In Reply: Drs Nagamatsu and Yamashita suggest important possible determinants of perceptions of appropriateness of care. However, in keeping with our study's aim, we sought to collect subjective perceptions from bedside clinicians. Perceived inappropriateness of care ranged between 8% and 49% across participating countries in our study and was related to differences in the ethical environment—the worse the ethical climate, the higher the prevalence of perceptions of inappropriate care. While we acknowledge that national laws, health care structures, and other societal factors have an important influence on perceptions of appropriateness of care, as shown in the examples given by Nagamatsu and Yamashita, we believe that actual perceptions are the most important targets for efforts to improve care for patients and working environments for clinicians across nations and cultures.
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