A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth-telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision-making and mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient-provider relationships, the public's trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception.

As of 2009, the number of donors in Japan is the lowest among developed countries. On July 13, 2009, Japan's Organ Transplant Law was revised for the first time in 12 years. The revised and old laws differ greatly on four primary points: the definition of death, age requirements for donors, requirements for brain-death determination and organ extraction, and the appropriateness of priority transplants for relatives. In the four months of deliberations in the National Diet before the new law was established, various arguments regarding brain death and organ transplantation were offered. An amazing variety of opinions continue to be offered, even after more than 40 years have elapsed since the first heart organ transplant in Japan. Some are of the opinion that with the passage of the revised law, Japan will finally become capable of performing transplants according to global standards. Contrarily, there are assertions that organ transplants from brain-dead donors are unacceptable because they result in organs being taken from living human beings. Considering the current conditions, we will organize and introduce the arguments for and against organ transplants from brain-dead donors in contemporary Japan. Subsequently, we will discuss the primary arguments against organ transplants from brain-dead donors from the perspective of contemporary Japanese views on life and death. After introducing the recent view that brain death should not be regarded as equivalent to the death of a human being, we would like to probe the deeply-rooted views on life and death upon which it is based.

In the issue of futile treatments, patients and healthcare professionals tend to disagree. We conducted an Internet questionnaire survey and explored the Japanese nurses' attitude toward this topic, comparing with that of laypeople. In total, 522 nurses and 1134 laypeople completed the questionnaire. Nurse respondents were significantly less in favor of providing potentially futile treatments in hypothetical vignettes and stressed quality of life of the patient for judging the futility of a certain treatment. Of them, 85.4% reported having experienced providing such treatments. Reasons for providing them included factors related to not only patients but also healthcare teams. Our results indicate that attitudes among Japanese nurses toward the issue of futile treatments are different from patients and that their actual practice is influenced by several situational factors.

Back groundEmpirical surveys about medical futility are scarce relative to its theoretical assumptions. We aimed to evaluate the difference of attitudes between laypeople and physicians towards the issue.MethodsA questionnaire survey was designed. Japanese laypeople (via Internet) and physicians with various specialties (via paper-and-pencil questionnaire) were asked about whether they would provide potentially futile treatments for end-of-life patients in vignettes, important factors for judging a certain treatment futile, and threshold of quantitative futility which reflects the numerical probability that an act will produce the desired physiological effect. Also, the physicians were asked about their practical frequency and important reasons for futile treatments.Results1134 laypeople and 401 (80%) physicians responded. In all vignettes, the laypeople were more affirmative in providing treatments in question significantly. As the factors for judging futility, medical information and quality of life (QOL) of the patient were rather stressed by the physicians. Treatment wish of the family of the patient and psychological impact on patient side due to the treatment were rather stressed by laypeople. There were wide variations in the threshold of judging quantitative futility in both groups. 88.3% of the physicians had practical experience of providing futile treatment. Important reasons for it were communication problem with patient side and lack of systems regarding futility or foregoing such treatment.ConclusionLaypeople are more supportive of providing potentially futile treatments than physicians. The difference is explained by the importance of medical information, the patient family’s influence to decision-making and QOL of the patient. The threshold of qualitative futility is suggested to be arbitrary.

BackgroundMedical care is obviously an important public service to ensure the health of a nation; however, medical resources are not always used appropriately. ‘Convenience-store consultations’ and inappropriate ambulance transportation represent instances of such improper use by contemporary Japanese citizens in recent years. This article illustrates two examples of misuse and discusses potential countermeasures by considering factors contributing to these behaviours.Main bodyFrom both public and medical perspectives, these patient behaviours are problematic, causing potential harm to others, negative consequences to such patients themselves, exhaustion of healthcare staff, and breakdown of emergency medical services. Although citizens need to recognize the public nature and scarcity of medical care, the more immediate need may be to identify and to remove personal and social causes inducing such misuse. In addition, healthcare professionals should become more trustworthy. To combat these issues, one-sided penalties such as accusations or sanctions for patients who misuse the system cannot be justified in principle. If measures taken to prevent misuse are ineffective, imposing surcharges or restricting consultations may be considered official policy, but these are not acceptable for several reasons.ConclusionFor now, we conclude that we must rely on the spontaneous motivation of patients who engage in ‘convenience-store consultations’ and ambulance transportation instead of taking a taxi.