Reconsidering the Japanese Negative Attitude Toward Brain Death and Organ Transplantation

- Masayuki Yoshida BA MA PhD.
8-3-19-102 Seijo, Setagaya-ku, Tokyo 157-0066 JAPAN
Email: ysd_m@ybb.ne.jp
Email: d_m@ybb.ne.jp

Eubios Journal of Asian and International Bioethics 14 (2004), 91-95.


Independent scholar and Tokyo-based academic journalist, with thanks to the generous help of Miss Hiroko Inoue.

Japanese Attitudes toward Death
In Japan, the view that emphasizes Japanese uniqueness still dominates the debate over brain death and organ transplantation. A sufficient number of journalists, philosophers, attorneys and others attack the idea of brain death and its consequent practice of organ transplantation by pointing out complex cultural reasons. For some details on the Nihonjin-ron arguments on brain death and organ transplants, see Ogiwara 1992.
1) that unlike the idea of Western Cartesian dualism (the formulation of the body and 'soul/mind') which assumes that a human body is regarded as a sort of machine or an arrogation of its diverse parts, the majority of Japanese consider human remains and ashes as the locus of spirit or soul;
2) that the old concepts of evil consequences and ancestral connections still remain present in contemporary Japanese society and they seem to believe that unless a person's complete body is cremated then the person's spirit or soul does not die peacefully;
3) that for the Japanese who understand death as a natural process, receiving harvested other's organs and thereby continuing to live is 'unnatural', and therefore think that they should die in a natural way by refraining from having artificial operations such as organ transplants in order to extend life; and
4) that contrary to the Christian idea of 'neighbourly love', Japanese have traditionally respected various ideas of Buddhism and Confucianism such as filial duty (k_) or loyalty (ch_) as a standard of behaviour.
However, the claim based on the Nihonjin-ron arguments or 'cultural uniqueness' is likely to generate a gap between real life and society, whereas it has a seat as a sort of national belief in Japanese society. Distorting people's perception may result in unsatisfied politics and policies. If this reality is what should be resolved then we are required to appropriately analyse the reality in various ways and furthermore lead it to a useful development based on the result of the reality.
From the above perspective, I will point out, in this essay, the gap between the nihonjin-ron and the social reality that is assumed on the debate over brain death and organ transplantation, and moreover suggest some constructive proposals regarding the gap. In comparison with Western countries it is needless to say that there is a dearth of practical cases where brain death, under Japanese law, has led to organ transplants. 30 cases of brain death and 29 resultant cases of organ transplantation have been reported under the law on organ transplantation since the enactment of the law as of 20 May 2004.

The Myth of Adopting a Passive Attitude
Japan, the new Constitution of which was enacted fifty-seven years ago, is a nation where the post-War generation occupies the majority of the population. The conception and idea of rights have already been settled in people's minds, and the practice and enforcement of rights have been carried out in people's everyday life. It might therefore be said that the debate on Japanese legal consciousness, which was held by Professor Kawashima and his opponents in the 1960s and 1970s, is over at last. For a detailed discussion on legal consciousness, see Yoshida 2003.
Due to the medical advent of organ transplants, the traditional debate on issues surrounding the rights of burial has dramatically entered a new phase. However, as it can be understood that rights of burial were influenced by cultural factors, so the rights on the new phase, i.e. intentions to donate organs, are affected by them. Speaking more concretely, we need to discuss how those rights have been influenced by society and culture, and have resultantly penetrated through society.
The debate on the intention to donate organs and the influence of wider cultural issues reveals the Japanese specific persistent belief based on the cultural uniqueness, or the Nihonjin-ron arguments, that Japanese traditional values are inherently incompatible with the concept and practice of brain death and organ transplants.
Kawai (1991) is one of those who take a more extreme position which argues the Japanese uniqueness of attitudes toward death and a corpse. He understands from a persuasive perspective (Lifton et al 1979) that Japanese attitudes toward death are emotionally an acceptance of the resignation of universal order and intellectually that of the natural and/or the cosmic order. Both acceptances are under the background of a culture that did not place emphasis on the severe separation between the living's daily life and death.
Death is a natural event, but the Japanese regard towards nature overlaps with that toward death. Western modernity regards nature as an opposite object of humans, and has become accustomed to definitely distinguish the two. Japanese, otherwise, think of humans and nature as a unit and that both are therefore intrinsically equal or in harmony, and have no universal standards despite there being degrees of values. This interpretation can be applied to attitudes toward death, so that they take it for granted that they evaluate human death and other entities' death at the same level of nature's perspective. In short, to the Japanese, the boundary of life and death is thin, and they would concord with the ambiguous boundary of human death and other entities' death that are never rigidly defined by Japanese, and even with that of self and other self (Kawai 1991).
Another aspect for the culture connections is related to ancestor worship. Feldman points out that '[a] central tenet of ancestor worship in Japan is the conviction that the welfare of the living is dependent upon paying homage to the dead' (1996, 237). Therefore, regarding brain death as an individual's death, damaging a corpse to harvest his/her organs may infringe against the respectful feelings held toward the recently deceased ancestor (see Fujii, 1993, 540-543; Backnik 1995, 108-142).

Attachment to Human Remains
Despite a good number of justifications supported by cultural connections with regard to the Japanese reluctance toward the practices of brain death and transplants, a sociologist points out that most of the traditions and values relating to death have vanished (Nudeshima 1991). With the efficient evidence of drastically changing city life since World War II, he argues that many customary ideas about funerals, burial and ancestors, which the cultural uniqueness thesis grounds its justification on, have not only changed but that such a thesis is not worthy of discussion. Wss (1992, 73-100) also underpins Nudeshima's conclusion in a recent summary of eleven public opinion polls carried out between 1953 and 1987 concerning Japanese attitudes toward death. According to the summary, for example, it seems that more people in German than in Japan believe in reincarnation (ibid., 87-89).
While Japanese tradition and culture have had a certain influence on the contemporary Japanese views of death, they are not decisive factors in determining the Japanese attitude toward death and a corpse. They are an inadequate explanation of the primary reasons for having delayed the practices of brain death and transplants in Japan, for which the main reason is the mistrust of physicians. A compiled book (Watanabe and Abe, 1994) edited by medical doctors who denounced the bill of the Law on Organ Transplantation provides us with diverse reasons why patients are mistrustful of physicians. The publication suggests that there have been not only many scandalous concealments, by physicians and their hospitals, on the practical judgement of brain death and the practice of organ transplantation since the medical scandal of Dr Wada and his team's first heart transplant in 1968 (see Ky_d_ts_shinsha shakaibu 1998), but also that the practice in daily medical services has led to the mistrust of medical doctors because of the extremely low level of information disclosure. This, it would seem, is a practice based on paternalism.
In addition, there are emotional and moral reasons for the reluctance. A journalist who was involved with the formation process of the Law on Organ Transplantation (1997) is of the opinion that contemporary medicine is likely to lack consideration for patients' and their relatives' feelings while they pay strong attention to inner organs and diseases, and therefore that disregarding their feelings in the face of organ transplants results in the leaving of deep scars in the mind (of the relatives) (Nakajima 2000, 133).
Another reason can be deduced from the assumption that donating organs is a good conduct which does not require a reward to the actor's self. This conduct is a far higher moral action called supererogation. From the moral construction based on such concepts as reciprocity, equality and impartiality the conduct is not regarded as a duty but as a high virtue or a kind of responsibility. Contemporary Japanese lack the consciousness of this virtue; for they have on many occasions had the regrettable experience that their purely self-sacrificial conducts (for the sake of the nation and their companies) historically came to nothing. They have acquired a kind of wisdom that self-sacrificial conduct is wrong and as a result have little interest in the supererogation or volunteer act such as donating their organs for others who need organ transplants.
As an example of the strong Japanese attachment to human bodies, an anthropologist discusses a jetliner crash on the Osutaka-Yama mountain, Gunma Prefecture, in August 1985. She points out that the Japanese have a way of thinking by which they identify themselves with the dead and possess a tendency to convert their feelings into the deceased person's words (Namihira 1990). By due process the bereaved identified the victims' bodies that were collected at the scene of the crash, and their attitudes while doing so drew attention. When we read a collection of the relatives' memoirs (8.12 Renraku-kai, 1987), we find that there were many expressions that the bereaved voiced about the dead, for example: 'Father must have felt very frustrated!' or 'When I think about the regret that the victims have'. These expressions suggest that the bereaved reconfirm that the dead persons can feel, think and suppose despite not being alive. The anthropologist understands that the bereaved, in a sense, put themselves and the victims in the same category. In other words it may be understood that the attitude is linked to the way by which the bereaved reconfirm their identity of themselves that is a sort of reflection within others -that is, the dead.
To illustrate the Japanese extreme attachment to human remains in cases of aeroplane clashes, which are more extreme than attitudes in other cultures (Sabata 1979; Miyata 1988; Namihira 1990), proponents of the cultural uniqueness thesis use the obsessive attitudes toward remains in order to justify their position. It is, however, a one-sided justification. Or rather, it should be understood that the strong attachment of Japanese people to a dead body does not only lead to the reluctance of the donation and transplantation of organs but also to positive attitudes toward them as explained later.
Contrary to the cultural connections for explaining the Japanese reluctance to accept the practices of brain death and their passive attitudes toward organ transplants, the cultural uniqueness, if any, might change their attitudes into positive ones toward the transplants. We will now propose four perspectives for their alteration.

Four Presumptive Reasons for the Positive Attitudes
Body Project
In the Edo times, or at least in the Meiji period, the Japanese people seem to have held deep persistent interests in human bodies in terms of the comparison with the shapes of Westners' bodies (Frhstck 2000). Their concerns about the bodies of others have been incorporated into the perceptions of their own bodies within a framework called 'body project' (ibid.). Shilling (1993) contends that the project of the self in modern society is the project of the body. Using the term 'the reflexity of self', Giddens (1991) explicates the association with the idea that the body seated in modern society expresses the self through the medium of cosmetic surgery, body transplants and implants, diets, keep-fit regiments, etc. In this way, it is possible to think that the Japanese located in the range of the body project may shift their deep interests of bodies to organ transplants.
According to a survey (Sh_ d_ ai 1986), about half of the questioned Japanese of all ages felt a complex concerning their faces and/or bodies. Their dissatisfaction with their own bodies covers many parts of the body such as skin, teeth, nose, weight, stomach, waist, hips, etc. Clients of aestheticians and surgeons seek to create a beautiful body and to make themselves more attractive. This body-orientation results in a radical change in their lives. The lifestyle is associated with their wishes to change themselves and will influence a set of values and interests in daily life. Hebi Ni Piasu (Snake with Pierced Tongue), newly winning novel of Akutagawa Prize, depicts a 19-year-old heroin who searches for the meaning of life by piercing her tongue. This novel became best-seller probably because its motif of transforming body part stimulated readers' emotions and interests (see Kanehara 2004).
Among the Japanese who have an extreme attachment to their own bodies, there would be some who think from the perspective of transforming external and internal bodies that the value of organ transplants may be incorporated into this set of values of the body project. In short, those who recognised the limitation of their own body project or who were not able to work off the frustration in their lives, may desire to develop their organs to continue to be alive after their death -as a new body project. Thus, posthumous organ transplants would imply manifestation of emancipation from the Japanese perception of the inferiority of antemortem bodies. They would wish to expand their lives and complete their attractive body project even after death.
Contemporary Japanese are unlikely to obey the old standards of morality. They regard harming their bodies (e.g., piercing or plastic surgery) as generating a new value of changing themselves. This is an understanding of emotions and perceptions rather than philosophical, ethical and rational points. At almost the same level of attention to a stylised image of the body in consumer culture, advertisements, the popular press, television, etc., people take part in the project relating to organ transplants (even a new way of disposal of a corpse such as scattering ashes). They desire after death to give vent to the frustration generated in contemporary stressful society by regarding organ transplants as emancipation from their frustrated feelings and bodies. The expectations of the posthumous emancipation are oriented to the body project of organ transplants.

A Japanese Habit
Japanese people have a habit of attempting to accept anything new. It can be said that on occasion, without full consideration as to whether something will be acceptable in the cultural and spiritual climate of Japan, Japanese people introduce new things into Japanese society. A philosopher points out, in light of this sort of innocence, that in Japanese society, social consensus can exist in the form of conforming to a present situation that has not gone through prudent examinations, criticism or exploit (Murakami 2000). Its vital example is abortion, which has an assumption that destroying a future human is allowed only if some conditions are satisfied for justifying abortion. He suggests and warns that there is the same risk in dealing with organ transplants.
In introducing a new object or idea, the basic test seems to be whether or not it projects a good image. And, unless the object is up to this standard, it is rejected by society or required to be modified or aborted. For example, at the time when Dr Wada and his team carried out the first heart transplant in Japan, mass media and the general people showed enthusiastic attitudes toward this advent, with extremely high expectations and a warm welcome. Furthermore, once something is introduced into society, people show a respect for the maintenance of its images. In that sense Dr Wada's case, where he and his team are accused of murder, ended up centring a totally bad image of heart transplantation, and it can be argued that this resulted in the delay of the enactment of the Law on Organ Transplantation of 1997.
In short, Japanese behaviour can be dictated by emotions or feelings, rather than being based on a rational assessment of the object. The consequence is that if only its image becomes good, the project of organ transplants will be considered as a kind of trend which can be easily accepted by the Japanese. In that regard the spread of donor cards may be seen as an 'image war'.

Expanding the Concept of Uchi/Soto
For more understanding of the cultural connections we may make use of the concepts uchi/soto (inside/outside) which Jane M. Bachnik (1994) proposes as the key Japanese organisational locus for 'self, social order and language' (ibid., 3). We concur with her view that the organising of self and society is situationally given meaning by the indexing of uchi/soto orientations. Therefore the Japanese social relation between self and others can be on many occasions understood by the application of the concepts uchi/soto., see:
"We concur with her [Jane M. Backnik] that uchi is an actor found in a collectivity, not an individual (Bachnik 1994, 26). Soto is a relationally defined concept with uchi. Both are interchangeable depending on a speaker's deictic reference" (Hayashi and Kuroda 1997, 24).
An uchi situation is inside a household and a soto one outside the household. In most cases of Japanese language usage an uchi speech is rougher than in a soto speech, as are daily greetings. It is a business custom that workers within a company (uchi) do not use honorific expressions when they talk about their bosses (uchi no hito / insiders), but they do with their customers (soto no hito / outsiders). In this way Japanese take into account the relation and language usage under the standard of uchi/soto.
We can now relate the competing concepts uchi/soto to organ transplants. To donate organs is, except for living donation within family and relatives, to do so to soto persons. Japanese are apt to feel reluctant to donate organs to people in the soto situation. They tend to respect the inner relational bond rather than to make a supportive contribution to society.
However, we challenge this assumption. The basic paradigm of uchi/soto can be applied to any situations and any human relations in Japan, so that the boundary of uchi/soto is inevitably uncertain. The structure of uchi/soto is so complex and situational that we can find soto in uchi, and uchi in soto. For example, a household is situated in uchi, but if a person is a stepmother, then it seems to her son that she is a person situated in soto.
The situated uchi/soto in society is, as well, uncertain in terms of the boundary of usage. The donation of organs by children under the age of fifteen is prohibited in the Law on Organ Transplantation. This means that children requiring organs have no alternative but to seek for medical operations abroad. We recognise that Japanese recipients of organs regard overseas as soto and Japan as uchi. To gain a sufficient amount of money for the costs of attending transplants abroad, the family is forced to raise funds for the undertaking in the uchi situation such as the father's work place or the neighbouring community, or through newspapers or other mass media. Those who sympathise with the patient have, despite any geographic distance, a feeling that they are involved with the uchi relation.
In this manner the consciousness of being in uchi that should be an obstacle to the soto orientation plays a vital role in pulling the soto people to the uchi world and conversely expanding them to the soto world. This becomes possible by the fluidity and dynamics of the uchi/soto concept. Therefore, proponents of organ transplants must need a strategy or tactics for embracing the uchi world donors who live in the soto situation, because transforming a soto society into an uchi one enables us to generate emotions such as sympathy, togetherness or affections, and to more easily persuade people to donate and receive organs.

Wrapping Culture
We will apply the concept 'wrapping culture', which Hendry (1993) provided as a framework for characterising Japanese society, to explain the positive attitudes that Japanese people have toward organ transplants. Although 'wrapping culture can, of course, be found in other nations, it is only Japan that it has such a wide variety of modes and kinds of wrapping per se, as opposed simply to different kinds of wrapped contents.
If the word 'wrapping' is regarded as a metaphorical expression or as analogous of the paradigm posed in the use of objects, especially gifts, then we may imagine that organs for transplants are wrapped in a human skin. Organs that are donated to recipients are wrapped in the donor's skin in a way that has a number of implications for the protection of organs.
Aranami and Taguchi, associated with an organisation for protecting children who suffer from gallbladder illness, point out an inconsistency of Japanese character (T_ky_ daigaku igakubu n_shi rons_ wo kangaeru kai 1991, 162-164). Japan has a national characteristic of caring much for gifts. Amongst most people, gifts are exchanged in the seasons of the Bon Festival and the year-end. However, Aranami addresses that the majority of those who give something as a seasonal gift wish to have something in return. He suggests that the donation of organs is a conduct that asks for nothing in return. Therefore, donating organs and customary gifts are fundamentally different (ibid.).
However, this refers to the different 'gift' perception that donors and their family hold in their minds. It is posthumously that donors give organs under the law prohibiting the commercial dealing of human organs. Since there are no subjects who can seek a reward in the posthumous situation, there is in reality no subject who can receive a reward.
Organs 'wrapped' in donor's skin can be also said to be a gift from his/her relatives, and the relatives may want to receive something in return. For them to expect to receive something from recipients and their relatives would mean confirming the value of donating organs. As a matter of fact, donors and their families do not receive anything in return from recipients, and must find satisfaction in the donation of organs even if there is nothing material in return. It is necessary to consider how such satisfaction is produced amongst people in society for the purpose of improving the frequency of donations.
In this way, by interpreting the meaning of organ donation in a similar way to the values of 'wrapping culture', we could persuade those that are uninterested in the medical practise to participate in the donation of organs, as there is a general need to increase their numbers.

Conclusions: Multilayered Structure
Understanding the practices of brain death and organ transplants in association with Japanese cultural connections suggests that cultural influences are apparent in the rights to dispose of a corpse. However, even if cultural factors are somewhat influential, it is not necessarily persuasive to argue that the factors have a power by which organ transplants are rejected or promoted. Although their perspectives can be applied to the arguments for and against donation, they could be central in the attempt to increase the frequency of voluntary donation and transplants. _In this respect, we have proposed what we consider as the four cultural factors which still prevail in contemporary Japan, although it should be noted that they each have their own pros and cons in the argument for the donation of organs and their transplants.
Apart for Japanese cultural factors, there are three reasons for the reluctance to donate organs. First, people have emotions or feelings that they would not like to donate their organs, they have a strong rejection for accepting their relative's death, and they harbour ill feelings toward the fact that medical doctors regard the interests of recipients as more important than the side of donors. Secondly, unlike objectionable emotions, the people who face the sudden death of a relative hesitate to give their consent to donation, or do not give it because they cannot understand or do not want to understand the situation and the following procedure. Thirdly, medical personnel involved with the donation fail to successfully persuade the case for donation.
Our argument is thus that the intention to donate organs has an extremely multilayered structure, rather than the simple Nihonjin-ron arguments, and that a compilation of negative reasons results in the passive attitudes of Japanese people toward organ transplants.

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