May 2, 2006

Kazuyo Uemura sat for nine months by her comatose mother's bed, finally reaching a wrenching conclusion to let nature take its course. "My mother was really active, so I knew being kept alive like that wasn't what she'd want, but we'd never talked about it," the Japanese housewife said of her 82-year-old parent. "I finally told the doctors to leave things to nature, but they made shocked faces, and I felt horribly guilty."

Living wills, outlining people's wishes should they become fully incapacitated, are still unusual in Japan despite its aging population, so Uemura is one of a growing number of people forced into a painful position. Though sure their loved ones would want to die if they could express a wish, they are legally unable to make that happen.

Now, spurred by recent cases of apparent euthanasia, Japan has begun grappling seriously with the difficult issue of "death with dignity," including legislation to make it possible.

"It would be a big help if there were clear laws and procedures to follow," said Michio Arakawa, a doctor who is also vice chairman of the Japan Society for Dying with Dignity.

"Without a law, many patients will go through pitiful deaths, since doctors are afraid of legal repercussions at present."

Last year, a doctor was convicted of taking the life of a comatose man by removing his breathing tube and injecting muscle relaxant, but given a suspended sentence. She said she had acted in line with the family's wishes, but the family denied it.

Just last month, news emerged that seven patients at a hospital in Toyama, western Japan, had died after a surgeon removed life support. The incident has rekindled debate since there was no written confirmation of the patients' wishes.

Although countries such as the Netherlands and Belgium have laws in place allowing assisted suicide, Japan's discussion at centers mainly on discontinuing treatment simply to prolong life when patients suffer from a terminal, painful condition.

OPPOSING TREATMENT

A large majority of Japanese and doctors oppose ongoing treatment in such cases, a 2003 Health Ministry survey showed. "My mother hates the idea of being staked to a bed by tubes," said Tamotsu Mizuno, a 60-year-old cancer patient.

"As for myself, though, it's hard to know what I'd do if it really came to that."
A growing number of Japanese are certain they do know, sending the number of living wills registered with the Japan Society for Death With Dignity soaring to more than 100 a day, three times the number before the Toyama deaths were reported.

Although publicity from the Toyama incident has played a part, social changes such as more medical openness, with cancer patients being told about their condition, have been key.

"There were numerous taboos up to now, including talking about death," said Keiko Iimura, 60, who works in a nursing home.  "But as society ages, this kind of thing needs to be discussed and decisions must be made." Compared to places such as the United States, where living wills are now often part of a patient's hospital file, Japan's debate is still in the early stages.

LIMITED DEBATE, LEGAL VACUUM

Some said that was due to traditions that put priority on groups like families and give less emphasis to personal will. "Because of their family, people feel they can't express a wish to die," said Masafumi Takai, a colleague of Arakawa. 

Families are also sometimes unwilling to go along. Organ donation is still relatively rare because even if a patient has a donor card, family members can overrule this.

Japan's traditional view that heart stoppage defines death also lingers, making many uncomfortable and hampering debate, but there is none of the religious opposition often seen overseas.

Only 39 percent of doctors and medical workers see brain death as a valid criteria for pronouncing a patient dead, a Health Ministry survey released recently showed.

Finally, with doctors unsure of whether living wills are even legal or not, laws with teeth must be enacted to see that doctors are not prosecuted for carrying out the patient's wishes.

A group of lawmakers led by ruling party member Taro Nakayama has begun work on a law to allow doctors to discontinue life support if the patient has asked them to do so beforehand.

But answers to questions, such as defining a terminal state and what is life-prolonging treatment, must still be resolved. "Actually, I believe euthanasia is already taking place, in ways that aren't at all obvious," Arakawa said.

A recent survey by the daily Yomiuri Shimbun of 75 doctors in critical-care units found that 90 percent said they had withheld care to patients without hope of recovery over the last year.

But many Japanese, such as 25-year-old financial worker Nobuyuki Tamaki, would simply rather not think about it. "The issue isn't especially revolting to me, but it does mean you have to face up to death -- and that's pretty distant from daily life," he said. 

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