• Physician's obligation
• nuclear disaster
• Fukushima
• Japan
• informed consent
• truth telling
• ethics committee
• biomedical ethics

On 11 March 2011, Japan experienced a 9.0-magnitude earthquake followed by a massive tsunami. This disaster released a large amount of radiation from the Fukushima Daiichi nuclear power plant, resulting in a crisis level 7 on the International Atomic Energy Agency scale.1 2 The medical system in the affected region has only recently begun to recover from the crisis. In fact, physicians are now at work 24 h a day, even at the nuclear plant, thanks to the efforts of the University of Occupational and Environmental Health.3 Nonetheless, medical needs—including those related to human resources—during the first few weeks after the earthquake for disaster victims in devastated areas were not adequately met. At the time, many physicians expressed interest in travelling to the affected areas, and some even headed to disaster zones in response to requests for aid or as volunteers with non-governmental organisations. However, should the physicians have been obligated to travel to the disaster zones after the earthquake?

The first issue that we must consider is physician responsibility to patients under their current care: are physicians obligated to put people in disaster zones before patients currently in their care? A doctor bears a special duty towards a patient once the physician–patient relationship is established. This duty derives from the moral relationship that exists between a physician and patient, and takes priority over the general moral obligation to other people (eg, those in disaster areas). Accordingly, physicians should not sacrifice their own patient's needs to travel to affected areas, except under special circumstances; for example, physicians should travel to affected areas if their professional skills are vital to the specific needs of disaster victims.4 Furthermore, physicians should not leave their patients, unless appropriate care is arranged, such as having another staff member or colleague fill in.

What if physicians have no patients currently under their care or have someone that can fill in for them? In such cases, the obligation of general beneficence arguably demands that physicians should go to disaster zones. This obligation mandates that physicians should do everything in their power to prevent a negative outcome from befalling others if it involves making a moderate sacrifice.5 6 Therefore, the obligation exists regardless of whether or not a contractual relationship has been established with patients undergoing treatment, or with family members or friends.

Does the aforementioned obligation suggest that physicians must travel to any disaster zone? To properly address this question, let us consider two different cases. In case A, a physician was requested to come to a temporary medical treatment station established at an evacuation centre after massive damage from the earthquake and tsunami (eg, Sendai City, Miyagi Prefecture, located roughly 94 km from the Fukushima Daiichi nuclear plant). At the time, just weeks after the earthquake, many people were living at evacuation centres, and health issues arose because of the harsh living conditions. In case B, a physician was requested to provide medical assistance (prevention of radiation exposure and health assessment) to those working tirelessly to repair radiation leaks. In fact, over 1300 workers were engaged in restorative work under severe conditions at the Fukushima nuclear plant. Workers received only two meals a day, had no shower facilities, and had inadequate sleeping quarters.7 In either case, having a physician nearby helped to reassure evacuees and workers. If support is requested, are physicians required to go to affected areas regardless of conditions? For instance, a colleague of ours expressed a strong conviction to go to Sendai (case A), but not to Fukushima (case B). Can such a conviction be ethically justified?

The scope of obligation of general beneficence affects how one thinks with regard to this problem. If the obligation has no limits or bounds, then this could result in excessive demands on the physician to never stop worrying about circumstances of unrelated people, or to strive to prevent negative outcomes from befalling them. For this reason, general beneficence is generally understood not as a boundless obligation, but rather as being somewhat limited in its application.8–10 In establishing these limitations, ethicists often consider the urgency of the situation, severity of the consequences if nothing is done, ability of the moral agent to prevent such severe consequences, and the appropriate sacrifice the moral agent would have to make.

For example, Beauchamp and Childress11 suggest that ‘a person X has a determinate obligation of beneficence towards a person Y if and only if each of the following conditions is satisfied […]:

1. Y is at risk of significant loss of or damage to life or health or some other major interest.

2. X's action is necessary (singly or in concert with others) to prevent this loss or damage.

3. X's action (singly or in concert with others) has a very high probability of preventing it.

4. X's action would not present significant risks, costs, or burdens to X.

5. The benefit that Y can be expected to gain outweighs any harms, costs, or burdens that X is likely to incur.’

What happens when we apply these five conditions to the two cases mentioned above? The first three conditions are clearly met because evacuees and nuclear power plant workers were obviously suffering from health problems, and the physician had the ability to help them. However, a divided judgement would likely exist with conditions 4 and 5. With regard to condition 4 in case A, although there was concern about aftershocks, the chance of a second disaster occurring was low, especially a few weeks after the earthquake. Thus this case presented a low risk of possible physical hazards and psychological burden on the physician. As for the risk of radiation exposure to the physician in case A, the location was somewhat removed from the nuclear plant—roughly 94 km from the Fukushima Daiichi nuclear plant. In fact, the measured amount of atmospheric radiation at Sendai City 2 weeks after the disaster was 0.14 μSv/h.12 The level of radiation exposure required for evacuation was set at 20 mSv/year by the Japanese government, per International Commission on Radiological Protection standards. The 0.14 μSv/h radiation in Sendai is far below this value. Furthermore, the evacuation advisory zone was set to a 20 km radius around the Fukushima plant. Taken together, the health risks associated with staying in Sendai were insignificant. However, higher than normal levels of radiation had been detected in the Fukushima vicinity, and on getting closer to the nuclear plant, the risk of radiation exposure grew, as well as direct physical and psychological harm. For example, a newspaper article reported that on 27 March, airborne radioactivity in the unit 2 turbine building remained so high (1000 mSv/h) that a worker there would reach his yearly occupational exposure limit in just 15 min.13 Thus it could be definitely argued that condition 4 is not met in case B.

With regard to condition 5 in case A, the physician could help prevent deterioration in evacuee health with minimal risk or burden. In contrast, although the physician in case B could help prevent radiation exposure and provide care to the heroic workers at the nuclear power plant, the physical risk associated with such help would be significant. Thus it becomes difficult to assess in which direction the risk–benefit balance tips for the physician offering medical assistance to workers at Fukushima.

In conclusion, all five conditions are met in case A. However, in case B, condition 4 is not met, while condition 5 is hard to determine. Therefore, we can conclude that, while physicians were obligated to travel to medical stations in affected areas (ie, the evacuation centre in case A), they were not necessarily obligated to lend assistance to workers at Fukushima Daiichi nuclear power plant.

Naturally, for the arguments presented here to be valid and sound, an accurate assessment of risks and benefits associated with the physician's trip to the affected region is absolutely necessary. In actuality, however, it was exceedingly difficult to obtain detailed and accurate information for proper risk–benefit assessment in the initial weeks after the earthquake, a time when even the scale of the devastation was not sufficiently understood. Furthermore, it was difficult to determine if the information on the nuclear plant (eg, whether a meltdown was in progress) and level of risk involved was being manipulated by the Tokyo Electric Power Company (TEPCO) and the Japanese government. Therefore, no choice existed but to believe the official announcements made by the government and utility company. Because the statements released by TEPCO and the Japanese government were generally vague, tending to excessively emphasise safety, distrust of all information reported by TEPCO and the Japanese government arose both domestically and internationally. As a result, it was difficult to accurately assess the risks and benefits after the disaster.

Given the backdrop of this epistemic difficulty, it was difficult to judge whether physicians had an obligation to serve disaster victims based on the obligation of general beneficence. Rather than relying solely on the obligation of general beneficence, we might consider the use of other methods (eg, the perspective of virtue ethics) to discuss the duty of physicians in such circumstances. Finally, even with such limitations, appealing to obligation of general beneficence would help formulate guidelines for physicians' conduct in a nuclear disaster.