Matters to address prior to introducing new life support technology in Japan: three serious ethical concerns related to the use of left ventricular assist devices as destination therapy and suggested policies to deal with them

Abstract

BackgroundDestination therapy (DT) is the permanent implantation of a left ventricular assist device (LVAD) in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering.Main textWestern ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment.ConclusionThere is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation.

Japan should initiate the discussion on voluntary assisted dying legislation now

“…The act should include respect for a patient’s right to self-determination, the right to refuse unwanted treatment including not-starting and stopping life-sustaining treatments, the right to prepare legally binding advance directives and the right to decline the preparation of such directives, and access to nationally insured healthcare including quality palliative care. The act should also refer to a healthcare professional’s right to conscientious objection to VAD [ 28 ].…”

“…This is because Japan currently lacks written legal regulations concerning the termination of medical intervention, and healthcare professionals are left with uncertainty about which actions are forbidden. A patient’s right to refuse life-sustaining treatment (including withholding and withdrawal) has not been substantially warranted, and advance directives are still not legally enforceable, even today [ 28 ]. Moreover, in East Asian medical practice, where physicians are increasingly wary of possible lawsuits, there is an increasing dependency on clearly defined legal documents [ 29 ].…”

“…Furthermore, there is no definite concept of an afterlife. Therefore, it should be noted that in many cases, doctors, families, and society still prefer to keep patients alive, regardless of their wishes or suffering [ 28 , 30 , 51 ]; this existence of this cultural tendency is precisely why we argue that we should begin to discuss the VAD in Japanese society.…”

Cross-sectional survey of surrogate decision-making in Japanese medical practice

“…They may have decided to respect preferences based on Japanese cultural values related to the sanctity of life. According to Asai et al, in Japan, there are deeply ingrained cultural and religious beliefs regarding death and the sanctity of life, and a deeply rooted belief that making the older adults suffer unnecessarily should be avoided [ 32 ]. It could be that the high frequency of ‘patient suffering’ (the basis considered most frequently for decision-making in this study) and other factors related to the best interests of the patient were due to cultural and religious values related to consideration for the older adults.…”

Grounds for surrogate decision-making in Japanese clinical practice: a qualitative survey

“…Differences in religious beliefs underlie such cultural differences, as well. The cultural and religious beliefs in Japan strongly endorse the sacredness of life and death, which promotes the notion that unnecessary suffering should be avoided [ 11 ]. Therefore, a consideration of such cultural perspectives in surrogate decision-making reveals that several aspects clearly differ between the surrogate decision-making practices followed in Japan and Western countries.…”