The United States performs more organ transplants than any other country. It also has more people on the waitlist to receive organs, over 80,000 currently. Japan was likewise a pioneer in transplantation surgery. However, between 1969 and 1999, Japan shut down heart transplantation and refused to allow cadaveric organ donation. It continued to allow and perform living donor transplants of kidneys, and developed and perfected techniques for living donor transplantation of a portion of the liver. Why the difference? Japan did not legally acknowledge brain death as death until 1997, and then it is only acknowledged for patients who are over 15 years of age, and have previously declared formally that they wish to be organ donors. Those who do not meet these criteria are treated as alive even after a declaration of brain death, and are kept on respirators until heart failure occurs.

One difference is in the Japanese beliefs about the nature of the self. For a traditional Japanese person, the self or soul is diffused throughout the body. In the western, post-Cartesian view, the self is associated only with the brain. It is the brain that makes a person who he is in United States' culture, and therefore when the brain is dead, the individual is dead.

Another difference in attitude between the United States and Japan is in the difference between how the two peoples view gift-giving. The Christian tradition is one of altruism, loving and giving gifts to strangers. In the Japanese tradition gift-giving is reciprocal. The idea of giving someone a body part when that person is neither a friend nor a relative is very strange to the Japanese mind.

The most important differences that relate to this difference in practice between the U.S. and Japan is the difference in attitudes towards western medicine. Japanese have a great distrust of western medical doctors. There are constant reports in the Japanese media about medical schools that sell diplomas or doctors who have bought their way into medical school or cheated on the exams. Doctors in Japan make the majority of their money off of prescriptions, rather than examination, diagnosis, and nonpharmaceutical treatment. In contrast, the average person in the United States has a very great respect for the medical profession. In studies of patients in clinical trials, for example, the vast majority of patients believe that the experimental medication must be of benefit to them personally or the doctor would not have prescribed it. Despite careful explanations that the patient needs to inform himself or herself about the experiment to be sure s/he wants to participate, patients have such trust in doctors working for their welfare in the United States that they feel no need to read the literature.

Moreover, although it has long been the case that the majority of Americans die in the hospital, this is only just recently true in Japan. As a result, Japanese tend to think of death in the context of family and society, while for Americans it is more and more removed from family and society. To accept brain death as death is to accept that hospitalization is required for a diagnosis of death.

Finally, and probably most importantly, the first heart transplant in Japan was performed under such suspicious circumstances that the Japanese people developed a strong fear of the procedures and doctors who wished to perform it. The first transplant, in 1969, was performed by a doctor from western Japan -- considered a somewhat outlaw region -- who had been trained in western medicine outside of Japan. The donor in this case had been injured in a drowning and seemed to have been recovering, but then was brought to the hospital where the transplant was to take place beforebeing declared braindead. The doctor who declared the donor braindead was the same doctor who performed the transplant. This is no longer allowed, even in the United States, for conflict of interest reasons. There was some question as to whether the recipient really needed a heart transplant. The doctor and transplant team were accused of murder, because the recipient did not live for very long after the transplant.

Upon investigation it was found that the doctor had replaced two valves on the defective heart with defective valves from another heart to make sure that the heart looked as though it had needed replacement. In fact, only one valve of the heart needed replacement or repair. The doctor had performed an unnecessary heart transplant using a donor heart from someone he himself had declared braindead. The people of Japan were obviously frightened by this murderous hoax being perpetuated by a team of surgeons for their own greater glory.

Even though brain death was legally declared death in Japan in 1997, the second Japanese heart transplant was not performed until two years later, in 1999. Even now, most Japanese people do not want to donate organs. They fear that they will be declared braindead when they are not in order to obtain useable organs.

For more information on these differences see Margaret Lock's Twice Dead,published in 2002 by the University of California Press.

Copyright © 2002 by Louisa Moon