Dr Flower’s manuscript impressed me by drawing an analogy between intensive care medicine (ICM) and martial arts.1,2 I began practicing Shotokan karate as a young child, followed by training in kobudo, aikido, mixed martial arts, and ultimately kendo and iaido. At the age of 58, I would like to offer my perspectives as both an intensivist and a martial artist.
Japanese martial arts are governed by the bushido code (way of the warrior) which, although it has evolved since its origins, emphasizes justice (“gi”), courage (“yu”), benevolence (“jin”), respect (“rei”), honesty (‘makoto’), honor (“meiyo”), and loyalty (“chuugi”). Similarly, intensivists face death regularly and must accept it as part of their profession. Table 1.
Similarity between the Bushido code and principles in martial arts and intensive care medicine.
| Bushido code | Equivalent in intensive care medicine |
|---|---|
| 1/ Justice | Principle of bioethics. |
| 2/ Courage | Bravely make important decisions, face reality, and accept potential risks. |
| 3/Benevolence | Act carefully. Apply your knowledge with kindness and compassion. |
| 4/ Respect | Demonstrating consideration, appreciation, and esteem, as well as courteously respecting the preferences of patients and their families, is fundamental. It is also important to acknowledge and value our instructors and recognise the contributions of our colleagues. |
| 5/ Sincerely | Acknowledge reality, particularly regarding patient prognoses and possible actions. Avoid paternalism; patients should make their own decisions. Be honest with colleagues. |
| 6/ Honor | To be able to see yourself clearly reflected in a mirror or to be able to sleep without remembering any blemishes is the way forward. |
| 7/ Loyalty. | You must prioritize the interests of our patients over our own. Committed to serving and caring for patients and the community with a focus on service over authority. |
| Principles in martial arts | Equivalent in intensive care medicine |
|---|---|
| 1/ Martial Arts must be restricted exclusively to legitimate self-defense. | Act according to evidence-based medicine and do no harm. |
| 2/ Martial Arts demand total and absolute dedication; the practitioner must train without interruption. | Understand that Intensive Care Medicine influences our lives and perseverance is required. A way to achieve this is through discipline. |
| 3/ One should carefully listen to the sensei's words and guidance, taking them in fully. | One must study and, at the same time, learn from the experience of masters. |
| 4/ Students of martial arts should consistently demonstrate respect and honour to their instructors. | We should respect our teachers, not ridicule them, and take their experience into account. |
| 5/ Students should always be kind, friendly, and act with complete kindness toward their classmates. | The intensivist should humanize; we cannot lose this perspective. Forgive colleagues' mistakes, help them grow, and improve yourself in the process. |
| 6/ The senior student (senpai) should help the junior (kohai), and the latter should accept their teachings. | We must share knowledge, teach in a pyramidal structure, and maintain teamwork. |
| 7/ Outside the school, the student must never show techniques to the uninitiated, even if it means refusing a challenge. | We must teach and apply knowledge with prudence and by levels. |
| 8/ The student should not be aggressive and must maintain constant harmony with Everything and with everyone. | We should avoid any act that could cause harm and keep extremist attitudes at bay. |
| 9/ The knowledge of Martial Arts should only be passed on to those who are peaceful. | We should share our knowledge with people who are honest and respectful. |
In martial arts, “Sensei” and students (“deshi” or “kohai”), remain lifelong learners. Discipline fosters focus and steady progress, helping one stay calm and clear-headed in danger. Dojo walls often display photos of respected senseis like Gichin Funakoshi, Morihei Ueshiba, Shinken Taira, and Nakayama Hiromichi, who became widely recognized for their modesty. As intensivists, we should honour our mentors. The experience of intensivists aged 60–70 can be as valuable as, or strongly complement, artificial intelligence. Younger trainees may have more energy, but a sensei’s skill and composure keep them ahead regardless of age. This perspective applies not only to ICM, but also to life itself. Student and teacher form a group in which both contribute. Fig. 1.
Placing emphasis on preserving life and minimising harm can sometimes require refraining from responding to aggression to avoid escalating the situation. In martial arts, it is considered more prudent to absorb a blow than to initiate conflict.
Intensivists may pursue interventions based on pride or incomplete understanding of pathophysiology, which often relies on trial and error. Ethical values like justice, honesty, and kindness must guide our actions. Medicine is becoming more administrative and technical, reducing genuine patient interaction and prioritizing documentation over care. While we discuss “humanization,” it is rarely practiced; martial arts exemplify human values such as discipline and respect. Medical practitioners should demonstrate perseverance and courage, avoid shortcuts like inadequate training or superficial online resources, and instead engage in thorough scientific research when addressing challenging cases.3–5
As intensivists, we must reflect on whether our decisions truly benefit patients, as overconfidence may lead to errors. Unintentionally, our field might see higher mortality rates than martial arts or the military. Intensivists should be open-minded, adaptable, patient, composed, and goal oriented. Mastery is an ongoing process, with the aim being protection rather than aggression.
When action is required, both intensivists and martial artists must adhere to this code: work together in an organized and hierarchical manner, avoid internal conflicts, and strive collectively for the well-being of the group and the patient.
I earned my first black belt young, and at 29 received intensive care certification. Both marked just the start of my learning. Ten years in kendo and iaido taught me that mastering a shinken requires experience, just as sound decision-making does in healthcare. Both fields demand facing fear; though failure is possible, perseverance, courage, honour, and loyalty lead to success or effective care.
We must maintain our own well-being before acting, support our team, communicate transparently, balance family life, and avoid burnout. Maintaining physical and mental health is essential for effectiveness, as we cannot offer what we lack.
While I have gained skills through training, I realize I still fall short of fully complying with this code, including in my ICM experience. My studies and work have only recently highlighted the importance of human values in patient care. I admit that at times I've prioritized my own interests over professional obligations, but acknowledging these shortcomings enables me to focus on self-improvement and better patient care.
In conclusion, ICM and martial arts are a way of life that shapes us as individuals.
CRediT authorship contribution statementSole author who completed all work.
Declaration of Generative AI and AI-assisted technologies in the writing process
Yes, for information gathering. https://www.openevidence.com/.
FundingNone.
I have no conflicts of interest.
I would like to thank and pay my respects to all my instructors in martial arts and intensive medicine.
