Brian Taylor Slingsby

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.

Perspectives on advance directives in Japanese society: A population-based questionnaire survey

BackgroundIn Japan, discussion concerning advance directives (ADs) has been on the rise during the past decade. ADs are one method proposed to facilitate the process of communication among patients, families and health care providers regarding the plan of care of a patient who is no longer capable of communicating. In this paper, we report the results of the first in-depth survey on the general population concerning the preferences and use of ADs in Japan.MethodA self-administered questionnaire was sent via mail to a stratified random sampling of 560 residents listed in the residential registry of one district of Tokyo, Japan (n = 165,567). Association between correlating factors and specific preferences toward ADs was assessed using contingency table bivariate analysis and multivariate regression model to estimate independent contribution.ResultsOf the 560 questionnaires sent out, a total of 425 participants took part in the survey yielding a response rate of 75.9 %. The results of the present study indicate that: 1) the most important components to be addressed are the specifics of medical treatment at the end of life stage and disclosure of diagnosis and prognosis; 2) the majority of participants found it suitable to express their directives by word to family and/or physician and not by written documentation; 3) there is no strong need for legal measures in setting up an AD; 4) it is permissible for family and physician to loosely interpret ones directives; 5) the most suitable proxy is considered to be a family member, relative, or spouse. Multivariate analysis found the following five factors as significantly associated with preferences: 1) awareness regarding living wills, 2) experience with the use of ADs, 3) preferences for end-of-life treatment, 4) preferences for information disclosure, and 5) intentions of creating a will.ConclusionsWritten ADs might be useful in the Japanese setting when the individual either wishes: 1) to not provide a lot of leeway to surrogates and/or caregivers, and/or 2) to ensure his or her directives in the cases of terminal illness, brain death, and pain treatment, as well as regarding information disclosure.

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.

Living related liver transplantation: a Japanese experience and development of a checklist for donors' informed consent

In the February 2002 issue of Gut , Broelsch et al argued for a controversial therapy of living related liver transplantation ( Gut 2002; 50 :143). The Japanese experience is somewhat different from those of other countries, as indicated in the article. Japan has long been the subject of sociocultural studies because of its delay in using the organs of brain dead persons for transplantation purposes. Since the Organ Transplant Law was enacted in 1997,1 only 16 liver transplant operations using brain dead donors have taken place. In contrast, more than 700 cases of liver transplants (with both children and adults as …

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.

The Nature of Relative Subjectivity: A Reflexive Mode of Thought

Ethical principles including autonomy, justice and equality function in the same paradigm of thought, that is, logocentrism--an epistemological predilection that relies on the analytic power of deciphering between binary oppositions. By studying observable behavior with an analytical approach, however, one immediately limits any recognition and possible understanding of modes of thought based on separate epistemologies. This article seeks to reveal an epistemological predilection that diverges from logocentrism yet continues to function as a fundamental component of ethical behavior. The issue of cancer disclosure in Japan is used to exemplify the nature of relative subjectivity (kankeiteki-shukansei), a term I define and believe to be an epistemological predisposition fundamental to ethical behavior. Relative subjectivity denotes an epistemology quintessential to the behavior of individuals who attend to the respective tides of each particular situation, each interpersonal relationship or, in the context of clinical medicine, to the needs and values of each patient.

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:

Four physician communication styles in routine Japanese outpatient medical encounters

BACKGROUND: Few studies have explored how physicians approach medical encounters in Japan. OBJECTIVE: This study examined how Japanese physicians conduct routine medical encounters in the context of outpatient care to patients with nonmalignant disorders. DESIGN: Qualitative study using semi-structured interviews and direct observation. SETTING: The outpatient department of a general hospital located in an urban area of Japan. PARTICIPANTS: Physicians and nurses providing care and patients receiving care for nonmalignant disorders. RESULTS: A 2-dimensional model was developed, with patient communication (how physician interacted with patients) along 1 axis, and nurse communication (how physicians collaborated with nursing staff) along the other axis. Four physician communication styles (individually adaptive, individually defined, collaboratively adaptive, and collaboratively defined) were identified as typical ways in which the Japanese physicians in the sample interacted with patients and nurses during routine medical encounters. CONCLUSIONS: Results suggest the need for amultiprovider-patient model of medical communication among physician, nurse, and patient. Further research is needed to establish the applicability of this model to the communication styles of physicians in other countries.