I always look forward to the annual Confederation of Medical Associations in Asia and Oceania (CMAAO) meetings in September, and this year it was hosted in Tokyo by the Japan Medical Association (JMA). Tokyo has always been special to most of us who have been there, and it is especially so because of the food. The quality of the sushi and sashimi, the delicacy of tempura, the elaborate courses of kaiseki, and the delicious sake and local beers have enthralled all of us with gastronomic delight.
Our meeting was held in Odaiba; to the uninitiated, that is the new part of the city bordering the Tokyo Bay. The hotel held a beautiful view of the bay with its Golden Gate Bridge lookalike – the Rainbow Bridge. The national medical associations (NMAs) present at the meeting included 20 member associations and an invited guest from the Israeli Medical Association. It is amazing how the 21 countries in attendance represented some 3.8 billion people.
The guest of honour was the first female governor of Tokyo, Yuriko Koike. She delivered her speech in perfect English and, in line with the topic of the meeting on end-of-life issues, spoke rather intimately about care giving and looking after her 88-year-old mother before she perished last year from dementia.
Updates from each NMA
The meeting commenced with the usual presentation of country reports where we learnt about problems relating to the respective NMA's populations, health systems, governments, disasters and epidemics.
Australia talked about getting its federal governments to reinstate the inflation-linked payments to its GPs, where a freeze on payments with regard to inflation has been in effect for the last few years. Bangladesh and India reiterated their problems with violence against doctors and healthcare workers. Japan continues to struggle with its super-ageing population, and Korea talked about the Fourth Industrial Revolution and on how artificial intelligence like IBM's Watson is impacting medical practice. Myanmar made us smile when we learnt that they launched a support group for elderly doctors above the age of 70. Nepal talked about the recent calamitous events of earthquakes, floods and landslides. Taiwan gave us insights into their concerns on medical indemnity insurance and Thailand reported its success on tobacco control. Pakistan, a founding member of CMAAO but had not been attending for many years, attended this meeting seeking to re-join the organisation and was warmly welcomed by all.
We had our symposium, "End-of-Life Questions", on the second day. The background to the selection of the topic had its origins in the active euthanasia (AE) and physician assisted suicides (PAS) occurring in North America and certain parts of Europe. In Switzerland, PAS is legal, while both AE and PAS are legal in Belgium, Luxembourg and Holland. In the US, certain states allow AE and PAS, and Canada has recently passed legislation to allow PAS.
The World Medical Association's (WMA) stand on both AE and PAS is that they have no place in medicine. However, with such legislations being passed in North America and Europe, there is pressure building up on the organisation to take a second look at its stand. Hence the WMA council has asked the various regions such as Asia/Oceania, Africa and South America to compile the stands of the regional medical associations on end-of-life issues.
Time to review our stand
The JMA had circulated questionnaires to the individual member NMAs of CMAAO regarding their nations' stands on matters pertaining to AE, PAS, advance medical directives (AMDs), withholding or withdrawing life-sustaining treatments, palliative care and end-of-life care for the super-aged. We heard the various NMAs present their individual country's stand on the various questions.
All nations had no legislations on AE and PAS, though Australia and New Zealand had several parliamentary bills that were defeated in the past. Several countries have AMDs and doctors do talk to their patients about "do not resuscitate" scenarios and on appointing a legal representative with regard to such scenarios.
In half the countries represented, there are legislations or court decisions that support withholding or withdrawing life-sustaining care. Most medical associations support the withdrawal of life-sustaining care in futile situations and such decisions must be made on clinical grounds.
In the questions regarding palliative care, most countries do have some form of palliative care for the terminally ill, ranging from rudimentary to very comprehensive programmes. All countries agree that religion plays an important role in these programmes. There was also a question on the use of opioids in palliative care that was to assess if there are restrictions on use of opioids that hinder its use in palliative medicine. Countries were also asked if palliation was available to patients other than the terminally ill and the majority highlighted that it was available to patients with seriou illnesses and/or those in distress.
In the final question, Japan highlighted its problem with the "super-aged" patients who have lost their mental capacity to make decisions, have no advance care planning or legal representatives, coupled with the absence of advanced directives in Japan. The Japanese are looking at some form of guardianship legislation to solvf the problem while most countries have addressed the problem with advance directives and advance care planning.
In the final analysis, the consensus was that countries in Asia and Oceania, with the exception of Australia and New Zealand, have no significant desire to move in the direction of AE and PAS. Most countries in this part of the world have support from their religion, family, extended family or clan, and palliative care plans, and therefore have no great desire for AE and PAS. I daresay that when there is great clamour for AE and PAS, it is actually a problem of societal breakdown of family structures and the medical fraternity is trying to solve a difficult problem that society itself cannot do so.