Shades of grey between life and death: Neuro-ethics across the Pacific. A cultural, ethical, medical and legal exploration of Japanese and American Societies

In light of the ongoing global COVID-19 crisis and worldwide travel restrictions, which are expected to remain in place for an indefinite period of time, Stanford University is suspending all BOSP Summer Quarter 2019-20 programs (see full announcement).

Seminar Quick Facts

Locations: Osaka and Kyoto, Japan

Faculty Leaders: Karen Hirsch, MD (Neurology) and Holly Tabor, PhD (Medicine)

Arrival date in Osaka, Japan:  June 28, 2020

Departure date from Kyoto, Japan: July 18, 2020

Information Session: November 19 (12pm - 1pm) in Sweet Hall rm. 403 - lunch will be provided

Program Cost: $600 program fee. Fee covers room and board, transportation and course activities during the program. Fee excludes airfare to/from the program location. Financial assistance towards the program fee and cost of travel may be available. Please visit the Overseas Seminar Overview webpage for complete information.

Academic Prerequisites
All prospective students are required to take the three unit prerequisite course, “MED 142: Modern Ethical Challenges in Neuroscience and Organ Transplantation” during the Spring Quarter 2019-2020. Students that will be off-campus in Spring Quarter may still enroll in the prerequisite course and should make arrangements with the faculty to complete the course remotely.

Additional Program Requirements
1) Ground Rules - In order to optimize safety during the program, students will be required to agree to and sign Ground Rules that may restrict behavior throughout the program. These Ground Rules are in addition to the BOSP Participation and Assumption of Risk, Release of Claims, Indemnification and Hold Harmless Agreement that all students sign and agree to at the time of program application. Students’ parents/families will also need to sign these Ground Rules to confirm that they acknowledge the specific dangers of travel to the program location.

Activity Level
Light/Moderate: Activities may include city walking tours, easy/short hikes, museum and other site visits as well as an occasional physical activity such as snorkeling, hiking, or kayaking. For a full list of program activity levels refer to the Overview page.

Center for Disease Control and Prevention: Health Information for Travelers to Japan

US State Department Country Information: Japan

Visa Information: Consulate General of Japan

General Information: Visit the Overseas Seminars Overview page

Application Deadline: January 26, 2020 at 11:59pm (applications will open in December 2019). Please visit BOSP's Application Process page for more information.

Questions? Schedule an appointment with a BOSP staff member.

General Description

This Overseas Seminar is designed to take special advantage of the opportunity to expose students to the far-reaching implications of societal cultural differences. How can a person be dead in America but alive in Japan? Why does Japan have some of the lowest rates of life-saving organ transplantation in the world despite being a highly developed society with an expert health system comparable to the United States? This course will explore cultural, medical, legal and ethical perspectives of life and death and the impact of those on organ transplantation and the broader healthcare system in the United States and Japan. Our goal is for students to develop an appreciation for how history and societal constructs have a direct impact on ethics, laws, and healthcare systems.

Death is broadly considered an absolute biological event, yet the space between life and death is often blurry and influenced by cultural, medical, and legal forces. Fifty years ago, with the advent of critical care medicine, the concept of brain death was first proposed: that a brain which sustains such severe injury that it is irreversibly and permanently damaged and the organism as a whole can never regain function is sufficient criteria for death. While the construct of brain death is generally accepted in America by medical personnel, ethicists, lawyers, and society as a whole, recent high profile cases and media coverage have brought novel challenges to these constructs, including, but not limited to, what it truly means to be brain dead, how brain death is/should be determined, and the societal implications of those definitions. With those debates come questions about consciousness, severe neurologic impairment, organ donation, and withdrawal of life supporting therapies - critical ethical questions that are colored in practice by sky-rocketing healthcare costs, a need for organs for transplant and limited health care resources. This uncertainty is compounded by the nature of living in a global society where different cultures may have highly divergent perspectives on and values surrounding these issues.

In Japan, brain death is not legally considered death. Cultural beliefs and legal cases have declared circulatory death to be the only criteria for death, thus rendering organ transplantation rates in Japan amongst the lowest in the world. Instead neurologically devastated patients, who would be considered brain dead in the US and Europe, are often supported in long-term care facilities at the wishes of the family and life-saving organ transplants, made possible elsewhere largely via donors who are declared “brain dead”, are incredibly rare.

This BOSP seminar will provide an in-depth exploration of neuro-ethical issues surrounding life and death in Japan and America. Participants will learn about the medical, ethical, cultural and legal dimensions of brain death and organ donation in two similar, yet different, cultural contexts. The immersive international experience will include on-site experiences and intimate learning opportunities with interdisciplinary and international experts both in the US and Japan, as well as patients and families affected by these medical-ethical dilemmas. It will also include visits to Japanese cultural sites as well experiential learning about Japanese culture and food. We also hope to have an opportunity for Stanford students to interact with Japanese university students.

Location

This seminar will take place in Kyoto and Osaka. Japan is comparable to the United States in its healthcare and socioeconomic status, but has extremely low organ transplantation rates, one of the lowest five countries in the world. Other countries with low rates of organ transplantation have either religious reasons precluding acceptance of brain death (i.e., Saudi Arabia) or inadequate medical infrastructure (Venezuela, Malaysia, Dominican Republic and Ukraine). Japan is unique in having neither of these constraints.  Drs. Tabor and Hirsch both have connections with Japanese colleagues who will provide excellent experiential opportunities for visiting students. 

Kyoto is the capital city of Kyoto Prefecture, in the Kansai region on the island of Kanshu. It was the seat of Japan’s imperial court from 794 to 1869. Kyoto is considered the cultural capital of Japan, and has numerous Buddhist temples, Shinto shrines, and palaces and gardens, many of which are listed collectively by UNESCO as a World Heritage Site. It is also the location of Kyoto University. During World War II, the city was largely spared from conventional bombing, and as a result it is one of the few Japanese cities that still have pre-war buildings.

Osaka is also in the Kansai region of Japan, and is the capital of Osaka Prefecture. It is considered one of Japan’s major financial hubs, and is the second largest metropolitan area, after Tokyo. Osaka is known for its food. It’s nickname is “the nation’s kitchen” and it has been called by some “the food capital of the world”. It is also home to the Hanshin Tigers baseball team, one of the oldest professional baseball clubs in Japan. 

In both Kyoto and Osaka, we will visit academic centers, medical schools and hospitals and interact with Japanese bioethicists and physicians. We will also engage in numerous cultural trips and activities, including temples and shrines, including an overnight visit to Koumyouin Temple. 

Living and Travel Conditions

Please note, both Kyoto and Osaka can be very hot and humid during the summer, when the seminar will take place. Many of the places we will work and visit will be air conditioned, but not all, and students should be prepared to face non-California summer conditions. Temperatures average in the high 80s to low 90s, but can get hotter, with high humidity and frequent rains. 

Students will stay in hotels in Kyoto and Osaka, and spend one night in the Koumyouin Temple in a ryokan, where they will sleep on tatami/futon mattresses on the floor. Students should expect to share rooms and bathrooms.  

If any of these conditions are likely to present a challenge, you are encouraged to contact BOSP well in advance: accommodations will be made to the extent possible.

Faculty

Dr. Karen Hirsch has a medical degree from Stanford University and completed neurology residency at Johns Hopkins and neurocritical care fellowship at the University of California, San Francisco. She returned to Stanford University as faculty in 2012. Dr. Hirsch’s clinical practice focuses on the care of patients with severe neurologic injury in the intensive care unit, including traumatic brain injury, stroke, aneurysms, and cardiac arrest. She runs an independent research program studying brain injury after cardiac arrest and prognosis for coma recovery and has grant funding from American Heart Association and the National Institutes of Health. She also serves on the American Heart Association Emergency Cardiovascular Care Science Committee, Society for Critical Care Medicine Neurosciences Steering Committee, and in other national leadership roles. She collaborates with Japanese neurocritical care physicians and recently coordinated sending a fellow to Japan for a one month externship. Dr. Hirsch is also the physician faculty liaison to the organ procurement organization Donor Network West, working with colleagues in Ethics (including Dr. Tabor) and legal to ensure seamless and compliant collaboration for organ transplantation at Stanford. In addition to her work at the medical school, Dr. Hirsch is involved in undergraduate education at many levels, serving as a pre-major advisor, teaching in seminar classes, working with undergraduate teams in bioengineering and chemical engineering, serving as the faculty-athletic fellow for the women’s soccer team, and in the summer of 2019 became a Resident Fellow in Soto House.

Dr. Holly Tabor has a PhD in epidemiology and a minor PhD in genetics from Stanford University, and an A.B. in History and Science from Harvard. She was a postdoctoral fellow in bioethics at the Stanford Center for Biomedical Ethics, and was Assistant and then Associate Professor of Pediatrics at the University of Washington and the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s from 2008-2016. Since 2016, she has been an Associate Professor of Medicine and the Associate Director for Clinical Ethics and Education at the Stanford Center for Biomedical Ethics at Stanford University. Her research focuses on ethical issues in genetic and genomic medicine and research, as well as health disparities and inclusive health for patients with disabilities. She is Co-Chair of the Stanford Hospital Ethics Committee and oversees the clinical ethics consult service at Stanford Hospital and coordinates all educational activities for undergraduates, medical students, graduate students, residents and fellows through the bioethics center. She has also been a faculty advisor to Stanford undergraduates.

Prerequisites and Expectations

This seminar is intended for students with a diverse range of backgrounds and interests, including but not limited to neuroscience, pre-law, philosophy, medicine, bioethics and East Asian studies/languages/cultures. Students do not need to have advanced knowledge, but should be able to describe their coursework or experiences that led them to apply for this program. Students should be able to work productively, efficiently and congenially in a small group setting. 

This course will discuss topics and emotions around brain injury, disability, dying and death. These discussions can sometimes be upsetting for some people, especially those who have had personal experiences in this area. The course directors will be available to support reflection and discussion, but applicants should consider carefully if they will be able to manage these kinds of discussions and assignments. If there are questions about this, they are encouraged to reach out to Drs. Hirsch or Tabor.

All prospective students are required to take the three unit prerequisite course, “MED 142: Modern Ethical challenges in Neuroscience and Organ Transplantation” during the Spring Quarter 2019-2020.

Application Process

Decisions will be based on application materials and interviews. The seminar capacity is 15 students.

Grading Basis

Students will receive a letter grade.

Passport and Visa

Students are solely responsible for obtaining their passport and visa (if applicable). Every BOSP participant MUST have a signed passport that is valid for at least 6 months after the scheduled RETURN date from the overseas program. Students who do not have a valid passport must apply for a new or renewed passport immediately. For information on obtaining or renewing a U.S. passport please visit the State Department website.

To determine whether a visa is necessary for your program, visit the Consulate General of Japan. You may also consult with the recommended visa service providers listed below.

VisaCentral by CIBT
VisaCentral by CIBT offers online Stanford rates, or contact the local office:

In person: 555 Montgomery St. Suite 700, San Francisco, CA 94111
Walk-in hours: 8:30 a.m. to 5 p.m.
By phone: (877) 535-0688

Health and Safety

Students on international programs should be aware that attitudes toward medical conditions, disabilities, sexual orientation, gender identity and expression and psychological conditions vary by culture and under the laws of the host countries. These differences impact the level of treatment and accommodation available abroad. Students should give serious consideration to their health and personal circumstances when accepting a place in a program and should consult with their clinician.

While the benefits of international travel can be enormous, it is often associated with certain health and safety risks. Thankfully, a number of interventions exist to mitigate these risks including vaccines, use of certain medications, and specific behavior changes. Health concerns vary by the particular destination, time of year, the health of the individual, type of accommodations, length of stay and specific activities. Participants should be up to date on all their regular immunizations, check the CDC website for vaccinations and immunizations. In addition, specific travel vaccines such as typhoid, yellow fever, or rabies vaccines may be indicated. Various types of medication may also be needed to prevent life-threatening malaria or altitude illness; or to treat traveler’s diarrhea. Finally, students should learn and utilize insect precautions, food and water precautions, and general safety precautions. These can prevent illnesses such as dengue fever, schistosomiasis, HIV; or accidents such as those involving motor vehicles. In spite of all the precautions, occasionally students do become ill or sustain an injury while traveling. Thankfully, most of these are minor. However, it is critical that students have a clear plan of care in case of an emergency on their trip. The travel clinic at the Vaden Health Center has produced an online travel health module that provides comprehensive strategies to help you stay safe and healthy while traveling.

Students must review the Centers for Disease Control and Prevention website for complete information regarding the health concerns and vaccine recommendations specific to Japan. Students must also discuss with the on-campus Vaden Health Center Travel Clinic or a travel health specialist about the best ways to protect their health.

Students must review the U. S. State Department’s Country Information for complete information on safety and security in Japan.

As with any foreign travel, students are advised to be alert to their surroundings, and be particularly aware of any health and safety advisories for the area in which they will be visiting. Students should consult with their health care provider(s) to be prepared for potential illness. Additional issues of personal health and safety and precautions will be discussed in detail during the mandatory pre-seminar preparation and upon arriving in the country.

If you are uncomfortable traveling under such conditions, you should not apply to this seminar.

Program Modification and Cancelation

Stanford reserves the right to cancel or modify the Program before or during its operation for any reason, including natural disasters, emergencies, low enrollment, unavailability of facilities or personnel, or compliance with the University travel policy at http://provost.stanford.edu/2017/03/03/international-travel-policy-2/.