Efficiency and irreplaceability: "Brain Dead Person" Ch.7

Brain-Dead Person
: Human relationship–oriented Analysis of Brain Death (1989)

I have often considered the following question: isn’t it possible to see science from the point of view of someone directly involved? When we look at medicine from the standpoint of an onlooker, we find medical efficiency. However when we look at medicine from the standpoint of someone directly involved, we find irreplaceability of life.

Science from the position of an onlooker has matured independently in spite of many problems. But science from the position of someone directly involved has not even taken shape yet. This new kind of science is to be found where ethical problems of medicine are being formed, like none other than those discussed throughout this book. Science from the position from an onlooker was formed in modern Europe, with astronomy at its heart; staring up at (looking on) the distant stars in the night sky from the earth. Modern medicine is medicine that has adopted this into its essence. Science from the position of those directly involved will probably be formed with modern medicine at its heart, after many people have been forced to become directly involved through matters of life and death. It will become science that constantly focuses on irreplaceability from the standpoint of someone directly involved. I think this idea will, in places of medical treatment, slowly germinate between people who perform nursing care of “irreplaceable” life.

*Translated by Alex Jones.
*Page numbers in the original (Hozokan edition) are marked by [(preceding page) / (following page)].

    In the future, I predict medical treatment will split into two opposite poles: automated treatment systems and person-to-person nursing. Even in present day medical treatment, these two elements can be discerned clearly. These two poles are “medical treatment as repair” and “medical treatment as nursing.”
    What could “medical treatment as repair” be? Please consider what happens when a car is repaired. A car in bad condition is taken apart in a workshop. Faulty parts are replaced or returned to working order, and then the car is put back together again. With that the repair is complete. Medical treatment that adopts the same attitude and stance of car repair towards the treatment of people is “medical treatment as repair.”
    There are two special characteristics of medical treatment as repair. One is the principle of compartmentalization. That is to say, medicine for repair heals the whole body by focusing attention on the faulty parts, tuning them up or replacing them. [149/150] The other is that medicine as repair pays attention only to the biological aspect of the human body. A human body, looked at biologically (physiologically and anatomically), has far more complex structures and systems than a car. In order to repair such a complex thing, we must focus all of our attention on the biological systems of the human body, and are forced to overlook the human aspects. In short, medical treatment as repair, rather than taking “a person” as the object of medical treatment, takes as its object the “living flesh” of the body’s systems.
    Medical treatment has developed continuously until today with the fundamental character of medical treatment as repair. This character appears most clearly with the medical process of organ transplantation. Organ transplantation is medicine that tries to heal the human body by replacing a part of the body. So organ transplantation is a typical example of medicine for repair as well as an example of the principle of compartmentalization.

    The number one value behind medical treatment as repair is “efficiency.”
    In discussions of brain death and organ transplantation, expressions such as "elimination of waste" and "effective utilisation of organs" often come up. For example, Sugimoto Tsuyoshi says the following: "The brain dead are only given attention as donors for organ transplants. Otherwise, the continuing meaningless treatment of their bodies, and the waste of huge amounts of medical funds and highly skilled staff would be seen as a serious problem."(Geka Chiryou [Surgical Medicine] 1984, Vol.50,No.1, p.6) [150/151] Sugimoto declares openly that giving medical care to brain dead people is meaningless and a waste. As I said in Chapter 2, I hold exactly the opposite view, but in general opinions similar to Sugimoto’s are still quite common.
    In Kazuo Oota’s book Kore ga Jin Ishoku Desu [This is Kidney Transplantation] (1987, 7th revised edition, 3rd printing, Nankoudou) cartoon organs are drawn running to a hospital at full speed, crying, "Don’t waste the kidney of a dead body!"(p.170) This reflects the attitude that we should try as much as possible not to waste organs that are no longer being used, and strive to utilise them quickly and efficiently.
    And Tetsuzou Akutsu says the following:

    Here the phrase, “organs will be regrettably and wastefully be thrown away” expresses regret about the fact that these organs could not be efficiently utilised.
    As this shows, the most prominent figure by far on the scene of brain death and organ transplantation is medicine that pursues efficiency and the elimination of waste. [151/152]
    “Pursuing efficiency” means that to achieve a particular goal you remove anything useless or anything that obstructs that goal, and, weighing up various choices against each other, you select those that will produce the best results with the least effort. It means continuously looking at things only with the aim of achieving a specific goal. For example, “pursuing efficiency” with respect to organ transplantation from brain dead people means that you continuously see the person to person relationships surrounding the brain dead person and recipient only from the standpoint of whether or not they will affect the success of an organ transplant. This attitude also reflects the compartmentalization of medicine, that concentrates only on achieving its immediate goals.
    Efficiency with regard to the goal of organ transplantation means, in concrete terms, to take as many organs as possible from the brain dead person, in as “fresh” a condition as possible, and give them to the most biologically suitable recipient with the best chance of successfully receiving them (based on the chance of the success of the operation, the chance of the organ not being rejected, and the chance of the recipient surviving). From the point of view of this kind of efficiency, cremating the bodies of brain dead people without utilising their organs, as well as the so-called nursing of brain dead people and the squandering of precious time and funds must seem like utterly wasteful acts. A certain group of people might think that this is the result of the general public not being sufficiently enlightened, and that their own scientific way of thinking is not understood. They might also think that discarding usable organs willingly is an unethical act that contradicts the idea that human beings should help one another.
    But is this really the way things are? [152/153]
    The pursuit of efficiency is only meaningful firstly with a clear and exact understanding of your goal, and secondly when your calculations for efficiency are restricted to a comparatively small sphere. For example, in the case of organ transplantation, the goal is to successfully replace bodily organs. Therefore your calculations for efficiency will be sufficient if they are restricted to roughly the following: the number of organs available and their condition, the staff and equipment available for the operations, the number of recipients, their suitability for transplants and their particular medical conditions, and the expenses required for transplantation. With this information you can calculate what kind of procedures will be the most efficient for organ transplantation (“calculate” is perhaps a strange word here, so readers may substitute “consider” or “investigate”). I assume that the “efficiency” spoken of by transplant doctors is generally this kind of thing.
    However, if these two conditions are not met, then there is little point in pursuing efficiency. For example, I said that the goal of organ transplantation is to successfully replace bodily organs. However this is a very narrow view of organ transplantation. I mentioned this in Chapter 3, but the goal of organ transplantation should be to save the life of the recipient undergoing the transplant operation, and also improve their quality of life. If this is your goal, then simply transplanting organs successfully will not suffice. In order to prevent the side effects of immuno-suppressants worsening the recipient’s quality of life, continuous care is necessary. And it’s not just care of the body - the mental health of the recipient and their family also enter into calculations for efficiency. And as I said in Chapter 2, another precondition for transplantation is the support of the family caring for the brain dead person who has become a donor. This means that one aim of organ transplantation is caring for the mental health of the brain dead person’s family. Which is to say that the mental state of the brain dead person’s family must be included in any calculations for efficiency. [153/154] Any expenses for this care are also included.
    If the goals of organ transplantation are thus broadened (as they should be) and calculations for efficiency begin to include all kinds of diverse elements, it becomes impossible to know just what methods will be most efficient. This is because the number of elements we have to consider has increased to a point where it overwhelms our ability to calculate, and also because some of the elements we now have to consider are human feelings and mental states, and this makes calculations extremely difficult. In other words, when we begin to slightly broaden the scope of our goals for “organ transplantation,” we become unable to decide generally what procedures will be the most efficient. And not only that. We will have to reconsider whether or not things like kidney transplants for people doing comparatively well on artificial dialysis machines are really efficient for achieving these goals.
    However the same things could be said about Tsuyoshi Sugimoto’s view that medical treatment of brain dead people is meaningless and a waste. Sugimoto sees medical treatment as basically “life extending treatment,” and because brain dead people won’t ever recover, he therefore seems to think that such medical treatment is meaningless and a waste (apart from in the case of organ transplants). However, the medical treatment of brain dead people should be treatment that supports the family of the brain dead person in their nursing care of the brain dead person. If you look at it from that point of view, then the medical treatment of brain dead people is certainly not meaningless and a waste. In short, it’s all about how broad your view is when you come to assess the issue. [154/155]

    In present day organ transplants, the kind of efficiency that is most strongly sought after is efficiency of organ “distribution.” As I said in Chapter 3, in order for organs to be regularly transplanted from brain dead people, it’s necessary to set up a close-knit information network between the hospitals extracting the organs and the hospitals performing the transplant operations. Once an organ donor is found, you have to search a computer database systematically for the most appropriate recipient, then request transplant surgeons straight away from a hospital that can perform transplant operations, and then transport the organs as quickly as possible to that hospital. Once these facilities are in place then efficient organ transplants from brain dead people can be made.
    In areas where transplants from brain dead people regularly take place, these kinds of large-scale organ distribution networks have been established without exception. In the U.S., there are over one hundred organ sharing organizations nationwide, and their data is collected at a national registration center in Richmond (called UNOS). Organs are then speedily carried by airplane or helicopter to their destinations. In Europe, such countries as Austria, Belgium, West Germany, Holland and Luxembourg participate in an organ sharing system called “Eurotransplant.” Transplants between the various countries take place through an office in Holland. In Japan, a computer in the National Kidney Transplant Center in Chiba prefecture is connected to fourteen hospitals and collects information from them (Zouki Chikan to Ishiki Henkaku [Organ Transplants and Reforming Awareness] pp.60-61). There are also moves in Japan to create a multinational organ transplant network across Asia. [155/156]
    If you follow this train of thought, then the first thing needed for a society that regularly transplants organs from brain dead people is a highly developed information network. This means establishing a system in which computers set up in each area send information to a central computer twenty-four hours a day. Next, it has to be a “distribution society.” This is a society in which doctors travel quickly between hospitals by plane or helicopter, and in which organs can be carried like luggage for a short time. For this, maintaining a precise high-speed transportation system is a precondition. The society also has to be one that accepts the idea that organs which were once part of a human being can be carried like luggage.
    A society in which organ transplantation from brain dead people is firmly established is a society that distributes information. This consists of techniques that are the same as those found in the “information distribution industry.” The information distribution industry includes for instance, when making home deliveries, the practice of entering the origin and destination of a customer’s goods into a computer and instantly determining the most efficient delivery route. It is also the network of regular and precise truck deliveries that quickly translates these directions into actions. In this way, the transplantation of organs from brain dead people can be seen as a manifestation of today’s “information distribution society.” The concept of transplanting organs is the concept of distributing goods. What is thought of as efficient for organ transplants from brain dead people, is the same as what is thought of as efficient for distributing goods.
    Distributing goods efficiently consists of exchanging goods for money equal to their value. Similarly, organ transplantation is the kind of medical treatment that tries to repair humans by exchanging failed organs with working organs. [156/157] Artificial organs are also the product of the same way of thinking. The basis of organ transplant medicine is exchanging one part with another, or substituting one part with another. Exchange and distribution. Amongst all the fields of medicine, the one that implements these concepts most comprehensively is organ transplantation.

Incidentally, the other pole of medical treatment, “medical treatment as nursing,” is characterised by the fact that unlike organ transplantation, it deals with things that cannot be replaced. In this book I will call things that cannot be replaced, - things that cannot have their place taken by another thing - “irreplaceable”[*2].

    In the medical world, representative examples of irreplaceability are “health” and “life.” Artificial organs might be able to take the place of failed organs, but if bad health takes away a certain period of your life, then no matter how much you recover afterwards, and no matter how much financial compensation you receive, you can never get that time back. Irreplaceable things, are in other words, things that you can never get back. A person’s life is the same. Certainly nothing can take the place of someone’s life. If a life is lost then it can never be taken back. Each moment of our life cannot be taken back. Nothing can take the place of the moments in our life; they are a continuous flow of once-only events. The irreplaceability of each moment of our life makes up the irreplaceability of our life itself.
    I think that respecting this kind of “irreplaceability” is the essence of nursing.[157/158] Consequently, in this book the use of the word “nursing” might be a little different from the normal usage. I do not have a satisfactory answer as to what nursing is actually about, but in this book I would like to use the word “nursing” in this way to answer the question at hand. Therefore “medical treatment as nursing” is medical treatment that has the primary goal of respecting that which is irreplaceable.
    Medical treatments that possess strong characteristics of medical treatment as nursing are things like care for the elderly and care for terminally ill patients. Care for the elderly does not try to repair the bodies of elderly people, but supports and respects each moment of an aged person’s life. Medical treatment as nursing for elderly people is concerned with the state of the person to person relationships around them. Care for terminally ill patients supports patients who are nearing death by relieving their physical and mental suffering, and this care helps them to be able to live comfortably until they pass away. I think this too does not have the goal of extending the patient’s life by repairing their body. Instead it respects the irreplaceable life of the patient nearing death by administering medicine and providing the best care possible. The attitudes and actions of this care show respect for irreplaceability. This is a real part of medical care, and we should realise that it is one element of what makes up medical care.
    In discussions of bioethics, the phrase “respect for life” comes up without fail. However because it is not explicitly clear what this phrase refers to, it is heavily criticised. I feel that what “respect for life” means is those attitudes and actions that respect irreplaceable things.
    Medical treatment is composed of both medical treatment as repair and medical treatment as nursing. [158/159] Organ transplantation is the same. For example, it’s possible to see a heart transplant from a brain dead person as repair work (replacing their heart with that of the brain dead person) done in order to save the “irreplaceable” life of the recipient.
    But we should consider this a little more carefully. In the case of an organ transplant from a brain dead person, the life of the recipient is not the only “irreplaceable” thing. The sphere of human relationships surrounding the brain dead person (that of the brain dead person’s family and close acquaintances of the brain dead person) is also in itself something “irreplaceable.” For example, the “sphere” of the human relationships that occur as family slowly begins to come to terms with the death of a blood relative is certainly something “irreplaceable” that cannot be substituted with something else.
    It is often said that, when we consider the suffering of patients who can only be helped through organ transplants, then proceeding with organ transplants from brain dead people seems particularly to be “medically ethical,” and opinions to the contrary are unethical. People who make such statements are often apt to overlook what I am describing here: the irreplaceability of the sphere of person to person relationships surrounding the brain dead person. The support of the “family’s nursing care of the brain dead person,” that I emphasised in Chapter 2, calls even more attention to this irreplaceability. I requested that we try to make it a practice to respect this irreplaceability in the actual place where medical treatment occurs. And I proposed that when there are organ transplants from brain dead people, they should proceed only if our attitude and actions respect this irreplaceability.
    Furthermore, I think that one reason why distrust in doctors is growing is because patients and their families have doubts about whether or not all the irreplaceable things in their lives that they have respect for will also be respected by the doctors in the place of treatment. [159/160]
    I believe that the ways of thinking found in “medical treatment as repair” and “medical treatment as nursing” stem from the two fundamentally different concepts in their backgrounds: “efficiency” and “irreplaceability.” It is an interesting phenomenon that in the case of organ transplantation from brain dead people these two should appear together so distinctly. It could be said that they might correspond to the distinction of “cure” and “care” that has been the subject of much recent discussion. However, I prefer the way of speaking presented here to the dichotomy of “cure” and “care.” Certainly, the dichotomy of “cure and care” is plain and simple, and just hearing the words gives you the feeling that you understand them. However if you really think about it, it is still not clear what exactly they refer to, and this is the disadvantage of using these words.

    I think that the two attitudes of pursuing efficiency and respecting irreplaceability are fundamentally incompatible. If you think about it carefully, everything is irreplaceable. If you pursue efficiency, then you are bound to sacrifice a certain amount of irreplaceability. On the other hand, if you fully carry out a policy of respecting everything irreplaceable, then it is impossible to pursue efficiency (those who have read Seimeigaku e no Shotai [An Introduction to the Study of Life] might be able to relate this to the principle of biosphere and the principle of the otherness). [160/161]
    In discussions of brain death and organ transplants, the issue of expenses always comes up. Common topics are, for example, the high cost of keeping a brain dead person alive, the fact that a successful kidney transplant will be much cheaper than keeping someone on a dialysis machine, and the question of who will bear the cost for heart transplants and subsequent post operative treatment. These kinds of economic problems are not limited to brain death and organ transplantation, but come up without fail during any discussions concerning bioethics. Within bioethics, there is even a particular field that concentrates on and discusses the problem of medical resources and the sharing the burden of expenses.
    One thing that I have long been concerned about is: why do problems of bioethics take the form of economic problems? Bioethics, even from the sound of its name, seems that it should be dealing with “life,” an area far removed from economics. So I wonder why serious discussions take place about economic problems. Economic problems are things like: how to lower costs, how to fairly distribute the burden of expenses, and how to use funds and medical resources efficiently. In these kinds of discussions, various choices have to be weighed up against each other. In bioethics, this means weighing up “life” against “life.” For example, in a situation where we only have one transplantable organ, and we are trying to decide who to give it to, the lives of the multiple prospective recipients become the choices that we have to weigh up against each other. Another example of this is, when we are deciding whether resources and facilities being used to develop an artificial heart should be switched to AIDS research, we are indirectly weighing up the lives of patients with heart disease against the lives of patients with AIDS.
    Weighing up two irreplaceable things is fundamentally impossible. Irreplaceable things are things that cannot have their place taken by anything else. And the process of weighing choices up against each other has a step in which it attempts to replace one thing with another. [161/162] Therefore it is fundamentally impossible to make a choice between irreplaceable things. But actually, we are sometimes forced to choose between two irreplaceable things that are fundamentally impossible to weigh up.
    To take an example, let’s assume that we have a heart available for transplant, and we have to make a decision quickly between many prospective recipients. All the lives of these patients with heart disease are irreplaceable. However amongst all these irreplaceable things we have to choose one. So how do we proceed with making this choice?
    One method is to temporarily forget that the lives of the candidates are “irreplaceable,” and replace them with other things. In other words, we arrive at a conclusion by making them into choices that we can weigh up against each other. In a sense, this takes human lives to be objects, and suggests that we see them as goods with a certain value. And if you follow this train of thought, the efficiency of heart transplants will become a matter of strict calculation. This is, in other words, a “onlooker’s” view of human lives. Organ transplant medicine has, somewhere along the line, made a step in which it has temporarily forgotten the irreplaceability of human life.
    A contrasting method is one that sticks to the position that the lives of all the candidate recipients are “irreplaceable,” until the very end. In this case it is impossible to weigh up the candidates against each other. So what we do is make the decision according to circumstance, chance and randomness. For example, we use a “first come first serve” system, or we draw lots. This way we can decide without weighing up irreplaceable things against each other. [162/163] With this method, organ transplants from brain dead people would become impossible in practice. This is because, as stated earlier, without strictly weighing up the biological suitability of recipients in a systematic way and taking into account the size of the organs and so on, organ transplants cannot feasibly take place. Moreover these kinds of transplants would be open to the criticism that the recipient’s safety is being ignored and that this is irresponsible.
    However this does not show that sticking to “irreplaceability” in a medical context until the very end is meaningless. It’s a simple fact that to the people directly involved. it’s impossible to make a decision by weighing things up against each other. For example, if you take the family taking care of a brain dead person, if you stick to the position that their care is “irreplaceable” until the very end, then it is impossible to weigh up the mental anguish they will feel if you extract an organ from the brain dead person against the successful recovery of a transplant recipient. Some people might say that this is the family being selfish. Even though that may be one side of it, to the family directly involved, it is still a simple fact and so it is not unfair to think this way.
    I agree that it is an undeniable fact that if we base our actions on economic principles, we must pursue efficiency and fair distribution of organs and resources, as far as that statement goes. But this is an undeniable truth from the position of an onlooker. The people directly involved think according to different principles. The people directly involved would stick to the “irreplaceability” of their own life and reject this kind of weighing up of value. This is an undeniable truth from the position of those directly involved. The important point is that people can be onlookers, or they can be one of those directly involved. And because we are speaking of medicine, even onlookers will, one day, necessarily become one of those directly involved. [163/164]

    I think that “medical treatment as repair” and “efficiency” represent of the side of medical treatment that concerns onlookers. “Medical treatment as nursing” and “irreplaceability” represent of the side of medical treatment that concerns those directly involved. The mainstream of modern medicine has progressed in the form of medicine as repair, and so it follows that in modern medicine, the position of the onlooker predominates over the position of those directly involved. This may well be the reason why modern medicine has forced many questions of bioethics.
    Why has modern medicine developed in this form? This cannot be explained without including the relationship between modern medicine and science. This is because modern medicine is, more than anything else, medicine produced from a synthesis with the achievements of the natural sciences. Part of the nature of modern medicine is obviously scientific.
    If you reflect on it, science has never abandoned the position of an onlooker. This is because through the position of an onlooker, it is thought that you can preserve universality and objectivity. At some point in the past, modern medicine began calling itself science. And correspondingly, modern medicine gradually began to change to medicine from the point of view of an onlooker. This is why, as we have seen in discussions of brain death and organ transplants, many people hold the opinion that arguing especially from the point of view of an onlooker is a scientific attitude to take towards discussion. The more modern medicine sticks to natural science, the more it transforms into medicine from the point of view of an onlooker. [164/165]
    I have often considered the following question: isn’t it possible to see science from the point of view of someone directly involved? When we look at medicine from the standpoint of an onlooker, we find medical efficiency. However when we look at medicine from the standpoint of someone directly involved, we find irreplaceability of life.
    Science from the position of an onlooker has matured independently in spite of many problems. But science from the position of someone directly involved has not even taken shape yet. This new kind of science is to be found where ethical problems of medicine are being formed, like none other than those discussed throughout this book. Science from the position from an onlooker was formed in modern Europe, with astronomy at its heart; staring up at (looking on) the distant stars in the night sky from the earth. Modern medicine is medicine that has adopted this into its essence. Science from the position of those directly involved will probably be formed with modern medicine at its heart, after many people have been forced to become directly involved through matters of life and death. It will become science that constantly focuses on irreplaceability from the standpoint of someone directly involved. I think this idea will, in places of medical treatment, slowly germinate between people who perform nursing care of “irreplaceable” life.
    It will probably require many months and years before science from the position of those directly involved takes shape. I am afraid that it may take the same amount of time that it took for modern European style science to form. It will probably happen in the coming centuries rather than in the coming years. To breed a new kind of science, you need to have a field of view that spans centuries. [165/166]
    I will finish this book with that fairy tale. I still have many things I would like to say about efficiency and irreplaceability. However at this point I have not collected enough materials worth talking about. What I have felt recently about irreplaceability is the following: those who promote organ transplants place emphasis on the network and facilities for organ transplants, and its efficiency. As I have already said, this efficiency is the kind of efficiency used for distributing goods. Interestingly, the same people get extremely nervous only about the subject of selling and buying organs. This is a very extraordinary phenomenon. Why are the same people who are so passionate about the organizations for distributing organs like goods, so disgusted by the idea of a recipient paying the family of the donor as part of a fair transaction? It would not particularly affect the fairness of organ transplants if a just amount was paid, because, according to transplant doctors, the recipient is chosen impartially based only on their medical suitability. However in practice, all organs are offered free out of goodwill. It is a strange thing that in this modern capitalist society such an advanced distribution system should have been developed simply for the purpose of carrying gifts.
    Here is what I think. I think that deep down, the people who have created this organ distribution network also feel the irreplaceability of brain dead people. At the same time as they believe that we should replace an organ of a human being while we can, otherwise it would be a waste, [166/167] they are also aware of the fact that this organ was once part of a brain dead person, and is therefore irreplaceable and cannot be exchanged for something supposedly having the same value. If we start to pay sums of money equal to the value of the transplant, and consequently exchange irreplaceable organs for a supposedly equal cash value, then we ourselves destroy their irreplaceability. But if we offer them out of goodwill, then this does not happen. This is because it is not an exchange for something of equal value, but a unilateral gift of “irreplaceability.”
    I don’t know if transplant doctors will read this and think, “that’s just how it is,” or instead think, “we are scientists, and have nothing to do with this kind of romanticism.” But how they respond is not important. What is important is that even at the forefront of modern medicine, charging onward in the pursuit of efficiency, we make sure that we can feel as if a strong and deep-rooted focus on “irreplaceability” remains. One key to solving the ethical problems of modern medicine is hidden in this area. And it will also be a key to understanding the character of the medicine and science of the future.

Philosophical study of life, death, and nature