‘Organ Donation in Japan’ by Maria-Keiko Yasuoka (Lexington Books, 2015)
Organ Donation in Japan: A Medical Anthropological Study broadens current debates on organ transplantation in Japan through personal narratives of transplant surgeons and coordinators, recipients, donor families, as well as the author herself, Maria-Keiko Yasuoka, an anthropologist who has been investigating organ donation for more than a decade. Brain death has remained controversial in Japan since it was made legal in 1997, and organ donations rates continue to be extremely low. Chapter One introduces the historical and legal circumstances in which organ transplantation has developed in Japan. Yasuoka argues that the scandal of the ‘Wada case’ (Weyrauch 1999) – the first Japanese heart transplant which resulted in a double murder investigation against the transplant surgeon – is a key factor for the low donation rates. Yasouka main hypothesis for the Japanese reluctance towards organ donation is mistrust of brain death, medical care and of transplant surgeons. This hypothesis follows on from Margaret Lock’s (2001) seminal book Twice Dead.
Chapter Two contains the narratives of nine transplantation staff: one transplant physician, five transplant surgeons and three transplant coordinators (these are nurses based in Japanese hospitals who are trained to support patients and families with organ transplantation and organ donation). Having been raised in Spain – the country with the highest organ donation rates for the last twenty years (see Matensanz et al 2011) – I was surprised by the negative representations used throughout the book and especially in this chapter, which featured sharp language and subheadings like ‘Cruel medical care: Harvesting organs’. The author’s views are contradicted by the narratives of her clinical participants, particularly the surgeons who refer to transplantation as ‘fantastic treatment’, ‘excellent’, ‘a wonderful thing’, and ‘a truly wonderful, brilliant jewel for human society’ (p. 33-34). Only one donor specialist transplant coordinator was interviewed (the other two were recipient transplant coordinators) and although she offered less positive views of donation, she was clearly struggling with the tragic context in which donation occurs: family decision-making within sudden death.
Chapter Three exposes narratives from six organ recipients. Four of the participants received organs overseas (two in Australia and two in the US) and only two received organs in Japan. It is surprising how much the data analysed in the book is based on overseas transplantation stories. Although health inequality is not discussed, only wealthy Japanese can afford organ transplantation because they have the means to cover the significant costs for this treatment abroad. According to Yasuoka, before the Declaration of Istanbul (Steering Committee of the Istanbul Summit, 2008) stopped international organ procurement, hospitals in the US used to have a 5% quota for transplanting foreign nationals and this allowance was sometimes completely taken by Japanese citizens (p. 48). Yasuoka also explains that since donation of organs belonging to deceased children (under 15) used to be banned in Japan until 2010, one Australian hospital had, at some point, one ward with eight Japanese children waiting for organ donation (p. 48). Strict national prohibition seems to have caused a displacement effect in the wealthy population. That is, organ procurement and transplantation still occurs but somewhere else.
Yasuoka’s main theoretical analysis to explain organ shortage is based on the Japanese practice of gift giving and reciprocation, which causes organ recipients’ guilt and shame because the donated organ can never be paid back. One of the recipient narratives clearly supports this explanation: Satoshi, a 35 year old man, hides his pancreas and kidney transplants from everyone except his parents, for ‘fear of being accused of shameful behaviour, or even cannibalism’ (p. 56). This hypothesis, however fails to explain why Japanese citizens travel abroad to receive organs and they have been accused of ‘taking from the organ pool but not donating to it’ (Weyrauch 1999: 109) or why they have engaged in organ purchases from questionable ethical sources (Budiani‐Saber and Delmonico 2008).
Chapter Four analyses six donor families’ narratives: one wife, two fathers, and three mothers (of these six, two are a married couple who donated their son’s organs following his death in Australia). These are highly valuable accounts since Japanese donor families are rare due to low rates and donor privacy rules. Nevertheless, some of the author’s statements on gender and grief in Japanese society are problematic. These are based on stereotypical generalisations of the male and female attributes in grief responses to loss without acknowledging the variety and continuum of grief responses for both sexes (Martin & Doka 2000). Chapter Five discusses interrelationships between different donation parties by focusing on how recipients and donor families speak out about their experiences; analysing thank you letters between recipients and donor families; and annual Transplant Games events. Chapter Six critically engages with traditional organ donation concepts like ‘gift of life’ and ‘renewable life’ and proposes ‘rebirthable life’ as a more adequate term. An afterword includes Yasuoka’s auto-ethnography during her father’s death and funeral. This is an excellent detailed account of Japanese funeral culture intended to show how ‘traditional funeral beliefs still remain intact’ (p. 162). Although Yasuoka’s father did not meet the medical criteria to be an organ donor, since Japanese cultural afterlife beliefs are often blamed for preventing organ donation, this section could have been a good opportunity to explore the relationship between beliefs, funeral practices, and the practicalities of organ donation for bereaved families.
In medicine, personal narratives are ‘sense-making devices’ that can embrace complexity (Greenhalgh & Hurwitz 1998) and this book delivers interesting material which is desperately needed for understanding the individual and contextual complexities of Japan’s organ transplantation system. Stories are, however, analysed and re-analysed in a repetitious manner but mainly from a narrow focus; engaging only superficially with evidence from other disciplines like, applied health sciences, bioethics, sociology and social policy. Albeit, light is shed – sometimes unintentionally – on institutional barriers to donation and transplantation in low performing countries. In Japan transplant units are scarce, the few transplant surgeons in the country are low paid and over-worked (i.e. due to staff shortages, the same heart surgeon retrieves the heart from the donor and then transplants it into the recipient p. 36), and nurse coordinators satisfaction and retention issues are present (the three coordinators interviewed had left their jobs before the book went to press). In summary, scarce infrastructure and insufficient levels of staffing and skill mix can impact transplantation and donation outcomes as much as legislation.
This book is probably not the best example of interdisciplinarity in the medical humanities. It contains some questionable generalisations, and a structure that does not always help the reader following the logic of the argument. Despite its shortcomings Organ Donation in Japan offers an accessible first attempt of understanding the complexities surrounding organ donation. Building from this book, scholars can expand accounts, refine meanings and increase capacity in a much-needed area.
Reviewed by Dr Ana Manzano, who is a Lecturer in Health & Social Policy at the University of Leeds. She has expertise in comparative organ donation policies. She is an associate member of the Centre for Health, Technologies and Social Practice
Correspondence to Dr Ana Manzano.
Budiani‐Saberi, Debra. A., and Delmonico, Francis. L. 2008. Organ trafficking and transplant tourism: a commentary on the global realities. American Journal of Transplantation, 8(5): 925-929.
Greenhalgh,Trisha, and Hurwitz, Brian. 1998. Narrative based medicine. Dialogue and Discourse in Clinical Practice. London: BMJ Books.
Lock, Margaret. M. 2002. Twice Dead: Organ Transplants and the Reinvention of Death (Vol. 1). Berkeley: University of California Press.
Martin, T. L., & Doka, K. J. 2000. Men don’t Cry, Women Do: Transcending Gender Stereotypes of Grief. London: Brunner/ Mazel.
Matesanz, Rafael, Domínguez‐Gil, Beatriz, Coll, Elisabet, de la Rosa, Gloria, and Rosario Marazuela. 2011. Spanish experience as a leading country: what kind of measures were taken? Transplant International, 24(4): 333-343.
Steering Committee of the Istanbul Summit. 2008. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet, 372(9632): 5-6.
Weyrauch, Samantha. 1999. Acceptance of whole-brain death criteria for determination of death: a comparative analysis of the United States and Japan. UCLA Pacific. Basin Law Journal 17(1): 91-123.