Jtournal ofMedical Ethics 1999;25:322-324 J Med Ethics: first published as 10.1136/jme.25.4.322 on 1 August 1999. Downloaded from

The ambiguity about death in Japan: an ethical implication for organ procurement John Robert McConnell, III The University of Tennessee, Knoxville, Tennessee

Abstract Japanese religion In the latter half of the twentieth century, developed To understand the fierce debate over transplanta- countries of the world have made tremendous strides tion that has plagued Japan for over a quarter of a in organ donation and transplantation. However, in century, one must examine the religious beliefs this area ofmedicine, J7apan has been slow to follow. that have precipitated this ethical dilemma. The Japanese ethics, deeply rooted in religion and major religions ofJapan are Shinto, Taoism, Con- tradition, have affected their outlook on life and fucianism, and Buddhism.' While these religions death. Because the J7apanese have only recently are unique and often practised separately in the started to acknowledge the concept of brain death, world, the typical Japanese household often transplantation of major organs has been hindered in adopts a combination of their traditions. For that country. Currently, there is a dual definition of example, Shinto's emphasis on the present is so death in J7apan, intended to satisfy both sides of the dominant that it does not address rituals or issue. This interesting paradox, which still stands to customs upon the death of a follower. Conse- be fully resolved, illustrates the contentious conflict quently, many Shinto priests observe Taoist and Buddhist practices to consecrate the dead. Be- between medical ethics and medical progress in copyright. Japan. cause of the religious overlap in many of the Japa- nese traditions, as with this one regarding the (Journal ofMedical Ethics 1999;25:322-324) treatment of the dead, a study of each religion Keywords: Organ transplantation; brain death; Japan and, specifically, how they play a role in their atti- tude towards transplantation, is critical. The majority ofthe population practises Shinto,

which is indigenous to Japan. The preservation ofhttp://jme.bmj.com/ Introduction life, the promotion of good health, and the In 1968, the first heart transplant was attempted harmonisation with nature in accordance with the in Japan; that was to be the last for over a quarter way of the kami, or Japanese divinities, are the of a century. In an unfortunate display of irony, three basic goals of Shinto. These principles ofthe the Japanese surgeon who should have been Shinto faith place such a priority on life that the heralded as a pioneer of an operation that would extraction of organs from a donor's body is save thousands of lives was instead charged with acceptable as long as it is saving or bettering on September 28, 2021 by guest. Protected a murder ofthe donor and criminal allegations were human life; otherwise, it is deemed sacrilegious. made that would inhibit all further attempts in the Living donor transplants, such as a kidney or par- years to come. This predicament, however, stems tial liver, and cadaverous transplants, such as skin from Japanese ethics that were established many grafts and corneas, are permitted and frequently years ago. Religion has a profound influence in used.' Yet it is because of these same principles Japan, one that dictates the Japanese attitude that the determination of death has been fiercely towards life, as well as their beliefs about death. debated in Japan. Shinto followers believe that to Undeniably, this phenomenon has its beneficial declare death while the heart is still beating is pre- effects. Yet in a seemingly technologically ad- mature, as well as unnatural; again, nature is para- vanced society, it also provokes adverse conse- mount in their beliefs. This has been the greatest quences when confronted with developments at obstacle in their acceptance of brain death, which odds with popular belief, as the issue of organ is absolutely necessary for the transplantation of transplantation illustrates. The ethical and spir- vital organs such as the heart and liver. itual foundations of the Japanese mentality have Taoism and Confucianism are religions that hindered the progress of transplantation in Japan, have migrated from China and have greatly influ- sacrificing thousands of lives each year, and thus enced the ethics of Japan. Confucius taught that invoking a reevaluation of their ideals. mankind possessed a general goodness and McConnell 323 J Med Ethics: first published as 10.1136/jme.25.4.322 on 1 August 1999. Downloaded from encouraged the suppression of individual desires Japanese medical community to study a proposi- in order to benefit humanity. Through the virtue tion accepting brain death.3 The prerequisite of ofjen, or kindness, the idea of organ transplanta- brain death, according to the Japanese study, was tion is supported. However, Taoism also affects the evidence of a gross primary brain lesion. The many Japanese beliefs and customs, especially the criteria for this diagnosis were deep coma, apnoea, attitude towards the afterlife. Basically, Taoism bilateral dilated pupils, absent pupillary and suggests that the human body is a microcosm of corneal reflexes, isoelectric electroencephalo- the universe. Taoists believe that the body must be grams (EEGs), and persistent hypotension, with preserved to provide the soul with a resting-place blood pressure 40 mmHg below normal. At that upon death, to ensure immortality. Accordingly, time, only four per cent of the Japanese subjects Taoist priests have incorporated complicated, and involved in the study met the criteria and sometimes elaborate, rituals to channel life- retrospective studies indicate that they were all enhancing spirits into the body. To mutilate any of diagnosed accurately, as having complete cessa- the body parts, for instance, by the extraction of tion of brain activity that was irretrievable. organs, would be considered heretical. Naturally, Evidently, this study did nothing to affect attitudes this has also contributed to the conflict between towards transplantation at the time. However, cultural tradition and modern practicality. growing public concern about the necessity of The Mahayana form of Buddhism plays a organ transplants escalated in the 1990s. One case minor, yet significant role in Japanese ethics, par- that received widespread media coverage in Japan ticularly in funeral proceedings and the belief in was the death of Miyuki Monobe, an eight-year- an afterlife. The goal ofthe Buddhists is to acquire old girl awaiting a heart transplant. The medical nirvana, or rebirth; they are on a never-ending establishment fed her story to the media to quest for enlightenment. Similar to Taoism, Bud- strengthen public sentiment in favour of dhism has developed complicated rituals for the transplantation.4 procurement of an afterlife. In addition, Bud- Until recently, Japan, along with Poland and dhists tend to hold a somewhat pacifist attitude copyright. Pakistan, discouraged the concept of brain death. towards the present life, resulting in a lack of in April 1997, the lower diet of the motivation to donate or receive tissue or organs However, for transplantation. Japanese parliament approved a measure which would legalise the determination of death by EEG. Although this same bill was rejected by the Death's ambiguity in Japan in in The blend of Shinto, Taoist, Confucian and Bud- upper diet, a resolution was passed June 1997

an effort to compromise between those who http://jme.bmj.com/ dhist beliefs in Japanese society has culminated in accepted brain-death determination and those a social consensus that organ transplantation who rejected it. The result, much to the dismay of devalues life, as well as the afterlife. While the majority of the medical establishment in Japan the medical establishment, is a dual definition of have suppressed these cultural attitudes in favour death in Japan.' In order to allow heart and lung of the concept of brain death and organ transplants, Japan has legalised brain death when transplantation, the vast elderly population con- the deceased is an organ donor; in cases where the tinues to uphold these traditional values. In com- deceased is not a donor, the time of death is on September 28, 2021 by guest. Protected bination with the tremendous respect that is recorded when the heart stops beating. This unu- displayed towards the elderly and their traditional sual stance has created a double standard on the values, there is a general mistrust of the Japanese determination of death that has added to the medical profession that has made government bureaucracy involved in Japanese medical care. officials reluctant to grant Japanese surgeons more The donor must consent to the diagnosis of brain authority in the determination of death and organ death prior to death and garner the support of his transplantation. or her family. In addition, the cessation of brain The recent effect of the Japaneses' inability to activity must be declared by two or more accept brain death has been profound. It has physicians who are not participating in the actual hampered the opportunity for Japanese citizens procurement or transplantation of the organs. who need heart, lung and liver transplants to While this resolution is a step in the right direction receive them, especially those of lower economic in the eyes of the Japanese, as indicated by recent status. In order to have such a transplant Japanese polls, its stringent conditions will probably keep citizens must travel outside the country to places the number of heart, lung and liver transplant such as India, Australia, and the United States. operations to a minimum. It remains to be seen Sometimes, this requires the purchase of organs, whether, as the older generation, with its con- as well. Prior to 1980, an effort was made by the servative attitude towards brain death and organ 324 The ambiguity about death in _Japan: an ethical implication for organ procurement J Med Ethics: first published as 10.1136/jme.25.4.322 on 1 August 1999. Downloaded from procurement, dies, greater acceptance of and an References inverse in Japanese organ transplantation will result. 1 Craven J, Rodin G, eds. Psychiatric aspects of organ transplanta- tion. New York: Oxford University Press, 1992. 2 Pallis C. ABC of brainstem death [2nd ed]. London: BMJ Pub- Acknowledgments lishing Group, 1996. I thank the University of Tennessee at Knoxville, 3 National Institute of Neurological and Communicative Disor- particularly the Philosophy Department, for use ders and Stroke. The NINCDS collaborative study ofbrain death. Bethesda: National Institute of Health, 1980. of its resources. 4 Jordan M. Brain-death bill passes easily in Japanese House. The Washington Post 1997 Apr 25: sect A:36 (col 1). John Robert McConnell, III is a student at the 5 WuDunn S. Japanese lawmakers vote to allow heart and lung University of Tennessee. transplants. The New York Times 1997 June 18: sect A: 6 (col 2). copyright. http://jme.bmj.com/ on September 28, 2021 by guest. Protected