The ambiguity about death in Japan: an ethical implication for organ procurement

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens

BACKGROUND

According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians' and citizens' attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment.

METHODS

Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment.

RESULTS

In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient's family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient's request than mechanical ventilation (49%).

CONCLUSIONS

A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND

In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.

METHODS

Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.

RESULTS

Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.

CONCLUSIONS

In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

Can the Wish to Receive Intensive Treatment in Elderly Patients with Respiratory Tract Infection Be Predicted?

Objective Almost no Japanese elderly patients have an advance directive (AD). Our aim was to determine whether or not the wish to receive intensive care in elderly patients with respiratory tract infection could be predicted from the prehospital data. Methods In this retrospective study, we reviewed patients ≥65 years of age with respiratory tract infection who had been transferred to our hospital by ambulance between September 2014 and August 2016. The patients were divided into two groups according to whether or not they wished to receive intensive treatment. We placed patients without a wish to receive intensive treatments (WITs) in Group A and patients with a WITs in Group B. We then analyzed parameters that could be determined in the prehospital phase and compared the findings between the groups. Results Thirty-seven patients were in Group A, and 67 patients were in Group B. None of the patients in this study had an AD. There were significant differences in the age, rate of residence in an extended care facility, frequency of inability to care for oneself fully, frequency of dementia, number of prescribed drugs, and Glasgow coma scale (GCS) on a univariate analysis. A logistic regression analysis showed that the inability to care for oneself fully [odds ratio (OR): 4.521, 95% confidence interval (CI): 2.024-10.096, p<0.001] and a low GCS (OR 0.885, 95%CI 0.838-0.935, p<0.001) were related to a WITs. Conclusion Elderly patients who are unable to care for themselves and who have a low GCS in the prehospital stage are likely not to want intensive treatment.

The ethical implications and religious significance of organ transplantation payment systems

One of the more polarizing policies proposed to alleviate the organ shortage is financial payment of donors in return for organs. A priori and empirical investigation concludes that such systems are ethically inadequate. A new methodological approach towards policy formation and implementation is proposed which places ethical concerns at its core. From a hypothetical secular origin, the optimal ethical policy structure concerning organ donation is derived. However, when applied universally, it does not yield ideal results for every culture and society due to region-specific variation. Since religion holds significant influence in the organ donation debate, three religions-Catholicism, Islam, and Shinto-were examined in order to illustrate this variation. Although secular ethical concerns should rest at the core of policy construction, certain region-specific contexts require cultural and religious competence and necessitate the adjustment of the optimal template policy accordingly to yield the best moral and practical results.

[Treatment choice for patients with hemorrhagic cerebral stroke expected to be in a disabled condition--An analysis of questionnaire responses of patients' families]

AIM

Many patients with cerebral stroke are successively treated with the latest advances in medical therapies. Surgical hematoma evacuation is a treatment option for patients with hemorrhagic cerebral stroke, however; it may result in a prolonged vegetative state. The difficult choice of whether or not such surgery should be performed is mostly made by the family, frequently in an urgent manner, and nurses need to understand the factors affecting this decision-making.

METHODS

We performed statistical analyses on the responses of 30 patients' families who answered our questionnaire, presuming disabilities after the surgery were expected. Multiple answers were obtained according to the severity of the expected disabilities after the surgery.

RESULTS

The refusal of surgery increased as the expected disabilities worsened, and the statistically significant factor affecting the decision-making process was "what they would wish if they suffered a stroke themselves." The 18 nurses working in the neurological ward who responded to the same questionnaire wished surgery more in the case of the patient's cognition being preserved.

CONCLUSIONS

Since it is rare for patients with stroke to have an advance directive, patients' families have to decide the treatment choice in most cases. In the clinical setting, such decisions frequently need to be made rapidly, however; the decision should be made by speculating on the patients' own will, and it is desirable for medical staff to explain the expected outcomes of the surgery in detail as far as possible.

An explanation and analysis of how world religions formulate their ethical decisions on withdrawing treatment and determining death

INTRODUCTION

This paper explores definitions of death from the perspectives of several world and indigenous religions, with practical application for health care providers in relation to end of life decisions and organ and tissue donation after death. It provides background material on several traditions and explains how different religions derive their conclusions for end of life decisions from the ethical guidelines they proffer.

METHODS

Research took several forms beginning with a review of books and articles written by ethicists and observers of Bön, Buddhism, Christianity, Hinduism, Indigenous Traditions, Islam, Judaism, Shinto and Taoism. It then examined sources to which these authors referred in footnotes and bibliographies. In addition, material was gathered through searches of data bases in religious studies, general humanities, social sciences and medicine along with web-based key word searches for current policies in various traditions.

RESULTS

Religious traditions provide their adherents with explanations for the meaning and purpose of life and include ethical analysis for the situations in which their followers find themselves. This paper aims to increase cultural competency in practitioners by demonstrating the reasoning process religions use to determine what they believe to be the correct decision in the face of death.

CONCLUSION

Patterns emerge in the comparative study of religious perspectives on death. Western traditions show their rootedness in Judaism in their understanding of the human individual as a finite, singular creation. Although the many branches of Western religions do not agree on precisely how to determine death, they are all able to locate a moment of death in the body. In Eastern traditions personhood is not defined in physical terms. From prescribing the location of death, to resisting medical intervention and definitions of death, Eastern religions, in their many forms, incorporate the beliefs and practices that preceded them. Adding to the complexity for these traditions is the idea that death is a process that continues after the body has met most empirical criteria for determining death. For Hinduism and Buddhism, the cessation of heart, brain and lung function is the beginning of the process of dying--not the end.

Donating in good faith or getting into trouble Religion and organ donation revisited

There is worldwide shortage of organs for solid-organ transplantation. Many obstacles to deceased and live donation have been described and addressed, such as lack of understanding of the medical process, the issue of the definition of brain death, public awareness of the need for transplants, and many others. However, it is clear that the striking differences in deceased and live donation rates between different countries are only partly explained by these factors and many cultural and social reasons have been invoked to explain these observations. We believe that one obstacle to both deceased and live donation that is less well appreciated is that of religious concerns. Looking at the major faiths and religions worldwide, it is reassuring to see that most of them encourage donation. However, there is also scepticism amongst some of them, often relating to the concept of brain death and/or the processes surrounding death itself. It is worthwhile for transplant teams to be broadly aware of the issues and also to be mindful of resources for counselling. We believe that increased awareness of these issues within the transplant community will enable us to discuss these openly with patients, if they so wish.

Addressing religious and cultural differences in views on transplantation, including composite tissue allotransplantation

Composite tissue allotransplantation is a rapidly developing field in plastic and reconstructive surgery and therefore imposes an obligation upon plastic and transplant surgeons to familiarize themselves with some unique aspects of this new discipline. The visible nature of extremities, and the face, presents a special hurdle when seeking the consent of the donor's family, as well as the recipient. Religious and sociocultural backgrounds of both the donor and recipient may have an important impact on the outcome of the donation and acceptance process. The purpose of this review is to present the current positions of major religious groups on allotransplantation and the cultural responses to the religious stances. In this context, we have investigated whether there are any specific religious or cultural restrictions against the practice of composite tissue allotransplantation.

Ethical perspectives on living donor organ transplantation in Asia

Live donors are a continuing source of organ grafts for solid organ transplantation in Asia. Ethical issues surrounding the development of living donor organ transplantation in Eastern countries are different from those in Western countries. Donor safety is still the paramount concern in any donor operation. Issues on organ trafficking remain societal concerns in low-income nations. Religion, cultural background, economic prerogatives, and timely legislation contribute to the social acceptance and maturation of organ donation.

A qualitative analysis of a significant barrier to organ and tissue donation: receiving less-than-optimal medical care

A key reason for the shortage of transplantable organs and tissue in the United States is the degree of resistance among the public to donating organs and tissue after death. In this article, we explore a single barrier to donation: the concern that medical personnel might provide "less-than-optimal" care to intended donors. Using 2 qualitative methodologies-analysis of family discussions about donation and analysis of in-depth interviews about donation-we explore what participants' discourse reveals about the variations and texture of this concern. The analysis revealed 4 aspects of this concern: (a) Participants expressed different versions of less-than-optimal care, each reflecting different assumptions about how medical personnel may approach the treatment of potential donors. (b) Participants expressed their concerns by describing hypothetical scenarios of medical treatment. These scenarios were designed to play up the plausibility of receiving less-than-optimal care and situated the speaker as the victim in the scenario. (c) Participants' uncertainty about the quality of medical treatment was sufficient grounds for not donating. (d) Participants expressed their concerns about medical treatment in terms of the perceived corruptibility of sociocultural institutions, including medical institutions. This analysis also revealed the lines of reasoning through which participants overcame a concern about receiving less-than-optimal-care. In our view, the most promising line of reasoning expressed by participants was to trust the legal and procedural protections built into the recovery process.

An Overview of Transplantation in Culturally Diverse Regions

Transplantation is one of the most progressive areas of medicine. Following its rapid development, organ transplantation has become part of the globalisation process, and is now available in all corners of the world in different social and cultural environments. Almost a decade into a new century, transplantation faces new challenges, with record numbers of patients on the waiting list, a scarcity of donor organs, inequity in access to transplantation, organ commercialisation, increasing living donation and the use of marginal donors. Probably more than in any other field of medicine, the cultural influences are very prominent in transplantation due to the complexity of the process and the ethical issues surrounding every step from donation, access to transplantation to outcome. These influences have led to different practical approaches around the world, which aim to be in agreement with the respective societal principles and moral values. Herein, we provide an overview of some of these challenges and their possible resolution in culturally diverse areas of the world. Key words: Access to transplantation, Living donor, Organ donation, Religion, Transplant laws, Transplant tourism

Facts versus `Feelings'

Researchers are already aware that decision making about health issues is not necessarily driven by rational or cognitive-based decision-making processes. This appears to be especially true for the decision to donate organs. Although hints about what is actually driving the decision-making process are scattered throughout the literature, noncognitive factors have not been tested systematically. Structural equation modeling of data gathered from 4426 participants at six different geographic locations in the United States demonstrates that cognitive-based factors (such as knowledge about donation) are less influential on the decision to donate than noncognitive variables such as the desire to maintain bodily integrity, worries that signing a donor card might `jinx' a person, and medical mistrust.

Current Knowledge and Attitudes About Organ Donation and Transplantation Among Chinese University Students

Current attitudes toward organ donation among university students in mainland China and the differences in attitudes between Chinese students in mainland China versus overseas are unknown. To address these issues, we conducted a cross-sectional survey using questionnaires among 922 Chinese undergraduates from mainland China and overseas regions of the world. Data were analyzed by descriptive statistics, Student t tests, chi-square tests, and a logistic regression analysis. We found that blood donors showed significantly better awareness of heart, liver, lung, skin, and tendon donation among commonly transplanted organs/tissues. As to the willingness for cadaveric organ donation, 61.3% of respondents consented, 8.5% objected, and 30.3% answered "not sure." The percentage holding an organ donor card was 15.7% among students from Hong Kong; 3.0%, mainland China; 2.8%, Macau; 2.6%, Taiwan, and 4.0%, other regions of the world. In a logistic regression analysis, female students (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.35 to 3.72) and blood donors (OR, 1.91; 95% CI, 1.10 to 3.32) did, but age and study specialty (medical vs nonmedical) did not show significantly more positive attitudes toward cadaveric organ donation. Compared with students from mainland China, overseas Chinese students from various regions did not show significantly different attitudes toward cadaveric organ donation. In summary, blood donors among university students have a greater knowledge of transplantation and a more positive attitude toward organ donation. Since university students are an important source of blood donors in China, they will be a potential pool of organ donors in the future.

New insights on brain stem death: From bedside to bench

As much as brain stem death is currently the clinical definition of death in many countries and is a phenomenon of paramount medical importance, there is a dearth of information on its mechanistic underpinnings. A majority of the clinical studies are concerned only with methods to determine brain stem death. Whereas a vast amount of information is available on the cellular and molecular mechanisms of cell death, rarely are these studies directed specifically towards the understanding of brain stem death. This review presents a framework for translational research on brain stem death that is based on systematically coordinated clinical and laboratory efforts that center on this phenomenon. It begins with the identification of a novel clinical marker from patients that is related specifically to brain stem death. After realizing that this "life-and-death" signal is related to the functional integrity of the brain stem, its origin is traced to the rostral ventrolateral medulla (RVLM). Subsequent laboratory studies on this neural substrate in animal models of brain stem death provide credence to the notion that both "pro-life" and "pro-death" programs are at work during the progression towards death. Those programs (mitochondrial functions, nitric oxide, peroxynitrite, superoxide anion, coenzyme Q10, heat shock proteins and ubiquitin-proteasome system) hitherto identified from the RVLM are presented, along with their cellular and molecular mechanisms. It is proposed that outcome of the interplay between the "pro-life" and "pro-death" programs (dying) in this neural substrate determines the final fate of the individual (being dead). Thus, identification of additional programs in the RVLM and delineation of their regulatory mechanisms should shed new lights on future directions for clinical management of life-and-death.

Living donor liver transplantation: the historical and cultural basis of policy decisions and ongoing ethical questions

Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.

Non-heartbeating organ donation: clinical process and fundamental issues

This case report outlines the clinical process whereby a patient with severe traumatic brain injury became a non-heartbeating organ donor after a withdrawal-of-care decision. This process raises a series of ethical questions regarding decision-making on grounds of futility, the role of the next of kin, informed consent, the accommodation of manoeuvres directed towards organ retrieval at maximal viability, and the timing and determination of death. Although many aspects of the process can be accommodated within fundamental ethical principles and a broad interpretation of the concept of the 'best interests', the variance with established law requires authoritative clarification if a need for transplantable organs is to be responded to without compromising the reputation of practitioners involved in this area of care. Therefore, this recruitment strategy warrants wide public and professional debate to achieve longer-term sustainability and ensure the protection of all parties.

Differences in Attitude Toward Living and Postmortal Liver Donation in the United States, Germany, and Japan

Living liver donation is a possible immediate option for decreasing the shortage of liver allografts worldwide. Risks related to the donation make this procedure ethically controversial. Study groups of medical students (N= 330) from three different nations were analyzed with a complex questionnaire, and data were subjected to multiparameter analysis. The readiness for living liver donation was dependent upon the cultural background of the study groups. It was higher in the U.S. than in Germany and Japan, with a higher donation readiness for children as recipients than adults. Major differences among distinct sociodemographic groups need to be carefully addressed when setting up consensus guidelines for the clinical practice of living donation.

Brainstem death testing in the UK'time for reappraisal? †

BACKGROUND

A diagnosis of brainstem death in the UK is based on clinical assessment rather than technical investigations, but is considered rigorous enough to be legally synonymous with death.

METHODS

A questionnaire in five sections concerning clinician details, initiation of support, criteria for testing, conduct of the tests, and the process of organ donation, was sent to all members of the Neuroanaesthesia Society.

RESULTS

The survey reveals evidence of failure to apply existing guidelines accurately and a wide variation in practice where the recommendations are not specific.

CONCLUSIONS

In an era of scrutiny of medical process, it is timely to consider whether the current guidelines should be revisited. Clarification of the approach to biochemical derangement, and the role of confirmatory tests when the residual effect of sedative agents cannot be excluded, are two areas worthy of debate.

Non-heart beating organ donation: old procurement strategy--new ethical problems

The imbalance between supply of organs for transplantation and demand for them is widening. Although the current international drive to re-establish procurement via non-heart beating organ donation/donor (NHBOD) is founded therefore on necessity, the process may constitute a desirable outcome for patient and family when progression to brain stem death (BSD) does not occur and conventional organ retrieval from the beating heart donor is thereby prevented. The literature accounts of this practice, however, raise concerns that risk jeopardising professional and public confidence in the broader transplant programme. This article focuses on these clinical, ethical, and legal issues in the context of other approaches aimed at increasing donor numbers. The feasibility of introducing such an initiative will hinge on the ability to reassure patients, families, attendant staff, professional bodies, the wider public, law enforcement agencies, and the media that practitioners are working within explicit guidelines which are both ethically and legally defensible.

Ethics and rationale of living-donor liver transplantation in Asia

Living-donor liver transplantation took root in Asia as a natural result of circumstances, because the supply of organs from the cadaveric pool remained scarce over the years. In contrast to Western countries, the majority of organs for liver transplantation in Asia come from live donations. As the expertise of the transplant teams grows, patient outcomes improve, and public awareness increases, the option of live donation of the liver is increasingly chosen. Although no live liver donor death has yet been reported from Asia, the risk is not eliminated and remains a major consideration in the potential donor's decision to donate. The low morbidity and mortality rate could be attributed to the extensive experience of surgeons in liver surgery, because surgical liver disease is highly prevalent in Asia. Although the donor risk is estimated to be low, live organ donation should be absolutely voluntary, with consent given on the basis of unbiased information and chosen only when the option for obtaining a cadaveric graft is practically nil. It is only under these conditions that living-donor liver transplantation should be perpetuated. Although the disease-donation-transplantation process involves a complex interplay of psychosocial and family dynamics, the potential candidate's perception will necessarily depend on the surgeon's explanation. The ethical soundness of the practice of living-donor liver transplantation rests primarily on the ones who deliver the service.

Ethics of organ transplantation in Japan: an example of cultural transplantation in medicine

Since the passage of the Organ Transplant Law in October 1997, only nine persons declared dead by neurological criteria have donated their organs in Japan. This article is an attempt by Japanese anesthesiologists to introduce the cultural and moral justification of Japanese transplant practice to the international community.