Denial of Death in Contemporary Japanese

Journal of Philosophy and Ethics in Health Care and Medicine, No.5, pp.
55-75, April 2011
Scientific Contribution
Denial of death in contemporary Japanese

from a traditional view of life and death and unrealistic
expectations of modern medicine
Noritoshi TANIDA
(Yamaguchi University, E-mailtanida@yamaguchi-u.ac.jp)
Abstract
In old days, people thought that the cessation of breathing was not
death, and they prayed for the return of the soul or revival for many days.
Such an ancient view of life and death affects the attitude of contemporary
people. Thus, denial of brain death is one example, and prolonging the
dying process in medical practice is another example. Such denial of death
and brain death stem from traditional religious belief, which has been
exacerbated by unrealistic expectations of modern medicine. The problem
here is simple: the minor or the weak has always suffered from irrational
medical practice, particularly in end-of-life care. Revision of the Organ
Transplant Law is unlikely to work for acceptance of brain death, whereas
authentic guidelines seem to work for acceptance of natural death in the
field of end-of-life care. In the meantime, irrational medical interventions
in end-of-life care should be stopped, and decision-making should be left in
the hands of the patient and family. And such important issues involving a
view of life and death should be discussed openly to attain deeper
understanding on issues concerned by all factions of Japanese society.
Keywords view of life and death, end-of-life care, artificial respiration,
decision-making, brain death, organ transplant, transplant
tourism, religion
1. Introduction
Japan has introduced all kinds of modern medicine from
Western civilization. However, traditional ways of thinking have
remained among people. Thus, the matter of Japanese tradition
55
Journal of Philosophy and Ethics in Health Care and Medicine, No.5, pp.55-75, April 2011
and Western technology is often at the center of discussion

regarding life and death as exemplified in the dispute over brain
death and organ transplant 1-3 .
In old days, people thought that the cessation of breathing was
different from death (Table 1). They thought death was a process
in which the soul left the body first, followed by unconsciousness,
cessation of breathing, and finally the loss of life 4 . Indeed, the
Japanese word shinu (to die) did not mean to die originally,
but meant highly exhausted 5 . People made a mogari-no-miya, a
special palace, in which to place the body, and they prayed for the
return of the soul or his/her revival for many days 6 .
Such an ancient view of life and death is not only seen in
history, but also affects the attitude of contemporary people
toward death and dying. In addition, the idea of "respect for life"
or "sanctity of life" has become fashionable for the last two to
three decades. And prolonging the dying process is now a
dominant medical practice. Accordingly, denial of death is
prevalent in Japan resulting in denial of brain death as well.
In this article, the author describes some typical examples of
denial of death in Japan. Then, the discussion moves to the
attitudes of people who do not accept brain death. Finally,
implications of the ancient view on death are discussed in
conjunction with unrealistic expectations of modern medicine
among contemporary Japanese.
2 . Denial of death among contemporary Japanese
When a patient suffers from an incurable fatal disorder such as
terminal cancer, it is biologically or medically futile to attempt
any procedure to prolong the dying process once the patient has
expired. As Annas noted, if cardiopulmonary resuscitation (CPR)
is never successful in hospitalized patients with metastatic cancer, it
is useless and futile in this category of patients; therefore, physicians
should not do CPR, and patients have no right to demand that they
do7. The patient on a respirator is not exceptional if the patients
condition is the same. Suppose the switch of a respirator is turned
56
off in this category of patients, the situation is exactly the same at

the time when he/she has expired spontaneously. When
respiration does not resume after the switch-off, it will mean
natural death of the patient. It is not a matter of patients rights
but a matter of good clinical practice 7 . It will be the breach of good
clinical practice if CPR or a respirator is introduced merely to
prolong the dying process in these patients 7 . However, there are
several examples where the Japanese judicial society does not
allow such a natural death.
2-1. Denial of death in the judicial society
The first was a Hokkaido Haboro Hospital case in 2004. A 90
year old patient was taken to a hospital with the condition of
death-on-arrival. He received CPR. And only his heart-beat
re-started, then he was kept on a respirator. Next day, the
respirator was removed from the patient because of the hopeless
situation. The Hokkaido police charged the doctor with murder 8 .
The second case was a Wakayama Prefecture University Kihoku
Hospital case in 2006. An 88 year old patient was taken to a
hospital for cerebral hemorrhage. Although surgery was carried
out, she became almost brain dead, which meant breathing
ceased. The family wished to extend her life until relatives could
meet her before declaration of death. So she was put on a
respirator. Next day, their meeting was accomplished. The family
then wished to stop the respirator, and the attending doctor
complied. The police charged the doctor with murder 9 .
The event most widely publicized by the mass media was the
Imizu Municipal Hospital case 10 . A director of the hospital sent 7
patients records to police in 2006, in which the attending surgeon
was alleged to have caused death by withdrawing the respirator
from each of the terminally ill patients. Although there was no
substantial breach of the bioethical principle in the surgeons
acts 10 , he was accused of murder and was examined by police. All of
these cases, including the Hokkaido and Wakayama cases were
eventually turned down at the prosecutors office by the end of
2009. However, similar cases among laypeople were heartrending.
57
2-2. Tragedies induced by medical and judicial societies

On April 22, 2010, Mrs. Kyoko Wada (67 years old) was
sentenced to a 3-year imprisonment (suspended for 5 years) for
murder of her son 11 . Her son had committed suicide on July 15,
2009 because of his financial difficulties. He was found
unconscious and sent to a hospital. Consequently, he was kept on
a respirator without a slightest hope of recovery. The family had
made every effort to have the respirator withdrawn from the
patient according to the familys consensus. However, the doctor
dismissed their wishes and kept the patient on a respirator.
Wadas family foresaw bankruptcy from hospital bills. Mrs. Wada
was arrested and prosecuted for murder. She testified on trial
that when she was about to stab him on July 25, 2009, she heard
her sons voice expressing please do it.
On October 12, 2009, Mr. and Mrs. Sugano attempted double
suicide but were unsuccessful. Later that evening Mr. Yukinobu
Sugano (66 years old) killed Mrs. Hatsuko Sugano (65 years old)
and gave himself up to police afterward 12 . Five years earlier, Mrs.
Sugano had been sentenced to a 3-year imprisonment (suspended
for 5 years) for murder of her son who suffered from amyotrophic
lateral sclerosis. Her son had been seriously ill for 3 years.
Although he tried a respirator at first, later he kept asking the
attending doctor and his family for comfort care upon
withdrawing the respirator. Actually the attending doctor
consulted the case to the Kitasato University Hospital ethics
committee regarding the Suganos and familys plea to withdraw
the respirator. However, the ethics committee did not come to a
conclusion, but kept saying under consideration. On August 28,
2004, Mrs. Sugano turned off the switch of his respirator then she
attempted suicide at the side of her sons body. She was found
alive and eventually prosecuted for murder. Although she was
released after the trial, she was depressed and kept asking her
husband to kill her.
In a society where the doctor has lost power over the patient
and family, the doctor has to comply with patients and families so
far as their wishes are within the scope of good clinical practice.
58
Nowadays, patients rights are accepted in general after a long

struggle among relevant factions in Japan. Accordingly, the
patient is free to make any medical decision. Indeed, life
threatening bleeding was not treated when the patient refused a
blood transfusion, and she soon died. The event occurred at Osaka
Medical College Hospital in 2007 13 . The general public and mass
media raised no questions about this case because of the current
understanding of informed consent and patients rights to be
medical decision-making. However, the Japanese society does not
accept withdrawing a respirator from a patient whose
spontaneous breathing stopped. Consequently, the patient and
family are placed in a very hard position. If the above described
families had lived in other countries, their doctors would have
stopped the respirator. Thereby, these families would have been
offered social, mental and spiritual care. They were unfortunate;
they were born in Japan.
3 . Issues concerning brain death and organ transplant
In conjunction with the international movement to ban organ
transplant tourism 14 , the Japanese Diet was forced to revise the
Organ Transplant Law (OTL) in 2009. The revised OTL included
such major changes as the allowance of organ removal by familys
consent and inclusion of children as candidates for organ removal.
These modifications were meant to increase the number of organ
donations and to allow organ transplant for children in Japan.
However, simply changing of the law is unlikely to result in
increasing organ donations from reluctant Japanese people. Here,
the means of the revision of OTL is briefly reviewed, and the
remaining issues are described.
3-1. The process of revision of the Organ Transplant Law
October 16, 2007 was the anniversary for OTL which had come
in effect 10 years before. The concept of the original OTL was
similar to laws in other countries, but was different in that an
authentic donor card with explicit written consent by the brain
59
dead was mandatory for organ removal and that only patients
older than 15 years could donate organs. In addition, brain death
was a human death only when an organ transplant was on
schedule.
During the period of 10 years, a total of 61 brain deaths were
diagnosed for organ transplant (Figure 1). However, a small
number of brain death and organ transplant cases frustrated
waiting patients and their advocators. Furthermore, young
children could not receive organs from the brain dead because of
the age limit in donations. There were many patients, both
children and adults, who went abroad for procurement of organs.
In the meantime, as instructed in the original OTL, the Japanese
Diet tried to modify the OTL in response to both pros and cons
groups. However, because of the inconsistent attitudes in the
ruling parties, proposed bills were left untouched and kept under
discussion in every term of the parliament.
Perhaps, the greatest driving force for revision of OTL was the
issue concerning organ transplant abroad or transplant tourism 14 .
On the one hand, Japanese people and mass media consider going
to developed countries for organ procurement as a brave and
reputable action and support patients and families in raising
money for the expenses. On the other hand, they criticize patients
going to developing countries with their own money for organ
procurement as involvement in organ-buying. Both cases are by
all means a kind of organ-buying 15 . Thus, an unfair unethical
atmosphere is fostered by Japanese mass media that those
receiving organs abroad with their own money are criticized,
whereas those receiving organs with publicly donated money are
cared for and respected 16 . This Japanese notion is in clear
contrast to the WHO report, which notes that, Commercial trade
in cells, tissues and organs continues to be a serious problem,
particularly in countries with substantial transplant tourism. In
order to gain easy access to organs, some people seek transplants
abroad that are paid for by private or governmental health
insurance in their home country even when trade in organs is
formally prohibited in that country 15 . In due course, the
60
declaration of Istanbul and the movement in the WHO to ban

transplant tourism pushed the Japanese Diet toward revision of
OTL, and they rushed to meet the demand of waiting patients.
3-2. Issues remaining after the revision of the Organ Transplant
Law
Although the revised OTL entered into force on July 17, 2010, so
far the discussion before and during revision of OTL seems to
have induced a negative impact on the number of organ donations
(Figure 1). It looks like Japanese people have become more
conservative in their attitudes toward brain death. Presumably,
the campaign by the mass media against the idea of brain death
during the revision of OTL has been influential to the Japanese
people, in that 1) there is no consensus to accept brain death in
Japan, 2) when the idea of brain death is accepted, the doctor will
abandon treatment of a patient who could recover with further
treatment. Indeed, both claims have firm bases.
The first heart transplant in Japan was done by Dr. Wada in
1968. It was so notorious, because it was highly probable that the
donor was not brain dead and the recipient did not need a heart
transplant 17 . Japanese medical practices are insufficient in terms
of disclosure of information to the patient. The official declaration
of professional ethics by the Japan Medical Association in 2004
did not mention patients rights. Although the phrase to respect
patients right was added to the revision in 2008 18 , there is no
such clause in the Principles of Medical Ethics of the Japan
Medical Association yet 19 . It may still take some time for
Japanese doctors to cooperate fully with the idea of informed
consent and patients rights. In this sense, a patients doubt about
the openness of medical practices is reasonable to a certain
extent.
The issue of the Japanese notion of life and death is the center
of the current theme.
4 . A traditional view of life and death in Japanpast and
present
61
Traditionally, Japanese people thought the departure of the

soul from the body was the start of the dying process. They
prepared a mogari-no-miya, and they prayed for the revival of the
dead person. The ceremony for revival of the dead is named
tamayobai or tamakaeshi, that is a call for the return of the
soul 5,20,21 .
4-1. A call for the return of the soul
The longest period of a mogari-no-miya took place for 6 years
and 8 months in the ceremony for Emperor Bidatsu starting in
585 6 . It is hard to believe that ancient people prayed for
revitalization or resurrection of the dead for such long periods. A
mogari-no-miya ceremony was thought to have had another
intention; that was the devoted time for sublimation of the dead to
a status of god. Nihonshoki describes that a mogari-no-miya
ceremony was carried out by singing and dancing for 8 days and 8
nights 6 . Thus, it seems likely that the former period of a
mogari-no-miya was prepared to pray for revitalization and the
latter period was disposed to ascertain death and to deify the
dead.
It appeared the periods of a mogari-no-miya ceremony were
getting shorter throughout history. One of the famous emperors,
Shomus mogari-no-miya period was 17 days in 756. Yanagita
Kunio interpreted that the periods of a mogari-no-miya were
getting shorter as people understood the dead would not revitalize
even if they prayed hard 21 .
Because Japanese people did not think the cessation of
heart-beat and breathing was death, they attached importance to
the body. More than one thousand years ago, the government
enforced cremation as a formal funeral as they introduced
Buddhism 6 . However, people harshly resisted cremation, and it
was one of the reasons that people attacked Buddhism during the
Meiji Modernization one hundred and fifty years ago. The Meiji
government established the Cremation Prohibition Law based on
Confucianism in 1873, although it was withdrawn in the same
62
year because of the unrealistic idea that cremation should be

prohibited.
4-2. Legacy of the ancient view of life and death in contemporary
people
Emperor Shomu was the last emperor in the ancient time whose
body was placed in a mogari-no-miya, because later Emperors
were dealt with a Buddhist ceremony at their deaths. A
mogari-no-miya was revived at Emperor Meijis death in 1912. In
1989, a mogari-no-miya palace was constructed for Emperor
Showa at his death.
It was a common practice until 1930s that when someone died,
i.e., heart beat and breathing stopped, people called out his/her
name on the roof or in the garden in order to ask for the return of
the released soul for revival 20 . Thus, Japanese people live in a
world where the ideology of a mogari-no-miya is still alive, or the
cessation of breathing is not death.
5 . The role of modern medicine in the denial of death among
people
Japanese people who do not accept brain death often claim that
the brain dead patient continues to be alive for a week, or at least
one or two days after a declaration of brain death 22 . These people
do not take into account the idea that the brain dead patient only
looks alive on the respirator. In other words, they do not think
that the cessation of respiration is death; that is the Japanese
notion held throughout her history. Probably, the introduction of
modern technology into medicine has strengthened the idea of
denial of death, because people have witnessed that the
declaration of death could be postponed using modern medical
equipment.
5-1. Prolonging the dying process is a supreme aim of society
When patients die in a hospital, doctors and nurses try to
prolong his/her life by CPR and other life-sustaining procedures.
63
For example, conscious or unconscious bedridden patients are

maintained on forced artificial nutrition in hospitals for the elderly.
When an unconscious terminal patient catches pneumonia, he/she
will receive antibiotics administration. Otherwise the doctors are
condemned by the mass media as having killed the patient 23,24 .
The concept that the dying process should be prolonged was a
brand-new idea in Japan, appearing probably in the last two or
three decades. Buddhism emphasizes the importance and respect
for any life. It also teaches that every effort should be made to treat
disease so far as the treatment is meaningful. However, there is no
teaching to about prolonging the dying process. At the end-of-life
"being natural" is the principle 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. This new attitude has probably been introduced from
Western ideology, first as "sanctity of life" then extended to
"prolonging the dying process."
5-2. Denial of death among contemporary people
Life-prolonging procedures for unconscious patients in the
dying process are widely practiced, and allowance of natural
death or death-with-dignity for terminal patients has been
greeted by sensational media coverage. In addition, Japanese
police procedure does not allow a natural death, as the police have
brought charges of murder against doctors who have withdrawn
the respirator from already expired patients.
Police action is not exceptional in the Japanese society. The
results of the survey carried out by a research group set up by the
Ministry of Health, Labor & Welfare in 2004 showed that
Japanese police acted according to the perception of Japanese
people 25 . Thus, in response to the question, would you want CPR
at death under the irreversible fatal condition with pain? only
22.7% of the general public answered CPR should be stopped.
9.2% answered that CPR should be continued. It is noticeable that
2.7% and 2% of doctors and nurses thought CPR should be
continued. Only about a half of doctors thought that CPR should
64
be stopped in such a case. Many health care professionals as well

as laypeople think that brain death and persistent unconscious
state are reversible conditions 26 . Thus, it clearly showed that the
polices action is not an isolated attitude among Japanese people.
5-3. Unrealistic expectations of medicine among people
There seem to be unrealistic expectations of medicine among
people as they think brain death is reversible and treatable 26 .
Modern medicine has introduced the respirator for treatment of
certain acute conditions and as equipment for anesthesia. People
have observed the efficacy of CPR in acute settings, although CPR
is never useful in terminal irreversible settings. Those people who
want CPR at the occasion of natural death misunderstood the
reality of medicine. Taken together with such unrealistic
expectations of medicine and peoples appetite for immortality
makes people believe that denial of death is meaningful and
modern medicine can do something to cure the situation.
Nowadays, seeking health is almost a religious target; health is
sacred, no one can object to this idea in Japan. Presumably,
hospital is now a kind of a mogari-no-miya, and artificial
respiration and other CPR techniques are modern tools to pray for
the revival of the dead or the return of the soul. Not only among
lay people and police but also among the medical society, nave,
unrealistic expectations of medicine have been increasing.
5-4. Resistance to brain death is being augmented
According to a media report, the number of clinically brain dead
children who are cared for longer than one month was 60 in 522
hospitals during August to October, 2007 in Japan 27 . The article
described that not only family members but also doctors who took
care of these children could not accept the situation. Mass media
deal with these stories as venerable tales. Thus, many Japanese
do not accept brain death as they do not think that the cessation
of heart-beat and breathing is death. Medical science has offered
modern tools to prolong the dying process so that Japanese people
can maintain this traditional view of death.
65
In addition, there has been a noticeable change of view toward

death in recent years in that as many as 40% of people thought
the soul stayed in the deceased's remains after death 28 . From the
authors personal experiences with classes of university students,
the number of people who think the soul stays in this world is now
far over 40%, reflecting the vast number of broadcasting programs
dealing with soul and supernatural phenomena. Thus, many
people now do not take the position of the traditional view toward
death, which is a separation of the soul and the body and that the
soul sublimates to deity eventually. Rather, the modern version of
the closer relationship between the body and the soul makes it
easier for people to think that the brain dead person keeps his or
her soul with or near the body; hence the number of people who
think that brain death is not death is probably increasing.
Above all, the traditional view of death and the changing views
of the soul, together with advance in medical science have only
exacerbated the attitude of people to reject the reality of natural
death and brain death.
6 . What can be done?
What can be or should be done to improve the current situation?
In the USA, nave, unrealistic expectations on the part of patients
and families have been rectified by the law society 7 . However, the
Japanese law society has been dealing with medical cases in ways
which only increase nave unrealistic expectations of medicine
among people. Here, implications of the background features of
the society including religious and secular beliefs are seen in
relation to the attitudes toward life and death.
6-1. Implications of religious belief
The Japanese notion of death, that the cessation of heart-beat
and breathing is not death, is rooted to a firm belief or religion.
The Japanese Imperial Family still maintains the notion of a
mogari-no-miya. Therefore, such a belief is ongoing. Simple
dismissal of this belief is unlikely to work as it has in other
religious issues.
66
It may be possible to tackle the denial of death by a religious

approach. For example, in case of the Roman Catholic, the absolute
restriction of cremation, which was the central doctrine of
Christianity from resurrection, was changed in 1963. Now, Church
law states that "funeral rites are to be granted to those who have
chosen cremation, unless there is evidence that their choice was
indicated by anti-Christian motives"29. If the doctrine of resurrection
had been applied dogmatically, the intact body would have been
necessary after death hence organ donation should have been banned
without exception. Thank to the monotheistic nature of Christianity,
religious people are now willing to donate their organs despite the
belief in resurrection.
However, it is highly unlikely that people would accept orders
from any religious faction in Japan because of the polytheistic
nature of people. Indeed, implementation of cremation by the
government encountered harsh opposition by Confucian people on
the one hand, and prohibition of cremation by the government
resulted in chaos because of the widely accepted Buddhism on the
other hand. In addition, the Japanese religious world is divided in
terms of their attitudes toward brain death and organ
transplant 2,28 . Therefore, unlike in the Western countries,
religion is not a tool for the solution regarding life and death or
acceptance of brain death. On the contrary, now people worship
health as if health were a sacred religious target, or Japanese
people now believe in kind of new religion healthism. This
healthism is easily linked to the idea of "sanctity of life"
resulting in "prolonging the dying process" or denial of any death.
6-2. Implications of Japanese ways of thinking
As described earlier, Japanese people raised no doubt about the
denial of blood transfusion in fatal bleeding, but they do not
accept the withdrawal of the respirator from a medically dead
patient. The former case undoubtedly causes death, but the latter
case does not cause death (because already dead). Thus, such a
difference in the attitudes of Japanese people, including the
judicial society and mass media between blood transfusion and
67
artificial respiration is irrational. Previously, the author showed

the hard evidence of this ambivalent attitude of Japanese people
in a questionnaire study regarding antibiotics administration and
artificial respiration 30 . Japanese people thought antibiotics
administration for end-stage pneumonia should be decided by the
doctor while the introduction of artificial respiration should be
decided
by
the
patient.
Presumably,
these
Japanese
characteristics are linked to the But-Also culture described by
Benedict 31 . As she noted these characteristics are based on
multiple standards. The resulting Japanese cultural attitude,
keep one at ones right position or once the position is changed,
one will behave as the new position orders to do so no matter how
the new behavior is different from the behavior derived from the
first position may be also contributory in Japanese
characteristics 31 .
The
findings
that
people
think
the
decision-maker in medicine should be different in each
therapeutic intervention indicate decision-making in medicine is
not coupled with the autonomy principle in Japan.
There is another example which shows the common observation
that Japanese social sanctions are not based on rationality.
Percutaneous endoscopic gastrostomy (PEG) tube feeding is
widely used among hospitals and long-term care facilities for
patients with dementia in Japan. However, neither patients and
families nor doctors wanted PEG tube feeding according to a
survey 32 . They raised several factors such as a legal barrier, an
emotional barrier, a cultural value and a reimbursement-related
factor for unwanted routine use of PEG tube feeding 32 . Above all, it
clearly showed that PEG tube feeding was not introduced via
rational reasons. These findings illustrate that PEG tube feeding is
to satisfy health care providers but not the patient and family.
Since there is no evidence that PEG tube feeding is effective in
patients with dementia 33 , PEG tube feeding is not in accord with
good clinical practice. The problem here is simple; the minor or the
weak always suffers from irrationality as exemplified in Section
2-2. The importance of understanding can never be over
emphasized in the field of medicine.
68
6-3. Learning from experiences

Baby Doe was born in 1982 with Downs syndrome and
tracheoesophageal fistula. The latter condition needed urgent
surgery for survival to repair the trachea and esophagus.
However, the parent chose just comfort care, and the baby died.
This incidence caused a harsh controversy in the country followed
by the establishment of so-called the Baby Doe squad. Once they
received an anonymous report indicating the neonate was not
given maximum treatments, the members of the squad made a
raid on the hospital and insisted the hospital staff offer all
possible medical and surgical treatments whatsoever. Raids by
the Baby Doe squad amounted to 1633 in 1983 34 . Targeted neonates
were mainly those with congenital multiple organ failure who
were diagnosed life expectancy of a matter of days or weeks
without the slightest hope of recovery by intervention. Therefore,
the squads insistence on treatment for those neonates resulted in
null benefit or even harmed the family and other persons
concerned. In due course, the activity of the Baby Doe squad
subsided, because they learned there was no benefit to those
babies by their activity. Eventually, the Federal Law was
established to prevent child abuse and neglect 7 .
The acts of Japanese police against doctors described in Section
2-1 were similar to the activity of the Baby Doe squad in the USA.
Experiencing that all murder charges were turned down at the
prosecutors office, Japanese police did not take up the latest case
of the withdrawal of a respirator at Fukuoka University Hospital
as murder in early 2009 35 . There was no sensational coverage in
media after the first report either. Presumably, Japanese police
and mass media have learned that there is no benefit in the
insistence of postponing the declaration of death.
6-4. What should be done to overcome irrationality?
To solve the problem, deep understanding is a key for
reasonable society in any field. The discussion of end-of-life care
is in serious confusion mainly because of the different notions of
69
the terminal stage. To make the discussion simple, it is

necessary to separate the terminal stage into before death and
after death. Before death, autonomy or the informed consent
rule is applied in conjunction with good clinical practice. It should
be emphasized that many life prolonging procedures do not show
evidence of benefiting patients; therefore, these procedures are
not included in good clinical practice. In the latter stage of after
death, the concept of natural death or death with dignity is
applied, where patients do not have a right to demand ways that are
contrary to good medical practice (7). In addition, futile procedures
prevent humane care of the dying patient and deprive families of
the opportunity to express their love, grief, and dedication at a
critical moment (7). Unfortunately, rational decision to natural
death by the patient and family has been disturbed by irrational
people in Japan.
With regard to introducing a rational view to irrational people,
several ways may be conceivable as possible scenarios for them as
suggested by Annas (36). In the first, doctors will do whatever
patients want, because medicine can be seen as a consumer
commodity like breakfast cereal and toothpaste. The second
scenario is to remove the task of defining good clinical practice
from doctors altogether and putting it in the hands of government
regulators, who will decide the content of medicine. These two
scenarios are highly unlikely to meet the wishes of patients and
families, nor to satisfy the professionalism of doctors. In addition,
there may be an approach from health insurance policy. Futile
life-prolonging procedures will disappear easily if the national
health insurance stops covering their costs. So far this
opportunistic approach may be unrealistic because of harsh
opposition from people who believe in healthism.
To avoid either of these scenarios, doctors must work toward a
third, in which they not only set standards for medical practice,
but also follow them. Doctors cannot expect patients, families,
judges, or government regulators to take practice standards more
seriously than they do themselves. And this is the way Japanese
professionals responded to settle the confusion in end-of-life care.
70
There are several movements in accord with this third scenario.

The Ministry of Health, Labor & Welfare, for example, set forth a
guideline to leave the decision-making to the hands of the patient
and family in 2007 (37). The Japanese Association for Acute
Medicine established a similar guideline in 2007 (38). In fact, both
guidelines seemed to have worked in the latest case at the
Fukuoka University Hospital; the termination of artificial
respiration was greeted calmly without sensational coverage or
accusation against doctors by mass media and police. This third
scenario may be a reasonable response of the medical society to
the challenge from irrational factions.
7 . Conclusion
Japanese denial of death and brain death stems from
traditional religious belief, which has been exacerbated by
unrealistic expectations of modern medicine. Revision of the
Organ Transplant Law is unlikely to work for acceptance of brain
death, whereas authentic guidelines seem to work for acceptance
of natural death in the field of end-of-life care. Perhaps, such
important issues involving a view of life and death should be
openly discussed to attain deeper understanding of issues
concerned by all factions of Japanese society including medical,
legal and religious sectors as well as laypeople. In the meantime,
irrational medical interventions should be stopped in end-of-life
care, and decision-making should be left in the hands of the
patient and family.
References
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7 Annas GJ. The Rights of Patients. The 3rd edition. New York: New York
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8 The patient died of removing the respirator, the first murder charge in
passive euthanasia. Yomiuri-Shinbun, May 19, 2005. (in Japanese)
9 The murder charge against a doctor who removed a respirator from a
patient in Wakayama Medical University Hospital. Yomiuri-Shinbun,
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11 Stabbed to death the eldest comatose son who had attempted suicide, a
mother was given a suspended sentence. Yomiuri-Shinbun, April 23,
2010. (in Japanese)
12 A husband gave himself up to police after he had killed a wife who
wished death. Yomiuri-Shinbun, October 13, 2009. (in Japanese)
13 Bleeding heavily during surgery, a patient died without blood
transfusion. Mainichi-Shinbun, June 19, 2007. (in Japanese)
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transplant tourism and commercialism: the Declaration of Istanbul.
Lancet 2008;372:5-6.
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WHO,
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Tokyo; Charles E. Tuttle Co. 1985
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1994
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Table 1. He expired, then died later
a jade box, he opened a little, a white cloud, left the box, drifted forward, to
another world, he run around, in horror, all in a tumble, promptly, fell in
unconsciousness, his skin wrinkled, the hair whitened, and he expired, then
eventually, he lost his life, on the coast, Urashimas home once stood, there
the ruin.
This is the latter part of a No. 1740 long poem in Man-yo-shu made by
Takahashi Mushimaro (8th century). It described a legendary story of a
man (Urashima) who had been to another world, and died on returning to
this world when he lost the magical power given by the immortal. The
white cloud represented his soul. Man-yo-shu or Collection of Myriad
Leaves is the oldest anthology containing a total of 4,516 poems which
was thought to be compiled at the mid 8th century by Otomo Yakamochi
(ca 718 - 785).
74
Figure 1. Numbers of the brain dead who donated their organs each year
(2010 at the end of July). One in 2000 was attempted for transplant, but
unsuccessful.
Data
from
the
Japan
Organ
Transplant
Network
(http://www.jotnw.or.jp/).
Note added in proof: the number of brain death donors was 32 at the end of
2010. The total number of donors was almost the same as those in previous
years, which indicated that an increase of brain death donors was attained
at the expense of a decrease of cardiac death donors. Thus, the revision of
the OTL has not induced a substantial change in the view of life and death
among Japanese people yet.
75

Denial of Death in Contemporary Japanese

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Denial of Death in Contemporary Japanese

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Journal of Philosophy and Ethics in Health Care and Medicine, No.5, pp.

55-75, April 2011

Denial of death in contemporary Japanese

and Western technology is often at the center of discussion

off in this category of patients, the situation is exactly the same at

2-2. Tragedies induced by medical and judicial societies

Nowadays, patients rights are accepted in general after a long

declaration of Istanbul and the movement in the WHO to ban

Traditionally, Japanese people thought the departure of the

year because of the unrealistic idea that cremation should be

For example, conscious or unconscious bedridden patients are

be stopped in such a case. Many health care professionals as well

In addition, there has been a noticeable change of view toward

It may be possible to tackle the denial of death by a religious

artificial respiration is irrational. Previously, the author showed

6-3. Learning from experiences

the terminal stage. To make the discussion simple, it is

There are several movements in accord with this third scenario.

19 Principles of Medical Ethics, Japan Medical Association.

33 Cervo FA, Bryan L, Farber S. To PEG or not to PEG. A review of

November 16, 2007. (in Japanese)

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