RECONSIDERING BRAIN DEATH: A Lesson from Japan's Fifteen Years of Experience

Article excerpt

Japan has been holding a nationwide debate over the nature of death for nearly twenty years. That debate led eventually to a law that gives citizens the opportunity to choose which of two views of death will apply to their own death, That law is now up for revision, and the debate is revving up.

Western scholars have recently been entertaining doubts about what had once seemed to be a settled consensus among them on the concept of death. In 1997, for example, Robert D. Truog pointed out several problems arising from the concept of whole-brain death and showed us three alternatives, namely, (a) returning to the traditional standard based on the permanent cessation of respiration and circulation, (b) recognizing the objections of particular religious views to the concept of brain death, and (c) giving permission to remove organs from brain dead patients, patients in persistent vegetative states, and anencephalic newborns whether they are alive or not.[1] In 1999, Stuart Youngner and colleagues published a collection of essays titled The Definition of Death that featured re-evaluations from various perspectives of brain death and its alternatives.[2] In this book, Robert Veatch argued that we should permit patients to choose "an alternative definition of death provided that it is within reason and does not pose serious public health or other societal concerns."[3] Veatch insisted that whole-brain death should be the default definition of death, but that we should permit, in addition, traditional cardiopulmonary death and higher-brain death as reasonable minority views. Finally, in 2000, Michael Potts and colleagues published another collection, Beyond Brain Death, offering further objections to the concept of brain death.[4]

This is a strange scene to a Japanese bioethicist. Japan has held nationwide discussions of brain death and transplantation since 1983, and the points that have emerged in the recent Western writings are very familiar there. But American and European bioethicists do not necessarily know of the recent Japanese debates, mainly because of the language barrier. Japan's Organ Transplantation Law, enacted in 1997, permits people to choose between brain death and traditional death by writing their preference on a donor card.[5] It is akin to the "conscience clause" found in New Jersey's Declaration of Death Act, which Veatch identifies as an attempt to allow people to choose an alternative concept of death, and which Robert Olick said "signals a new direction for the development of public policy governing the declaration of death in pluralistic communities."[6]

The Japanese transplantation law permitted organ transplantation in Japan, but it also generated new problems we had not anticipated.

A Brief History of the Japanese Debates

Japan's first heart transplantation from a "brain dead" patient was performed in 1968, several months after the world's first heart transplantation in the Republic of South Africa. However, Dr. Juro Wada, who performed the operation, was accused of illegal human experimentation and also of poor judgment in the determination of dead. This event engendered grave doubt about brain death among journalists and the public. The phrase "heart transplantation" became taboo for fifteen years.

In 1983, the Ministry of Health and Welfare established an ad hoc committee on brain death and transplantation, which then started to establish criteria for brain death. At the same time, the Japanese Transplantation Society began to publicize the necessity and urgency of organ transplants. In 1985, criteria for brain death were announced. The committee distinguished "medical criteria for brain death" from "the concept of human death" and declared that the latter depended on the consensus of the Japanese people.

Two well-known journalists, Michi Nakajima and Takashi Tachibana, immediately published popular books that criticized the concept of brain death. …

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