Akira Akabayashi

The first donor death after living-related liver transplantation in Japan.

On May 4, 2003, the first donor death after living-related liver transplantation (LRLT) occurred in Kyoto, Japan. The donor who died was a mother in her late forties who in August 2002 donated the right lobe of her liver to her adolescent daughter with liver cirrhosis caused by congenital biliary atresia. The mother’s liver function had deteriorated progressively after the donation. In January 2003, the mother finally fell into liver failure after an unsuccessful domino liver transplant from a donor with a metabolic disease. She died 4 months later without regaining consciousness. The daughter, who has recovered well, had initially received a liver from her father in 1994. Because of graft rejection, however, the daughter’s condition eventually deteriorated and she became critically ill before her second LRLT. The only potential living donor was her mother, who unfortunately had mild hypertension (systolic blood pressure, 150–160 mm Hg) and a slight fatty liver diagnosed by preoperative computed tomographic (CT) scan and echogram. After intense discussion, the transplant team reached the decision to undertake emergent LRLT surgery. When the donor later developed liver failure and died, the university hospital opened the case to the media and invited external inspection by the Japanese Liver Transplant Society. Histologic examination of the donor liver revealed that she had nonalcoholic steatohepatitis (NASH), a rare disease with a poor prognosis that is capable of progressing to liver cirrhosis or cancer (1). The transplant team initially planned to perform a right lobectomy without the middle hepatic vein, leaving an estimated residual liver volume by CT volumetry of 37%. During the operation, however, the team judged it better to perform a right lobectomy with the middle hepatic vein. The donor’s residual liver volume by CT volumetry was 28%, lower than the suggested safe range of 30%. LRLT has the potential to reduce the shortage of organs for transplantation worldwide (2). Although the pros and cons of living donation have been widely discussed (3), the ultimate priority is undoubtedly the safety of the donor. This is the first donor death that has occurred in some 2,300 LRLT undertaken in Japan. At Kyoto University, where approximately 900 cases have been undertaken, an institutional ethics committee evaluates each case and ensures adequate informed consent (4). In spite of these precautions and a procession of successful cases, the Japanese medical community has now experienced the ultimate tragedy inherent in living-related organ transplantation—the loss of a donor’s life. The Japanese transplant professionals now intend to (1) include testing for NASH (by biopsy) in the criteria for selecting donors at potential risk; (2) establish safer standards for preoperative CT volumetric analysis; (3) increase the required education team for selecting donors; and (4) amend the process of informed consent by including disclosure of unpredictable risk of rare complications including NASH. We hope that Japan’s experience of a death after LRLT and the procedural modifications learned from this misfortune will help contribute to the future sound development of LRLT worldwide.

Informed Consent Revisited: Japan and the U.S.

Informed consent, decision-making styles and the role of patient–physician relationships are imperative aspects of clinical medicine worldwide. We present the case of a 74-year-old woman afflicted with advanced liver cancer whose attending physician, per request of the family, did not inform her of her true diagnosis. In our analysis, we explore the differences in informed-consent styles between patients who hold an “independent” and “interdependent” construal of the self and then highlight the possible implications maintained by this position in the context of international clinical ethics. Finally, we discuss the need to reassess informed-consent styles suitable to the needs of each patient regardless of whether he or she resides in the United States or in Japan.

The development of a brief and objective method for evaluating moral sensitivity and reasoning in medical students

BackgroundMost medical schools in Japan have incorporated mandatory courses on medical ethics. To this date, however, there is no established means of evaluating medical ethics education in Japan. This study looks 1) To develop a brief, objective method of evaluation for moral sensitivity and reasoning; 2) To conduct a test battery for the PIT and the DIT on medical students who are either currently in school or who have recently graduated (residents); 3) To investigate changes in moral sensitivity and reasoning between school years among medical students and residents.MethodsQuestionnaire survey: Two questionnaires were employed, the Problem Identification Test (PIT) for evaluation of moral sensitivity and a portion of the Defining Issues Test (DIT) for moral reasoning. Subjects consisted of 559 medical school students and 272 residents who recently graduated from the same medical school located in an urban area of Japan.ResultsPIT results showed an increase in moral sensitivity in 4th and 5th year students followed by a decrease in 6th year students and in residents. No change in moral development stage was observed. However, DIT results described a gradual rising shift in moral decision-making concerning euthanasia between school years. No valid correlation was observed between PIT and DIT questionnaires.ConclusionThis studys questionnaire survey, which incorporates both PIT and DIT, could be used as a brief and objective means of evaluating medical students moral sensitivity and reasoning in Japan.

A model of donors' decision‐making in adult‐to‐adult living donor liver transplantation in Japan: Having no choice

This study examined the decision‐making processes of donors in adult‐to‐adult living donor liver transplantation. Twenty‐two donors were interviewed using a semi‐structured format. Interview contents were transcribed verbatim and analyzed qualitatively using grounded theory. A decision‐making model was developed consisting of 5 stages: (1) recognition, (2) digestion, (3) decision‐making, (4) reinforcement, and (5) resolution. The second and the third stages described donors experiences of “reaching a decision”; the fourth and fifth stages described those of “facing transplantation.” The central theme of this model was “having no choice,” which consisted of 4 codes: (1) priority of life, (2) only LDLT, (3) for family, and (4) only me. In conclusion, this model can help health care professionals to understand the donor experience and, based on that understanding, to provide sufficient support to the donor. Liver Transpl 12:768–774, 2006.

An eight-year follow-up national study of medical school and general hospital ethics committees in Japan.

BackgroundEthics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nations ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan.MethodsThis study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovahs Witnesses.ResultsCommittee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovahs Witnesses, among both medical school and hospital ethics committees.ConclusionOverall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.

Biomedical ethics in Japan: the second stage.

In Japan, modern biomedical ethics emerged in the early 1980s. One of the main triggers was the nationwide debate on organ transplantation and brain death. A lengthy process of academic, religious, and political discussion concerning organ transplantation, lasting well over a few decades, resulted in the enactment of the Organ Transplantation Law in 1997. 1 The defining of death and other bioethical issues, including death with dignity and euthanasia, were also stimulating topics throughout the latter end of the twentieth century. For instance, the death-with-dignity movement, which started around the late 1960s, developed into a hospice/palliative-care movement by the end of the 1980s.

Clinical Ethics Consultation: Examining how American and Japanese experts analyze an Alzheimer's case

BackgroundFew comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimers case regarding ethics consultation.MethodsWe presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews.ResultsEstablishing a consensus was a common goal among American and Japanese participants. In attempting to achieve consensus, the most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an ethics facilitation approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate.ConclusionOur findings suggest that consensus building through an ethics facilitation approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country.

A five year follow-up national study of ethics committees in medical organizations in Japan.

Compared to institutional and area-based ethics committees, little is known about the structure and activities performed by ethics committees at national medical organizations and societies. This five year follow-up study aimed to determine (1) the creation and function of ethics committees at medical organizations in Japan, and (2) their general strategies to deal with ethical problems. The study sample included the member societies of the Japanese Association of Medical Sciences (n=92 in 1998, n=96 in 2003). Instruments consisted of two sections: (1) the structure, function and activities of ethics committees, and (2) the strategies for dealing with ethical problems. Response rates were 84.4% in 1998 and 64.4% in 2003. Findings showed a significant increase of ethics committees at medical organizations between 1998 (25.6%) and 2003 (50.0%). Members were mostly male, medical doctors in clinical or basic medicine, and members of the organization. The major functions of ethics committees were ethical reviews of research protocols, policy making and ethical reviews of manuscripts submitted for journal publication. Among organizations that did not have an ethics committee, a significant decrease was found in organizations that replied that they had never experienced an ethical problem which needed further investigation (p<0.01). Findings suggested an overall rise in awareness of the importance of ethical issues and also highlighted an increase in recognition of responsibility regarding ethical problems.

Public, Experts, and Acceptance of Advanced Medical Technologies: The Case of Organ Transplant and Gene Therapy in Japan

In 1997, after long social debates, the Japanese government enacted a law on organ transplantation from brain-dead bodies. Since 1993, on gene therapy, administrative agencies have issued a series of guidelines. This study seeks to elucidate when people became aware of the issues and when they formed their opinions on organ transplant and gene therapy. At the same time, it aims to examine at which point in time experts, those in university ethical committees and in academic societies, consider these technologies became accepted among the public. A self-administered questionnaire was sent by mail to a stratified random sampling of 3000 people nationwide in Japan. Another questionnaire was sent both to the member societies of the Japanese Association of Medical Sciences and to the ethical committees of all the medical schools in Japan. Results of the surveys indicated that many of the public remained undecided on the desirability of organ transplant or gene therapy at the time of enactment of official guidelines. A substantial part of them formed their opinions in subsequent periods, especially around the time of first implementation and thereafter. Experts of the academic societies and of the university ethical committees regarded the time of implementation as an important factor in the acceptance of the technologies in society. Since many people formed their opinion during the period of technological implementation, communications efforts to facilitate public understanding of science and technology, as well as to advance practical discussion on policy alternatives in this period can play a key role in determining the fate of technological innovation and ethical debates in medicine.

Is Asian bioethics really the solution

Today Asia is attracting attention in the area of bioethics. In fact, the potential of bioethics is beginning to be discussed seriously at academic centers across Asia. In Japan, this discussion began a decade ago with the publication “Japanese and Western Bioethics.” The book is one of the principal explorations of biomedical ethics involving Japan to date. Tom Beauchamp, an author of one of the books chapters, compares Japanese and American standards of informed consent and refutes relativistic positions, concluding that: