- Ralph Seewald, Ph.D.
Kyushu Institute of Design, Fukuoka
;Both in the West and in Japan anthropologists have commented on the reluctance of the Japanese to accept organ transplantation as a standard form of treatment, Morioka (1995), Lock (1995). The assumption is that elements in the Japanese culture; like the Japanese folk religion, view of the dead body, and distrust in the medical profession make it very difficult to see organ transplantation as an acceptable medical treatment.
;The purpose of the study below is to clarify with the aid of a 75-item questionnaire:
There was hardly any relation according to the data between features of the Japanese folk religion like; making the first Shrine visit of the year, wearing an amulet, or thinking it is possible to have contact with a deceased family member, believing in life after death or not, and being positive about organ donation. However, nurses who have a donor card or are positive about organ donation, agree more that brain death is the death of a person. 80.2% of DONOR agreed that brain death is the death of a person, as compared with 49.6% of NON-DONOR.
NON-DONOR have more fear of the mutilation of onefs dead body than DONOR. If we compare nurses who were positive about organ donation (DONOR) with those who were negative about organ donation (NON-DONOR), yields the following relations:
Organ Transplantation has been a subject of debate in Japan since 1968 when the first heart transplant was performed by surgeon Juro Wada of Sapporo Medical University. The recipient; Miyazaki Nobuo lived for 83 days, a record achievement for that time. A civic group became concerned with the rights of the donor of the heart, Yamaguchi Yoshimasa, and accused Prof. Wada of murder, but prosecutors did not indict him due to a lack of evidence. Since this so-called Wada-case, books, articles and surveys about the Japanese attitude towards organ transplant and brain death have been published in a steady flow.
There are a lot of arguments that organ transplantation is incompatible with the Japanese culture and religion. Umehara (1990) claims that the idea of brain death and organ transplantation is an invention of the West, namely a consequence of the Cartesian Philosophy. His Dualism of mind and body is not compatible with the Japanese culture, which is based on animism where everything is deemed to be spiritual. The journalist, Tachibana wrote in 1986 a bestseller, named Brain Death, that although a person is declared brain dead, and even if the electroencephalogram shows no activity in the brains it is still unclear whether all the brain cells have died or not. He attests that brain death is not equal to human death. Morioka (1989, 2000) argues that brain death should be considered from the viewpoint of human relationships. In his "brain death as human relationships" theory he argues that: "The question whether brain death is humanfs death deeply depends on the relationships that the brain dead person has had with each surrounding person on the bedside". Macer (1992, 1993) asserts "that in every culture one can find people who reject removing organs from bodies, of their own or family members, and their views should be respected". Also an opinion survey from 1990 shows that more than 51% of the respondents agreed with donation of their relatives' organs. Another survey conducted in 1998 among 2157 Japanese gave almost the same result (Sourifu houkokushitsu). Namihira (1988) says that the Japanese believe that the happiness and peace of the soul after death are determined by the state of the body, and the state of the spirit will affect the fate of the surviving family members and that is a deterrent to organ transplantation. In Japan, many consider mutilating the body of a relative as taboo. Most of the Western anthropologists, such as Lock (1990) and even more Ohnuki-Tierney (1986) agree with arguments that culture give rise to a negative attitude of the Japanese toward brain death and organ transplantation.
Most research in Western countries regarding organ transplantation and brain death does not put the practice of organ donation into question but is usually done with the purpose of how to increase the number of organ donors. Since organ transplantation is carried out in hospitals, for those working in hospitals, nurses and other medical personnel, signing a donor card is seen as a moral obligation. The majority of the nurses in western hospitals, at the time of the survey, had already signed a donor card or marked their driver's license for organ donation (Kiberd 1992), (Kent 1995).
In Japan, surveys among nurses and/or other medical personnel are scarce. There is one study done among 179 nurses (response rate 87.7%) which shows that nurses who have experience with brain death patients tend to be more negative about organ transplantation (Furoshiro 1993).
In the present study, a question-answer research was carried out in an attempt to clarify the attitudes of Japanese nurses toward organ transplantation.
On April 19, 1999 and June 2, 1999, 279 questionnaires were distributed in two hospitals (Hospital A and B) located in Fukuoka City. Neither hospital A or B perform organ transplantation surgery nor do they harvest organs. Hospital A is a relatively small hospital with 149 employees of whom 102 are nurse and 11 are medical doctors. It is mainly involved with the nursing of the elderly. Hospital B is a general hospital with 307 employees of whom 180 are nurses and 37 are medical doctors.
Of the 102 questionnaires that where distributed in hospital A, 99 were retrieved at April 26, 1999 (response rate 97%). From the 177 questionnaires that were distributed in hospital B, 153 were retrieved on July 13, 1999 (response rate 86.4%). The overall response rate was 90.3%.
The nurses's knowledge, attitudes, and beliefs regarding organ and tissue donation and transplantation were assessed using a 75-item questionnaire in Japanese, 5 questions were subdivided in open questions. Finally the data were analyzed using Statistical Package for Social Science (SPSS).
1. Nurses attitudes towards Organ Transplantation
The average age of the nurses was 39.7 years. Among the 252 nurses, 21 (8.3%) had filled out a donor card (Table 1). Those that had filled out a donor card were mostly between the ages of 15-24 (32%) and 25-34 (11%). In the 35-44, 45-54 and 55 or above age bracket, the number of nurses that had a donor card was respectively 6.1%, 1.6% and 2.9%.
Table 1: Did you sign a donor card?
Of the nurses that filled out a donor card, 18 nurses (86%) carried the card always with them, and 17 nurses (81%) also declared on the donor card that brain death is equal to the death of the whole person. Among the organs one was willing to donate, most nurses where willing to donate all the organs, however five nurses (24%) had objection to donating the small intestines.
The 231 nurses who did not sign a donor card were asked with an open question, why they did not so. The reasons for not having a donor card where as varied as the reasons that where given for donation, and 69 (32%) of the nurses neglected to answer. Of the nurses, 23 (11%) claimed "not to have an opportunity to fill out a donor card". Fifteen (7%) nurses said, "I do not have a special reason for not making a donor card". The majority of the nurses appeared reluctant to give a precise reason for not having a donor card.
Table 2: Age of DONORs as compared to NON-DONORs
Table 3: Which of the following organs would you like to donate (DONOR only)? n=116
|Yes/More or less yes||No/More or Less no||Missing|
2.The role of the Family
Table 5: The Japanese law on organ donation requires besides the donor himself the explicit consent of the family. How do you think about this?h
It was found that in DONOR more nurses (52%) considered the consent of the family necessary compared to NON-DONOR (48%), (Table 5). The reason why the consent of the family is necessary were asked by an open question: "Why do you think that the consent of the family is necessary?"
Because of different feelings that my family has, I feel an uneasiness (14.4%)
One is not living alone in this world(9.3%)
If there is no consent of the family all kinds of problems arise
The person himself has not enough sense for a good judgment
It is the expectation of the bereaved family(4.2%)
I thought that the consent of the family was always necessary
Because they are my family(3.1%)
Other sentiments included: "Because organ transplantation is an emotional thing" "If organ donation is done against the will of the family, the family is the one that suffers" "The body is not just something of the person himself, but also something of the family" "The family has to honor the ancestors".
Table 6: Have you ever talked with your family about a donor card?
The overall number of nurses that talked with their family about a donor card was 52% (Both DONOR and NON-DONOR), (Table 6), however only 8% finally signed a donor card. Of those nurses who discussed the matter with their family, in 52% of the cases their family agreed or more or less agreed with signing a donor card. More nurses in DONOR (61%) than in NON-DONOR (45%) had talked with their family about having a donor card. The family was against, or more less against in 41% of the cases.
3.View on the Death Body and Body Image
In DONOR, 30% do not mind to give their body to a hospital for medical research, three times that of NON-DONOR, of which only 13% were prepared to give their body to medical research after death. In DONOR 61% are against or more or loss against autopsy after onefs death against 83% in NON-DONORs (Table 8).
Table 7: Do you mind to give your body to a hospital for medical research?
No/More or less
I donft mind
|Against/More or less against||Missing|
Table 8: Do you mind if an autopsy is performed on your body after your death?
or less yes
or less no
Table 9: Do you have objection if a dead body is cut open to take out organs in order to perform organ transplantation?
No/More or less
Table 10: Do you think it is possible that when a corpse is mutilated, the spirit of this corpse will bring misfortune to the bereaved family?
or less impossible
Table 11: Do you think it is possible to communicate with a deceased family member?
|Possible/More or less possible||
or less impossible
Table 12: Do you think there is a life after death?
|Yes/More or less yes||No/More or less no||Missing|
Table 13: There is a religious belief that says "Humans have also in the afterlife the same body shape as they have in this world". Does this view resemble your view of afterlife?
|Yes/More or less yes||No/More or less no||Missing|
Table 14: Which of the following religious views is the most close to your view? Choose from the following: Buddhism, Shinto, Christianity, New religion, Non religious.
Table 15: February 2 1999, the heart, liver, kidneys and corneas were transplanted from a brain death person. Which organ do you think is emotional the most essential organ of the human body? Choose from the following organs: Kidneys, Brain, Liver, Lungs, Heart, Other.
1. Nurses Attitude towards Organ Transplantation
Most young nurses have signed a donor card, and it is also the young nurses who are positive or more or less positive about organ donation. In the 15-24 and 25-34 age brackets, 68% and 59.5% respectively were positive about organ donation, while in 35-44, 45-54 and 55 or above age brackets those who are positive comprise 47%, 33% and 32%, respectively.
That most young nurses have a donor card or are thinking about making one is a reflection of the changing attitude of the Japanese youth. Although it must be said that also the majority of these young nurses are still convinced that it is necessary to consult the family members before filling out a donor card.
2.The Role of the Family
Most remarkable is that even more nurses in the DONOR group than in NON-DONOR are convinced that besides the consent of the donor the consent of the family is necessary. One would think that the decision to acquire a donor card would express a greater autonomy.
In Japan, however, decisions inside the family are usually not taken on an individual base. It is not unusual in case where a family member is admitted to a hospital, the family members consult with the doctor in charge, rather than the patient themselves. In the Japanese law on organ donation the explicit consent of the bereaved family is necessary. During the discussion in the Diet (Dai 140 kai kokkai honkaigi 1997), it was decided that the feelings of the bereaved family should be taken into consideration.
When a family member has died, other members of the family must fulfill an important role. Bai (1984), a legal scholar states that "the family of the deceased has a certain voice in the disposal of any part of his body even during his life, although their voice is secondary to his own while he is alive. After his death, their voice becomes predominant". He states further that "as far as the cadaver has effects on the life of a surviving family, the latter should be entitled to dispose of it in accordance with its life style".
Of the nurses, 130 (52%) had talked with their family about a donor card. The families of 68 nurses agreed in making a donor card, however, only 21 (8%) of the nurses signed a donor card. Of the 21 nurses that signed a donor card, four of them did so against the will of the family.
3.Views on the Dead Body and Body Image
The resistance that the Japanese nurses have against organ donation comes mostly from the fear of mutilation the body., as shown in Table 7, 8 and 9. As table 10 shows, there are not many nurses who thinks it is possible that the spirit of a family member whose body is mutilated will have a bad influence on the surviving family.
It is well known that it is difficult for Japanese hospitals to collect cadavers for medical research, even if the dead person himself has given consent to the donation. The same is true for autopsy after a murder crime. After the sarin attack on March 1995 by the Aum sect in the Tokyo subway, an autopsy was performed on the twelve victims. The forced autopsy of the victims and the additional mutilation of the body was for some family members much harder to bear than the death of their beloved ones (Chikatetsu sarin jiken higaisha no kaicho 1998).
The special care Japanese take of the body after a family member has died is expressed by the cultural anthropologist Namihira (1997) in the following way: "The body is cremated only as far as the bones itfs not reduced into ash. The bones must remain in the shape of the body with each bone in place. Bones are placed into a ceremonial jar in a fixed order. For the Japanese a body is both material and immaterial, biological and social". She concludes with: "For the Japanese cremation is a way of changing the life time identity rather than disposing of it. Cremated bones are not seen, by the Japanese, as human remains but as the actual body of the dead person".
In the West a dead body is referred to with words that depersonalize the dead body, like "corpse", "remains" or "cadaver": in other words an object of dissection. One can say that in the West the body devaluates after onefs death, while in Japan the value of the body before and after death stays the same.
The Japanese usually use the word itai, or go-itai for a dead body which also has the meaning of a body that contains ties between the deceased and his relatives, family and friends (Namihira 1988).
Some Western anthropologists have argued that the Japanese do not accept organ transplantation because, for the Japanese, the center of the body is not the brain. As Feldman (1994) states when commenting about western anthropologists who try to explain the resistance of the Japanese towards organ transplantation:
(Abbreviated) In their pursuit (Western academic anthropologists, Lock (1990) and Tierney-Ohnuki (1986) ) of the cultural identity of modern Japan, they have argued that the locus of the self of the Japanese lies resides not in the brain but in some other part of the body, but those same scholars are unable to agree where the elusive Japanese self resides. Heart transplants are taboo because the heart is the home, or the abdomen with the kidneys and intestines is seen as the place were the self resides, and therefore there is reluctance to accept brain death as equivalent to the death to the entire human body.
However, both the nurses in DONOR and in NON-DONOR choose either the heart or the brain, when asked to point out the emotional most essential organ. The only difference is that a higher number (31.0%) of nurses in DONOR compared with NON-DONOR (24.4%), choose the brain as the most important organ. Also in NON-DONOR 52.1% indicated the heart as most important next to the brain with 24.4%. NON-DONOR also has more variety in the organs. They choose, aside from the brain and heart, the liver with 4.2%, cornea 3.4%, and the kidneys 2.5%
Half of the 252 nurses, who were surveyed, thought positive about organ transplantation, however only 21 of them filled out a donor card. Apparently thinking positive about organ donation is one thing, and signing a donor card is something else. The majority of the nurses, who wanted to make a donor card, were also convinced that consultation with the rest of the family was necessary.
As shown in Table 3, most of the nurses who are positive about organ donation, do not have any problem with donating the heart. The heart can be viewed as that organ that symbolizes the human emotions, but to deduce that because of that there is a reluctance to donate the heart is too far reaching a conclusion.
When asked to point out the emotional most essential organ, more than half of the nurses, in both DONOR and in NON-DONOR choose either the heart or the brain. The idea that the Japanese have some special affinity with one part or organ of the body and therefore oppose to organ donation is not supported by the data gathered.
The most remarkable result was that the nurses, who said that they have a donor card or wanted to make one, have reserves against the necessary surgery that goes along with the removal of the organs from the body. Other questions about "giving onefs body for medical research", and "autopsy" show aversion to mutilation of the body after death. Essentially they are willing to donate organs, but not if it means the body must be operated on to do so.
In the Japanese myths, there is not much difference between the life on earth and the life after onefs death. Rather than gods, the actors in the myths are depicted as normal humans who need to eat, sleep and have emotions like human beings. Even in present Japan, food is offered in front of the Buddhist altar for the sake of the ancestors. Although everyone knows that the food will not really be eaten, it is supposed that the spirit thought to be existent in the food can be transmitted. In the survey the question gDo you think it is possible to communicate with a deceased family memberh, showed that about half of the nurses thought that this was possible. If such kind of sentiments exist, one can imagine that cutting open a body and taking out the organs is unconsciously repulsive for many nurses.
Also in the Western cultures, Islamic culture, and Jewish culture people also have objections against organ transplants, because of believes that it is good to be buried with the whole body intact. Muslims who believe in bodily resurrection fear bodily mutilation. Dorff (1996) says that in the Jewish folk religion gThe body must be buried with all its parts so that they will all be there when it comes time for resurrectionh He claims that even Jews who are totally secular in their thoughts have this idea. Judeo-Christianity: a mixture of biblical teachings, Hellenic, Greek and historical traditions of the church has also this concept of bodily resurrection, but anyone brought up in that tradition has the image of Jesus who sacrificed his body at the cross ingrained in his mind. Therefore, for many Christians organ donation is not a sacrifice, but something that one ought to do to help a fellow-creature.
I would like to thank especially Prof. K. Yamamoto, MD at the Health Service Center of the Kyushu Institute of Design, who introduced me to the two hospitals in Fukuoka City and helped me with making the questionnaire.
Also I would like to thank Prof. E. Namihira of the Ochanomizu University, who suggested me more than three years ago to take a look at the stance of medical personnel towards organ transplantation and brain death.
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