20 years of organ transplants

Twenty years have passed since the Organ Transplant Law entered into force, and yet the number of organ transplant operations from brain-dead donors in Japan remains far lower than in many other countries. Parties concerned should uphold the spirit of the law and work ceaselessly so that the desire of people who agree to donate their own or their relatives’ organs will not come to naught.

The law was enacted in 1997 after long and heated discussions, paving the way for heart, lung, liver, kidney, pancreas and small intestine transplants from patients diagnosed as having suffered brain death. Under the law, a patient declared brain dead should be regarded as being dead only in so far as the person’s organs are to be removed for the purpose of transplant. Thus, in other circumstances a person who is in the state of brain death is not regarded as being dead in the usual sense. The law defines brain death as a condition in which the function of the total brain, including the stem, has irreversibly stopped.

Since the law took effect, there have been 477 cases in which patients were judged to have fallen into the state of brain death as stipulated by the law, and 2,072 cases in which organs removed from these patients were transplanted. The number of organ donations per capita remains far lower than in other countries — about one-fortieth the level in the United States and one-tenth that of South Korea. Some 14,000 patients are on waiting lists for a new organ, but only about 300 can receive a transplant each year. However, the five-year survival rate for patients who receive a heart or liver is 92 percent and 80 percent, respectively — indicating the skill of doctors and other staff involved in transplant operations in this country.

Under the original law, removal of organs from brain-dead patients was only possible if the patients had expressed in writing in advance their willingness to donate their organs and their family members approved the transplant. This requirement automatically excluded donors under 15 since the Civil Code does not recognize wills written by people below that age.

However, an amendment that took effect in 2010 has made it possible to harvest organs from patients who had not expressed their readiness to donate. Unless patients had clearly indicated their refusal to have their organs removed, transplants can be carried out with the approval of their relatives. Following the revision, the number of organ donations from brain-dead patients increased from about 10 cases a year to around 60. Last year saw a record 64 donation cases, including 51 that involved a heart transplant. The amendment also paved the way for organ transplants from small children. For example, a boy less than 6 years old was judged to be in a state of brain death in a hospital in Hiroshima Prefecture in May and his lungs were transplanted to a 1-year-old girl at Okayama University Hospital and his heart to a boy under 10 at University of Tokyo Hospital.

There are about 900 designated hospitals nationwide that can make a judgment on brain death and harvest organs for transplant. But according to the Health, Labor and Welfare Ministry, about half of those hospitals are in fact not prepared to remove organs from brain-dead donors. One reason is they’re short on doctors. This is one factor behind the relatively low number of organ transplants in Japan. Dispatching specialists for brain-death diagnosis to those institutions may be one solution. Another problem is that doctors and nurses are too busy to explain the organ donation system to family members of brain-dead patients. Also in recent years, there have been some cases in which the Japan Organ Transplant Network made errors in selecting patients to receive organs.

In most European and North American countries, brain death is considered to be the death of the person, and as long as the patient has not expressed his or her refusal, the organs can be used for transplant. However, such an approach is not likely to be accepted immediately in Japan, given the social sensitivities over the issue as reflected in the discussions when the law was enacted.

The medical profession must steadily do what it needs to do so public trust in the transplant system will deepen. In doing so, they should strictly follow the principle that organ transplants are possible only when donors or their family members have voluntarily expressed their willingness to donate.