The article “Facts and Ideas From Anywhere” in the January 2012 issue of the Baylor University Medical Center Proceedings reminded the reader that Japan’s surrender after the Second World War was followed by 7 years of United States occupation that sought to restructure the health care system as part of the goal of democratization. Reconstruction continued after Japan regained sovereignty in 1952. The government had already succeeded in changing medical practice from Chinese to Western medicine. Universal health insurance was established in 1961. Unlike other Asian countries, Japan did not permit independent schools of Chinese medicine.

Despite these forward steps, organ transplantation lagged far behind. Japan’s first heart transplantation was performed in 1968, several months after the world’s first heart transplantation in the Republic of South Africa. The recipient died, the procedure was stigmatized in Japan, and in an unfortunate display of irony, the Japanese surgeon, who should have been heralded as a pioneer, was sued for murder of the donor.

The strict transplantation laws in Japan reflected strong undercurrents of religious and superstitious sentiments against “‘defiling’” the body of a recently deceased individual. Confucianism teaches that our bodies should be kept intact even after death because they are gifts from our parents and our ancestors. The blend of Confucian, Shinto, Taoist, and Buddhist sentiment fueled a social consensus that organ transplantation devalued both this life and the afterlife. Organs could not be removed until the body was dead. Strict laws defined death as cessation of the heartbeat. Once the heartbeat stops, the organ rapidly deteriorates and becomes unsuitable for transplantation. Japan, Pakistan, and Poland were the only major nations that did not recognize brain death.

In 1983, the Japanese Transplantation Society began to publicize the necessity and urgency of organ transplantation, and the Ministry of Health and Welfare established a committee on brain death and transplantation. In 1985, the committee distinguished “medical criteria for brain death” from “the concept of human death,” and declared that the latter depended on popular consensus. Ordinary people at the bedside of a family member could not accept brain death, because the patient’s body was still warm and moist.

Why did the Japanese reject the concept of brain death, which was accepted in so many other countries? Brain death is “invisible death” that conflicts with everyday intuition. In 1994, the Diet was presented with a bill to permit organ removal from brain-dead patients if family consent were obtained, but the bill did not pass.

The long-lasting debate on organ transplantation in Japan was finally resolved on April 24, 1997. By a vote of 323 to 144, the Lower House of Parliament passed a bill recognizing brain death. On June 17, 1997, the bill passed in the Upper House by a vote of 181 to 62. There were few abstentions.