It is important to understand that an individual’s perspective of death and dying is greatly impacted by their culture. In this paper I will discuss how the Japanese culture approaches death and dying. I will also discuss the unique concept of organ transplantation that surrounds that Japanese culture. This paper presents the law of organ transplantation in Japan, which allows people to decide whether brain death can be used to determine their death in agreement with their family. Japan could become a unique example of individual choice in the definition of death if the law is revised to allow individuals choose definition of death independently of their family. The death and dying rituals involved in the Japanese culture will be discussed.
Overview of the Japanese Culture
In the latter half of the twentieth century, developed countries of the world have made remarkable strides in organ donation and transplantation. However, in this area of medicine, Japan has been slow to follow. Japanese ethics, deeply rooted in religion and tradition, have affected their outlook on life and death. The Japanese have only recently started to acknowledge the concept of brain death and transplantation of major organs has been hindered in that country. Currently, there is a dual definition of death in Japan, intended to satisfy both sides of the issue. This interesting paradox, which still stands to be fully resolved, illustrates the controversial conflict between medical ethics and medical progress in Japan.
The Japanese culture considers a human being both alive and dead, an integrated body, mind, and spirit (Dennis, 2009, p.12). Therefore removing an organ from a brain-dead person involves a disturbance in this natural integrated unit. In the Japanese culture organ donation and organ transplantation are unpopular and rare (Dennis, 2009). According to Dennis (2009), the Japanese culture believes that a dead body must remain whole because if they are not whole, that dead person will be unhappy in the next world.
Japanese Culture on Death and Dying
It is crucial to understand that an individual’s perspective of death and dying is greatly impacted by their culture. Japan is the only country, which permits individual choice in death definition for the purpose of organ transplantation, and in agreement with the person’s family. The Japanese organ transplantation law of 1997 is a long debate on brain death and organ transplantation. Over almost three decades, medical, legal and public discussion has occurred; a lack of consensus on the definition of human death caused a long delay in adopting a law on organ procurement (Akabayashi, 1997). Finally, policy makers in Japan have adopted a law with unique features, such as giving an opportunity to individuals to choose the definition of death based on their own views. Therefore, in Japan individuals may choose either cessation of cardio‐respiratory function or loss of entire brain function for their death pronouncement (Morioka, 2001).
However, the choice is permitted in Japanese law only if organs can potentially be used for transplant with the agreement of the family, which means that although individuals can choose the definition of death based on their own views, the law gives power to the family to confirm or reject the choice. The law allows the family to override the individual choice in death definition (Akabayashi, 1997). The first effort to pass a law on organ transplantation following brain death failed in 1994. The main reason why the proposed law was rejected in 1994 is said to be because it stated that brain death is equal to death, and also because it approved surrogate decision making by the family. These issues raised serious arguments and concerns among some members, resulting in defeat of the legislation (Akabayashi, 1997). However, the situation has changed since then and, as public polls show, the number of people who accept the concept of brain death has increased from 29% to 60%. (Lock, 1996).
The current law states that for organ removal, the donor’s prior declaration and family agreement are both necessary requirements (Japan Ministry of Health Labor and Welfare, 1997). The organ donation provisions of the law apply for brain dead donors as well as any cadaver. The law authorizes organ removal from a brain‐dead person only if the donor has, during his life expressed in writing his consent to the diagnosis of brain death, as well as, his intention to donate his organ(s). Therefore, the law authorizes individuals to choose between the traditional definition or the alternative standard based on brain function by signing an “Organ Donation Decision Card”. Individuals can state their wishes at the back of this card by marking one of the following items: (1) I wish to be a donor based on the brain‐oriented definition; (2) I want to be a donor after cardiac death; or (3) I refuse to donate organs (Bagheri, 2003).
The law is not free of criticism, especially in terms of adopting a double standard regarding the role of the family. On the one hand, it gives the family the power to veto an individual’s willingness to donate. On the other hand, it does not authorize the family to be a surrogate decision maker based on the interests of their beloved ones when they are in a brain‐dead state and the organ donor card cannot be found. Nevertheless, the unbalanced role and power of veto of the family under the present law can be seen as a hindrance to organ procurement in Japan (Bagheri, 2003). The process of dying is regarded not as an individual event but as a family event in the Japanese culture (Kimura, 1998).
There is no doubt that any transplant‐related legislation should be concerned with inclusion of the opinion of the family in the decision‐making process. This forms a basis for social acceptance of the legislation. However, in any culture a practical question arises: to what extent is the family’s opinion to be taken into consideration? According to the law, family consent is required both for organ procurement and for declaration of death according to brain‐based criteria. Therefore an individual can choose the definition of death with the agreement of her or his family, but not independently (Kimura, 1998). Japan is the only country that allows individuals to choose either the traditional definition or the brain‐oriented definition of death, but individual choice must be confirmed by the family; therefore, it is a family based choice (Kimura, 1998).
Death and Dying Rituals in the Japanese Culture
A Japanese funeral includes a wake, the cremation of the deceased, a burial in a family grave, and a periodic memorial service. According to statistics, 99.82% of all deceased Japanese are cremated. While the ashes of many are buried in family graves, the scattering of ashes has become more common in recent years, including a burial at sea (Wakabayashi & Sekiguchi, 2011). Many funeral services are carried out in the form of Buddhist ceremonies. After a person has died, their lips are moistened with water, in a ceremony referred to as Matsugo-no-mizu “Water of the last moment” (Wakabayashi, & Sekiguchi, 2011). The household shrine is closed and covered with a white paper, to keep out impure spirits. This process is known as Kamidana-fuji. A small table placed beside the deceased’s bed is also decorated with flowers, incense, and a candle. A knife may placed on the chest of the deceased to drive away evil spirit (Wakabayashi & Sekiguchi, 2011).
Funeral arrangements are made and the body is washed and the orifices are blocked with cotton or gauze. The funeral clothing will consist of either a suit for a male or a kimono if the deceased is a female. Makeup may also be applied in order to improve the appearance of the body. The body is then put on dry ice and placed inside the casket with the head positioned towards the north or west, along with a white kimono, sandals and six coins for the crossing of the River of three hells. Items which the deceased was fond of will also be placed inside the casket as well, so long as they are flammable. The casket is then placed on the altar in preparation of the wake (Nakata, 2009). Guests who attend the funeral are expected to dress in black attire. The men usually wear black suits with a white shirt and a black tie, while women wear either a black dress or a black kimono. A Buddhist prayer bead called juzu may also be carried by guests. Guests are expected to bring condolence money in a special black and silver decorated envelope. At the funeral, the guests will be seated, with the next of kin closest to the front.
The Buddhist priest will read a sutra. The family members will each in turn offer incense three times to the incense urn in front of the deceased. The closest relatives may stay and keep vigil with the deceased overnight in the same room (Nakata, 2009). Japanese funerals are usually performed on the day following the wake. The funeral service is similar to that of the wake service, the difference being that during the funeral service, the deceased will receive a new Buddhist name to prevent the return of the deceased if their name is called. At the end of the ceremony, flowers may be placed inside the casket before it is sealed and carried to an elaborately decorated hearse where it is transported to the crematorium. In some regions of Japan, the casket may be nailed shut by mourners using a stone (Wakabayashi & Sekiguchi, 2011). Once the casket has arrived at the crematorium, the family witnesses the sliding of the body into the cremation chamber, then leave.
After the cremation process is complete, the family returns to pick the bones out of the ashes and transfer them to an urn using chopsticks. In some instances, two family members will hold the same bone at the same time with their chopsticks or pass the bones from chopsticks to chopsticks. According to Japanese custom, this is the only time when it is proper for two people to hold the same item at the same time with chopsticks. The bones are picked up and transferred to the urn in a manner which ensures that the deceased is not placed upside down in the urn. Therefore the bones of the feet are picked up first, the bones of the head last (Nakata, 2009). A typical Japanese grave is usually a family grave consisting of a stone monument with a place for flowers, incense, and water in front of the monument and a chamber underneath for the ashes.
The date of the formation of the grave and the name of the person who purchased it may be engraved on the side of the monument. The names of the deceased may or may not be engraved on the front or left side of the monument or on a separate stone in front of the grave Nakata, 2009). The Japanese honor the dead with shrines in their homes and tending to the gravesite (Dennis, 2009). During three days in August, the Japanese Buddhist celebrate at The Bons Festival in honor of the departed spirits of ones’ ancestors (Dennis, 2009). Until the early twentieth century most bodies were buried and cremation was limited to the wealthy. Cremation became more common after World War II due to its efficiency and cleanliness. In 2009, 99.9% of Japanese bodies were cremated, and some local governments ban burials (Wakabayashi & Sekiguchi, 2011).
I learned a lot about the Japanese culture while researching my paper. One of the things that I found surprising was that the majority of Japanese bodies are cremated. The similarities that I found between the American and the Japanese culture are that both cultures were black to funerals. In both cultures items that are valuable are placed in the caskets and funerals are followed by the wake. While cremation is popular in Japan, I was surprised to learn that cremation is on the rise in the United States; however, not everyone approves of it (Dennis, 2009).
Akabayashi A (1997). Japan’s parliament passes brain death law. The Lancet, 349 (9069). Retrieved from http://www.lancet.com. doi:10.1016/S0140-6736(05)63895-0. Bagheri A. (2003). A criticism of brain death policy in Japan. Kennedy Institute of Ethics Journal 13 (4), 359-372.
Dennis, D. (2009) Living, Dying, Grieving. Sandbury, MA: Jones and Barlett Publislhers. Japan Ministry of Health Labor and Welfare, The law concerning human organ transplants The law no. 104 1997. Translation 1999.
Kimura R. (1998). Death, dying and advance directives in Japan: socio‐cultural and legal points of view. In: Sass HM, Veatch RM, Rihito K, eds. Advance directives and surrogate decision making in health care. Baltimore: Johns Hopkins University Lock M. (1996). Deadly dispute: ideologies and brain death in Japan. In: Stuart J, Youngner Laurence J, O’Connell Renee C, eds. Organ transplantation meaning and realities. Fox. Madison: University of Wisconsin Press. Morioka M. (2001). Reconsidering brain death: a lesson from Japan’s fifteen years experience. Hastings Center Report 31, (4), 41-46.
Nakata, H. (2009). The Japan Times. Japan’s funerals deep-rotted mix of ritual, form. Retrieved from http://www.japantimes.co.jp/text/nn20090728i1.html.
Wakabayashi, D., & Sekiguchi, T. (2011). “After Flood, Deaths Overpower Ritual”. Wall Street Journal.