It has been 20 years since the government legalized organ transplants from brain-dead donors, and seven years since the law was revised to allow children to donate organs and families to approve organ donations of loved ones unilaterally.

But while the transplant rate in Japan has increased sixfold since 2010, it is still relatively low. According to a May 12 article in the Yomiuri Shimbun, only 64 took place in 2016 for all organs. The Japan Organ Transplant Network (JOTN) says that as of April there were 593 patients waiting for hearts, 321 for livers and 11,965 for kidneys.

In the United States, the organ donation rate is 26 transplants per million; in South Korea it is 8.4. In Japan, it’s only 0.7. On the occasion of the anniversary of the transplant law, various media have pondered their role in spreading awareness of organ donation and while there are still cultural barriers that prevent understanding, there are other, structural difficulties that have to be overcome in order to make transplants an integral part of medical treatment in Japan.

Japan has the strictest organ donation law in the world. Before 1997, donations could only be made to other family members and from people whose hearts had stopped, which greatly limits the kind of organs that can be transplanted. The 1997 law made it possible for individuals to indicate their willingness to donate organs if declared brain dead, but there was no net increase in the number of possible donors, because the same people who agreed in surveys to donate organs to family members now signed up to donate to anyone.

Following a revision in 2010, which widened the pool of possible donors to children under the age of 15 and individuals whose families consented to donating their organs even if they themselves hadn’t indicated such beforehand, the number of actual brain-dead donors increased, but the number of heart-dead donors decreased. JOTN estimated that most of the people who prior to the revision were willing to donate organs if their heart stopped were now instead agreeing to donate organs if they were declared brain dead. In effect, there was no appreciable increase in new donors.

NHK basically made a similar point on a recent installment of its explanation program, “Jiron Koron.” The show cited a Cabinet Office survey in which half the respondents said they would not consent to a relative’s organ donation if that relative was declared brain dead. In cases where individuals themselves agreed to donate organs if they were declared brain dead, 87 percent of their relatives said they would give consent (family consent is still necessary for removing organs from brain-dead donors).

Many believe the main obstacle to donation is an uneasiness with the idea of cannibalizing one’s own body or the body of a loved one, so the media, they believe, should provide clearer examples of organ donations. But since donors are anonymous, coverage is sketchy at best.

Somehow, however, attitudes are changing. NHK found that young people are much more likely to fill out donor cards, so there should be a higher number of available organs in the future. But the system as it stands may not be able to take full advantage of a greater willingness to donate. The health ministry has designated 896 hospitals as being qualified to participate in the organ donation program, but of these only 435 say they are ready. In most cases, the other facilities say they have yet to draw up proper “manuals” for procedures, so if a situation occurs where an organ is available because a consenting donor dies at one of these hospitals, they will not be able to process the organs for transplant. Over the past 20 years, 60 percent of donations took place at 62 hospitals.

Another issue is that brain death is often determined in emergency rooms, which are hectic under normal circumstances. ER doctors are not sufficiently prepared to deal with donors in such situations. What is needed is full-time professional support staff who can process donations. NHK says the work of transplant coordinators requires extensive training and experience, and there is a high job turnover rate in the field.

The best impetus for organ donations is showing how successful transplants have become in Japan, and some media have highlighted the work of Dr. Takahiro Oto of Okayama University Hospital, considered one of the world’s foremost lung transplant surgeons. Several years ago, Oto was the subject of an award-winning Fuji TV documentary that simultaneously showed how advanced transplant techniques are in Japan and how far the donor system needs to go in order to properly exploit such techniques.

Three years ago, Oto’s patients had a five-year survival rate of more than 80 percent, whereas the average five-year survival rate worldwide for lung transplants is around 50 percent. Oto could perform many more transplants than he does now, but he doesn’t have the time because he must also screen recipients and donors, as well as provide aftercare to transplant patients. In other countries, transplant surgeons only operate. Other necessary tasks are handled by different medical professionals.

At one point in the documentary, Oto is in the middle of a surgery when he receives an urgent call from a hospital about a possible donor, but he can’t address the matter until the 10-hour operation is over. With donations, especially in the case of organs that are only viable from living — meaning brain dead — donors, time is critical.

Japan’s medical world needs to work on these structural obstacles, then the problem of convincing people to donate may actually take care of itself. It depends on the circumstances. A recent article in the Asahi Shimbun told the story of a woman whose husband became brain dead after a series of strokes. Although grief-stricken, she saw a poster in the hospital about organ donation and asked the doctor if she could donate her husband’s organs. The doctor said, of course she could. He just hadn’t thought to ask her if she was willing to.

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