Advance care planning in Japan: Gaps between policy, ethical understanding, and its translation into clinical practice

Background: Advance care planning (ACP) has become central to end-of-life policy in Japan, aiming to uphold autonomy and dignity. However, conceptual confusion about its ethical and legal foundations risks promoting a procedural rather than ethically grounded approach to ACP. Aims: This study aimed to (1) assess healthcare professionals’ knowledge of ethical and legal concepts in medical decision-making, (2) examine how patient autonomy is respected through clinical vignettes, and (3) identify factors associated with respect for autonomy. Design: Cross-sectional questionnaire survey. Methods: Healthcare professionals ( n = 549) in a Tokyo geriatric hospital completed measures of attitudes toward and experiences with end-of-life care, knowledge of legislation and ethical concepts underlying medical decision-making, and response to two clinical vignettes depicting decision-making dilemmas. Analyses included descriptive statistics, comparisons across occupational groups, and multivariate regression to identify factors associated with respect for patient autonomy. Results: Misconceptions were common: 38% of participants equated ACP exclusively with decisions to forgo active treatment, and many conflated ACP with current rather than future-oriented care planning. The vignette study further demonstrated that a dementia diagnosis alone reduced respect for patient preferences in 27.8% of cases. Ethical dilemmas frequently arose when ACP was applied in practice, especially regarding withholding or withdrawing treatment, suggesting that ACP does not necessarily resolve such dilemmas and may generate new ones in some cases. Two independent factors related to greater respect for patient autonomy were identified: greater knowledge of ethical concepts and personal experience witnessing harm from insufficient medical intervention. Conclusion: ACP policies in Japan have advanced more rapidly than healthcare professionals’ ethical and legal understanding, risking procedural rather than ethically grounded practice. Systematic, cross-professional education integrating legal literacy, ethical reasoning, and reflective learning is essential to ensure that ACP genuinely safeguards patients’ rights and supports ethically sound decision-making.