By Melanie Fridl Ross
GAINESVILLE, Fla.---As Japan Thursday legalized organ transplants from brain-dead donors, officials are turning to the University of Florida for guidance as they struggle to educate their citizens -- many of whom believe death occurs only once the heart stops beating.
Since 1994, Charles McCluskey, executive director of UF's Organ Procurement Organization, has traveled to Japan to teach physicians and politicians about brain death. In turn, Japan has sent more than 30 visitors -- including health officials, physicians, organ procurement coordinators and members of the news media -- to UF and Shands hospital at UF to shadow its transplant team.
They have logged sleepless nights flying as far as New York, Texas and Puerto Rico to recover organs, and have donned surgical scrubs to watch as the life-saving transplants were performed. One coordinator, who has spent the past year at UF, has traveled on more than 52 organ recovery missions.
Two more surgeons arrive next week, McCluskey said. Early next year, Japan's deputy director from the Health Service Bureau's Office of Organ Transplantation, part of the Ministry of Health and Welfare, will visit.
"They want to know how we keep track of donor and recipient information and how we share that information with other procurement organizations and transplant centers," McCluskey said. "The coordinators themselves are particularly interested in how we communicate with and counsel donor families.
"They want to know how we perceive the family feels when we talk to them about donation and whether we provide any support to these families after donations. All of this is new to them."
Japan's new law permits the transplant of hearts, livers and other vital organs from donors declared legally brain dead -- but only if they have given prior written permission. All donors must be at least 15 years old and their families must consent.
"This has been the most important bioethics debate in Japan -- an enormous national debate just as big as the abortion debate on this side of the ocean and just as emotional," said medical anthropologist Margaret Lock, a professor at McGill University in Montreal. Lock, who spoke on transplantation before the upper chamber of the Japanese Diet earlier this year, is writing a book about the controversy.
In the United States, the legal definition of brain death varies by state, but all recognize it as the irreversible cessation of brain function. Physicians conduct a battery of clinical and laboratory tests before declaring brain death.
While transplants gleaned from living donors have been widely accepted in Japan for years, (for example, those involving the kidneys), up to now no clear guidelines existed for transplantation of other organs. This is partly because of deeply entrenched cultural traditions and spiritual beliefs.
"This metaphor we live by, 'the gift of life,' just simply doesn't have any meaning in Japan because the idea of a gift is part of a traditional exchange system, a giving and receiving of obligations and reciprocal obligations," Lock said. "So the idea of giving something anonymously and not having it slotted into a system of exchange is really very odd.
"Although in Buddhism the idea is you should be able to give to others, that has stayed very much more in a religious context rather than being extrapolated into modern society."
Furthermore, many Japanese believe death only occurs once the heart stops beating. Yet organs removed after the heart stops beating are rarely healthy enough to be used in transplants.
"In Japan, historically physicians had to wait for the heart to stop before the transplant could proceed," McCluskey said. "It's been difficult to get the elder political representatives to understand brain death and really make a tremendous move in medicine. The government has very strong control of how health care has been delivered."
Many people fear doctors will try to remove organs before everyone's agreed the patient is dead, Lock said.
Shunko Muroya, a visiting lecturer in UF's department of Asian languages and literature, said some Japanese view brain death as a Western idea.
"A well-known Japanese cultural critic, Takeshi Umehara, gives the example of plants, grass and trees. They do not have a brain, but you can't say they are not alive," Muroya said.
In addition, informed consent is not legally institutionalized in Japan, Lock said. "That's in fact why quite a number of Japanese intellectuals and cultural critics have been opposed to the brain deathconcept. They are not actually opposed to brain death but really want to push medicine into the 20th century and they've held brain death ransom over the larger issue of ethics in general."
In transplantation's early history in the United States, all organ donors were pronounced dead when their hearts stopped beating. This changed in the late 1960s to early 1970s as brain death criteria were developed and applied, said Joel Newman, spokesman for the Richmond, Va.-based United Network for Organ Sharing.
Physicians found that organ transplantation was more successful in cases where brain death occurs while the donor, though dead, is kept on a ventilator so that circulation and breathing are maintained mechanically until the organs are removed for transplantation, according to UNOS. This allows oxygenated blood to continue to pass through the organs, keeping them viable.
"Clearly the experience of reluctant donors in the United States provides insight into what Japan needs to do," said UF transplant surgeon Dr. Mark Staples, who once lived in Japan. "It entails mostly education on a personal level at churches or religious groups and business organizations. The Japanese must develop confidence in their medical system to make these decisions of declaring brain death, and this is going to take time.
"In our own country, there are still pockets of resistance to organ donation among some ethnic groups and among older donors, and among those who have not been educated in the process of organ donation," Staples added. "Some of it is related to spiritual beliefs, and some is related to a distrust of the medical community."
In the United States, more than 55,000 people are awaiting a transplant, and 10 of them die each day.
"Japan has a rich medical history, and this should begin a new era in that history," Staples said. "It may take some time for the Japanese culture to fully embrace the concept, but with good publicity and public education it should become a success."
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