Since the late 1980s, many foreign workers have come to Japan, and the number of registered foreigners in Japan has exceeded 2.5 million (including special permanent residents) [1]. A multilingual and multicultural society has been created in Japan. There is no way to avoid the communication problems that foreign residents face while living in Japan. One of them is the problem that occurs when visiting a medical institution. Many patients who do not understand Japanese may want to visit a medical institution due to health problems, but give up because of the lack of communication [2]. There are also foreigners who cannot receive satisfactory medical care due to the language barrier. The fact that they cannot receive medical care with peace of mind even when their lives are in danger means that their rights as human beings are not being protected. With the Tokyo Olympics to be held in 2020, there is a growing need for medical interpreters in medical institutions in Japan. In urban areas and large hospitals, medical interpreters are increasingly intervening, and some medical institutions have 24-hour telephone medical interpretation available. However, in Japan, there are few medical institutions where medical interpreters can intervene and allow foreign patients to communicate with medical personnel. One of the reasons for this is that medical interpretation is not widely used in Japan due to the lack of social recognition [3]. The anxiety of foreign patients who have to communicate with medical personnel without understanding the language is immeasurable. When medical interpreters intervene, foreign patients can receive medical care with peace of mind, which also leads to the prevention of medical accidents [4]. However, how will the nursing care of foreign patients be provided? Many medical professionals do not know how to care for foreign patients, how to deal with foreign patients through medical interpreters, or how to use medical interpreters [2] under these circumstances, are medical professionals and medical interpreters cooperating in the medical care of foreign patients and respecting the right of foreign patients to receive medical care? With the increase in the number of foreigners in Japan, I felt that as nurses in Japan, we need to think about nursing care for foreign patients and "advocacy" for the rights of foreign patients. In the first place, I wondered if Japanese nurses were caring for foreign patients and advocating for the rights of foreign patients. The word "advocacy" has been translated into Japanese as advocacy, instruction, advocacy, advocacy, and (rights) advocacy, but its true meaning is a process in which so-called experts stand in the shoes of the socially vulnerable, sometimes advocating and sometimes advocating on their behalf, and taking the initiative to confront social inequality, injustice, and inequity [5]. Foreign patients may be suffering not only from some disease, but also from the fact that their rights as patients are not being upheld due to language barriers. Nurses must provide equal care to all patients, with or without medical interpreters. We must avoid a situation where patients' rights are not protected because they cannot receive nursing care due to language barriers. What is important in nursing foreign patients who do not understand Japanese or English? What kind of nursing should we do? Research on nursing care for foreign patients is still in its infancy in Japan, and there are few studies that suggest nursing care for foreign patients. Even if there is a language barrier, nursing care must be provided equally, and as nurses, we must protect the rights of foreign patients. What is important for us as nurses to practice nursing that does not divide foreign patients? In this study, we will focus on the "protection of patients' rights" in the nurses' code of ethics for foreign patients, and compare and analyze it with the code of ethics of other healthcare professionals and the code of ethics and common standards of medical interpreters who work with foreign patients, to find issues about how nursing should be for foreign patients.

To compare and analyze the codes of ethics of medical professionals and medical interpreters working with foreign patients, focusing on "advocacy" for rights, and to identify similarities and differences. In addition, we will discuss how to understand "advocacy" in the code of ethics for medical treatment of foreigners, and examine the challenges of nursing care for the increasing number of foreign patients in the future.

As professionals working with foreign patients, we will compare and analyze the codes of ethics of nurses, doctors, and medical social workers in Japan and the codes of ethics and common standards of medical interpreting organizations in Japan, the U.S., Canada, and Australia, focusing on how "advocacy" is handled. Those written in English will be translated into Japanese. All codes of ethics, codes of ethics, and common standards are available on the Internet, so there are no ethical issues.

Items directly or indirectly related to "advocacy" were extracted from each code of ethics, code of ethics, and common standards, and the English text was translated into Japanese and a summary is listed below.

Code of Ethics for Healthcare Professionals

Code of Ethics for Nurses: Nurses shall respect human life, human dignity, and human rights. Nurses shall provide nursing care equally to the target population regardless of nationality, race/ethnicity, religion, beliefs, age, gender and sexual orientation, social status, economic status, lifestyle, or nature of health problems. Nurses shall establish a relationship of trust with the target population and provide nursing care based on that trust. Nurses shall respect and protect the rights of people to know and to self-determination. Nurses shall protect people and ensure their safety when nursing care of the target population is interfered with or endangered.

Professional Ethics Guidelines for Physicians

Physicians recognize the importance of their responsibility and serve all people based on love of humanity.

Respect and Defend the Rights of Patients: Physicians must put the interests of patients first, respect the rights of patients, and strive to protect them. Patient rights include the right to receive fair medical care, the right to receive medical care based on one's own will after receiving an explanation, the right to refuse medical care, the right to privacy, and the right to a second opinion.

Explanation of the name and condition of the disease to the patient and family: Doctors have a duty to inform the patient of the diagnosis, including the name of the disease, and to explain the future course of the disease, as well as the contents and methods of examination and treatment, in a detailed and easy-to-understand manner so that the patient can understand.

Code of Ethics for Medical Social Workers (Human Dignity)

Code of Ethics for Medical Social Workers (Human Dignity): Social workers respect all human beings as irreplaceable beings, regardless of their origin, race, gender, age, physical or mental condition, religious or cultural background, social status, or economic situation.

Respect for users' Self-Determination

Respect for users' self-determination: Social workers respect users' self-determination and assist users to fully understand and utilize their rights. Social workers respect the self-determination of users, and assist them to fully understand and utilize their rights. (Responding to the decision-making capacity of users)Social workers always use the best methods to protect the interests and rights of users with insufficient decision-making capacity.

Sharing of Information: Social workers will use best practices to maintain confidentiality when sharing information about users with related organizations and staff in order to assist users.

Prevention of Violation of Rights: Social workers advocate for clients and prevent any violation of their rights. Social workers always use best practices to advocate for the interests and rights of patients with impaired decision-making capacity. The medical social worker's advocacy of interests and rights encompasses a wide range of decision-making (informed consent, choice) situations in the medical and health fields, as well as involvement with clients' social situations (economic deprivation, abuse, etc.) as they emerge through illness and disability. Health care social workers must stay abreast of laws and systems that protect the rights of people with impaired decision-making capacity, provide appropriate advocacy, and continue to protect clients from various forms of oppression and deprivation. The voices of clients with diminished decision-making capacity are often suppressed and difficult to hear in society. It is not only laws and systems, but also the keen sense of human rights and courage of medical social workers that enable them to hear the suppressed voices of the voiceless and protect their interests and rights. Medical social workers, as the guardians of human rights in the health care field, should always strive to maintain a good sense of human rights.

Code of Ethics and Common Standards of Medical Interpreting Organizations

JAMI (Japan Association of Medical interpreters), Japan Accuracy: Medical interpreters should faithfully interpret the meanings of statements made by patients and medical personnel, and should take into consideration differences in society, culture, customs, religion, etc., in order to establish good communication.

Neutrality: Medical interpreters should interpret fairly for all people. Medical interpreters shall interpret fairly for all people, recognizing that they have the best understanding of the content and circumstances of conversations between patients and medical personnel, and shall not take advantage of their position to benefit anyone in particular.

Improvement of the Medical interpretation Environment and Cooperation with Other Professionals: Medical interpreters should make the role of medical interpreters known to medical professionals and society, and work to improve the interpreting environment so that communication in medical situations can proceed smoothly. They should also understand the roles of medical professionals and other professionals, and cooperate with them.

Protection of Rights: Medical interpreters respect the dignity of all people and their right to lead a healthy and cultured life, and strive to realize this right to the extent that the patient's independence is not compromised.

Contribution to Society as a Professional: Medical interpreters shall give priority to the public interest, and their abilities shall be used to benefit society at large.

NCIHC (National Council on Interpreting in Health Care):  Interpreters shall strive to translate messages accurately, taking into account cultural contexts, so that the content and spirit of the original statement are conveyed intact. Interpreters will strive to maintain impartiality and will refrain from consulting, advising, or presenting personal preconceptions or beliefs. Interpreters will refrain from personal involvement and will maintain the scope of their professional work. Interpreters will strive to continually cultivate an awareness of other cultures (including the medical field) and their own culture that they experience while performing their work. Interpreters will treat all patients with respect. Interpreters may justify acts of advocacy when the health, welfare, or reputation of the patient is at stake. Advocacy for patients' rights is understood as acting on behalf of an individual, beyond the scope of assisting with communication, for the purpose of supporting better health outcomes. Advocacy should be engaged in only after careful analysis of the situation and only when less intrusive actions have failed to solve the problem. Interpreters must act ethically and in a professional manner at all times.

CHIA: (California Healthcare Interpreting Association),  California Medical Interpreting Association: Each of the following code of ethics items is based on consideration of the health and welfare of the patient.

Neutrality: Interpreters are required to disclose any personal views, values, beliefs, opinions, and potential or actual conflicts of interest that might lead to discriminatory behavior or bias affecting the quality or accuracy of interpretation.

Respect for Individuals and Their Communities: Interpreters should strive to support a mutually respectful relationship among all three parties (patient, client, and interpreter) in their interactions, while supporting the health and well-being of the patient as the highest priority of all health care professionals.

Professionalism and Integrity: Interpreters will act in accordance with the Standards of Professional Conduct and Code of Ethics for Medical Interpreters.

Accuracy and Completeness: Interpreters will convey the content, spirit, and cultural context of the original message in the target language to enable effective communication between patient and client.

Cultural Sensitivity: The interpreter will strive to understand the importance of diversity, cultural similarities and differences in the medical setting. Interpreters play an important role in identifying cultural issues and in considering when and how to transition to being cultural interpreters. The cultivation of cultural sensitivity and cultural sensitivity is a lifelong process that arises from self-reflection.

DSHS (Department of Social and Health Services), Washington State Department of Social and Health Services, Washington State Medical Interpreter Certification Agency

Accuracy: Interpreters and translators shall always translate the message of the source language completely and faithfully, without omission or addition, taking into account linguistic diversity in both the source and target languages, and maintaining the message, tone, and spirit of the source language.

Cultural Sensitivity-Courtesy: Interpreters and translators shall be culturally competent, sensitive, and respectful of speakers and listeners.

Disclosure: Interpreters and translators shall not publicly discuss, report, or comment on matters in which they have been engaged, even if such information is not required by law to be kept confidential.

Non-discrimination: Interpreters and translators shall be neutral, impartial and unbiased at all times. Interpreters and translators shall not discriminate on the basis of gender, disability, race, color, nationality, age, social or economic status, educational background, religion, or political beliefs.

Fairness-Conflict of Interest: Interpreters/translators shall disclose any facts or perceived conflicts of interest that may affect their objectivity while performing their work.

Scope of Work: Interpreters/Translators shall not consult, refer, advice, or offer personal opinions to speakers, listeners, or readers, and shall not engage in any other activities that could be construed as services beyond interpretation/translation. Interpreters are prohibited from contacting a client without the supervisor's knowledge, including calling the client directly, unless requested to do so by a DSHS employee.

Ethics Violation: Interpreters/translators will immediately cease any activity that is found to be in violation of this Code. Violation of any of these rules of professional conduct may be grounds for termination of contract.

AUSIT (Australian Institute of Interpreters & Translators, Australian Association of Translators and Interpreters)

Behaving in a Professional Manner: Interpreters and translators shall at all times perform their duties in a manner and with an attitude consistent with the objectives of AUSIT, the professional organization for interpreters and translators. Interpreters and translators are responsible for providing quality services in a respectful and culturally sensitive manner, for dealing fairly and impartially with all parties involved, and for performing all their duties with integrity. Interpreters and translators will disclose any conflicts of interest or situations that may jeopardize their impartiality. Interpreters and translators will respond in good faith to the business needs of other parties, adhering to common professional ethics.

Fairness: Interpreters and translators will observe impartiality in all professional contacts. Interpreters will maintain impartiality at all times while communicating with relevant parties. Interpreters and translators play an important role in enabling effective communication between parties who do not speak a common language. Interpreters and translators will seek to ensure the full meaning of the communication conveyed. Interpreters and translators are not responsible for the content of the communication between the parties, but are responsible for conveying the message in a complete and accurate manner. Interpreters and translators are not allowed to weaken, strengthen, or alter the message being conveyed, nor are they allowed to have prejudices that affect their work.

Accuracy: Interpreters and translators will use their best professional judgment to remain faithful to the meaning of the source text and message at all times. For the purposes of this provision, accuracy means conveying the best and most complete message in the target language, while preserving the content and purpose of the original message or text.

Clarity of Roles and Responsibilities: Interpreters and translators will maintain a clear line of demarcation between their role as a communication intermediary and the duties that may be assumed by other parties throughout the delivery of the message. Interpreters and translators focus on the delivery of the message. In the course of their interpreting or translating duties, interpreters and translators will not engage in other activities such as advocacy, teaching, or advising. Interpreters and translators will insist on a clear scope of work agreed upon between interpreting, translating, and other duties, even when such other duties are delegated by special employment agreements. Where appropriate, interpreters and translators will explain the principles of this provision regarding the scope of work.

WRHA (Winnipeg Regional Health Authority): Winnipeg, Canada)

Accuracy: Interpreters will translate messages in the origin language into the target language accurately and truthfully.

Fairness: Interpreters will maintain impartiality, refrain from giving advice or direction regardless of personal bias or beliefs, and disclose any conflicts of interest.

Respect: Interpreters will be respectful of all people.

Cultural Sensitivity: Interpreters will be aware of cultural similarities and differences encountered in the course of their work.

Role Scope: Interpreters shall maintain the scope of their professional role and refrain from personal involvement.

IMIA (International Medical Interpreters Association)

The IMIA was one of the first organizations to formulate a code of ethics specifically for the conduct of medical interpreters. Since then, various codes of ethics have been established. The establishment of a code of ethics is essential for medical interpreters to maintain their professional standards, which will enable them to fulfill their accountability and operational responsibilities to the recipients of this professional service, as well as to gain their trust. Interpreters shall use language and methods of expression that most accurately convey the content and intent of the speaker's speech. Interpreters will not accept assignments where they cannot be impartial due to the influence of their own family members or other persons with whom they have a personal relationship. Interpreters will not interject their own opinions or give advice to patients. Interpreters shall not act as interpreters for matters beyond the scope of medical services unless they are qualified to do so. Interpreters shall act as an advocate for the rights of the patient and, only when appropriate and necessary for the communication of information, use their professional judgment to explain cultural differences and practices to health care providers and patients as a cross-cultural mediator. The interpreter interprets with skillful timing without being conspicuous, so as not to interfere with the flow of conversation in the three-way relationship between the health care provider, patient, and medical interpreter.

Considerations

Looking at the code of ethics for medical professionals, the code of ethics for nurse’s states, "Respect the right to self-determination and defend that right. In the section on the protection of human rights and respect for the right to self-determination in the Code of Ethics for Medical Practitioners by the Japan Medical Association, it is stated that "physicians must put the interests of patients first, respect the rights of patients, and strive to protect them. In addition, the code of ethics for medical social workers states that "social workers shall always use best practices to advocate the interests and rights of patients with inadequate decision-making capacity. These codes of ethics for health care professionals are based on the World Medical Association Lisbon Declaration on the Rights of the Patient, in order to respect the rights and wishes of patients and to provide impartial medical care. The differences in wording regarding the protection of patients' rights among nurses, doctors, and medical social workers in each profession can be attributed to the differences in their interactions with patients. Nurses are considered to be in a position to clearly state that they protect the rights of patients because they have a role to take care of patients' medical treatment and spend a lot of time in contact with patients. Furthermore, medical social workers are more likely than nurses to state that they protect the rights of patients, since they also act as consultants for patients in their daily lives and financial matters. Next, comparing the code of ethics and common standards of each medical interpreter, the code of ethics for interpreters in the U.S. states that their role is to "advocate for patients' rights" and "explain cultural differences and practices. The Common Standards for Interpreters in Japan do not specify rights advocacy, only "explaining cultural differences," and in "neutrality" it states "not interjecting opinions or giving advice. Interpretation organizations in Canada and Australia clearly state that they "do not provide advocacy, guidance, or advice" and that "even if you do not agree with what is said, you must not raise objections or distort the content" in the "neutrality" section. The wording of the section on advocacy varies from one code of ethics to another, with some countries and organizations clearly stating that they advocate for rights, while others state that they do not allow any advocacy. Thus, a survey of some of the ethical codes and common standards for medical interpreters revealed that there are more interpreting-related organizations that do not explicitly include advocacy in their ethical codes or common standards. Although the code of ethics for medical professionals includes advocacy, it seems that Japan has not yet reached the stage of clearly stating in its code of ethics that interpreters should act in an advocacy manner. In Japan, however, there seems to be a lack of a clear code of ethics for interpreters to act as advocates. This is due to the fact that medical interpreting has not yet been institutionalized or professionalized, and the role of interpreters is to maintain a neutral position and translate accurately, and the act of advocating for patients should not be included in the code of ethics for interpreters [3]. Advocacy is "a process in which experts stand in the shoes of the socially vulnerable, sometimes advocating for them, sometimes speaking for them, and taking the initiative in confronting social inequalities and injustices" [5]. The experts who can advocate in the medical field described here are interpreted to mean nurses. Originally, the code of ethics for medical interpreters covered foreign patients, but since the code of ethics for medical professionals covers all patients regardless of nationality, language, or religion, foreign patients should be included. Advocacy for foreign patients should not be left to medical interpreters, but should be done by nurses. While advocacy is not explicitly mentioned in the code of ethics of Japanese medical interpreting organizations, it is explicitly mentioned in the nurses' code of ethics, and they are in a position to advocate. Therefore, it would be logical for nurses to advocate for foreign patients. In the medical and welfare fields, this function of advocacy is considered important to protect the rights of the socially vulnerable, such as terminally ill patients who are unable to exercise and express their own rights, the disabled, the bedridden elderly, the elderly with dementia, and pediatric patients [6] argues that advocacy in the medical field must be conducted by professionals who are knowledgeable about patients' rights, and for this purpose, it is important to understand the following three points: [1] what are patients' rights [2],  how they may be violated in the current situation, and [3] how to actually act to protect these rights [3]. What should we do to protect these rights? Considering these three points as the right of foreign patients to receive nursing care, it can be said that the right to receive equal nursing care and the right to receive explanations in a way that can be understood may be violated if the current situation continues. In order to protect the right of foreign patients to receive nursing care, it is necessary for professionals to care for foreign patients and advocate for them even if they cannot speak the language. How to actually care for foreign patients and advocate for them will have to be discussed as a future issue [7-13].

The Code of Ethics for Nurses clearly states that patients' rights should be protected, and patients should include foreign patients. In the Code of Ethics and Common Criteria for Medical Interpreters Interpreting for Foreign Patients, some clearly stated that advocacy could be done by medical interpreters, while others stated that medical interpreters should not do advocacy. Rather than leaving the advocacy of foreign patients to interpreters, it is necessary for nurses who have advocacy clearly stated in their code of ethics to actively care for foreign patients so that they can perform advocacy. [8-20].

The definition and scope of advocacy for foreign patients is unclear, and nurses are forced to make decisions and consider how to care for foreign patients who do not speak the language, depending on the situation and circumstances. In the future, it will be necessary for medical professionals and medical interpreters to collaborate and work together on nursing and advocacy for foreign patients who cannot speak or understand either Japanese or English. Furthermore, if nurses understand how to respond to, treat, and use medical interpreters, foreign patients will be able to receive medical care with peace of mind. In addition, for nurses to care for foreign patients in Japan and abroad, it would be desirable for them not only to learn medical English but also to understand the different cultures of foreign patients and to be able to provide cross-cultural nursing care. The time has come for nurses to think about how to care for foreign patients, leaving the language barrier in the medical field to medical interpreters and interpretation machines.

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