Eye on religion: understanding the cultural/religious melange in treating Japanese patients.

Until late 19th century, Japanese health care was closely tied to medical practices that migrated from China. Herbal preparations and poultices, external physical manipulations, moxibustion, astrology, divining procedures, shamanism, and appealing to ancestors and deities were all methods for dealing with illness. The focus on preventive care left the Japanese population with little help in times of severe trauma. To solve this problem, the Japanese government advanced Western emergency medicine as the model for health care and medical practice in Japan. (1) More recently, the Japanese propensity to resolve health and spiritual concerns with multiple religious and medical approaches has allowed the re-incorporation of traditional practices. Japan is now experiencing rapid technological, social, economic and demographic changes that affect how the government funds and how clinicians provide, medical care. Western medical technology and practices are the norm in Japan but the early religious influences remain. The concepts and world views that are strong in the population are affiliation with the spirit world; regard for family and ancestors; concepts of a vital life force and pollution; diffuse location of self and personhood in relation to the body and the social structure; and karma, life, and death as a process rather than a set of events. These ideas will be a part of Japanese experience of health care in the foreseeable future.

The emphasis on modernization has not eradicated the connection between the Japanese sense of affiliation with the spirit world and their understanding of the practice of medicine. Shrines and temples supplement the clinical care system and are an important part of the remedy when illness strikes. Visits to temples and appeals to the deities through use of talismans, requests for prayers, and performance of rituals are the method for communicating with the supernatural world and meeting immediate health needs in this world. When this approach is combined with modern medicine, the resulting health outcome is considered a joint action of the medical intervention, the person and the cosmos. (2) Patients often incorporate the use of talismans, representations of deities and performance of rituals in conjunction with clinical and technical care. This combination of modern clinical and traditional religious applications is just one expression of cultural acceptance of using a wide variety of approaches when solving health problems.

Family and ancestral relations are modeled on the Confucian ideals of familial and relational piety, which include a tradition of hierarchy, reciprocal obligation and interdependence. The elders and ancestors are viewed as having given bodies and life itself to the next generation, and they must be cared for in return. One who is aging, or dying, is not looked upon as needing to make additional contributions to the living. This understanding of the nature of one's contribution during life is key to the Japanese understanding of organ transplantation. (1) The proper care of deceased ancestors continues to be crucial to the health and well being of the family for the majority of the Japanese. Improper care of family members is expected to bring bad luck, ill health and other problems and failures to the remaining relatives. (3)

Clinicians can expect that family members will be highly involved in the process of dealing with an illness or pending death. A patient may want the family to make all medical decisions, including whether the patient will be aware of a diagnosis. However, conflict could occur between the patient and family. A majority of Japanese patients are now stating that they would like to have direct communication regarding their diagnosis while at the same time stating that they feel it would not be good for most other family members to be aware of their own terminal diagnosis. (1) It is important to recognize the perception of the family as a "moral or legal agent" of an individual and at a minimum recognize that the will of the family may be the will of the individual. (1) However, the rapid social and generational change makes patient communication preference difficult to immediately discern. Physicians have been resolving this by asking the patient's preference for communication and allowing the family to determine the flow of information when the patient has deferred to the family. (4)

The Shinto belief regarding the animating quality of life, its disbursement throughout nature and the potential pollution that may occur as it is released upon death, is a foundation for the performance of purification activities. The lingering and uncontrolled dispersement of a ghostly consciousness where a person has died is seen as a potential source of pollution to the living, particularly when the death has been an unexpected or bad death. (5) Avoiding polluting elements is incorporated in the activities of daily Japanese life. For example, one should complete a purifying process when entering a home, or leaving to begin the day and laundry is sorted and washed to accommodate the understanding that the lower half of the body is impure and the upper half is pure. (2) In the clinical setting, providers would want to be aware that daily life and more importantly serious illness and death, require purification rituals to protect the ill or deceased, their relatives and community members.

Both Buddhist and Shinto themes have formed the Japanese view of self and personhood in relation to the body and the social structure. Oneness, nonduality and the illusion of the individuated self, are Buddhist themes that apply to the Japanese concept of person and the body. Shinto ideas of vital energy, and the inseparability of human beings from nature, the spirit world and the cosmos also have formed the Japanese view of personhood, self and body. The resulting understanding is that the vital quality of each person is located throughout the body and social space. In the clinical setting, organ transplants, brain death, autopsies, and any other disruption of the body while approaching, or soon after, death will cause distress for family members. The use of technology to prolong life will be expected and accepted, but making a decision to withdraw life support based on a determination of brain death is not an acceptable idea. The person's life is not understood to be located only in the mind. The desire to avoid disruption to the body continues to appear to remain strong in Japanese American culture. (6,7)

Karma (or the enduring elements of past existence) impacts the larger events of people's lives. Circumstance at birth, marriage, serious illness and other meaningful life events can be affected by unknown past actions. One area where the consequences of karma can be dire is during the process of death. In Buddhism, an individual's last thoughts and emotional posture at death can affect the afterlife and subsequent rebirth. The rituals performed at this time and the nature of the familial adherence to ongoing ritual after the death affects the afterlife as well. Family members will expect to be present at death and have the opportunity to chant, and perform rituals to ease the passage of the spirit. The need to attend to family members, and be attended to by family members, at death is significant for Japanese patients and their families. Providing time and space for the family to perform the rituals following death will help ease the process of death in a hospital setting. (5)

In the Japanese world view, life is considered to be a constant process of becoming and ending, rising and falling, and emerging and dissipating. Events occur in cycles of movement and social context, rather than in static moments. Flexibility, choice, paradox, perplexities, and situational and social assessment of circumstances, are ingrained in Japanese culture. (1) Understanding how to address the concepts of flux and process in communication with patients and families is helpful. Initially, it may appear that communication is unclear and too indirect to manage. With close listening, and an ear for a culture that allows perplexities, one can negotiate conversations with increased skill. A clinician who is open to the use of metaphor, is willing to be flexible according to circumstance, and has an understanding that crucial communications will often be nonverbal, will be the most successful in supporting positive family relations and patient outcomes.

Industrialization, urbanization, rapid assimilation of medical technology, an increase in the elderly population, separation of multigenerational living situations, and some loss of commitment to the ideas of filial relations, all have affected the modern Japanese population. Due to the social and cultural effects of migration, assimilation, and generational change within the Japanese population in the United States, it is impossible to present an "expected set" of Japanese beliefs to health care providers. What is clear is that knowledge of culture, religion and belief is an essential tool that clinicians can use to improve patient outcomes, promote health, and facilitate communication with patients and their families. (8)

References

1. Becker CB. Aging, dying and bereavement in contemporary Japan. International Journal of Group Tensions 1999;28:59-83.

2. Ohnuki-Tierney E. Health care in contemporary japanese religions. In: Sullivan LE, ed. Healing and Restoring: Health and Medicine in the World's Religious Traditions New York, Free Press, 1989, pp 59-87.

3. Mullins MR. Christianity Made in Japan: A Study of Indigenous Movements Honolulu, University of Hawaii Press, 1998.

4. Lapine A. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 2001;4:475.

5. Long SO. Final Days: Japanese Culture and Choice at the End of Life Honolulu, University of Hawaii Press, 2005.

6. Braun KL, Nichols R. Death and dying in four Asian American cultures: a descriptive study. Death Stud 1997;21:327-359.

7. Lock M. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley, University of California Press, 2002.

8. Matsumoto D, Pun KK, Nakatani M, et al. Cultural differences in attitudes, values, and beliefs about osteoporosis in first and second generation Japanese-American women. Women Health 1995;23:39-56.

From the Comparative Religion Department, Western Michigan University, Kalamazoo, MI.

Reprint requests to Cindy Visscher, Western Michigan University, Comparative Religion Department, 1903 West Michigan Avenue, Kalamazoo, MI 49008. Email: [e-mail]