Rethinking Good Death: insights from a case analysis of a Japanese medical comic

1. Rethinking Good Death:insights from a case analysis of a Japanese medical comic Hiroshi Yamazaki, PhD Uehiro Chair for Death and Life Studies, Graduate School of Humanities and Sociology, University of Tokyo

2. Aim • Critiquing existing Western literature on “good death” by exploring a case of “good (enough) death” portrayed in a Japanese medical comic [=“manga”] • Broadening the scope of discussions on “good death”

3. Why focus on manga? (1) • Enormous influence on contemporary Japan • Huge market: • \470 billion (domestic sales value in 2007) • 40% of all books & mags sold in Japan (1995) • Meta media burgeoning business: • Magazines→paperbacks, hardbacks, TV animations, TV dramas, film animations, live-action films, CDs, toys, stationary, videogames, operas, novels…etc.

4. Why focus on manga? (2) • Enormous influence on contemporary Japan • Wide generational, gender & structural coverage • Almost all ages (not only for kids!) • Both genders (but more popular among men) • Readers from every walk of life (incl. academics!) • Wide genre coverage • sport, horror, science fiction, school life, romance (both heterosexual and homosexual), sex, religion, history, biography, business, environmental issues, cooking/gourmet, fashion, gambling, police/crime, mystery, education, animals, classic literature, ……and medicine

5. Why focus on manga? (3) • Manga disclose general Japanese values and ideals to a great extent • Hollywood films for Americans: Manga for Japanese

6. The case: Nurse Aoi • Commercially successful • 21 vols of paperbacks (still cont.) • Made into TV drama (2006) • Chief protagonist = nurse • Nurses play a more key role in end-of-life care (Glaser & Strauss 1965) ⒸRyo Koshino/KODANSHA

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24. Argument 1 • Good deaths must be analyzed more in the view that it is a series of interactions between stakeholders. • Fact: listing key ingredients of good death still common • Concern: temporal & interactive nature of death and dying undermined and an ideologized master-narrative of good death may dominate • Suggestion: more qualitative research and case studies focusing on the processes and interactions should be conducted

25. Argument 2 • Discussions on good death must focus more on cases with caring comatose patients. • Fact: good death literature predominantly based on palliative medicine Patients are usually conscious and have relatively long time to interact with healthcare providers and family till the final moment of death

26. Typically listed components of good death • Management of physical and psychological pain and distress • Collective decision-making over treatment • Preparation for death • Completion of unfinished business • A sense of usefulness as a social being • Unique and empathic treatment of the dying • Dying with dignity • Not dying alone Strong emphasis on the importance of an awareness of dying and active autonomous reciprocity between patients and caregivers

27. Argument 2 • Discussions on good death must focus more on cases with caring comatose patients. • Concern: presupposing and overemphasizing patient’s awareness of dying and autonomy for his/her good death may imply that the issue of good death ceases to exist once patients become irreversibly unresponsive.

28. Argument 3 • Discussions on good death must focus more on non-Western clinical cases. • Fact: good death literature predominantly based on Western palliative medicine

29. Western cultural scriptof good death • “With regard to ‘good death’, authors on terminal palliative care are remarkably consistent in describing the general features of an ideal dying trajectory: awareness, autonomy, a self-chosen coping style, and open and honest communication. This can be seen as a ‘cultural script’ that is dominant in the international literature of Western palliative care” (Goldsteen et al, 2006: 378–9).

30. East Asian(?) cultural scriptof good death • empathic reading/gauging • appropriate downplaying of dying awareness • appreciation of the relational self

31. Empathic reading/gauging • Willingness of caregivers not only to elicit the needs of patients and family through verbal communications, but also to gauge empathically their “unvoiced needs, providing comfort without actually being asked” (Mok & Chiu, 2004: 480) • Its nature, however, is inconsistent

32. Appropriate downplaying of dying awareness • Attitude and act of caregivers not assuming the primacy of awareness of dying • Adjusting to cultural taboos and norms • Danger of inappropriately downplaying dying awareness • Constant self-reflection on the part of care providers must accompany

33. Appreciation of the relational self • Willingness of caregivers to appreciate comatose patients’ existence by acknowledging their “self” as their own part of the web of human relationships or society, which they do not have to work to gain as it is given to all of us spontaneously. (=consciousness and awareness not prerequisites) • Two “self”: ji-bun (relational self) and ji-ko (autonomous self)

34. Conclusions • Good deaths must be: • analyzed more in the view that it is a series of interactions between stakeholders • Discussions on good death must: • focus more on cases with caring comatose patients • focus more on non-western cases • empathic reading/gauging • appropriate downplaying of dying awareness • appreciation of the relational self