Here in the US, organ donation is a highly respected practice and thought of as the last gift one can give. The practice can save and improve many lives. But other countries may not share that same sentiment. The Japanese, for example, are much more hesitant to become organ donors than we are in the US. In this post, we will take a look at the United States and Japan, and the cultural considerations surrounding organ transplant in both countries.
Organ donation and transplant are controversial topics cross-culturally, and even between people of the same cultural background. For many people, becoming an organ donor may just seem like the right thing to do- when you pass away, your healthy organs should be used to give someone in need of organ transplant a second chance, right? The idea sounds great in theory, but there are many concerns and doubts cast on this subject, leading to much debate. Some concerns that arise pertain to medical malpractice- the issue of declaring death too quickly for the sake of facilitating transplant is a major concern for many people. Other concerns may arise from the issue of procurement from individuals presumed to be “brain dead,” and how brain death is diagnosed and regarded cross-culturally. There may be a myriad of reasons for deciding to either be a donor or reject the idea, and many of these reasons are influenced by cultural constructs and ideology surrounding death. The purpose of this research is to compare organ donation and transplantation between the United States and Japan, and how cultural beliefs regarding death play a large role in the acceptance of organ donation.
Organ Donation in Japan
Japan is known as an international leader in technology and innovation, and their medical care is no exception. The Japanese have a high-quality medical care system that is backed by technological advancements and professional expertise. The Japanese population has the longest life expectancy in the world (Tokudome et al., 2016). But eventually, the end of life comes, and a decision must be made: to donate or not? Organ transplant in Japan, not unlike other countries, is a controversial subject that requires delicate consideration. A recent study suggests that Japan has a mortality rate of 30-40% for patients on the waiting list for organ transplant (Egawa et al., 2011). Globally, there is a shortage of organs viable for transplant, and an increasing number of individuals waiting for a transplant.
Despite the highly advanced technological and medical achievements in Japan, cultural beliefs surrounding death have been a hinderance to the expansion of organ donation and organ transplant practices. In recent history, there have been initiatives and governmental intervention strategies that have been used to promote organ donation, especially from the deceased individuals. Secondary education textbooks and curriculum were revised by the Ministry of Education, Culture, Sports, Science, and Technology in the early 1990s, and these revisions incorporated the issue of organ transplant and aimed to promote donation through increased awareness (Akabayashi et al., 2018). As of 2013 poll, it was evident that the awareness of organ donation had increased, likely because of these curriculum changes- the population with the most acceptance of organ donation were adults in their 20s and 30s who were the first to have been exposed to this education in the school system (Akabayashi et al., 2018).
Additionally, in 1997, Japan enacted the Organ Transplant Law, which legalized organ transplant from brain-dead donors. This law required a written declaration from the donor (who had to be older than age 15) stating their intent to donate, and also required family consent. In 2010, a revised version of the Organ Transplant Law came into effect in response to the extremely low numbers of deceased donors. The revised version was an “opt-out” format and deemed family consent acceptable even without the consent of the donor. Individuals under the age of 15 were also now allowed to be donors after the revision. In both the revised version and the original, family consent is required (Akabayashi et al., 2018). It is noted that living organ transplants have somewhat alleviated Japan’s organ deficiency, and the number of deceased donors has increased slightly due to the Organ Transplant Law. Although it has been over 20 years since this law was established, the number of deceased organ donors is still remarkably low (Akabayashi et al., 2018).
Japanese Cultural Considerations Regarding Death and Organ Transplant
In the past 20 years in Japan, decreased resistance of organ donation has been noted, likely due to an increase of intent declarations, knowledge, and respect for family member’s wishes who choose to be donors. Despite this, there are cultural considerations still at play that are hindering widespread acceptance of organ transplant and donation in Japanese culture. There is a traditional Japanese perspective that without the body being physically intact, the soul cannot rest after death (Akabayashi et al., 2018). This seems to be one of the major reasons why individuals and families choose not to give consent for organ donation and the numbers of deceased donors remains low in Japan. Gotai manzoku, the idea of “5-body satisfaction,” which is defined as an intact body with a head and 4 limbs, and indicates no defective body parts, is a traditional Buddhist concept that is deeply rooted in Japanese culture (Akabayashi et al., 2018). Many Japanese, whether religious or not, are considered “funeral Buddhists,” meaning they desire a Buddhist funeral. It’s evident that influences of Buddhism remain strong in the areas of death, burial and afterlife in the Japanese culture (Akabayashi et al., 2018). In Buddhism, more emphasis is placed on the physical body after death, as opposed to Christian cultures, where there is more focus on the soul. The concept of gotai manzoku leads many Japanese to have the desire to be cremated with all body parts intact. The idea is to prevent the person from becoming trapped between the realms of life and death- and to make it into a place of rest, one must be gotai manzoku (intact). Due to this cultural perspective, the concept of organ transplant and donation in Japan is accepted far less than many other countries.
Further, Japanese culture is heavily family-oriented, and medical decisions are usually made at the discretion of family members, not solely by the individual (which is more common in the United States). The body of the patient in Japanese culture is not only seen as belonging to the individual, but also seen as a part of a larger whole of the family. Japanese patients many times relinquish their decision making and leave it up to their family members to decide treatment for them. This family-facilitated approach to medical decision making can pose a challenge to organ donation, especially when the deceased’s wishes are unknown prior to death. But even if the deceased donor gave consent during life and expressed their desire to be an organ donor, the decision is still left up to the family. According to research, some of the strongest reasons why families withhold consent for organ donation of a deceased loved one include worry or regret, the inability to make the decision, concerns about making it to afterlife (gotai manzoku), or simply pushing the decision making onto other family members (Akabayashi et al., 2018). Although the family has the last say when it comes to donation in Japan, newer research is showing that families have recently started to show more respect toward their deceased loved one’s wishes if they expressed the desire to be donors while they were living (Akabayashi et al., 2018).
However, it is noted that the strong familial aspect in Japanese culture has led to more acceptance of living donation, where a healthy family member donates tissues to a loved one in need of transplant (Akabayashi, et al., 2018). In Japanese culture, family members usually do not hesitate when it comes to saving their loved ones, and this may be one reason why living donations are on the rise. Living donation in Japan is now increasing at a faster rate than anywhere else in the world (Akabayashi, 2018).
Another cultural consideration that has been a hinderance to organ donation and transplant stems from issues in the early history of organ transplant in Japan. In 1968, distrust in Japanese medical system arose after the brain-death determination for the first heart transplant was deemed premature. As a result, brain death was (and still is for some) considered a socially taboo subject and is one of the reasons cited when rejecting organ donation. In contrast to United States, the topic of brain death and organ donation garnered attention from all aspects of society- the government, the general public, medical professionals, religious groups, academia, and more. The topic was fueled by extensive discussions and debates that focused on the definition of death, the uncertainty of the brain-death diagnosis, distrust in medicine, lack of infrastructure, and cultural and familial perspectives on corpses and religion. The media took hold of the decades-long debate, and eventually the issues were tentatively resolved in 1997 with the introduction of the Organ Transplant Law (Akabayashi et al., 2018).
In Japan, terminating care for a brain-dead individual is also a slower process than in the United States. In many cases, Japanese doctors will gradually reduce treatment in cases of brain death, which gives families more time to cope and accept the idea of death. This practice is termed “slow weaning,” or “prolonged terminal weaning.” This is also practiced occasionally in the United States when families are having difficulty accepting the diagnosis, but is definitely less common than in Japan (Robben, 2018).
Organ Donation in the United States
The United States leads the world in actual organ transplantation rates, meaning more of the organs that are harvested from an individual can be used than in any other country (Lupkin, 2013). Despite this, and the fact that the US ranks fourth in the world for organ donation rate, and about 18 people die each day waiting on the transplant list (Lupkin, 2013). There are approximately 106,000 candidates on the waitlist for transplant (US Department of Health and Human Services, 2022). Although there are many social campaigns to encourage and increase donation rates, there has been an ongoing shortage of organs, and an ever-increasing list of people waiting for organ transplant. In the US, consent for organ donation may be obtained by the donor during life, or by next-of-kin after death. Organ donation in the United States is based on an “opt-in” model, which means the donor or next-of-kin must explicitly choose to donate their organs. In some countries, like France, Spain, and Austria, organ donation is based on an “opt-out” model, where people are presumed to be organ donors unless they specifically express otherwise (Childress et al., 2017).
In the 1960s, the United States began promoting organ donation and transplantation. In 1968, the Uniform Anatomical Gift Act was introduced by the National Conference of Commissioners on Uniform State Laws. The Uniform Anatomical Gift Act was designed to be a template for each state within the US to use as guidance for their own organ procurement and donation laws. The Uniform Anatomical Gift Act is not a law in itself but it serves as the foundation for individual state laws regarding organ donation. Each state, including the District of Columbia, adopted the Uniform Anatomical Gift Act of 1968. This act permits adults over the age of 18 to consent to donate all or some body parts after death, and requires written proof of intent. If the decision is not made by the individual before death, the act allows next-of-kin to authorize donation if they so choose. The act also ranks relatives’ legal authority based on status- for example, a spouse ranks higher than adult children and siblings. This helps eliminate confusion as to who gets to decide if their deceased love one’s organs should be donated or not.
There have been periodic revisions made to the Uniform Anatomical Gift Act, which has led to less uniformity between states due to lower adoption rates of the revisions. Not every state has adopted revisions made to the original act of 1968. Specifically, the Uniform Anatomical Gift Act of 1987 was where the United States saw the most controversy and divide- there were legal disputes over this version of the act due to inequities and racial disparities in body part removal. The 1987 version allowed for the procurement of organs to be made with authorization of coroners and medical examiners if next-of-kin couldn’t be contacted in sufficient time, and if the deceased did not specify their wishes prior to death. In 2006, this provision was removed from the act, which led to acceptance from 46 states, the District of Columbia, and The US Virgin Islands, and more uniformity across the nation.
The most recent version of the Uniform Anatomical Gift Act states that anyone over the age of 18 may choose to be an organ donor or not, and permits legal adults applying for a driver’s license to authorize donation. If one chooses to become an organ donor, the driver’s license will reflect this symbolically, and can be utilized as a tool to determine their choice upon death. In the US, an individual can choose which body parts they want to donate. If they have objections to donation of certain body parts, this can be noted.
In contrast to Japan, the wishes of the deceased when it comes to organ donation, if explicitly stated prior to death, cannot be changed. The rights of the deceased individual take precedence over the wishes of the loved ones- if an individual decides to be an organ donor and puts that in writing, the family cannot veto that decision. This is a probable reason for higher organ donation rates in the United States, and this can also take the burden off loved ones. Having to make this decision can be psychologically taxing on family members of the deceased, so knowing the wishes of the individual prior to death can be beneficial for all parties involved.
American Cultural Considerations Regarding Death and Organ Transplant
In America, organ transplant is widely regarded as an altruistic action. Having the ability to save lives post-mortem can be a thrilling idea. Being an organ donor can be somewhat seen as a status symbol- from my own experience, when my friends and I turned 18, we all discussed organ donation and the reasons why we decided to become donors or not. Those who chose organ donation were proud of the symbolic representation on their driver’s licenses. On the other hand, my husband, for example, chose not to be an organ donor because of the potential for medical malpractice through a hastened death declaration. There is legitimate concern for this, as seen in the first Japanese heart transplant case in 1968 that was previously discussed. There is concern in American culture that if someone if an organ donor, they will be considered “more valuable” after death, leading to less medical intervention to save their life. According to research, the average organ donor can provide life for an additional 30.8 years through the average donation of 2.9 organs. If all organs are viable for donation, 55.8 additional years of life can be provided to the recipients (Schnitzler et al., 2005). Some may find this data to be compelling enough to undoubtedly choose organ donation, in the hope to save lives after death. But for some, this may lead to skepticism as to whether or not a medical team will be more apt to hasten a death declaration if they know they can procure organs and save more lives.
It has also been noted that in America, in contrast from Japan, persuasion to donate organs is more commonplace (Siminoff, 2001). For some, the persuasiveness of medical professionals may lead to feelings of mistrust and lead to declination of consent for organ donation. In Japan, their culture avoids this type of persuasion for ethical and moral reasons (Robben, 2018). To avoid the need for persuasion, having the discussion about organ donation wishes prior to death with family members can alleviate confusion. A study from 2004 suggests that in cases where the deceased individual was not registered to be an organ donor prior to death, the family consent rate was near 95-100% if the family was at least aware of their desires to donate prior to death (Ojo et al., 2004).
Conclusions
There has been much dispute over the declaration of death, especially in the case of brain-dead individuals. In order to combat these ethical and legal dilemmas, the “dead donor rule” was enacted as a requirement to ensure donors are dead before organ procurement (Miller et al., 2010). The scientific community around the globe is in agreement for the most part as to when death should be declared. However, there is still ambiguity when it comes to the issue about when someone is actually considered dead in the case of brain death. Cultural views surrounding death also play an important role in this issue- countries like Japan have proven to take a more conservative and cautious approach when determining death of an individual, whereas the United States has proven to rely on current scientific literature to buttress their prompt death declarations. Despite more understanding and clarification when it comes to determining death through medical developments and legislation, there is still public hesitancy in both cultures when it comes to organ donation and transplant.
References
Akabayashi, A., Nakazawa, E., Ozeki-Hayashi, R., Tomiyama, K., Mori, K., Demme, R. A., & Akabayashi, A. (2018). Twenty years after enactment of the organ transplant law in Japan: Why are there still so few deceased donors? Transplantation Proceedings, 50(5), 1209–1219. https://doi.org/10.1016/j.transproceed.2018.02.078
Childress, J. F., Liverman, C. T., & Domnitz, S. (2017). Opportunities for organ donor intervention research: Saving lives by improving the quality and quantity of organs for transplantation. The National Academies Press.
Egawa, H., Tanabe, K., Fukushima, N., Date, H., Sugitani, A., & Haga, H. (2011). Current status of organ transplantation in Japan. American Journal of Transplantation, 12(3), 523–530. https://doi.org/10.1111/j.1600-6143.2011.03822.x
Lupkin, S. (2013). Organ Donation Rates: How the US Stacks Up. ABC News. Retrieved from https://abcnews.go.com/Health/organ-donation-rates-us-stacks/story?id=19437070
Miller, F. G., Truog, R. D., & Brock, D. W. (2010). The dead donor rule: can it withstand critical scrutiny?. The Journal of medicine and philosophy, 35(3), 299–312. https://doi.org/10.1093/jmp/jhq019
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Robben, R. A. C. G. M. (2018). Death, mourning, and burial: a cross-cultural reader. John Wiley & Sons, Inc.
Schnitzler, M. A., Whiting, J. F., Brennan, D. C., Lentine, K. L., Desai, N. M., Chapman, W., Abbott, K. C., & Kalo, Z. (2005). The life-years saved by a deceased organ donor. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 5(9), 2289–2296. https://doi.org/10.1111/j.1600-6143.2005.01021.x
Siminoff, L. A. (2001). Factors influencing families' consent for donation of solid organs for transplantation. JAMA, 286(1), 71. https://doi.org/10.1001/jama.286.1.71
Tokudome, S., Hashimoto, S., & Igata, A. (2016). Life expectancy and healthy life expectancy of Japan: the fastest graying society in the world. BMC research notes, 9(1), 482. https://doi.org/10.1186/s13104-016-2281-2
US Department of Health and Human Services. (2022). Organ Procurement and Transplantation Network. OPTN. Retrieved April 20, 2022, from https://optn.transplant.hrsa.gov/data/
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