- Noritoshi Tanida, M.D. Professor and Chairman Department of Medical Humanities, Yamaguchi University School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Email: firstname.lastname@example.org
In Japan, the discussion on euthanasia has begun openly since the Tokai University and Keihoku Hospital euthanasia cases. The Tokai University Hospital case (1992) was non-voluntary active euthanasia using a potassium chloride injection to a dying cancer patient on the request of his family. It was the first euthanasia case where a physician was prosecuted and was convicted of the murder of a patient in Japan. The Keihoku Hospital case (1996) was also non-voluntary active euthanasia, which is a physician gave a muscle relaxant to a comatose cancer patient without the request of him or his family. The physician of Keihoku Hospital first proclaimed that his act was active euthanasia. However, on facing fierce condemnation by nurses, colleagues and media as a murderer, he changed his claim to say that he intended to reduce convulsion not euthanasia. Police questioned him, but finally he was not prosecuted because the patient died before the amount of muscle relaxant reached the lethal dosage. During the discussion over these incidences, there was public pretense that euthanasia did not exist and that no one asked for euthanasia in Japan (1). On the other hand, media surveys showed repeatedly that 40 to 70% of laypeople thought that euthanasia was permissible.
Religion may influence medical practices, particularly for care of terminally ill patients. Thus, the religious world has been deeply involved in discussion on euthanasia and other end-of-life issues. Catholicism, for example, views that euthanasia is not allowed in any circumstance, whereas extraordinary treatments may not morally be forced on patients against their wish (2); Judaism views that once treatment is initiated it may not be withdrawn (3). Although an affirmative attitude of Japanese Buddhism toward euthanasia is indicated in literature (4), the Japanese religious world has kept mostly silent during the discussions on euthanasia among secular people. The author's survey as to how Japanese religions thought of euthanasia indicated that Japanese traditional religions showed affirmative attitudes toward euthanasia compared with Christianity (5), and Shinto and Buddhist organizations advocated "being natural" when medical treatment for cure became futile at the terminal setting (6). Implication of these attitudes of Japanese religions is discussed in contrast with that seen in health care professionals and mass media.
Details of the source of data were described before (5,6). Briefly, a mail questionnaire survey was conducted among a total of 388 inclusive religious corporations, asking them to answer questions on several forms of euthanasia and futile treatment at terminal setting. The Table shows the results of Shinto, Buddhist and Christian corporations.
The results showed that a total of 69% of the religious corporations agreed with the act of voluntary passive euthanasia. The corresponding figure was 75% when the family asked for it. Among Buddhist corporations, Zen corporations were significantly less favorable to non-voluntary passive euthanasia than other corporations. A total of 20% of all religious corporations and one in four Shinto and Buddhist corporations agreed with voluntary active euthanasia. There was significant difference in responses to active euthanasia among religious groups, which was due to a more favorable attitude of Shinto corporations and less favorable attitudes of Christian corporations. Notably, all Catholic corporations disagreed with voluntary active euthanasia, whereas 40% of Protestant corporations did not oppose this act. Shinto corporations were more favorable to non-voluntary active euthanasia than other religions, where they made no distinction between the use of potassium chloride and sedative. Buddhist corporations showed a slightly favorable attitude toward the use of a sedative. Christian corporations were less favorable than other religions toward non-voluntary active euthanasia. Furthermore, Catholic corporations were less favorable to this act than Protestant corporations.
In remarks, nearly all Shinto corporations advocated, "being natural" from the religious faith in the immortality of the soul. Some noted prolongation of life using artificial means is a disgraceful act against life. Others noted that the patient should abandon control of his or her own health and rely on the doctor or medicine, and Shinto would accept any result regardless of the cause or intention. In Buddhism, many corporations noted that medical treatment is necessary for curable disease; however, mere prolongation of life is not appropriate, as one corporation noted "do not kill" and "being natural" in facing death and dying. One Zen Corporation noted that the patient could make one's own decision. Christian corporations expressed objection to active euthanasia and futile treatment, while respecting decisions by the patient. The necessity of advance directives was also mentioned.
The same questionnaire studies were conducted among health care professionals in 1997 (7), pharmaceutical students in 2000, and medical students in 2001. Among the secular people, attitudes of health care professionals toward voluntary passive euthanasia showed a similar tendency with those of religionists. On the other hand, attitudes of pharmaceutical and medical students were different from them, i.e., students favored voluntary acts over non-voluntary acts. Attitudes toward active euthanasia were similar to those of Shinto and Buddhist corporations. Both students showed the most favorable attitudes towards voluntary active euthanasia, i.e. 38 to 44% agreed with this act. More favorable attitudes of the students were also evident towards non-voluntary active euthanasia; their trends were the same with Shinto corporations. Health care professionals showed a similar trend with religious corporations regarding potassium chloride. It is noticeable that 37% of health care professionals agreed with this act using a sedative as the drug of choice, which seemed to indicate that they did not distinguish between non-voluntary active euthanasia and so-called sedation at the terminal setting. These respondents tended to emphasize respect of patient's wishes.
Euthanasia has been prohibited in medical ethics since the implementation of Hippocratic morality in the 12th to 15th century (8). However, circumstances surrounding euthanasia are gradually changing and there are now some exceptions (9). For example, physicians may practice voluntary active euthanasia lawfully in the Netherlands. Belgium has now followed. Physicians can legally prescribe a lethal dose of drugs to terminally ill patients for assisted-suicide in Oregon. Between July 24, 1996 and March 25, 1997, voluntary active euthanasia was legalized in the Northern Territory of Australia.
Japan has a long history of practicing euthanasia. The Japan Medical Association has admitted the practice of euthanasia by physicians and allowed its practice in very exceptional occasions in a report by her Bioethics Council (10). There are two court rulings that permitted active euthanasia in Japan. In the latest decision, which concurred with the previous 1962 Nagoya High Court decision, the Yokohama District Court determined in 1995 that there were four criteria for acceptance of euthanasia by physicians; 1) the patient suffered from unbearable somatic pain, 2) patient's death was unavoidable and near, 3) there was no alternative to alleviate pain, 4) there was an explicit request by the patient (9). Regarding passive euthanasia and indirect euthanasia, the Japanese Academy of Science and Art has approved of these practices (11), whereas passive euthanasia is always condemned by Japanese media as having killed patients. Thus, there appear to be two extreme opinions regarding the discussion on euthanasia: allowance of active euthanasia on the one side, and denial of passive euthanasia on the other side; the two do not communicate with each other.
During these disputes, the Japanese religious world has kept silence. The attitude differed from other religions like Judaism and Christianity (2,3). Traditional and contemporary views of life and death derive mainly from Shinto and Buddhism. The typical feature of Shinto is belief in the immortality of the soul and ancestor worship (12). According to this traditional thinking, death is a separation of the soul and body. And the soul can be deified regardless of the result from euthanasia or suicide, when the dying process is natural, brave, virtuous or meaningful. The core of Buddhist philosophy regarding life and death is metempsychosis or transmigration of the soul (i.e., suffering) until nirvana or full comprehension (i.e., release from metempsychosis). Therefore, euthanasia or suicide is by no means a solution from suffering in original Buddhism (4). It may be natural that Buddhist philosophy of metempsychosis and nirvana and the Shinto ideology regarding the soul influenced each other. For example, metempsychosis is not always a form of suffering in Japanese Buddhism. The corpse is mere existence without importance in original Buddhism, whereas Japanese Buddhism teaches that the corpse must be left untouched for a while before proceeding to have a funeral; Shinto teaching is the same. Euthanasia and suicide is not a continuation of suffering but a way to the Pure Land (heaven) from this Defiled World (4).
In accord with the idea of "being natural," a majority of the Japanese religious organizations are favorable to passive euthanasia at the terminal stage. Active euthanasia was greeted unfavorably among the religionists in general. Nevertheless, it is significant that one in four traditional religious organizations agreed with active euthanasia. Shinto organizations were more favorable to active euthanasia compared with Buddhist and Christians. Both similarity and difference were observed in the attitudes towards euthanasia between secular people and religionists in the surveys. Namely, attitudes of pharmaceutical and medical students towards active euthanasia were similar to those of Shinto and Buddhist organizations. Particularly, those students showed more favorable attitudes towards voluntary active euthanasia than religionists and health care professionals. In general, health care professionals tended to prefer life-prolonging acts, whereas Shinto and Buddhist organizations advocated "being natural" when medical treatment for cure became futile at the terminal setting. Such a negative attitude toward euthanasia among health care professionals was ascertained by a recent study, which specifically studied their experiences of complying with or refusing patients' requests to directly hasten death (9,13). Although requests for voluntary euthanasia are frequently made to doctors and nurses who care for dying patients, only 6% of doctors and no nurses had accepted their wishes.
What makes Japanese health care professionals less affirmative to euthanasia or more reluctant to comply with a patient's wishes to hasten death? Presumably, health care professionals may esteem secular moral views derived from sanctity of life, which has been introduced from Christian ideology. Furthermore, since the introduction of modern medicine from the United States, Japan also has introduced the Americans' firm belief in "infinite progress of medicine" (14). When Japanese learned of cardiopulmonary resuscitation technique, for example, it was naturally introduced as everyday practice by doctors and nurses. A doctor who did not perform cardiopulmonary resuscitation on a dying cancer patient was fiercely condemned by ward nurses and expelled from the hospital in 1997 (15). According to the 1996 nationwide survey (16), only 12% of doctors ever experienced withdrawing life-sustaining treatment in the terminal stage. More recently, a survey among pediatric hospitals who deal with severely disabled neonates showed that only about 15% performed so-called death with dignity according to their parents' wishes but many doctors and health care workers persuaded the family to consent to maximum life-sustaining treatment for those neonates in the terminal stage (17). In hospitals for the elderly, conscious or unconscious bedridden patients are fed on forced artificial nutrition. When an unconscious terminal elderly patient gets pneumonia, he or she will receive antibiotics treatment. Otherwise the doctor is condemned by mass media as having killed the patient (18,19). Furthermore, when physicians abandon life-sustaining treatment or antibiotics in the hospital, they will inevitably lose out in the care of terminally ill patients in the Japanese fee-for-service system (20). Most important of all may be attitudes of Japanese people and media to solve any issue by producing scapegoats and a fear of doctors to be treated as a scapegoat (21). Once euthanasia became evident as in Tokai University and Keihoku Hospital, mass media and most doctors and lawyers condemned the physician as a murderer. Such media coverage are sufficient enough to force society to believe that prolonging life is a supreme aim of society and none could argue about euthanasia. A consequence is the prevalence of all kinds of life-prolonging medical interventions for dying patients.
The number of Japanese people who believed religion was 32% (26% for Buddhism, 2% for Shinto, 1% for Christianity), and 63% answered as atheists (22). However, among the so-called atheists, 70 and 46% believed in Buddhist cause/effect thinking and the immortality of the soul, respectively. And 79 and 71% of these atheists visited the family grave and believed in superstitious phenomena. In reality, a huge number of people go to Shinto shrines and Buddhist temples asking gods for safety, health, prosperity, success in examination, promotion and any other divine favors not only at New Year's celebrations but also at any other occasions. Thus, many people answered they are atheistic, however many of them practice religious acts and believe in superstition and the existence of the soul and spirit. These phenomena indicate that religions are deep-rooted in the Japanese everyday life and the way of thinking. In fact, significantly more health professionals who believe in Buddhism would practice active euthanasia if it were legal than those who believe in Christianity (9). Thus, religion has considerable impact on Japanese people, albeit unconsciously.
Dealing with death and dying is the essence of religion. Buddhism emphasizes the importance and respect for any life. It teaches to make every effort to treat disease so far as the treatment is meaningful. At the end of life "being natural" is the principle; there is no teaching to prolong the dying process in Buddhism. In this regard, Shinto is open as in other aspects. However, the principal idea of love of completeness in Shinto is incompatible with prolonging the dying process. Whatever the origin of the concept "denial of extraordinary treatment" for Catholics or "being natural" in Shinto and Buddhism, consequences were the general tendency in rejection of futile treatments among Japanese religionists. However, Japanese religious organizations tend to keep silent on these important issues. In fact, religionists were the last to be involved in the discussion over brain death and organ transplantation (23). The present survey indicated that the attitudes of religious organizations were mostly modest and sensible. It is unfortunate for Japanese laypeople that have not been able to listen to the wisdom of religionists. People who have better understanding of medical intervention at the terminal stage tend to want natural death or death-with-dignity (24). Indeed, passive euthanasia and indirect euthanasia have been allowed by Japanese Academy of Science and Art (11). However, the discussion over euthanasia among secular people appears to be at a standstill facing two extreme ends of allowance of active euthanasia and denial of passive euthanasia. Religion and medicine are so distinct, but both devote themselves to caring for patients. Although the Japanese religious world has been mostly isolated from the rest of society, religious sectors should be more courageous to speak publicly about their policy with confidence. There is an example from the USA that Catholicism advocates accepting the limits of medical technology (25). Diverse attitudes among religionists are not disadvantageous here, because the general public will be able to think of this important issue by themselves through different opinions. Thus, open discussion involving religionists and secular people is essential to expand and to deepen understanding of these complex controversial end-of-life issues that face every person.
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