Karoshi: death by overwork. Lessons from Japan

THE work culture of modern Japan took shape after World War II, when rebuilding the economy was a top national priority. Young men were offered lifelong job security in exchange for loyalty, leading to the now infamous salaryman culture.

The salaryman works his whole life at one company, which also becomes his social life. Hierarchy is strict, with workers expected to arrive before and leave after their senpai (senior colleague). Even after the workday is done, which is typically 12 hours long, employees take part in social activities – frequenting izakaya (informal bar) for drinks and nibbles with their work colleagues in favour of going home and eating dinner with their families. Indeed, most salarymen don’t see their wives or children until the weekend.

As this fierce loyalty to the workplace escalated, the term “karoshi” was born in the 1970s, which directly translates to “death by overwork”. Workers were dying from suicide as well as cardio- and cerebrovascular disease from the effects of chronic sleep deprivation and stress.

One high profile suicide was the death of 24-year-old woman Matsuri Takahashi on Christmas Day 2015. Takahashi had been working more than 100 hours of overtime that month at an advertising firm, before taking her own life. Her company was fined approximately $6600 for violating the Labour Standards Act. While this fine may be small, it was significant in making workplaces accountable for the working hours and conditions of employees. Another woman, journalist Miwa Sado, who worked for broadcasting network NHK, died in July 2013 from heart failure aged 31. Her death was also attributed to karoshi, after she had worked 159 hours of overtime in the month leading up to her death, with only 2 days off.

Following these high profile deaths, the Japanese government passed the Work Style Reform Law, which sets limits on overtime to 45 hours a month. However, “highly skilled professionals” are exempt from this protection, which will affect doctors.

In Australia, all states but New South Wales are undergoing legislative changes to protect workers from conditions that have an impact on their physical and mental health.

The Workplace Safety Legislation Amendment Bill was passed in Victoria on 26 November 2019, and is expected to come into effect by 1 July 2020. Workers have a right to work in a physically and psychologically safe workplace, and deaths caused by failed duty of care or negligence may be punishable under this Bill as “workplace manslaughter”. This includes death by suicide from the trauma of bullying and harassment.

Moreover, not only is bullying in the workplace an offence under Occupational Health and Safety laws, it is also a criminal offence. Brodie’s Law has been in place since 2011 after 19-year-old waitress Brodie Panlock was bullied relentlessly at work and subsequently committed suicide. Her coworkers were fined and did not receive a custodial sentence. Now, bullying can be punishable with a 10-year maximum imprisonment.

What does this mean for doctors?

We already know that junior doctors are unlikely to complain due to fear of reprisal. This is especially the case for unaccredited registrars awaiting selection onto highly competitive training programs. Furthermore, there is a loophole in the legislation with working on-call, which is not reflected in the number of overtime hours worked.

While legislation may hold employers accountable for work-related deaths, there is a huge spectrum of work-related ill health that still needs to be addressed. After a certain threshold, we know that working more does not lead to more productivity. Overwork can compromise doctors’ performance and lead to burnout before the onset of physical and mental health diagnoses.

In order to prevent doctors from becoming clinically unwell, legislation is needed to put a firm limit on working hours and on-call rostering. Safe working hours guidelines, while useful, are not enforceable. Therefore, they have failed to protect doctors from morbidity and mortality.

Without legislation, doctors will continue to work overtime for their patients and for career progression, at the mercy of hospitals who will take advantage of them.

Dr Yumiko Kadota is a lecturer at the University of New South Wales Department of Anatomy, and an ex-plastic surgery registrar.

Dr Geoffrey Toogood is a cardiologist and a long-time advocate for mental health. He has swum the English Channel. He came up with the idea of crazysocks4docs day. He was the 2019 AMA President’s Award recipient.

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