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    The most striking finding were the significant differences found between the Japanese and American psychiatrists on their responses to the reasonability of commiting suicide under 9 of 10 of the various social, medical, and psychiatric conditions presented (question 3, b through j). The overall pattern was significantly more Japanese psychiatrists responding with some agreement to the reasonability of suicide in these cases. Although the vast majority of both American and Japanese psychiatrists agreed that there may be times when suicidal ideation, or completed suicide in med-surg patients is logical or reasonable, most Japanese psychiatrists did not agree even slightly that commiting suicide could be logical or reasonable in terminal illness with major depression irrespective of the quality of life, or in terminal illness with good quality of life and no major depression. This was despite the fact that 18-33% of Japanese psychiatrists had some degree of acceptance of suicide in non-terminal cases with inability to function in various social roles, 26% agreeing at least slightly that a murder-suicide could be reasonable (question 3e through j) .

    These results may reflect the value a number of Japanese psychiatrists put on the Japanese concept of duty and responsibility to others that may even include one's life. American culture is characterized by more of an individualism which would be less likely to result in this degree of duty sense. The value of loyalty to others tapped by this study in the medical setting can also be seen, sometimes dramatically, in other aspects of Japanese culture. Sacrifice of one's life for others in Japan was perhaps most visible to Westerners in the World War II "Kami Kaze" suicide bombers. "Karoshi" is an often used term that means death from overwork due to intense devotion to one's company. "Inseki jisatsu" is a suicide in order to take responsibility for a defeat or shame by persons who feel loyal to their superiors. This is perhaps best exemplified by the Japanese soldiers who killed themselves outside the palace gate after the surrender of world war II, and can sometimes be seen in the news in Japan today [23-25].

    This degree of loyalty to the group is anathema to the American way of thinking (Americans do not have specific terms for "karoshi", "inseki jisatsu", or "kamikaze" etc.) where it might even be acceptable to pose risk to the group in order to protect the individual (ie. the right to bear arms, early parole of violent offenders etc., that go against Japanese norms). Funerals and other customs in Japan reflect minimal seperation between the dead and the living and suicide is not strictly forbidden as it is in western cultures; the death of Buddha was a peaceful transition into Nirvana while that of Christ was suffering [26].

    The finding of 16% and 6.5% of Japanese, and 0%and 0% of U.S. psychiatrists responses to questions 3j and 4j respectively (items inquiring on agreement to the reasonability of suicide and physician assisted suicide along with one's children) is also probably related to these dynamics. This is called a "Muri-Shinju" suicide in Japanese, where the word "Shinju" formed from the Chinese characters that mean "heart-inside" or "oneness of hearts", probably refelecting a psychological fusion of those involved. Japanese culture fosters a mutual interdependency in the socialization process quite in contrast to the emphasis placed in individuality put in the west [27], this may relate to the close bond Japanese children have with their mother [23-27]. As a consequence, the boundaries, both conscious and unconscious, in ones nuclear family can be more blurred than in western society and this may have lead to the development of shinju as a Japanese cultural phenomena.

    The trend for more Japanese psychiatrists to rate termination of life supports on question 5 as a "killing" may relate to the wide media coverage of the recent Tokai case described in the introduction in which the court frowned on active intervention on the part of the doctor. Differences between the Japanese and U.S. psychiatrists on questions 8 and 10 may relate to differences in training or the emphasis put on these issues in the psychiatric literature between these countries, although it is not clear at this point.      

    The differences in responses to question 13 between Japanese and U.S. psychiatrists (29% of Japanese psychiatrists vs 2 % of U.S. psychiatrists responded "usually" or "always" to this item) probably reflect the trend in Japan not to tell patients their diagnosis directly: it has been reported even that while most Japanese physicians answer that terminal diagnoses should be told to patients, this is rarely performed in actuality [28]. Consequently, very few of these seriously ill patients can make an informed decision [29]. This may be fuled in part by the medical community's fear of causing suicidal ideation in the patient. The fear of suicidal ideation here may relate to the Japanese ethic 'I should not cause trouble to those close to me', as it would be better to choose death rather than become a burden to others for care.

    Differences between the two groups on the correlation between answers seemed to reflect the attitudes of the groups in general. For example, the differences on question 5 outlined in the results points to Japanese psychiatrists' association of labeling a request to terminate life supports as a suicide with being unable to fulfill family duties (similar to being a burden), while the U.S. psychiatrists were more likely to associate this with terminally ill cases in whom physician assisted suicide might be reasonable, possibly reflecting increased public interest in legalizing physician-assisted suicide and euthanasia in the U.S. [30]. Differences in the attitudes of the two groups as described above also seems to be reflected in the differences in correlation seen on questons 8, 9 and 11 as described in the results section.

    Japanese respondents who felt that only "rarely" or "sometimes" was distorted thinking or psychopathology involved in medical patients' wishes to die had a significantly lower mean number year of experience. This younger and less experienced group, which was also more likely to rate termination of life support in an incurable non-terminal patient with poor quality of life as "letting the patient die naturally" rather than a "suicide" or a "killing", may not be as sensitive to the relationship of psychopathology to suicidal ideation in this group of patients as their more experienced colleagues.

    This may be somewhat in contrast to the Americans where there was some correlation of age with degree of agreement to the reasonability of suicide and physician assisted suicide under three of the conditions presented (3d,3f, 4b). Whether this reflected an experiential influence or a life-phase influence is not clear from the data. It could be that some of the older psychiatrists have more personal concern for end-of-life issues and can empathize with more choices for terminal patients. This is an interesting idea that requires further study.

    These findings also raise the importance of sensitizing psychiatrists on both sides of the Pacific to the need to determine when depression in the terminally ill may affect the decision to forgo life-sustaining medical treatment [13-15]. While 92% of Japanese and 100% of U.S. psychiatrists responded that it is "usually" or "always" important to give optimal medical and psychiatric treatment to medical patients who refuse life saving treatment; 25% of Japanese psychiatrists responded "sometimes", and 10% "usually" or "always" valuable to accept a medical patient's decision to die even if they are depressed. 33% of U.S. psychiatrists responded "sometimes", and 2% "usually" to this question.

    In addition, while both the relationship of suicidal ideas among the terminally ill to psychiatric disorder, and the assumption of distorted thinking in medically ill patients who desire death were thought to be at least sometimes the case in the opinion of well over 90% of both Japanese and American psychiatrists respectively, there was a stronger trend for the Japanese psychiatrists to feel "usually" or "always" that psychiatric patients are more likely to have their wishes for death rooted in psychopathology (Japanese 94% vs. American 53.5%, difference significant) when compared with this response for medical patients' psychopathology (Japanese 39% vs. American 22%, difference not significant). This kind of finding may indicate that Japanese psychiatrists are less likely to view medical patients who desire death as having a psychiatric condition. Diagnosing psychopathology in medical patients even in the face of "the reality of the situation", however, is an important task of the general hospital psychiatrist [13-15]. A view of depression in the face of serious illness as reasonable may be a form of "pseudo-empathy" against which psychiatrists should be warned, especially as physicians have been shown to underestimate seriously ill patients' quality of life and their desire for life-sustaining treatment [20-31].

    Our study has several strengths and several limitations. One of the major limitations is the relatively small sample size. On the Japanese side we choose psychiatrists known to be actively involved in general hospital work who were likely to have actually encountered the proposed situations. Hospitals known to the authors were chosen because of the predicted difficulty obtaining cooperation on these sensitive issues. The high degree of cooperation by the Japanese respondents and the manner of their selection may have carried with it some inherrent bias that we are unaware of. On the U.S. side, a larger subject pool was used with a much lower response rate. Whether the responses we obtained would differ from those who did not respond is not known.

    Japan is a more homogeneous social environment than the U.S. is as a whole. Recent media coverage in Japan on euthanasia may have informed the psychiatrists further about these issues, although it may have also colored their opinions in the wake of the court's ruling. The American psychaitrists may have a more varied social influence depending on the atmosphere of these issues in the individuals state of practice, religon, ethnic backround etc., and these demographic variables were not studied. Interpretation of the questions may have some linguistic and/or cultural differences as well. Although we discussed the rational for including the non age-matched samples in this study, there may have been influences none the less. The major purpose of the study, however, was to get a feel for the overall similarities and differences between the two groups. Finally, the fixed-response format of the questionnaire could have limited the respondents' ability to evaluate the whole picture as in a real-life situation, although this may also have elicited their uncensored responses.

    Sociolegal policy needs to be directed at least in part by research findings. This study indicates that the items used in the SAI data base may be helpful in clarifying health care workers' attitudes toward the issues discussed in these studies. For example, courts should actively consider the role of affective impairment in determination of decision making capacity [13]. Even if there is a living will that coincides with the patient's request, the patient could have been affectively disturbed at the time of making the will. Legislation permitting assisted suicide or euthanasia would need to specify the need for evaluation of depression, unrecoverable poor quality of life, and, in Japan, degree of distortion in the estimation of failure in duty to others as well as degree of priority placed on the family's wishes as opposed to the patient's. Development of a competence standard that assesses the patient's appreciation of their clinical situation in addition to whether they understand their situation is one way to evaluate a depressed patient's refusal of life-saving treatment [20]. Both the U.S. Consultation/Liaison organizations and the Japanese Society of General Hospital Psychiatry could develop guidelines that go beyond the legal prerequisites and also help to initiate educational programs in medical school and residencies in order to sensitize young physicians to these issues.

    Further study is still needed on many of the issues discussed in this study. Complicated issues like when and how to die will necessarily be dictated by the history and culture of each society, and debated by the differing opinions of individuals within each society. Looking at how other societies handle these matters may help to understand one's own approach to them.


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    Douglas Berger, M.D.1,2,3, Isao Fukunishi, M.D.3, Mary Alice O'Dowd, M.D.2, Takashi Hosaka, M.D.4 Tomifusa Kuboki, M.D.1, Yoshihiro Ishikawa, M.D.3

    1Department of Psychosomatic Medicine, Tokyo University Branch Hospital, Tokyo Japan. 2Department of Psychiatry, Albert Einstein College of Medicine, Bronx New York. 3Tokyo Institute of Psychiatry, Tokyo Japan. 4Department of Psychiatry and Behavioral Sciences, Tokai University School of Medicine, Kanagawa Japan.

    Psychotherapy and Psychosomatics, (In press);1997.



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