Allocating physicians to rural areas in Japan: Validity and ethical considerations

By Masatoshi Matsumoto.

Physicians predominantly cluster in urban areas, often leaving rural populations underserved. This phenomenon is observed worldwide. Consequently, the question arises: is it both necessary and justifiable for governments to allocate physicians to rural regions?

In addressing this issue, the Japanese government has adopted an approach involving the establishment of Jichi Medical University (JMU) and the implementation of regional quotas (RQs) for medical schools. Through JMU/RQs, local students aspiring to practice medicine in rural areas are recruited. These students receive a six-year education at no cost (JMU) or with a scholarship (RQs), followed by licensure and assignment by their home prefecture government to serve in the prefecture for a nine-year period. This includes 4-6 years of rural service within the prefecture. Currently, JMU/RQs participants comprise 11.6% of all medical school entrants. While JMU/RQs have demonstrated a high level of effectiveness in addressing rural physician shortages, ethical concerns surrounding these policies have surfaced. These concerns pertain to the necessity of utilizing public funds for policy implementation and the ethical implications of constraining physicians’ personal freedoms.

The justification for governmental management of these programmes and the allocation of physicians to rural areas can be evaluated through the lens of principles of social justice, utilitarianism, luck egalitarianism, the concept of liberty, and medical professionalism. All these principles, concepts, and norms lend support to the notion of government control over physician distribution, particularly in cases where a shortage of physicians exists in certain regions while others experience an excess. Moreover, the concept of allocation aligns with the fundamental assumption (equal burden for equal benefit) of the national health insurance system that encompasses the entire population, as well as the basic human right (the right to a healthy life regardless of place of residence) enshrined in the Japanese Constitution. These principles and concepts do not preclude the validity of allocation, even when it entails a temporary limitation of individual physicians’ freedom.

A debate in Japan revolves around the current penalties imposed on JMU/RQs physicians who decline the mandated service and opt to buy out their contracts. Some contend that the penalties are severe and ethically questionable, while others argue that they are too lenient given the substantial investment these physicians receive and the disproportionately low price they pay for contract buyouts. Instituting certain improvements in this area is necessary to further ensure the integrity and maturity of these systems.


Paper title: Ethical issues arising from the government allocation of physicians to rural areas: A case study from Japan.

Authors: Masatoshi Matsumoto, Tatsuki Aikyo

Affiliations:  Department of Community-Based Medical System, Hiroshima University

Competing interests: None declared

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