Ever since the Liberal Democratic Party regained power last year, standard-bearer Shinzo Abe has been conspicuously cautious with his public pronouncements, cooling it on the nationalist rhetoric and keeping the bravado to a minimum. Deprived of excitement, the media was delighted by Vice Prime Minister Taro Aso’s comment, made at a government meeting to discuss social-security reform, that sick old people should “hurry up and die” (sassa-to shineru yo ni shite morau) and relieve the country of the financial burden of taking care of them. Aso’s penchant for gaffes has always endeared him to both the domestic and foreign press as someone who makes the predictable political beat in Japan a little more interesting, and the quote, which everyone agreed “insulted” the elderly, was reported in the spirit of entertainment, as if to say, “He’s back, and more offensive than ever!”
As always happens when Aso gets eyes a-rolling, he later apologized, qualifying the remark as his own personal preference with regard to terminal care, which hardly placated anyone since he’s one of the richest men in the country and can afford any type of care he desires. Nevertheless, most media overlooked the context. The Social Security Citizens Conference where he uttered the remark was a condition demanded by the Democratic Party of Japan in return for calling a general election last fall. Before it became the ruling party, the DPJ pledged to reform social welfare, and the conference is a means of maintaining a dialogue on the subject. The DPJ made the LDP promise to continue it even though the LDP is not interested in changing a system it created in the first place. Aso, an infamous straight talker with a streak of impatience, didn’t enjoy participating in a function he considered a waste of time and stated his views without any varnish of tact.
In an editorial, Asahi Shimbun’s Yotaro Hamada thought Aso was making a political statement on a topic that is taboo regardless of the manner in which it is approached. Four years ago, before the DPJ took power, the LDP proposed that doctors discuss end-of-life scenarios with patients in order to put down in writing whether or not those patients desired extraordinary measures to stay alive, including the use of respirators. The media bolstered public resistance to the proposal by focusing on a minor administrative aspect that allowed doctors to charge ¥2,000 to draw up documents for refusing “life-prolonging care,” thus giving it a mercenary cast. Weekly magazines warned that greedy doctors would “leave boomers to die.”
The controversy boosted onto the best-seller list Yumiko Kawaguchi’s award-winning book about her mother, who suffered from ALS, the same disease that afflicts the physicist Steven Hawking. Kawaguchi opposed the LDP idea because it standardizes a practice that would put pressure on patients like her mother, who needed a respirator and feeding tube to survive. As the opposition party at the time, the DPJ used her to protest the proposal.
Hamada says the issue deserves a public debate, but as the strong reaction to Aso’s comment shows it’s still something people don’t want to talk about. The notion that patients might choose to “die quickly” is repugnant to many and overshadows considerations that affect quality of life in the final stages of illness or old age. The problem is not just the limited vocabulary, but the structure of the national health system, which is built on the belief that a doctor’s mission is to prolong life at any cost. It is illegal for care professionals to not try to resuscitate a patient.
At any given moment, there are up to 400,000 people in Japan hooked up to feeding tubes, the majority in a vegetative state. These measures cost the system — and the families of the patients — billions of yen a year, and practically guarantee that people die in hospitals. As reported in this column a year ago, surveys have shown that, given the choice, most people would prefer to die at home, which is hardly surprising, but at least 80 percent of nonaccidental deaths occur in hospitals because until the heart stops beating the protocol is to assume that there is always a possibility for recovery, even when everyone knows there isn’t. Several weeks ago, NHK aired a documentary on the lack of nursing facilities for indigent seniors, and one of the biggest concerns is the constant moving of residents in and out of hospitals because public nursing facilities are not equipped for terminal care, even though their charges are, to all intents and purposes, at the very end of their lives.
Some lawmakers whom Tokyo Shimbun describes as “transcending party affiliation” have proposed a songenshi (dignified death) bill that makes it easier for a patient to decline life-prolonging measures before he or she enters a terminal stage of treatment. Physicians are still wary of carrying out such wishes because they believe families may sue anyway. By codifying the procedure the government gives doctors legal protection, but certain interest groups oppose the law. The Japan ALS Association thinks that the practice “creates an atmosphere” that makes it easier for disabled people to feel they have to sign away their lives, but the law would not compel anyone to do anything. It would clarify end-of-life medical procedures and make people understand what they entail, according to a nurse interviewed by Tokyo Shimbun, who added that, as it stands now, doctors and patients (and their families) talk past each other.
A more open and enlightened discussion of death is needed before anyone feels comfortable with this law. The reality of terminal care is too emotionally complex for most people to process effectively. The media can help, but it’s more fun to demonize Taro Aso, who could pay for a heart transplant as easily as he could a comic book. God forbid he might have had a point beneath that cold, clownish bluster.