A majority of Japanese, at present, feel that the modern biomedical and technological innovations pertaining to human life and death have been forcing a change in our common understanding of what, historically, was simply the natural event and process of death and dying. The meaning of death and the dying process in our lives is changing as have the traditional criteria for determining death, namely, cessation of heartbeat and respiration.
An individual's death should be a personal and private matter as well as a familial, communal, and social matter. It has been regarded as such for many thousands of years in our Japanese society and culture. It is well understood that our traditional socio-cultural understanding of human life positively admits the natural process of death as the final event of life. The ideas expressed in Zen-Buddhist phrases such as "accept death as it is" and "life-death as one phenomenon" have been key motifs totally integrated into our traditional understanding of life (Tomomatsu 1939).
However, the traditional perception of death as an acceptable process has been vanishing as the Japanese have applied modern biomedical technologies more frequently in well-equipped hospital settings. Although the involvement of family members in the process of dying and particularly in the death event continues in a variety of ways, the care of dying patients in Japan is becoming much more similar to that delivered in advanced hospital settings in many countries of the world, than it is different. Now, in Japan, a majority of people end their lives in the hospital, surrounded by high-technology machine. Yet, in a survey by the Yomiuri Shimbun of 15 June 1991, half of the respondents said they would prefer to die at home.
In addition, there has been a tradition of not explaining to terminally ill people the true nature of their condition, on the ground that this is most appropriate way to proceed (Kashiwagi 1994, pp. 78-85). However, views on this matter are changing. There is a gradual move toward telling patients the truth, and the notion of informed consent has been widely publicized in the clinical setting (Leflar 1996, pp. 96-107). In the 1991 nationwide opinion poll by the Yomiuri Shimbun, 65 percent of the participants said that they would like to be given full diagnostic information about themselves even if they were terminally ill. Nevertheless, only 22 percent of the people questioned said they themselves would definitely be prepared to disclose such information to a family member.
The same survey indicated that 78 percent of people considered palliative care desirable, even though it might shorten life, while 16 percent thought life should be sustained as long as possible, irrespective of the pain that patients might be suffering.
| CHALLENGES OF CARE FOR THE DYING |
A special task force on terminal care, set up by the Ministry of Health and Welfare, issued a report in 1989 that encouraged the disclosure of diagnostic information to patients, provided that consideration was given to patients' life histories, personalities, relationships with family members, and other factors. The report favored the use of drugs for pain control; it also dealt with matters such as spiritual requirements and the care of the family members.
Traditionally, the physician-patient relationship in Japan is based on a complete and unquestioning trust of the physician by the patient, such that the physician acts to make health care decision on behalf of the patient (Kimura 1991). However, increasingly it is believed that people should not have to accept without question the authority of doctors in the treatment of disease. Responsibility for the care of the dying should be shared between family members and all health professionals, not only physicians. Changes are needed in the mentalities of health care providers, patients, and family members, and it must be recognized that the medical system and institutions are not immutable (Annas and Miller 1994, pp. 374-76).
To complicate matters even further, although a patient's family is informed of the incurable nature of the disease affecting their family member, the patient, as noted above, usually is not told of the terminal diagnosis. Therefore, patients often do not have the information necessary to make their health care wishes known in advance should they desire to do so.
Some people express their uneasiness with the idea of a documented expression of their wishes at the end of life. They think that this serious event at the end of life should be dealt with in a more harmonious way by "tacit agreement" or "Ishin-denshin" (heart-to-heart communication without word) among the patient, family members, and the attending physician.
| A LEGAL CASE FOR EUTHANASIA IN JAPAN |
One of the most important Japanese legal precedents relating to issues of death and dying has never been applied since its establishment in 1962. The case, which is usually cited as the "Nagoya High Court Decision of 1962", involved a son who prepared poisoned milk to kill his terminally ill father in order to fulfill his father's request to spare him continued pain and suffering. The son urged his mother, who did not know that the milk was poisoned, to give it to her husband. In reaching its judgment, the court identified six conditions that must be fulfilled before one is legally permitted to end a suffering patient's life.
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(1) The patient's situation should be regarded as incurable with no hope of recovery, and death should be imminent;
(22 December 1962, Nagoya High Court, Collected Criminal Cases at High Court, vol. 15, no. 9, p. 674). |
In this case, the Nagoya High Court ruled that the first four criteria had been met, but that the final two conditions had not. The son was sentenced to four years imprisonment with three years suspended. The Japanese Criminal Code provides for severe punishment, capital punishment or life imprisonment, for ascendant homicide; however, in this case, the Court felt that the son's desire to honor his filial duty to follow his father's spoken "directives" was evident and so applied a lesser sentence.
In the light of medical and technological advances, the ramifications of the Nagoya High Court decision have changed in many ways. Conditions once considered fatal, can now be treated effectively or cured. Better methods of pain control have been developed, and about 25 hospitals with palliative care units, including hospices, have been officially recognized since 1990.
In 1991, however, a physician actively ended the life of a patient at Tokai University Hospital. The case has captured great media attention because the physician acted on the surrogate request of a family member. According to the physician, the patient's son asked the physician to alleviate his father's suffering. However, when questioned later, the son stated that he had not meant the physician to end his father's life. At the time of the alleged request, the patient was hospitalized with an incurable and terminal condition, and the patient was already comatose when the physician administered potassium chloride by injection. Due to the family's denial that they asked for help in ending the patient's life, the physician was accused of murder and dismissed from the hospital. On 28 March 1995, the physician was sentenced to two years in prison with two years suspended. Even though the case does not involve a patient's advance directive, public opinion is rather supportive of the defendant physician and of a family member's oral "directive" to ease the life of a dying patient. The involvement of family members in making surrogate decisions on behalf of patients is generally accepted behavior, and the relationship among patient, family, and physician is very important in the Japanese social context (Kimura 1995).
| CONCLUSION |
There is a widening gap between the positions of medical professionals and the lay public on issues in terminal care. The general public is more supportive of the actions of the accused physician at Tokai University and of a more recent case of active euthanasia at Kyoto Keihoku Town Hospital in April 1996. In contrast, the medical profession has a very negative view of such actions even in the case of terminally ill patients. Indeed, at present, there is no legal recognition of any type of advance directive.
However, if advance directives are legally recognized in Japan in the future, these advance directive documents preferably should be based on a more familial model of decision making. Family members might reach a decision different from that desired by the patient. Thus, individuals should share their wishes with other family members so that they can be respected. A "Family Unit Advance Directive", directed toward the family, would permit families to prepare for future decisions concerning life and death issues so they may accurately convey the patient's wishes to the physicians.
This is an abridged presentation of my research work on "Death, Dying, and Advance Directives in Japan", part of a comparative research project with Germany and the United States supported by the Volkswagen Foundation. I would like to express my great thanks to the foundation and to the directors of the research project, Dr. Hans-Martin Sass and Dr. Robert Veatch.
| REFERENCES |
Annas, George J., and Miller, Francis H. 1994. The Empire of Death: How Culture and Economics Affect Informed Consent in the U.S., the U.K., and Japan. American Journal of Law and Medicine 20: 357-94.
Kashiwagi, Tetsuo. 1994. Supporting Peaceful Death (in Japanese), 6th printing. Tokyo: Inochinokotoba Sha.
Kimura, Rihito. 1991. Fiduciary Relationships and the Medical Profession: A Japanese Point of View. In Ethics Trust, and the Professions, ed. Edmund D. Pellegrino, Robert M. Veatch, and John P. Langan, pp. 235-45. Washington, DC: Georgetown University Press.
_______. 1995. History of Medical Ethics: Contemporary Japan. In Encyclopedia of Bioethics, revised edition, ed. Warren T. Reich, pp. 1496-1505. New York: Simon & Schuster Macmillan.
Leflar, Robert B. 1996. Informed Consent and Patients' Rights in Japan. Houston Law Review 33 (1): 1-112.
Tomomatsu, Entai. 1939. The Human Being and Death (in Japanese). Tokyo: Kaiseisha.
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