This chapter is an excerpt from Chapter I of the forthcoming VOLUME II: A New Socially Engaged Buddhism in 21st Century Japan: From Intimate Care to Social Ethics. (Ontario, Canada: The Sumeru Press, 2023)
JONATHAN S. WATTS
Introduction
We begin this section of the volume on case studies with the issue of end-of-life care for a number of reasons. First, it serves as a microcosm for the other issues we have examined in the previous chapters on Japanese Buddhism in the modern era and the subsequent ones on the variety of types of social engagement by Japanese Buddhists. Here we experience concretely the struggles of Japan to define their own vision of modernity, principally in the denial of war trauma, the bankruptcy of their spiritual traditions by the conclusion of the war, and the contradictions of adopting western secular liberalism to structure their post-war society. Second, the end-of-life care issue also serves as the epitome of the mu-en society that has emerged in full force during the new millennium. The elderly are dying alone in increasing numbers, abandoned in their countryside homes or forgotten in their single-dwelling urban ones—a phenomenon now dubbed as koritsu-shi 孤立死 or even mu-en-shi 無縁死. The experience of an isolated lonely death is also common in hospital environments where doctors have given up on patients as manifestations of their defeat as caregivers and religious professionals are either barred or unconcerned with offering spiritual care to secularized patients and families largely dismissive of their potential services. The institutional and cultural walls between the pre-mortem world of modern Japanese medical care and the post-mortem world of traditional “funeral Buddhism” (葬式仏教soshiki bukkyo) bring to fore a third aspect that makes this issue so relevant for our overall study: the crisis in Japanese Buddhism and its attempts to revitalize itself and Japanese society. Rev. Tomatsu Yoshiharu 戸松義晴—a Jodo Pure Land priest who teaches at the International University of Health and Welfare in Narita and has served two tenures as the Directer General of the Japan Buddhist Federation (JBF)—speaks eloquently to this point:
It is not ironic at all that one can see the Buddhist foundations in this term mu-en, in which en 縁 refers to the “karmic relationship” that we as Japanese have tried to preserve for generations upon generations through our Buddhist forms of ancestor veneration. Yet today, we have arrived at this place of mu-en, no relationship, where in particular people are dying alone without each other’s support. From a Buddhist standpoint, I feel it less important for priests to develop new doctrinal and ritualistic applications for dying than it is to become deeply involved with the very experience of death by engaging directly with people before they die. From each individual priest’s own personal experience in such work, we will see the development of meaningful Buddhist responses and initiatives. This is the real way to recover the meaning and role of Buddhism concerning death and dying and in turn to recover Buddhism’s role in Japanese society at large. As the dying issue is part of a much larger holistic social problem, by engaging in it actively and directly, we can touch the many other social issues that need our attention today and come to a much broader holistic solution to them.[1]
The Dukkha of Death & Funeral Buddhism
As the 20th century came to a close, Japan began to face the due bills from investing in industrial capitalism, principally in the form of a warped generational demographic. At the dawn of the Meiji Restoration, Japan’s still predominantly rural based population stood at roughly 35 million. It grew to around 51 million by the end of the Meiji in 1910 and surged under the military fueled industrialism of the Taisho and early Showa periods to 73 million in 1940. The sacrifices of the war marked the only five-year period in which the population declined (by 1.5% to just under 72 million in 1945) until the most recent period of 2010-15 and 2015-2020 where it shrank by 0.8% and 1.2% respectively. Under the period of high growth industrial capitalism in the 1960s and 70s, Japan’s population grew at a steady rate of 5-7%, surging over 100 million in 1967 and reaching its apex of 128 million in 2010. However, as the birth rate and population steadily declined with the bursting of the economic bubble in the early-mid 1990s, Japan began to lose it demographic balance. As of 2011, more than 30 percent of Japanese were over the age of sixty, and by 2020 28.8% were over 65. It is estimated that in the next thirty to forty years, roughly 80 million Japanese people will die due to natural causes.[2]
The rapid advance of depopulation has become a central concern of the Japanese government in terms of labor productivity and the costs of medical and social welfare. It is also a deep concern for the population in general, especially young people who worry about the economic and personal burden of having to take care of so many elderly and dying people. By 2025, it is estimated that the annual number of deaths will be 1.5 million, and the population will decrease by 700,000. By 2040-2050, it is estimated that the annual death rate will rise to 1.68 million with 40% of the population living alone and 1 in 4 elderly having some form of dementia. By 2065, as the population declines to around 88 million, Japan will enter a phase of called “super aging society” in which 48% of the population will be elderly and 1 in 3 of whom will have dementia.[3] This distortion in demographic has already led the Japanese government to begin importing foreign laborers—an issue that will be focused on in a later chapter and highlights ongoing issues with labor policy, poverty, and racial discrimination.
Carl Becker—Director of the Kyoto University Kokoro (Heart-Mind) Research Center and renowned thanatologist—sums up the wider meaning of these statistics:
Never in the history of humankind have 127 million people, the present population of Japan, lived in such a small land area, nor have so many people ever died in such a short time with so few people to care for them. Postindustrial countries will likely follow Japan in this aging pattern, especially ones from the Organization for Economic Co-operation and Development (OECD), South Korea, and China, with its one-child policy. So the eyes of the world are watching Japan’s experiment in aging. If Japan can manage aging and dying successfully, it will prove a model for the rest of the world. However, if the Japanese government poorly handles its elderly population problems, it will lose credibility with foreign cultures as well as with its own people. In this sense, Japan’s management of its elder care and medicine is a critical issue, both internationally as well as domestically.[4]
Such a crisis would appear to be a ripe opportunity for Japanese Buddhism to come to the assistance of its nation and people. Yet there remain deep doubts of whether the antiquated rituals and structures of Japanese Buddhism can offer any support to Japan’s increasingly post-industrial and post-modern society. In the earlier chapters of this volume, we traced the historical development of Buddhism’s role in caring for the dying and bereaved, culminating in the Tokugawa era with the expansive system of funeral and memorial rites that constitute the core of contemporary “funeral Buddhism. In short, beyond the system of wake and funeral ceremonies held right after someone dies, Buddhist temples and priests historically have hosted an ongoing series of memorial services for the dead on the 49th day after decease, and then on 100th day, 1st anniversary, 3rd anniversary, 7th, 13th, 17th, 25th, 33rd, and 50th anniversaries[5]. Rev. Taniyama Yozo 谷山洋三—a Jodo Shin Pure Land Otani priest and director of the Interfaith Chaplain (rinsho-shukyo-shi 臨床宗教師) program at Tohoku University—notes:
The monthly memorial service has been an especially important function to develop the relationship between the priest and his parishioners. In this system, a priest would visit the parishioner’s house to chant sutras in front of the home Buddhist altar (butsudan 仏壇) in which mortuary tablets (ihai 位牌) of deceased family members are installed. However, this custom and hence relationship has become weaker, principally because many people have relocated to other regions and do not know the name of the temple to which their parents have belonged. Consequently, when a new death in the family occurs and they are introduced to an unknown priest through the intermediation of an undertaker, they may not ask for such extended memorial services after the funeral.[6]
He further notes that the number of funerals now held at funeral homes and performed in a non-Buddhist style has increased, as well as the performing of only a cremation without out rituals, called chokuso 直送. The previous social roles of priests have become so marginalized that even undertakers and the expanding diversity of funeral homes are replacing them in the most fundamental of priestly activities.[7]
The secularization of society and marginalization of priests’ social roles has severely eroded the relationship of the common people with the Buddhist temple where most graves are located and where more than 90% of funeral services were carried out until the 20th century.[8] Rev. Okochi Daihaku 大河内大博—a Jodo Pure Land priest, Clinical Buddhist Chaplain (臨床仏教師 rinsho-bukkyo-shi), and founder of his own temple’s home-visit nursing station—notes that, “There are many people who feel they no longer need to be a member of a temple, so they close down their gravesite and the connected Buddhist altar in their house. Many temple members are also cancelling their membership. Temple buildings are also becoming old and decrepid. Members who used to donate to the repair and rebuilding of the temple are no longer involved so there is the challenge of not having enough funding resources.” Further, due to the mass shift of the population out of the countryside where high concentrations of Buddhist temples were constructed under the Tokugawa military government, there is a mass shuttering of Buddhist temples now occurring in these regions. One estimate by Takanobu Nakajima, Professor of Business and Commerce at Keio University, indicates the number of 76,000 Buddhist temples nationwide in 2010 will become as few as 6,000 by 2060 due to population decline, disinterest in religion, and marginalization as a niche business involving funerals only.[9]
Most priests and their denominations have not been able to find concrete solutions to this crisis. However, this is not just an institutional crisis. Priests themselves, especially young ones, are facing the crisis of the meaning of their existence as well as what will become of their livelihoods. In a survey conducted of priests by the Japan Young Buddhist Association in 2003[10], priests expressed such sentiments like, “I am not actively concerned with living people.” In the pre-modern period, Buddhist priests were actively involved in the pre-mortem process, providing palliative and medical treatments as well as deathbed rituals and counsel to devoted laypeople. Priests also gave the certificate of death and executed the funeral. Even as late as 1955, 76.9% of Japanese were dying at home and 12.3% in hospitals. At homes, especially in the countryside, the local priest could maintain a role in the premortem process. By 2000, however, these numbers had flipped and have remained steady with 12-13% dying at home and 74-79% dying in hospitals, where priests are systematically barred from significant interaction with patients.[11] As the human connection (en) has become thin between Buddhist priest and temple member, much less common citizen, the feeling of care and concern by priests in the sensitive moments of death and grieving have deteriorated. Rev. Iijma Keido 飯島惠道—a Soto Zen nun and palliative care nurse—relates a situation that has become far too common in modern Japan:
The first time I served as an assistant priest at a funeral after resigning from my hospital work, the other priest engaged in casual conversation about where he had been recently, what kind of good food he had, and the nice condition of the golf course he had played. I understand that he was just chitchatting, but he never mentioned anything about the bereaved family or the deceased; for example, “He died after fighting the sickness and the family took care of him for a long time”. We can do a funeral without knowing about the person and the family, but I feel this is a sad situation. Back then, I questioned if this kind of routine work with no heart in it was acceptable. As I do more funerals, I started to think that this is how it is. However, for example, the main mourners are usually very tired if the person died after a long fight with a disease. In this way, how you speak to them will be different if you know about that situation. I think also that the family will be very depressed if the deceased has committed suicide. Let us say a priest is busy and in a hurry while he is chanting and striking a wooden block (mokugyo 木魚). The family may sense this and think, “Why is he doing it in such a superficial manner?” In this way, I’m afraid that the memorial service does not become a service, and people get further away from Buddhism.[12]
This anecdotal evidence is further confirmed in a study by the Jodo Shu Research Institute that shows many priests do not even bother to give a dharma talk at the funeral; that when they do, it is usually no more than 5-10 minutes; and that the impact is very little to none on the bereaved family.[13] From these initial reflections on the dual crisis of death in industrialized Japan and the loss of spiritual resources to cope with it, a deeper investigation of structural and cultural causes will help provide appropriate context for the initiatives of Socially Engaged Buddhists to confront and resolve them.
Awash in a Sea of Medicine: The Structural Dukkha of Medical Care in Japan
Let us now turn to a more in-depth look at Japan’s medical system and how it has been dealing with those suffering from disease, aging, and death. What we see is that by the turn of the millennium, Japan had become one of the most medicalized societies on earth. Carl Becker in his analysis of this situation makes four observations: 1) Japan hospitalizes its patients an average of five times longer than America; 2) Japanese visit doctors thrice as often as people from Britain and New Zealand, who share a comparable socialized medical system; 3) Japanese spend thrice as long as the average European does sitting in doctors’ anterooms, waiting for diagnoses and prescriptions; and 4) Japan prescribes an average of four to five times more medicine per patient than do other industrialized countries with comparable medical systems.[14]
This over-medicalization feeds into another area of crisis which is that Japan without an integrated team care system that includes religious chaplains over taxes its doctors and nurses leading to high rates of burnout, depression, and suicide.[15] Based on OECD statistics from 2008, Japan had 15.6 doctors and 69.1 nurses per 100 beds, while Germany had 43.4 and 130.2, England 76.8 and 280, and the United States 78.4 and 346.8 per 100 beds respectively. What is interesting is that the number of beds and average length of stay is in opposite proportion with Japan having an average of 13.8 beds per 1,000 citizens staying for an average length of 18.8 days, while Germany has 8.2 beds for 7.6 days, England 3.4 beds for 7.1 days, and the United States 3.1 beds for 5.5 days. Thus, although Japan has proportionately a fifth of the number of doctors and nurses compared to the U.S., there are more than four times as many available beds with patients staying on an average of more than three times longer during their hospitalizations.[16]
This situation reveals a third major problem that Japan is attempting to run a national medical system on an insufficient tax system. By the turn of the millennium in 2000, we find that in order to support a heavily socialized medical welfare system, the average income tax base in northern European countries like Denmark, Sweden, Finland, and France constituted roughly 45% of their Gross Domestic Products (GDPs), while Japan’s was about 25 percent of its GDP.[17] Their income taxes and value-added sales taxes have totaled anywhere from 50 to 70 percent of personal income, while Japan’s has been less than 25 percent.[18] In other words, more than half of the European countries’ economic activity is absorbed by taxes, largely in order to support their medical welfare systems. Becker concludes, “Japan is thus trying to provide far more medicine and hospital beds on far less tax money, which is simply impossible and largely accounts for Japan’s staggering national debt.” One solution to this crisis has seen the Japanese government seeking a wide variety of ways to collect new tax revenues. One of which was discussed in the previous chapter is the new “public benefit corporations law” (ko-eki hojin 公益法人), which directly targets religious organizations including Buddhist temples. Due to the excesses of such organizations and the wayward behavior of priests during the bubble economy, many government officials no longer see temples as having a public benefit function. Further, they act as havens for tax-free business earnings in the lucrative funeral industry of Japan.[19]
Another obvious response is to cut medical costs. However, the Japan Medical Association and the Japanese pharmaceutical industry stridently lobby against cutting medical expenditures. Further, the Evidence Based Medicine (EBM) system for prioritizing types of treatment, allocating budgets accordingly, and receiving remuneration from the national insurance system for treatment disregards mental, emotional, and especially spiritual care in favor of care that provides tangible physical and medical benefit. In this way, the medical system is yet another realm of liberal capitalism in which profits and economic margins are prioritized. The system, Becker points out, seeks “to hospitalize patients, and if they weaken in the hospital, to medicate them; if the medications fail, then to intubate them; and when all else fails, to sustain them on mechanical life support systems … Many doctors’ primary motivations have shifted—at least in part—from cure to profit or experimentation, which necessitates keeping patients for extended periods. Further, many Japanese hospitals have already bought so much expensive diagnostic machinery that even now there is not enough money to support them.”[20]
The World Health Organization (WHO) mandates that addressing pain and defining health include four comprehensive areas of physical, social, psychological, and spiritual. Spiritual pain itself has been defined as “any physical or psychological symptoms, disorders of relationships, and specifically spiritual symptoms, such as meaningless, anguish, duality, and darkness.”[21] This definition is congruent with the Buddhist definition of dukkha as not only the suffering of “aging and death” (jara-marana) also the psycho-spiritual suffering the ensues in sorrow (soka), lamentation (parideva), pain (dukkha), grief (domanassa), and despair (upayasa).[22] From a Christian perspective, the founder of the modern hospice movement in the West, Cecily Saunders has defined spiritual pain as a feeling of meaninglessness and an anger at the unfairness at what is happening at the end of life.[23] EBM, however, systematically reduces all forms of suffering into medical, physical ones. This is one of the reasons why there is no system of trained spiritual care professional or chaplains working in Japanese public medical facilities. Simply, a doctor who spends extra time getting to know a patient personally or trying to handle a patient’s personal anxiety around his/her treatment will not only not be remunerated for such care but is technically wasting time since they could be administering actual medical treatment to another patient. Furthermore, while insurance will pay for a first psychological consultation, further psychological care is only remunerated when medication is given.[24]
The hopeful news is that when this situation was repeated in the United States, it eventually led to a movement to prove the necessity of such holistic care and that such expertise should not be provided by doctors but by new groups of professionals in these fields. The key in the movement to legitimize such care was building the scientific data and evidence that showed that patients tangibly improved in their medical and quality of life conditions due to mental, emotional, and spiritual interventions.[25] The next important step was showing that this care saved hospitals, insurance companies, and governments money. These advancements became the tipping point in the present movement towards spiritual care facilities and integrated team care in hospitals in the United States.[26]
As this system in Japan began to collapse in on itself in the first decades of the new millennium, hospitals increasingly began to push patients with less profitable conditions out of the system, creating a new phenomenon called “medical refugees” (医療難民 iryo-nanmin). New regulations in the national insurance system designed to cut costs put a limit on staying in a specific hospital to three months, unless a patient pays up to $500 per day in separate room fees. For the growing number of economically challenged Japanese, this is not a choice they can afford. If a patient then requires extended hospitalization, they must move to a new hospital where they start a new three-month period, which again may be extended by yet another move. Rural hospitals, which are in financial crisis due to depopulation, become natural havens for such patients but are located far from where their families live, thereby increasing their isolation. These kinds of financial conditions also restrict the development of palliative care wards which do not bring in as much income as other units devoted to surgery and intensive medical procedures.[27] In terms of the effect on the elderly facing their final days, Carl Becker concludes that, “The combination of outdated bureaucratic legislation, lack of transparency, failure to document and prioritize patients’ wishes, and economic incentives to prolong life frustrates a nationwide advance in palliative medicine.”[28]
In conclusion, the demographic distortions that Japan is being hit with now will force it, willingly or not, to abandon its overreliance on medicine. On the one hand, there are simply not enough medical personnel, beds, nor money to enable eighty million patients to die in highly mechanized hospital settings. On the other hand, surveys document that most Japanese elderly indeed do not want to have their lives artificially and mechanically prolonged while wishing to die at home.[29] However, the increasing economic precarity of common Japanese, 38% of which are irregular laborers, suggest this will not be possible. The Japanese home is no longer held down by a devoted housewife who does not need to provide her family with extra income nor has a spacious enough setting to care for a dying parent or in-law. Here is where a revitalized Buddhism could play a very significant role in birthing Japan through its crisis using wisdoms both old and new. But is it up for the challenge? And will the common Japanese be even interested in accepting it? This is where a complimentary analysis of cultural issues is required.
Denial, Silence, and Fear: The Cultural Dukkha of Medical Care in Japan
We begin here again with a fascinating observation by Carl Becker. He begins by noting that in traditional societies, like Japan, one qualification for “coming of age” was having watched and cared for elders in the process of death. However, in the past few decades, with the breakup of extended families, the death of most people in hospitals, and the subjection of the young to the all-consuming life of preparing for college entrance exams, young people rarely have an intimate experience with a dying elder. In this way, the whole subject area of death has been excluded from their worldview, resulting in a cycle of silence, fear, and avoidance carrying on into their adult lives and, eventually, as they grow old. Becker notes that, “As recently as sixty years ago, shortly after World War II, international surveys ranked the Japanese among the least death-fearing people in the world. Within the forty years between 1960 and 2000, among the dozens of countries surveyed, Japan became the most death-fearing country in the world.”[30] Looking at this survey and the multiple levels of structural violence in the present medical system, one asks why would the Japanese choose such a path? This question returns us to the core themes of the previous chapters on the struggle of Japan to define modernity on their own terms in the face of western colonialism and imperialism, the trauma of the war and corruption of their spiritual traditions, and ultimately the denial to face this suffering by adopting a stilted form of western secular liberalism and industrial capitalism. As this denial remains in a state of suspended animation, coming to clear conclusions on its effects and its resolution is not possible at this time, yet remains an important thread of inquiry for the rest of this volume.
In this section, we will try to see where modern influences and traditional culture have intertwined into a system of values and beliefs that have manifested this crisis. Firstly, it is ironic is the Japanese tendency to overmedicate is contradicted by a reluctance to prescribe pain relieving palliative medicines—particularly opioids, like morphine—even at the end of life. The logic seems to be that in taking refuge in the infallibility of modern science and medicine, one medicates until the bitter end. However, when confronted with the ultimate failure of medicine in death, the use of palliative medicines that requires an acceptance of this “defeat” cannot be permitted. Rev. Iijima explains, “For doctors in Japan, death has meant the defeat of medicine, and palliative care or pain control using morphine has also meant the defeat of medicine… However, when you look at death from the perspective of reality, every person is destined to die, and no amount of medicine can eliminate the reality of death… I think this sensibility is proof of the tendency of medical practitioners to turn away from the reality of death.”[31] She notes that when she was in training as a nurse in the mid 1980s, the doctors taught that a patient’s pain should not be treated until the cause of pain is determined. She was instructed to simply write on the patient’s chart that their pain was “under self-control” (jisei nai 自制内), which also feeds into longstanding collectivist norms in Japan such as ganbaru (頑張る “doing one’s best”) and gaman (我慢 “perseverance/patience”) ensconsed in daily speech. This culture of the denial of death also hits deeply on issues of euthanasia in Japan. The late Dr./Rev. Masahiro Tanaka—a Shingon priest and former researcher and practicing physician at the National Cancer Center of Japan—ran into difficulties at his own temple-based hospital in the 1990s when he withdrew treatment for the purpose of organ transplantation on the basis of brain death from a patient with an organ donor card. As a result, he was accused and prosecuted for murder, of which he was ultimately absolved. His conclusion of this matter was that, “This case shows the problems of passive euthanasia in Japan, particularly the difficulty for medical professionals to discontinue a medical intervention when it is clear that it no longer benefits a patient and merely serves to maintain their physical sentience. The core of this problem is the culture of the denial of death in Japanese society.”[32]
The denial of death ensconsed in Japanese medical professionals by the western scientific denial of death has, of course, a major effect on patient autonomy, especially around the issue of “truth telling” in cases of terminal illness. Carl Becker notes, “Doctors have not been trained how to tell the truth about dying, because the taboo of silence over death and dying pervades Japanese medical education.”[33] Surveys done in the mid 1990s found that as little as 10-13% of doctors would inform their patients of a diagnosis of cancer, preferring to share this information with family members who felt it was not appropriate to inform their loved one.[34] While nurses may feel the desire to to communicate more fully with their patients, there is a common fear that “truth telling” will depress patients and lead to a rapid decline and decease. However, studies have shown that anywhere from 65% to 80% of patients were satisfied to be informed of their diagnosis and would have insisted on receiving it against their families wishes.[35] In contemporary Japan, dying patients may retain no close relationships either with friends, family, or caregivers, with whom to work out the issues of their final days. In terms of terminal care, such a lack of intimacy can indeed make the practice of truth telling harmful. This situation leads us into a complex interface between traditional non-verbal forms of communication in Japan, the culture of silence surrounding death in modern medicine, and the loss of human relationship and connection (en) in modern Japan.
Dr./Rev. Tanaka offers a fascinating analysis of these intersections between Buddhism, traditional Japanese culture, and modern medicine. He notes that the word “religion” (shukyo 宗教) has been translated into Japanese using two Chinese characters, shu 宗 and kyo 教, which literally mean “mystery” and “teaching” respectively. The latter character, “teaching” (kyo), corresponds to what he feels is the rational part of religion that can be transmitted easily by words. The first character, “mystery” (shu), corresponds to the part of religion that is outside rationality and cannot be transmitted by words. It requires a master-disciple type transmission. As we have seen in the early chapters of this volume, the formation of early Japanese culture in the Nara and Heian periods was deeply influenced by the esoteric Buddhism of the Shingon and Tendai sects that followed the formality of “mystery and teaching” and included a master-disciple type transmission. Later, when the classical Zen influenced arts of tea ceremony, flower arrangement, poetry, calligraphy, and painting, developed, they continued to use such esoteric master-disciple forms of transmission. Rev. Tanaka explains that from this influence a non-verbal communication style gradually became more important than one of open verbal communication in Japan. The most difficult things to understand, such as the mystery of the Buddha’s realization, are thus called “secrets”. However, for Japanese, the word “secret” in Japan has not meant to hide the truth but rather to describe something that is difficult to understand by verbal communication.
As Rev. Tanaka trained as an expert in gastric cancer, he also understands well the typical style of doctors not informing their patients of their true diagnosis. He feels that the way Japanese doctors do not approach patients using open verbal communication shows the vagueness and “secrecy” originating in Japanese Buddhism is still an important part of Japanese culture. However, as Buddhism became increasingly marginalized first under the Shinto based regimes of the pre-war period and then later under the western secularism of post-war culture, the people who dealt with spirituality disappeared from Japanese hospitals. In the end, the formal vagueness of Japanese communication has been left without any attachment to its important roots in Buddhist spirituality. Without the support of chaplains and spiritual care workers who have some notion of these forms of communication, doctors in Japanese hospitals do not provide a true diagnosis much less a realistic prognosis to cancer patients. Rev. Tanaka concludes that the principle of informed consent in which a patient is given a detailed diagnosis still is not well maintained in Japan, although it has become the most important principle in medical ethics through the Helsinki (1964) and Lisbon (1981) international declarations on patient rights.[36]
The issue of “truth telling” reveals further fissures and contradictions in the world of Japanese medical care. Without a team care system in which professional chaplains are on call to help medical workers with this difficult work of “truth telling”, it all falls on doctors who have never been trained in such work. The six to nine years of medical education for doctors in Japan cover diagnosis, operations, treatment, and medical cures. They are taught neither to communicate bad news nor to deal with patients’ inevitable facts of death. These communication skills need more training, preferably during medical school, or at least in workshops after medical school. Rev. Tomatsu was for a period from 2005-2010 taught such a course to young doctors at Keio University School of Medicine. However, there is precious little room in the Japanese medical system for retraining or continuing education units, and his course was terminated after a regular updating of the curriculum. Rev. Tomatsu points out that this problem is evidenced in the increasing number of medical lawsuits from the early 1990s to early 2000s, which almost tripled in a ten-year span.[37] Tellingly, suits were initiated most often because of emotional frustration by families with the attitude and manner of the doctor and the lack of mutual trust from little personal interaction, rather than actual medical malpractice.[38]
The core of the issue is much more than doctors with poor communication skills. Patients should not be relying on the wrong people to provide the kind of psycho-spiritual support they need in addition to their medical care. However, in a 2008 study by the Japan Hospice Palliative Care Foundation[39], the question was posed to general respondents, “In the moment of facing death, which person would you most rely on?” Their responses were in descending order: spouse/partner (77.4%), children (71.4%), friends (30%), doctor (27.8%), acquaintance with same condition (20.8%), relatives (19.4%), nurses (17%), social worker (6.3%), religious professional (4.7%), work colleague (2.7%), and no one (4.9%). Compared to the results from the same survey taken in 2005, there were significant increases for spouses (+8.2%), friends (+10.3%), nurses (+5.8%), and doctors (+4%). In the previous chapter, we noted Japanese alarming lack of trust in religious groups (8-9%), and these statistics above reconfirm that. As we can see in the above survey, doctors are the first care professionals depended upon in the critical moment of facing death, surprisingly ahead of nurses who are usually the main medical caregivers. This data does not just apply to patients but also to families who rely heavily on the support and guidance of the doctor.
In the wider scheme of things, this is further evidence of the widespread secularism and faith in scientific materialism in Japan, which in fact serves as a new sort of religion that people look to for answers to the meaning of life and death. Rev. Taniyama, who served as a Buddhist chaplain in the vihara palliative care ward of Nagaoka Nishi Hospital in Niigata prefecture, comments that:
In contemporary Japanese society, which has been heavily secularized, we refrain from talking about religious and spiritual matters in public places. It is the same in hospitals, where it is extremely rare for patients to appeal to medical staff about their own religious needs. In addition, the hospitals with no religious affiliation do not have chapels or a place to pray calmly. On the other hand, some patients do wear Buddhist rosaries, have sutra texts or the Bible at their bedside, and pray under the glancing eyes of medical staff. In this way, it is rare for patients to request to the staff, “I want a chaplain to pray.”[40]
Rev. Sengoku Mari 千石真理—a priest of the Jodo Shin Honganji denomination and the first Buddhist chaplain at the Vihara Hongwanji Nursing Home and Asoka Vihara Clinic for terminal patients in Joyo City, Kyoto—echoes these sentiments that, “Japanese patients and elderly do not comfortably express their feelings about their lives and deaths to chaplains.”[41] In fact, the impetus for her becoming a chaplain was the traumatic event of losing her fiancé at a young age. As he passed away in the hospital and she was struck with grief, she found herself crying in a toilet with no place to seek solace and no one to comfort her. She comments, “In Japan, few medical staff perform spiritual care for patients and their families. I wish I had been able to see a chaplain for my own spiritual comfort when I was grieving. Bereaved without spiritual support, I suffered depression for three years.”[42]
Yet from a religious standpoint, because of the deep secularism ingrained in Japanese since the end of the war and the corruption of their spiritual traditions, even many elderly patients do not understand the meaning or importance of religiosity or spiritual care offered by Buddhist priests. Dr. Hayashi Moichiro 林茂一郎—founding director of the department of palliative care and vihara ward at the Kosei Hospital run by the major new Buddhist group Rissho Koseikai—explains the problem of educating both the medical world and the general population on role of spirituality in end-of-life care:[43]
The problem for most Japanese, however, is that they cannot understand why the term “spiritual” should be added to the definition of health … Japanese still dislike having their own self seen through by mental counselors. Many of them do not express this directly, but those that do say, ‘Oh, I don’t want that.’ That means they are happy just talking with the usual volunteers. The problem with bringing up religious or spiritual topics is that if people do not accept these topics when they are healthy, then when they become sick, there won’t be any room to accept them. By that time, they are just struggling to live. After becoming hospitalized is not the time to begin religious dialogue.[44]
In setting up the Kosei Vihara, Dr. Hayashi and his team studied the work of Rev. Taniyama and those who established the first Buddhist hospice at Nagaoka Nishi Hospital. In this way, they created a position for Buddhist chaplains at their ward to work with the medical team and support patients. However, they soon found there was no demand or interest by patients to speak to such chaplains, and the position was eventually terminated. It has come to the point in Japan that Buddhist priests in their black robes are considered omens of death, like the Grim Reaper. If a patient who does have a strong belief in Buddhism wishes a priest to come to their bedside, the priest must enter the hospital using a back entrance. Further, if the patient is not in a private room, any rituals must be conducted behind a curtain in hushed tones as to not disturb other patients or interfere with their freedom of, or perhaps from, religion. Dr. Hayashi relates that if a priest would suddenly appear at a patient’s bedside and ask, “What’s the matter?”, the response will be something more like, “If you are asking about the funeral, we have prepared for that.” More alarming anecdotes include patients responding in anger, “What does he want? Money for a posthumous name (kaimyo) and other things?” or “Why does the priest come today? I’m still alive damn it!”. In this way, Dr. Hayashi concludes that Buddhist priests must first show the people how Buddhism can have meaning in the midst of everyday life before they suddenly appear in hospitals as spiritual counselors.[45]
In speaking about the wall between pre-mortem and post-mortem worlds in Japan, Rev. Tomatsu sums up the crisis of care in both Japanese medicine and religion:
This specialization of roles, from the doctor as purely physical mechanic to the priest as purely spiritual mechanic, leads to a fundamental alienation from the human relationship with the patient. When one considers the work of doctors or priests, one might think that their intense experiential work with people in great suffering would deepen their awareness and create a critical wisdom and compassion. However, the opposite seems to be true … In both cases, the common point is the very low level of communication skills in both doctors and priests. They have become master mechanics in their craft, but they have lost sight that their materials are living human beings whose mental, emotional, and spiritual needs have a fundamental impact on their physical well-being.[46]
As we will now examine in the actual activities of the above priests and others, much work needs to be done to cross this divide and support patients, their families, and caregivers re-unite the physical and the spiritual in a complete system of care. Rev. Iijima expresses the potential of such work. When working as a palliative care nurse, she had a natural interest to report to the priest of the patient’s temple that the patient died after his whole family took very good care of him together until the end and that he died happily with his will fulfilled. She was never actually able to do such a report but sees the importance of hospital chaplains providing such a bridge between medical and religious institutions to guide the dying and bereaved from hospital to temple in a holistic manner.[47]
[1] Tomatsu, Yoshiharu. “Tear Down the Wall: Bridging the Premortem and Postmortem Worlds in Medical and Spiritual Care”. In The Vihara of Compassion: Buddhist Care for the Dying and Bereaved in the Modern World. Eds. Jonathan Watts & Yoshiharu Tomatsu. (Boston: Wisdom Publications, 2012), pp. 55-56.
[2] Becker, Carl. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. In Buddhist Care for the Dying and Bereaved. Eds. Jonathan S. Watts & Yoshiharu Tomatsu. (Boston: Wisdom Publications, 2012), p. 19.
[3] Okochi, Daihaku. “A Society of Extreme Elderly & End-of-Life Care”. Public lecture at “Japanese Engaged Buddhism: From Caring for the Individual to Transforming Society”. An International Conference on Socially Engaged Buddhism at Ryukoku University, Kyoto, Japan. December 17, 2020. https://jneb.net/national-meeting-2020/
[4] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 19.
[5] Nakamura. Ways of Thinking. p. 425.
[6] Taniyama, Yozo. “The Vihara Movement: Buddhist Chaplaincy and Social Welfare in Japan”. In The Vihara of Compassion: Buddhist Care for the Dying and Bereaved in the Modern World. Eds. Jonathan Watts & Yoshiharu Tomatsu. (Boston: Wisdom Publications, 2012), p. 76.
[7] Taniyama. “The Vihara Movement: Buddhist Chaplaincy and Social Welfare in Japan”. p. 75.
[8] Taniyama. “The Vihara Movement: Buddhist Chaplaincy and Social Welfare in Japan”. p. 75.
[9] Takanobu Nakajima, “Is There a Path Towards Reviving the Temple?: Let’s Think about the Needs of Citizens Today (otera saisei-no michi-ha aruka: ima-koso kokumin-no neezu-wo kangae-yo お寺再生の道はあるか？今こそ国民のニーズを考えよ)”. Public lecture at Japan Buddhist Federation’s Special Public Symposium “Performing Funerals is for Whom? Thinking about the Problem Surrounding Donations” (soshiki-ha dare-no tame-ni okonau-no-ka? O-fuse-wo meguru mondai-wo kangaeru 葬式は誰のために行うのか？お布施をめぐる問題を考える). Akihabara Convention Hall, Tokyo, September 13, 2010.
[10] Funeral Buddhism Never Dies (soshiki bukkyo-wa shinanai 葬式仏教は死なない). (Tokyo: The Japan Young Buddhist Association, 2003).
[11] http://www.mhlw.go.jp/english/database/db-hh/xls/1-25.xls.
[12] Iijima, Keido. “Amans: A Buddhist Nun’s Efforts to Unite the Medical and Religious Worlds in Death”. Unpublished manuscript. Translated and Edited by Jonathan S. Watts. Jodo Shu Research Institute Ojo & Death Project. 2011.
[13] Tomatsu. “Tear Down the Wall”. p. 40.
[14] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 20.
[15] Japanese resident physicians have much higher rates of depression at 25.2% than of citizens in general at 6–7%. “Factors related to burnout in resident physicians in Japan”. International Journal of Medical Education. 2019. 10: 129–135. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766397/. Also see, Khurana, Deepika. “Why more and more Japanese doctors are committing suicide?” Health Analytics Asia. August, 9, 2019. https://www.ha-asia.com/why-more-and-more-japanese-doctors-are-committing-suicide/
[16] Japan has actually halved its average length of stay from 34.4 days in 1994. OECD Health Data 2010: Frequently Requested Data, http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html.
[17] These numbers have stayed generally the same for the aforementioned four nations ranging between 42-46%. However, Japan’s increased significantly around 2013, going from 25.8% in 2000 to 32% in 2018. https://www.oecd.org/tax/revenue-statistics-japan.pdf
[18] While Denmark and France have reduced personal income taxes since 2000, Sweden and Finland have stayed about the same. From 2014 to 2020, the Abe administration raised Japanese consumption tax from 5% to 10%. Some 80% of Japanese taxpayers occupy the lower rungs of the personal income tax base between 10-20%.
[19] Tomatsu. “Tear Down the Wall”. p. 49.
[20] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 20.
[21] Mehta, Anita & Chan, Lisa S. “Understanding of the Concept of ‘Total Pain’: A Prerequisite for Pain Control”. Journal of Hospice and Palliatiave Nursing. Vol. 10, No. 1. January/February 2008. p. 30.
[22] All these states may also arise in a physically healthy person who mismanages their encounters with the world. Jaramarana is the final link in the classical 12-fold link of Dependent Orgination (paticca samuppada) that the Buddha taught as the causual system for the arising of suffering (dukkha) in humans. Payutto, P. A. Dependent Origination: The Buddhist Law of Conditionality. Translated by Bruce Evans. (Bangkok: Buddhadhamma Foundation, 1994). pp. 31-32.
[23] Mehta & Chan. “Understanding of the Concept of ‘Total Pain’”. p. 30
[24] Tomatsu. “Tear Down the Wall”. p. 41, 43-44.
[25] Jon Kabat-Zinn is one of the earliest examples in his pioneering work on the tangible benefits of meditation and mindfulness practice for medical patients.
[26] Tomatsu. “Tear Down the Wall”. p. 43.
[27] Tomatsu. “Tear Down the Wall”. p. 50.
[28] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 20.
[29] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 21.
[30] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. pp. 24-25.
[31] Iijima, Keido. “Amans: A Buddhist Nun’s Efforts to Unite the Medical and Religious Worlds in Death”.
[32] Tanaka, Masahiro & Tanaka, Teiga. “The Saimyo-ji Temple-Hospital Care Facility: Continuing the Ancient Tradition of Holistic Care from Buddhist Temples”. Unpublished manuscript. Edited by Jonathan S. Watts. Jodo Shu Research Institute Ojo & Death Project. 2011.
[33] Becker. “Challenges of Caring for the Aging and Dying: Lessons from Japan”. p. 24.
[34] Fortunately, there was a movement in the early 2000s to change this culture, and by 2016, the National Cancer Center of Japan found that 94% of major hospitals do tell patients their cancer diagnoses, as doctors usually reassure their patients that cancer is no longer a fatal disease.
[35] Asai, Atsushi and Fukui, Tsuguya. “Ethical issues in Japanese clinical settings in 1990’s: Attitudes and Experiences of the Japanese”. Eubios Journal of Asian and International Bioethics. 7 (1997), pp. 39-43. https://www.eubios.info/EJ72/EJ72F.htm
[36] Tanaka & Tanaka. “The Saimyo-ji Temple-Hospital Care Facility”.
[37] Overall lawsuits remained steady during this period, reflecting an actual decrease of other types of suits. “The Situation and Problem of Medical Malpractice: The Heart of Improving Basic Policy for Medical Malpractice”. National Diet Library. Issue Brief No. 433 (December 11, 2003) & The Supreme Court of Japan public data.
[38] Tomatsu. “Tear Down the Wall”. pp. 38-39.
[39] “In the moment of facing death, which person would you most rely on? (shi-ni chokumen-shita-toki-no kokoro-no sasae 死に直面した時の心の支え),” Japan Hospice Palliative Care Foundation, http://www.hospat.org/research2-12.html.
[40] Taniyama. “The Vihara Movement: Buddhist Chaplaincy and Social Welfare in Japan”. p. 85.
[41] Sengoku, Mari. “One Dies as One Lives: The Importance of Developing Pastoral Care Services and Religious Education”. In The Vihara of Compassion: Buddhist Care for the Dying and Bereaved in the Modern World. Eds. Jonathan Watts & Yoshiharu Tomatsu. (Boston: Wisdom Publications, 2012), p. 102.
[42] Sengoku, Mari. “One Dies as One Lives”. p. 99.
[43] In the WHO’s definition of palliative care, there is the addition of a spiritual element: “Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” http://www.who.int/cancer/palliative/definition/en/
[44] Hayashi, Moichiro. “‘True Regard’: Shifting to the Patient’s Standpoint of Suffering in a Buddhist Hospital”. In The Vihara of Compassion: Buddhist Care for the Dying and Bereaved in the Modern World. Eds. Jonathan Watts & Yoshiharu Tomatsu. (Boston: Wisdom Publications, 2012), pp. 62-63.
[45] Hayashi. “‘True Regard’”. p. 68.
[46] Tomatsu. “Tear Down the Wall”. pp. 39-41.
[47] Iijima, Keido. “Amans: A Buddhist Nun’s Efforts to Unite the Medical and Religious Worlds in Death”.
Contemporary Buddhism in Japan & Asia 