- Email: [email protected]
Japan approves brain death to increase donors: will it work?
Comment
cology and disease management, health-services research, surveillance, and public health); and development of exchange programmes for leaders and administrators. This bringing together of academic health centres worldwide provides unprecedented opportunities for constructive collaboration. In research, for example, large clinical trials across academic health centres will be possible, with the sharing of research materials and expertise, the generation of large databases, and evaluation of important areas such as outcomes, patients’ safety, and cost–efficacy. Clinically, the new organisation could mobilise the international academic community to combat the threat of, for example, an H1N1 pandemic.6 AAHC International could help facilitate threatmodelling to advise on issues such as school closures and clinical trials, search for important biomarkers, examine cytokine profiles and organ dysfunction in diverse populations, and study societal and bioethical issues to advise governments and international health organisations. The association will also enable the academic community to explore the potential for harmonisation of education and training programmes to prepare students and trainees for work in a global society. A key challenge for the new organisation will be to address the problem of health inequality, particularly in countries with underdeveloped health-care systems.7 This new international organisation of academic health centres will serve to mobilise and speak on
behalf of their enormous collective strengths and resources, while helping to ensure that they can effectively contribute in international matters that affect health, research, and the economy. In so doing, AAHC International will help to foster an international community of academic health centres, a community driven by the ideal of improving the public good. Steven A Wartman, *Edward W Hillhouse, Louise Gunning-Schepers, John E L Wong Association of Academic Health Centers, Washington, DC, USA (SAW); School of Medicine, University of Leeds, Leeds LS2 9JT, UK (EWH); Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands (LG-S); and Yong Loo Lin School of Medicine and National University Health System, Singapore (JELW) [email protected] We have attended several meetings about the establishment of AAHC International and are part of an informal steering group. 1 2
3 4
5 6 7
Wartman SA. Towards a virtuous cycle: the changing face of academic health centers. Acad Med 2008; 83: 797–99. Dzau VJ, Ackerly DC, Sutton-Wallace P, et al. The role of academic health science systems in the transformation of medicine. Lancet 2009; published online Oct 1. DOI:10.1016/S0140-6736(09)61082-5. Davies SM, Bennett A. Understanding the economic and social benefits of academic clinical partnerships. Acad Med 2008; 83: 535–40. Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. Acad Med 2006; 81: 189–92. AAHC International. http://www.aahcdc.org/international.php (accessed Aug 24, 2009). Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature 2009; 459: 931–39. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet 2009: 374: 65–75.
Japan approves brain death to increase donors: will it work? On July 13, 2009, Japan’s legislature passed a bill to revise the Organ Transplant Law to discard the law’s unique double standard on brain death, in which brain death constitutes death only when the patient has given previous written consent to be an organ donor and the family does not oppose the donation. The revised law, which does not stipulate that brain death constitutes death but is designed for uniform recognition of people who are brain dead as legally dead, will take effect in a year. The legal revision seems to have finally made Japan like many other countries on this issue. However, the time lag has clarified that the majority understanding of brain death is not appropriate. With the advancement of intensive medical technology in the past few decades, www.thelancet.com Vol 374 October 24, 2009
inconsistencies inherent in the concept of whole-brain death, which has been adopted by the USA and many other countries including Japan, have become evident.1–4 Even James Bernat, the world’s leading defender of the idea of whole-brain death, has admitted that it is a social construct rather than a scientific concept.5 In December, 2008, the US President’s Council on Bioethics issued a White Paper titled Controversies in the determination of death6 that examined many questions about the clinical and ethical validity of the whole-brain concept of death. Although the Council concluded that the neurological standard is defensible, they say that the term brain death is highly problematic and should be replaced by total brain failure. The report also emphasises that to maintain a distinction between naming the 1403
Comment
Getty/AFP
medical diagnosis and declaring an individual dead on the basis of that medical diagnosis is important. Controversies about brain death are well known in Japan, which has held a protracted nationwide debate on brain death since the 1980s.7 This debate led to the original Organ Transplant Law that was enacted in 1997 and allowed discretion over the choice of brain death as death, because a uniform definition of brain death would violate the rights of those who do not recognise this state as death. The law and relevant guidelines state that brain death is human death only when a patient has given previous written consent to be a donor. In an attempt to protect the rights of those who do not want a brain-death diagnosis for themselves or family members, the law grants the patient or patient’s family the right to veto a brain-death diagnosis.8 The pluralistic nature of brain death is said to be similar to the conscience clause in the New Jersey Declaration of Death Act.9 However, Japan’s legislature voted for the bill to revise the law in a way to uniformly recognise brain death as death and enable family consent to be sufficient for organ removal unless the brain-dead person has previously refused to be a donor, while the right to veto a braindeath diagnosis has been preserved. Observers believe that lawmakers felt pressured because a number of patients’ groups and medical professional organisations complained that the original law resulted in a very small number of organ donors—81 brain-dead donors in the past 12 years. Moreover, the legal requirement for previous written consent to be a brain-dead donor has prevented children younger than age 15 years from being donors, because the nation’s law states that people able to leave a will should be 15 years and older. This age restriction has forced parents with sick children to raise funds of between US$1 million and $2 million to seek transplants abroad. In one case, a university-affiliated hospital in the USA required the parents of a child in need of a heart transplant to deposit a sum of $4 million.10 To make matters worse for patients in Japan, domestic media widely reported that WHO intends to stop overseas transplants. WHO was originally expected to officially ask member states to discourage people from seeking overseas transplants in May, 2009, but the plan was delayed by a year while WHO dealt with the ‘flu pandemic.11 Thus revision of the transplant law is mainly intended to increase the domestic supply of organs by allowing 1404
organ donation through family consent only, in addition to scrapping the age restriction to allow children to be donors. For this purpose, brain death should be uniformly recognised as human death. Brain death as death began as a utilitarian legislative decree and has remained a conclusion in search of a justification, clung to for the sake of the transplantation enterprise in the USA.12 Japan is following suit. However, it remains to be seen if the legal revision will lead to a substantial increase in the number of organ donors in Japan, where public opinion is still divided over recognition of brain death as death. A national survey done immediately after the legal revision showed that 40% of respondents support recognition of brain death as death, whereas 39% do not.13 Many Japanese people would become sceptical about the legitimacy of brain death if they learned of the frequent careless brain-death diagnoses in the USA,14 the world’s leading nation for transplantations. Then, uniform interpretation of brain death might cause more trouble at end-of-life care in Japan. Kaoruko Aita Global Centre of Excellence Program Death and Life Studies, Graduate School of Humanities and Sociology, University of Tokyo, Tokyo 113-0033, Japan [email protected] I declare that I have no conflicts of interest. 1 2 3 4 5
6
7 8 9
10
11
12 13 14
Halevy A, Brody B. Brain death: reconciling definitions, criteria, and tests. Ann Intern Med 1993; 119: 519–25. Truog RD. It is time to abandon brain death? Hastings Cent Rep 1997; 27: 29–37. Shewmon DA. Chronic “brain death”: meta-analysis and conceptual consequences. Neurology 1998; 51: 1538–45. Chiong W. Brain death without definitions. Hastings Cent Rep 2005; 35: 20–30. Aita K. It’s a matter of life and death: US consensus frays on brain-death criteria. Japan Times (Japan) Oct 25, 2000. http://search.japantimes.co.jp/ cgi-bin/nn20001025b5.html (accessed July 14, 2009). President’s Council on Bioethics. Controversies in the determination of death. http://bioethicsprint.bioethics.gov/reports/death/index.html (accessed July 14, 2009). Morioka M. Reconsidering brain death: A lesson from Japan’s fifteen years of experience. Hastings Cent Rep 2001; 31: 41–46. Aita K. Diet enacts law for transplants from brain-dead. Japan Times (Japan) June 18, 1997. Veatch RM. The conscience clause. In: Younger SJ, Arnold RM, Schapiro R, et al, eds. The definition of death: contemporary controversies. Baltimore, MD: Johns Hopkins University Press, 1999: 137–60. Kato M. An organ in US won’t be cheap. Japan Times (Japan) June 19, 2009. http://search.japantimes.co.jp/cgi-bin/nn20090619a4.html (accessed July 14, 2009). Martin A. Kids can be donors: Lower House. Japan Times (Japan) June 19, 2009. http://search.japantimes.co.jp/cgi-bin/nn20090619a2.html (accessed July 14, 2009). Shewmon DA. Brain death: can it be resuscitated? Hastings Cent Rep 2009; 39: 18–24. Anon. Our national survey shows public opinion is divided over recognizing brain death as death. Asahi Shimbun (Japan) July 23, 2009: 38 (in Japanese). Powner DJ. Certification of brain death: take care. Lancet 2009; 373: 1587–89.
www.thelancet.com Vol 374 October 24, 2009
cology and disease management, health-services research, surveillance, and public health); and development of exchange programmes for leaders and administrators. This bringing together of academic health centres worldwide provides unprecedented opportunities for constructive collaboration. In research, for example, large clinical trials across academic health centres will be possible, with the sharing of research materials and expertise, the generation of large databases, and evaluation of important areas such as outcomes, patients’ safety, and cost–efficacy. Clinically, the new organisation could mobilise the international academic community to combat the threat of, for example, an H1N1 pandemic.6 AAHC International could help facilitate threatmodelling to advise on issues such as school closures and clinical trials, search for important biomarkers, examine cytokine profiles and organ dysfunction in diverse populations, and study societal and bioethical issues to advise governments and international health organisations. The association will also enable the academic community to explore the potential for harmonisation of education and training programmes to prepare students and trainees for work in a global society. A key challenge for the new organisation will be to address the problem of health inequality, particularly in countries with underdeveloped health-care systems.7 This new international organisation of academic health centres will serve to mobilise and speak on
behalf of their enormous collective strengths and resources, while helping to ensure that they can effectively contribute in international matters that affect health, research, and the economy. In so doing, AAHC International will help to foster an international community of academic health centres, a community driven by the ideal of improving the public good. Steven A Wartman, *Edward W Hillhouse, Louise Gunning-Schepers, John E L Wong Association of Academic Health Centers, Washington, DC, USA (SAW); School of Medicine, University of Leeds, Leeds LS2 9JT, UK (EWH); Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands (LG-S); and Yong Loo Lin School of Medicine and National University Health System, Singapore (JELW) [email protected] We have attended several meetings about the establishment of AAHC International and are part of an informal steering group. 1 2
3 4
5 6 7
Wartman SA. Towards a virtuous cycle: the changing face of academic health centers. Acad Med 2008; 83: 797–99. Dzau VJ, Ackerly DC, Sutton-Wallace P, et al. The role of academic health science systems in the transformation of medicine. Lancet 2009; published online Oct 1. DOI:10.1016/S0140-6736(09)61082-5. Davies SM, Bennett A. Understanding the economic and social benefits of academic clinical partnerships. Acad Med 2008; 83: 535–40. Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. Acad Med 2006; 81: 189–92. AAHC International. http://www.aahcdc.org/international.php (accessed Aug 24, 2009). Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature 2009; 459: 931–39. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet 2009: 374: 65–75.
Japan approves brain death to increase donors: will it work? On July 13, 2009, Japan’s legislature passed a bill to revise the Organ Transplant Law to discard the law’s unique double standard on brain death, in which brain death constitutes death only when the patient has given previous written consent to be an organ donor and the family does not oppose the donation. The revised law, which does not stipulate that brain death constitutes death but is designed for uniform recognition of people who are brain dead as legally dead, will take effect in a year. The legal revision seems to have finally made Japan like many other countries on this issue. However, the time lag has clarified that the majority understanding of brain death is not appropriate. With the advancement of intensive medical technology in the past few decades, www.thelancet.com Vol 374 October 24, 2009
inconsistencies inherent in the concept of whole-brain death, which has been adopted by the USA and many other countries including Japan, have become evident.1–4 Even James Bernat, the world’s leading defender of the idea of whole-brain death, has admitted that it is a social construct rather than a scientific concept.5 In December, 2008, the US President’s Council on Bioethics issued a White Paper titled Controversies in the determination of death6 that examined many questions about the clinical and ethical validity of the whole-brain concept of death. Although the Council concluded that the neurological standard is defensible, they say that the term brain death is highly problematic and should be replaced by total brain failure. The report also emphasises that to maintain a distinction between naming the 1403
Comment
Getty/AFP
medical diagnosis and declaring an individual dead on the basis of that medical diagnosis is important. Controversies about brain death are well known in Japan, which has held a protracted nationwide debate on brain death since the 1980s.7 This debate led to the original Organ Transplant Law that was enacted in 1997 and allowed discretion over the choice of brain death as death, because a uniform definition of brain death would violate the rights of those who do not recognise this state as death. The law and relevant guidelines state that brain death is human death only when a patient has given previous written consent to be a donor. In an attempt to protect the rights of those who do not want a brain-death diagnosis for themselves or family members, the law grants the patient or patient’s family the right to veto a brain-death diagnosis.8 The pluralistic nature of brain death is said to be similar to the conscience clause in the New Jersey Declaration of Death Act.9 However, Japan’s legislature voted for the bill to revise the law in a way to uniformly recognise brain death as death and enable family consent to be sufficient for organ removal unless the brain-dead person has previously refused to be a donor, while the right to veto a braindeath diagnosis has been preserved. Observers believe that lawmakers felt pressured because a number of patients’ groups and medical professional organisations complained that the original law resulted in a very small number of organ donors—81 brain-dead donors in the past 12 years. Moreover, the legal requirement for previous written consent to be a brain-dead donor has prevented children younger than age 15 years from being donors, because the nation’s law states that people able to leave a will should be 15 years and older. This age restriction has forced parents with sick children to raise funds of between US$1 million and $2 million to seek transplants abroad. In one case, a university-affiliated hospital in the USA required the parents of a child in need of a heart transplant to deposit a sum of $4 million.10 To make matters worse for patients in Japan, domestic media widely reported that WHO intends to stop overseas transplants. WHO was originally expected to officially ask member states to discourage people from seeking overseas transplants in May, 2009, but the plan was delayed by a year while WHO dealt with the ‘flu pandemic.11 Thus revision of the transplant law is mainly intended to increase the domestic supply of organs by allowing 1404
organ donation through family consent only, in addition to scrapping the age restriction to allow children to be donors. For this purpose, brain death should be uniformly recognised as human death. Brain death as death began as a utilitarian legislative decree and has remained a conclusion in search of a justification, clung to for the sake of the transplantation enterprise in the USA.12 Japan is following suit. However, it remains to be seen if the legal revision will lead to a substantial increase in the number of organ donors in Japan, where public opinion is still divided over recognition of brain death as death. A national survey done immediately after the legal revision showed that 40% of respondents support recognition of brain death as death, whereas 39% do not.13 Many Japanese people would become sceptical about the legitimacy of brain death if they learned of the frequent careless brain-death diagnoses in the USA,14 the world’s leading nation for transplantations. Then, uniform interpretation of brain death might cause more trouble at end-of-life care in Japan. Kaoruko Aita Global Centre of Excellence Program Death and Life Studies, Graduate School of Humanities and Sociology, University of Tokyo, Tokyo 113-0033, Japan [email protected] I declare that I have no conflicts of interest. 1 2 3 4 5
6
7 8 9
10
11
12 13 14
Halevy A, Brody B. Brain death: reconciling definitions, criteria, and tests. Ann Intern Med 1993; 119: 519–25. Truog RD. It is time to abandon brain death? Hastings Cent Rep 1997; 27: 29–37. Shewmon DA. Chronic “brain death”: meta-analysis and conceptual consequences. Neurology 1998; 51: 1538–45. Chiong W. Brain death without definitions. Hastings Cent Rep 2005; 35: 20–30. Aita K. It’s a matter of life and death: US consensus frays on brain-death criteria. Japan Times (Japan) Oct 25, 2000. http://search.japantimes.co.jp/ cgi-bin/nn20001025b5.html (accessed July 14, 2009). President’s Council on Bioethics. Controversies in the determination of death. http://bioethicsprint.bioethics.gov/reports/death/index.html (accessed July 14, 2009). Morioka M. Reconsidering brain death: A lesson from Japan’s fifteen years of experience. Hastings Cent Rep 2001; 31: 41–46. Aita K. Diet enacts law for transplants from brain-dead. Japan Times (Japan) June 18, 1997. Veatch RM. The conscience clause. In: Younger SJ, Arnold RM, Schapiro R, et al, eds. The definition of death: contemporary controversies. Baltimore, MD: Johns Hopkins University Press, 1999: 137–60. Kato M. An organ in US won’t be cheap. Japan Times (Japan) June 19, 2009. http://search.japantimes.co.jp/cgi-bin/nn20090619a4.html (accessed July 14, 2009). Martin A. Kids can be donors: Lower House. Japan Times (Japan) June 19, 2009. http://search.japantimes.co.jp/cgi-bin/nn20090619a2.html (accessed July 14, 2009). Shewmon DA. Brain death: can it be resuscitated? Hastings Cent Rep 2009; 39: 18–24. Anon. Our national survey shows public opinion is divided over recognizing brain death as death. Asahi Shimbun (Japan) July 23, 2009: 38 (in Japanese). Powner DJ. Certification of brain death: take care. Lancet 2009; 373: 1587–89.
www.thelancet.com Vol 374 October 24, 2009