In her anthropological study Final Days: Japanese Culture and Choice at the End of Life
(2015), American academic Susan Orpett Long examines the culture that surrounds dying and death in Japan, offering comparisons with the American approach. Long argues that culture creates the symbols through which death acquires meaning, while social and cultural connectedness limits individual autonomy in choosing a way of dying. She also argues that to some extent, postindustrial cultures force a measure of choice on the dying.
Chapter 1, “Culture and Choice at the End of Life,” introduces the book’s topic and gives an overview of the argument, opening with an anecdote drawn from Long’s own life, about the death of her close friend Judy, an American woman who wished to “die with dignity” at home. Long argues that in a postindustrial cultural and economic context, dying patients have choices about how to die, but they are also forced to choose. Chapter 2 turns to turns to the anthropological study of dying, placing Long’s work in the context of existing anthropological literature of death and bioethics.
Chapter 3 introduces the Japanese context. Long begins by pointing out that individuals’ choices about how to die are constrained by the “structure and institutions” of society at large. Japan’s postindustrial economy is a major factor in shaping how Japanese people die. To a large extent, it dictates which causes of death are the most common, as well as the medical options accessible to the dying. Long also considers a range of other factors shaping Japanese choices about dying, including demographic, institutional, and political considerations.
With these factors carefully mapped, Long can turn to those which particularly concern her. Chapter 4, “Metaphors and Scripts for the Good Death,” considers the purely cultural factors which shape Japanese approaches to death. She argues that there are four cultural “scripts” for a “good death” available to contemporary Japanese people, each setting out a slightly different approach to dying. The first is the “modern medical” script. This emphasizes the primacy of medical authority, encouraging the dying to submit to the recommendations of their doctors and other medical professionals. The second is the “revivalist” script, which instead emphasizes the autonomy of the individual patient, prioritizing his or her wishes. Third, there is a range of religious scripts, which embrace one or (often) more of Japan’s coexisting religious traditions: Shinto, Buddhism, Taoism, Confucianism, and Christianity. Lastly, Long considers anti-revivalist scripts, such as the cultural pressure to accede to family wishes.
Chapters 5 through 8 examine the many ways in which these scripts are drawn upon and adapted in different medical contexts. Long walks the reader through the process of dying, beginning with the perspectives of ordinary, non-dying people on the end of life.
Chapter 5, “Who Decides,” introduces the role of social relationships in dictating individuals’ choices about how to die. To explore this topic, Long draws on bioethical research on topics such as informed consent and surrogacy. This leads into an examination of the hospital setting, the place where—in a postindustrial society—most people go for treatment and most people die. Long considers the way these two roles of the modern hospital co-exist and interact with one another.
Next, she turns to the ways Japanese people choose to disclose a terminal diagnosis to friends and family, and the ways they or their families might choose to discontinue further treatment. She argues that end-of-life decisions are “social processes” which depend on patients, families, and medical professionals negotiating the differences in their values and priorities. Long looks at hospice care and euthanasia, before turning to some of the contemporary dilemmas, such as organ transplantation from brain-dead patients, which have forced creative adaptation of traditional scripts for dying.
Long finds that people rarely, if ever, follow one “script” in a rigid way. Rather, they treat the scripts as guidelines, drawing on different scripts at different stages of their progress towards death.
In Chapter 9, “Choice and the Creation of a Meaningful Death,” Long sets out her conclusions. Culture creates the possibility for symbolic choices that empower the dying to imbue their deaths with meaning. In a postindustrial context, a certain amount of choice is forced on the dying. However, these choices are shaped and constrained by social and cultural factors. In Japan in particular, the choices of the dying are often shaped by social relations to a greater extent than in other postindustrial societies, such as America, where individual autonomy is given greater emphasis.
For these reasons, although the physical realities of death in Japan and America are similar—people tend to die in hospital and of the same causes—Japanese and American people view and experience death differently. Nevertheless, there is no “Japanese” or “American” way to die. Rather, both cultures are engaged in an ever-shifting cultural project in which individuals make choices that suit them.