Most Western nations are facing the problem of aging populations, but Japan is really leading the pack, with its combination of a very low birth rate, healthier diet and a good medical system.

Japanese older people are just like elderly from any other part of the world, sometimes friendly and interesting to talk to, and other times unwilling to take crap from anyone as they dive for the last pair of shoes at a department store bargain sale. As an American living in Japan, it’s can be interesting to strike up conversations with older Japanese, who will often talk about what the war years were like for them, or the time they saw General MacArthur, and there’s an unspoken acknowledgment of all that’s changed in the past 60 years.

Since it’s generally expected that the oldest son or daughter will take over the family house and care for the parents in their silver years, elderly folks generally have the benefit of lots of family around them, at least in the semi-rural prefecture where I live. Partially because of this system, and also (I’ve been told) because Japanese rarely leave the area where their family grave is located, you don’t see people migrating to a different part of the country when they retire as is the case with Florida.

The main social activity of Japanese retired people seems to be going to the doctor’s office every day to sit and chat with friends while they wait to be seen by the doctor for some (usually imagined) pain, and if you ever get sick in Japan you’d better have a strategy for getting to the doctor’s office early.

While most of the older people living in my neighborhood are very genki (healthy, full of energy), there’s one poor woman whose back is stuck at a 90 degree angle, making her unable to stand up at all. I’d always assumed this problem came a lifetime of planting rice by hand, but supposedly it’s caused by a chronic vitamin B1 deficiency that was a problem in the first few decades of the 20th century.

Blaine Harden of the Washington Post penned a thought-provoking article about modern Japanese women that touches on many topics which have been raised here on Japundit. It asks why women are postponing or even eschewing marriage and children; a trend which I, too, have seen. Off the top of my head, I can name about 10 single Japanese women friends in their mid-to-late thirties; far fewer than the number who are married.

Takako Katayama has not closed the door on marriage and children. When she meets girlfriends for dinner, they ask each other, “Where are the good guys?” But she refuses to settle for a man who works long hours, declines to share in child-rearing and sees marriage mainly as a way to acquire lifetime live-in help.

“I want a mature, equal-partner kind of marriage,” she said. “Anyway, there are complete lives without a baby.”

Therein lies a dismal prognosis for Japan and for many of the other prosperous nations of East Asia. In numbers that alarm their governments, Asian women are delaying marriage and postponing childbirth. In Japan, the percentage of women who remain single into their 30s has more than doubled since 1980.

“We need to organize our society so that women and families will be able to raise children while working,” Japanese Prime Minister Yasuo Fukuda said in an interview in May. “I think we still lack adequate efforts on that front.”

This year, Fukuda’s government is pushing a “work-life balance” program that addresses the country’s famously punishing work ethic. It pressures companies to shoo workers (primarily men) out of the office at night. The intent is to improve the quality of family life and, in the process, make more babies.

The stakes are high here in the world’s second-largest economy, which now has the world’s highest proportion of people over 65 and lowest proportion of children under 15. According to a recent forecast, population loss will strip Japan of 70 percent of its workforce by 2050.

Norimitsu Onishi of the New York Times is back with another interesting article, this time on foreign workers in Japan. One thing I have noticed in my time in Japan is the consternation many Japanese feel towards foreigners. My wife trains foreign workers (largely in Japanese language and culture) who are employed by Japanese companies both here and abroad and it opens a window for me into these attitudes. Soon her organization will be training a large group (50 +/-) of Indonesian nurses and the hand wringing continues…

With one of the world’s most rapidly aging populations and lowest birthrates, Japan is facing acute labor shortages not only in farming towns but also in fishing villages, factories, restaurants and nursing homes, and on construction sites. Closed to immigration, Japan has admitted foreign workers through various loopholes, including employing growing numbers of foreign students as part-timers and temporary workers, like the Chinese here, as so-called foreign trainees.

The labor shortage has grown serious enough that a group of influential politicians in the long-governing Liberal Democratic Party recently released a report calling for the admission of 10 million immigrants in the next 50 years.

The foreign work force in Japan rose to more than one million in 2006 from fewer than 700,000 in 1996. But experts say that it will have to increase by significantly more to make up for the expected decline in the Japanese population. The government projects that Japan’s population, 127 million, will fall to between 82 million and 99 million by 2055. Moreover, because the population is graying, the share that is of working age is expected to shrink even faster.

The large presence of the Chinese workers has unsettled some Japanese here even as they have become increasingly dependent on them. Some vaguely mentioned the fear of crime, though they acknowledged that crime rates had not risen. No Japanese interviewed welcomed the idea of immigrants here or elsewhere in Japan.

“I feel a strange sense of oppression,” Toshimitsu Ide, 28, a lettuce farmer who had not hired any Chinese workers, said of seeing large groups of Chinese hanging around town. “They seem hard to approach.”

Perhaps because of the Japanese unease, the Chinese workers were given directives apparently aimed at curbing their movements, even before they arrived. They said they were told to go home by 8 p.m. and not to ride bicycles except for work. Some even said they had been instructed not to talk to young Japanese women.

“Though I’m in Japan,” said Toshimitsu Yui, 57, who works in construction, “I feel this is not Japan anymore.”

according to an article in the new york times online,written by norimitsu onishi, the ashes in a japanese urn are an apt metaphor for the future of the system of funeral buddhism in the country.

where as in the past, the japanese reliably counted on buddhist priest’s and their rituals as a source of comfort during the time surrounding the death of a loved one, many now are choosing to go with services provided funeral homes or cremations with no services at all (preferring instead to dump their loved one’s remains in the nearest ashtray and keep their kaimyo in the toilet in case they need something to aim at when they’re drunk).

photo of a priest staring disinterestedly at a wall, hat tip to the old grey lady

while there are a myriad of reasons for this shift in attitudes towards death and the proper place of religion during this time, to numerous to be discussed in detail here, there are a few notable trends listed in the articles.

1) the accelerated drop in religious belief in the cities combined with their ever increasing populations has led to a large group of people who have no religious belief whatsoever and see no need to start on the day of their death.

2) the rural demographic, where until recently buddhism was still strong, is aging and dying off as the younger generations move to cities and the birthrates are not enough to make up for the exodus of population and businesses. this leaves country temples serving an ever dwindling number of less affluent elderly to serve, thus making many temples financially insecure.

3) the sense of japanese that buddhism doesn’t cater to the needs of the living, thus making them more indifferent to what it teaches about what happens after death; and the lack of change in that area the clerics seem to want to make in this regard.

4) a lack of moral authority apparent in the buddhist temples since the end of wwii when they began to sell prestigious posthumous names to people who paid them enough money, thus denigrating names once reserved for revered buddhist adherents with strong moral characters to an indulgence of sorts. as appropriate in situations like these payments are usually made in unmarked in envelopes on a no receipt-cash only basis.

5) the general expense of traditional funerals combined with new rent a priests employed by funeral homes to provide services for people they most likely have never met before and willing to provide honest listings of fraudulent extravagant titles that can be attained at rock bottom prices and you get a receipt.

all these factors are combining together to create an a daunting challenge to the continuing existence of temples across the country. with funeral expenses being analogous in importance to these temples as tithing is to churches and synagogues in the west in terms of revenue sources, many priests face being the last generation of clerics ministering their religion in japan.

as a consequence many temples are expected to close their doors over the coming decades, taking with them (they claim) a major source of local history and sense of community and continuity in their local precincts. of course some of the major private and state sponsored temples and unesco tourists sites will be unaffected, but many charming repositories of small town rural culture will be disappearing. so if you always wanted to visit that one out of the way zen garden that somehow escaped being listed in the travel guides and is free of tourists, now might be a good time.

soon places like this might be overgrown memories of a different age

few random closing thoughts…
a) what’s going to happen to all the libraries of coin lockers supposedly holding parishioners souls? talk about a crappy afterlife, you’re closed in a hole in the wall until the local priest can’t make ends meet and then bulldozed; lame.

b) i find it darkly humorous that the priests see many of the sources of their decline, recognize they are preventable, and then do nothing. this lethargy in response to their situation seems to come from a certain amount of apathy about their beliefs. they talk about how other religions provide sermons and community services outside of funerals to keep their faith relevant to their congregations as if it would be some theoretically nice thing to do, and then take no action to emulate. has buddhism in japan become this esoteric that it no longer has an application in people’s daily lives? i suspect that it’s just laziness on the part of the priests

c) perhaps this is just the logical conclusion to japan’s seeming cognitive dissonance on the issue of religion. after all if you don’t believe in it and didn’t live your life according to its precepts and went to your death this way, how would having an extravagant funeral change this? it you believe that human existence ends when the lungs stop breathing, the heart stops beating, and the neurons stop firing signals through their dendrites why waste your money to commemorate, dedicate, exalt, and provide a home for a soul you don’t even believe exists? and if you do believe in a deity or higher power of some sort exists, do you really think that a life spent living in sin and unbelief can be made up for by having a really cool name and a nice funeral? i guess these types of services are more for the living, but if that’s true why not remember the dead in your own way? it would be a lot more meaningful and cost effective than spending over ten thousand dollars for a piece of lacquered wood and empty platitudes from some guy who never even met the deceased.

d) think of the boon to the horror movie industry. decrepit buildings, abandoned alters, moss covered statues, rooms with soul lockers; this will be great!

As a group, the Japanese are fortunate enough to enjoy extremely long lifespans, with the current average being 78.5 years for men and 85.5 years for women. There are many reasons for this longevity, including a healthier diet, an extremely safe society, and a tendency to build lifelong relationships that provide important support in later years. (My mother-in-law is still close friends with women she went to elementary school with six decades ago, something that’s unthinkable to me.)

Another reason Japanese live a long time is the health care system here, in which private institutions provide health services according to highly structured price schedules imposed by the National Health Insurance System.

Currently Japan is going through “Health Insurance Hell” as various changes that kicked in April 1st continue to cause mass confusion.

For starters, Japan used to offer free healthcare to everyone over the age of 75, but this has changed, and under the new system, some elderly users must pay a monthly premium. It’s not clear which groups this applies to, however, and it’s feared that the new system, which makes people pay more for health insurance the more often they use medical services, will keep sick people from going to the hospital.

In addition, the government saw fit to change the Health Insurance Card from a large booklet to a paper-thin card, which is easily lost or thrown away by elderly Japanese.

The Japanese government announced recently that it is considering relaxing the country’s immigration laws in a bid to reach a alien resident population of 10% by the year 2050. At the time we thought they were talking about people from other countries, but Reuters is reporting:

[A] project, led by Japanese astronomers, will bring together a dozen or more observatories from all over the country to study one star that researchers see as a potential home to an extraterrestrial civilization.

“Everyone wonders at least once in their lifetime whether space is infinite and whether aliens really do exist,” said Shinya Narusawa, chief researcher at Nishi-Harima Astronomical Observatory in western Japan.

The search for aliens and UFOs is not new to Japan. Last year, unidentified flying objects grabbed the headlines after a lawmaker submitted a question to the cabinet on whether the country had confirmed any cases of their existence. The government’s answer: no.

In the scientific world, Japanese researchers have used antennas to catch radio signals from outer space and analyzed the prisms of celestial lights to see if any laser emissions from space can be found, Narusawa said.

Thanks to RTN.

The things you learn online…  In this week’s issue of Time Magazine there is an um, ah, er, interesting piece on Japanese pornography featuring the elderly.

Japan is repeatedly found to be one of the most sexless societies in the industrialized world. The WHO reported in March this year found that one in four married couples in Japan had not made love in the previous year, while 38% of couples in their 50s no longer have sex at all. Yet, at the same time, the country has seen a surge in demand for pornography that has turned adult videos into a billion-dollar industry, with “elder porn” one of its fastest growing genres.

Tokuda’s exploits have proved to be a goldmine for Glory Quest, which first launched an “old-man” series, Maniac Training of Lolitas, in December 2004. Its popularity led the company to follow up with Tokuda starring in Forbidden Elderly Care in August 2006. Other series followed, and soon elder porn had revealed itself as a sustainable new revenue stream for the industry. “The adult video industry is very competitive,” says Glory Quest p.r. representative Kayoko Iimura. “If we only make standard fare, we cannot beat other studios. There were already adult videos with Lolitas or themes of incest, so we wanted to make something new. A relationship between wife and an old father-in-law has enough twist to create an atmosphere of mystery and captivate viewers’ hearts.”

Japan’s adult video industry is believed to be worth as much as $1 billion a year according to industry insiders, with the largest rental video store chain Tsutaya releases about 1,000 new titles monthly, while and the mega adult mail-order site DMM releases about 2,000 titles each month. Although films featuring women in their teens and 20s are the mainstay of the industry, a trend toward “mature women” has become evident over the past five years. Currently, about 300 of the 1,000 adult videos on offer at Tsutaya, and 400 out of the 2,000 at DMM, are “mature women” films.

The same Washington Post reporter who gave us Jero earlier in the week (Blaine Harden) is reporting on the Japanese labor shortage due to the greying of Japan and a hesitancy to increase immigration to deal with the problem.

Now Japan faces a fundamental threat to its future — demographic decline that experts say will delete 70 percent of its workforce by 2050.  Inside the government, there is growing agreement that Japan can head off disastrous population decline by significantly increasing immigration. Japan has the world’s highest proportion of people older than 65 and the world’s smallest proportion of children younger than 15. Without immigration in substantial numbers, it will soon run perilously low on people of working age.

Yet among highly developed countries, Japan has always ranked near the bottom in the percentage of foreign-born residents. In the United States, about 12 percent are foreign-born; in Japan, just 1.6 percent. Most immigrants here are from Asia or South America. The largest number come from Korea (about 600,000 people), followed by China and Brazil. The Brazilians are mostly of mixed Japanese descent.

Yet there is little or no political will here to persuade or prepare the public to accept a sizable influx of foreigners. “There are people who say that if we accept more immigrants, crime will increase,” Fukuda said. “Any sudden increase in immigrants causing social chaos [and] social unrest is a result that we must avoid by all means.”

There is another way for Japan to slow population decline and maintain its workforce: persuade more Japanese women to marry, have children and remain on the job. The percentage of women who choose to stay single has doubled in the past two decades. When they do marry and have children, they drop out of the workforce at far higher rates than in other wealthy countries. To that end, the government is working on a bill to require companies to offer shorter hours to parents with young children and to stop requiring them to work overtime.

I often have conversations with a slightly older generation of people in Japan about how cultural values have changed, and how youth no longer respect their elders. An izakaya owner put it to me like this: “They are now more individual, but they do not have the respect for tradition that we did.” It’s a lament you hear constantly.

It was interesting, therefore, to read Haruki Murakami’s thoughts on the subject in a somewhat rare interview published in the Japan Times, which I’d encourage all of you interested in contemporary Japan to read. Some salient quotes:

Murakami, 59, is a baby boomer who is deeply interested in the problems of his generation. “Our generation tended to pick the best of everything by upholding idealism while engaged in a revolutionary struggle without believing in a revolution.”

But once members of this generation graduated from school, many became company employees. “This time, they became corporate soldiers, developed the economy, created a bubble and called it quits by bursting it. The baby-boom generation was at its core. So, I think someone has to take responsibility.”

I found this notion that Murakami’s generation was engaged in revolution–without actually believing in revolution–fascinating, as though there really is a half-way commitment to change. Certainly Japundit has fostered numerous conversations over the years about how slowly change takes place, and how uncommitted people are to seeing it through.

The collapse of the bubble economy in the first half of the 1990s coincided with the collapse of the Cold War structure. Everybody thought peace was at hand, but what came was a chaotic world.

“Especially after Sept. 11 (2001), we live in a world in which nobody knows what will happen next. My novels are about stories in which nobody knows what will happen next. That may be the reason readers have an affinity for my novels.”

The Japanese also harbored the illusion that if they worked hard, they would become rich and happy, but that has been totally crushed. “So, they were forced to face the facts about what they are. But that is very uncomfortable.”

On a somewhat related note, I was curious to see very few Louis Vuitton handbags in Japan this time around. Even a few years ago, the outrageously expensive (and to my eye, bland) Hermes tote bag seemed to be everywhere. I have no real way of proving what I saw–aside from a bunch of photos of people in trains not carrying designer gear. Perhaps there is a change of sorts, more in attitude than anything else, about wealth and the future and relating to the world at large. Others disagree, and perhaps are completely correct.

What do all of you out there think: is the baby boomer generation, as Murakami suggests, not committed to change? And on a shallow note, do you see fewer brand items circulating around?

The city of Fukuoka has announced plans to set up collection boxes at nine location around the city to allow people to discard used dentures.

False teeth that are collected will be recycled to recover any precious metals, and 80 percent of any profits earned will go to charities

Recycling the gold, silver and palladium in false teeth can yield as much as 3,000 yen per set — enough to buy eight blankets — and officials are hoping that the collection of dentures will add some teeth to their charity efforts.

In still one more piece of news that does not bode well for Japan’s shrinking population, the number of single households here has surpassed the number married with at least one child households for the first time in 2006, according to a report published by the National Institute of Population and Social Security Research.

There were 14.71 million single-member households, eclipsing the 14.55 million households of married couples with one child or more, which had prevailed until 2005, the report said Friday.

The research institute estimates the gap between the two categories will further widen, and in 2030, single households will increase to 18.24 million and households of married couples with one child or more will decrease to 10.7 million.

Households headed by people aged 75 or older will reach 11.1 million in 2030, almost double the 5.54 million registered in 2005. The number of single households where residents are 75 or older will increase to 4.29 million in 2030 from 1.97 million in 2005. Households headed by people aged 65 or older will rise from 13.55 million in 2005 to 19.03 million in 2030, according to the report.

He made his only previous appearance in the Olympic Games in Tokyo in 1964 at the age of 22. You might expect 66-year-old Hiroshi Hoketsu to be looking forward to spectating at this year’s games, but remarkably, after a 44-year absence, he stands to make a record-breaking comeback when Japan officially announces its Olympic team next week.

Azusa Kitano of the Japan Equestrian Federation said of Hoketsu -

He will be in the team dressage. He hasn’t been at an Olympics since 1964, which was 44 years ago, but he has continued riding all this time. He’s up at 5 am every day. He’s what horse riding is all about. I want to congratulate him with all my heart.

Mr Hoketsu, who will almost certainly garner an enormous amount of media attention (he was all over the breakfast shows today), would not however be the oldest ever Olympic competitor. That record belongs to Sweden’s Oscar Swahn, who took part in the 1920 Antwerp Games aged 72.

Photo: Japan Equestrian Federation

For those needing another statistic indicating that the Japanese population is aging, the National Police Agency (NPA) has revealed that people 65 and older accounted just about half of all traffic fatalities last year.

The poll showed there were 2,727 elderly people who died in traffic accidents in 2007, making up 47.5 percent of all traffic accident fatalities across the nation, which stood at 5,744 in total. The figure was the highest since records started being kept in 1967.

Meanwhile, traffic fatalities involving young people aged between 16 and 24 stood at 670 in 2007, about one-third of the figure reported in 1997.

Before giving the impression that demented geezers are dying because they are running into brick walls in their Toyotas, it should be pointed out that half of the fatalities involved seniors being killed while they were on foot.

A starving homeless 70-year-old woman who was dumped by an ambulance outside the Hamamatsu, Japan city hall died after municipal officials did nothing to help her.

Officials said a police officer found the homeless woman in a weak state near Hamamatsu Station at about noon on Nov. 22, and called for an ambulance. The woman told paramedics that she had not eaten for four days and wanted some food. Since she did not show any signs of illness or injury, she was taken to city hall, which has a social welfare division.

The woman got out of the ambulance herself, but she soon lay down on the asphalt. Social welfare division officials gave her a packet of dried rice used as emergency food. To eat it, however, she had to open the packet and wait 20 to 30 minutes after adding hot water or 60 to 70 minutes after adding cold water.

Municipal government officials watched over the woman and considered what to do with her, but she was not taken anywhere.

A member of a support group for homeless people was the one who discovered the woman had died.

“Before I came, no one touched her body and checked her condition even though a public health nurse was present,” the member said. “Couldn’t they have taken her inside or at least have laid a blanket down on the road for her?”

The member said that when he approached the woman, the emergency food was unopened on her chest.

Rather than showing any remorse for the poor woman who died on their doorstep, government employees insisted they handled the situation the best that they could.

“Within the scope of what we were authorized to do, we did everything that should have been done,” a social welfare section official said. “To workers, the woman didn’t appear debilitated. They aren’t doctors so they couldn’t predict that her condition would suddenly change.”

. . .

“Workers gave emergency food to the woman, who was complaining of hunger, and considered what welfare facilities she could be taken to. They also called for an ambulance the second time. They did not evade their duties or fail to carry out their legal responsibilities,” a report by the Naka-ku social welfare division said.

The cause of death was acute heart failure.

Yesterday was Coming of Age Day, a national holiday in Japan during which everyone who will reach majority (20 years old in Japan) during the year celebrates their new status.

This year’s festivities, however, were a bit dampened by the news that new adults in Japan last year numbered only 1.35 million (690,000 men and 660,000 women), the lowest number on record.

Of course, the big question facing Japan right now is how is a dwindling pool of workers going to be able to pay for the care of a rapidly expanding population of retirees.

A recent incident in Osaka underscores a government-created medical emergency in Japan that most probably will only get worse.

Last week an 89-year-old woman whose family called an ambulance when she started experiencing vomiting and diarrhea died after she was rejected for admittance by thirty hospitals. The poor woman was finally admitted two hours after the family called the ambulance.

The hospitals rejected the woman because they claimed they were too full or that doctors were not available to treat her.

The latest case underscores Japan’s health care woes, in part created by a shortage of doctors in the country’s rapidly aging society. Critics say long working hours and a government policy change several years ago to keep the number of doctors down are to blame.

Faced with a rapidly aging society, the government implements a policy to limit the number of doctors in the country. . . Brilliant!

Thanks to Vin Alsace

In a “free trade pact” with Indonesia, Japan has agreed to accept 1,000 nurses and health care workers starting from next year. This is the first time that Japan has agreed to bring in full-time foreign nurses and care workers.

For two years from April, Japan will annually accept 200 licensed nurses and 300 certified care workers, the newspaper said. If the program is well received, the figures may be increased for the third year, the Nikkei said.

Nurses will be limited to staying for three years and care workers for four years on their Indonesian certificates and licenses. But they can extend their stay by passing Japanese nursing exams or receiving Japanese caregivers certificates.

The workers will work as assistants at hospitals and nursing care facilities after receiving language training.

The Japanese government also is in negotiations with The Philippines for a similar partnership in order to alleviate shortages of 450,000 to 550,000 such workers, which is expected to hit by 2014.

By now, just about everyone has heard that Japan’s population is getting older at a rate that promises to increase in the coming years. Nevertheless, I was pretty surprised to find out that oldsters 75 and older already make up 10% off Japan’s population.

People 75 and older now constitute 10 percent of the population, the government said Wednesday, underscoring the rapid growth in Japan’s elderly.

The figure was 1.3 percent in 1950, when the government first started tracking such data, and rose to 5 percent in 1991 before breaking the 10 percent mark this year, the Internal Affairs and Communications Ministry said.

At in the people 65 and older, and the ratio jumps to 21.5%.

How about the youngsters?

Those aged 14 or younger, meanwhile, totaled 17.28 million, down 140,000 from a year ago and making up 13.5 percent of the population. The ratio was 35.4 percent in 1950.

Whoa!

Workers at an Osaka hospital abandoned a blind patient, who also suffers from diabetes, at a public park after his ex-wife refused to take him off of their hands.

Four workers took the 63-year-old patient to his home in Sumiyoshi-ku, Osaka, by car on the afternoon of Sept. 21 after he failed to pay medical fees to the hospital for two years, hospital and local health center officials said. The man was healthy enough to be released from hospital.

After his former wife refused to take him in because she was ill, the four workers took him to a park in Nishinari-ku, Osaka, later in the day, and abandoned him there, according to the officials.

One of the workers called an ambulance saying that a man appearing to be in his 60s, who apparently was visually impaired, had collapsed at the park. Paramedics rescued him there.

The man was admitted to the hospital seven years ago, but was unable to keep up with payments from about two years ago after his welfare benefits were cut. The man was violent during his stay at the medical institution, destroying hospital equipment and verbally abusing nurses.

As anyone who listens to our Japan Talk podcast knows, pregnant women can have a very hard time getted admitted to a hospital should an emergency situation suddenly come up during their pregnancy.

Well, according reports coming out of Yokohama City University, the situation does not look like it will change any time soon, and may even be destined to become worse.

Most medical students at Yokohama City University are shunning a career in obstetrics-gynecology, according to a survey released Thursday that seems to suggest the nation’s shortage of such specialists will only worsen.

The poll, conducted by medical students at the school and covering 320 students, including 307 from the college, found only 4 percent willing to pursue OB-GYN as their first career choice, although 29 percent said they had once wanted to enter the field.

The main reasons students give for shying away from the OB-GYN field is inconvenient on-call shifts and a high risk of being involved in malpractice suits.