SCHPactivities as one case of a community development and health project that was implemented based on Rifkin’scommunity development approach. To improve living conditions, SCHP conducted literacy education for adultwomen’s and children’s empowerment programs in schools. For health activities, SCHP worked with traditionalhealers and conducted local health manpower development through a scholarship program. As a result, the adultwomen’s literacy rate improved from 16% in 1996 to 50% in 2000 and the majority of them formed self-helpgroups, made kitchen gardens, and started income-generating activities. The schools became more active inhealth activities through child clubs and improved hygiene facilities. Traditional healers’ treatment skills andreferral to government health institutions were also improved. In addition, one more achievement of this projectmight be the change of the local villager’s consciousness from ‘development as a gift’ to ‘development fromwithin.’ Community development and health projects can in this way contribute to improving the health and livingconditions of rural people. It also has the potential to raise the consciousness of people who jointly work forcommunity development from within. More efforts should be made to scale up these activities in a country wherethe rural population still suffers from poor health conditions.

Key words World health, Community health, Community development, School health, Empowerment, Nepal

first democratic revolution in 1951. The secondis to describe SCHP activities as one case of acommunity development and health project. Thefirst part was written by using selected literatureon the community development approach. Thesecond part was written mostly using publishedpeer review articles on SCHP.

Why a Community DevelopmentApproach?

Democratic revolution and health in NepalNepal’s overall health status has progressivelyimproved since 1951, when Nepal decided to


Jimba M, Poudel-Tandukar K, Poudel KC

open the door to the rest of the world through thefirst democratic revolution. It allowed foreign aidagencies to come to Nepal, and their supportbegan in the 1950s. As a result, the infant mortalityrate (IMR), once estimated to be 255 per 1,000live births in 1951, declined to 156 in 1969 andfurther to 79 in 1995.1 The most current Demo-graphic and Health Survey (DHS) showed that itreached 48 in 2006.2

Despite a great achievement in improvinghealth in the past half a century, there was a hugegap in IMR among the 75 districts of Nepal. In1994, IMR in urban areas was 62, whereas that inrural areas, it was 105.3 More strikingly, IMR ofthe best district was 32, whereas in the worst dis-trict, it was 201 in 1991.4 A similar disparity wasalso visible in other development indicators suchas the overall composite index of development,the poverty and deprivation index, the women’sempowerment index, etc.5

Considering the declining IMR over the decadesand the existing gap in IMR among the districts,it is important to know the reasons for both. Bycomparing district-wise IMR data in 1991, Thapa(1996),4 for example, revealed that female literacywas the most important factor in accounting forvariations in IMR. Using the 1991 DHS data,Suwal6 suggested that the most influential vari-ables on IMR were parity, place of residence,immunization, and ethnicity.

Need for a community developmentapproach in NepalAlthough both Thapa4 and Suwal6 also consideredthe importance of health care-related factors, it isworth noting that they found that demographic,socio-economic, and culture-related factors weremore important in reducing IMR. Knowing thatsuch demographic, socio-economic, and culture-related factors are important to improving health,how can these considerations be put into healthplanning in Nepal and how can they be imple-mented in practice?

According to Rifkin,7 health planning can becategorized into three approaches: medical,health service, and community development.

Over the five decades after the opening ofNepal, medical and health service approacheshave been common in this country. In the 1950sand ’60s, hospital-based and vertical programswere implemented. First, hospital upgrading wasthe major focus of the government. NGOs also

took the hospital-based approach. Then, verticalprograms were implemented for malaria, lep-rosy, tuberculosis, smallpox, family planning, andchild welfare.8 Although such vertical approachesreduced malaria, eradicated small pox, and haveproduced other successful outcomes, influentialhealth sector agencies recognized that the hospital-based approach benefited only the urban popula-tion and that vertical programs were expensive tooperate.

Then, as an improved method of health serviceapproach, the concept of integration was intro-duced. The term “integration,” however, appliedonly to the health sector of USAID and theNepalese Ministry of Health.8

These medical and health service approacheshave had limited success in achieving healthfor all in a country like Nepal for several reasons.First, despite the increased number of heathposts (HP) and sub-health posts (SHP) in ruralvillages, only about 45% of households canaccess them within a travel time (in many caseson foot) of 30 minutes.9 Even if villagers canreach HP/SHP, absenteeism of HP staff iscommon and the annual drug rations allocatedto HP/SHP are adequate for only three to sixmonths.10 As a result, nearly three out of fivehouseholds, on average, do not have adequateaccess to health care services. These householdsare disproportionately located in the western andfar-western regions.10 Tailor & Tailor11 describedthis situation as the ‘anatomic structure’ of thehealth system, without the ‘physiologic function’for it to accomplish societal goals.

It is this situation, Rifkin’s7 community devel-opment approach has the potential to improvehealth in rural settings, if it works. However, thereare several problems with the practical applica-tion of this approach. According to Rifkin,7 thecommunity development approach is differentfrom the other two approaches in six points:views about community participation, the role ofthe professional, the role and the training of com-munity health workers to support the program,evaluation of the program, and financial supportof the program. Lastly, the most striking point ofthe community development approach is thatcommunity people take the initiative in solvinghealth problems using health professionals asone of their resources.


SCHOOL AND COMMUNITY HEALTH PROJECT

School and Community Health Projectin Nepal

Khopasi primary health care centera) How did it start?In 1990, the second democratic revolution tookplace, which allowed Nepal to start a new, demo-cratic political system. After the revolution, thenewly elected government created a new healthpolicy based on a primary health care approach.It was in this context that the Nepalese govern-ment requested support from Japan for imple-mentation of the new health policy.

To respond to a request made by His Majesty’sGovernment of Nepal (HMG/N), the JapanInternational Cooperation Agency (JICA) senta project formation survey team in 1991, whichwas headed by Dr. Toshiro Murase, then deputypresident of the JMA. The mission report made

four key recommendations. 1) A healthy villageapproach should be taken; 2) The bottom-upfunction should be strengthened; 3) Communityhealth activities should be conducted throughHP/SHP; and 4) Nepal’s new health policy shouldbe supported. Dr. Tadatoshi Kuratsuji then madean additional survey in 1992, and on December15, 1992, HMG/N, JMA, and JICA launched theSCHP in the Khopasi village development com-mittee (VDC, the minimum local governmentbody in Nepal, with a population 2,000 to 5,000 foreach VDC in a hill region). JICA dispatched twoJapanese experts for SCHP, and JMA has workedas an international non-government organizationand allocated the budget for project activities.b) Target area and initial activities (Fig. 1)Three parties agreed to implement the project inKhopasi in response to the government need toimprove rural health care in Nepal. Khopasi waslocated in Kavrepalanchowk, a hilly district roughly

Fig. 1 Map of Nepal

Far WesternRegion

Mid WesternRegion

Western Region

Eastern RegionCentral Region

Kathmandu

0 10 20km

N

To Kathmandu

Kavrepalanchowk

Banepa

Bagmatiriver Taldhunga Area

Mahabharat Range

Roshi river

Sunkoshi river

Bhugdeu Area

Sindhuri District

1918m1952m

2084m

1589m

2943m2803m

2109m

Makwanpur District

2254m

Target Area ofSchool and Community Health Project (SCHP)

Khopasi

Area : 147,181 sq km


sixty-five kilometers southeast of Kathmandu.During the initial phase of the project, SCHP

completed the construction of the Khopasi pri-mary health care (PHC) center in December1993 and started its operation in January 2004.The center was equipped with a laboratory andan ambulance car, and provided both preventiveand curative services to a population of 100,000in the southern part of the Kavrepalanchowk dis-trict. However, mostly due to difficult geographi-cal conditions, only residents who live aroundthe center tended to use the center and outreachactivities were also limited. That is why since 1995,SCHP started to take a community developmentapproach conducting a pilot literacy educationprogram for women and a pilot school healthprogram.

Community development and health activitiesin rural Nepala) Shifting focus from central to ruralWhile the Khopasi PHC center retained thetarget population of 100,000 in the southernKavrepalanchowk district, SCHP decided to nar-row down its target area from a center to tenrural VDCs, and then later, it was increased tofifteen. The estimated population of the fifteenVDCs was approximately 45,000 in 1997.12 Sev-eral different ethnic groups reside in the area,including the Tamang, Newar, Brahmin, andChhetri. Among them, the Tamang comprise themajority. The villagers had no electricity, tele-phones, or vehicular roads. Reaching the nearestvehicular road required a two- to sixteen-hourwalk from these communities. The area includedeighty-four schools and fourteen governmenthealth institutions (HPs, SHPs) in 1997.b) Major activitiesSCHP had two major objectives. The first was toimprove living conditions through communitydevelopment activities. The second was to improvehealth through local human resource developmentfor health. Both objectives were made consideringRifkin’s six points for community developmentapproach in mind.b-1) Improving living conditionsThis activity consists of two major programs.The first is women’s empowerment through lit-eracy education and self-help groups (SHGs).The second is children’s empowerment throughchild-to-child activities.

b-1-1) Women’s empowerment through literacyeducation

Literacy education was taken up as part of SCHPactivities based on two articles. One article showedthat increasing rural female community healthvolunteers’ literacy levels improved the quality oftheir services in Nepal.13 The second article statedthat an improved literacy level was the main con-tributor to reducing infant mortality rates.4

Started in 1995, SCHP’s Adult Literacy Programmade more than 3,500 adults literate through 170basic literacy classes and 168 post-literacy classes.Both classes were conducted for six months peryear. Among the post-literacy classes, 157 formedSHGs for launching savings and credit groupsand kitchen gardening activities.

As a result, the female adult literacy rate in thetarget area increased from approximately 16% to50% during the period between 1996 and 2000.

According to Acharya et al.,14 during their dis-cussions with the women, participants valued thepost-literacy classes on sanitation, immunizationof children, dehydration therapy, and family plan-ning. More specifically, they became familiar withimmunization against tetanus, diphtheria, pertus-sis, measles, and various malnutrition problems.The discussions revealed that these programsimproved awareness of the use of Jeevan Jal(oral rehydration solution) in diarrhea, greenvegetable intake, safe drinking water, and theprotection of food from dust, flies, and insects.Moreover, approximately one third of the partici-pants began recording income and expenditurein their daily lives.b-1-2) Kitchen garden trainingSCHP started kitchen garden training for literacyclass graduates and attendants as literacy skillsthemselves were not sufficient to improve livingconditions and some husbands started to com-plain of their wives’ absence at night.

At the time of the mid-term evaluation ofSCHP in 2000, 2,197 participants had receivedkitchen gardening training, of those, 44% hadalready made kitchen gardens prior to the train-ing. Encouragingly, nearly one third had juststarted it after receiving literacy training. Approxi-mately two thirds had developed traditional gar-dens. After five years of program interventionin rural areas, nearly all the participants madekitchen gardens. However, participants expressedvarious problems in this activity during discus-sion. Disease and pests were the most frequently




reported problems in the community regardingkitchen gardening activities. Likewise, there wereother problems such as lack of seeds, training,and information, and water for irrigation.14 Still,it was effective to improve living conditionsinstead of simply conducting literacy education.

b-1-3) SHG activitiesb-1-3-a) Development process of one SHGA self-help group called “Khushiyali (Happy)Women’s Group (KWG)” was first formed in Kvillage after completion of the basic and post-literacy classes. The development process of KWG

Table 1 Development process of a self-help group

Steps Dates SHG activities SCHP support and requests

Forming Dec-94 Construction of classrooms for literacy education � Needs assessment meeting

Participation for basic literacy education � Implementation of basic literacy education(supervision and teaching for 6 months)

Provision of support for a literacy educationcampaign on nationwide educational promotion day

Activities other than literacy education(e.g., street cleaning)

May-95 End of literacy education

Implementation of making home gardens � Implementation of training for making homegardens

Requesting practical literacy education � � Provision of technical training for facilitators forpractical literacy education

Dec-95 Participation for practical literacy education � Initiation of practical literacy education

� Provision of second training for facilitatorsEnd of practical literacy education

Jun-96 SHG establishment � Recommendation of establishing SHG

Norming Aug-96 Group works(e.g., rule creation, role sharing, monthly meeting)

Requesting training for construction of portable toilets � Provision of training for construction of portabletoilets

Constructing toilets in every SHG member’shousehold

Requesting support for constructing a library � � Provision of library construction funds

Provision of support for a nationwide vaccination � � Requesting support for a nationwide poliocampaign vaccination campaign

Dec-96 Requesting training in first aid � � Provision of training in first aid

Requesting training for income-generating � � Provision of training for income-generating activitiestechniques (i.e., management solution for the “goat bank”)(SHG members invested their pocket money in Provision of partial loans for the “goat bank”a “goat bank.”)

Revision of group rules

Performing Mar-97 Three SHG members implemented training for � Requesting training for a women’s group in aconstruction of pit latrines in a nearby village. nearby village to construct pit latrines

Financial support for a critically ill mother

Volunteer activities for UNDP river conservationproject

Provision of support for construction of portabletoilets in nearby villages

� : Request from SHG to SCHP� : Support or request from SCHP to SHG*Cited and modified from “Sato C, Jimba M, Murakami I. Adult literacy education as an entry point for community empowerment: evolution ofself-help group activities in rural Nepal. Technology and Development. 2000; No.13: 35–44.


and a description of the cooperative relationshipbetween KWG and SCHP is offered in Table 1.15

Below is a summary to explain the process.Step 1: The Process of FormingTable 1 shows the steps in the growth of theSHG in K village. A quick glance at Table 1reveals heavy support from SCHP for KWG,which is indicated by arrows pointing to theleft. It is clear that there were more approachesfrom SCHP to KWG than vice versa, and thatmost activities, during this stage, were under-taken on SCHP’s initiative.Step 2: The Process of NormingAs indicated in Table 1, the number of arrowsfrom the right increased during this stage. Thisreflects SCHP’s responses to KWG’s requestsfor support. Thus, during this stage, the SHGgradually began to initiate more activities thanSCHP.Step 3: The Process of Storming and

PerformingTable 1 indicates that during this period, theSHG started to become more self-reliant. Inkeeping with this, the relationship between

KWG and SCHP moved from ‘aid agency’ and‘beneficiary’ to ‘partners’ as the SHG was ableto respond to SCHP’s requests. Thus, in thisperiod, a partnership between them developed.

b-1-3-b) Scaling up SHGAfter KWG, SCHP was successful in scaling itup, and 157 SHGs were formed by the end of2000. These SHGs initiated several activities. Theexample below highlights the income generationactivities of four SHGs.

‘. . . SHG funds were on an increasing trend inevery community. According to a four-case studyin three villages (one from Mate, two fromGairigaun, and one from Bhanjyangkhark) inthe mid-term evaluation, the average annualinterest income earned by group investmentwas Rs. 600 (Nepali rupees: 1US$ = Rs 68.25 inJuly 2008), and the interest rate was 24% in allgroups. In half of the cases, however, groupmembership was declining. According to thediscussion, the major reason was the inclusionof many unmarried young women in the groups.Once they got married, they left the villageand became less interested in continuing fund-


LaxmiNarayan

SecondarySchool Health

Post

AgriService

Seti DeviPrimarySchool

Bank

DistrictOffice

VDCOffice

Syauri

Size of circle = importance to community

Direction & width = orientation & intensity of relationship

(1997 PRA Survey)

Fig. 2 Participatory rural appraisal survey about the importanceof available institutions in Syauri village

School is the most important institution!


raising activities, whereas the married womenwere supporting these activities, as they werepermanent dwellers in the community. Thenature of group investment varied. Accordingto the discussion, Mate community participantswere receiving loans for household expenses,whereas in Gairigaun, money was borrowedfor poultry and pig raising. Of the three peoplereceiving loans in Bhanjyangkhark, one wasproducing local liquor, another was producingdalo (bamboo baskets used for household pur-poses) and namlo (the rope or band passedround the forehead that supports a load carriedon the back), and the third was raising goats.Although small, these were also noteworthyimpacts of the SHG activities.’14

b-1-4) Children’s empowerment througha school health approach

b-1-4-a) Why school health?School health has been prioritized by donoragencies as it is cost effective,16 the target popu-lation is big,17 school children are not as healthyas expected,17 and better health can contribute tobetter educational achievement.17 In addition tothese perspectives, SCHP found out several addi-tional reasons to justify school health activities intheir target areas. A participatory rural appraisalin 1997 revealed that of twenty-eight target com-munities in fourteen VDCs, approximately 70%of them regarded schools as the most importantinstitutions compared with other institutionssuch as government offices (district office, VDCoffice, and agricultural office), banks, and others.One example is shown in Fig. 2. As the villagersconsider schools to be the most important insti-tutions, they get together when they conductmass meetings, and a school can thus be used asa center for different types of community devel-opment activities.18

To implement school health programs, SCHPinitially targeted school teachers, but most ofthem came from urban areas and frequently tookextended leave. SCHP was then obliged to targetschool children and their parents for their schoolhealth activities. Then, SCHP initiated the Sup-portive Healthy Environment Program in 1997and the Child Initiative Program in 1998.18

b-1-4-b) Supportive Healthy EnvironmentProgram

This program aimed at creating a supportiveenvironment for health in schools. Its majoractivities were to establish safe drinking water

and toilet facilities in schools and to implementhealth education programs for hygiene.

For this program, first, the school children’sparents and other villagers made significantcontributions. To install one school toilet with aseptic tank system and a safe drinking watersupply system, it cost approximately US$1,100.As many drinking water supply projects wereactive in the target villages, it usually requiredonly water pipes to link them from nearby, exist-ing pipes. Of $1,100, the donor agencies provided65% in cash to buy materials. The remaining 35%was provided as labor cost from the villagers. Inaddition to SCHP’s own budget, UNICEF alsosupported this program.

As a result, while only 20% of all the targetschools had both a functioning toilet and watersupply system in 1995, 100% of them had set upthis system by 2001. Every time after completionof these two facilities, a health education pro-gram was also implemented.b-1-4-c) Child Initiative ProgramSCHP initiated the Child Initiative Program usinga child-to-child approach. This is an approach tohealth promotion, which focuses on the contribu-tion that children and young people can make totheir own health and well-being and that of theirfamilies and communities. Through an activelearning process, children are able to participatein identifying health problems and in playing anactive and effective role in providing solutions.19

In Nepal, the Save the Children Fund (UK)first adopted the child-to-child approach firstin 1989 to involve schools as part of its out-reach program from maternal and child health(MCH) clinics. Similarly, Redd-Barna, HatemaloSanchar, and other NGOs adopted this approach.

In practice, SCHP helped each of eighty-fourschools to form a child club with seven to ninemembers and facilitated various activities, suchas school toilets and drinking water management,health quiz competitions, and deworming orimmunization campaigns. UNICEF also startedto support this program from 1999.

As a result, whereas no such child clubsexisted in any of the schools in 1998, all theschools formed a child club in 2001. The clubmembers joined the above-mentioned healthactivities and have also come to work as healthmessengers for their families and communities.



b-2) Human resource development for healthb-2-1) Healthcare-seeking behavior surveyImproving living conditions through communityempowerment may help to improve health, but ittakes time. To improve health, certain kinds ofhealth-specific activities are also necessary. SCHPconducted several health-specific activities afterconducting a healthcare-seeking behavior survey.

In 1997, SCHP carried out a healthcare-seekingbehavior survey for randomly selected 425 house-holds, and obtained data from 405 of them.20 Theresults revealed that some form of illness strikesabout 50% of households in rural Nepal eachyear. When rural Nepalese feel sick, they seekhealthcare only when the sickness is moderateor severe. Mild illnesses are treated at home.When the villagers seek healthcare, it was foundthat rural Nepalese preferred to visit traditionalhealers first, before visiting other health workers.They prefer to visit traditional healers becausethey are highly accessible, do not charge cash,and can tell whether the diseases are caused byevil spirits according to another study of SCHP.21

When health planners devise health policies,they tend to focus first on improving the hospitals,then on HP/SHP, and finally community-basedhealth workers including traditional healers.However, these results show that the majority ofrural Nepalese seek care of community-basedhealth workers first and they use HP/SHP sec-ondarily, only if they find it necessary. This studythus urged SCHP to work with traditional healers.b-2-2) Working with traditional healersSCHP started to work with traditional healers,also supported by further evidence of the benefitsof working with them.22–25

In 1996, SCHP conducted a traditional healertraining program in western medicine for fiftyhealers. These healers were selected from 269healers in ten VDCs, based on the followingcriteria: the healers should be interested in thetraining, highly respected in their communities,and physically fit and enthusiastic to work any-time in their own VDCs. The first objective ofthe training was to give basic knowledge aboutcommon illnesses (diarrhea, stomach ache,helminthes, fever, etc.) and HIV/AIDS. Thesecond objective was to increase healers’ refer-rals to HPs and SHPs when the healers wereunable to treat illnesses. The third objective wasto provide them with a first aid kit that containedsimple western medicines so that they can increase

treatment skills for common illnesses.Using a training manual developed in

Nepalese, four instructors trained the healers.One year after the training, SCHP conducted anevaluation survey with forty-eight healers (twodied within a year) and thirty randomly selecteduntrained healers. As a result, SCHP found thatthe trained healers had a better knowledge ofallopathic medicine, practiced modern treatmentusing the first aid kit, and were more likely to referpatients for HPs and SHPs.26 They also improvedtheir relationship with the governmental healthworkers in these institutions.b-2-3) One doctor from one VDCWhen referral was made, it was questionablewhether government health workers were in thehealth institution and could indeed help thesereferred patients. As most health workers camefrom outside the target area and none of themwere local, SCHP decided to give scholarship toyoung, local applicants who were interested inbecoming skilled health workers in the future.As a result, SCHP gave scholarship to at least oneto two from each VDC (eighteen in total) andtrained local health manpower. They attended afifteen-month auxiliary heath worker course (agraduate can become a SHP in-charge) or assis-tant nurse-midwife course; some of them becamegovernment employees and others became pri-vate physicians in their own villages.c) Selected outcomesIn 2000, SCHP conducted a mid-term evaluationwith support from New Era, a well-known healthresearch institute in Nepal. In 2002, SCHP alsomade an internal evaluation. Although the evalu-ation results were not published, below are themajor outcomes of the SCHP activities.c-1) School healthIn 1996, only 20% of schools had functioning toi-let and water facilities, but in 2002, 100% of theschools had them (by 2002, target schools wereincreased to 103). During this period, 100% ofschools formed child clubs and received a first aidkit and formed school management committees.c-2) Community healthIn community health, the adult literacy rate wasimproved from nearly 16% in 1996 to 50% in2000 in the target area. The number of SHGsincreased from zero to approximately 160, and12,633 community people took part in severalhealth education courses (some who attendedtwice or more were counted multiple times).



Ninety-six traditional healers were also trainedand eighteen local villagers became assistanthealth workers or assistant nurse-midwives.c-3) ConscientizationOne of the hidden outcomes of this project wasraising consciousness about development. In thebeginning when the project started in rural vil-lages, people used to say ‘development means agift from outside.’ ‘It is a hospital, it is a road,there is nothing I can do or I should do for devel-opment.’ It was a common consciousness in thetarget area. However, in 2001, one local staffmember from one target community sent a letterto a Japanese public health nurse expert, which isshown in Box 1, and which showed her internalchange as a conscientized human being after her


Box 1 A letter from a SCHP project staff member to a Japanese public health

nurse expert which shows raising consciousness after joining SCHP

‘Sister, how I can express my heartfelt thanks for you. I have changed a lot in

the past four to five years, which I could not imagine in the past. I feel like I am

now standing on a new world. When you first came to my village, I wanted to talk

to you, but could not. I had no confidence about what I would say in Nepalese.

I was so disappointed.

Then later, I got a chance to attend a literacy education training course

as I was selected to be a teacher of a literacy class in my community. The

other participants were older than I and were highly educated. I again lost my

confidence.

However, little by little, I started to feel, ‘I am also the same human being, I can

do as they can do.’ I attended the training course enthusiastically and studied

until late at night. Then the course ended. Then, I became confident in myself

and could manage to run a six-month literacy course in my community.

After that, I attended more and more courses and became more confident in

development activities. I graduated only from 8th grade. I am not well educated

and am not rich. However, I started to realize that ‘being rich’ means that I have

confidence within myself, and I can be being a fighter in seeking a better living.

My parents gave me birth and raised up. But it was you who have shaped my

life. You showed me the way to go, too. Then I could gain a confidence and hope.

Now I am going to marry . . . . I want to still continue to work with you. Please

do not forget me even after my marriage.

Please come to my wedding ceremony with the project staff members. Finally,

I am sorry if I’ve made any mistakes in this letter.’

(Cited and modified from “Jimba M. Public health and globalization. In: Hoshi T. ed. Social Security and Healthof the Individual 2: public health, Textbook for Nurses 8, Igakushoin; 2002: pp. 264–277.”)

involvement with SCHP.

Conclusions

SCHP conducted a variety of community devel-opment activities considering Rifkin’s six pointsfor community development approach. It aimedat improving the living conditions and healthof rural Nepalese. As a result, it gained positiveoutcomes mentioned above. Improving the num-bers is indeed important, but one letter shownin Box 1 is also precious for those who remain indevelopment activities. Community developmentand health projects can in this way contribute toimproving the health and living conditions ofrural people. It also has the potential to raise


References

1. Pradhan A, Aryal RH, Regmi G, Ban B, Govindasamy P. Nepalfamily health survey 1996. Kathmandu and Calverton, MD:Ministry of Health [Nepal], New ERA, and Macro InternationalInc.; 1997.

2. Ministry of Health and Population [Nepal], New ERA, MacroInternational Inc. Nepal Demographic and Health Survey 2006.Kathmandu: Ministry of Health and Population, New ERA, andMacro International Inc.; 2007.

3. Central Bureau of Statistics (CBS). Population monograph ofNepal. Kathmandu: Central Bureau of Statistics; 1995.

4. Thapa S. Infant mortality and its correlates determinants inNepal: A district-level analysis. Journal of Nepal Medical Asso-ciation. 1996;34:94–109.

5. ICIMOD. Districts of Nepal: indicators of development.Kathmandu: International Centre for Integrated Mountain Devel-opment; 1997.

6. Suwal JV. The main determinants of infant mortality in Nepal.Social Science & Medicine. 2001;53:1667–1681.

7. Rifkin SB. Health planning and community participation: casestudies in Southeast Asia. London: Croom Helm Ltd.; 1985.

8. Justice J. Policies, plans, and people: culture and health devel-opment in Nepal. Berkeley, CA: University of California Press;1986.

9. Central Bureau of Statistics (CBS). Nepal living standards sur-vey report 1996. Kathmandu: Central Bureau of Statistics; 1997.

10. Nepal South Asia Centre. Nepal Human Development Report1998. Kathmandu: Nepal South Asia Centre; 1998.

11. Taylor CE, Taylor DC. Population planning in India and Nepal.Growth and Change. 1976;7:9–13.

12. National Research Associates. Nepal district profile.Kathmandu: Nepal Research Associates; 1997.

13. Bentley H. The organization of health care in Nepal. InternationalJournal of Nursing Studies. 1995;32:260–270.

14. Acharya S, Yoshino E, Jimba M, Wakai S. Empowering ruralwomen through a community development approach in Nepal.Community Development Journal. 2007;42:34–46.

15. Sato C, Jimba M, Murakami I. Adult literacy education as an

entry point for community empowerment: evolution of self-helpgroup activities in rural Nepal. Technology and Development.2000;13:35–44.

16. World Bank. Investing in Health: 1993 World Bank Report.Washington DC: The World Bank; 1993.

17. Rosso JMD, Marek T. Class action: improving school perfor-mance in the developing world through better health and nutri-tion. Washington DC: The World Bank; 1996.

18. Jimba M, Wakai S. School health in rural Nepal: Why and How?Southeast Asian Journal of Tropical Medicine & Public Health.2005;36:237–239.

19. Zaveri S. Learning from children: a review of child to child activi-ties of Save the Children Fund (UK) in Nepal. London: Child-to-Child Trust; 1997.

20. Jimba M, Poudyal AK, Wakai S. The need for linking healthcare-seeking behavior and health policy in rural Nepal. SoutheastAsian Journal of Tropical Medicine and Public Health. 2003;34:462–463.

21. Shimobiraki C, Jimba M. Traditional vs. modern medicine: whichhealthcare options do the rural Nepalese seek? Technology &Development. 2002;15:47–55.

22. Dhakal R, Graham-Jones S, Lockett G. Traditional Healers andPrimary Health Care in Nepal. Kathmandu: Save the ChildrenFund (UK); 1986.

23. Gillam S. The traditional healer as village health worker. Journalof Institute of Medicine. 1989;11:67–76.

24. Pigg SL. Acronyms and effacement: traditional medical practitio-ners (TMP) in international health development. Social Science& Medicine. 1995;41:47–68.

25. Oswald H. Are traditional healers the solution to the failures ofprimary health care in rural Nepal? Social Science & Medicine.1983;17:255–257.

26. Poudyal AK, Jimba M, Murakami I, Silwal RC, Wakai S, KuratsujiT. A traditional healers’ training model in rural Nepal: strengthen-ing their roles in community health. Tropical Medicine & Inter-national Health. 2003;8:956–960.


the consciousness of people who jointly workfor community development from within. Moreefforts should be made to scale up these activities

in a country where the rural population stillsuffers from poor health conditions.


Report

Police Agency, a total of 250 medical malpracticecases were sent to the public prosecutors officeduring the 3 years from 2003 to 2005, whilethe number of those indicted was 79 during the5-year period from January 1999 to April 2004.Eighty-four cases were sent to the public pros-ecutors office, with approximately 16 cases beingindicted per year. Seventy-nine medical malprac-tice suits underwent litigation in court during the5 years from January 1999 to April 2004; 20 casesof 36 accused were brought to trial, and summaryorders were issued in 59 cases of 76 accused. Onthe other hand, only 137 medical criminal caseswere addressed during the entire 54 years from1950 to January 1999, indicating that criminalcases related to medical malpractice have beenincreasing recently.

Why Has the Criminal Prosecution ofMedical Disputes Become MoreCommon?

Initially, the civil responsibility of doctors wasdefined by Supreme Court decisions in marginalcases including the decision of “high probability”issued in February 1999, the conclusion of thecase of denial of blood transfusion by membersof Jehovah’s Witnesses in February 2000, and thedecision stipulating “considerable likelihood” inSeptember 2000.

Second, disturbing instances of medical mal-practice occurred in large-scale hospitals at aboutthe same time as the court was altering its rulings.Such malpractices included the incorrect identifi-cation of patients at Yokohama City UniversityHospital in January 1999, erroneous infusion ofan antiseptic solution at Tokyo MetropolitanHiroo Hospital in February 1999, an anticancer

Introduction

Two types of risks related to medical disputesare creating confusion in the field of clinical prac-tice in Japan: civil lawsuits, such as those seen inother countries, and the handling of medical dis-putes as criminal cases, the latter exemplified bythe Fukushima Prefectural Oono Hospital case(Table 1). In the Oono Hospital case, an ob-gyndoctor was arrested and indicted for professionalnegligence and violation of the professional obli-gation to report any unusual death (i.e., violationof the Medical Practitioners Law, Article 21). Thedeath in question was in regard to death fromhemorrhage during a cesarean section. The doc-tor was the only ob-gyn doctor in the prefecturalhospital that had assumed a significant role incommunity healthcare, and the doctor’s arresthad a heavy impact on the medical profession.The number of medical facilities that handlechildbirth, which had already decreased to a criti-cal number because of the risk of civil litigation,decreased even further after this case (Fig. 1).Not only ob-gyn related societies but also surgi-cal societies such as the Japan Surgical Societyand the Japanese Society of Anesthesiologistsconcurrently posed questions in regard to thiscase, and medical organizations such as the JapanMedical Association and the Japanese Associationof Medical Sciences issued statements objectingto this particular case. Thus, during the past fewyears the medical profession in Japan has beenexperiencing unprecedented change.

Are Medical Criminal Cases Increasing?(Fig. 2)

According to an announcement by the National

*1 Research Director, Japan Medical Association Research Institute (JMARI), Tokyo, Japan ([email protected]).

A Healthcare Crisis in Japan:Criminalizing medical malpractice

JMAJ 51(4): 235–241, 2008

Rintaro SAWA*1


Sawa R

Table 1 Fukushima Prefectural Oono Hospital case

● In December 2004, a 29-year-old woman who received cesarean section at Prefectural OonoHospital in Okuma Town, Fukushima Prefecture, died from hemorrhagic shock. In March 2005,the Investigation Committee of the prefecture published the accident report that attributed thecase to medical error. The prefectural police department, which received news of the accidentfrom news reports, initiated an investigation of the accident. On February 18, 2006, the 38-year-old ob-gyn doctor who performed the operation was arrested for professional negligence resultingin death and for violation of the Medical Practitioners Law. On March 10, the Fukushima DistrictPublic Prosecutors Office prosecuted the case at the district court level. The doctor was releasedon bail on March 14.

● After four sessions of pretrial proceedings, the first trial hearing was begun on January 26, 2007.Following the 13th hearing (prosecutors’ closing arguments) in March 2008 and the 14th hearing(summation) in May, the case is expected to conclude in June.

drug overdose at Saitama Medical Center, anaffiliate of Saitama Medical School, in October2000, and tampering with medical charts at the

Heart Institute of Japan, an affiliate of TokyoWomen’s Medical University, in March 2001. Thenews media gave prominent coverage to these

Fig. 1 Medical facilities that deal with childbirth and delivery have already decreased to a critical limit

Newly opened hospitalsHospitals no longer offering childbirth deliveryDecrease in the number of hospitalsNewly opened clinicsClinics no longer offering childbirth deliveryDecrease in the number of clinics

Doctor at Oono Hospital arrested (Source: National Police Agency)

2002

110.0

82.5

55.0

27.5

0.02003 2004 2005 2006

Fig. 2 Intervention of criminal justice in medical disputes

Annual changes in the number of notifications of police from healthcare professionals and the number of cases sent to prosecutors

Number of notifications by healthcare professionals

Number of cases sent to prosecutors

Cases Cases250

1997

3

1998

9

1999

10

201912

2000

24

80

2001

Year

51

80

2002

58

118

2003

68

195

2004

91

199

2005

91

117

200

150

100

50

0

100

80

60

40

20

0

(Source: National Police Agency)


A HEALTHCARE CRISIS IN JAPAN: CRIMINALIZING MEDICAL MALPRACTICE

cases, leading to distrust and disaffection inregard to the medical profession.

Third, the situation of the police and prosecu-tion, who must face the emotions of patients andbereaved individuals, is involved. For example, inthe Okegawa stalking/murder case that occurredin October 1999, a female college student wasmurdered near Okegawa station of the JapanRailway Takasaki line in Okegawa City, SaitamaPrefecture, on October 26, 1999, by a man hiredby her ex-boyfriend and his brother. The victimhad been threatened by stalking behavior thatincluded close scrutiny, maligning, and threaten-ing from these men. The victim and her familyconsulted with the local office of the prefecturalpolice department many times and submitted awritten accusation. The police, however, ignoredthe accusation and did not undertake an inves-tigation, but instead requested that the familywithdraw the accusation. It was also revealedlater that they tampered with the written accusa-tion. The police officers who had been involved intampering were given a dishonorable discharge,and eventually were convicted in court. Anotherinfluential case was the Tochigi lynching case,a case of confinement, assault, and murderuncovered in Tochigi Prefecture on December4, 1999. The Tochigi prefectural police depart-ment failed to investigate the incident, despitethe fact that the victim’s parents had asked thepolice department nine times to search for theirson. This lack of action left an emotional scaramong the general populace. This case, together

with the Okegawa stalking/murder case, arouseddissatisfaction toward the authorities. After theexposure of this incident, the Tochigi prefecturalpolice department was subjected to harsh criti-cism from both the public and the court. In thesecases, claims for damages resulting from negli-gence in regard to the investigation were entered.Currently, in response to increased advocacy byvictims’ groups, the investigative authorities arenecessarily conducting more thorough investiga-tions. In addition, the current state of affairs issuch that the prosecutor has almost no choice butto bring in indictments, although the prosecutorhas the authority to conduct prosecution, repre-senting the principle of discretionary prosecutionprescribed in Article 248 of the Criminal Proce-dure Law (the prosecutor can avoid institutingprosecution if there is no need for legal action,considering the personality, age, and circum-stances of the criminal, grade and circumstancesof the offense, and the situation following theoffense). It must be borne in mind that there isno difference in handling the cases of doctorsand criminals once they are involved in criminalproceedings.

The Flow from Medical Disputes toCriminal Disputes in Japan

The flow from medical disputes to criminal dis-putes in Japan is shown in Figs. 3 to 7.

If a criminal proceeding is initiated, it is impor-tant to know when to contact the lawyer. If a

Fig. 3 Difference between prosecution and non-prosecution

Before prosecution (called “suspect”) After prosecution (called “defendant”)

Clues in investigation

Investigation on a voluntary

basis

Arrest (maximum

72 h)

Detention (maximum

20 days)

House arrest

Prosecution Request for trial

Types of non-prosecution- Insufficient evidence- Impeccability- Suspension of prosecution

No legal accusation. No criminal record.

It takes about 3 months to resolve the case if guilt is admitted, but can take several years if a not-guilty plea is entered.

Summary proceedings

Fine of several hundred thousand yen

Non-prosecution

Application for bail (high bail)


person is informed of the right to remain silentduring questioning by a police investigator, heor she is already a suspect from the legal pointof view. Therefore, the person should consult alawyer immediately at this point. It is a disad-vantage to call a lawyer after arrest. Criminaldefense requires the support of evidence, but allevidence including medical charts is impoundedat the time of arrest. Thus, information is sealed,and it is extremely difficult to obtain such sealed

information. When a doctor is arrested, theprosecutor is usually confident of the guilt ofthe suspect through consultation with a superiorgovernment agency. Therefore, it can be quitelikely that the doctor will be prosecuted. Manydoctors who are covered by medical compen-sation insurance assume that a lawyer from theinsurance company will support them. Althoughthe insurance company acts on behalf of theinsured in civil cases, selection of a defense

Sawa R

Fig. 5 Difference between court proceedings and summary proceedings

Fig. 4 What does “sending papers to prosecutors” mean?

Clues in investigation (e.g., accusation

by the victim)

Investigation on a voluntary basis

(interviews, on-the-spot

inspection, etc.)

Arrest

Sending the case to prosecutors

Detention (maximum

20 days)

Sending papers to prosecutors House arrest

Prosecution

Non-prosecution

It means “sending the record of interrogation and other papers pertaining to the accused person from the police to the public prosecutors office in order to help assess the propriety of prosecution without detaining the accused person.” (Translated from the Daijirin dictionary, Sanseido Co., Ltd.)

Investigation should be primarily by the police, and “prosecutors investigate particular crimes by themselves when they recognize it as necessary” (Article 191, Section 1 of the Law of Criminal Procedure). The police must report to prosecutors all cases that they have investigated, excluding minor offenses (Article 246 of the Law of Criminal Procedure).

This is not legal terminology, but rather a term used by the mass media. It is the state in which the accused person is not arrested as a result of police discretion. The accused person receives no legal disadvantages by “sending papers,” but is not relieved of the possibility of future prosecution.

Court proceedings (formal trial) Summary proceedings (Article 461– of the Law of Criminal Procedure)

• In open court

• No limitations in type of sentence

• When the accused person is detained, he or she is kept in custody unless bail is admitted.

• If innocence is asserted, at least 2 years may be necessary. It is difficult for a single lawyer to deal with the entire case, and expenses incurred in defending may be high.

• Mass media response: Reported by national newspapers

• Proceedings not open to the public

• Limited to cases of a penalty or a non-penal fine of 500,000 yen or less (1 US dollar�110 yen)

• The basic premise is that the accused person admits his or her own guilt → risk of false accusation

• Papers are prepared by the prosecutors office and the court, and a decision is given on the day of institution of prosecution or a few days later.

• Mass media response: Reported in a corner of a local news page


attorney is a separate requirement in criminalcases. Considering the time, labor, expertise, andcompensation provided, not many lawyers arewilling to take on this responsibility. This furtherincreases the anxiety of Japanese doctors.

Confusion Related to the ExpandedInterpretation of Article 21 of the MedicalPractitioners Law

In Japan, when a medical dispute becomes acriminal case, violation of Article 21 of the Medi-cal Practitioners Law as well as professionalnegligence resulting in death are among the rea-sons for prosecution. However, the view that a

doctor’s violation of Article 21 of the MedicalPractitioners Law includes the death of a patientduring treatment is an extremely new interpreta-tion. Prosecution for this charge was unheard ofa decade ago.

Article 21 of the Medical Practitioners Lawhas been in effect since 1874. Its legislative intentwas to facilitate the discovery of crimes becauseabnormal deaths are more likely to be associatedwith crime. For instance, when a patient broughtto a hospital died in spite of emergency treat-ment and when the administration of poison wassuspected, the doctor in charge would reportthe case to the police. Originally, doctors wereobliged to report an abnormal death within 24


Fig. 6 Difference between detained cases and house arrest cases

Open

Not open

Small burdenof procedure

Great burdenof procedure

� Request for court under detention

� Request for court without detention

� Summary proceedings with detention

� Summary proceedings without detention

Tokyo Women's Medical University case, Prefectural Oono Hospital case, HIV-tainted blood products (Teikyo University route) case, Jikei University Aoto Hospital laparoscopy case

Kyorin University Hospital chopstick case, Misidentification of patients at Yokohama City University Hospital, Tokyo Metropolitan Hiroo Hospital case

Extremely high risk of false accusation

Common in medical criminal cases

(As an unusual example, a non-suspended sentence of imprisonment was imposed in both the first and second trial hearings of the Ujigawa Hospital case.)

Fig. 7 Difference between detention cases and house arrest cases (bail guaranty deposits)

� HIV-tainted blood products (Teikyo University route) case in October 1996 100 million yen

� Tokyo Women's Medical University Hospital artificial heart lung clogged filter case in July 2002 20 million yen

� Prefectural Oono Hospital case in March 2006 5 million yen

The above three were detention cases that required high bail, although they all resulted in a decision of not-guilty. The accused doctors in the second and third cases were both hospital doctors in their 30s.

In detention cases, application for bail is possible after prosecution, although bail money is necessary.

(1 US dollar�110 yen)


hours to avoid the escape of the criminal in casessuch as the above.

However, no prosecutors, jurists, or any otherpersons have considered that doctors who expe-rience the unexpected death of a patient under-going treatment and who might be accused ofprofessional negligence resulting in death becauseof the death would also be under obligation toreport the death according to Article 21 of theMedical Practitioners Law.

Attention was first focused on Article 21 ofthe Medical Practitioners Law after the TokyoMetropolitan Hiroo Hospital case occurred in1999. In this case, a patient died because a wrongdrip infusion was confused with another drug andadministered by a nurse. The attending doctorand the director of the hospital, who dealt withthe incident after the fact, and the supervisingTokyo Metropolitan Government Bureau ofPublic Health attempted to cover up the incidentby recording false information on the deathcertificate. The two nurses who were directlyinvolved in this incident of malpractice werepromptly assigned 1 year of imprisonment and7 months of imprisonment, with each givensuspended sentences for professional negligenceresulting in death. Other persons involved wereprosecuted for the preparation and exertionof a signed false public document and viola-tion of Article 21 of the Medical PractitionersLaw (failure to report an abnormal death of apatient within 24 hours after confirmation), andthe suit against some of the defendants went tothe Supreme Court.

Acting under the influence of this case, theRisk Management Standard Manual Committee,Department of National Hospitals of the thenMinistry of Health and Welfare, prescribed inAugust 2000 that, in cases of death or injury fromdefinite or suspected medical malpractice, thedirector of the hospital has to report the casepromptly to the police station under jurisdiction.Notification of this rule was immediately sent tonational and public hospitals, and was later dis-tributed to private university hospitals and otherlarge-scale hospitals.

In response, medical societies began to publishguidelines. Representative is the 2002 Guidelinesof the Japan Surgical Society. In the statemententitled “report of death and injury of patientsrelated to medical conduct,” it is said that “it isdesirable that medical accidents be reported to

a specialized organization other than police, butin the current absence of any such organization,it is desirable for the time being that, in cases ofdeath or serious injury resulting from definite orstrongly suspected serious medical malpractice,the doctor in charge report it promptly to thepolice station under his or her jurisdiction.”

In 2004, the Supreme Court gave its final deci-sion in the Hiroo Hospital case. It concluded thatplacing the obligation of filing a report accordingto Article 21 of the Medical Practitioners Lawon the doctor who has carried out medical mal-practice does not contravene Article 38 of theConstitution (infringement of right to silence).

However, since 2000, convictions for violationof Article 21 of the Medical Practitioners Lawhave shown distinct features in common. Thedefendants were not only accused of professionalnegligence resulting in death but also of variousadditional infringements. One example is thesuspected intentional hiding of correspondencerelating to an accusation of preparing a falsemedical certificate. Another is rudimentary mal-practice obvious to anyone, such as death result-ing from the erroneous use of an inappropriatemedication as a result of error or from an extra-ordinarily high overdose. In contrast, no casesof the violation of Article 21 have resulted inconviction without additional reasons. Therefore,at present, violation of Article 21 serves only asa hook for the investigation of professional neg-ligence resulting in death.

The Future of Institutional Design

In Japan, there is almost no effective functioningof administrative punishment by experts, andno professional organizations for extra-judicialresolution of disputes, such as offices at which tofile complaints or tribunals of professions. Theseare cited as underlying factors for the tendency ofmedical disputes to become criminal cases.

Any medical action necessarily involves somerisk. There is the view that civil or criminal penaltyand administrative punishment represent certainmeasures to control the quality of medical care.However, it is not possible to restructure systemerrors by pursuing individual responsibility alone.The current status, which is inclined to criminalaccusation, creates only a negative profile, leadingto defensive medicine. It is becoming increas-ingly important to understand these circum-

Sawa R


stances and realize the governance provided byprofessional organizations. Institutional designsthat are urgently needed include the following:(1) Reinforcement of civil compensation: introduc-

tion and expansion of the no-fault compensa-tory system (already targeted for introductionin the case of cerebral palsy in departments ofobstetrics)

(2) Amendment of laws that serve as a gatewayto criminal proceedings; particularly, improve-ment or elimination of Article 21 of the Medi-cal Practitioners Law.

(3) Setting up of independent organizations todeal with medical accidents: model projectsfor survey analysis of deaths related to medi-cal actions, Medical Accidents InvestigationCommittee (Fig. 8)

(4) Oversight and self-monitoring by the medicalcommunity

Concluding Remarks

Initially, medical providers in Japan conceived ofan accident investigation committee that wouldhave the main aim of preventing the recurrenceof accidents. However, the current Medical Acci-dents Investigation Committee is an organizationinside the Ministry of Health, Labor and Welfare,and the Committee members include representa-tives of the bereaved and lawyers. In addition, itis possible to use investigative reports in civil andcriminal investigations. Surgery-related societies,in particular, have issued a statement that vehe-mently objects to these features of the currentCommittee. No resolution has yet been found forwhat is probably the greatest dispute in medicalcare in Japan since the war.


Fig. 8 Schematic image of the Medical Accidents Investigation Committee

Investigative commission on the proper way of investigating the cause of death, etc., concerning medical action-related death, set up in the Ministry of Health, Labor and Welfare

Medical care-related

death

Medical institution

Notification (Should it be obligatory?)

Investigation and Evaluation Committee

Instituted as a national organization or by regional block or prefecture

Clinicians Anatomists Lawyers

Dissection, survey, analysis, evaluation, etc.

Report of survey results

Reporting

Repor

t

Bereaved familyMedia

Disclosing the case, excluding private information


*1 Director, Ishiwata Obstetrics and Gynecology Hospital, Mito, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.136, No.7, 2007,pages 1300–1302).

What Maternity Clinics Can Do for More ReliablePerinatal Care

JMAJ 51(4): 242–246, 2008

Isamu ISHIWATA*1

AbstractThe collapse of perinatal care is imminent, unless measures are implemented for its smooth operation in acommunity care system. However, we are now faced with the prospect of the destruction of perinatal health care.The number of maternity clinics supporting childbirth is decreasing. The presence of maternity clinics supportingprimary care is an essential prerequisite for maintaining the community perinatal care system. The followingactions are required: (1) prompt recruiting and training of workforce including physicians and midwives;(2) revision of the medical fees for perinatal care to appropriate levels and ensuring the salaries of employedphysicians to meet their work burdens; (3) realization of the community care initiative, in which general andcommunity perinatal care centers treat high-risk patients, while normal and low-risk patients are treated at primarycare facilities (maternity clinics and small/medium-sized hospitals); (4) conducting publicity activities on themedical risks associated with childbirth; (5) establishing a system to minimize the risk of medical lawsuits andcreating a system for no-fault compensation and independent organization investigating medical accidents.

Key words Maternity clinic, Perinatal health care, Community health care system, Actions

exaggeration to say that if we can overcome thisproblem, health care problems in all other fieldscan be resolved. This article analyzes the causesof the withdrawal of maternity clinics from child-birth service, and explores what maternity clinicscan do to ensure safer and more reliable perinatalhealth care.

What Caused the Drastic Decreasein Childbirth Centers, ParticularlyMaternity Clinics?

(1) The shortage and uneven distribution ofobstetricians, NICU (neonatal intensivecare unit) physicians, and midwives pushedthe fatigue of physicians in obstetric practiceto an extreme, and the decrease in childbirthcenters and the shortage of NICU became amanifest problem. The increased burden onmedical institutions still offering childbirth

Introduction

Japan has a history of providing the world’s highestquality perinatal health care to its citizens forapproximately 10 years. However, we are nowfaced with the devastation of health care, par-ticularly perinatal health care. The number ofmaternity clinics supporting childbirth is decreas-ing, and childbirth centers are disappearing inmany communities. Many childbearing women,reportedly 200,000 or 300,000, have become healthcare refugees and are having difficulty in findingchildbirth services. The shortage of midwives,the functional insufficiency of secondary andtertiary care hospitals, poor work environment,and increasing lawsuits are also accelerating thedevastation of health care. While this devastationis taking place in all fields, its impact is moststrongly felt in perinatal health care. It is no



service caused more to withdraw like fallingdominos.

(2) As a result of the introduction of the newprogram for the clinical training of physi-cians, obstetricians who had been working athospitals associated with universities werecalled back to universities, and the hospitalsthat became unable to recruit obstetricianswithdrew from childbirth service. At the sametime, the number of residents and medicalstudents aspiring to obstetrics decreased.Because the entry of new workforce hasdecreased, the situation is expected toworsen over a period of several years to 10years in the future.

(3) The system for perinatal health care proveddefective. This surfaced as the failure of thecommunity care initiative, in which healthinstitutions were to be classified into levelsfrom primary to tertiary according to func-tion and scale, and a community healthcare system was to be established based onrole sharing and collaboration. The numberof health institutions accepting emergencytransport of patients is decreasing.

(4) The curtailment of the national healthexpenditure caused worsening of the workenvironment and medical fees of physicians,and induced the decrease in the number ofobstetricians.

(5) The “year 2007 problem”: many obstetri-cians in the baby boom generation arereaching retirement age and leaving their

jobs.(6) There was criminal prosecution involving

medical practice, charging violation of theMedical Practitioners Law, Article 21 (report-ing of abnormal death) (e.g., FukushimaPrefectural Oono Hospital) and chargingviolation of the Criminal Law, Article 211(professional negligence resulting in injuryand death) (e.g., Fukushima PrefecturalOono Hospital and Oyodo Town OyodoHospital, Nara Prefecture).

(7) There was criminal prosecution involvingobstetric practice, charging violation of thePublic Health Nurse, Midwife, and NurseLaw (vaginal examination by a nurse). Thisforced maternity clinics without midwives towithdraw from childbirth services.

(8) Users came to have high expectations ofmaternity centers (particularly of theiramenities, expected to be like those ofhotels). Maternity clinics that could not meetsuch expectations withdrew from childbirthservice.

(9) Many clinics withdrew from obstetric prac-tice because of aging of the physicians and alack of successors.

(10) The devastation of the perinatal health caresystem and the decrease in medical institu-tions accepting emergency transport ofpatients produced a situation where mater-nity clinics cannot offer childbirth servicewith confidence.

(1) Difficulty in recruiting midwives(2) Low medical fees for childbirth

(3) Insufficient availability of hospitals accepting NICU transport(4) Low medical fees for obstetric outpatient care

(5) Difficulty in recruiting nurses(6) Insufficient availability of hospitals accepting transport of mothers

(7) Difficulty in recruiting obstetricians(8) Difficulty in increasing the number of maternity patients visiting the clinic

(9) Diversification of the needs of maternity patients in the community(10) Insufficient system for collaboration of clinics in the community

(11) Other problems

74.251.0

44.544.0

40.636.034.2

29.924.1

14.78.8

0 10 20 30 40 50 60 70 80 (%)

(Quoted from Eguchi N et al. A Survey for the Future of Obstetric Practice, Japan MedicalAssociation Research Institute Working Paper No.141, 2007.)

Fig. 1 Major operational problems (n�1,040, multiple answers)

WHAT MATERNITY CLINICS CAN DO FOR MORE RELIABLE PERINATAL CARE


Analysis of Present Conditions fromthe Standpoint of Employed Physicians

The four elements to run a health institution aresaid to be persons, material things, money, andinformation.(1) The present crisis of obstetric and gynecology

practice derives from a serious shortage ofpersons or physicians.

(2) The burdens of overwork, low salaries, medicallawsuits, and resident training have induced aphenomenal increase in physicians leavinggeneral hospitals.

(3) The collapse of the medical office system hasaccelerated the movement of physicians fromhospitals with poor working conditions tothose offering better conditions. Althoughconcentrated allocation of workforce hasbeen proposed as a solution to the shortage ofphysicians, it is difficult to promote exchangeof personnel among hospitals operated bydifferent entities. The regulations on nationalgovernment workers also present an obstacle.

(4) Because the training of midwives requirestime, this must be rapidly promoted. Mea-sures should be taken to re-train and mobi-lize inactive midwives (which can be done ona prefectural basis). The establishment of mid-wifery clinics in hospitals (midwifery depart-ments) may also be an option for coping withthe shortage of obstetricians.

Operational Problems of MaternityClinics and Proposed Solutions

The survey conducted by Japan Medical Associa-tion Research Institute covering 1,040 maternityclinics1 identified the following issues as opera-tional problems reported in a multiple-answerquestionnaire (Fig. 1).

(1) Difficulty in recruiting midwives: While 18%of midwives are working at maternity clinics,only 2.4% of new midwives enter employ-ment at maternity clinics. The difficulty inrecruiting midwives is expected to intensifyfurther in the future. In fact, 75.7% of mater-nity clinics are troubled with a shortage ofmidwives. It is necessary to rapidly train newmidwives. New midwifery courses should beestablished (within nurse schools operatedby medical associations in communities) so

that nurses working at maternity clinics mayobtain qualification in midwifery.

(2) Low medical fees for childbirth: The fees arein the range from 300,000 to less than400,000 yen (USD 3,000–4,000) at 68.1% ofclinics. The Japan Association of Obstetricsand Gynecology estimates that the appro-priate range of fees is 600,000 to 700,000 yen(USD 6,000–7,000). Considering the needfor equipment, the work environment ofmedical staff, and wages, it is necessary tosecure fund sources through appropriaterevision of medical fees. A preconditionfor securing medical staff is the appropriaterevision of medical fees including the feesfor childbirth service and perinatal care.

(3) Insufficient availability of hospitals accept-ing NICU transport: More than 60% oftransport of pregnant women is requestedfor conditions involving fetuses, i.e., threat-ened premature delivery. It is often the casethat such transport is hampered by theshortage of NICUs despite the availabilityof obstetric beds.

(4) Low medical fees for obstetric outpatientcare: To lessen the burdens on medical insti-tutions performing childbirth service, clinicsthat are not performing childbirth serviceare required to offer health examinations ofpregnant women. It is necessary to revisefees to appropriate levels that can supportthe sound management of clinics.

(5) Difficulty in recruiting nurses: The cooperationof nurses is essential to perinatal medicine.Nurses can perform internal examinationonly under the instructions of a physician.The cooperation of nurses is indispensablefor delivery monitoring continued 24 hoursa day.

(6) Insufficient availability of hospitals accept-ing transport of mothers: There is a shortageof secondary and tertiary care hospitalsaccepting emergency transport of mothers(postnatal bleeding, abruption of the pla-centa, pregnancy-induced hypertension, etc.)

(7) Difficulty in recruiting obstetricians: Obste-tricians are generally in short supply, andrecruiting them is extremely difficult. Mater-nity clinics with relatively few restrictions onthe setting of working terms can readjustworking terms to facilitate the employmentof female obstetricians and obstetricians

Ishiwata I


after retirement age.(8) Difficulty in increasing the number of mater-

nity patients visiting the clinic: A means toincrease the number of maternity patientsvisiting clinics is role sharing among medicalinstitutions, such as treating high-risk patientsat secondary and tertiary care facilities andnormal and low-risk patients at maternityclinics.

A survey of future directions pursued byclinics showed that maternity clinics are tak-ing various stances, including treating allcases except for high-risk delivery (56.5%),treating only normal delivery and electivecesarean delivery (19.1%), withdrawingfrom delivery (18.9%), focusing on obstetricoutpatient care such as maternity healthexaminations (10%), treating only normaldelivery (9.4%), decreasing the number ofdelivery cases (8.5%), and employing a semi-open system (7.7%) and an open system(4.1%).

(9) Diversification of the needs of maternitypatients in the community

(10) Insufficient system for collaboration ofclinics in the community

Positions of Maternity Clinics andActions for the Future

In Japan, most women in childbirth leave theirhomes after the appearance of signs of labor(beginning of labor pains) and go to a maternitycenter located within a 30-minute drive by privatecar. Small and medium-sized maternity clinicsand hospitals have been the mainstay supportingperinatal care in communities. However, theroles of clinics are changing depending on thesituation of the community perinatal care system.There are several patterns of practice as follows.(1) Non-participating clinics: These clinics do notparticipate in perinatal care. (2) Obstetric out-patient clinics: These clinics perform maternityexaminations up to about 36 weeks’ gestation andalso cooperate in neonatal examination. (3) Semi-open system clinics: These clinics perform mater-nity and neonatal examinations, but patientsin labor are transported to childbirth centersand physicians at childbirth centers assist withdelivery. (4) Open system clinics: These clinicsperform maternity and neonatal examinations,and patients and physicians at the clinics go to

childbirth hospitals for delivery. (5) Clinics offer-ing complete care: These clinics provide completecare including maternity and neonatal examina-tions and childbirth service.

From the standpoint of patient safety, a pre-requisite for providing childbirth service at primarycare facilities is the establishment of a system forproviding care through involvement of multiplephysicians or a cooperation system to respond tothe emergency needs of primary care facilities inthe community. It is important to promote thecommunity care initiative in perinatal medicine.In the present situation, the attempt to overcomethe shortage of obstetricians and NICU physi-cians through concentration and prioritization atsecondary and tertiary care facilities has beenunsuccessful. Although maternity patients areconcentrated at childbirth centers, there is ashortage of workforce to be concentrated atthese centers.

In any case, the following actions are neededfor the improvement of perinatal care: (1) promptrecruiting and training of workforce includingphysicians and midwives; (2) creation of an envi-ronment to facilitate the cooperation of nursesand total legalization of internal examinationperformed by nurses; (3) revision of the medicalfees for perinatal care (fees for childbirth) toappropriate levels and ensuring the salaries ofemployed physicians to meet their work burdens;(4) realization of the community care initiative,in which general and community perinatal carecenters treat high-risk patients (measures toensure sound business operation without theneed to treat normal and low-risk patients areneeded), while normal and low-risk patients aretreated at primary care facilities (maternity clinicsand small/medium-sized hospitals); (5) conduct-ing publicity activities about the medical risksassociated with childbirth; (6) establishing a sys-tem to minimize the risk of medical lawsuitsand creating a system for no-fault compensation(NFC) regarding complications that may occurin perinatal care (e.g., cerebral palsy); and(7) creation of a system to prevent undue crimi-nal prosecution against medical professions,including the establishment of an independentorganization investigating medical accidentsand the amendment of Article 21 of the MedicalPractitioners Law.

WHAT MATERNITY CLINICS CAN DO FOR MORE RELIABLE PERINATAL CARE


Reference

1. Eguchi N et al. A survey for the future of obstetric practice. JapanMedical Association Research Institute Working Paper No. 141;2007.

Concluding Remarks

The collapse of perinatal care is imminent, unlessmeasures are taken to operate it smoothly in acommunity care system. If the business perfor-mance of maternity clinics does not improveand their withdrawal from childbirth service con-tinues, secondary and tertiary care facilities willbe crowded with normal delivery cases, and the

function of higher-level medical institutions willbe disrupted. On the other hand, if secondary andtertiary care facilities are not able to fulfill theirfunction, it will be impossible for primary carefacilities to provide childbirth services, whichalways involve risks. The presence of maternityclinics supporting primary care is an essentialprerequisite for maintaining the communityperinatal care system.

Ishiwata I

247JMAJ, July/August 2008 — Vol. 51, No. 4


*1 Professor, Department of Obstetrics and Gynecology, Kitasato University School of Medicine, Kanagawa, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.136, No.7, 2007,pages 1288–1293).

Present Status of Obstetric and Perinatal Careand the Action Plan Issued by the Japan Societyof Obstetrics and Gynecology

JMAJ 51(4): 247–254, 2008

Nobuya UNNO*1

AbstractThe recent decline of doctors in the field of clinical practice, particularly from regional emergency care services,has caused serious problems in Japan. This trend is especially problematic in the field of obstetrics, which, incomparison with other specialties, rests on a rather weak foundation and has a variety of complex structuralissues. As a result, the obstetric care system in Japan is facing a serious situation that will require radical changesin order to maintain its stability.

Recent years have seen rapid changes in obstetric practice in Japan, including an aging population of doctors,an increasing proportion of female ob-gyn doctors, and the influence of a new clinical training system. Introductionof the new clinical training system has caused a delay in the supply of newly minted ob-gyn doctors and a declinein the number of doctors who are entering this specialty. These factors have resulted in a significant declinein the clinical workforce and have been followed by the closure of many regional childbirth facilities. In addition,a defensive attitude toward medical practice has recently emerged as a precautionary measure against civilsuits and criminal prosecution for malpractice. To solve these problems, the Japan Society of Obstetrics andGynecology has formulated an action plan for obstetric care reform and has initiated a variety of activities.

Key words Shortage of doctors, Pressure of lawsuits, Support for doctors in clinical practice

session on maternal and child health supportedby the Japan Medical Association in March 2007[Journal of the Japan Medical Association 136;4 (supp.):48–55]. This paper describes some ofthe changes currently taking place in the field ofobstetric practice and includes additional dataobtained after the session. The direction of reformunder consideration and the action plan of thecurrent year designed by the Japan Society ofObstetrics and Gynecology (JSOG) will also beaddressed.

Current Status of Obstetric Practice

An aging population of doctorsAlthough the number of doctors as a whole is

Introduction

One of the serious problems in Japan’s health-care is the withdrawal of doctors from the fieldof clinical practice, particularly from regionalemergency care services. This trend is especiallyprominent in the field of obstetrics. The area ofobstetrics in Japan rests on a weak foundationcompared with other specialties, creating manycomplicated structural issues. As a result, fun-damental reform is required in this particularspecialty so that a stable and sustained structurecan be ensured.

The author presented an outline of the currentstatus of obstetric care in Japan at an educational

248 JMAJ, July/August 2008 — Vol. 51, No. 4

Unno N

increasing in Japan, the number of obstetriciansand gynecologists is decreasing (Fig. 1). Aging isanother factor that differentiates obstetriciansand gynecologists from doctors in other spe-cialties. Physicians in their 60s or older accountfor about 20% of all doctors, whereas the per-centage of doctors in this age group is 26%among obstetricians and gynecologists (Fig. 2).Current obstetric practice is sustained by doctorsrecruited in the 1950s and ’60s, when obstetrics

and gynecology were often chosen as a specialtyby young doctors.

Increasing numbers of female ob-gynsThe number of female doctors has been increas-ing among ob-gyn doctors as a whole over thepast two decades. Prior to that, the percentage offemale ob-gyns was only about 10%, whereasnow female ob-gyns account for about 50% ofall ob-gyns in their 30s, and the corresponding

Fig. 1 Changes in the number of ob-gyn doctors

Fig. 2 Age distribution of doctorsProportion of those aged 60 or older: 26.0% among ob-gyndoctors, 19.6% among pediatricians, 3.7% among anesthe-siologists

Fig. 3 Number of members of the Japan Society of Obstetrics and Gynecologyby age and sex (as of November 2006)

(Based on the results of a survey of doctors, dentists, and pharmacists by the Ministry of Health, Labor and Welfare)

Tota

l no.

of d

octo

rs

No.

of o

bste

tric

ians

and

gyn

ecol

ogis

ts

Total no. of doctorsNo. of obstetricians and gynecologists

(persons)(persons)

12,000

11,500

11,000

10,500

10,000

9,500

9,00020042002200019981996

255,000

240,000

225,000

210,000

195,000

(year) (As of the end of 2004, based on a survey of doctors, dentists,and pharmacists by the Ministry of Health, Labor and Welfare)

TotalOb-gyn doctorsAnesthesiologistsPediatricians

(Age)

(%)40

�29 30–39 40–49 50–59 60–69 �70

30

20

10

0

(persons)

450

400

350

300

250

200

150

100

50

023 28 33 38 43 48 53 58 63 68 73 78 83 88 93

FemaleMale

(age)


PRESENT STATUS OF OBSTETRIC AND PERINATAL CARE AND THE ACTION PLAN ISSUED BY THE JSOG

percentage is at least 70% among those in their20s (Fig. 3).

The increase in female doctors in the field ofobstetrics and gynecology is considered to berelated to an increase in female doctors overallas well as to changes in social mores associatedwith progress in the medical sciences focused ongender differences and the growth of women-only outpatient services. However, further detailsof the reasons for change remain unclear. As aresult, there has been a fundamental change inthe male/female composition of doctors whoprovide obstetric and gynecological services. Inparticular, since advanced or emergency care atuniversity hospitals and regional core hospitalsis largely conducted by doctors of the youngergeneration, structural changes in manpower inthis particular field have had a serious impact onlocal sites of secondary and tertiary care.

In 2006, the Committee for the Support ofFemale Doctors in Their Careers, a subgroup ofthe Japan Society of Obstetrics and Gynecology(JSOG), conducted a survey concerning the cur-rent work sites of doctors who had begun trainingin obstetrics and gynecology at university hospi-tals over the past 15 years. The results showedthat more than 80% of male doctors were work-ing in facilities that handled delivery and child-birth, whereas female doctors tended to leave

such facilities after 6 years; the percentage offemale doctors remaining in delivery and child-birth facilities was just 60% at 6–10 years and50% at 11–15 years (Fig. 4). This generation cor-responds to those in their 30s, and it is apparentthat the changes in gender composition amongdoctors has had a direct influence on the work-force in clinical practice. Since younger femaledoctors, who currently account for 70% of allyounger ob-gyns, will soon be in their 30s, mea-sures to retain them at childbirth and deliveryfacilities appear to be essential to securing theworkforce at sites of secondary and tertiarymedical care.

Influences of the new clinical trainingsystem on the clinical practice ofobstetrics and gynecologyInnovations in the clinical training system havepresented two serious issues in the field of obstet-ric and gynecologic care.

Since the compulsory training for two yearsafter passing the national board examination wasintroduced in 2004, the supply of junior doctorsentering clinical practice has been suspendedfor two years. In the field of obstetrics and gyne-cology, most young doctors used to be sent frommedical schools to hospitals for clinical trainingin a rotation program of a relatively short period

Fig. 4 Proportions of doctors working for deliveryand childbirth facilities within 15 years afterbeginning obstetric training

Fig. 5 Number of members of the Japan Societyof Obstetrics and Gynecology by year ofgraduation from medical school (graduatesin 2005 estimated at 304)

(Based on a 2006 survey by the Japan Societyof Obstetrics and Gynecology)

Statistically significant difference betweencolumns designated by the same letter

Period of time after the beginning of training2–5 years 6–10 years 11–15 years

100a,b,d

a,e b,f c,d

c,ec,f

(%)

80

60

40

20

0Male Female

After introduction of the new clinical training system

FemaleMale

(persons)

400

2001

227

144

2002

216

132

2003

229

134

2004

206

85

2005

3020

2006

1318

350

300

250

200

150

100

50

0(year)


of time. In small-scale hospitals with limited man-power, disruption of the supply of young doctorsresulted in a significant decrease in the workforce,and this change has been too great to be over-come by the efforts of people involved in thelocal areas. (The number of members of JSOGdecreased by 450 from 2004 to 2005, whereasthere had never been a decrease in excess of 40members per year, although a gradual decreasehad been noted.)

Second, the new training program requires allsecond-year residents to be engaged in obstetricand gynecological care. This program also requiresob-gyn doctors in clinical training facilities to bein charge of resident education in addition totheir daily clinical activities, although in fact anyof the training facilities could afford to secureadditional personnel for education or clinical ser-vices. Thus, an additional burden has been placedon the working conditions of ob-gyn doctors, mak-ing working conditions in this specialty moredifficult than those in other fields. On the otherhand, it became possible for residents to have theopportunity to work in a department of obstetricsand gynecology prior to making a final decisionas to their choice of specialty.

An important event was the withdrawal ofobstetric and gynecological services fromuniversity-affiliated hospitals, which occurredjust prior to the introduction of the new clinicaltraining program. According to a survey con-ducted by JSOG, at least 117 hospitals closedtheir departments of obstetrics and gynecologyin 2003–2004.

Among all medical graduates in 2004, a totalof 291 residents chose obstetrics and gynecologyas their specialty in 2006 after completion of thetraining program. As shown in Fig. 5, the numberwas around 350 prior to 2006, and the number ofnew JSOG members decreased about 15–20%.This decrease was largely attributable to the factthat the residents had experienced the difficultworking conditions in the actual hospital settingsof obstetrics and gynecology during their initialresidency program. The main cause of theseproblems may have been due to the fact that thenew clinical training system was introduced tofacilities that were not prepared to improve theirworking environment.

Decreases in childbirth facilitiesFigure 6 presents historical changes in the num-

ber of facilities that handle childbirth and deliv-ery in Japan. In the 12 years from 1993 to theautumn of 2005, the number of facilities handlingdelivery and childbirth decreased from 4,286 to2,933. This represents an annual decrease of 100hospitals and clinics. The number of childbirthfacilities per se is not related to introduction ofclinical training program or the health policyof the Ministry of Health, Labor and Welfare.Rather, the decrease reflects a structural problemin obstetric and gynecology services in Japan. Thedecrease in the number of childbirth and deliveryfacilities not only limits the access of pregnantwomen to such facilities, but also imposes agreater burden on doctors working for these fa-cilities because the decline in facilities is greaterthan the decline in childbirths. It seems that asteady decrease took place up to 2005, prior tothe Government’s policy of consolidation.

Influence of the Oono Hospital case onobstetric practiceObstetrics is the specialty that receives thelargest number of malpractice suits per doctor, asindicated by the figure of 12.4 lawsuits per 1,000doctors in 2004. High compensation damages areoften awarded in the case of lawsuits related

Fig. 6 Decrease in delivery and childbirth facilities

Unno N

(Based on a survey of medical facilities by the Ministry of Health,Labor and Welfare)

(1,000 persons)

Hospitals

5,000 1,400

1,200

1,000

800

600

400

200

0

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1993

2,490

1,796

1996

2,271

1,720

1999

2,072

1,625

2002

1,803

1,503

2005

1,612

1,321

1,000

500

0

Clinics No. of births

Del

iver

y an

d ch

ildbi

rth

faci

litie

s

Ann

ual n

o. o

f bir

ths

(year)



to newborn central nervous system damage, suchas cerebral palsy. Although these facts are notreadily made public, they can be an importantfactor in discouraging young doctors from takingobstetrics and gynecology as their future specialty.

The clinical practice of obstetrics today isefficiently managed, and the results of childbirthare generally favorable. Still, unexpected com-plications resulting in poor outcomes occur andcannot be avoided. It is natural for a marriedcouple and family to expectantly await the birthof a new family member, but when they are facedwith a poor outcome, it is extremely difficult forthem to accept the reality.

Medical disputes are more common in thefield of obstetrics, not only in Japan, but alsoin other countries worldwide. Disputes in thisfield probably occur more often than in otherspecialties because it deals with life processeslike pregnancy, delivery, and childbirth. It isnecessary to decrease the pressure of lawsuitson obstetric departments through an institutionalapproach. Otherwise, obstetric services will cometo an impasse as a result of a decrease in serviceproviders.

In the Fukushima Prefectural Oono Hospitalcase, a doctor was criminally accused of theintra-operative death of a pregnant woman withplacenta previa accreta who had a history ofcesarean section. The charge levied against thedoctor was professional negligence resulting indeath. This case had an extremely strong impacton not only ob-gyn doctors but also all otherclinicians, because of the fact that an unfortunateincident that occurred in the process of ordinarymedical practice had been linked to criminalprosecution. As is commonly known, the JapanMedical Association, Japanese Association ofMedical Sciences, and various other health-related organizations expressed their strongconcern regarding this kind of judicial action.

The case is currently (as of October 2007)undergoing trial at the Fukushima District Court.It is important in regard to future health careactivities for the court to clarify its rulings inregard to judicial intervention in medical care.

In regard to the influence of this case onobstetric practice, the most substantial changehas been that secondary care hospitals or regionalcore hospitals have been referring a larger num-ber of high-risk patients, who otherwise wouldhave been treated at their facilities, to tertiary

care facilities. For example, cases of placentaprevia or low-lying placenta accounted for 0.88%and 1.13% of all obstetric cases in 1974–1978 and2001–2005, respectively, at Kitasato UniversityHospital. This indicates no significant differencebetween the two periods. However, the corre-sponding percentage increased significantly to2.44% in 2006. Similar changes were noted atother hospitals such as the University of TokyoHospital, Jichi Medical School Hospital, and theNational Defense Medical College Hospital.

This trend is not limited to placenta previa, butto a wide range of high-risk pregnancies. Thesechanges seem to result from an oversensitivereaction on the part of medical facilities to thepossibility of criminal intervention and excessivecoverage by the media when the results of treat-ment prove to be unfavorable. Although theconcentration of high-risk cases in advanced-carefacilities may be reasonable, the problem is anincrease in the number of patients while medicalresources lag behind. Tertiary care facilities alsoface the problem of a lack of doctors. An exces-sive concentration of high-risk patients increasesthe burden on tertiary care facilities, leading tothe possible flight of doctors.

Since the spring of 2006, hospitals that havewithdrawn delivery and childbirth facilities haveincreased to more than 100. Although there havebeen no detailed data on changes in clinics since2005, it seems clear that an increasing number ofclinics are withdrawing delivery and childbirth.

Obstetric Care Reform

Discussion of the JSOG Study Committeeon the Ob-Gyn Care SystemThe Committee on the Ob-Gyn Care System,which was set up in November 2005, proposedsuggestions for ob-gyn care in its final reportissued in April 2007 (Table 1). The full text of thisreport is available from the website of JSOG inJapanese as follows: (http://www.jsog.or.jp/news/pdf/iryouteikyotaisei_last12APR2007.pdf).

The fundamental premise is that any furtherdamage to the current regional obstetric care sys-tem needs to be avoided, and that the currentsystem be transformed to a new system thatensures stable, sustained provision of obstetriccare. Given the marked increase in female doc-tors, it is absolutely necessary to carry out effortsto secure and retain them in the field of delivery


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Table 1 Final report: Future prospects of obstetric and gynecologic care in Japan and specificmeasures proposed to establish them (summary)

Recognition of the current situation: the obstetric care system in Japan is currently in crisis owing to a numberof complex reasons

Issues of human resources(1) Shortage and further decline in ob-gyn doctors as a whole as well as those engaged in childbirth and

delivery- Harsh working conditions and poor treatment at hospitals- Aging of doctors and increasing numbers of female doctors among younger ob-gyn doctors- Introduction of a new clinical training program

(2) Shortage of midwives and their uneven distribution among facilities(3) Limited capacity to handle childbirth and delivery among clinical departments that may involve childbirth

and delivery, such as general medicine(4) Shortage of pediatricians and anesthesiologists who also assume responsibility for perinatal care

Institutional issues(1) Inadequacy of system to resolve medical disputes(2) Legal problems related to Article 21 of the Medical Practitioners Law and Article 30 of the Public Health

Nurse, Midwife, and Nurse Law(3) Application of criminal law to medical errors

Future prospects of the obstetric and gynecologic care system: The current system should be transformedinto a new system that allows for the stable provision of obstetric and gynecologic care in an atmosphere ofwell-established safety

Proactive formation and maintenance of a hierarchical network in the obstetric care zone, and positiveadministrative support and guidance for the network(1) Development of an obstetric care system that can respond promptly to emergency cases(2) Groups of regional childbirth delivery facilities where prompt instrumental or operative delivery, including

cesarean section, are always available(3) Regional obstetric and gynecologic centers that offer 24-hour services(4) Establishment of a perinatal emergency-care system

Improved working conditions and treatment of doctors(1) Provision of working conditions that facilitate the retention of female doctors(2) Better treatment of hospital doctors by improving the flexibility of employment conditions: provision of

rewards suited to the actual work provided

Specific measures for achieving the future vision. In regard to obstetric care:

It is necessary to prepare conditions that will ensure existing obstetric care providers remain and work aslong as possible to prevent future crises in obstetric practice. As long as there is shortage of midwives inthe clinical field, nurses should be permitted to perform pelvic examinations as assistants in medicaltreatment.

After the current situation of clinical practice stabilizes, transfer to a better, safer system should beattempted through policy making. In this process, regional obstetric and gynecology care centers andcore hospitals should be rebuilt to larger size. Decreasing the number of childbirth delivery facilities will beunavoidable.

Development of a medical dispute-resolution system by the national government(1) Alternative dispute resolution for medical disputes(2) Organization to determine the cause(s) of medical errors(3) A no-fault compensation system for medical errors

Ob-gyn doctors should play a proactive role in the establishment of obstetric care zones and in the growthof groups of regional childbirth delivery facilities and regional obstetric and gynecologic centers. Thegovernment should provide active support for these activities.

Ob-gyn doctors should make proactive efforts to achieve better working conditions and treatment, andthereby attempt to increase the number of new ob-gyn specialists and to maintain and develop obstetricand gynecologic care. The ob-gyn profession should actively help to resolve problems that female doctorsencounter.

(April 12, 2007, Exploratory Committee on the Ob-Gyn Care System of the Japan Society of Obstetrics and Gynecology)



Table 2 2007 JSOG obstetric care system-related action plan (summary)

Activities of JSOG

(1) Provide information and education- Enhance public relations activities to facilitate the public’s understanding of obstetric and

gynecologic practice (obstetric care system and ethics issues)

(2) Support clinical practice from the standpoint of medical sciences- Develop practice guidelines- Reinforce specialist training

(3) Stress the appeal of obstetrics and gynecology to recruit more medical students andtrainee doctors- Recruiting DVDs- Summer school- Encourage more male medical students and doctors to enter the ob-gyn profession

(4) Support doctors in clinical practice- Provide perinatal emergency doctors with a proper allowance for emergency care and

childbirth delivery care- Ensure good working conditions- Ensure that the work environment does not result in Karoushi (death from over-working)- Ensure that the work environment enables female doctors to continue working

(5) Develop regional obstetric and gynecologic centers- Consolidate core hospitals with the aim of enhanced functioning- 24-hour emergency services to meet the needs of the local community- Create facilities that provide good working conditions and enable female doctors to

continue working- Improve hospital management such that it creates an environment in which doctors and

other medical staff wish to continue working

Approach government and administrative authorities

(1) Establish a system to handle medical disputes- Organization for Alternative Dispute Resolution (ADR)- Organization to identify the causes of medical errors- Development of a no-fault compensation system

(2) Enhance perinatal care promotion projects- Review the general framework of obstetric care- Resolve the shortage of neonatal ICUs- Intensify cooperation between regional medical facilities- Problems involved in the operation of projects (e.g., modification of cases subject to

“additional charges for maternal and fetal ICU” in the medical fee system)

(3) Add payment to the “additional charge for management of high-risk pregnancies” inregional medical centers and core hospitals- Additional charges for management of high-risk pregnancies and deliveries

(4) Stabilize conditions surrounding childbirth and delivery- Increase the lump-sum allowance for childbirth and nursing- Secure regional childbirth delivery facilities- Provide information about childbirth delivery facilities

(5) Intensify regional healthcare cooperation- Revise the medical fee for cooperative management of high-risk pregnancies and

parturient women


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and childbirth. Thus, reform is indispensable.Reform will be necessary to improve workingconditions and the level of care through muchcloser cooperation among regional perinatal carefacilities and the restructuring of existing corehospitals into more modern, up-to-date facilities.

Action plan related to the obstetric caresystemIn 2007, JSOG formulated an obstetric caresystem-related action plan as a specific actionprogram and initiated activities to support healthcare providers in the field of obstetric practice(http://www.jsog.or.jp/news/pdf/actionplan_H19_06_16.pdf) (in Japanese). Table 2 presentsa summary of the action plan. In particular,

JSOG intends to address the issue of providingdoctors with a proper allowance for emergencycare as well as delivery and childbirth care ser-vices in the field of perinatal emergency care,thereby supporting ob-gyn doctors practicingunder the severe working conditions of under-staffed facilities.

Postscript:In August 2008, Fukushima District Courtdeclared the Ob-Gyn doctor was not guilty in allthe charges, and the prosecutor abandoned toappeal to a higher court. The doctor is going toresume Ob-Gyn clinical practice. The long-terminfluence of this case needs to be clarified byfuture investigation.



*1 Professor, Graduate School of Health Sciences, Hiroshima University, Hiroshima, Japan ([email protected]).*2 Associate Professor, Kobe City College of Nursing, Hyogo, Japan. (Present Affiliation: Student of Graduate School of Health Sciences,Hiroshima University, Hiroshima, Japan.)*3 Awano Maternity Hospital (BFH), Toyama, Japan.This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.136, No.7, 2007,pages 1294-1295).

Current Status and Future Prospects of HospitalMidwifery Departments

JMAJ 51(4): 255–257, 2008

Kyoko YOKOO,*1 Mayumi OKANAGA,*2 Masayo AWANO*3

AbstractAlthough the recent shortage of obstetricians in Japan has resulted in the closure of obstetric wards at a numberof hospitals, various countermeasures are being developed to deal with the problem. The Midwifery ProfessionalCommittee of the Japanese Nursing Association has prepared a guidebook entitled “Midwives at Hospitals andClinics: Toward a System of Independent Care.” The guidebook advocates a system that would allow midwivesto independently assess whether the conditions of the mother and child are normal or abnormal and to providecare during pregnancy, delivery, and the postpartum period, while taking into consideration the preferences of theparturient woman and her family, as well as cooperating and apportioning duties with doctors. We believe thatestablishing such a system would adequately compensate for the current shortage of obstetricians. To facilitatemidwives in undertaking a more independent role, it is necessary to establish systems of re-education and trainingof midwives, to obtain better understanding from obstetricians and pediatricians, and to define the distinctive roleof the midwife.

Key words Hospital midwifery departments, Shortage of obstetricians, Midwives, Independence

system, in which midwives would provide mid-wifery care independently, this paper discussesthe current status and future prospects of themidwifery department.

Creating a System in Which MidwivesWould Provide Midwifery CareIndependently

The subcommittee initially attempted to developa guide for setting up an in-hospital midwiferyclinic to promote such clinics within hospitals.However, there was concern that the name“in-hospital midwifery clinic” in Japanese mightinfringe on Article 3 of the Medical Care Lawthat prohibits the use of the term midwiferycenter and similar terms for facilities that do notcorrespond to defined midwifery centers. In addi-tion, this expression has been used commonly

Introduction

A shortage of obstetricians has resulted in theclosure of obstetric wards at a number of hospi-tals in Japan, and countermeasures are beingdeveloped to deal with this problem. The Mid-wifery Professional Committee of the JapaneseNursing Association set up a subcommittee in2004 and in March 2006 developed a guidebookentitled “Midwives at Hospitals and Clinics:Toward a System of Independent Care.”1 Thissystem proposes a new approach to providingcare of both mother and child in addition tomaking good use of midwives’ expertise. Webelieve that the establishment of this system willbe able to adequately compensate for the short-age of obstetricians. In regarding a midwiferydepartment at hospitals as a unit of the entire


Yokoo K, Okanaga M, Awano M

Table 1 Model cases of the system in which midwives provide midwifery care independently

Saiseikai Fukaya Red CrossSano HospitalUtsunomiya Hospital Hospital

To aim at practicing an To realize the ideal vision of Simultaneous pursuit ofobstetric department chosen midwives under the current feeling secure in the hospital

Motive for setting up the system by parturient women in spite situation of the shortage of environment and feelingof decreasing cases of full-time doctors homey in a midwifery centerdelivery

Basic data

Number of beds in obstetric ward 32 in obstetric ward 42 in mixed ward of ob-gyn 33 in mixed ward of ob-gynand internal medicine and other specialties

Annual number of deliveries 1,000 700 520

Affiliation of midwives Obstetric ward staff Obstetric ward staff Clinical Technologybelongingto the Nursing belonging to the Nursing DepartmentDepartment Department (Midwifery Division)

Mode of providing nursing care Module-type (partly by Primary nursing In-hospital midwifery carefunction) two-shift system (in combination with system (team midwifery

module-type) irregular care: two-team formation,two-shift system on call at night)

Childbirth expenses 420,000–450,000 yen 400,000–450,000 yen 300,000–350,000 yen

Midwifery outpatient clinic

Scale Open once a week from Open 5–6 days a week from Open 6 days a week from14:00 to 17:00. 8:30 to 15:00. 9:00 to 16:00.30 min per person 15–20 min per person 45 min per person

Target Applicants who are at Pregnant women with Applicants who are at or20–40 weeks of gestation established due date who after 24 weeks of gestation

are not at risk (applicants and who fulfill eligibilityare seen by a doctor) criteria

Evaluation by a doctor Early gestation to 20th From the initial Until the 24th week ofweek, at 34 or 35 weeks examination until the due gestation, at 28 weeks, and(once), and after 40th week date is established one month after delivery

Delivery

Attendance by a doctor Present even in cases Absent in cases of Absentof normal delivery normal delivery

Mode of delivery Freestyle delivery, delivery Freestyle delivery Freestyle delivery, deliveryin water in water

Fetal monitoring Intermittent auscultation Intermittent auscultation Intermittent auscultation

Vascular access Implementation as needed. None None

Medication When judged necessary None Noneby a doctor.

Hospital care in puerperal period

Evaluation by a pediatrician At birth, at discharge, Neonates are managed Once on admission,one month after birth by the Department of one month after birth

Pediatrics

Maternal care provider Midwife Midwife and doctor Midwife

Mode of hospital stay of the mother 24-hour rooming-in Rooming-in Rooming-inand neonate

Examiner at discharge Doctor Midwife and doctor Midwife

[Prepared from “Current status of midwifery systems in midwifery center models (1)–(3). Japanese Journal for Midwives. 2006;60(4):295–306.”]


CURRENT STATUS AND FUTURE PROSPECTS OF HOSPITAL MIDWIFERY DEPARTMENTS

without a clear definition of its meaning or asocial consensus in regard to it. Consideringthese circumstances, the subcommittee discusseda system in which midwives would provide mid-wifery care independently, without using thespecific term “in-hospital midwifery clinic.”1,2

This system, in which midwives provide mid-wifery care independently is defined as a one thatallows midwives to independently assess whetherthe conditions of the mother and child are normalor abnormal and to provide care during preg-nancy, delivery, and the postpartum period, whileconsidering the preferences of the parturientwoman and her family, and while cooperatingand apportioning duties with doctors in a medicalinstitution capable of emergency treatment.1

Current Status and Future Prospects ofHospital Midwifery Departments

Three model cases of a system in which midwiveswould provide midwifery care independently areshown in Table 1.3–5 Even among these cases,there is a difference in the degree of indepen-dence of midwives’ roles, as reflected in varia-tions in the timing of reference to the midwiferyoutpatient clinic, presence or absence of a doctorin cases of normal delivery, and consultation withthe puerperal woman and neonate at discharge.In order to cope with the shortage of obstetri-cians, it is indispensable for midwives to carryout their role and uphold their responsibilities.However, under the current situation, midwiferypractice is necessarily under the supervisionof doctors. To achieve greater independence ofmidwives at work will require re-education andtraining of midwives, better understanding fromobstetricians and pediatricians, and a definitionof the distinctive role of midwives.

The formulation of functional structures is also

an important issue. What should be noted whenwe refer to the midwifery department at a hospi-tal is the affiliation of midwives. At Sano hospital,one of the model cases in Table 1, two separatesystems (the in-hospital midwife care systemmanaged by midwives and the doctor care systemmanaged by ob-gyn doctors) are functioning torealize the initial target, i.e., simultaneous pursuitof safety, security, and comfort. The in-hospitalmidwife care system is independent of the nursingdepartment; midwives in this system belong to theMidwifery Division of the Clinical TechnologyDepartment, which also includes Pharmacy andthe Division of Nutrition.5,6 We believe that it isdesirable for the midwifery division to become amidwifery department independent of the clinicaltechnology department, and that thereby mid-wives can play a more independent role in pro-viding midwifery care and compensate for theshortage of obstetricians, responding to pregnantwomen who wish to give birth to their babies athome or at a midwifery center.

Conclusion

Given the current trend promoting the consoli-dation of obstetric facilities, we think that birthcenters affiliated with hospitals, but not restrictedto a narrowly-defined “midwifery departments athospitals,” are necessary to serve the needs ofpregnant women and to support the health ofmothers and children and their families. Suchbirth centers represent a modern-day version ofthe “maternal and child health centers” (pre-scribed by the Maternal and Child Health Lawin 1965) that used to be an important base forregional maternal and child health, and theyseem to correspond to the system that wouldensure that midwives provide independent mid-wifery care.

References

1. The Midwifery Professional Committee of the Japanese NursingAssociation. Midwives at Hospitals and Clinics: Toward a Sys-tem of Independent Care. Tokyo: Japanese Nursing Association;2006. (in Japanese)

2. Endo T. Japanese Journal for Midwives. 2006;60(4):288–294.(in Japanese)

3. Hodaka R et al. Japanese Journal for Midwives. 2006;60(4):

295–298. (in Japanese)4. Kakinuma N et al. Japanese Journal for Midwives. 2006;60(4):

304–306. (in Japanese)5. Ishimura A et al. Japanese Journal for Midwives. 2006;60(4):

300–303. (in Japanese)6. Nakano J. Perinatal Care. 2007;26(3):308–311. (in Japanese)



Further, the hospital promptly set up an investi-gative committee, illustrating its lack of intentionto cover up the incident. One of the reasons forthe arrest was violation of Article 21 of the Medi-cal Practitioners Law. This article specifies “doc-tors who examine a dead body or a stillborn babyat a gestational age of 4 months or more andrecognize an abnormality must report the caseto the police station in charge of jurisdiction.”Violators of this regulation are subject to a fine of500,000 yen or less, as prescribed by Section 2,Article 33, of the Medical Practitioners Law.

This paper discusses the significance of Article21 of the Medical Practitioners Law, which hadattracted almost no attention until approximately10 years ago, and considers how the criminaljustice system should deal with medical incidents.

Introduction

On February 18, 2006, newspapers reported thata doctor in Fukushima Prefectural Oono Hospitalwas arrested. The doctor was accused of profes-sional negligence resulting in death and violationof the Medical Practitioners Law in regard to thedeath of a pregnant woman who died from exces-sive bleeding because of improper medical careduring a cesarean section. However, the JapanSociety of Obstetrics and Gynecology and theJapan Association of Obstetricians and Gyne-cologists raised serious questions as to the actionsof the police, for the following reasons: it wasdifficult to attribute the death to the fault of thedoctor since placenta accreta, as in her case, isextremely difficult to diagnose preoperatively.

*1 Professor of Law, Law Department, University of Tokyo, Tokyo, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Separate Vol.136, No.4,2007, pages 10–12).

Article 21 of the Medical Practitioners Law

JMAJ 51(4): 258–261, 2008

Norio HIGUCHI*1

AbstractSince 2000, attention has been focused on the professional obligation to report any unusual death to the police,a requirement based on Article 21 of the Medical Practitioners Law. However, facilitation of its enforcement hascaused confusion in the field of clinical practice in Japan. In 1999, an incident that occurred in the TokyoMetropolitan Hiroo Hospital became a major social issue. In this case, a patient died because an incorrect dripinfusion was confused with another drug and administered by a nurse. Following the incident, some of the personsinvolved attempted to cover it up. With this incident serving as an incitement, a movement was initiated to improvemedical practice by reporting medical errors to the police to inquire into the criminal responsibility of medicalproviders. However, several years after this movement was initiated, it has become apparent that this policy isnot working well.

First, it is unclear whether the original concept of Article 21 of the Medical Practitioners Law (obligatoryreporting of unusual deaths within 24h) included medical care-related deaths. Second, examining the criminalresponsibility of medical providers does not necessarily lead to disclosure of the cause of medical errors or to theprevention of recurrence, nor does it help to eliminate mistrust in the arena of medical services. Rather, it placesa heavy burden on the medical care system. It appears that the time has come to abandon dependence on thecriminal justice system and to formulate a mechanism that will offer an improved form of patient safety.

Key words Patient safety, Medical errors, Article 21 of the Medical Practitioners Law, Report to the police,Medical care and law


Past and Present of Article 21, MedicalPractitioners Law

History of Article 21, Medical PractitionersLawArticle 21 of the Medical Practitioners Law hasbeen in existence since 1874. The article obligatesthe medical reporting of unusual deaths by doc-tors to facilitate the detection of crimes, becauseunusual deaths are likely to be associated withcrimes. A typical case would be one in which apatient who was brought to a hospital died despiteefforts to save his or her life. If the doctor in chargesuspected poisoning, he or she would report it tothe police. If a crime were indicated, the criminalmight be at large and might escape or carry outrepeat criminal offenses. Because of the need toinitiate an investigation as soon as possible, doc-tors are required to report the case within a periodof 24 h. Although cooperation in an investiga-tion normally should be a voluntary action, it isimposed on doctors as a legal obligation becausethey are more likely to come into contact withunusual deaths that may be associated with crimes,such as the above example. Criminal sanction forviolating this obligation, however, remains at thelevel of a monetary penalty.

As indicated by this specification, unusualdeaths should be understood in the broad sense.The prewar Supreme Court advocated that anunusual death meant a death in any situationthat caused doubt as to simple death by disease(p.1226 of the report of court decisions, vol. 24,issued September 28, 1918), and opinions fromthe academic circle have upheld this opinion.

However, it is questionable whether the courtwould have assumed the following cases: 1) Doc-tor A intentionally administered poison to PatientB on the occasion of medical treatment. In thiscase, does Doctor A have an obligation to reportthis as prescribed under Article 21 of the MedicalPractitioners Law? Article 38 of the new Consti-tution formed after the war admits that any per-son is free from coerced confession (the right toremain silent). Therefore, it is unreasonable thatonly doctors who commit murder are obliged tosurrender themselves. 2) Doctor B mistakenlyinjured an artery outside the affected site of apatient, causing the patient to die as a result ofexcessive bleeding. The doctor admitted fault,and explained what had happened and apolo-

gized to the bereaved family. In this case, wouldthe obligation to report unusual death as pre-scribed by Article 21 of the Medical PractitionersLaw be applicable? If this case is a criminal case,the charge is professional negligence resulting indeath. However, under the present constitution,obligation to report unusual death by Doctor Bmay be inconsistent with Article 38 of the con-stitution, the same as in the aforementioned case.In addition, it is questionable whether these caseswere assumed at the time the law was formulated.The administrative governmental agency thatholds jurisdiction over the Medical PractitionersLaw held a clearly different view. According to“Interpretation of the Medical Care Law and theMedical Practitioners Law/Dental PractitionersLaw” issued in 1981 under the head of the Gen-eral Affairs Division, Health Service Bureau, thethen Ministry of Health and Welfare, Article 21of the Medical Practitioners Law was explainedas follows:1 “Since dead bodies or stillborn babiessometimes show signs of crimes including murder,assault resulting in death, damage to a corpse,and criminal abortion, for the convenience of thepolice, obligation to report such unusual caseshas been prescribed.” Note that there was no refer-ence to cases of professional negligence resultingin death where medical malpractice caused bythe doctor him- or herself was involved.

The situation, however, has changed greatly inrecent years, following a series of actions takenafter 1990 by the then Ministry of Health andWelfare and forensics experts based on the scar-city of autopsy cases in Japan, as well as two trig-gering major medical errors that occurred in 1999.

Recent changesIn January 1994, the Japanese Society of Foren-sic Medicine developed guidelines concerning“unusual deaths.” In their guidelines, “any unex-pected death related to medical action and anysuspicious case” were considered cases of unusualdeath, regardless of whether or not there wasnegligence. In addition, in 1995, the Health PolicyBureau of the then Ministry of Health and Wel-fare issued a note clearly stating that these guide-lines be used as reference.2

In January 1999, an operation was performedon a wrongly identified patient at Yokohama CityUniversity Hospital. In February of the sameyear, a patient died in Tokyo Metropolitan HirooHospital because a wrong drip infusion was con-

ARTICLE 21 OF THE MEDICAL PRACTITIONERS LAW


fused with another drug and administered by anurse, and there was a movement to cover-up thematter by the persons involved. Two nurses whowere directly involved in this case were promptlyassigned 1 year of imprisonment and 7 months ofimprisonment (each with suspended sentences)for professional negligence resulting in death.The director of the hospital and other personswere prosecuted for the preparation and execu-tion of a signed false public document (recordingof false information on the death certificate) andviolation of Article 21 of the Medical Practitio-ners Law (failure to report an unusual death of apatient within 24 h after confirmation), and thesuit against them was sent to the Supreme Court.

As a result of these circumstances, the Depart-ment of National Hospitals of the then Ministryof Health and Welfare prescribed in August 2000that, in cases of unusual death, the director of thehospital has to report the case promptly to thepolice station under its jurisdiction, and sentnotification of this rule to national and publichospitals throughout Japan. In July 2002, guide-lines of the Japan Surgical Society were pub-lished, ruling that the doctor in charge promptlyand voluntarily report cases of death or seriousinjury to the appropriate police station. In 2004,the Supreme Court concluded in the case of theHiroo Hospital that application of Article 21 ofthe Medical Practitioners Law to doctors whohave carried out professional negligence doesnot contravene the Constitution.

Patient Safety and Criminal Justice

Role of criminal justiceRobert Leflar, a law professor at the Universityof Arkansas, states in regard to the legal controland support of patient safety in Japan that themost important difference between Japan andthe US is the magnitude of the role of criminaljustice.3 According to him, both the FukushimaPrefectural Oono Hospital case and the TokyoMetropolitan Hiroo Hospital case, and eventhe case involving the incorrect identification ofpatients at Yokohama City University Hospitalwould not be dealt with as criminal cases in theUS. Although civil litigation does occur, and thenurses and doctors involved are subject to admin-istrative punishment, medical providers in theUS are seldom involved in criminal proceedings.

Professor Leflar explains this difference between

the two countries in terms of two reasons peculiarto Japan. First, a charge of “professional negli-gence resulting in death and injury” is part of theJapanese Criminal Code, and it is understoodthat even simple negligence can constitute a crime.Although the US also has a charge of negligenceresulting in death, it is restricted to serious negli-gence and demands a higher level of criminalintent as a subjective requirement. Second, inJapan, there is no choice but to rely on the criminaljustice system because no other mechanism func-tions to respond to and sanction medical errors.

However, he also points out that criminalprosecution in several cases has clearly served asan effective “alarm” to the Ministry of Health,Labor and Welfare and to health professionals,but continuously placing emphasis on the crimi-nal justice system in the regulation of medicalactivities has resulted in obvious problems andadverse effects.

First, criminal intervention may result in cover-ing up the truth, rather than uncovering it. Crimi-nal responsibility is characteristically focused ona particular individual, and is therefore not suit-able for, or rather in opposition to, the recentrecognition of medical malpractice as an issue ofthe system as a whole.

Second, criminal intervention enhances mutualdistrust within the medical institution. In contrastto today’s trend that stresses team medical care,bringing a serious criminal charge against a doctoror nurse who made an error has repercussionsamong teams of health professionals. Targeteddoctors and nurses may suffer a sense of isolation,which then can interfere with their cooperationin the peer review process or other approachesto the prevention of recurrence of errors in thehospital.

Third, since medical errors are within thescope of medical practice, to leave cases to thepolice, who do not have specialized medicalknowledge, seems to deviate from the pursuit ofprofessional responsibility of medical providers.Such an attitude cannot rebuild trust in the medi-cal profession. In the first place, medical errorsare different in character from traffic accidentsand other recent accidents in Japan in which themanufacturers of elevators and water heatershave been held accountable for violating safetyprecautions.

Unfortunately, medical providers cannotpromise cure to their patients. The current situa-

Higuchi N


tion of medical care is that certain success cannotbe guaranteed. In addition, even if people tendto distrust health care, they still have to rely onit. It is also difficult for police officers, whoare unfamiliar with medicine, to determine thepresence or absence of negligence. It should benoted that administrative punishment, such asthat of suspending a driver’s license, for instance,is unlikely to have a profound impact on mostdrivers who cause traffic accidents. In contrast,forfeiture of one’s medical license underminesthe foundation of a doctor’s life, thereby impos-ing sanctions on the doctor without instigatingcriminal punishment. In fact, if all unusual deathsand unusual stillbirths under the definition of“unusual death” as determined by the Societyof Forensic Medicine were reported to the police,they would exceed the ability of the police tofunction, thereby limiting police capacity to pur-sue criminals.

References

1. Yamauchi T (Head, General Affairs Division, Health ServiceBureau, Ministry of Health and Welfare). Interpretation of theMedical Care Law and Medical Practitioners Law/Dental Prac-titioners Law, Revised 14th edition. Tokyo: Igaku-tushinsya;1981:360–361. (in Japanese)

Bibliography

1) Higuchi N. Medicine and Law Reconsidered. Tokyo: Yuhikaku;2007:24. (in Japanese)

Future Directions

In recent years, criminal justice has played amajor role in the control of medical errors andpatient safety in Japan. However, it is a seriousproblem to regard medical errors as crimes underArticle 21 of the Medical Practitioners Law andto assign every case to criminal justice. To reducemedical errors and regain trust in health services,the use of Article 21 of the Medical PractitionersLaw in its current form should be abandoned.Procedures to this end should be formulatedpromptly.

To realize truly patient-oriented health ser-vices, it is necessary for medical societies and theMinistry of Health, Labor and Welfare to amendcurrent guidelines and to establish a new systemthat is independent of the police and that securesthe transparency of health care and prevents therecurrence of medical errors.

2. Medical Professions Division, Health Policy Bureau, Ministry ofHealth and Welfare. Handling of unusual death. Japan MedicalJournal. 1995;3711:127. (in Japanese)

3. Leflar RB. Law and patient safety in the United States and Japan(Translated by Mise T). Jurist. 2006;1323:17. (in Japanese)

ARTICLE 21 OF THE MEDICAL PRACTITIONERS LAW



*1 Professor, Graduate School of Medicine, The University of Tokyo, 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.136, No.4, 2007,pages 13–15).

A Model Project for Survey Analysis of DeathsRelated to Medical Treatment

JMAJ 51(4): 262–266, 2008

Masashi FUKAYAMA*1

AbstractA model project for the survey analysis of deaths related to medical treatment has been in operation sinceSeptember 2005. When a death related to clinical practice occurs, an investigative report is prepared through thefollowing procedures: 1) submission of an application based on the consent of the bereaved family and themedical institution; 2) autopsy by a pathologist, forensic doctor, and witness clinician; 3) preparation of a draftreport of the evaluation results by doctors in charge of clinical evaluation; and 4) discussion in an evaluationcommittee that includes legal professionals and an overall coordinating doctor. Then, the results of the survey arereported at a briefing session where both the bereaved family and representatives of the medical institution arein attendance. Problems currently recognized include the following: an average period of 7 months is requireduntil the briefing session is held, and confusions in the application and acceptance of cases under the enforce-ment of Article 21 of the Medical Practitioners Law. Another problem is that a heavy burden is placed on eachmember of the committee, but this can be overcome through the cooperation of academic societies of clinicalmedicine and by addressing institutional design. Autopsy and medical survey in this model project approximatethe function of a clinicopathological conference. If a national consensus is reached as to the “unusual deathreporting system,” this project can serve as a model of a new system aimed at ensuring better medical care.

Key words Medical treatment-related death, Medical evaluation system, Model project,Clinicopathological conference, Article 21 of the Medical Practitioners Law

cal institutions. Summary reports about limitednumber of cases are available on the abovewebsite.

This model project is a new system of medicalevaluation (Fig. 1). Although the system currentlyhas many problems, we believe that most of themcan be overcome. More specifically, we believethat it is possible to formulate a system of medi-cal evaluation that addresses medical treatment-related deaths in a form that approximates theautopsy and clinicopathological conference (CPC)that has been used in cases of death from illness(Table 1).1 However, the basic premise is that anew consensus as to the definition of unusualdeaths and a proper system of reporting suchdeaths needs to be formed.

Introduction

The model project for survey analysis of deathsrelated to medical treatment, in which autopsy,analysis, and investigation of medical treatment-related deaths are carried out in a neutral settingto determine the cause of death and to preventthe recurrence of similar cases, was begun inSeptember 2005, with a grant from the Ministryof Health, Labor and Welfare (http://www.med-model.jp/). Applications of 40 cases had beenmade in 7 areas by January 19, 2007. In the Tokyoarea, 23 cases were accepted, 8 of which hadalready been evaluated, and the results werereported to the bereaved families and the medi-


Table 1 Comparison of the types of autopsy in clinical practice

Autopsy in model project Pathologic autopsy Judicial autopsy Administrative autopsy

SubjectUnexpected death during the

Death from illnessDeath suggestive of

Death of unknown causeprocess of medical practice crime

PurposeElucidation of the cause of Elucidation of the cause

Criminal investigation Public healthdeath, prevention of of death and the diseaserecurrence state

Executive bodyModel project

Medical institution Police and prosecutionTokyo metropolitan

(third-party organization) government, etc.

Autopsy doctorPathologist, forensic doctor, Pathologist, doctor in

Forensic doctorForensic doctor

witness clinician charge of the patient (medical examiner)

Involvement ofWitnessing, evaluation CPC Comments —

clinician

Form of disclosure

Issuance of repot Report to the bereaved

Expert opinion inAttestation

of information

to the bereaved and

writingthe medical institution

Summary report to the public Case report

Person briefingRegional evaluation committee

Doctor in charge of theNone —

the bereaved patient or pathologist (rarely)

Legal force None None Present None

(Cited from Fukayama M, Kaji K. Jurist. 2006;1323:48–53.)

Medicalinstitution

Bereavedfamily

� Explanation of the project

� Consent

� Request of survey

�Report of

the evaluationresults!

?

Model project

Model area

� Acceptance

� Autopsy� Implementation

of survey

� Analysis and evaluation

Implementation of surveyWere the process and proceedings of the medical treatment proper?

Within 1–2 monthsPreparation of the report of evaluation results

Autopsy on the day or the day after acceptance

Was there any significant defect in the diagnosis and treatment?

Within 1–2 monthsPreparation of the report of autopsy results

[Adapted from the website of the model project for survey analysis of deaths related to medical treatment(http://www.med-model.jp/flow.html)]

Fig. 1 Model project for survey analysis of deaths related to medical treatment

A MODEL PROJECT FOR SURVEY ANALYSIS OF DEATHS RELATED TO MEDICAL TREATMENT


Flow of Procedures in the ModelProject (Tokyo Area) (Fig. 1)

The process from application to autopsyWhen the unexpected death of a patient hasoccurred during the process of medical care, ora patient’s death has occurred as a result of medi-cal treatment (medical treatment-related death),an application of the case is filed on the basis ofconsent of both the bereaved family and themedical institution.

Most of the cases that are handled by thismodel project have been those that hospitalshave reported to the police in their jurisdiction asunusual deaths and were determined as deathsfrom illness or to be suitable for the modelproject rather than judicial autopsy.

Flow of case evaluation in the model projectAfter autopsy of the case has been carried out bya pathologist, forensic doctor, and witness clini-cian, a draft report of the autopsy results is pre-pared by the doctors involved in the autopsy.Then, based on the results of the autopsy, the

doctors in charge of clinical evaluation prepare adraft report about the results of evaluation of themedical treatment. Usually, two doctors are incharge of the clinical evaluation, each having beenrecommended by the relevant academic society.Using this draft report as material for discussion,a meeting of the evaluation committee consistingof about 10 members is held. Such meetings gen-erally include two sessions. Through deliberationin committee, the final report is then prepared.

In the final stage of the project, a briefing sessionis held to provide information to the bereavedfamily and the medical institution. An outline ofthe case is then published, based on consent fromthe bereaved family and the medical institution(see http://www.med-model.jp/kekka.html).

Composition of the evaluation committeeThe evaluation committee is composed of 9 or 10individuals including a pathologist in charge ofthe autopsy, a forensic doctor, a witness clinician(occasionally), primary and secondary evaluatingdoctors, an internist and a surgeon, a lawyer on theside of hospitals, a lawyer representing bereavedfamilies, and a doctor from the local community

Acceptance

Actual target time

A representative of the locality determines whether to accept the application for the case.

Implementation of autopsy Autopsy is performed by a pathologist, forensic doctor, and witness clinician.

6 weeks

12 weeks

Preparation of a draft report of autopsy results A draft report of autopsy results is prepared based on discussion.

Preparation of a draft report of evaluation resultsThe primary and secondary evaluating doctors carry out close examination of the medical records, diagnostic images, etc., and prepare a draft report of the results.

16–20 weeks Discussion at meeting of the evaluation committee

The pathologist in charge of autopsy, forensic doctor, witness clinician (occasional), primary and secondary evaluating doctors, surgeon, internist, overall coordinating doctor, lawyer on the hospital side, and lawyer on the bereaved side discuss the case.

24 weeks Preparation of the report of autopsy results and the report of evaluation results

Meeting of the evaluation committee is usually held once or twice.

6 monthsBriefing session for the bereaved and the medical institution

Briefing by the primary evaluating doctor, chairman of the committee, and the overall coordinating doctor is conducted.

Fig. 2 Practical processing of the case

Fukayama M


mean of about 7 months per case (Fig. 2). Theamount of time required varies among casesdepending on the autopsy, evaluation, andpreparation of the case report.

(2) A large burden is imposed on each memberof the committee, particularly on the primaryevaluating doctor who prepares the finalreport.

(3) The greatest problem is the confusion as tothe distinction between cases subject tocriminal proceedings and those amenable tothe model project, when they have not been

who serves as coordinator. The internists andsurgeons in the committee, knowledgeable pro-fessors or directors of hospitals, and solicitedby the coordinating doctor.

Problems Involved in the Model Project

It has become apparent that the model projecthas the following problems.(1) It was initially expected to take 3 months

till the briefing session from acceptance ofthe application, but in actuality has taken a

Medical treatment-related death

Reporting

Third-party organization

Pathologist Clinician and evaluating doctor

Forensic doctor and legal professionals

Review of medical treatment-related deathTyping of unusual deaths, and establishment of criteria for judgment

Reporting unusual deaths

Criminal proceedingsJudicial autopsy

Publicdisclosure

Overview of the case

Measures to prevent recurrence

Medical institution

Medical evaluation

Proposal of measures to prevent recurrence

Patient (bereaved family)

Explanation and relief

Alternative disputeresolution (ADR)

Fig. 4 Future perspective on measures for medical treatment-related death

Medical treatment-related death

Death from illnessNo report to the police

Unusual death reported to the policeContact with the police

Pathologic autopsy Autopsy and

clinical evaluation in the model project

Postmortem inspection and examination

Judicial autopsy

Fig. 3 Model project and Article 21 of the Medical Practitioners Law

A MODEL PROJECT FOR SURVEY ANALYSIS OF DEATHS RELATED TO MEDICAL TREATMENT


Reference

1. Fukayama M, Kaji K. Formulation of the “medical evaluationsystem for medical treatment-related deaths” based on autopsyand improvement of the legislation. Jurist. 2006;1323:48–53.(in Japanese)

reported as unusual deaths to the policestation (Fig. 3). In addition, some of the casesthat were transferred to criminal proceed-ings may have been better addressed by themodel project, because assessment as to thedetails of medical conduct from a clinicalviewpoint was required. (In actuality, 2 of 23accepted applications and 6 of 21 counsellingcases were subjected to judicial or adminis-trative autopsy in the Tokyo area.)

Future Prospects of the Model Project

Unusual death and death related to medicaltreatment should be handled separatelyBased on current experience with the modelproject, the Ministry of Health, Labor and Wel-fare and other related government ministries and

agencies are discussing the amendment of Article21 of the Medical Practitioners Law and revisionof the operational rules, and are considering theestablishment of a third-party organization.

It is important to improve the reporting sys-tem (Fig. 4) as well as to introduce the alternativedispute resolution (ADR) and the no-fault com-pensatory system in the field of obstetrics, inorder to formulate a more effective system. Atthe same time, it is required for medical providersto make a public appeal for such a system. Inaddition, efforts of medical providers in dailypractice are also important to having such asystem accepted. One of such efforts should beaimed at maintaining a high level of autopsyand CPC in cases of “death from illness,” and atproperly disclosing the results of evaluation tothe bereaved family.

Fukayama M



obstetric malpractice were a necessary side effectto protecting consumers against obstetrics mal-practice.4 Obstetricians in Korea, however, arelikely to disagree with such conclusions. Instead,like their U.S. counterparts, doctors here are morelikely to point to disruptions in medical care andin particular, an exodus of doctors from the prac-tice. In fact, in a 2006 survey of 116 hospitals, areport found that the field of obstetrics had thehighest rate of attrition of any field of practice inSouth Korea (16%); coming far behind in secondwas chest/breast medicine, which had a 10.6%rate of attrition.*2 While this rate may be shapedby the recent dramatic decrease in birth rates inKorea,*3 undoubtedly the threat of civil suits andthe corresponding rising insurance premiumsplay a role like in the U.S.

Nevertheless, there are significant differenceswith malpractice actions in the United States.Despite the changing face of obstetrical medi-cine in Korea in part resulting from malpracticesuits, Korea generally has fewer malpracticeactions. While other cultural differences mayweigh in, a key reason stems from the significantdifferences between the legal systems of the twocountries. Based on a tradition of civil law, SouthKorea’s legal system does not create the same setof incentives and low-entry barriers to raising asuccessful malpractice case as in the U.S. system,where pro-plaintiff evidence collecting proce-dures and potentially enormous damage awardshave converged, turning malpractice actions intoits own separate industry.

This memorandum examines some of the

In the U.S., the number of medical malpracticecases generally has begun to fall each year. How-ever, in obstetrics medicine, this decrease alsocorresponds to a falling number of practicingobstetricians in the United States. A 2002 USAToday article reported that the increased cases ofmedical malpractice and the concurrent rise ininsurance premiums for doctors were causing asignificant shortage of obstetricians in certainstates where damage awards were akin to “lotteryprizes.” 1 The American Council of Obstetriciansand Gynecology (ACOG) reconfirmed this trend,reporting that disruptions to obstetrical care arenow prevalent in nearly half of the states withinthe United States.2 Politicians spear-heading anagenda of “tort reform” in Washington D.C. oftenreference this impact in the field of obstetrics toemphasize the need for changes in the system.

While the high insurance premiums and costsassociated with malpractice cases have had asignificant impact in the United States, in SouthKorea malpractice in obstetrics medicine has alsohad negative effects. A 5-year study compiled bythe “Medical Citizen Consumers Association”found that medical malpractice suits in the areaof obstetrics were a significant problem, rankingsecond highest of all malpractice cases after ortho-pedic surgical malpractice.3 The study looked atthe number of cases from 2003 through 2007 andfound that obstetrics malpractice comprised15.6% (or 1,248 out of 7,977 cases) of the totalnumber of medical malpractice cases.

Recently, the Korean Consumer ProtectionUnit (KCP) reported that the damage awards in

*1 Professor, Sogang University College of Law. Executive Board Member of Legal Affairs, Korean Medical Association, Seoul, Korea([email protected]).

*2 Quite notably, the Korean National Statistical Office confirmed in 2006 that South Korea had the lowest birth rate in the world.*3 The CIA World Factbook notes that the population growth in 2007 was a meager 0.394%. The UN Division on Population also notes in a 2006

survey report that the Korean population will be smaller in 2050 than the population in 2005. World Population Prospects Report by UN Divisionon Population.

Medical Malpractice in Obstetrics—A look into the practice under South Korean law

JMAJ 51(4): 267–271, 2008

Sanghan WANG*1


most significant differences in the treatment ofmalpractice, and also looks at how the SouthKorean legal system has handled malpractice suitsin obstetrics medicine. In particular, I will explorethe consequences of Korea’s civil law systemand the lack of precedent, which has affectedevidence-collection procedures and other logis-tical issues, including the possibility of concurrentcivil and criminal actions. I further examine therole of South Korean criminal law, which penalizesprofessional negligence, on any potential civilsuits including the effect on damage awards andevidence-collection.

Civil Law vs. Common Law

South Korea has adopted much of the ContinentalEuropean Civil Law system, but also has mixedin some elements of Anglo-American commonlaw. The most notable distinction from the com-mon law is the lack of precedent. Precedent is thebinding power of previous decisions of superiorand/or previous courts.*4 As such, courts inSouth Korea are not required to adhere to priordecisions, even those decisions by the KoreanSupreme Court. While there is deference to supe-rior court decisions, particularly to the KoreanSupreme Court, a lower court may choose to baseits rulings without being restrained or controlledby prior decisions. Instead, the primary source fordecisions rests upon the actual language of thelegislation or statute. Consequentially, judgesoperating within this system have latitude in ren-dering their decisions, bound only to the languageof the statute, and not, as in the common law, tothe decisions of prior courts and any relevantstatutes.*5

For those in a common law jurisdiction, sucha description naturally raises concerns that thedecisions and awards will vary wildly. Despitethese first impressions, the truth is that the out-comes of cases do not vary widely. There is a strongsense of respect and deference to the decisions ofjudges. Instead, and most significantly, the impli-

Wang S

cations of the civil law system manifest in thetiming and logistics of the proceedings. Withoutprecedent, it is conceivable that a criminal actionand civil action may occur concurrently. A singledefendant could be subject to a private civil actionat the same time that a criminal suit is pending.While in practice this is unlikely, it does, never-theless, highlight an important consequence: priorfact-findings and/or decisions have no bindingpower on another court.*6 They exist in differentspheres. Moreover, such a system has importanttactical consequences for would-be plaintiffs,who utilize the criminal system for evidence-collecting purposes in their private civil action.

Criminal Negligence

Article 268 of the South Korean Criminal Codepunishes “professional or gross negligence” whichcauses death or injury.*7 The statute punishessuch acts by either imprisonment for not morethan 5 years, or by fine not exceeding 20 millionwon (or roughly $20,000). Thus the crime is con-sidered more than a minor offense. As a cause ofaction, criminal negligence parallels the elementsof medical malpractice civil action in the UnitedStates, which is based in the common law of torts.The elements for finding guilt under Article 268also mirror the necessary elements in a civilaction by a South Korean plaintiff; the primarydistinction, as would be the case under U.S. law, isthat the burden of proof in a Korean civil actionis a “beyond a reasonable doubt” standard.*8

To prove criminal professional negligence, theprosecution must show that: 1) the professionalhad knowledge of the bad result; 2) the profes-sional did not exercise good judgment, based ona comparison with other professionals who workin the same field or same circumstance; 3) the badresult was caused by the care/treatment of theprofessional; and 4) that there were actual dam-ages. Distinguishably, the standard of care forall professionals, including doctors, is a nationalstandard, and also requires consideration of the

*4 Black’s Law Dictionary defines precedent as “the making of law by a court in recognizing and applying new rules while administering justice.”Black’s Law Dictionary, 8th Edition, Bryan A. Garner, ed.

*5 Lower courts are, however, bound to the Supreme Court’s decision if the case has been remanded back to the lower court. From “The KoreanJudiciary System,” www.korealaw.com

*6 Under the common law, the term is titled “res judicata” or an issue already decided by the court. The term encompasses both fact-finding (orcollateral estoppel) and final decisions (or issue preclusion). Black’s Law Dictionary, 8th Edition, Bryan A. Garner, ed.

*7 South Korea Supreme Court webpage translated decisions, case # 2005Do3832, delivered on June 29, 2007.*8 For a criminal action, the burden is on the prosecution to prove guilt beyond a reasonable doubt; in a civil action, the standard is generally

guilt by a preponderance, or majority of the evidence.


MEDICAL MALPRACTICE IN OBSTETRICS

time and place where medical treatment was pro-vided (i.e. hospitals, clinics or private offices).This is slightly different from the U.S., wherethe standard of care for general practitioners isbased on a local standard, while for specialistslike obstetricians it is a national comparison ofother similarly-practicing specialists. In essence,however, by factoring in considerations of timeand place of treatment, the Korean standardbecomes very similar to the U.S. standard of care.

Illustratively, the Korean Supreme Court in2006 dealt with the issue of criminal negligence inobstetrics, delineating the necessary elements.5

The Court found the obstetrician not guilty, rea-soning that the obstetrician did not cause thedeath of the fetus. In this case, the prosecutioncharged the obstetrician with negligence after hefailed to discover that the fetus was invertedwithin the mother’s womb, which caused the fatalcomplications during childbirth. The Court heldon behalf of the obstetrician, finding that thefetus died not because of the doctor’s negligence,but because the fetus suffered complicationsfrom being premature and because the expectingmother was already in poor health. These werethe primary causes of death, not the obstetrician’scare. The Court went on to say that the obstetri-cian had actually exercised reasonable judgmentin light of the circumstances of the case and hadactually provided sufficient care. His decision notto administer an ultrasound test and to disregardthe mother’s early labor pains were deemed rea-sonable decisions, and well within the bounds ofhis reasonable medical judgment.

Criminal Negligence andEvidence-collection

While the criminal action is, in and of itselfsignificant, it carries even greater consequencesin the Korean system, where an individual plain-tiff has virtually none of the evidence-collectingpowers conferred to a U.S. plaintiff in civil liti-gation. More specifically, Korea lacks a true dis-covery system, leaving would-be plaintiffs withoutthe enforcement means to depose witnesses andparties. This includes expert witnesses, who areoften critical components to a malpractice action.Also significant for medical malpractice cases,the Korean system leaves plaintiffs without the

critical power to compel production of evidence.Civil litigation, in this respect, is a “come-as-you-are” system.6 To compensate for these shortcom-ings, plaintiffs turn to, and build their cases from,the evidence collected during the criminal caseby the prosecution. In the Korean system, theprosecution has significant powers, includingconfiscation of evidence and the ability to compeldocument production. These investigation recordsmay later be used by civil courts. While underKorean civil procedure it is the judge who isempowered to collect facts and sift through evi-dence, it is a major advantage for a plaintiff tohave such a record in existence. Thus, it is in thevictim’s best interests to raise malpractice issuesto the Supreme Prosecutor’s Office, which hasthe discretion to file a criminal negligence actionand commence an investigation. Adding to theimportance of this evidence is the high eviden-tiary burden in civil cases. Whereas the U.S.employs a “preponderance of the evidence” stan-dard of proof for determinations in a civil liti-gation, the Korean system employs the heavier“beyond a reasonable doubt” standard normallyreserved for only criminal actions in the U.S.Without the means to thoroughly gather evidence,would-be plaintiffs look instead to the evidencegathered by the prosecution during the criminalinvestigation. In this respect, the Korean govern-ment bears a substantial share of the costs for aplaintiff’s civil action.

Korean System of Damages

It is perhaps an equitable trade-off to have gov-ernment resources fund a large portion of thelitigation expenses in light of the actual damageawards. The fines and penalties resulting from thecriminal action go directly to the state and notto the victim. While Korea has a system of depositmoney that is used in criminal actions as anindemnity for the victim, the victim never collectsdirectly from the fines issued by a criminal court.The system is unique, however, in that any settle-ment agreement reached between the victim andprofessional prior to the final verdict of the crimi-nal action bears upon the sentencing meted outby the criminal court judge.*9 Moreover, if thereis no stipulation within the settlement agreementto the contrary, a settlement amount could be

*9 This creates an incentive for the criminal defendant to reach an agreeable settlement with the victim in order to mitigate criminal penalties.


deducted from any civil action awards.As a recent New York Times article reported,

the U.S. has one of the most unique damageaward systems in the world, with punitive dam-ages conferring substantial windfalls to plain-tiffs.7 In the U.S. system, the potential profit of acivil suit counterbalances the equally burden-some litigation expenses borne by a plaintiff. Incontrast, under Korea’s system, the inability toindependently gather evidence coupled with thelower damage awards institutionalizes certaindisincentives, dissuading many who would nor-mally seek civil compensation.

Despite the discrepancy in the amountsawarded for malpractice, like damage awards inthe United States, in South Korea damages arecalculated to include both compensation for theactual damages suffered, any consequential costsfor care required as a result of the injury, as wellas mental pain and suffering. The end figure, how-ever, is much less than the average in the U.S.The typical civil litigation actions award plaintiffswith actual compensatory damages for the injuriessustained and for any resulting treatment requiredas a result of the injury. Damages also includepain and suffering automatically awarded to theimmediate family, which includes parents andgrandparents. For other relatives, such as siblings,compensation for “grief” requires some proof ofsuffering. Pain and suffering, however, are oftenminimal amounts. Moreover, general awardamounts are low. This is in part results from theuse of a table of money damages, which a judgeturns to in a civil proceeding for guidance. Thistable not only systematizes but also limits thetotal damage amounts. In calculating these num-bers, the table factors in the nature of the job ofthe injured party, which serves to calculate lostwages/earnings. For obstetric malpractice actionsin particular, where an infant is often the injuredplaintiff, the damage awards are calculated toconsider not only how long the infant has beenliving, but how much the infant could have poten-tially earned. Accordingly, these numbers aresmall.

In a 2002 case heard by the Korean SupremeCourt, the court dealt with this issue of damagecalculations.8 There, the infant suffered shoulderdystocia, which resulted from the obstetrician’sfailure to identify and treat the mother’s sugardiabetes. The Supreme Court found on behalf ofthe mother and injured infant, reasoning that the

infant’s injury directly resulted from the obstetri-cian’s failure to provide proper medical care. TheCourt reasoned that any obstetrician exercisingproper care would appreciate the dangerouscomplications resulting from the mother’s dia-betes. In addition, the doctor failed to administeran ultrasound, which would have revealed theenlarged size of the fetus, further increasing thechances of complications from shoulder dystocia.In this case, the obstetrician failed to take appro-priate precautionary measures to prevent thisdangerous and likely complication. However,despite finding on behalf of the plaintiffs, theCourt reduced the amount of damages awardedto half the amount asked by the plaintiffs. Guidedby the table of money damage awards, the Courtexamined the length of the injured child’s life inorder to determine the amount that the infantcould have potentially earned. Instead of thegranting the original 85 million W (or $85,000),the Court awarded the infant 43 million W (or$43,000). For the mother and father’s pain andsuffering, the Court awarded each 3 million W(or $3,000) instead of the original 5 million Wasked for each parent.

Conclusion

An examination into obstetric malpractice lawsin Korea not only highlights important differ-ences and fundamental similarities in the twolegal systems, but perhaps is also a helpful guidefor U.S. tort reform measures, especially in thearea of malpractice. The objectives of the Koreansystem, similar to many other legal systems aroundthe world, distinguish and separate retributivejustice from compensatory justice. It is a systemthat punishes through action by the criminal sys-tem and compensates under the civil litigationsystem. Like many other jurisdictions in theworld, the civil courts in Korea provide compen-sation to victims, and generally are not used tomete punishment (vis-à-vis punitive damages);that is a job for the state in criminal proceedings,where there are certain protections are built into protect the defendant. Victims should not beallowed to receive a windfall from punitive dam-ages. From this perspective, criminalizing negli-gence seems not only reasonable but necessary.

As a growing segment of the U.S. populationpush for limits to the damage awards conferredin medical malpractice actions in particular, it is

Wang S


References

1. “Obstetricians Dwindle Amid High Malpractice Costs,” by MarilynElias, USA Today, May 6, 2002.

2. “Dispatches from the Tort Wars” 85 TXLR 1465, fn 55.3. From Medical Today, January 30, 2008.4. “With Effort, Doctors and Consumers Can Reduce Obstetrical

Medical Malpractice,” Annual Report, July, 2001.

5. South Korean Supreme Court, 2006Do1790 (December 7, 2006).6. “Understanding Evidence Shortcomings in Civil Trials,” by Doil

Son, Korea Herald, September 12, 2007.7. “Foreign Courts Wary of U.S. Punitive Damages,” by Adam

Liptak, NY Times, March 26, 2008.8. South Korean Supreme Court, 2002Da3822 (January 24, 2002).

illuminating to look beyond the actual dollaramounts of punitive damages, and examine otherlegal systems where the problem is approachedfrom a different angle. While punitive damagesand generally large damage awards are likely amainstay to the U.S. system, it is important to

MEDICAL MALPRACTICE IN OBSTETRICS

examine the underlying purpose and theoriesinvolved when considering reform programs. Bycomparing and learning from the differenceswith the Korean approach to malpractice, theremay be a better understanding of how to improvethe U.S. approach in the future.



*1 Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan ([email protected]).

Management of the Open Abdomen—Usefulness of the bilateral anterior rectusabdominis sheath turnover flap methodfor early fascial closure

JMAJ 51(4): 272–277, 2008

Shigeki KUSHIMOTO,*1 Hiroyuki YOKOTA,*1 Makoto KAWAI,*1 Yasuhiro YAMAMOTO*1

procedures may aggravate the vicious cycle ofcoagulopathy, acidosis and hypothermia.1–3

The practice of damage control includes threeseparate components: 1) abbreviated resuscita-tive surgery for rapid control of hemorrhage andcontamination, as well as for temporary abdomi-nal wall closure; 2) ongoing core rewarming,correction of coagulopathy and hemodynamicoptimization in the ICU; and 3) reexplorationfor definitive injury management and abdomi-nal wall closure.1–3 However, prolonged openabdominal management is required if visceraledema continues for more than several days afterdamage control surgery.

Abdominal compartment syndrome (ACS)is an increasingly recognized clinical entitywhich occurs when intra-abdominal pressure isabnormally high in association with organ dys-function. Although the most common causeof ACS is blunt abdominal trauma associatedwith massive hemorrhage, ACS can also occur incases of burns and other non-traumatic condi-tions such as complex major abdominal surgeryand severe acute pancreatitis requiring massivefluid resuscitation.4,6,7 When a sustained increasein intraabdominal pressure is observed despitemedical management (i.e. sedation, neuromuscu-lar blockade, evacuation of abdominal fluid col-lection), decompressive laparotomy is requiredto treat the increased intraabdominal pressureand improve abdominal visceral perfusion andsystemic cardiovascular/respiratory derange-ment.7 However, this abdominal decompressionprocedure leaves the abdomen open.

The development of the concept of damage con-trol and improved understanding of the patho-physiology of abdominal compartment syndromehave been great advances in both trauma care1–3

and nontraumatic surgical conditions.4 However,these approaches require open abdominal man-agement for a considerable period. We developedthe anterior rectus abdominis sheath turnoverflap method for early fascial closure in patientsrequiring open abdominal management who can-not undergo standard abdominal wall closure.5

To the best of the authors’ knowledge, this is thefirst report of this method being used as a tech-nique for abdominal wall reconstruction in theearly stages. The method may reduce the need forplanned ventral hernia, in which the abdominalcontents are covered with only a skin graft andabdominal wall reconstruction is required at alater date.

What Are Damage Control andAbdominal Compartment Syndrome?

In conventional trauma care, definitive controland repair of all injuries is accomplished in theimmediate postinjury setting. However, thephysiologic derangement of the massive shockstate often leads to a fully repaired but deadpatient. In response to these catastrophic chal-lenges, the concept of “damage control” hasarisen as a treatment merely to control but notdefinitively repair injuries. Although control ofhemorrhage and contamination is mandatory,the time required for performing formal surgical

Japanese Association for Acute Medicine


Conventional Approach to OpenAbdomen

In typical management scenarios for patientsrequiring open abdominal management whocannot undergo early standard fascial closure,many patients require prolonged open abdomenbecause of visceral edema. During this interval,the musculofascial structure of the abdominalwall contracts laterally, leaving patients with alarge midline defect where standard fascial clo-sure is not possible. Many patients have a largeventral hernia for a period during which thegranulated abdominal contents are covered withonly a skin graft, requiring subsequent complexabdominal wall reconstruction. To reduce theneed for an intermediate period with a large ven-tral hernia that requires abdominal wall recon-struction at a later date, several techniques suchas vacuum-assisted wound closure and applica-tion of a Wittmann patch have been employedas methods of achieving temporary abdominalwall closure.9–11

Risk of Enterocutaneous Fistula

Enterocutaneous fistula formation is a devastat-ing complication of open abdomen and has beenreported to occur in 5% to 25% of cases.10,12–14

Although lower fistula rates have been reportedusing vacuum-assisted wound closure, patientsrequiring prolonged mesh application have highrisk of enterocutaneous fistula. The risk of entero-cutaneous fistula may increase as the duration ofopen abdominal management is prolonged.12

Moreover, the development of 3 of 14 fistulaeafter skin grafting of the granulated open woundhas been reported,10 suggesting the importanceof early definitive wound closure to preventfistula formation.

Reconstruction of Abdominal Wall afterPlanned Ventral Hernia

Several methods have been proposed to accom-plish late reconstruction of the abdominal wallfor patients after a period with a planned ventralhernia following open abdominal management,such as component separation,16 rectus turnoverflap,17 and modified component separation tech-niques.12 Although use of the “open-book” varia-

tion of component separation as a technique forabdominal wall reconstruction after 6 to 12 monthsfrom initial operation has been reported,18 appli-cation of such techniques in the early phase ofopen abdomen has not been evaluated.

Application of the Bilateral AnteriorRectus Abdominis Sheath TurnoverFlap Method for Early Fascial Closureand Prevention of EnterocutaneousFistula5

Management of open abdomenIn our institution, patients who required tempo-rary abdominal wall closure underwent eitherBogota bag closure (suturing of a sterile openedintravenous fluid bag to the skin edges) or avacuum pack closure using the modified methoddescribed by Garner et al.9 Recently, the latter

Fig. 1 Cross-sectional schematic diagram of thetechnique for creating a turnover flap fromthe anterior rectus abdominis sheath

The procedure is begun by separating the skin and underly-ing adipose tissue from the anterior rectus sheath to createa flap, with a base several centimeters beyond the lateralborder of the rectus sheath (A). The turnover flap is thenfashioned from the anterior sheath by longitudinally incisingthe sheath along the entire length of its lateral border. Thesite of this incision must be chosen carefully to avoid enter-ing at the conjoined point of the internal oblique aponeurosisand the external oblique aponeurosis (B). The anteriorsheath then is dissected from lateral to medial, freeing itfrom the rectus muscle. The linea alba is kept intact to serveas a medial hinge. The anterior rectus sheath turnover flapis approximated using interrupted sutures (C), and the skinis closed primarily (D) (from reference 5).

A

B

C

D

OPEN ABDOMEN AND ANTERIOR RECTUS SHEATH TURNOVER FLAP


has been the preferred technique in all casesexcept for initial damage control surgery whereaggressive resuscitation is ongoing and visceraledema therefore may increase after surgery.Dressings were changed every 48 to 72 hr untilfascial closure or the decision was made to per-form skin grafting over an intentional ventralhernia. If the abdominal fascia could be fullyapproximated under no tension, standard fascialclosure was performed. After 10 to 14 days fol-lowing initial laparotomy, use of a turnover flapconstructed from the anterior rectus abdominissheath was considered instead if the distanceto be closed with fascia was less than 15 cm inpatients unsuitable for standard fascial closurebecause of prolonged visceral edema. Formationof a planned ventral hernia using a skin graft overgranulated abdominal contents was chosen in

patients without edema resolution 3 weeks ormore after the initial laparotomy who were notcandidates for either method of fascial closure.

Surgical procedure for the anterior rectusabdominis sheath turnover flap methodThe procedure is begun by separating the skinand underlying adipose tissue from the anteriorrectus sheath to create a flap. Next, creation ofa turnover flap from the anterior sheath isbegun by incising the anterior sheath along theentire length of its lateral border. The anteriorsheath then is dissected from lateral to medial,freeing it from the rectus muscle. Kept intact, thelinea alba serves as a medial hinge to mobilizethe flap (Fig. 1). The fascial flap is then reflectedmedially with care so as not to damage the ante-rior sheath.

Fig. 2-1 Intraoperative view of the anterior rectus abdominis sheath turnover flap method (initial steps)A: View just after vacuum packing removal (11th day of open abdomen). B: First, skin and underlying adipose tissue are separatedfrom the anterior rectus sheath to create a flap. C: Skin and adipose tissue is completely dissected from the anterior sheathbilaterally beyond the lateral border of the rectus sheath. D: The anterior rectus sheath flap is reflected medially by dissection fromlateral to medial, freeing it from the rectus muscle. The linea alba is kept intact as a medial hinge (from reference 5).

A B

C D

Kushimoto S, Yokota H, Kawai M, et al.


After creating bilateral turnover flaps, weapproximate the flaps to cover the abdominalcontents using interrupted sutures. Thereafter,the skin and underlying adipose tissue areapproximated (Figs. 2 and 3).

Results of our approach for open abdominalmanagementFifty-four patients (21 trauma, 33 non-traumapatients) who required open abdominal manage-

Fig. 2-2 Intraoperative view of the anterior rectus abdominis sheath turnover flap method (later steps)A: Approximating the bilateral turnover flaps. B and C: Turnover flaps from the anterior rectus sheaths are approximated usinginterrupted sutures. D: Skin and subcutaneous tissue are sutured primarily (from reference 5).

A B

C D

Fig. 3-1 Open abdominal management in a pediatric patient with severe torso traumaAn eight-year-old girl with lung contusion, left diaphragmatic rupture, mesenteric injury, pelvic fracture and bilateral femurfracture. A: The abdomen was covered temporarily using Silo closure (3 days after initial laparotomy). B: Vacuum pack closure10 days after initial surgery. C: The abdomen was covered using vacuum pack closure 30 days after laparotomy.

A B C



ment between April 1997 and August 2007 weretreated. Patients with an acute abdominal walldefect arising from necrotizing fascial infection,or who died despite resuscitation within 48 hr ofopen abdominal management were excluded.Most patients had developed massive intestinaledema with coagulopathy secondary to large vol-umes of fluid resuscitation, precluding primaryabdominal closure without undue tension afterthe initial laparotomy.

The mean duration of open abdomen was13.9�21.2 days for all study patients. Of 33nontrauma patients, 15 survived, as did 12 of the21 trauma patients. In nontrauma patients, thetime from initial laparotomy to standard fascialclosure was 1 to 5 days in 8 patients; to turnoverflap closure was 1 to 31 days in 10 patients; and

to skin grafting over a ventral hernia was 49 to69 days in 3 patients. In trauma patients, thetime to standard fascial closure was 1 to 5 daysin 8 patients; to turnover flap closure, 6 and 30days in 2 patients; and to skin grafting, 78 to 89days in 3 patients. During the study period, noenterocutaneous fistulae or abdominal abscessesoccurred.

Fistulae and complications in patientstreated with a turnover flap constructedfrom the anterior rectus abdominis sheathNo fistulae developed in 12 patients. Woundinfection developed in 4 patients, with 1 infectionbeing major. In that patient, the midline skin clo-sure dehisced, but the approximated fascial flapremained intact. The skin was closed secondarily.

Fig. 3-2 Intraoperative view of the turnover flap method using the anterior rectus abdominis sheath carried out 30days after initial laparotomy

A: View just after vacuum packing removal (30th day of open abdomen) showing granulated abdominal contents and retractedmusculofascial structures of the anterior abdomen. B: The anterior rectus sheath flap is reflected medially, dissected from lateralto medial to free it from the rectus muscle. C: Bilateral turnover flaps from the anterior rectus sheaths are approximated usinginterrupted sutures. D: Skin and subcutaneous tissue are sutured primarily (from reference 5).

A

C D

B

Kushimoto S, Yokota H, Kawai M, et al.


Although midabdominal bulging was observedin more than half of patients who underwent ante-rior rectus abdominis sheath turnover flap closure,no abdominal wall hernia requiring secondaryreconstruction developed up to 80 months afterthe procedure.

In many patients requiring conventional openabdominal management, the granulated abdomi-nal contents are covered only with a skin graft,which carries with it the risk of enterocutaneousfistula. These patients ultimately require complex

abdominal wall reconstruction at a later date.Early abdominal wall reconstruction in noncan-didates for standard abdominal wall closure hasreceived little attention. Early fascial closureusing the anterior rectus abdominis sheath turn-over flap may reduce the need for skin graftingand subsequent reconstruction. This approachcan be considered as an alternative techniquefor the early management of patients with openabdomen.

References

1. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damagecontrol”: an approach for improved survival in exsanguinatingpenetrating abdominal injury. J Trauma. 1993;35:375–383.

2. Moore EE, Burch JM, Franciose RJ, et al. Staged physiologicrestoration and damage control surgery. World J Surg. 1998;22:1184–1191.

3. Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control:collective review. J Trauma. 2000;49:969–978.

4. McNelis J, Soffer S, Marini CP, et al. Abdominal compartmentsyndrome in the surgical intensive care unit. Am Surg. 2002;68:18–23.

5. Kushimoto S, Yamamoto Y, Aiboshi J, et al. Usefulness of thebilateral anterior rectus abdominis sheath turnover flap methodfor early fascial closure in patients requiring open abdominalmanagement. World J Surg. 2007;31:2–8.

6. Wyrzykowski AM, Feliciano D. Trauma damage control. In:Feliciano DV, Mattox KL, Moore EE ed. Trauma, sixth edition,New York: McGraw-Hill; 2008:851–870.

7. Cheatham ML, Malbrain MLNG, Kirkpatrick A, et al. Results fromthe International Conference of Experts on Intra-abdominalHypertension and Abdominal Compartment Syndrome. II. Rec-ommendations. Intensive Care Med. 2007;33:951–962.

8. Rasmussen TE, Hallett JW Jr, Noel AA, et al. Early abdominalclosure with mesh reduces multiple organ failure after rupturedabdominal aortic aneurysm repair: guidelines from a 10-yearcase-control study. J Vasc Surg. 2002;35:246–253.

9. Garner GB, Ware DN, Cocanour CS, et al. Vacuum-assistedwound closure provides early fascial reapproximation in traumapatients with open abdomen. Am J Surg. 2001;182:630–638.

10. Miller PR, Thompson JT, Faler BJ, Meredith JW, Chang MC.Late fascial closure in lieu of ventral hernia: the next step in openabdomen management. J Trauma. 2002;53:843–849.

11. Wittmann DH, Aprahamian C, Bergstein JM. Etappenlavage:advanced peritonitis managed by planned multiple laparotomiesutilizing zippers, slide fastener, and Velcro analogue for tempo-rary abdominal closure. World J Surg. 1990;14:218–226.

12. Jernigan TW, Fabian TC, Croce MA, et al. Staged managementof giant abdominal wall defect: acute and long-term results. AnnSurg. 2003;238:349–357.

13. Fabian TC, Croce MA, Pritchard FE, et al. Planned ventralhernia: staged management for acute abdominal wall defects.Ann Surg. 1994;219:643–653.

14. Nagy KK, Filder JJ, Mahr C, et al. Experience with three pros-thetic materials in temporary abdominal wall closure. Am Surg.1996;62:331–338.

15. Suliburk JW, Ware DN, Balogh Z, et al. Vacuum-assisted woundclosure achieves early facial closure of open abdomens aftersevere trauma. J Trauma. 2003;55:1155–1160.

16. Ramirez OM, Ruas E, Dellon AL. “Components separation”method for closure of abdominal-wall defects: an anatomic andclinical study. Plast Reconstr Surg. 1990;86:519–526.

17. DeFranzo AJ, Kingman GJ, Sterchi JM, Marks MW, Thorne M.Recus turnover flaps for the reconstruction of large midlineabdominal wall defects. Ann Plast Surg. 1996;37:18–23

18. Ennis LS, Young JS, Gampper TJ, Drake DB. The “open-book”variation of component separation for repair of massive midlineabdominal wall hernia. Am Surgeon. 2003;69:733–743.




*1 Vice-President, The Japanese Orthopaedic Association, Tokyo, Japan ([email protected]).

Current Status of Musculoskeletal Disorder Carein Japan

JMAJ 51(4): 278–280, 2008

Kazuo YONENOBU*1

and (2) 6-meter walking test. The former mea-sures the length of time standing on one leg. If theperson can stand on one leg stably for 15 secondsor more, there is deemed to be no problem. Thetest mainly examines balance capacity. The lattermeasures the time for a person sitting on a chairto stand up and walk to a point 3 meters away,then turn around and walk back to the chair.If this can be achieved within 11 seconds, theredeemed to be no problem; nursing care is deemednecessary for daily life if the task takes 30 secondsor more to complete. In addition to these twoindices, if the person is evaluated as Rank J or A(requiring support�requiring nursing levels 1, 2)on Index of Independence in ADL (Activitiesof Daily Living) for the nursing care insurance,Musculoskeletal Ambulation Disability Syndromeis diagnosed.

Using these methods screening is implementedand further testing is carried out if problems arefound. A patient’s clinical condition is analyzedand treatment appropriate for that condition(drug therapy, musculoskeletal rehabilitation,surgical treatment) is carried out. Such screeningaims to restore mobility capability in order toextend healthy life expectancy and avoid theneed for nursing care.

The Japanese Orthopaedic Association is alarge medical society with approx. 23,000 members,of which approx. 16,000 are board-certificatedorthopaedic surgeons. Activities range broadly,from the gerontological field to pediatric ortho-paedics, and also include basic medicine.

In basic research, study in the field of regenera-tive medicine is particularly active. Basic researchis advancing at a remarkable pace in the fields ofcartilage regeneration, spinal regeneration, anddisk regeneration, with some research at or near

Japan has entered the era of the aging society,with the 65–74 age group comprising 11% ofthe total population in 2005 and the 75 and overage group comprising 9%—a demographic com-position in which 1 out of 5 people are elderly.Moreover, 1 out of 7 of these elderly peoplerequires nursing care or support in their dailylives. Reasons for requiring nursing care or sup-port (Fig. 1) overall include cerebrovascular dis-ease, debilitation due to advanced age, falls/bonefractures, dementia, joint disorders, and heartdisorders, with musculoskeletal disorders suchas falls/bone fractures and joint disorders com-prising a large proportion of these. In particular,musculoskeletal disorders were the reason forrequiring support in more than one-quarter ofcases, and since debilitation due to advancedage may also be included in deterioration ofmusculoskeletal skills, the proportion of peoplerequiring care or support due to musculoskeletaldisorders is in reality extremely high. In 2004 theJapanese Government formulated the “The NewHealth Frontier Strategy” and has been workingto improve all kinds of health indices. In face ofthe facts outlined in the previous paragraph, thegovernment’s efforts include promoting preven-tion of nursing care and extending healthy lifeexpectancy. In view of this social situation, theJapanese Orthopaedic Association has proposedthe concept of “Musculoskeletal AmbulationDisability Syndrome” (Table 1) and has beenconducting clinical studies and research on themedical examination system with the aim ofextending healthy life expectancy and preventingan increase in the number of people requiringnursing care or support. The diagnostic indicesfor Musculoskeletal Ambulation Disability Syn-drome are (1) single-leg standing with eyes open

The Japanese Orthopaedic Association


the stage of clinical testing. Incidentally, Profes-sor Nobuya Yamanaka of Kyoto University, whois drawing attention for his successful develop-ment of induced pluripotent stem cell (iPS cells)from human skin cells which have equivalentcapacity to embryo-stem cells (ES cells), began inorthopaedics before switching to basic research.

In Japan, biomaterial research is also activelypursued; in particular, a wide variety of research

is being conducted with success on the develop-ment of ceramic-based biomaterials due to theexistence in Japan of a long-flourishing ceramicsindustry. Through the development of such bio-materials, combined with the above-mentionedadvances in regenerative medical technology,function rebuilding technologies for treating mus-culoskeletal disorders are expected to improvemore and more.

Table 1 Disorders causing motor deterioration

(1) Compression fracture of the spine and spinal deformities(kyphosis, high lumbar kyphosis/lateral curvature, etc.)

(2) Lower leg fracture (femoral neck fracture, etc.)

(3) Osteoporosis

(4) Osteoarthritis (hip joint, knee joint, etc.)

(5) Lumbar spinal canal stenosis

(6) Spinal disorders (cervical myelopathy, spinal cord injury, etc.)

(7) Neurological/muscular disorders

(8) Rheumatoid arthritis and various articular inflammations

(9) Lower limb amputation

(10) Musculoskeletal atrophy following prolonged immobility

(11) Frequent falls

0% 20% 40% 60% 80% 100%

29.1

11.8 22.2 10.53.3

17.5

14.9 10.9 12.5 8.9People requiring nursing care

Cerebrovascular diseaseDebilitation due to advanced ageFalls/bone fracturesDementiaJoint disordersHeart disordersVisual/hearing impairmentsRespiratory disordersDiabetesSpinal injuriesOther

People requiring support

Fig. 1 Reasons for requiring nursing or support

(Compiled from the Comprehensive Survey of Living Conditions of the People on Health and Welfare 2004)

CURRENT STATUS OF MUSCULOSKELETAL DISORDER CARE IN JAPAN


Returning to the clinical field, the followingare characteristics of orthopaedics in Japan. Firstof all is the high standard of spinal surgery care.Because in the past Japan had a high incidenceof tuberculous spondylitis, which was treated byorthopaedic surgeons, it became traditional fororthopaedic surgeons to treat spinal disorders.The incidence of tuberculous spondylitis droppeddramatically with the introduction of antituber-culosis drugs, but even after this a broad rangeof activities in this field—from the developmentof cervical spine surgery techniques to researchon cervical spinal cord pathology—were carriedout due to the prevalence of conditions such asossification of the posterior longitudinal ligamentof the cervical spine and cervical spondyloticmyelopathy. Amidst this trend, microendoscopicsurgery techniques have advanced and increas-ingly are being partially applied to not only lum-bar disorders but also cervical spine disorders.

Orthopaedics includes specialized treatmentsand research being carried out in many subspe-cialties, such as bone and joint surgery, traumasurgery, sports medicine, hand surgery, and bonetumors—so many in fact that there is not enoughroom here to mention them all. Through suchactivities, international exchange is flourishing.Begun in 1991 and expanded with the addition

of Europe, the Combined Meeting of Ortho-paedic Research Societies (the United States,Canada, Europe and Japan) will next be held inKyoto in 2010. Japan also has active exchangewith countries throughout Asia, and lecture topicapplications for symposiums and conferences arealso increasing.

The government has been attempting toimplement policies in response to the increase inthe aged population and accompanying increasein medical expenses, as well as changes in thehealthcare content and standards required bythe public, but there is not necessarily agreementon these issues. Thus Japanese medical societiesare in difficulties. As one of these societies, theJapanese Orthopaedic Association is also facingmany problems such as difficulty in maintainingthe number of orthopaedic surgeons to keepup with the increasing number of orthopaedicpatients with the aging of society. However, weintend to bring together the wisdom of manyorthopaedic surgeons in order to overcome thissituation. Once we have successfully achievedthis, we believe that Japanese orthopaedic sur-geons will be able to apply their useful experi-ence to the aging society-related musculoskeletaldisorder issues in other countries that have yetto experience these.

Yonenobu K



along the border with Nagano in the mountain-ous forested region famed for its cypress stands.Well-known sightseeing destinations includeHida Takayama, the Gero hot springs and theShirakawago UNESCO World Heritage site. Theprefecture is divided into the five community andmedical districts of Gifu, Seino, Chuno, Tono andHida.

Features of the Five Districts

Gifu District: Gifu district has the largest pro-portion of physicians to population in the prefec-ture, and Gifu city in particular has such a highconcentration of physicians as to contest for thefirst and second positions nationally. In additionto Gifu University Hospital, the district is alsohome to numerous public and private hospitalsand enjoys sufficient numbers of ob-gyn andpediatrics practitioners. However, depopulation,population aging and physician shortages areemerging in mountainous areas.Seino District: Bordering Aichi and Mie prefec-tures in the south, the Seino district reaches fromKaizu city in the Waju river basin to Ibi county in

A Regional Medical Association ThatWorks

Every autumn the President of the Gifu MedicalAssociation (GiMA) leads its full board memberson a tour of the five districts in Gifu prefecture(the prefecture is divided into five communitiesand medical districts) to communicate and gatherinformation, provide collective leadership to phy-sicians qualified to treat health insurance patientsand seek closer relations with district medicalassociation members. We call this “a regionalmedical association that works.”

An Overview of Gifu Prefecture

Situated roughly in the middle of Honshu, Gifuprefecture is the center of gravity of the Japanesepopulation. Running 120 kilometers east to westand 160 kilometers north to south, the prefectureis the seventh largest in Japan with an area of10,598 square kilometers. An inland prefecturebordering on Aichi and Mie to the south, Naganoto the east, Shiga to the west and Fukui, Ishikawaand Toyama to the north, Gifu has a populationof some 2.1 million people.

The prefectural capital of Gifu city is locatedin the center of the Nobi plain and is home tosome 400,000 people. Mt. Kinka, on which OdaNobunaga’s*2 famed Gifu Castle stands, is locatedin the center of the city, known for its scenicbeauty as the location of cormorant fishing in theNagara river flowing along the foot of the moun-tain. The city of Nagoya may be reached in 17minutes by the shortest route on the JR railway.In the west is Sekigahara, renowned as the siteof the decisive battle, and in the north mountainsrise to heights of 3,000 meters in the Northern Alps

*1 Executive Board Member, Gifu Medical Association, Gifu, Japan ([email protected]).*2 A famous feudal warlord in the 16th-century Japan.This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.135, No.11, 2007,pages 2382–2383).

Tochigi

Tokyo

A Regional Medical Association That Works

JMAJ 51(4): 281–282, 2008

Hidenori TORIZAWA*1

Gifu

Pop. 2.1mil.Area 10,600km2


the north, a mountainous area bordering onFukui prefecture. Healthcare conditions varywidely from urban to mountainous areas.Chuno District: The Chuno district straddles thecenter of Gifu prefecture east to west. It is madeup of five cities and two counties, from Gujo cityin the north bordering Fukui and Ishikawa pre-fectures to Kani city in the south bordering Aichiprefecture and serving as a bedroom suburb forNagoya. This district too encompasses both moun-tainous and urban areas, and healthcare condi-tions vary widely among them.Tono District: Lying along the JR railway’s ChuoLine and the Chuo Expressway, the Tono districtborders Aichi prefecture in the south andNagano prefecture in the north and is made up offive cities. The southern part serves as bedroomsuburb for Nagoya and also features the ceramicstown of Tajimi, and in the north Magomejuku, away-station on the Nakasendo route borderingNagano prefecture made famous by the early20th-century author Shimazaki Toson, is now thecity of Nakatsugawa. Healthcare conditions varywidely from urban to mountainous areas.Hida District: Made up of three cities and onecounty, the Hida district is home to numerous sight-seeing destinations of national renown, includingHida Takayama, the Shirakawago UNESCOWorld Heritage site, the Oku Hida hot springsand the Gero hot springs. Among its hospitalsare the Gero Onsen Gifu Prefectural Hospitaland the Takayama Red Cross Hospital, but evenrelatively large hospitals in the district haveproblems securing physicians. As the greater partof the district is mountainous, it suffers severeshortages of emergency medical services andob-gyn and pediatric practitioners.

Issues Arising from District Conditions

Gifu district is the one that enjoys a sufficientsupply of healthcare services, including even twoperinatal centers. However, these two are theonly perinatal centers in all of Gifu prefecture.Hospitals capable of treating acute myocardialinfarctions are likewise concentrated in Gifudistrict, and although the prefecture has twodispatch helicopters, they cannot be dispatchedat night or in poor weather. There is severe

depopulation and aging among the residents ofthe mountainous areas that make up the greaterpart of Gifu prefecture, healthcare backwatersexcept where pediatric and ob-gyn practices areconcerned.

Activities of the Gifu Medical Association

In 2006 the several district medical associationsheld events such as training courses and roundtables. The topics covered by these events werecomplaints against medical practices, law suits,death with dignity, efforts underway in hospital-clinic partnership by the district medical associa-tions, and district healthcare issues such as theinadequacy of attending physician opinions inlong-term care insurance, guidance on checkupsand healthcare for the newly insured, obstetriccare and physician shortages.

Participants attending social gatherings withdistrict medical association boards also raisedissues such as the shortage of physicians in ob-gynand other practices, long-term insurance and theLaw for Support of Independence among theDisabled. Those of the district medical associa-tions’ questions that could be answered immedi-ately were provided with replies on the spot, andthe others were provided with considered repliesseveral days afterwards. The boards are deliberat-ing their requests and proposals, and consideringwhat directions ought to be taken.

Proposals to Local Governments andPolitical Leaders

Issues and proposals studied by the Board arecommunicated to the prefectural governor, itsrepresentatives and committees convened by theprefecture as opportunities arise. Under currentconditions many problems, including those ofob-gyn and pediatrics practices and the unevenallocation of physicians, will take time to resolve,but we consider the roles of the GiMA to be tostate our opinions and proposals to local govern-ment and political leaders at the prefectural leveland to provide Gifu residents with security intheir lives through cooperation in healthcare andmedical treatment, and we are working daily toachieve these goals.

Torizawa H



and the AiMA has a membership of 8,700, thethird largest among the local medical associa-tions in Japan.

The AiMA is also honored to be the leadingmedical association of the Chubu region.

We are fully aware that our responsibilityto this community as the local medical associa-tion is to provide healthcare and welfare servicesresponsive to the rapidly changing needs andsocial environment of the prefecture’s residents.

Our activities as community physicians arefundamentally grounded in the prefecture’s com-munity healthcare plan. The basic element of theprefectural plan currently is to build a systematicframework to reduce the incidence of in particularlifestyle-related diseases in an effort to cooperatewith the nationwide campaign goal of securinglimited financial resources for healthcare.

The prefecture’s community healthcare plandivides the prefecture into 11 medical regionsand establishes an individual healthcare plan foreach region that may meet with the requirementsof its local culture. These plans is subject to reviewwithin 5 years.

The role of the medical association is to providebackup for these healthcare and welfare servicessuited to the needs of the community, while the

People say that Aichi is on fire now economicallyand socially. In 2005 the prefecture hosted theAichi Expo, welcoming over 22.05 million domes-tic and international visitors, and human inter-action with countries around the world is thrivingthanks to the opening of Chubu InternationalAirport in this area. This means that our commu-nity is continuing to grow and remains economi-cally vibrant. The themes of the Aichi Expo werethe development of modern societies and theprevention of global warming, literally the pres-ervation of our global environment. Our localprefectural authorities and residents are unitedin ongoing efforts in these areas, and it’s thanksto their efforts that Aichi prefecture is home toboth an ample natural environment and modernadvanced industrial society.

The new airport has made a gateway for prod-ucts, culture and international human exchange.

Aichi prefecture is in fact basis for a key indus-try such as Toyota, the world-famous automaker.Also prominent in the prefecture is Mitsubishi’saerospace systems manufacturing operations andthe many manufacturers clustered around them,said to be the largest such cluster in Japan. Thefull economic benefit derived from their presenceis beyond measure.

The movement inwards and outwards of bothgoods and people has therefore grown dramati-cally in recent years, and while people’s liveshave thus become more active, their social milieuis also growing more complex.

The Aichi Medical Association (AiMA), locatedin the Chubu region of Japan, is one of the 47prefectural medical associations which make upthe Japan Medical Association.

With a population of 7.3 million people, Aichiprefecture is home to four medical universities,

*1 Vice-President, Aichi Medical Association, Nagoya, Japan ([email protected]).

Tochigi

Tokyo

The Aichi Medical Association and CommunityHealthcare Provision System

JMAJ 51(4): 283–284, 2008

Akio FUJINO*1 Aichi



hospitals and medical institutions of local mem-bers coordinate to provide those services to localresidents. The distinguishing feature that hasemerged is the construction of a framework forthe provision of “comprehensive healthcare ser-vices” that include trends in prevention, health-care, rehabilitation and home medical care suitedto particular complaints associated with lifestyle-related diseases.

Against the foregoing social background, theAiMA continues to provide public service.

The medical association’s operational planfor this year comprises 38 individual elements.Below I discuss briefly those attached especialpriority this year and some that are especiallydistinctive of the AiMA.

(1) Patient safety measures: A mandatoryprogram imposed at the national level in 2004,this includes programs to provide residents withsafe medical care of higher quality. It covers com-plaints and disputes and physician training andhandles some 830 cases annually.

(2) Information technology: Although themedical field has adopted these advanced infor-mation and communications technologies to aconsiderable extent, we have yet to achievethe level indicated by national calls for a basice-japan strategy and it cannot be denied thatwe are behind other industries and fields in thisrespect. We appreciate the significance of thismatter, exhort efforts on the part of our membersand are making steady progress annually.

(3) Measures for emergency and disastermedicine and communicable disease prevention:The AiMA now hosts an emergency medicalinformation center, which employs a staff of 23and the Internet to exchange information withprefecture residents. Perhaps due to populationgrowth and changes in the social environment,the number of emergency calls annually has risento 195,000 in recent years.

We work continuously with regional diseasecontrol authorities and health research institutesto prepare against the incursion of communicablediseases, and especially emerging and re-emergingcommunicable diseases with the increasing inter-national exchange. Both historically and geo-graphically, Aichi has suffered extensive floodand earthquake damages, and we have been

warned that a major earthquake may occur in ourPacific coastal region in the near future. We arecreating a system for exchanging informationover the Internet and wireless networks.

(4) Measures for securing physicians: Japanfaces extremely severe circumstances in terms ofboth a shortage of hospital physicians and theiruneven distribution. The phenomenon is a nationalone, not confined to remote rural areas but alsonotable in urban locations, and is an extremelyserious issue for local residents. Its cause lies inthe breakdown of the system by which universi-ties have supplied physicians. The AiMA hasestablished a “doctor bank,” but it has unfortu-nately not been able to cope with the needs ofhospitals.

(5) Clinical trial program: The Japanese sys-tem of clinical trials is considerably behind thoseof other advanced countries, in terms of both itseconomics and time to approval.

This may be due to the excellent Japaneseuniversal heath insurance system. Citizens whoenjoy coverage for many high-cost drugs throughhealth insurance lack motivation to participate inthese clinical trials. This constitutes a waste ofhealthcare expenses.

A further disadvantage to Japanese citizensresults from the lack, according to national law, ofinsurance coverage for pharmaceuticals that havereceived approval abroad. In order to resolve thisproblem, the state must call for both physiciansand citizens to participate. The AiMA is one ofthe few regional medical associations success-fully participating in this program.

(6) Formation of the AiMA Research Institute(including reconstruction of community medicine[ROC]): Published statistics relating to varioushealthcare systems deriving from the research ofnational and prefectural authorities tend occa-sionally to lapse into national or extensive regionalreports and often fail to reflect seen in reality thelocal areas.

To open the bottleneck, the AiMA has begunconducting its own studies and research and for-mulating healthcare policy proposals for presen-tation to the various organizations concerned onthe basis of conclusions reached. The institutionengaged in this work was established and beganoperation in 2006.

Fujino A



tures. The Japanese universal health insurance,which allows all citizens in Japan to receive qual-ity healthcare services anytime and anywherewith impartiality, is now on the brink of crisis. Inorder to avoid the breakdown of the universalhealth insurance and strengthen the social infra-structure of healthcare, health professionals mustjoint with the general public to assert the needfor increased public health expenditures, and theCommunity Health Care Promotion Council forOsaka Prefecture has a major role to play inachieving these goals. An assembly of prefectureresidents was held in January 2007 at which over1,700 people assembled to adopt the appeal. Wehave submitted requests to the Osaka Prefecturaland City governments for appropriate budget toenhance the level of community healthcare.

Female Physicians and Gender Equality

Recent years have seen a marked increase in thenumber of female physicians. They are playinga rapidly growing role in healthcare in Japan.In 2005 the OMA started a Female PhysiciansCouncil to address the issues currently faced byfemale physicians and discuss what roles theyshould play and how to reflect their opinions on

The Osaka Medical Association (OMA) wasrelaunched as a new democratic medical asso-ciation on 1 November 1947 and last year cel-ebrated its 60th anniversary. The OMA is thesecond largest medical association in Japan.

The OMA is based in the Osaka prefecturecomprised of 64 city-level medical associations.As of June 2007 it had a total membership of17,552, of which 7,917 member doctors are prac-ticing at their clinics and 9,605 doctors are work-ing for the hospitals.

The OMA has pursued a wide range of activi-ties with the objectives of “giving prominence tomedical ethics, the development of medical scienceand technology, the improvement of public healthand contributing to the advancement of socialwelfare.”

Community Healthcare PromotionCouncil for Osaka Prefecture

Established in 1973 aiming at “expanding andenhancing health and welfare policy in Osakaprefecture and actively promoting communityhealthcare in order to achieve advances inhealthcare and improve welfare of residents ofOsaka prefecture,” the Council is comprised of30 organizations, including the three leadingprefectural medical groups (the OMA, the OsakaDental Association and the Osaka Pharmaceuti-cal Association), other medical organizations,women’s groups, the confederation of senior citi-zens clubs and other groups of local residents.

Its activities include efforts to make the localresidents aware of difficulties which are faced byhealth professionals and protect the universalhealth insurance. In order to eliminate its finan-cial distress, the Japanese government has recentlybeen attempting to implement healthcare reformthat focuses only on reducing medical expendi-

*1 Former Board Member, Osaka Medical Association, Osaka, Japan ([email protected]).

Tochigi

Tokyo

Osaka Medical Association Activities

JMAJ 51(4): 285–286, 2008

Yasuyuki TAKAI*1

Osaka



the activities of the OMA. In 2006 the councilwas renamed the Gender Equality Study Com-mittee and is now examining measures to improvethe work environment of female physicians tosupport and promote their employment.

Discussions are underway on measures to sup-port childbirth and child-rearing for female phy-sicians, and efforts have been initiated towardsthe construction of a network of day care centerslocated within medical facilities.

Medical Issues Study Committee

The OMA established Medical Issues StudyCommittee in 1998, composed primarily of youngmid-career members who are potentially compe-tent to create a future OMA, this committee isresponsible to study a wide range of health issuesand bring a fresh air to the OMA.

City level medical associations nominate onepromising member each and the hospital-basedphysicians group nominates two members to thecommittee. The nominees are expected to be lessthan 50 years of age. They meet regularly on thesecond Wednesday of every month to discusssuch issues as the health insurance system andcommunity healthcare. They hold debates ontopics of timely interest, thus training debateskills and enhancing their interaction skills aswell. This committee has 59 members.

The committee members constantly considerwhat physicians and medical associations can doto improve and strengthen the healthcare systemas one of the most important components of socialsecurity and develop community healthcare. Theyalso are expected to be engaged in the committeeactivities with a strong sense of mission to enhancethe health status of prefecture residents andpublic health as well. At the board meetings oftheir local medical associations, the committeemembers report the committee activities. Theseactions will lead to further improvement of localactivities of the medical associations using by theacquired knowledge and human networks.

Activities in the first year of the committeehave generally focused on lectures provided byOMA officers, followed by debates based onthose lectures in workshops during the secondyear. Topics covered in 2006 included the follow-ing items:(1) Partial revisions to the Medical Care Law and

Health Insurance Law and their implications(2) Home healthcare in the future(3) Activities of the medical associationThe themes of the debates are as follows.(1) Whether or not the medical association mem-

bership should be mandatory?(2) Whether or not an insurance exemption should

be adopted?(3) Whether or not family doctors should be

institutionalized?Once a year, the committee also invites well-

known researchers of health economics andhealth policy for special lectures to nurture theirknowledge.

Designated School Physician Program

In April 2004, the OMA introduced its uniqueprogram of the designated school physician, thefirst such a trial in Japan, for improved quality ofschool physicians in its efforts to meet with theincreasing requirements according to the changesin social environment.

In addition to school physicians’ primary dutiesof performing checkups and follow-up measures,there are increasing demands from schools forhealth education. The OMA Designated SchoolPhysician Program is the avenue through whichwe seek to upgrade the qualifications of schoolphysicians and play a role in coping with differentschool health issues. JMA is also planning to intro-duce JMA Designated School Physician Program(tentative), but this has yet to be implemented.

The major activities of the OMA have beenintroduced as above. I would like to add that theOMA also runs a nursing school and healthcarecenter in its activities.

Takai Y



cedures and authority granted heretofore by lawto physicians by renaming them “nursing proce-dures.” These procedures have historically beenpart of the medical profession because of theirinherent medical nature and the need to exerciseprofessional discretion in their regard.

The legislator created a mechanism in the pastwhereby the Director could grant an individualpermit to a specific nurse to perform “excep-tional procedures” that are basically technical innature and don’t presume to replace the profes-sional discretion of the doctor. Nonetheless, theDirector decided, without any legal authority andwithout bringing the matter to a discussion in theadvisory committee, as the law requires, to createa process whereby the power to make medicaldecisions requiring discretion would be broadlytransferred to nurses.

Since the decision was publicized, variousparties have taken advantage of the IMA’s oppo-sition to create a rift between the physiciancommunity and the nursing community. This willnot work. Doctors and nurses have and will con-tinue to work as a team, whose success arisesfrom the fact that each party contributes aspecific aspect to patient care and neither canfunction without the other. Physicians see innurses a vital part of the medical team and recog-nize their great contribution. However, we mustbe careful not to blur the distinction between thetraining received by doctors and that receivedby nurses, who are trained for different tasksaltogether. Physicians learn medicine for a periodof 7 years, followed by an average of 6 years ofresidency and often an additional 2 to 3 years ofsub-specialties or fellowships. This lengthy periodof training allows for the broad professional dis-

Recently, we have been a witness to increasedinstances worldwide of tasks, traditionally per-formed by physicians, transferred to the purviewof nurses and other medical (or sometimes non-medical) professionals.

In many countries, this is due to a shortage ofdoctors. These countries face the very real ques-tion of whether to provide medical treatment vianurses or not at all.

Reforms at the Expense of the Patients

Where a country has an insufficient number ofdoctors, there will either be patients waiting weeksor months for treatment or left untreated alto-gether. Alternately, or in addition, physicians willbe forced to work extra shifts and ultimately col-lapse under the superhuman workload. However,if the solution to the physician’s heavy workloadis the transfer of authority to perform certainprocedures to nurses, how will we solve the prob-lem of the nurses’ increasing workload? Thelogical outcome would be to transfer their work-load onward, to paraprofessionals and orderlies.

In Israel, the media has dealt over the last 6months with the memo issued by the DirectorGeneral of the Ministry of Health (the “Direc-tor”), which transfers authority to nurses to per-form procedures legally allowed to be performedonly by physicians. Many philosophical state-ments have been thrown about, slogans thatdon’t reflect reality. I would like to set thingsstraight and explain why the IMA opposes thistrend and fears that it will seriously endangerpublic health.

The decision of the Director, which took effectat the beginning of June, transfers to nurses pro-

*1 President, Israeli Medical Association, Tel Aviv, Israel ([email protected]). President-Elect, World Medical Association.

Task Shifting: Necessary practice or dangerousprecedent?

JMAJ 51(4): 287–289, 2008

Yoram BLACHAR*1


cretion, including the analysis of various factors,data and scenarios regarding the patient’s condi-tion and the continuation of care, so essential tothe practice of medicine. For instance, a doctormust weigh factors that may have caused a patientto react poorly to a medication and to understandthe implications of prescribing a new drug. Onlythe comprehensive and lengthy training receivedby physicians allows them to make complexdecisions and give optimal care. If the decisionmaking process is transferred to nurses, as indi-cated in the Ministry of Health memo, they willbe able to deal only with the symptoms withoutthe ability to investigate the reasons behind suchsymptoms. Moreover, intervention on the part ofthe nurse may prevent the doctor from being ableto exercise his or her own professional discretion.As an example, if a nurse gives Petidin to a womanin labor, the woman may become disoriented andthe anesthesiologist may then be unable to giveher an epidural, although the situation mighthave warranted such.

Let us make no mistake: the IMA recognizesthat in an era of rapid technological developmentand change the function of nurses has beengreatly expanded, and nursing skills have becomemore complex. Nurses take advanced coursesand undergo specialized training in areas such asintensive care, operating rooms etc. We have noobjection to this; on the contrary, it is a welcomeand essential process. However, this has nothingto do with the move to allow nurses independentdiscretion in medical decision making. Anytraining they receive, other than formal medicaltraining, will not help them view the wholepicture and enable them to reach a well thoughtout, educated medical decision.

The Ministry of Health memo has aggravatedthe current situation; not only does it transferauthority from doctors to nurses, it even statesthat training will be offered by nursing personnel,a designation that is difficult to understand, ashow can members of one discipline be expectedto teach and train topics related to another disci-pline. This point was conveniently absent fromthe array of slogans tossed around in recentmonths, and it is no wonder why.

There are those who have criticized the IMA,subtly alleging that we are actually looking outfor the interests of the doctors under the guiseof concern for patients. Such arguments have noconnection to reality and don’t even make sense

Blachar Y

—if our entire purpose were concern with therights of the physician, we should praise the Min-istry memo for transferring procedures fromdoctors to nurses and thus lessening the work-load and the responsibility of the doctors.

But this is not the case. Specifically because ofour concern for public health, we have decided toact forcefully against the memo, which we haveno doubt has the potential for real, tangible dam-age. For instance, the power given to nurses tostop treatment for high blood pressure becauseof the accompanying side effects is potentiallylife threatening to that patient. The physician isthe one best suited to weighing the severity ofthese side effects and the only one who can makea decision regarding alternate treatments.

As to the argument that in other countriesnurses have been given duties and responsibili-ties of physicians, I would note that these coun-tries have for the most part done so because ofa severe shortage of physicians. They faced thedilemma of giving treatment through nurses ornot at all. The State of Israel, at least in the shortterm, does not face such an acute shortage ofdoctors, one that would justify such compromisesto the public health.

There is no question that doctors deal witha heavy workload, but the path chosen by theMinistry of Health to deal with this problem isstrange, to put it mildly. Instead of increasing theamount of positions for doctors in the public sys-tem, it has decided to transfer medical authorityto nurses as a convenient, readily available andmost importantly, cheap solution. What then isthe next step? According to this logic, whenthe nurses become overburdened because of theincreased responsibilities, will the Ministry ofHealth decide to transfer medical functions toparaprofessionals or orderlies? In addition, wehave recently been witness to claims of a grow-ing shortage of nurses in this country. If so, it isdifficult to understand how nurses will be able tofulfill their traditional functions while at the sametime taking upon themselves additional medicalduties.

We can only conclude that the puzzling, hastydecision of the Ministry of Health, which grantsmedical authority to nurses, will in the end causegreat harm to the unique professional relation-ship that currently exists among all members ofthe medical team and will negatively impact thequality of care, even to point of endangering life.


TASK SHIFTING: NECESSARY PRACTICE OR DANGEROUS PRECEDENT?

The IMA has petitioned the High Court ofJustice to nullify the decision; they in term haverequested the Ministry to delineate and justifywhy the memo should stand as is. If they are not

able to do so to the satisfaction of the court, thememo will be cancelled. As of the writing of thisarticle, we await a final decision on the matter.



*1 Ethics Advisor, World Medical Association. Adjunct Professor, Department of Medicine, University of Ottawa, Canada ([email protected]).

Ethics at the World Medical Association:From policy to practice

JMAJ 51(4): 290–293, 2008

John R. WILLIAMS*1

The Declaration of Geneva and InternationalCode were just the first, although arguably themost important, of a long list of WMA policystatements on a wide variety of medical andhealth topics. Despite a small staff and fluctuat-ing membership, the Association proved capableof international leadership on difficult and con-troversial issues such as the ethics of research onhumans (Declaration of Helsinki, 1964), medicalparticipation in torture (Declaration of Tokyo,1975), patients’ rights (Declaration of Lisbon,1981) and abortion (Declaration of Oslo, 1983).2

That physicians from many different countrieswere able to reach agreement on these issues,which have proved so politically and socially divi-sive, can be explained by their shared commit-ment to the fundamental principles of medicalethics and their friendship and respect for oneanother as they work together at WMA meetingsto search for the best solutions to the issues.

Beginning in the late 1960s in the USA andsomewhat later in other countries the medicalprofession was joined by other health profes-sions and academic disciplines in its concern forethics. Medical ethics expanded into bioethicsand rapidly became an ‘industry’, with full-timesalaried practitioners, national and internationalassociations, conferences, journals, legislationand regulations. The WMA was no longer theonly international association dealing with medi-cal ethics; other, much larger and better funded,bodies such as the Council for InternationalOrganizations of Medical Sciences (CIOMS),WHO and UNESCO began to issue statementson medical ethics issues that were generally, butnot always, consistent with WMA policies. More-over, the WMA lacked legal authority to enforceits policies, even among its member National

Introduction

In October 2004 the World Medical Association(WMA) held its General Assembly in Tokyo.The theme of the scientific session at the Assem-bly was “Advanced Medical Technology andMedical Ethics.” The program featured presen-tations by prominent Japanese experts1 as wellas international guest speakers. The event rein-forced the longstanding commitment to medicalethics of both the Japan and the World MedicalAssociations.

This article will describe the roles and activi-ties of the WMA in medical ethics, from its begin-ning in 1947 to the present. Its main focus willbe the relationship of ethics policies to medicalpractice.

History of WMA Ethics

The WMA was established shortly after the endof the Second World War. Physician leaders inmany countries saw the need to re-establish thegood reputation of the medical profession inreaction to the widely publicized breaches ofmedical ethics committed by physicians in NaziGermany and elsewhere. The first task of thenewly established Association was the reformu-lation, in modern language, of the HippocraticOath by which physicians would commit them-selves to high ethical standards. The new oathwas named the Declaration of Geneva after thecity where it was adopted. The next task wasthe development of an International Code ofMedical Ethics, which elaborated the principlesof the Declaration of Geneva. Both these docu-ments have been revised recently in keeping withdevelopments in medicine and society.


Medical Associations. These factors have posedmajor challenges to the WMA as it strives todefine its role among the many voices speakingon ethics.

The WMA has risen to this challenge innumerous ways. It has more than doubled itsmembership in the past decade, welcoming newNational Medical Associations in Latin America,Africa and Eastern, Central and Southern Europe.These new members have enabled the Associa-tion to speak with greater authority on behalf ofall the world’s physicians, not just those from thehighly industrialized countries. The WMA hasalso refined its policy development process toensure that its policies are always up to date.Each policy is reviewed at least every ten yearsto determine whether it should be reaffirmed,revised or rescinded and archived. Finally, theWMA has developed educational and advocacyprograms to promote the implementation of itspolicies.

The WMA Medical Ethics Manual

The WMA has for many years promoted ethicseducation in medical schools. One of the obstaclesto such education, particularly in countries withlimited resources, was the lack of a basic text forstudents. In 2003 the WMA decided to developand distribute such a text. An international groupof advisors was constituted whose first task wasto comment on a proposed outline of the text.On the basis of their comments a first draft waswritten and circulated to them for review. Asecond draft followed and the advisors once moreprovided comments. One of them, a medicalstudent in Egypt, asked ten fellow students toreview the draft and mark words that they didnot understand. The most frequently markedwords were either changed to simpler ones orelse were defined in the text or in a glossary. Thefinal version was then sent to the publisher fordesign work and printing. The official launch ofthe English version of the WMA Medical EthicsManual took place in January 2005.

In order to make the Manual widely and freelyavailable, the WMA put the text on its websitein its three official languages, English, Frenchand Spanish. Two copies of the English printversion were distributed to most of the world’smedical schools, one for the library and the otherfor the faculty member responsible for medical

ethics education. The WMA invited its memberNational Medical Associations to translate anddistribute the Manual in their own languages, andmany of them responded positively. The Japaneseversion was published by the Japan MedicalAssociation in 2007. Twelve other translations,including Chinese, Korean, Indonesian, Arabicand Russian, are available either in print oronline, and others are in progress.

The Manual is based to a large extent onWMA policies and is therefore one means,although an indirect one, of putting these policiesinto practice. It provides medical students andpractising physicians with a basic knowledge ofthe principles of ethical decision making andbehaviour. Of course, this knowledge needs tobe supplemented by the development of ethicalskills and attitudes, which is a task for others thanthe WMA.

The success of the Manual prompted the FDIWorld Dental Federation to ask the WMA forpermission to adapt it for dentists. Permissionwas granted and the FDI World Dental Federa-tion Dental Ethics Manual was published in 2007and has already received widespread distributionand requests for translation.3

Online Ethics Course

In recent years the WMA has formed partner-ships with other organizations to produce onlinecontinuing medical education/continuing profes-sional development (CPD) courses. In 2006 a CPDcourse on medical ethics was launched.4 Basedon the Medical Ethics Manual, it is availablefree of charge and is accredited by the Norwe-gian Medical Association. Although its primaryintended users are practising physicians, it isespecially useful for medical school faculty whoare involved in ethics education.

Declaration of Helsinki (DoH)

The DoH is perhaps the best known and mostinfluential of all the WMA’s policy statements.Adherence to its principles is a requirementfor research on humans in many countries andit is widely used by research ethics committeesto determine whether or not proposed researchprojects should be approved. However, it is nolonger the only international ethics guidance formedical research as it was for some time after its

ETHICS AT THE WORLD MEDICAL ASSOCIATION: FROM POLICY TO PRACTICE


adoption in 1964. In order to maintain the DoH’spre-eminence among all the other documents onresearch ethics, the WMA has undertaken thefollowing activities:• The DoH has been revised periodically to take

account of developments in medical researchand social changes. In 1975 a requirement forethics committee review of proposed researchprojects was added. In 1996 placebo-controlledtrials were mentioned for the first time. Between1997 and 2000 a major revision process tookplace that resulted in a significantly reorganizedand expanded version. Notes of clarificationto this version were added in 2002 and 2004.Currently (2008) another review is underway,which is expected to result in a new version tobe recommended for adoption by the WMAGeneral Assembly in Seoul in October 2008.An extensive consultation process has resultedin widespread awareness of and participationin this review.

• WMA representatives have spoken at numerousconferences and meetings on research ethicswhere they have promoted the DoH and invitedother parties to adopt its principles.

• The WMA has played an active role in severalprograms designed to strengthen research ethicscommittees in developing countries, includingNEBRA (Networking for Ethics on BiomedicalResearch in Africa)5 and TRREE-for-Africa(Training and Resources in Research EthicsEvaluation for Africa).6 These programs haveproved very useful for promoting the DoH.

Torture

The WMA has been a strong advocate for theabolition of torture wherever it is practised andhas worked closely with other organizations toimplement the Declaration of Tokyo and relatedWMA policies on this topic. It maintains closelinks with the International Committee of theRed Cross, which has provided valuable inputto WMA policies and which uses these policiesin its fieldwork in prisons and disaster situa-tions. The WMA joined with the InternationalRehabilitation Council for Torture Victims in the

design and testing of a manual to assist physiciansand lawyers to detect evidence of torture. WMAofficials participated in five national trainingworkshops in which the draft of the manual wasfield tested.7

Conclusion

Ethics is both a theoretical and a practical activity.The WMA documents are strong theoreticalstatements about how physicians should act andwhat public policies on ethical issues should beadopted. However, unless the documents aremade known and implemented, they do not serveany useful purpose. Realising this, the WMA hasincreased its efforts to have its policies incorpo-rated in practice.

As noted above, the WMA’s implementationactivities include education and advocacy. Sinceit is not an educational organization, it worksindirectly by developing and distributing educa-tional resources such as the Medical EthicsManual and the online ethics CPD course. Itsadvocacy activities are more direct, for example,intervening with national governments on behalfof physicians whose human rights are threatenedand supporting the efforts of the WHO to reducetobacco use. In order to increase its effectivenessin both education and advocacy, the WMA joinswith other organizations to develop programsand materials and strategies for intervention.

It is easier to evaluate policy developmentthan practice. The former can be determined bythe number of policies approved, the time it takesto complete them and the reception they aregiven by the intended users. Changes in practiceare usually of longer duration and involve mul-tiple variables. The WMA does not have theresources to measure the effectiveness of itseducational and advocacy activities, even if thiscould be done. Nevertheless, it is committed tocontinuing and even expanding these activities, inthe hope that they will contribute to the realiza-tion of the WMA’s mission, namely, to achievethe highest possible standards of medical care,ethics, education and health-related human rightsfor all people.

Williams JR


References

1. Takaku F. Advanced medical technology and medical ethics.World Medical Journal. 2005;52:14–17. Uematsu H. Moderndemands in health care. World Medical Journal. 2005;52:17–20.Kaihara S. Coordination of progress in information technologywith health care in the 21st century. World Medical Journal.2005;52:21–23. (All articles available online at www.wma.net/e/publications/pdf/wmj5.pdf).

2. All WMA policies are online at www.wma.net/e/policy/handbook.

htm.3. www.fdiworldental.org/resources/4_6ethics-manual.html4. http://lupin-nma.net/index.cfm?m=2&s=1&kursid=143&file=

kurs/K143/intro.cfm5. www.trree.org/phpwcms133/index.php?id=36,29,0,0,1,0&

highlight=NEBRA6. www.trree.org/phpwcms133/en_home.phtml7. www.irct.org/Default.aspx?ID=2719

ETHICS AT THE WORLD MEDICAL ASSOCIATION: FROM POLICY TO PRACTICE


minds of leaders of the medical field in Brazil.The second visit was for the “DoH 2008 São

Paulo Conference,” which was held in August atthe head office of the Paulista Medical Associa-tion. The meeting was attended by participantsfrom the region and throughout the world, whoactively discussed their ideas about the DoHover two days. In the Latin American manner, thediscussions were carried out in an enthusiasticand passionate fashion. The meeting was a pre-cious moment for promoting understanding ofthe DoH in the South American region andfor the members of the WMA working group togain a better understanding of the positions andopinions of doctors in the region. We becameconfident of finding a way to achieve a final ver-sion of the DoH, which will be discussed at theup-coming WMA General Assembly in Seoul inOctober, 2008.

Brazilian culture with people from all over theworld and wonderful food and products was mostimpressive to me. I was also touched by the richmusical variety that spices the Brazilian lifestylewith the sophisticated cords of Bossa Nova,joyful rhythmic patterns of Samba, classical sym-phony orchestra and opera performances, andcontemporary MPB (Musica Popular Brasileira)at a live house in Sao Paulo. I enjoyed all of theseexperiences during my short stay in Brazil.

Masami ISHII, Executive Board Member, Japan Medical Association( [email protected]), Secretary General, Confederation ofMedical Associations in Asia and Oceania (CMAAO), CouncilMember, World Medical Association.

Visit to Sao PauloI recently had two opportunities to visit SaoPaulo in Brazil. The first occasion was the“Congresso Médico Do Centinário Brasil-Japão”commemorating the centennial of Japaneseimmigration to Brazil which was hosted by theBrazilian Medical Association, and the secondwas the “Declaration of Helsinki (DoH) 2008São Paulo Conference,” a forum organized forthe purpose of revising the World Medical Asso-ciation (WMA) DoH.

At the “Congresso Médico Do CentinárioBrasil-Japão,” held in June, very impressive paperson various activities related to community healthissues, which were being carried out by Japaneseand Japanese-Brazilian doctors in areas through-out Brazil, were passionately presented over twodays. The congress was held at a special momentin history when Japan’s Crown Prince Naruhitowas visiting Brazil to celebrate the centennial ofJapanese immigration to Brazil. Accordingly, afew participants attended other events held inhonor of Crown Prince Naruhito. I noticed thatthe spirit of traditional Japan still exists amongthe Japanese community in Brazil, certainlymore strongly than in Japan today. Moreover, thememory of former JMA president Taro Takemiand his successors, who promoted the globalcontribution of the JMA after World War II andalso took part in the establishment of a new hos-pital for the Japanese community and all thepeople of Sao Paulo as well, remains strong in the

Presentation at the Medical Congress of Brazil-Japan

Stone memorializing the arrival of Japanese immigrantsin Santos Harbour in 1908

From the Editor’s Desk

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