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In October, New Zealand voters approved a referendum proposal to legalize medically assisted suicide, thus joining a small group of countries and territories that allow euthanasia under specific circumstances. The proposal sprang from a lawsuit brought by a lawyer dying from a brain tumor, and while she herself was not seeking to end her life prematurely, she felt frustrated that the option did not exist. In court, she argued that euthanasia was not suicide, which is a crime, because the person in question was going to die anyway of the affliction that made their life difficult. She lost the case and died in 2015, but her husband continued to work on the issue, and, as a result, the topic received attention from the media, which discussed the ramifications, including what kind of safeguards were needed to prevent patients from simply ending their lives due to advanced age or disability.

Such a discussion has yet to emerge in Japan, although a criminal case in Kyoto that came to light in July has highlighted the issue in a sensational way. Two doctors were arrested on suspicion of murder after they helped a woman named Yuri Hayashi with the neurological disease amyotrophic lateral sclerosis (ALS) fulfill her wish to die. One of the doctors, Yoshikazu Okubo, provides hospice care, and apparently read on social media of Hayashi’s desire. He somehow contacted her and offered to help. Hayashi ended her life last November, but because of her condition, which made it impossible for her to feed herself or move any part of her body, the physicians’ assistance necessarily required more than just providing a lethal dose of drugs.

Media coverage has focused mainly on the criminal aspect. Prior to her death, Hayashi transferred ¥1.3 million to the bank account of Naoki Yamamoto, the second doctor arrested, thus prompting the police to charge both physicians with “murder by contract.” Police have released scant information about Yamamoto, although he may have written a how-to book about helping someone die without any signs that it was an assisted suicide. Police insist that Hayashi’s death is not a case of euthanasia.

On Nov. 3, the NHK series “Heart Net TV” presented Hayashi’s side of the story through her Twitter account and blog, which chronicled her situation for 586 days prior to her death.

NHK was cautious in its presentation. At one point, Hayashi tweeted that she felt “miserable” when she saw herself in a mirror. It’s the kind of statement that advocate groups for people with disabilities cite as representing a line of thought that sees people with disabilities as a burden on society, and thus encourages discrimination. However, at another point Hayashi speculates that if euthanasia were legalized, it might extend more lives, since those with terminal conditions could live a more fulfilling life with the knowledge that they could choose to end it if day-to-day existence became too much to bear physically.

NHK mentions Okubo once, but does not detail how the plan to die was realized. The half-hour program is essentially an ongoing argument that Hayashi has with herself about whether ending her life is better than continuing on as she is. She veers widely between despair and moments of contentment, and parties on either side of the euthanasia argument will probably find remarks that support their respective positions.

Associate professor Hitoshi Arima of Yokohama City University, who has published a book about euthanasia, was interviewed in Toyo Keizai last August, in which he addressed the Kyoto incident in order to determine if it was a case of murder or medically assisted suicide undertaken for humanitarian reasons. The biggest problem Arima has with the case is that neither Okubo nor Yamamoto were Hayashi’s physician. They were basically outside contractors brought in by the patient to perform a one-off service. Under such circumstances, the doctors did not have as deep an understanding of Hayashi’s medical condition and state of mind as that of a primary care physician, who would have been following Hayashi’s situation for a long period of time and thus possess insight into her stated desire to die. A service relationship conducted mainly over social media cannot provide such insight.

Arima is opposed to legalizing assisted suicide, but his point about close communication is the foundation of euthanasia policy in countries where it is legal. There are certain steps that a society must take first in order to arrive at an understanding of what assisted dying entails, and Japan has yet to take these steps. The first would be to normalize the practice of living wills and do-not-resuscitate declarations, which express a patient’s refusal of extraordinary measures to keep them alive in the case of a medical emergency.

The government has tried to promote this way of thinking through the advanced care planning program, mainly for budgetary reasons. Japan’s national insurance system spends a lot of money to keep people alive in a vegetative state simply because doctors are compelled to administer extraordinary measures to keep patients alive regardless of the outcome in terms of quality of life. The advanced care planning program, more familiarly known as jinsei kaigi (life council), promotes family discussions on end-of-life care well before an elderly or terminally ill member would require such care. In 2017, a health ministry survey found that only 2.8% of families had held any such discussion, and only 3.3% were even familiar with the advanced care planning program. Since then these numbers have gone up, but not by much.

The government’s subsequent actions to promote the advanced care planning program has been clumsy at best, as evidenced by an embarrassing poster campaign briefly carried out last year. Medically assisted suicide is still a controversial topic, even in those countries where it is legal. But before it can even be discussed in Japan, people have to be willing to talk openly and frankly about their own death.

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