April 21, 2021 TOPICS

New Zealand the latest country to move toward legalizing euthanasia: Is acceptance if euthanasia growing in the world?

In October 2020, a referendum was held in New Zealand on whether to legalize euthanasia. After the votes were counted, the number of supporters were found to greatly exceeds those who opposed the measure, and it is expected to be legalized this year as well. Discussions on euthanasia appear to be picking up pace primarily in the West, as evidenced by deliberations on legalization that have begun in Spain and Portugal. So, why are so many countries legalizing euthanasia now? We sat down with Professor Tatsuya Mima of the Graduate School of Core Ethics and Frontier Sciences to talk about the different perceptions of death in various countries and the context of this push for institutionalization.

In a word, active discussions on euthanasia and death with dignity are not a purely Western phenomenon.

In New Zealand, euthanasia is expected to come into force after the new law is enacted in November 2021. We asked Professor Mima how he perceives this situation.

“Right now, most of the discussions on euthanasia outside Japan refer to what is known as active euthanasia or doctor-assisted suicide. In terms of the details of the system itself, I think it will be similar to what is practiced in some states in the United States, some countries in Europe, and parts of Australia. In other words, euthanasia can only be performed based on a set of rules which state that i) two doctors must sign a document confirming that a patient has a difficult-to-treat illness and has a life expectancy of less than six months, ii) the patient has unimpaired judgement, and iii) the patient must administer the drug on their own. Above all, the right of self-determination is the most important point common to euthanasia in all countries and regions where it is practiced.
The image is that there is a robust discussion on euthanasia and death with dignity in Europe and the United States, but in areas where Christianity, and especially Catholicism, has a strong influence, it is extremely difficult to institutionalize the practice because people believe that life and death lie within the realm of God, so humans must not try to control it on their own. It is important to keep in mind that legalization is not progressing across the board in Europe and the United States,” explains Professor Miwa.

Professor Miwa also raised points about the population of New Zealand, which is moving toward legalization, and the functionality of referendums there.

“As you may know, the population of New Zealand is only about five million, or less than half of Tokyo Prefecture. In terms of scale, this is akin to just one municipality in Japan making a decision. Since the legalization of euthanasia is a fundamental change in the system with regard to the issue of life and death, it is difficult to make a decision based solely on legislation and judicial precedents in parliament. This is why, in most cases, the decision is made after a national debate and referendum. Another point is that the popular referendum does not work well unless the country is small or it is held at the local government level.”

In addition to the issues of cultural and religious background, decision makers face other extremely complicated hurdles when it comes to enforcing euthanasia as an institution. Although it is not directly related to euthanasia and death with dignity, the size of the country appears to be a critical factor.

How is the Japanese view of self-determination at the end of life different from that of its East Asian neighbors?

What is the situation like in East Asia, which is culturally closer to Japan than Europe and the United States?

Professor Mima explains: “There are some countries in East Asia where death with dignity and euthanasia are currently being discussed. In Taiwan and South Korea, laws have been passed to permit death with dignity and natural death at the end of life. On the other hand, as per the discussion at last year’s annual conference of the Japanese Association for Bioethics, many scholars feel that the enactment of legislation in these countries could act as a brake on patients being coerced to die with dignity. I think that the views in these countries on protecting the rights of patients by passing legislation on euthanasia and death with dignity differ from those in Japan. Some of the graduate students enrolled in our graduate schools have come to study these differences in terms of cultural background and socio-economic mechanisms.”

As Professor Mima pointed out in a previous shiRUto article entitled “Did you know there is a recognized form of euthanasia in Japan? Thinking about prolonging life and self-determination of death,” the issue of self-determination at the end of life has yet to be discussed in depth in Japan. In the Japanese social climate where people decide how they live with an emphasis on the relationships with those around them, there may be an insufficient foundation for leaving independent judgments about death up to the individual.

Bioethics focuses on the difference between self-determination and autonomy. For example, Kant, a philosopher with a strict interpretation of autonomy, believes that the act of making one’s own decisions does not necessarily make someone autonomous. According to Kant, to make a decision based on one’s family circumstances and personal preferences is not an autonomous judgement based on reason. In Japan, self-determination is linked to individual responsibility, so I think many people have a vague anxiety about the mechanism for signing legal contracts. For example, some may worry that they are the only one who can adhere to the letter of the ‘final decision’ that they signed. Alternatively, there concerns that self-determination will, in effect, act as social pressure that forces the individual to opt for euthanasia. These problems are actually the same ones posed by Kant. Rather than focus on the social and cultural circumstances peculiar to Japan, I think we need to think deeply about this issue in the context of the philosophy of what constitutes human autonomy.”

The concept of self-determination varies greatly depending on one’s country, culture, and religion. With regard to institutions concerning life and death in particular, it is not possible to seamlessly adopt a practice from another country. When viewing euthanasia and death with dignity as rights, it seems that we will need to engage in a deeper discussion instead of just focusing on what would be realistic in Japan.

Talking with your family and your doctor about the end of life: Can advance care planning (ACP) deepen the debate on euthanasia?

The Ministry of Health, Labour and Welfare is currently promoting advance care planning (ACP) based on the policy that it is crucial for medical staff to provide appropriate information and explanations to patients (and their families) so that end-of-life medical care is provided based on the patient’s own decisions. Since December 2018, the government has pursued a wide range of efforts to raise awareness about ACP using the more colloquial term jinsei kaigi (life meeting).

“ACP refers to the process in which an individual holds a series of discussions on end-of-life medical and/or nursing care with his/her family and the medical and/or nursing care team in advance.
In Japan, because there is a strong sentiment that it would be out of character to pass legislation such as a euthanasia law, the preference is to adopt a more indirect approach like ACP. In this way, it is important for the person to engage in deep discussions with his/her family and medical staff on a regular basis. However, even with such a process, the issue of how to deal with the gap between self-determination and autonomy remains in the end.
Finally, the will of the individual identified through the ACP process must be preserved in document form. Doing this means one is bound by the document they created, so they can end up in a situation where insofar as a document exists, it cannot be altered even if circumstances change, or alternatively, where items that have not be written down cannot be carried out.

To envision your death in advance and discuss the final stages of your life with trusted family members and your doctor is a truly wonderful thing. However, when death is imminent, there is a chance the individual can end up bound by the advance directive they have created even if it may not be suited to the latest changes in circumstances or changes to their intentions.
Outside Japan, there is data that shows that the ACP process improves the satisfaction of patients’ families and reduces their levels of stress, anxiety, and depression. However, this is circumstantial and differs entirely from the issue of the individual’s autonomy. In order to deepen the discussion on euthanasia and death with dignity in Japan, it seems that we will need to gradually search for end-of-life practices that suit Japanese sensibilities based on a process such as ACP.

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