Is Japan still in the medical Stone Age? A look at American depictions of the medical profession might make you think so. Last Tuesday, NHK had a bunch of celebrities sitting around and rapturously discussing the American hospital soap opera “ER” and its mature take on the physician-patient dynamic. This weekend sees the opening of the new Sean Penn movie, “21 Grams,” about a mathematician with a bad ticker who receives a replacement from a guy who is run over by an ex-con. The movie gives the impression that heart transplants are as common as Starbucks openings.
Actually, about 3,000 organ transplants took place last year in the United States, which is a smaller number than it sounds considering that 2.4 million Americans died in the same year. But it’s a huge number compared to Japan, where only 30 organ-transplant operations have taken place since they were legalized in 1997.
The Liberal Democratic Party has drawn up a bill to make it easier for Japanese doctors to harvest organs from brain-dead patients. Sponsored by lawmaker Taro Kono, who two years ago donated part of his liver to his father, former president of the LDP Yohei Kono, the bill may not come up during the current session, but it’s only a matter of time before it’s passed in one form or another.
Under the current law, organs for transplants can only be removed from individuals who are 16 or over and who have filled out a “prior declaration,” often referred to as a donor’s card. The doctor must also receive permission from the donor’s family.
Under the proposed revision, a doctor can harvest organs from a patient determined to be “brain dead” if his or her family approves the removal and the patient did not make any “prior declaration” that he or she did not want to donate organs. In addition, the age limit is effectively removed.
The sticking point is the definition of “brain death.” According to surveys, 30 percent of Japanese people do not equate brain death with actual death, and the Diet took this finding into consideration when it made the law in 1997. In essence, people who fill out and carry donor cards define their own deaths as being brain death, while the definition of death for everyone else is the cessation of a heartbeat.
Except for eyes and kidneys, organs for transplant must come from a living body, so the number of viable hearts, lungs and livers, etc. is greatly limited under such a law, especially given that the number of adults with donor cards has never risen above than 9.2 percent of the population.
Obviously, the Japanese populace isn’t sold on the idea of transplants, which is why the LDP wants to give doctors more leverage in the matter. The general opinion in the media and the medical profession is that Japan is still stuck on the notion that brain death is not death, an idea that smacks of backwardness and superstition. Transplant cases are high melodrama, especially when they involve children, who cannot receive organs in Japan, so they go overseas at incredible expense. A few months ago a Japanese boy went to Europe for a heart transplant but died before he could receive one, whereupon his own organs were harvested to help local kids. The media set him up as a shining example.
Last week, the Konos discussed their operation with the Asahi Shimbun. They didn’t make a big deal two years ago when it took place because they didn’t want to give the impression that “it’s natural for someone to give part of his healthy liver to a sick relative.”
Such organ donations are on the increase, and it is Taro’s belief that if the donor system is revised, fewer living donors will need to give their livers to relatives. The seeming logic of Taro’s position is enhanced by the image of responsibility he exudes: Here is a man who made a great sacrifice for his father and wants to save others in his position from having to make such a grave choice. But his logic is flawed. In America, where it is easier to harvest organs from brain-dead patients (such laws are determined at the state level), the number of living donor transplants is also increasing.
What this says is that, as the technology improves, more and more doctors accept organ transplants as a viable medical procedure (some still don’t), so they look for more ways to harvest organs. The acceptability of such procedures increases greatly as so-called lifestyle diseases — diabetes , heart disease, etc. — skyrocket in countries where people are rich enough to pay for them.
Japanese groups who are against the revision point out that the only reason for determining brain death is to harvest organs, which means doctors will be pressured into making such a determination as quickly as possible. These determinations are very strict and involve detailed criteria, but some of the criteria involve procedures that themselves spur brain death. In essence, the purpose of making such a determination is to prepare the body for organ harvesting. In the end, treatment could be compromised by the need to keep the organs ready for removal just in case.
The main obstacle to such removal, and one that will remain in place even with the revision, is families, who are often portrayed as being selfish by denying someone else the chance to live. But many of these families just may not trust doctors.
Before a viable transplant system can be developed, Japan at least has to improve its emergency medical-care system, which even Japanese doctors admit is not as good as it should be. Almost all determinations for organ removal are made in emergency situations. If the revision is passed without a debate about these related matters, then a trip in an ambulance will become even scarier than it is now.