This survey reveals the latest status of CEC, an ethics support in clinical practice in Japan. It found that in 2004, about 25% of hospitals designated for clinical training had CECs. In 2016, 71.6% had this system. Furthermore, CEC was a function of existing ethics committees and newly established clinical ethics committees. Until 2013, 1–3 hospitals had CECs per year. Since then, the number of hospitals with CECs has increased to eight in 2014 and 14 in 2015. The presence of CEC was not significantly different between hospitals with more than 400 beds and those with fewer, indicating that hospitals had this mechanism regardless of their size. However, the largest number of requests for CEC was 1–10 per year, with some respondents reporting no requests. This finding indicates that although CEC has been established in Japan, it is not yet fully functional. This section discusses our results in relation to the background that has influenced CEC development.

An external factor may have led hospitals designated for clinical training to develop CEC systems, that is, the accreditation of hospital functionality evaluation. The Japan Council for Quality Health Care (JCQH) started evaluating hospital functions in 1996 to assess medical care’s quality and safety. Since then, JCQH has revised the evaluation items every 5 years. Each time, the items related to clinical ethics have been revised to evaluate the actual performance of the hospital, from the establishment of a clinical ethics system to how it manages ethical issues and the hospital’s understanding of them. The present study’s results indicate that the number of teaching hospitals that established CEC services increased in 2007 and 2015 in response to these revisions. The external evaluation of hospitals may motivate the establishment and organization of new systems, such as CEC. However, this survey reports numbers of consultations ranging from 1–10. Some hospitals have had no consultations since their inception. Therefore, although the mechanisms have been established, they may not function properly. As the results of the analysis indicate, the reasons for the lack of functionality include issues related to the operation of the CEC system, such as “difficulty in coordinating CEC time,” “problems related to cases handled by the CEC system,” and “immaturity of the CEC system” in which the person in charge is not identified. These issues were identified in the operation of the CEC system. In addition, issues arise on the consulting side, such as “misunderstanding of the function of CEC on the part of medical professionals.”

One solution to the problems associated with CEC operation, such as the need to ensure coordination of dates and times, the speed of response, and the immaturity of the consultation system, is to appoint a full-time person to supervise and centralize the contact points. However, even in the USA, a leading CEC country, few professionals have formal CEC education. Furthermore, difficulties have been reported in assigning a full-time person to this task due to operational obstacles. CEC is reported to be conducted by teams with various educational backgrounds (Fox et al. 2007). In Japan, where CEC has just started, assigning full-time ethics consultants is challenging, although training of ethics support personnel has begun. In such a situation, CEC might be operated in Japan within a banking system that pools roughly 20 people who can provide consultation and respond to problems as they arise. However, educating supervisors on the CEC knowledge and skills required is necessary. Brief educational programs are available for the education of ethics consultants in Japan. In addition, graduate education programs have begun to provide the knowledge necessary for CEC. However, compared to the USA, education and certification in Japan are still in their infancy. Currently, a need exists to build the knowledge and skills required for those who practice CEC to resolve ethical issues in clinical practice in Japan. At this point in time, when the certification of ethics consultants is still in its early stages, one alternative solution is peer education, in which those who work together collaborate and build on each other’s knowledge and skills. In Japan, the Hospital and Clinical Ethics Committee Collaboration Conference was launched in 2019. Efforts to share clinical ethics support activities among hospitals with specific functions began voluntarily (Takeshita et al. 2022). In addition, the Clinical Ethics Consortium was launched to create a forum for those responsible for CEC in clinical settings to collaborate, exchange information, and discuss issues. The accumulation of opinions and discussions on CEC activities at each facility in the future will help improve professional knowledge and skills.

Furthermore, “misunderstanding of the function of CEC” was identified as a problem for those who requested a CEC. The first problem, “seeking the hospital’s judgment and throwing the decision to the hospital,” may be a mismatch between the expectations of the consulting healthcare professionals for CEC and ethics consulting practitioner functions. Value conflicts that arise in clinical practice require adjustments and compromises that are acceptable to both parties. However, some healthcare professionals are frequently exhausted from conflicts with patients and their families. They would prefer that the CEC decide. Especially in Japan, the discontinuation of life support equipment is detached from any legal basis for the patient’s advance directive, in contrast with Europe and the USA. In some cases, the risk of criminal prosecution is considered to be a psychological defense, promoting feelings of exhaustion and emotion. A change in mindset is needed to address these problems. Discussing the issue from a domestic legal and ethical perspective may also protect healthcare professionals. Furthermore, opportunities to introduce support and education about ethical considerations are needed.

The other problem is that of ‘confusion of functions and roles’ with other hospital organizations. The problem may stem from steps taken by hospitals to increase the number of CEC requests, as inferred from their scarce number. Hospitals consult with frontline healthcare providers about managing medical care challenges and difficult cases. Moreover, they also consult with patients about difficult cases when responding to their complaints. Of course, patient complaints may also include ethical issues requiring assistance, such as that offered by CEC. However, given the current state of CEC in Japan, providing a wide range of consultation services, including various types of consultation, is required to make the CEC system function. However, some people may be uncertain about what they need, so they may decide to seek advice in any case, which may lead to problems in making distinctions.

In addition to the challenges of CEC, the survey also revealed the constructive impact of this service. In particular, our findings indicate that they “feel safe and secure by having gone through an organized procedure” and that it “provided a mechanism for hospitals to support policies and responses based on legal, ethical considerations.” Requests for CEC are often accompanied by a value conflict between the healthcare professional and the patient/family, resulting in emotional communication, an inability to dialog, and a relationship in which trust is undermined. Therefore, the presence of an ethics consultant as an objective party to the case and the parties involved is intended to neutralize the situation (Stephens et al. 2019). In addition, a positive impact was extracted from the fact that “the ethics support system improves staff awareness and control of medical care in the hospital.” Consulting a CEC can lead to reassurance in resolving conflicts over medical care with patients and their families and confidence in basing the medical care options being contemplated on ethical considerations. Moreover, it is beneficial for managing medical care within the hospital and helping to ensure its appropriateness and fairness (Fox et al. 2022; Hauschildt and De Vries 2020).