Vanessa Hayashi

KHC PH101
Prof. George Annas
Dec. 8, 2014
To what extent can nursing homes be improved by incorporating benefits
from American and Japanese ones and be approved by both cultures?
Although there are nursing homes around the world, most elderly
people agree that they would prefer not to go to a nursing home, which
indicates that there are several problems concerning the institutions
quality of care. Though its effectiveness is not proven, these problems
may be improved by incorporating elements from varying countries
nursing homes. However, since each nursing home is governed by the
culture of the country they are located in, it may be challenging to
combine components from different cultural groups to achieve a form that
is acceptable for everybody. This essay aims to determine whether it is
possible to make a better model of nursing homes from beneficial aspects
of both Japanese and American nursing homes. Since these two cultural
groups are very different, as Japanese culture is collectivistic, while
American culture is mainly individualistic, there may be conflicts when
combining aspects from both.

The main argument is that significant

improvements could be expected in a few areas, if both groups would not

allow their cultures to make them biased.
Nursing homes in both Japan and the United States were initially
developed to provide for the increased physical needs of the elderly
people that had insufficient means of support1. Traditionally, the Japanese
may not have needed nursing homes, as the social norms were that the
first son and his wife would take care of his parents, and this in turn meant
that many houses had two or three generations living under the same roof.
However, it should be noted that as Japan became influenced by western
culture, the grown children opted to leave their homes, and therefore
there is now an increasing number of old people who live alone. This may
explain why the number of nursing homes has increased steadily to a

1 Sidney D. Watson, From Almshouses to Nursing Homes and Community Care: Lessons
from Medicaids History, Georgia State U. Law Review 26 (2009).

number of approximately 13,800 in 2011 2, and why Japan developed

several types of facilities3 to best account for the persons needs.
Compared to the original norms in Japan, American people used to and still
prefer to maintain autonomy, and since it became socially acceptable and
affordable to live in their own homes as time progressed 4, many old people
today live either by themselves or with some minimal support from their
families. Nursing homes are an option for those who have incapacities that
prevent them from living independently. Although there are over 15,400
facilities in the United States5, a study revealed that the percentile of
Caucasians who preferred to be taken care of by a nursing home in the
case of dementia was lower (38%) than the percentile of Japanese
Americans (53%)6. Moreover, 37.3 million or 85% of the people aged 65
and over in 2012 lived in non-institutionalized settings 7. This may indicate
that the people with individualistic culture mostly avoid situations in which
they need to be dependent on people, including family members and the
nursing homes staff. As seen, there are cultural differences between the
Japanese and Caucasian Americans traditional care of the elderly, and
their view of nursing homes.
One improvement to be proposed would be to apply the focus on acquiring
informed consent directly from the resident rather than the family
members as the United States nursing home system does 8. This applies to
both nursing homes and other health facilities: since health professionals
in the U. S. tend to openly discuss the inevitability of death and the
various ways to delay it9, they assess that it is most appropriate for the
patient who will undergo a medical procedure or who may have possibility
of proximal death to be informed of their condition, with or without familial

2 Cordial Corporation, The Number of Nursing Home Facilities (2012)

3 Ruth Campbell, Nursing Homes and Long-Term Care in Japan, 78 Pacific Affairs, U of
British Columbia (1984)
4 Atul Gawande, Being Mortal (2014)

5 Kaiser Family Fundation, Total Number of Certified Nursing Facilities (2011).

6 W. C. McCormick et al., Similarities and Differences in Attitudes Toward Long-Term Care
Between Japanese Americans and Caucasian Americans. J. of the Amer. Geriatrics Society,
50: 11491155 (2002).
7 A Profile of Older Americans, U.S. Department of Health and Human Services (2012)

8 Patricia Kolb ed., Social Work Practice with Ethnically and Racially Diverse Nursing Home
Residents and Their Families (2013).
9 George J. Annas & Frances H. Miller, The Empire of Death: How Culture and Economics
Affect Informed Consent in the U.S., the U.K., and Japan, Amer. J. of Law & Medicine 20
(1994).

consent of disclosure. Differently, medical staff and nurses that work in

Japanese nursing homes feel the need to ask for consent of the residents
family before disclosing new and possibly unfortunate information to the
resident10. Sometimes the disclosure to the patient is delayed if the
familys approval is not obtained 6. This hesitation roots in the norms of
traditional Japanese society, which tries to avoid topics related to death
and illness7, as well as direct communication of bad news especially
concerning health8. Although some residents may sense the truth
regarding their condition, others may not find out for some time. From an
American viewpoint, this behavior would be judged as unethical, but as
stated in the article The Empire of Death7, In countries where health care
is publicly financed, disclosure requirements are much less explicit, and
local law may actually discourage doctors from revealing information
about

diagnosis,

prognosis,

and

alternative

forms

of

treatment.

Nevertheless, people ought not to need to submit to the usually preferred

procedures, like those which postpone death, but to be able to make an
informed choice free of medical control 11. In addition, as the person who
carries the health condition, it should be the resident or patient that is
allowed to know the truth as early as possible, so that they can live
without uncertainty even if only for the last days of their lives. Similarly,
the

elder

people

in

nursing

homes

who

are

adults

capable

of

understanding should be allowed to participate in their own business

without their families making decisions for them. Therefore, nursing
homes could include this aspect of American individuals independence to
better the system for the residents.
On the other hand, a point from the Japanese system that could be used to
benefit nursing home care is to develop a minimum ratio of home staff to
residents, which is not fixed in the U.S. 12, but is set by the Public Nursing
Care Insurance Law in Japan. Japanese visitors are often shocked to see
that many places in America have ratios that are higher than the legal
standards in Japan. Even in the state of Virginia, which ratios are lower
than that of all other states, the minimum ratios are 1:5 residents (day),

10 E. Konishi & A. J. Davis, Japanese nurses perceptions about disclosure of information at

the patients end of life. Nursing & Health Sciences 1: 179187 (1999)
11 George J. Annas, Some Choice: Law, Medicine, and the Market (1998)

12 Robert Pear, 9 of 10 Nursing Homes in U.S. Lack Adequate Staff, a Government Study
Finds, N.Y. Times, Feb. 18, 2002.

1:5 (evening), and 1:10 (night) [for certified nurse assistants] and
minimum licensed nurse-to-resident ratios of 1:15 (day), 1:20 (evening),
and 1:30 (night)13. Compared to these numbers, the law in Japan states
that the minimum ratio must be of 1:314 regardless of the time of day. The
reason why setting a minimum staffing ratio would benefit nursing home
residents is that it would ensure better efficiency for the staff to provide
more assistance to each resident. In a survey conducted by the University
of Pennsylvania15, the researchers found 47% of nurses at nursing homes
reported that, their workload caused them to miss important changes in
their patients condition. This shows that needing to take care of many
handicapped people could even lead to dangerous consequences because
the personnel cannot monitor residents regularly. Thus, a set minimum
ratio of staff to residents would improve care in the U.S., as it would force
nursing homes to have more staff to care for the increasing numbers of
elderly people more attentively.
For the proposition of making information about the resident available to
the resident first, there may be quite a strong cultural conflict that may
dissatisfy members of the traditional Japanese cultural group. Japanese
people who are influenced by Western perspective would likely embrace
this proposition, because they would want to maintain independence
about themselves even at an old age when they are dependent on family
and nursing staff for most of the time. Some may have felt fear from the
cases like Makino v. The Red Cross Hospital 16, because anyone could have
made the wrong choice to ignore a health condition due to poor advice
from ones physicians. However, those elders and their families with a
traditional point of view may dislike that an unfortunate truth is directly
told to the resident, because it would go against their normative beliefs of

13 Kirsten Black, Barbara Ormond & Jane Tilly, State-Initiated Nursing Home Nurse Staffing
Ratios: Annotated Review of the Literature, U.S. Department of Health and Human Services
(2003).
14 Cordial Corporation, Nursing Homes Staffing
Structure (2012)
15 M. D. McHugh et al., Nurses Widespread Job Dissatisfaction, Burnout, And Frustration
With Health Benefits Signal Problems For Patient Care. Health affairs (Project Hope) (2011)
16 Nagoya District Court Judgment, 1325 Hanji 103 (May 29, 1989). As cited in George J.
Annas, Some Choice: Law, Medicine, and the Market (1998)8 Patricia Kolb ed., Social Work
Practice with Ethnically and Racially Diverse Nursing Home Residents and Their Families
(2013).

letting the person live in relative bliss even if it requires ignorance of an

evil8. An argument against this view would be that people with families
that hold a traditional view on disclosure of lamentable information do not
always hold the opinion themselves, and would prefer to know their true
condition ahead of time. Despite this claim, it would be challenging to
change the nursing staffs mindset so that they could openly notify people
with terminal illnesses of their situation. Traditions and beliefs are highly
valued in collectivistic cultures like Japans, and to break the norms would
be a source of criticism to the staff, especially from the families. Thus, it
may be possible to implement this advantage of American caring facilities,
but it may require a significant amount of time and willingness on part of
the staff.
Differently, the option to set minimum staffing ratios as Japanese
facilities should be simpler to implement, as the changes improve quality
of care, and does not strongly violate American cultural norms. Despite
this, some

may argue that providing minimum staffing ratios is

counterproductive, since they do not consider that some patients are

sicker than others12. An additional argument could be that since Americans
tend to dislike governmental regulation, the nursing home owners may be
displeased with an additional rule that may decrease their profits. The first
argument may be valid or not depending on the perspective, but it could
be argued that providing a minimum does not require nursing homes to
have that set ratio, and therefore they can adjust the number of staff
according to their residents needs. The problem arises when the nursing
homes try to lower the number of staff in order to increase gains, which
causes the numbers to be too small for appropriate care. The second
argument is likely to hold true, but there have been multiple examples in
which corporations and state facilities have been restricted for the best
interest of the general public, which should be the priority of nursing
homes. Therefore, implementing a minimum-staffing ratio should be able
to improve nursing homes and not receive major claims from either
culture.
In short, both prioritizing information disclosure to the residents and
employing a minimum worker-resident ratio are seen to be adaptable to

nursing homes, though cultural conflict may vary according to personal

views from both Japanese and American residents. As shown, it is difficult
to propose a model that two different cultures could voluntarily agree
upon, but it is also evident that there are improvements that could be
made to either of the current systems to cater for the preferences and
needs of nursing home residents. Thus, the proposed ideas ought to be
employed in nursing homes in order to better guarantee safety and quality
of care for the residents.