That which is afoot everywhere in the Capital

The rakusho, or graffiti, of Nijo Kawara, which begins with the congeries, “That which is afoot everywhere in the Capital–nightly raids, robbery, conspiracy, mistresses, urgent tidings, and much ado about nothing,” is said to have been left on a wall near the banks of the Kamogawa River in 1335 during the Kenmu Restoration. The graffiti consists of eighty-eight verses sardonically commenting on the social upheaval of the period by listing the vices which were rampant in the times as ‘hayarimono’ or ‘things in fashion’ and ends with the wry observation, “Oh happy the day that has seen our empire united! Strange and wonderful are the things which this age has spawned; yet have I given but a tenth of all that be if the rumors of the folk of Kyoto are true.” We are left wondering what sort of person felt compelled to inscribe this mordant observation on the times. The trenchant wit, the exquisitely sardonic turns of phrase, and the wide-ranging satire with which the author of these lines captures scenes from the lives of lowly, common folk, happenings on the streets, and the business of the government offices suggest that he was no ordinary citizen of Kyoto. The pointed reference to the ‘unification of empire’ indicates that the author had survived the collapse of the Muromachi Shogunate and had lived for some years as an ordinary resident of Kyoto but was also privy to the goings-on in houses of the samurai aristocrats. When I look around me today as our author did during his age, I see indiscriminate murder, cunning fraud, deception, forgery, perjury, cover-ups, convenient forgetfulness, power harassment, sexual harassment, voluntary resignations…the list goes on. Should the rumored cabinet restructuring happen anytime soon, we would doubtless see in the scandals and outrages of our times an uncanny resemblance to the tumult of those ancient days.
Enough for the introduction; today, I’d like to focus on a special subset of ‘That which is afoot everywhere’ in our own Capital today, namely, ‘bullying, abuse, independent committees, research, hospitals, and ethics committees.’ To anyone watching the nightly news, it might seem as though not a day goes by when we do not hear about children driven to suicide by bullying or dying at the hands of abusive parents. When the principal and the superintendent of education are deservedly pilloried by the media for overlooking or condoning the violence that led to these children’s death, they invariably invoke, as in one voice, some independent investigative committee or other to which the investigation of the case has allegedly been entrusted.
On the other hand, if you serve as the director of a large institution like Matsuzawa Hospital and the chair a number of academic societies, you will note that not a day goes by when you do not hear the words, ‘ethics committee’ mentioned in one context or another. When an issue arises in the medical world, an independent investigative committee is sure to be established to investigate the matter, and the question then of whether prior approval of the ethics committee had been obtained becomes a matter of heated debate. When, for example, the Mainichi Daily took up the news about a patient who had died after asking to be put off dialysis, the newspaper triumphantly declared that the physician’s decision had not been approved by an ethics committee. And so we come to the topic of this column, the evils of independent investigative committees and ethics committees.
I do not know when independent investigative committees started coming into vogue. No doubt their rise in popularity coincides with the “2010 Independent Committee Guidelines for Corporate Scandals” of the Japan Federation of Bar Associations. The medical world as well has been quick to respond to problems with independent investigative committees to investigate medical problems, as we saw in 2014, when it became publicly known that several patients at Gunma University Hospital and Chiba Cancer Center died after laparoscopic surgery. Yet no one has openly questioned whether such interventions by independent investigative committees are an appropriate solution to these problems. I cannot help feeling that independent investigative committees have only been used to stifle discussion and deflect the criticism of the media.
Setting aside for the moment the farcical scene of an independent investigative committee established and peopled by the officials of the Ministry of Health, Labour and Welfare to investigate its own unscrupulous handling of statistical data, we may very well ask what manner of organization it is which foists the duty of uncovering the truth onto an independent investigative committee? Does such an organization not shirk its duty of enforcing accountability within its own ranks and abandon wholesale its powers of regeneration by doing so? Medical university hospitals are difficult to govern because the professors of each department enjoy a high degree of autonomy; hence the difficulty of addressing problems that arise in one department by the intervention of a research committee organized by an executive department below the hospital director or by a professor from another department. Yet university hospitals that do not permit each department this high degree of autonomy are bound to lose their dynamism owing to the restrictive powers of the executive department.
You can imagine how uncomfortable it must be for colleagues to interrogate one another. However, investigating scandals, forming judgments, and preventing the recurrence of problems that affect the life or well-being of patients depends on physicians’ seeing past the discomfort occasioned by such investigations and institutional limitations to make enquiries and judgments of their own accord and exercise self-discipline for the sake of their patients. Delegating these responsibilities to an independent investigative committee only results in a cumbersome ‘due process’ which may help prevent malicious, illegal activities but can equally hinder quality medical practice and research. Medical care is always a matter between the doctor and the patient, between one person and another no matter where you are. Unnecessary procedures that shackle the activities of researchers are clearly a hindrance to their work.
A hospital’s ethical committee’s job is to judge whether proposed research is ethically permissible and to help make difficult medical decisions. It is not meant to be established after some scandal has erupted to adjudicate in the matter, as in the case of an independent investigative committee, but to make the correct decision before the problem occurs. However, I cannot avoid suspecting that the same disingenuousness of intent lurks behind the ethical committee as behind the independent investigative committee formed to adjudicate in a problem after the fact. Together with Dr. Yoshie Ito of Matsuzawa Hospital, I am a regular contributor to the column, “Moral Challenge” in the Geriatric Psychiatric Journal, in which we discuss the process of resolving morally difficult problems encountered in daily clinical practice with young doctors, nurses, and SW. A younger physician who read one of our contributions commented, “In other hospitals, these subtle problems are left to the ethics committee so that doctors needn’t worry about them.” The column gave me the opportunity to think long and hard about such matters, and I have come to the conclusion that it is vital for both the physician and the patient to confront the risks to the patient’s well-being and health head-on and together through a process of trial and error in order to aid the patient’s own ability to make decisions regarding treatment. Even if the ethics committee decides after examining the relevant evidence that a given treatment is the correct one, absent the process of trial and error by the physician and the patient, the treatment becomes nothing more than an imposition which leaves the patient neither satisfied nor the physician any wiser or knowledgeable. When a similar problem surfaces again, all independent thought is arrested, recourse is had to the judgment of the ethics committee, and whatever decision it hands down is blindly followed. While the physician has to do nothing more than repeat this process whenever necessary, the patient may suffer irreversible consequences as a result of any such determination made on his or her behalf by the ethics committee.
Every passing scandal has left the ethics committee’s power over research planning more robust. It is now very difficult to conduct research enrolling patients. It is difficult to consult the ethics committee, let alone pass its requirements, if you happen to be working as a private practitioner or at a small, local hospital. The process of obtaining approval can be very confusing and fatiguing indeed for anyone unfamiliar with it. On the other hand, once obtained, the approval of the ethics committee serves like a magic charm to smooth the way for research no matter what troubles may arise. While this may be advantageous when such approval relieves one entirely of accountability, and medical care and research can be done by robots and computers with no need for thinking or judgment, my wish is rather to nurture physicians and researchers who can think on their own, have the capacity to endure and learn from the vicissitudes of their work, and develop empathy for their patients.
The anniversary of the end of the Second World War is approaching, and though 70 years have passed, I still feel something catch in my throat when I think of the victims. The aggressor may very well tell the victim to put up with the facts; but even if we are told that the firebombing of Tokyo and the dropping of the atom bomb prevented further deaths and paved the way for a democratic government, we may still feel unconvinced. Why is it that we cannot, as a nation, express our desire for world peace without appealing in the same breath for sympathy and understanding as the only nation to have suffered a nuclear attack? This may sound a little far-fetched, but I think this is due to the same mindset that allows us to foist all responsibility onto the independent investigative committee and thereby relieve ourselves of any need to think. We delegated all judgment concerning our responsibility in the war to the outcome of the Tokyo Trial, quelled all the conflicting emotions in our breasts with its singular judgment, and muddled our own role in the conflict through an official, collective apology, all the while protecting the ruling elite who were the very instigators of the conflict until we achieved the postwar miracle of reconstruction under the wartime rallying cry of ‘Onwards, you hundred million souls!’
In its preamble, the Constitution of Japan states: “We, the Japanese people, desire peace for all time and are deeply conscious of the high ideals controlling human relationship, and we have determined to preserve our security and existence, trusting in the justice and faith of the peace-loving peoples of the world. We desire to occupy an honored place in an international society striving for the preservation of peace, and the banishment of tyranny and slavery, oppression and intolerance for all time from the earth. We recognize that all peoples of the world have the right to live in peace, free from fear and want.”
Now that we have achieved prosperity, we must restore our capacity to think with our own heads and to act according to our own conscience. Those who applaud the ‘first citizens’ of our nation would do well to think carefully what a society in which everyone strives to be ‘me first’ would look like.