Why Nearly 90% of Physicians Would Refuse Life-Prolonging Treatment for Themselves: What a Survey Reveals About the Reality of End-of-Life Care

Doctors Admit the Truth Behind Aggressive End-of-Life Treatment: “Some Interventions May Offer Little Meaningful Benefit”

Tetsuya Tanimoto, MD.

Chairman of Accessible Railway Medical Services Tetsuikai Medical Corporation.

Director of Navitas Clinic Kawasaki

Record-High Death Toll Since World War II

According to population estimates released by Japan’s Ministry of Internal Affairs and Communications, the number of people aged 75 and older reached approximately 21 million by the spring of 2025, an increase of 620,000 compared with the previous year. At the same time, Japan has entered what is often described as a “mass-death society,” a stage in which the number of deaths continues to rise due to rapid population aging.

Statistics show that Japan recorded 1,605,298 deaths in 2024, an increase of 29,282 from the previous year. This was the highest number of deaths recorded since the end of World War II and exceeded the number of births by nearly one million. Although future projections vary, many experts believe that the annual number of deaths will reach its peak around 2040.

The question of how people should spend the final stage of their lives is becoming increasingly important. Decisions regarding how far life-prolonging treatments should be continued—or whether they should be withheld altogether—as well as how to respect an individual’s personal wishes, are not merely medical issues. They are deeply connected to broader social factors, including culture, law, economics, and beliefs about life and death.

This raises an important question: how do physicians themselves view their own end-of-life care?

Let us first examine findings from other countries.

A recent paper published in the Journal of Medical Ethics analyzed international surveys conducted among physicians in North America, Europe, and Australia. The researchers asked doctors what kind of medical treatment they would want if they themselves were placed in a terminal condition due to diseases such as advanced cancer or end-stage dementia.

Many Physicians Also View Euthanasia Positively

The results were remarkably consistent.

More than 90 percent of physicians stated that they would not want life-sustaining treatments such as cardiopulmonary resuscitation (CPR), mechanical ventilation, or tube feeding if they reached the final stage of life. Instead, many preferred palliative care focused on relieving suffering and maintaining comfort.

Furthermore, in countries where euthanasia or physician-assisted dying is legally permitted, physicians were more likely to view these options positively. This highlights the fact that legal frameworks and social environments can influence not only medical practice but also healthcare professionals’ perspectives on death and dying.

Across East Asia, the concept of patient autonomy—the right of individuals to make decisions about their own medical care—is also gradually gaining recognition.

In South Korea, the Supreme Court recognized a patient’s right to self-determination in 2009 through a landmark case involving the withdrawal of life-sustaining treatment from a patient in a persistent vegetative state. Following this decision, the Life-Sustaining Treatment Decision Act was implemented in 2018, allowing terminally ill patients to refuse treatments such as CPR and mechanical ventilation.

Advance directives, in which individuals record their preferences regarding future medical care, have since spread rapidly. Within only seven years, the number of registered advance directives reached approximately three million, meaning that 6.8 percent of the adult population had documented their own wishes.

Taiwan has also made significant progress in this area. In 2016, the Patient Right to Autonomy Act was enacted, making Taiwan the first country in Asia to establish a comprehensive legal framework for respecting patients’ choices regarding end-of-life care. After the law came into effect in 2019, reports indicated that tens of thousands of people had registered advance directives.

Europe has introduced even more advanced systems.

The Netherlands became the first country in the world to legalize euthanasia in 2002. By 2024, nearly 10,000 cases of euthanasia were performed, accounting for approximately 5.8 percent of all deaths in the country. Belgium has also seen an increase, with euthanasia accounting for around 3.1 percent of all deaths in 2023.

In France and Germany, advance directives have legal authority, meaning that physicians are required to respect patients documented wishes. In the United States, all 50 states recognize some form of legally valid advance directive, and approximately 30 percent of people die at home rather than in medical institutions.

However, what about Japan?

In Japan, however, the situation remains quite different.

Awareness of Advance Care Planning (ACP)—a process in which individuals discuss and record their preferences regarding future medical care before they become unable to make decisions themselves—remains remarkably low. According to a government survey conducted in 2023, only 5.9 percent of people were familiar with ACP, and this figure has remained almost unchanged in recent years.

Although approximately 69.8 percent of people support the idea of ACP, very few have actually taken action by formally documenting their wishes regarding life-prolonging treatment.

One major reason is the lack of clear legal recognition. Because advance directives and living wills do not have strong legal authority in Japan, physicians often face uncertainty about how much they can rely on a patient’s previously expressed wishes. In reality, decisions are frequently made through discussions among hospitals, healthcare professionals, and family members rather than being determined solely by the patient’s own preferences.

The same government survey also revealed a significant difference between healthcare professionals and the general public. More than 80 percent of physicians and medical workers stated that they would not want interventions such as mechanical ventilation or CPR if they reached the end of life. In contrast, fewer than 60 percent of the general population expressed the same preference.

Similar to findings from international studies, these results suggest that people with greater medical knowledge tend to be less likely to choose aggressive life-prolonging treatments at the end of life.

CPR Even When Recovery Is Unlikely

How do Japanese physicians themselves perceive this situation?

According to a 2024 survey conducted by the medical information website m3.com, 91.5 percent of private practitioners and 90.3 percent of hospital-employed physicians stated that discussions regarding end-of-life care in Japan remain insufficient.

Many hospital physicians expressed concerns about the current state of end-of-life medicine.

Some doctors commented:

“End-of-life care in Japan still appears to be overly aggressive. Treatments such as unnecessary central venous nutrition and feeding tubes are frequently provided. However, without these interventions, nearby end-of-life care facilities may refuse to accept patients, leaving physicians with little choice but to provide them.”

Others stated:

“Many patients are transported to hospitals even though their condition could have been managed through hospice care or home-based end-of-life support. In the end, all we can do is provide a peaceful death in the hospital. While it may not be possible to prevent every case, better education for patients and families could reduce unnecessary medical interventions.”

In reality, among elderly patients brought to emergency departments, there are many cases involving individuals with terminal cancer or advanced dementia who may have been better served through a natural and peaceful end-of-life process rather than emergency treatment.

The author of the original article, who has experience working in emergency medicine, describes encountering cases such as elderly patients in their nineties with dementia who lose consciousness and are transported to hospitals after cardiac arrest.

From a medical perspective, even with extensive resuscitation efforts, it is often highly unlikely that these patients will return to their previous level of functioning. However, when there is no advance directive or prior discussion regarding their wishes, healthcare providers may feel obligated to continue CPR and other interventions until family members arrive and everyone involved feels that sufficient efforts have been made.

This reflects a difficult reality within the current healthcare system: medical professionals may understand that aggressive treatment is unlikely to benefit the patient yet still feel pressured to continue because the patient’s wishes have not been clearly documented.

The Serious Issue of Overlooking Patients’ Wishes

Perhaps one of the most serious problems in Japan’s end-of-life care system is that patients’ own wishes are often overlooked.

There are cases in which patients are unable to communicate their preferences because they are bedridden or have severe cognitive impairment due to dementia. However, even when patients are still capable of expressing their own decisions, discussions about their medical condition are often conducted only with family members, without the patient being present.

This situation raises a fundamental ethical question: who should have the final authority in decisions about the end of a person’s life—the patient themselves, or those around them?

When Patients’ Wishes Are Ignored at the End of Life

Even when patients are fully capable of expressing their preferences, their wishes are not always respected if their family members disagree.

This issue is particularly common among elderly patients. Many older adults hesitate to clearly communicate their own wishes because they do not want to become a burden on their children or family members. As a result, they may eventually accept decisions based more on their family’s expectations than on their own values.

Disagreements among family members can make the situation even more complicated. In some cases, the opinion of the most outspoken relative ultimately determines the course of treatment, while the patient’s own wishes gradually disappear from the decision-making process.

The author has personally been involved in caring for elderly patients at the end of life and has experienced situations where unconscious patients continued to receive multiple injections and medical interventions every day. These experiences have led to difficult questions: “Are these treatments truly being provided for the benefit of the patient?”

Similar concerns have been reported among hospital pharmacists. Surveys conducted among pharmacists have shown that many question the necessity of certain medications given to terminally ill patients, particularly expensive drugs that have little evidence of improving medical outcomes or quality of life.

The challenges surrounding end-of-life care in Japan are not caused by a single factor. Rather, they result from a complex interaction between institutional systems and cultural attitudes.

One major issue is the structure of Japan’s healthcare reimbursement system. While advanced medical technologies, specialized procedures, and expensive medications often receive relatively high financial compensation, palliative care and home-based end-of-life support tend to receive much lower reimbursement.

This imbalance creates what can be described as a distorted economic incentive, encouraging healthcare institutions to continue aggressive life-prolonging treatments rather than focusing on comfort-oriented care.

In some cases, nursing homes and hospice facilities require medical interventions such as central venous nutrition or feeding tubes as conditions for accepting patients. As a result, hospital physicians may find themselves providing treatments they personally believe are unnecessary simply because alternative care options are limited.

For example, the benefits of feeding tubes for patients with advanced dementia remain controversial. There is no clear evidence demonstrating that feeding tubes significantly improve quality of life or extend survival in these patients. Therefore, many healthcare professionals continue to question whether such interventions are always appropriate.

Another significant challenge is the uncertainty surrounding the legal basis for withdrawing or withholding life-sustaining treatment.

Many physicians worry about potential legal consequences when deciding not to continue aggressive medical interventions. Previous cases involving criminal complaints against doctors have contributed to a sense of caution and fear among healthcare professionals.

Currently, physicians must rely on guidelines issued by the Ministry of Health, Labour and Welfare and recommendations from medical organizations. However, these guidelines do not have legally binding authority. As a result, final decisions often depend on the judgment and responsibility of individual physicians.

This places doctors in an extremely difficult position: they must balance medical ethics, the patient’s wishes, family expectations, and possible legal risks when making decisions at the most critical moments of a person’s life.

Building a Culture That Encourages Conversations About Death

In Japan, hospitals remain the most common place where people spend their final moments. Although the proportion of people who die at home has gradually increased, only 17.0 percent of deaths occurred at home in 2023, compared with 13.9 percent in 2020.

However, surveys consistently show that approximately 60 to 80 percent of Japanese people would prefer to spend the final stage of their lives in their own homes or in a familiar environment.

This significant gap between reality and personal wishes represents one of the central challenges facing Japan’s end-of-life care system.

To address these issues, the first step is to create a society where people feel comfortable discussing death.

In contemporary Japan, conversations about death are often avoided within families because the topic is considered uncomfortable or even taboo. As a result, many people are forced to make important decisions for the first time during a medical crisis, when emotions are already high and time is limited.

Introducing education about life, death, and personal values from an early stage of schooling could help change this situation. Collaboration among educational institutions, religious communities, healthcare professionals, and the media will also be essential in creating a culture where death is not something to be feared or avoided, but rather something that can be discussed openly.

At the same time, Japan should consider establishing a legal framework for end-of-life care that reflects its own cultural background while also learning from systems developed in other countries.

Reforming the healthcare reimbursement system is another important step.

As previously discussed, Japan’s current system provides relatively high financial rewards for advanced medical technologies, expensive medications, and surgical procedures. In contrast, palliative care and home-based end-of-life support often receive significantly lower compensation.

This imbalance should be corrected in order to reduce unnecessary incentives toward aggressive life-prolonging treatments. Greater investment is also needed to address regional differences in access to hospice care and home medical services, ensuring that people can receive appropriate end-of-life support regardless of where they live.

Most importantly, Japan needs to establish a decision-making system that places the patient’s own wishes at the center of medical care.

Many physicians state that if they themselves reached the end of life, they would not choose aggressive life-sustaining treatments but would instead prefer a peaceful and natural death. However, in actual clinical settings, providing patients with the same choices remains difficult because of legal uncertainty, institutional barriers, and family dynamics.

The solution begins with communication.

Families should discuss their values and preferences before a medical emergency occurs. Patients should be encouraged to express their own wishes, and healthcare professionals should support decisions that reflect each individual’s priorities and dignity.

Even today, countless patients and families throughout Japan are facing difficult decisions regarding the final stage of life. To ensure that people can make choices without regret, society must urgently develop a system that respects individual autonomy and provides comprehensive support for patients, families, and healthcare workers.

Ultimately, the goal of end-of-life care should not simply be to extend life for as long as medically possible. Instead, it should be to help each person experience the final chapter of their life with dignity, comfort, and respect for their own values.

This article was originally published in Toyo Keizai Online on September 13, 2025.