Abstract
Although the patient’s right to decide what they want for themselves, which is encompassed in the notion of ‘patient-centred medicine’ and ‘informed consent’, is widely recognised and emphasised in Japan, there remain grave problems when it comes to respecting the wishes of the no-longer-competent when death is imminent. In general, it is believed that the concepts above do not include the right to refuse treatment when treatment withdrawal inevitably results in death, even when the patient previously expressed the wish to exercise this right when competent. In this paper, I first explain the current social and legal situation in Japan, where the lack of legal clarity regarding the right to reject treatment tends to result in doctors adopting the interpretation of patients’ words that is least conducive to treatment withdrawal. I then argue that the right to refuse treatment should be taken seriously, even when the patient is no longer competent, or the treatment refusal will result in death. I suggest that the concept of relational autonomy might have some practical and valuable implications in a country where individual autonomy is considered incompatible with societal values. Finally, I answer possible objections to relational autonomy and address the widespread societal concern about sliding down the slippery slope from allowing the right to refuse treatment to the obligation to die.
Highlights
While the right to refuse treatment is widely recognised in western countries, it is still controversial whether it is legally and ethically permissible to withdraw life-sustaining treatment in Japan at the patient’s request
I suggest that the concept of relational autonomy might have some practical and valuable implications in a country where individual autonomy is considered incompatible with societal values
In Japan, the right to reject treatment is normally understood to exclude cases where treatment withdrawal will inevitably result in death, even if withdrawal in such a case would comply with an advance directive
Summary
Medical interventions are administered with the aim of enhancing our well-being. The reluctance of doctors and patients to leave a written advance directive may reflect people’s concerns about a possible change in the situation that would affect their way of thinking, something unexpected happening in the future, or the process becoming a banal, tick box exercise (Gómez-Vírseda et al 2019) Whatever reason they may have, the current landscape, where doctors are afraid of legal charges and, as a result, cannot withhold or discontinue treatment (Kondo and Mikami 2018), needs to be changed to ensure that people’s wishes are respected. In addition to legal reforms designed to respect advance directives better, I suggest that a more fundamental rethinking of autonomy with greater attention given to the concept of relationality might help to facilitate better understanding and realisation of advance directives in Japan
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