- Noritoshi Tanida, M.D.
Department of Internal Medicine 4,
Hyogo College of Medicine,
1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan.
Email: noritanida@pop07.odn.ne.jp
Eubios Journal of Asian and International Bioethics 10 (2000), 34-7.

Religion may be an influential factor for care of terminally ill patients. Since there was no information of how Japanese religions thought of terminal care, a questionnaire survey was conducted among a total of 388 religious corporations, including 143 Shinto, 157 Buddhist, 58 Christian and 30 miscellaneous religious groups. Respondents were asked to answer questions based on their religious faith regarding a living will, and the introduction or withdrawal of life-sustaining treatments at the terminal stage. Results showed that Japanese religions accepted the concept of living will and "being natural" at terminal care. Many corporations were critical about introduction of life-sustaining measures to the terminally ill patient, though some Shinto corporations were favorable to such acts. The Catholic policy denying extraordinary treatment was approved of by about three fourths of Shinto and Buddhist corporations. The present survey indicated that Japanese religions hold esteem in medicine. They advocate "being natural," when medical treatment becomes futile. Thus, religionists' views may facilitate to deepen and to expand discussion on this important issue among the general public.

Introduction

Religion and medicine are so distinct, but both devote themselves to caring for patients (1). Yet, religion alone cannot deal with life and death, nor can medicine alone. In practice, religious person's views play an important role in decision-making for end-of-life issues. Catholicism, for example, views that extraordinary treatments may not be morally enforced on patients against their wish (2); Judaism views that once treatment is initiated it may not be withdrawn (3). Japanese religions, Shinto and Buddhism, have a considerable influence on the everyday life of Japanese people explicitly and implicitly. It is likely that religions are influential particularly to the care of terminally ill patients. Since attitudes of Japanese religions toward end-of-life issues have not been surveyed, a questionnaire study was conducted on the attitudes of Japanese religions toward end-of-life issues such as living will and introduction or withdrawal of life-sustaining treatments at the terminal stage. Questions were raised from the events during the last days of a highly respected Buddhist.

Methods

Religious Organizations and Survey:

Official figures of religious organizations are reported by the Division of Religion in the Agency for Cultural Affairs of the Ministry of Education (4). Although numbers of believers are overestimated, current activities of Japanese religions are well overviewed (Table 1). There are three principal religions, Shinto, Buddhism and Christianity, with additional miscellaneous religious groups in Japan.

Shinto has been a mixture of Japanese indigenous belief in the soul, animism, Chinese religion and ideologies such as Confucianism and Taoism, and Buddhism (4). Shinto organizations can be divided into 3 denominations; Jinja (Shrine)-Shinto, Kyoha (Sectarian)-Shinto and Shinkyoha (New-Sectarian)-Shinto (4). Jinja-Shinto is based on activities in Shinto shrines. Kyoha-Shinto consists of sects of followers of the concept or spiritual experiences of each Shintoist organizer or founder. Shinkyoha-Shinto schools are in the group of Kyoha-Shinto but were not born from the oldest 13 schools. Japanese Buddhism is composed of several sects such as Tendai, Shingon, Zen, Jodo (Pure Land) and Nichiren. The former three sects were introduced from China into Japan in the 9th to 12th century, and the latter two sects were founded in Japan around the 12th to 13th century. Japanese Buddhism is characterized by the idea that everyone has a potential to be Buddha (Tendai and Shingon), enlightenment by oneself (Zen), or the teaching of Salvation by Faith (Jodo and Nichiren). Christianity, both Catholics and Protestants, are also active. There are other miscellaneous religious schools which have founders but do not belong to any of the three principal religions.

Table 1: Profiles of the 388 "inclusive religious corporations" in December 31, 1997

Religion Organizations Teachers Believers

Shinto (143) 86,785 65,484(5) 95,953,951

Jinja-Shinto (16) 80,249 26,975 91,674,061

Kyoha-Shinto (80) 5,687 35,020(5) 3,724,877

ShinKyoha-Shinto (47) 849 3,489 555,013

Buddhism (157) 84,336 216,919(38) 61,996,616

Tendai (20) 5,033 18,225(1) 2,659,958

Shingon (46) 14,987 61,664(25) 12,987,266

Jodo (23) 30,274 62,303(7) 19,571,212

Zen (22) 21,033 22,421(2) 3,270,740

Nichiren (38) 12,652 50,864(3) 23,306,275

Others (8) 357 1,442 210,165

Christianity (58) 7,751 10,641(2,103) 916,011

Catholic (14) 2,045 1,825(816) 455,557

Protestants (44) 5,706 8,816(1,287) 460,454

Miscellaneous (30) 41,163 262,658(7) 6,874,650

Total (388) 220,035 555,702(2,153) 165,741,228

Total figures* 227,558 649,937(7,241) 207,758,774

Organizations include shrines, temples and churches, most of which are qualified as individual religious corporations. Teachers include priests, monks and missionaries. All Japanese are considered to be parishioners of Shinto, hence the number of believers is the total population of Japan minus the number of those who believe exclusive religions. Buddhists count the number of believers based on the number of families. Figures in parentheses immediately after religious group names are numbers of inclusive religious corporations in each religion. Figures in parentheses of the teachers are foreigners. *Total figures derived from all religious corporations registered in Japan.

Because of the legal system, Japanese religions are unified as religious corporations. When their activities or organizations go beyond the Prefectural boundary, they are registered as "inclusive religious corporations" by the Ministry of Education. Thus, "the Annals of Religion 1998" lists a total of 388 "inclusive religious corporations," including 143 Shinto, 157 Buddhist, 58 Christian and 30 miscellaneous religious corporations (4). Among these religions, Catholics have a centralized doctrine. Other denominations and sects in each religion have their own religious faith and practice religious activities. Thus, in September, 1998, a questionnaire was mailed to the 388 corporations asking them to answer questions based on their religious faith of corporations or leaders. According to the report (4), these corporations comprise 80% in terms of number of the believers in Japan (Table 1).

The Events at the Terminal Stage and Each Question

A highly respected Buddhist suffered from a series of small strokes in his early 80s. He declined to receive modern medicine and medical technologies (Question 1: Would you agree with declining modern medicine?). He believed in the healing power of Dharma. Also, one short visit to hospital for another illness had convinced him that the modern hospital was not desirable to humane care. On his return from that hospitalization, he wrote a "living will" stating that in case of irreversible coma he did not wish his life sustained by such devices as ventilators and intravenous feeding (Question 2: Would you agree with writing a living will?). He spoke clearly to his disciples about his wish to die naturally (Question 3: Would you agree with "being natural"?). On May 29 1993, he suffered from a major stroke at 86 years old. His monk disciples began to care of him at the monastery in accordance with his wish (Question 4: Would you agree with not to hospitalize the patient?). However, a lay disciple, a leading neurologist persuaded the monks to allow the patient to be carried to hospital. The doctor said that if no improvement was seen within seven days, the patient would be returned to the monastery. The monks agreed and the patient was hospitalized (Question 5: Would you agree with eventual hospitalization?). He was in a deep coma. During the next few days, medical interventions were intensified according to medical rationale. The patient was eventually put on a ventilator, parenteral feeding and hydration (Question 6: Would you agree that the doctors had to introduce life-sustaining treatment?). The monks who had accompanied him protested; the doctors responded that they had a duty to continue once they had begun treatment (Question 7: Would you agree that life-sustaining treatment must be continued?). The doctors' decision prevailed over the monk disciples' (Question 8: Would you agree that once started the treatment should not be stopped?). But finally the doctors realized that their interventions were meaningless, and they let their patient be taken back to his monastery. He passed away on July 8, 1993, still tied up with the medical technologies he had repudiated (Question 9: Would you agree that his dignity was respected?).

In addition, respondents were asked whether they would approve of the Catholic policy regarding extraordinary treatment; the concept that patients are not morally required to receive extraordinary treatments disproportionate to their state in life (2). Answers were chosen from one of 5 items; "agree strongly," "agree," "neutral," "disagree," "disagree strongly." Any comments were encouraged to be written down. For summarizing the data, percentages were calculated based on the total corporations that responded to each question. Results were tested by chi square test at the 5% level of significance.

Results

Recovery of Questionnaire:

Questionnaire was recovered from 73% of religious corporations. A total of 43% of corporations responded to questions. "No unified policy," "Do not answer to questionnaire" and "Not working" were reasons for returning questionnaire without answering. Since "Not working" corporations were mainly of smaller size, these figures of 73 and 43% represented 86 and 54% in terms of number of believers in the "inclusive religious corporations," respectively. If "No unified policy" was included as covered corporations, this survey would mean to represent 55% of the "inclusive religious corporations" and 63% in terms of number of the enrolled believers.

Answers to Questions

Results are summarized in Table 2. Regarding "Declining modern medicine," respondents gave almost normal distribution, that is the religious groups were more or less neutral toward modern medicine. Shinto denominations disagreed more often than Buddhist and Christian corporations in this regard. Statistical difference in "Endorsing living will" among 4 religions was due to a small number of "agree strongly" in Shinto. However, overall results of "Endorsing living will" and the concept of "Being natural" was greeted favorably among all religions. Regarding "Declining hospitalization" at the major stroke, Shinto and Christian corporations showed wider distributions of opinions from agree strongly to disagree strongly than Buddhist corporations. "Eventual hospitalization" was approved of by many religious groups. Many were critical about the introduction of life-sustaining measures to the patient, though some Shinto and Miscellaneous corporations were favorable to this doctor's decision. An almost uniform unfavorable opinion was observed to continue life-sustaining measures even if they were started. Differences were marked regarding "Dignity was respected." Buddhist and Christian corporations thought that patient's dignity was damaged, whereas 41% of Shinto corporations thought that his dignity was respected. A typical answer was given by one of the Shinto corporations that Shinto would accept any result regardless of the cause or intention.

When the trends among each religion were compared, marked difference was observed in the attitude toward "Declining modern medicine" between Kyoha-Shinto and Shinkyoha groups (chi square=8.81, p=0.06, df=4), and in the attitudes toward "Declining hospitalization (chi square=10.56, p=0.03, df=4)," "Doctor had to treat (chi square=6.26, P=0.09, df=3)" and "Treatment must be continued (chi square=4.77, p=0.09, df=2)" between the Catholic and Protestant corporations. Thus, Kyoha-Shinto schools were more favorable to modern medicine than Shinkyoha-Shinto schools. And Protestant organizations were more favorable to modern medicine than Catholic. Accordingly, the trends between Kyoha-Shinto and Protestants, and those between Shinkyoha-Shinto and Catholic were similar regarding attitudes toward modern medicine and life-sustaining treatments.

Regarding extraordinary treatments, results showed that the Japanese Catholic corporations followed the view of the Vatican (2) and considered extraordinary treatments could be rejected by the patient at the terminal setting (Table 2). This Catholic policy was approved of by 71 and 85% of Shinto and Buddhist corporations, respectively. Although there was no significant difference in the results among the four religious groups, Shinto corporations were less affirmative to this Catholic view compared with the other three religious groups (chi square=11.21, P=0.02, df=4).

Remarks:

Among the respondents, 41 Shinto, 40 Buddhist, 21 Christian, and 7 Miscellaneous religious corporations made notes in reply. Nearly all Shinto corporations advocated "being natural" from the religious faith in the immortality of the soul. Several corporations noted that the patient should leave his or her health to the doctor or medicine, however, prolongation of life using artificial means is a disgraceful act against life. Others noted that 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 can make one's own decision.

Nearly all notes from Christian corporations expressed the objection against futile treatment, while respecting decisions by the patient. The necessity of advance directives was also mentioned. Remarks of the Miscellaneous corporations were not different from above notes.

Table 2: Attitudes of Japanese religious corporations toward terminal care and extraordinary treatment*

Shinto Buddhism Christianity Miscellaneous p value

Declining modern medicine (Q1) 2/12/20/17/1 2/19/32/12/0 1/6/18/7/1 0/5/5/5/0 0.702

Endorsing living will (Q2) 3/38/9/3/0 10/50/5/0/0 10/16/6/1/0 3/10/1/1/0 0.036

Being natural (Q3) 7/34/10/2/0 6/47/13/0/0 3/23/7/0/0 1/9/3/2/0 0.243

Declining hospitalization (Q4) 2/20/12/18/1 2/39/18/7/0 2/13/8/9/1 0/7/3/5/0 0.237

Eventual hospitalization (Q5) 0/35/11/6/1 2/33/22/9/0 2/22/7/2/0 1/7/4/3/0 0.474

Doctor had to treat (Q6) 0/19/8/19/6 1/11/14/30/9 0/3/4/18/7 0/7/4/4/0 0.055

Treatment must be continued (Q7) 0/3/9/31/9 1/1/19/33/12 0/0/6/21/5 1/1/2/9/2 0.443

Treatment should not be stopped (Q8) 0/6/13/27/6 0/3/12/39/12 0/0/8/20/4 1/2/3/9/0 0.066

Dignity was respected (Q9) 1/20/9/17/4 1/10/19/31/4 0/3/15/11/3 1/6/1/6/0 0.010

Denial of extraordinary treatment 10/26/6/8/1 14/40/6/3/1 6/24/2/0/0 2/12/0/0/1 0.140

*Figures indicate the numbers of religious corporations by "agree strongly"/"agree"/"neutral"/"disagree"/"disagree strongly" in answers. P values are results of chi-square test among the four religions.

Discussion

Although the appropriateness of life-sustaining treatments has not been discussed, "sanctity of life" has made people believe that introduction of life-sustaining treatment is mandatory and prolongation of life becomes the supreme aim of medicine in Japan. Thus, the decision not to introduce life-sustaining treatments at the terminal stage is always condemned by media as having killed patients (5,6), although so-called passive euthanasia and indirect euthanasia have been approved of by the Japanese Academy of Science and Art (7). A consequence of these phenomena in end-of-life issues is the prevailing practice of "prolongation of dying process" in contemporary Japan (8).

Japanese traditional and contemporary views of life and death derived mainly from Shinto and Japanese Buddhism. The typical features of Shinto are love of cleanliness and belief in the immortality of the soul and ancestor worship (4,9). 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. Thus, the dying process was important, but death itself was a moot point in Shinto. It was mostly Buddhism which dealt with the value of life and death in Japan. 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). It may be natural that Buddhist philosophy of metempsychosis and nirvana and the Shinto ideology regarding the soul influenced each other. For example, euthanasia and suicide is not a continuation of suffering but a way to the Pure Land (heaven) from this Defiled World (10).

This study was probably the first survey to have covered the whole religious world in Japan. Although the recovery rate was 73% and the response rate was less than half, this survey covered 54% in terms of number of enrolled believers. Thus, the present results represent the attitudes of Japanese religions, at least the majority of corporations or of those who speak to the secular world. One may wonder why analytical study was done in religion, since doctrine or theology usually suffice for answering questions regarding religious issues. This rule may be applicable to monotheistic religion. But, diverse opinions were anticipated from their independent activities among Shinto and Japanese Buddhism. In addition, it has been pointed out that the discussions by theologians were sometimes oversimplified or incorrect (11,12). Therefore, such a survey is necessary to attain deeper understanding of the issues concerned. Regarding the validity of this study, there is no data to compare with the present results. However, all Catholic corporations agreed that the patient is not morally enforced to receive extraordinary treatment against their wish and they opposed active euthanasia. These results are consistent with the Catholic doctrine (2,13), which indicated the reliability of the present study.

The present results indicated that Japanese religions approved of the concept of "being natural." Acceptance of "being natural" is compatible with Shinto and Buddhist thinking as described earlier. Accordingly, Japanese religions agreed that when medical treatment become futile, life-sustaining treatment should not be enforced to the patient or should be stopped. These attitude were consistent with the Catholic doctrine regarding "denial of extraordinary treatment" (2) and "naturalness of death" (13). Indeed, the Catholic view of denial of extraordinary treatment at the dying process (2) was approved of by the majority of Shinto and Buddhist organizations. Whatever the origin of the concept; "denial of extraordinary treatment" or "naturalness of death" in Catholics (2,13) or "being natural" in Shinto and Buddhism, consequences were the general tendency in rejection of unnecessary life-sustaining treatments among Japanese religionists.

On the other hand, some Japanese religious corporations were critical about "declining modern medicine" and "declining hospitalization." Their attitudes may probably stem from Japanese tradition and culture, which hold medicine in esteem. Particularly some Shinto corporations recommended to leave everything to the doctor and medicine as shown in the results of "doctor had to treat." The same reason may be applicable to such findings, namely Shinto corporations did not think that the dignity of the patient was damaged while Buddhist and Christian corporations thought that his dignity was damaged. Currently, Japanese attitudes toward medical decision-making show complex features caused by mixture of Japanese tradition and a recently introduced idea of the autonomy principle. Presumably, a gradual time-taking process may be necessary for solving this issue of the autonomy principle in the framework of Japanese tradition.

The number of people who said they believed in a religion was 32% (26% for Buddhism, 2% for Shinto, 1% for Christianity), and 63% answered as atheists (14). However, among the so-called atheists, more than 70% believed in Buddhist cause/effect thinking and practiced Buddhist and Shinto religious activities (14). Thus, religion has considerable impact on Japanese people, albeit unconsciously. The variety of religionists' views will facilitate people to think by themselves about these important end-of-life issues in medicine. Particularly, the appropriateness of life-sustaining treatments at the terminal setting should be discussed openly among religionists and secular people to expand and to deepen understanding of these complex controversial end-of-life issues.

Acknowledgement

The questionnaire study would have been impossible without the cooperation of many religious corporations, to whom the author is sincerely grateful. The author is also thankful for advice from the Agency for Cultural Affairs of the Ministry of Education for this survey, who courteously consented to reproduce their data.

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