How should we assess Shinmi ethically? Shinmi is not an ethical principle, rule or duty. Rather, it appears to be a cluster of attitudes and behaviours. It is a potential characteristic of ethical doctors. Moreover, as already noted in the case and in the comments of patients, it may be over or under-expressed. In that sense, analysing Shinmi through the lens of virtue ethics may be helpful.

Virtue ethics is often distinguished in its emphasis on virtues, or moral character, in contrast to approaches that emphasises duties or rules (deontology) or the consequences of actions (consequentialism) (Hursthouse and Pettigrove 2022). Edmond Pellegrino (2002) has argued that the traditional professional medical norms were virtue-based, linking good physicians to specific character traits. Citing Aristotle’s moral virtues (which on Aristotle’s account were to be pursued neither excessively, nor insufficiently), he defined an excellent (virtuous) physician as one who most effectively achieves the goals of medicine and exhibits traits essential to achieving those goals. Pellegrino’s influential account included six specific virtues of doctors: fidelity to trust, honesty, compassion, effacement of self-interest, courage and justice. No indication of familism, an element of Shinmi, is listed here, but emotional involvement is mentioned in the form of compassion, which refers to the need to enter the patient’s predicament and feel their suffering (akin to cognitive empathy).

While Pellegrino’s virtues are grounded in Western culture, there are also physician virtues that have been described in Eastern culture. Some of these include similar elements to Shinmi. According to Daniel Tsai and colleagues, ancient Chinese medical ethics were derived from Confucian virtue ethics. The central theme of this is “仁 (Ren)”, with family values and filial piety, particularly being the root of benevolence (Tsai 2005). As evidence of the influence of this, it has been suggested that the book “Bushido”, written by Inazo Nitobe (2012), which described the way of the Samurai and has its origins in Buddhism, Confucianism and Shintoism, has influenced professionalism in Japanese medicine. Bushido is similar to chivalry or noblesse oblige in the West. In Bushido, seven virtues are advocated. Rectitude (義 Gi), Courage (勇Yu), Benevolence (仁Jin), Politeness (礼 Rei), Honesty (誠Rei), Honour (名誉 Meiyo) and Loyalty (忠義 Chugi) (Nishigori et al. 2014). Of these, “仁 (Jin)” and “忠義 (Chugi)” are similar to concepts of Shinmi. “仁 (Jin) Benevolence”, which means love and compassion towards others, is an attitude of emotional involvement and empathy towards others. According to a survey of Japanese physicians, many stated that “仁 (Jin)” is an integral part of medicine. Furthermore, “忠義 (Chugi) Loyalty” prioritises loyalty to the needs and interests of the group, such as a family, in contrast to Western individualism.

In analysing Shinmi through the lens of virtue ethics, we could find similarities between the elements of physician virtue and Shinmi. On the other hand, in the previous section, we described that elements of Shinmi potentially contrast or conflict with the traditional medical ideals in the West. However, the importance of familism and emotional involvement has recently been recognised or reassessed in Western cultures.

The first element, familism, appears particularly desirable in cultures with a Confucian regard for the importance of family. However, many patients, even outside Japan, regard being treated like family by healthcare professionals as something that medical care should aspire to. Perhaps people believe that a doctor’s family member receives better care than a doctor’s non-family members (Abbate 2014)? In the UK, the “Friends and Family Test” is used to assess healthcare quality, asking people (including those who work in the National Health Service) whether they would be willing to recommend a healthcare provider to a family member or friend if they were in the same situation. It suggests that the level of healthcare that would be sufficient to refer to one’s loved ones may be considered the minimum required (NHS England Insight Team 2014).

The second element, affective closeness has also been re-evaluated. Although, as noted, analysis of doctors’ empathy has previously suggested that doctors should avoid affective empathy (Halpern 2011; Hojat et al. 2009), Michalec et al. express concern that focusing too much on cognitive empathy to the exclusion of emotional empathy ultimately might have a negative impact on patient care (Michalec and Hafferty 2022). Such an approach may lead to overemphasis on clinical knowledge, clinical detachment and scientific rationality. Wong et al., in a study of exploration of oncologists’ professional emotional experiences, found that some professionals reported engaging more emotionally with their patients to meet their affective needs and perceive it as an essential strength of being a doctor (Wong et al. 2020). In this research, doctors attempted to strike an appropriate balance between keeping themselves as objective and competent doctors and engaging more emotionally with their patients.

From our analysis of Shinmi through the virtue ethics lens, we argue that Shinmi can potentially include desirable character traits if doctors properly pursue Shinmi. What should doctors look for to achieve the golden mean of Shinmi in healthcare?

The risks common to the two elements of Shinmi are loss of professional objectivity due to the blurring of professional boundaries with the patient and lack of equity as a public servant. Additionally, affective closeness can undermine the mental well-being of the doctor.

Firstly, to keep professional objectivity, as it has been suggested that self-reflection is necessary in terms of an awareness of the boundaries between doctor and patient for ethically sound clinical practice to take place (Kelly et al. 2003; Malbois and Hurst-Majno 2023). Wong and Fromme suggested two reflective questions, “Am I being a professional?” and “Am I acting professionally?” are essential questions to ask doctors, themselves when performing emotional labour (Fromme et al. 2008; Wong et al. 2020). These questions are also important to maintain professional justice and proper emotional distance with the patient.

Secondly, for balanced emotional involvement, sharing emotional experiences with colleagues, friends and family may support doctors to reflect on their feelings (Kerasidou et al. 2021). Kerasidou et al. also suggested that it is not enough to support the individual for the doctor to pursue the virtue appropriately, but it is also essential to create a supportive work environment that does not hinder the expression of the virtue. They mentioned that doctors could learn and acquire virtuous characters, but virtuous development is hindered if there is no place or opportunity to practise virtue.