The 85th HGPI Seminar featured a lecture from Dr. Seiji Bito. While serving on the front lines of the clinical field at Tokyo Medical Center, where he provides medical examinations, Dr. Bito is actively engaged with the themes of decision making in healthcare and communication between medical staff, people receiving healthcare, and others most affected through various publications and presentations. Together with everyone in the audience, we took this opportunity to deepen our understanding of decision-making in healthcare.

<Key Points of the Lecture>

• There are difficult ethical problems that must be considered within healthcare decision-making.
• Informed Consent (IC) is a process that occurs when a patient provides or denies consent based on information provided by a healthcare provider. This is a process performed independently by the patient.
• An important process called Shared Decision Making (SDM) takes place when consensus on the best possible option for the person receiving healthcare is obtained through repeated acts of bilateral communication between the person receiving healthcare and the person providing it. In this process, the role of patients and other parties most affected is not to passively listen to explanations. They must act as experts on their personal health, values, or preferences and must provide explanations on those topics in that role.
• Like when collecting objective data, overcoming the conflicts that arise during the changes that occur in the mind over the course of interacting with oneself or with others is a necessary process for making decisions that one will not regret.
• In the era of Artificial Intelligence (AI), more information can be collected and analyzed than ever before. This will eventually effect the decision-making for people receiving healthcare and other parties most affected. Particularly after the novel coronavirus (COVID-19) pandemic, many people have become uncertain as to which sources of information can be trusted. Moving forward, enabling patients to achieve a sense of satisfaction with decisions they have made based on their own values or by completing decision-making processes that take their desired lifestyles into account will grow more important.

■The Characteristics of Healthcare Decision-Making
In healthcare decision-making, we must consider ethical problems related to life and medicine. The Principles of Biomedical Ethics recognize the following four basic principles for solving ethical problems in healthcare.

• Beneficence
• Non-maleficence
• Respect for autonomy
• Justice

The principals of beneficence and non-maleficence mean to act in the best interest without being a cause of harm to the person receiving healthcare or related parties. Respecting autonomy means to provide care in accordance with the wishes of the person receiving it or related parties, while the principle of justice calls for the fair distribution of limited resources. However, in real-world clinical settings, physicians encounter many situations in which no option satisfies all four of these principles, and many healthcare professionals find the decision-making process to be difficult.

■Informed Consent and Shared Decision Making as part of the Decision-making Process
Successfully achieving IC requires four criteria to be met. First, a competent person with the capacity to give consent (whether it is the patient or their representative) must be present in an unrestrained environment. Second, they must listen to an explanation from an expert. Third, they must comprehend the explanation and consider their options. Finally, they must express their agreement or disagreement.

Healthcare professionals tend to focus on the second step in the aforementioned process, and many believe that providing explanations in their role as experts is the same as completing the IC process. However, IC is not a process the healthcare provider completes, it is a process in which the patient or person most affected consents or does not consent based on the information they have been provided by healthcare professionals. It is meant to be a process that the patient completes independently.

Completing this process is extremely difficult. There are cases in which the concerns of healthcare providers towards their patients drives them to paternalism, in which physicians recommend treatments without providing sufficient explanations. There are also cases in which physicians explain the objective qualities of a treatment method, but their explanation only serves to make the patient feel like they have been pushed away. There are even cases in which treatments are completed without the patient ever obtaining a sufficient understanding towards or acceptance of their physician’s explanation. The healthcare decision-making process requires a two-way conversation between both healthcare providers and beneficiaries and is  an important and necessary step for achieving mutual understanding towards differences in awareness and values between both parties. If these two parties do not oppose each other, I believe they can create a relationship of mutual support.

The concept of SDM has also come to be emphasized in recent years. SDM does not refer to a normal exchange in which a healthcare professional provides a technical explanation to a patient, then the patient understands the explanation and makes a decision. Rather, it is when the patient acts as an expert on their own values, preferences, or life situation as part of the decision-making process. Then, over the course of repeated mutual exchanges, both parties reach a consensus on the best possible choice for the patient. Rather than being based on medical science, this process emphasizes patients’ individual values and preferences –  namely, what the patient themselves wishes to emphasize or what they are seeking to acquire from healthcare. It means asking the patient, “What do you want to avoid?” The answer to that question is crucial. This is something that I would like for everyone to clearly communicate to their healthcare providers. Meanwhile, I believe it is the duty of healthcare providers to ask their patients this question and listen carefully to their answers.

■Clinical Decision-Making in the Era of AI and in a Post-COVID-19 World
Due to the effects of the novel coronavirus (COVID-19) pandemic, the institution I currently belong to is still providing medical consultations remotely. My impression after engaging with telemedicine is that patients tend to ask more questions or share their opinions more openly when communicating remotely compared to in-person examinations.
The examination room and hospital ward cast a spell that controls people. People who are under the spell tend to prioritize the values of a health or life authority over their own life perspective or values and are mesmerized into becoming patients. However, telemedicine casts no such spell over people. In the future, I believe the spread of telemedicine can transform the patient-physician relationship.

With its ability to quantify current risks and predict future trouble, healthcare can be a highly convincing force. For example, a physician might tell a patient, “If you do not get your current blood sugar levels under control, you might have a stroke and lose your sight or the ability to control your lower body.” Hearing that, many people would decide they have no choice but to prioritize behaviors that are based on medical science over their own values and opinions. Future advances in AI will make it possible to gather even more information and conduct even deeper analyses, and that information will begin to have a greater influence on patients’ decisions than medical specialists.

However, for someone to make a decision that is right for them, the most important thing is not necessarily limited to having a foundation of trust. Just like with objective data, I believe the personal growth that takes place leading up to a decision when one resolves mental conflicts or interacts with oneself and others is crucial for making decisions that one will not regret later. I refer to two concepts, which we can call “deciding” and “arriving at a decision.” What I want to emphasize is not the act of weighing the ratio of gains to losses to measure the efficiency for various options to independently make a decision, but to arrive at a decision after going through the process of conflict leading up to a decision by weighing the aforementioned elements. I believe this might be the ideal way to reach decisions that will not be regretted. It is because many people are at a loss concerning what information to trust or what actions to take, particularly in the face of the approaching era of AI and the effects of the COVID-19 pandemic, that I believe decision-making processes that allow us to arrive at decisions are so important.

■ Profile
Dr. Seiji Bito
Born in Aichi Prefecture in 1965. After graduating from Gifu University in 1990, he worked at the National Nagasaki Central Hospital, the National Tokyo Second Hospital, the National Sado Sanatorium, and the UCLA School of Public Health before assuming his current position. Aside from engaging in clinical practices as a general physician to help members of his community with general health problems, he is also active in resident education and serves on a medical ethics support team. His fields of research include clinical ethics, decision support, the relationships between people receiving healthcare and medical staff, and communication in healthcare. Behind the scenes, he serves as the vocalist for rock band Haloperidolls. He can be found at bitoseiji on Facebook and Twitter, or on his website “The Body and Mind that Do Not Function Well” at http://umaraka.net.

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