Brain Death and Transplantation: The Japanese

Mona Newsome Wicks, PhD, RN, CCRN

Disclosures

April 25, 2000

Introduction

All cultures struggle with issues related to life and death; however, the reasons for conflict are often embedded within the unspoken assumptions of each culture.[1] The Japanese have grappled with the ethical, legal, and moral issues surrounding brain death for over 30 years. While the 1997 Organ Transplant Law legalized organ procurement from brain dead donors, the controversy surrounding this issue persists. Sixteen months elapsed between passage of the law and performance of the first legal heart, cornea, kidney, and liver transplant procedures using organs procured from a brain-dead donor.[2] Like most nations, Japan has a very limited supply of donor organs. Given the extreme shortage of living donor organs and the existence of the Organ Transplant Law, why are the Japanese reluctant to use brain-dead donors? A complex mix of historic events, cultural and bioethical factors, and resource issues hinder widespread acceptance of the procedure.

Unlike many industrialized nations, Japan is unique in its reliance on living donor organs.[3] Approximately 70% of transplanted kidneys and 80% of segmental liver procedures performed in Japan are live donor organs. This is in contrast to the United States, where 68% of kidneys and 98% of livers transplanted in 1998 were obtained from cadaveric donors.[4]

Japan's organ transplant legislation protects donors' rights and emphasizes the voluntary nature of organ donation, while preserving the rights of families to refuse organ donation.[3] The law also provides clear guidelines regarding when relatives can and cannot decide on organ donation for a brain-dead donor when documentation of the donor's wishes do not exist.[3] The law stipulates that 2 physicians confirm brain death prior to organ procurement and that donors must be over 16 years of age and recipients at least 6 years of age.[5]

Debates regarding the determination of brain death as a criterion for organ procurement began in Japan in 1968[6] when Japanese surgeon Dr. Wada performed the world's second heart transplant using an organ procured from a brain-dead donor.[1] Although initially heralded as a scientific achievement, Wada was later arrested for murder but acquitted after 6 years of litigation.[7] This controversial event left a legacy of mistrust related to the appropriate use of brain death criteria within the context of transplantation. Allegations of impropriety associated with the donor's treatment and determination of brain death were extensively publicized. In addition, the organ recipient's condition was reportedly noncritical and did not warrant the procedure.[6] Unfortunately, the recipient died 83 days after receiving the transplanted heart. As a result of the scandal, the phrase "heart transplantation" was forbidden in Japan for nearly 15 years.[6]

Survey data indicate that almost 50% of Japanese people equate brain death with human death.[6] Although this figure is similar to that reported in Western countries,[8,9] there was no parallel outcry by the Western news media regarding the source of these organs.[10] Morioka suggests that the combined influence of the Wada case, traditional Japanese beliefs related to death, distrust of Japanese physicians, doubts about the criteria used to establish brain death, and the clash between the Japanese autopsy system and transplantation procedures potentially explains the Japanese brain death debate. The graphic and intrusive nature of recent media coverage of families who have willingly donated organs from brain-dead relatives may have also dissuaded widespread acceptance of the procedure.[5]

Bioethics emerged from the patients' rights movement that occurred in the United States during the 1960s and 1970s.[6] The movement challenged paternalistic medical practices, gave patients the right to participate in healthcare decision making, and provided a forum for public policy development.[6] Interest in bioethics occurred in Japan during the early 1980s in response to the brain death debate. Prior to the emergence of bioethics, Japanese physicians practiced "closed-door" medicine and policy development was the responsibility of academicians, bureaucrats, and appointed professionals.[3] Within the closed-door system, patients were neither given information about their health nor permitted to criticize their physicians. Fear regarding the process of brain death determination, the lack of information shared by physicians, and the possibility that doctors might threaten families that refused to donate the organs of brain-dead relatives led patients' rights advocates to press for a more open-door policy. Japanese advocacy groups are more vocal in their desire to participate in policy development, despite the fact that professional bioethics committees typically exclude participation by laypersons.[3] Exclusion of laypersons obscures the brain death debate from public scrutiny and fuels questions regarding the scientific integrity of the process.[3]

Brain death and transplantation also reflect the modernization of medicine, which many Japanese believe is a reflection of Western influence[6] Like most cultures, Japanese culture has evolved as a result of both internal and external social forces. The maintenance of cultural identity, however, is important to cultural integrity. Morioka notes that some Japanese scholars advocate that East Asian bioethics must be culturally relevant and need not reflect Euro-American values.

Acceptance of the evolving Japanese position on brain death and transplantation requires a basic knowledge of the cultural meanings ascribed to death. Diverse opinions exist among the Japanese regarding the meaning of death. Traditionally, however, death is viewed by the Japanese as a social event, rather than medically determined phenomena.[7] Many Japanese have an aversion to tampering with the integrity of the corpse because they believe that the body and soul remain together and arise in the next life.[11,12] Traditional Buddhist and Shinto teachings provide the basis for these beliefs.[11] Brain death criteria focus on the cessation of brain function although other vital functions continue. Death as cessation of brain function separate from other bodily functions is inconsistent with the Japanese perspective of death of the whole person.[12] Within the Western perspective, in general, the mind and body are perceived as separate, and personal identity is thought to reside within the brain. Traditional Japanese perspective places equal if not greater symbolic importance on the heart, because bodily warmth is equated with life energy.[11] Determination of brain death creates confusion because the final result is a warm body with a beating heart and reflex movement.[12] Cessation of heart function is shrouded within the confines of organ procurement, creating a death that is mienai shi (death that cannot be seen).[7]

According to Hasegawa and colleagues,[13] the Organ Donation Law, along with related regulations, limits donor institutions to university hospitals and hospitals authorized by the Japan Emergency Medicine Association. Future plans exist, however, to include emergency medical centers and hospitals authorized by the Japan Neurosurgery Association.[13] Many authorized institutions are not ready to determine brain death. The Japanese Health and Welfare Ministry acknowledged, in November 1998, that approximately 50% of authorized institutions were prepared to implement the procedure.[5]

Coupled with the need to prepare institutions to procure organs from brain-dead donors, Japanese transplantation programs are faced with the reluctance of some physicians to authorize organ removal because of the threat of litigation.[5] Neurosurgeons have advocated that the Ministry of Health and Welfare clarify the legal responsibilities of organ transplantation, establish reserve systems to provide staff and materials to diagnose brain death, clarify the cost for the diagnosis of brain death and organ removal, and educate the public about organ transplantation.[14]

While almost half of Japanese people accept brain death as consistent with death, organ procurement from brain-dead donors is not widely accepted in Japan. Several factors contribute to this position, including distrust of physicians, past improprieties in determining brain death, insufficient resources (ie, staff and technology) to adequately apply brain death criteria, and traditional cultural beliefs concerning life and death. Whether or not Westerners accept the rationale for the ongoing Japanese debate about the use of organs from brain-dead donors is not the primary issue. Clearly there is the need to explore the social and cultural context of this controversy to better understand and facilitate cross-cultural discourse. Marshall and Koenig[15] argue that cultural aspects of transplantation should not be viewed as barriers to be overcome, but as opportunities for understanding complex social and biomedical issues associated with the practice of organ transplantation.

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