A. The Uniqueness of the Aged Japanese Population

Japan is a small country. Its total territory is almost the same size as the state of California, but only 21% of this area is inhabitable. The total population is about 118 million, which is just over half of the U.S. population (1982). The Japanese population is only 2.5% of the total world population and Japan's land space occupies only 0.28% of the world. Also noteworthy is the fact that Japan's economic activity is so high that it is consuming 10 times more energy than the U.S.¹ In this setting, Japan's elderly population is growing rapidly, even when compared with other industrially developed nations (see Chart I).
__The birth rate in Japan has been slightly decreasing since the 1920s. Since the end of World War II, both birth and death rates have been rapidly decreasing. In 1955, the elderly (over 65 years old) composed 5.3% of the total Japanese population; 7.1% in 1970; 10.1% in 1985 (see Table 1). The second unique fact about Japan's elderly population is the high number of persons who live with one of their married children, usually the eldest son. Even though this traditional life style is changing rapidly, many households contain three generations, particularly in rural areas (see Chart II). Thirdly, because the "aging process" and "old age" are to be respected, Japan celebrates a unique national holiday every September 15th - "Respect-for-the-Elderly Day". This began in 1966. "Respect-for-the-Elderly Day" (Keirô-no-Hi in Japanese) came about, according to some cynical critics, due to the lack of such an attitude in Japan's rapidly-changing society.² However, the Japanese believe respect remains of prime value even among the young generations as is reflected in their language and social behavior as members in three-generation families.
__Because of the vitality of these kinds of social values, the elderly themselves view their future happily as one in a peaceful family setting, playing with the grandchildren and ending their lives surrounded by their offspring within their home-setting and in their own community. However, a trend toward an independent life style (rather than security within family dependency), lack of housing in urban areas in order to accommodate elderly parents, economic motivation for the elderly to continue to work as long as possible (even after retirement), and rapidly changing social values that erode the traditional life style, all cause hardship on the aged.

B. Health of the Elderly in Japan

In 1891, the average longevity of the Japanese male was 42.8 years, and 44.3 years for the female. In the 1950s, the longevity for both sexes rose to 60 years and above. In 1984, life expectancy for women was 80.18 years, and 74.54 for males.³ Today, Japan has the highest average life expectancy in the world. Extended average life expectancy, very low infant mortality rate, a decrease in deaths caused by infection, a higher living standard, and the establishment of various public health programs throughout Japan, have made an enormous contribution to the health of the aged Japanese. However, so-called "geriatric diseases" have increased very significantly - from 46% in 1960 to 63% in 1983. Both Great Britain and the U.S. have also experienced an increase in "geriatric diseases" (the most important of these are cardiac disease, high blood pressure, cerebral apoplexy, and cancer), and the death rate has increased very gradually in 60% and over. For many years, in Japan, cerebral apoplexy has been the number one cause of death for the aged, but this has been decreasing since 1970; today cancer has become the major cause of death, followed by apoplexy. (The death rate from cancer is 148.3 per 100 thousand; the death rate from apoplexy is 122.8 per 100 thousand.)
__Before 1960, the Japanese elderly usually died at home. In Japan, a census questionnaire included items relating to the place of death; according to this survey, in 1955 only 16.5% died in an institutional setting (e.g., hospitals or nursing homes). The situation has been changing rapidly, and in 1975 over 50% died in institutional settings; 63.1% in 1983. These changes are also due to the increasing accessibility of health care for the elderly became almost cost free. According to this data, the percentage of elderly who still die at home is relatively high compared with previous generations. Statistics on causes of death at home reveal the following: 1) rosui (naturally caused "senility" due to old age)=83.9%; 2) cardiac disease=43.0%; 3) cerebrovascular related disease=41.6%; 4) pneumonia and bronchitis=34.1%.⁴
__It is projected that health care costs for the elderly, if recent trends continue (1978-1979), will increase enormously during the period 1980-2025 (see Table 2). The growth pattern of the number of hospital patients per day () and that of the number of in-patients per day () are described by age and sex for two different years, one in 1980 and the other in 2025 (see Chart III and IV). These computerized charts indicate that the number of aged hospital patients and in-patients will increase enormously in the 21st century when the aging of the population dramatically accelerates. The greatest demand for hospital and clinic services will appear around the year 2020 (see Table 3), if present trends continue.

II. Cultural, Bioethical, and Legal Aspects of Treating the Aged

It seems that some physicians still hold onto rather traditional notions of "death criteria", as does the Japanese lay public. According to statistical data on the issue of "brain death criteria" surveyed in 1985, the situation is changing rapidly. Physicians tend to avoid "malpractice" suits or conflicts with the family members of dying patients who accuse them of ceasing treatment before the patient's end of life. One physician regretfully mentioned his own experience of having provided long hours of explanation to family members of a dead patient who accused the attending physician of misconduct.⁵
__There is now a trend to diagnose the death of patients by applying total "brain death criteria" as the accepted standard and thus to cease treatment when this condition arises.⁶
__The moral, financial, and social aspects of "brain dead" patients have become a very critical problem in Japan. If the family members do not agree with the physician's judgment that the patient is dead, all treatment, including hydration and nutritional support, will be continued. It usually takes three to five days and at the most two weeks after the physician's judgment for the family members to agree that the patient is dead on the basis of "brain criteria".⁷
__In many cases almost all Japanese family members agree that aggressive and positive intervention to support the patient's life is a sacred obligation of the society. Thus, faced with the reality of continuous and expensive life support of unconscious, bedridden elderly patients, many serious problems arise.
__Japanese physicians educated to defend paternalistic Confucian ideology of medical morality (known as "Jin-Jutsu ") usually think of themselves as final judges in decisions to provide treatment or to withdraw or withhold it. A patient's autonomy and rights are not yet well established values as is the case in the U.S. All the information relating to patients is not necessarily given to the patients themselves, or to their families.⁸ "Right of treatment" by physician is an established principle and is recognized by law; the patient's obedience is expected as part of his tacit agreement with his physician. However, there is a trend toward more open, informed, and patient-centered approaches, although change is slow in coming.⁹
__So-called DNR orders (do not resuscitate) are not officially accepted among medical professionals even though there has been some agreement to employ DNR coding in each medical professional group which work in the same clinic and hospital setting.¹⁰ Application of DNR orders differs among physicians.

A. Foregoing Treatment in Japan: The Legal Problems

There are three unique yet common phenomena among the Japanese which relate to end-stage medical treatment, particularly in the case of terminally ill patients: 1) not telling the truth because of fear of increasing the patient's despair; 2) right to treat which is strongly confirmed in legal cases; and 3) medico-technological interventions up to the last moment of a patient's death; this is expected to be provided and every effort must be made by the medical team.¹¹
__Though this situation is changing gradually, many people still think that the patient's obedience to his physician is mandatory. The patient's exercise of his autonomy is not possible in the Japanese medical setting; even the notion of "informed consent" has not yet become a well-established principle in Japanese medicine.¹²
__Due to the dehumanizing process of recent medical services in Japan, and because of the lack of communication between medical staff and patients over treatment decisions and the use of medical treatment in prescribing medicine and surgical operation (not to mention increasing misconduct of some medical professionals),¹³ malpractice suits are now increasing in number, though the total number of litigations is quite small compared to the U.S. There were approximately 1,400 malpractice suits in Japan by November 1984.¹⁴ The Japanese people prefer to resolve disputes out of court since medical problems are not usually remedied by resource to legal solutions. The special resolution called "Jidan " (private settlement) is very common by the arrangement of the persons concerned together with medical professional belonging to each local medical association. "Wakai " (reconcilement) and "Chôtei " (conciliation) are also possible in several cases.¹⁵
__Actually, almost all patients in Japan are given an opportunity to sign a document at the time of admittance to the hospital usually for a surgical operation which says "no complaint whatever happens to patients themselves".¹⁶ This is only a matter of formality, according to hospital administrators; however, many patients believe that this has some legal binding power over patients. But appeal to this has been declared void when set forth to justify malpractice litigation and compensation.¹⁷
__The "living will" has not been accepted among the Japanese public, even though the Japanese Euthanasia Association has been active since the 1960s, and has changed its official name - since 1983 it is the Japanese Society for the Right to Die with Dignity. This organization is affiliated with the World Federation of Right to Die Societies and in 1976 organized the first International Conference on Euthanasia in Tokyo, Japan.¹⁸
__There is also a different type of association which claims the right not to be treated. The official name of this association is the "Association for the Rejection of Medical Treatment".¹⁹ Even though a member of each organization holds membership which is recognized at the time of an accident or some emergency situation, this person presumably would be treated because this attitude is the physician's professional calling according to their ethical and legal obligation provided by law.²⁰
__There is no "ethical" or "critical care" committee in Japan which would provide medical services or assistance in clinical and moral "decision-making". Physicians are the decision makers in almost all cases, even though the patient's family members would be given some information and given an opportunity to state their opinions.²¹ "Persuasive communication" from the side of the physician is quite common, especially when the case is serious. This is an expression of the traditional paternalistic approach by the physician to the patient; this attitude will in all likelihood prevail in the future.²²
__A positive attitude of Japanese physicians is found in their strong sense of commitment to their patients and family members; this includes concern for the patient's and family's daily life as well as participating in the funeral ceremony. In some cases this is an expression of professional responsibility considered in wider perspective. It should also be mentioned that the Japanese Health and Insurance System which is controlled by the government includes the prescribing of drugs, thus the over-prescription of drugs, unnecessary surgical operations, and futile efforts to prolong life regardless of the terminal situation of the patient.²³ Patients as well as patients' family members might themselves have caused these trends by placing too much emphasis on the dependency and respect for the medical professional to whom many people are reflexively obedient.
__For more than 1,000 years, in the Japanese culture, medical and health care was regarded as "Jinjutsu ". "Jin " signals human compassion and love, and "jutsu " is art. According to Confucian moral teaching, medical practice should be "art of Jin" (which first appeared in print in 982 A.D. in the oldest existing Japanese Medical Encyclopedia of 30 volumes. The Japanese medical profession has integrated some key religious ideas from Shintoism - purifying the body by washing; from Buddhism - giving mercy to the sick and aged; and from Confucian ethical teaching - to practice the action of love.²⁴
__Traditional Japanese and Chinese medicine have been well accepted as part of daily health practice: acupuncture, moxibustion, and herb medicine are all based on a long tradition and employed to alleviate particular diseases, such as stomach pain and headaches. In the context of feudalistic Japanese society, respect for the aged as well as respect for those who have extraordinary knowledge and wisdom in the medical arts was presumed. In many cases physicians were regarded as intellectuals who were literate in the Japanese and Chinese classics and the teaching of Confucius.
__However, this has been rapidly changing in recent years due to the acceptance of Western medical practice in the mid-19th century. One result has been the government initiated modernization and socialization of Japanese medical services.
__There has been a strong undercurrent of traditional Japanese and Chinese medicine even during this recent process of Japanese medical modernization, particularly since the beginning of the 1970s. We today are witnessing a revival of this traditional medicine. It is also evident that Japan's elderly people have a tendency to consult traditional medical professionals for alternative healing treatments.²⁵ In order to practice Eastern medicine government regulations require the practitioner to have a professional license.²⁶

III. Financing Health Care and the Right to Treatment ___Japanese Medical and Health Care Legislation for the Elderly: ___1963 to 1985

The Law for the Elderly's Welfare was promulgated in 1963. In Article 2 of this law, the fundamental aim of the legislation was stated: "The elders shall be loved and respected as those who have contributed for many years to the progress and development of society, and healthy and peaceful life shall be guaranteed." Article 3 (2) says that in accordance with their desire and ability, elders shall be given opportunity to engage in appropriate work and to participate in other social activities.
__In 1961, before the enactment of this law, Japan had established a system of national health and medical benefits for all of its people, regardless of the premium paid (based on income) or financial situation. The original pattern of this plan, under the name of Health Insurance Law, was promulgated in 1922, and had been enforced since 1927. In 1938, a National Health Insurance Law was enacted. Due to the unusual situation during and after the war, however, the government could not implement this law until 1961. The welfare, health, and medical insurance policy became part of the political agenda around the end of the 1950s, and was expanded during the 1960s following Japan's economic growth in world trade.²⁷
__In Article 25, the Japanese Constitution of 1946 specifies the following responsibility of the State: "All people shall have the right to maintain the minimum standards of wholesome and cultural living." In all parts of life, the State shall endeavor to promote and extend social welfare, security and the public's health. Usually, this provision is regarded as state principle, and people's claim to these rights is guaranteed through the enactment of particular positive laws which relate to welfare, health, and medicine. The 1963 Law for the Elderly's Welfare was a positive law for the implementation of Article 25, as well as of Article 13 which provides that: "All of the people shall be respected as individuals. Their right to life, liberty, and the pursuit of happiness shall, to the extent that it does not interfere with the public welfare, be the supreme consideration in legislation and in other governmental affairs."
__One of the most radical policies for the elderly relates to virtually cost-free medical and health care, which was officially accepted by the Japanese government in 1972, following the success of excellent free medicine and health programs of several local governments. This was one of the most unique welfare accomplishments in recent Japanese history.²⁸
__In the framework of Confucian ethical principles, the medical profession maintained its strong paternalistic values even after the radical reformation of medical education from the traditional Chinese system to a modern Western one. In pre-war Japan, medical benefits and health services were not regarded as a "right" of the people.²⁹
__One of the earliest movements toward "free health and medical services for the elderly" occurred in the northern mountain province - Iwate Prefecture. Formerly, this region was known as a poor area, with no resident physicians in full service to provide medical and health care. In 1949, in the village of Higoroichi (Kasen-gun) an integrated policy for insurance and medical services was initiated by the mayor, Suzuki; it was expanded to 24 local governments in the prefecture by 1952. The policy was almost abolished around 1955, however.
__In the same prefecture, the Sawauchi village started a regional health and medical service system, with the full cooperation of the people, physicians, the medical organization, and the Administration. This is now well known as the "Sawauchi System".³⁰ In 1960, for the first time in the nation, a totally free program was available for health and medical services for those over 65 and for newborns and infants. In 1961, those aged 60 or older could apply for this program.
__The Sawauchi System, initiated by a local people's movement, had a powerful impact on local communities throughout Japan. By the end of 1962, 69 local communities had established a similar system. In 1969, the Tokyo Municipal Government also decided to provide a similar service for people over 70. More significantly, the success of the Sawauchi System led directly to the government's amendment to the Law for the Elderly's Welfare and it endorsed free health and medical care for people over 70.³¹
__Until 1982, therefore, there were continuous improvements in the provision of health care for the elderly. The Japanese Constitution, the 1963 Law for the Elderly's Welfare, the amendment of 1972 that provided free medical care for the elderly, and the existence of social insurance, as well as national health system - all were the embodiment of the people's "right to health and medical care".
__Social movements in local communities, together with strong endorsements and medical service staffs, were the initial forces behind realizing these rights in the context of Japanese state policy. However, pressure arose to resist socialization of health and medical care, for financial reasons. The equal distribution of health and medical care resources became a powerful item on the political agenda in the 1980s.³²
__The Law for the Health of Elderly aims to improve national health and to promote the welfare of the elderly, by implementing a policy incorporating prevention, treatment, and rehabilitation for the aged. This legislation is regarded as one of the positive laws which fulfills the "right to health care and social security" of the Constitution of 1946. Just as with the Law for the Elderly's Welfare, however, Article 2 (2) of the new law mentions that "the people shall be given the opportunities to receive appropriate health services in order to enhance the health of the aged." There is no positive statement about the "right" of people, including the aged, to state or local government health and medical services. Paternalistic and bureaucratic attitudes can be traced very easily in the legislative process regarding the wording of laws relating to the welfare of the elderly.

__According to Article 12 of this law, the following health services for the elderly are provided:
__1. Health notebooks,²⁵
__2. Health education,
__3. Health consultation,
__4. Health examination,
__5. Medical services,
__6. Rehabilitation therapy,
__7. Visits to provide home-care for patients at home, and
__8. Other necessary services in accordance with particular ordinances.

__These medical services are provided by the local government for those 70 or older, and for those between 65 and 70 who have designated disabilities (according to the Ministry's ordinance and after confirmation by the local authority), and are covered by medical care insurance; public and insurer contributions are used as resources. In the case of out-patient treatment, the cost-sharing is 400 yen (approximately $1.60) per month, while the in-patient elderly have to pay 300 yen ($1.20) per day for the first two months (or for the first 50 days for insured persons). The other health services specified in this law are provided for those 40 or older and are arranged at the local level.
__There are some problems related to the enforcement of this law. First, not all local governments have a "cost-sharing health and medical care policy for the aged". In 1983, there were still 26 local governments in 9 prefectures that had their "free" health and medical policy for the aged, which was contrary to policy of the central government. The sanction against these local governments took the form of cutting government support for the programs at the local level.³³
__The second problem arises with the special limit regarding the elderly's medical costs. Medical treatment and hospital-related expenses have been limited to certain lengths of stay in the hospital. These gradual stages or limits are too rigid and too unreasonable for some patients with chronic, serious conditions.²⁶ The amount of out-of-pocket expenses for the continuation of such medical care in the future will surely increase.³⁴
__The third problem: the extremely low funding allowed for visiting services to provide home-care to patients, especially the elderly. It was certainly admirable that such a fee was approved for the first time for home-care patients in the community, but again, the time limit for this service affects the quality of care. The elderly are not encouraged to stay in the hospital for long periods of treatment; and furthermore, after they are discharged, they are not given continuous care.³⁵

IV. Technological Issues ___Related to Geriatric Care of the Critically and Terminally Ill Elderly

Japan's medical practice reflects the values of Japanese society, and is affected by historical, moral, and religious traditions. Medical treatment is usually equally given to all the people according to the need and the urgency, regardless of age, sex, and source of payment. The entire Japanese population is protected by National or government-regulated health insurance. The elderly are shown great respect because they have contributed so much to the society during their long lives. This is one reason which explains the provision of free medical care at the local and National level, and has been supported by public funding since 1983 to those who are over 70 years of age. (The Law for the Health of Elderly, 1983) Even though the idea of cost-sharing by the elderly was introduced by amendment to this Law of 1983, the expenses accrued by the elderly are not too burdensome (according to the official statement of the Ministry of Health and Welfare, 1984).³⁶ There are positive incentives to Japanese physicians who receive elderly patients, and the reimbursement for medical services fees is guaranteed by the National and/or local government-controlled health and medical insurance scheme.

A. End Stage Renal Disease (ESRD)

The most recent data relating to chronic haemo-dialysis treatment, published in 1984, shows an increasing number of patients in higher age groups. The average age of dialysis patients in 1983 was 51.9 for males and 52 years for females. In 1983, the oldest patient receiving dialysis treatment was 98 years old, and in addition, in the same year, 164 patients over 80 years of age began dialysis treatment.³⁷
__There were 48 dialysis machines in 1966 and in 1983, 24,474 machines were working (with a maximum capacity to assist 68,813 patients). In 1968, there were only 215 dialysis patients in Japan, and in 1983 the number of patients was 53,017, about 246 times more than in 1968. In comparison to other countries, the number of dialysis patients is very high in Japan. There are 404.2 patients per million in Japan and 237.0 in the U.S.; 25.0 in Canada; 350.0 in Europe, respectively (per million population).³⁸
__Because it is still unexplained why so many Japanese dialyzed, it may be that this technology is being used more than is necessary.
__There are no criteria other than need in order to receive dialysis treatment in Japan. All those who need dialysis were totally compensated by one insurance scheme; they applied to all Japanese citizens until 1984. Amendments to the Health Insurance Law of 1984 require dialysis patients to pay partial costs of treatment, up to 10,000 yen (approximately U.S. 50 dollars per month). The rest is paid by the insurance scheme to which each patient belongs.
__One of the reasons for the increase in use of dialysis machines is the comparatively easy access to dialysis centers that are readily accessible in Japan's major cities. A network is also provided for prefectures. Thus, a patient finds it possible to go to a center for dialysis treatment several times a week that is within a short distance from his or her home.
__Dialysis treatment is also available at home. Only 132 persons (0.2% of total dialysis patients) were dialyzed at home as of December 1983. But this number of patients is now increasing given the use of the relatively new popularized method of Continuous Ambulatory Peritoneal Dialysis (CAPD). In 1985, 1,400 patients were using CAPD because of the official endorsement for insurance policies by the Ministry of Welfare and Health, and 800 patients were receiving this CAPD at home. CAPD use is much more convenient for many patients due to the simplified method of dialysis, less cost, and flexible application according to the working and life styles of individual patients.³⁹
__Because of this national insurance incentive, even though medical treatment fee by point for this CAPD is not enough according to some critics (consultation and advising fee for CAPD patients at home was decided at 1,500 fee points limited twice a month only; total amount per month would be around U.S. 160 dollars), this CAPD would be used more and more in Japan. There are now approximately 500 institutions (as of 1987) throughout Japan which offer CAPD patients' affiliation due to the notice issued by the Director of Medical Service Section of the Ministry of Welfare and Health.⁴⁰
__Under the present scheme of health insurance, Japanese men and women, young and old, utilize opportunities for the treatment by dialysis at various regional centers. A very recent policy to provide home treatment of dialysis is the result of a policy shift from financially expensive hospital care to moderately inexpensive home care. However, in order to make home care more avilable to those who prefer to stay at home rather than remain in hospital, elderly patients need an effective support system which must include the establishment of a "visiting nurse" network; this began only recently with the endorsement of the Ministry of Health and Welfare. It applies to those patients who are under the care of medical institutions but who stay at home. The independent "visiting nurse" service cannot be reimbursed by the insurance policy under the central control of government.⁴¹
__On the other hand, from the point of view of the elderly's family, there is a kind of tendency to place elderly patients in hospital, since in hospital all treatment is provided by the national and local government. (Law for the Health of Elderly, 1983) It is convenient for the supporting family to have its elderly family members in hospital because here there is easy accessibility to regular medical treatment, lack of housing space for totally bedridden elderly, and inexpensive cost. In the case of elderly dialysis patients, one of the family members (usually a non-employed female family member) becomes extraordinarily busy bringing the patient back and forth three times a week, and additional time for the dialysis treatment. This is one of the reasons dialysis centers have many available beds for hospitalization which were in the past fully occupied.
__There are very few cases wherein a family member of an 80 year old kidney patient decides not to bring this person for treatment. According to a nurse in charge of dialysis, this is a very rare case. Generally speaking, Japanese family members who have elderly patients bring them in and ask what treatment should be done at the time. Later, they will be faced with continuous arrangements for treatment by dialysis. If there are no beds available under the government insurance plan, people will pay an additional amount to fill the gap between the cost of the insured bed and the private bed. This system is called "Sagaku Chôshû " - collecting payment for the gap in costs.⁴²
__Kidney transplantation is available, but is not widely performed, due to the lack of available kidneys. Neocortical brain death criteria have not yet been accepted. However, in 1982, an advisory board on "life and ethics" was formed and attached to the Ministry of Health and Welfare; it is dealing with this issue of "brain death criteria" as one to be studied. There is also a special task force for determining "brain death"; it was established in 1983 as one of the advisory groups to the Ministry of Health and Welfare.⁴³
__Due to the absence of an officially formulated policy - except for professional criteria established by the Japanese Society of Brain Wave Research (Committee on Brain Death) in 1974 - organ transplantation is proceeding rather slowly in order to avoid legal disputes over traditional notions of time of death.⁴⁴
__This lack of official policy had led to one of the unique phenomena in the Japanese situation, in which large numbers of organ donations (mainly kidneys) are from living human bodies (Neomorts). As of December 1982, the total number of kidney transplantations was 2,457, of which 1,949 were from living donors and 508 were from cadavers.⁴⁵
__There are now nine active kidney transplantation information centers in Japan on which 3,562 patients are registered as candidates for future kidney transplants. Retrieval searches were accomplished 84 times by May 1984, the opening date of this information system; 42,285 persons were registered as possible kidney donors, according to the data provided by the Association for the Promotion of Kidney Transplantation.³⁷
__There have been several cases where kidneys were acquired from the U.S. due to the lack of available cadaver kidneys in Japan. In the case of two hospitals in Sendai City (Miyagi Prefecture in northern Japan), at Sendai Social Insurance Hospital and Tohoku University's 2nd Surgery Department, 33 cadaveric kidneys air-transported from the U.S. were used for transplantation as of December 1983. Since 1981, kidney transplants using cadaveric kidneys have increased compared to preceding years. One reason for this increase was the special arrangement to acquire cadaveric kidneys from the U.S.; another reason is the changing attitude of the public.⁴⁶
__However, there are large gaps between those who are waiting for kidney transplants and the actual transplants performed. Around 25-48% of the dialysis patients expressed their wish to have kidney transplants even though less than one percent of such transplants goes on annually.⁴⁷

B. Nutritional Support

Nutritional support for elderly patients is generally one of the most well-provided life-sustaining technologies in Japan. Some serious problems relating to nutritional support are: 1) cases of terminally ill, elderly patients; 2) cases of prolonged unconsciousness; and 3) cases where patients reject nutritional support.

__1. The situations are very different from case to case in providing nutrition and/or hydration to terminally ill patients. All of these treatments have received endorsement by the Ministry of Health and Welfare and count in computing medical fee points. Only since early 1985 has nutrition support (by Central IV outside the hospital) been accepted as official medical treatment under the direction of physicians and operated by the patients themselves: 70 points (around U.S. 40 dollars) is counted for consultation and advising fee for this treatment (The Government Notice from the Director, Medical Service Section, Ministry of Health and Welfare, 18 Feb. 1985).
__In the case of terminally ill cancer patients, symptomatic treatment, such as pain relief, should be done, while active and aggressive intervention, such as chemotherapy and radiation therapy, would be withheld. Because during this end stage of cancer both chemotherapy and radiation treatment usually cause side effects, and patients get weaker. IV nutrition support would also be undesired by many patients at this terminal stage. If "the Performance Status" is classified "under 3", all positive interventions would be regarded as more disadvantageous for the patient. The end-stage patient who is terminally ill and unconscious, should not be given aggressive medical intervention if it would only serve to prolong the dying process; this would violate the dignity of the patient as some physicians see it.⁴⁸
__Another physician, working in a pioneering Japanese "hospice", has mentioned that even the dying patient should receive nutritional support, including hydration, up to the last moment. Patients as well as family members who want to have the elderly patient live as long as possible should be given that opportunity, according to some physicians.⁴⁹

__2. Patients suffering prolonged unconsciousness are usually given nutritional support regardless of age and sex, as cases in Number 1. There are various causes for these kinds of prolonged losses of consciousness; in many cases nutritional support would be given to these patients by naso-gastral tube, mouth, or IV. The nutritional support is given as part of the integrated treatment to the patient, but under the strict control of the medical care team.

__3. Patients sometimes reject nutritional support by intentionally removing the naso-gastral tube or IV tubes. The rejection of any kind of medical treatment, knowing death will follow, is not common among Japanese patients, even though there now exists a patients' rights movement which claims patients are autonomous and have a right to reject treatment. Patients are expected to obey the physician and many health regulations reflect this paternalistic tradition. Unjustifiable rejection against the treatment given by physicians is supposed to be reported to the local authorities, under the Law for the Health of Elderly (1983); Article 37 and 38 provide non-treatment and non-benefits for medical services in cases where patients act "maliciously" or intend criminal acts or where patients cause their own sickness or wounds due to misconduct like fighting and intoxication.
__There are cases, such as the case of an elderly patient (83 years old, male), who was admitted to the ICU for treatment of shock caused by myocardial infarction and pulmonary edema. After one week of treatment, the patient had another shock, then he requested that all treatment cease and he removed all life-support tubes himself. Because of his clear diagnosis of fibrosis of the lung and the difficulties of his recovery, following tracheotomy, the patient was discharged from hospital; he died of dyspnea at home three days later. In this case it took 38 days of painful and aggressive treatment, including nutritional support at the penultimate stage, thanks to various technological interventions. The physician in charge of this patient had serious reservations, and expressed his doubt regarding the value of this expensive and aggressive treatment.⁵⁰

__Public debates in Japan are now taking place on various issues related to bioethical problems. One of the most important issues is the need for a coherent public policy on "brain death" in the context of the gradually-changing social values rooted in bio-technological achievements. The nutritional support technology should also be reexamined in terms of a patient's dignity and his right to medical treatment; it is a reasonable balance to the notion of patient's autonomy for final medical and ethical decision-making to have a peaceful dying process in more humane care environment without having aggressive, painful and extraordinarily expensive intervention.

C. Resuscitation

In the case of elderly, terminally ill cancer patients, there are rare cases where resuscitation is required. One of the reasons for resuscitation in Japan is the traditional attitude toward the dying patient who should be seen by his relatives at the moment of death. It is an important Japanese ceremonial event to have the closest persons at the bedside of a patient. So, in order to maintain this tradition, patients are resuscitated even though hopeless; sometimes this practice is accomplished with the ceremonial support of members of the medical and nursing hospital team.
__According to a survey by the National Cancer Center of Japan, approximately 74% of dying patients had a resuscitation attempt.⁵¹
__Age and sex have never been factors for deciding who should be resuscitated, whereas a complete diagnosis of a patient's medical status might reflect that the decision to resuscitate should be made with the patient's or family member's consent.

D. Ventilation

Mechanical ventilation is widely available in Japan. In many cases hospitals and nursing homes have the necessary equipment.
__According to the amendment of a recent regulation issued by the Director of the Medical Service Section, Ministry of Health and Welfare, Government of Japan (Notice No. 11, 18 Feb. 1985), ambulatory oxygen use at home by patients was officially endorsed and should be counted in the medical practice fee for 700 points (U.S. 35 dollars).
__This oxygen treatment would be given by the patients themselves, while at home, and mainly for those having chronic pulmonary problems but who are in rather stable condition when discharged from hospital. Physicians then should be responsible for giving particular directions for home treatment by patients, and hospitals should be prepared to have these patients rehospitalized in case of emergency.
__Because of the acceptance of this home treatment as official medical practice, the cost for the treatment is covered by health insurance according to the proportion required by each insurance scheme.⁵²
__Ventilation machine treatment in the ICU is very common, and expenses are also covered by insurance.
__A Critical Care Committee has not yet been formed in many medical service institutions, and generally speaking physicians who are in charge of a particular patient's care and treatment would decide what the medical treatment should be.
__There are no common guidelines to be applied where ventilation treatment is in question.

E. Antibiotics

In Japan, chief causes of death have been drastically changing during the past ten years. Formerly, particularly before World War II, various infectious diseases were the common causes of death; now, various "geriatric diseases" are the chief causes of death.⁵³
__However, the causes of death in the elderly population, particularly at home, are called "Rôsui " which means the "senility" and "weakness" caused by old age. In this case, it is quite common to have infectious diseases weaken the patient's physical condition and lead to weakness and death. In this case, it is quite common to have infectious diseases weaken the patient's physical condition and lead to weakness and death.
__So-called "influenza" combined with secondary types of pneumonia, are increasingly high among the elderly in recent years. This clearly reveals the very sharp contrast of the infant and the elderly mortality due to influenza and/or pneumonia.⁵⁴
__The use of "antibiotics" is very common for the treatment of influenza and pneumonia. However, in order to avoid the negative reaction of the elderly patient, a very careful selection of "antibiotics" should be made. Sometimes the prescription for "antibiotics" will be construed as a preventive treatment against pneumonia. The elderly are often regarded as being a high risk group; some have suggested the elderly be given an injection to immunize against influenza, but on a voluntary basis.⁵⁵
__In the case of terminally ill cancer patients, the statistical data show that antibiotics are commonly used for symptomatic treatment. These data were gathered at the hospital of the National Cancer Center of Japan during six months between June and November 1982. Chemotherapy was given to 48.4% of the patients, and antibiotics were used in 75.5% of the cases. In most terminal patients, the positive intervention by the medical team for prolonging life has been going on frequently. Only 29% of the patients at this hospital with terminal cancer had symptomatic treatment rather than aggressive intervention.⁵⁶
__All of these medical interventions require chemotherapy as well as surgical interventions and were done within one month of the patient's death. It is frequently necessary to refrain from positive and aggressive medical treatment if the patient's situation and symptoms do not bring about a reduction of pain or amelioration of the disease.⁵⁷

V. Concluding Remarks

The Japanese are now facing both a radical change in traditional values, including attitudes toward health and rapid technological changes which call for everything possible to be applied in the clinical medical setting.
__Technological interventions - such as life-sustaining technologies - now impact on other issues of economics, ethics, and public policy.
__By emphasizing Japan's traditional value system and value of family and communal relationships, which more and more influence everyone's daily life, a new and fundamental shift in health and medical policy-making is taking place though initiated by government policy planners of the Ministry of Health and Welfare. Yet there is not enough public involvement. Elderly people are now expected to pay for increasing costs and to share as is not required by the recent amendment of the Law for the Health of Elderly. Those who are insured in Health Insurance Societies, under government control, are now obligated to pay 10% of the total cost of medical treatment, which had been free of charge since 1927.⁵⁸ On the other hand, and in the name of cost containment goals, private patient incentives are now being introduced. Multinational health and medical industries, as well as large insurance corporations, are currently seeking to expand their market in Japan - a policy which is unprecedented.⁵⁹
__This critical turning point in Japan's health policy requires the Japanese public to take a more active role, participating in open debate on these issues, in order to achieve a more secure and excellent level of health and medical services in Japan.

Footnotes | Charts&Tables