Final Days: Japanese Culture and Choice at the End of Life (review)

For the middle class and above in advanced postindustrial societies, death frequently involves a series of decisions that force individuals and fam-ilies to address questions not only of how to prolong life, but of what is a good death and, ultimately, what is a good life. Final Days is an ethnography of the final days and months of life in Japan. It addresses narratives of what constitutes a good death and explores how individuals who are dying, their families, and medical staff negotiate and discuss end-of-life decisions.

Susan Long argues that "Japanese today do not have a 'Japanese way to die' despite wide consensus on some bioethical issues" (p. 12). Long draws on British sociologist Clive Seale's argument¹ that people have multiple cultural scripts available to them in regard to dying which they flexibly combine and rework to interpret their world. She writes, "real-life decisions are not limited to the application of explicit cultural rules or moral principles but rather are tied up with a cacophony of multiple, sometimes conflicting values and interpersonal relationships" (p. 2). Long points out that in contrast to most accounts of dying written in Japanese which tend to be normative, her book describes how ordinary people experience dying through multiple cultural scripts. She focuses on conflicting values, differing opinions, and negotiation at the personal and institutional levels in the dying process. The book effectively brings together narratives about death with description and analyses of the ways in which medical professionals, patients, and the families of these patients make and explain end-of-life decisions.

Long's study is based on seven months of participant observation and in-depth interviews conducted in 1996 with follow-up fieldwork in subsequent years. Long divided her time between a hospice ward of a private hospital, an internal medicine department in a university hospital, and a specialty hospital operated by the national government. She also attended university seminars and accompanied caregivers on home visits. Readers will be interested in her accounts of meetings between patients, clients, and families; descriptions of patients as they move from hospitals to hospices; and analyses of individual cases from the perspectives of the nurses, doctors, patients, and their families. The research could not have been easy to undertake emotionally as informants died throughout the course of her field stay. The pain and doubt experienced by doctors and family members who feel responsible for the patient are also quite evident.

The structure of the book proceeds from a macrostructural introduction to microlevel case studies, and from an introduction of formal narratives to descriptions of the informal application of these narratives. Chapter three looks at how individual decisions are constrained by the demographic, structural, and institutional arrangements of the larger society. Long points out that dying in Japan will most likely involve an extended chronic illness followed by acute care and death in a hospital. During this process, most individuals will seek help from family members and from health care professionals. She explains that due to state provision of health care in Japan, end-of-life decisions are framed not so much by economic issues as they are in the United States, but through interaction between medical professionals' expertise and the patient's and the family's knowledge of how the patient has lived his or her life. Thus establishing the structural context for the study, chapter four examines people's ideas of what constitutes a good death. Long introduces terms that commonly emerged in her interviews, such as "rōsui," or the gradual decline of old age which allows for preparation for death, and "pokkuri," or sudden death which allows one to die without pain. Metaphors such as "shinime ni au" (being there to "meet the dying eye") and "yasu-raka" (peaceful) are used to establish that a death has been a good one. She also identifies a...