Background:

Government regulation of medical practice influences not only specific physician behaviors, but also alters the culture of medical care and the dynamics of physician-patient relationships. With the internationalization of discourses regarding medical ethics in the developed world, political discourses in varying cultural contexts have assumed that government intervention is warranted to promote greater physician adherence to ethical models focused on patient rights and autonomy. Comparative data regarding physicians' medical ethical approaches, and what would be expected of them by non-physicians, in varying cultural contexts may help researchers gain a better understanding of this assumption and its validity.

Purpose:

To develop a cross-cultural instrument for evaluating and comparing conceptions of patient rights and autonomy in physicians (PH) and non-physicians (NP) with quantitative and qualitative techniques, and to evaluate the appropriateness and utility of this instrument with a pilot-test examining the hypothesis that physicians in Japan and the United States adhere to an ethical model more focused on patient rights and autonomy than socioeconomically similar non-physicians.

Methods:

A literature review guided development of a bilingual draft survey instrument regarding medical ethical controversies related to patient rights and autonomy. Respondents were asked regarding their agreement with propositions about medical ethical scenarios, and free-form text responses were requested. The draft instrument was reviewed by a convenience sample of Japanese (JA) and US physicians and non-physicians. Feedback guided development of a bilingual internet-based pilot instrument, prepared according to a translation/back translation methodology. Participation in the pilot survey was requested by postal mail of PHs and high socioeconomic status NPs in New York and Tokyo.

Results:

Requests for participation were presumed delivered to 700 PHs and 691 NPs in New York, and 453 PHs and 483 NPs in Tokyo. Online responses were initiated 672 times by US, and 559 times by JA, recipients, excluding duplicate computer environments, for a response initiation rate of up to 48% for US and 60% for JA respondents. Full responses were provided by 25 US PHs, 41 US NPs, 39 JA PHs, and 57 JA NPs (response rates 3.6%, 5.9%, 8.6%, 11.8%). Incomplete responses were discarded.

Open coding of text responses for conflict resolution strategies revealed that references to the law were significantly more common among physicians than non-physicians. Non-physicians cited beneficence as a value which may over-ride patient rights and autonomy more frequently than physicians, and a tendency for non-physicians to cite social good as such as value approached significance (p=0.06).

PHs opposed notification of the partner of an HIV+ patient of the patient's HIV status against the patient's wishes, while a plurality of NPs favored this. All PHs were more likely than NPs to believe a patient should be told of a cancer diagnosis prior to family. All groups favored a patient's right of full medical record access, even if the physician wished to withhold portions due to suspected malingering, though a plurality of JA NPs (42%) agreed with sending records sent to a third party physician for discussion with the patient, rather than providing them immediately, a significant finding compared with JA PHs (13% agreement). PHs also opposed abbreviated informed consent processes in emergency situations to a greater extent than NPs.

Additional findings were that, while 66% of JA PHs did not oppose placing a patient on life support against their stated wishes on request of family, 69% opposed this if there was a written advance directive. Support among US PHs for following patients' end of life wishes also strengthened with advance directives. Compared with US respondents, JA respondents more often cited the roles/interests of family members or of physicians as sometimes able to take precedence over patient rights/autonomy, and JA respondents more often sought to build consensus or find exceptions to rules as conflict resolution strategies. JA respondents favored, and US respondents opposed, parental notification of a pregnant teenager against the minor's wishes. JA NPs were evenly divided regarding whether clinical trials could employ abbreviated informed consent when obtaining traditional informed consent is difficult. US respondents resisted this idea.

Conclusions:

Among the studied groups, physicians applied a greater emphasis than non-physicians on patient rights and autonomy, relative to competing principles, though a low response rate limits generalizability of the results. Consistency of quantitative results with existing prior research and coherency of qualitative results with the quantitative data support the appropriateness and utility of the instrument in the evaluation of cross-cultural differences in perceptions of medical ethical issues. A revised survey instrument and methodological improvements for future applications are proposed.

This research sought to develop a cross-cultural instrument for evaluating and comparing medical ethical ideas in physicians and non-physicians in Japan and the United States with quantitative and qualitative techniques, and to evaluate the appropriateness and utility of this instrument with a pilot study examining the hypothesis that physicians in Japan and the United States adhere to an ethical model more focused on patient rights and autonomy than socioeconomically similar non-physicians. The following results were achieved.

1.A novel vignette-based instrument for evaluating medical ethical ideas among physicians and non-physicians in Japan and the United States was developed in three stages, using both quantitative (Likert-scale questions) and qualitative (free-form text response) techniques. In a draft stage, a novel instrument was generated based on results of prior research, and was submitted to groups of Japanese and American physicians and non-physicians for review and commentary. In a pilot survey stage, a revised version of the instrument was employed in a study involving physician and non-physician respondents in Tokyo and New York. Finally, the results achieved in the first two stages guided development of a final proposed cross-cultural survey instrument.

2.Methods of qualitative data analysis involving open coding to identify conflict resolution strategies employed by respondents in controversial medical ethical situations, as well as to identify values or principles which may take precedence for respondents over a strict patient rights and autonomy-based ethical model, were developed and pilot-tested.

3.The pilot study of physicians and high socioeconomic status non-physicians in Tokyo and New York was used to evaluate the utility and appropriateness of the instrument in assessing the hypothesis that physicians in Japan and the United States, compared to non-physicians, subscribe to an ethical model that more strictly respects patient rights and autonomy than non-physicians. An importance of this hypothesis to the topic of government regulation of medical ethics in the United States was proposed based on a review of prior literature and on a historical review of American governance.

4.A coherent pattern of quantiative and qualitative data in the pilot survey results regarding the research hypothesis supported the utility and applicability of the survey instrument for the evaluation of the research hypothesis. Additionally, response patterns in the pilot survey regarding issues that have previously been well investigated were generally consistent with the results of prior research, supporting the ability of the instrument to capture relevant medical ethical ideas in the examined populations.

Accordingly, this research developed a novel instrument using both quantitative and qualitative methods for the evaluation of medical ethical ideas among physicians and high socioeconomic status non-physicians in Japan and the United States, gathered evidence regarding the ability of the instrument to capture relevant phenomena among the studied populations, and evidence regarding the utility and applicability of the instrument in the evaluation of the hypothesis that physicians in Japan and the United States, compared to non-physicians, subscribe to a medical ethical model that more strongly respects patient rights and autonomy. This research was the first to develop and apply an instrument using qualitative as well as quantitative methods to the cross-cultural evaluation of controversial medical ethical ideas among Japanese and American physicians and non-physicians, and the first cross-cultural research regarding Japanese and American physicians and non-physicians that utilized a general population sample, rather than a patient sample, in the non-physician group. This work also adopted a novel theoretical perspective that asserts that government regulation of medical ethics fundamentally influences the culture of medical practice, and that evaluation of such regulatory efforts must therefore assess both what the relevant current ethos of medical practice actually is, and compare this with what would be expected of physicians from the populations they serve, to determine whether regulatory efforts are appropriate and desirable. Accordingly, this work has made a significant contribution to cross-cultural medical ethics that is worthy of the granting of a degree.