The ageing population means that dementia is a serious social problem in Japan. Attitudes toward ageing in Japan are increasingly negative, and views of life and death among older people vary. Numerous ethical problems exist in the medical treatment of dementia. Amidst such conditions, it is important and beneficial to examine films that depict demented patients and to consider the issues raised by these films. Through film we see many aspects of a country and its times: culture and ideology, morality and religion, medical treatments, views on life and death, social conditions and what issues are viewed as problems. The best films both entertain audiences and provide viewers with opportunities to think about social problems. In the past 30 years, 10 films about dementia had been made in Japan and two of these—The Twilight Years (Kôkotsu no hito) and Memories of Tomorrow (Ashita no kioku) are the main focus of this paper. In our analysis we consider three points: how the patients are informed of their disease, the characters’ wishes for death, and terminal medical care.
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DEMENTIA-RELATED BIOMEDICAL ISSUES AND FILMS
As the population of Japan ages, there is an accompanying increase in patients with dementia. The research section of Japan’s Ministry of Health, Labor and Welfare estimates that the number of patients with dementia will have doubled from 2.05 million in 2005 to 4.45 million in 2035.1 In addition, because of the excessive burden of elderly care givers taking care of elderly relatives, there have been a number of cases where elderly demented patients have been murdered by their care givers.2
Numerous ethical problems exist in the medical treatment of dementia. Issues include the question of whether or not patients should be told about their illnesses and, if so, how best to tell them; the significance and role of advance directives; the provision of terminal care for elderly patients and the need to provide care for care givers of demented patients. Finally, the issue of what is in the best interests of bedridden, apathetic and unresponsive patients, who no longer feel any subjective suffering or hopelessness, raises numerous ethical and social questions that concern the very meaning of human life, including whether euthanasia and assisted suicide should be available or outlawed.3 4 Against this backdrop, we undertook an examination of a selection of films that depict demented patients, paying particular attention to the following: if and how the demented characters are informed of their disease; whether or not they wish for death; and the type and quality of care they receive in the last phase of their lives.
THE TWILIGHT YEARS AND MEMORIES OF TOMORROW
An initial search of Japanese books, scholarly papers about film and biomedical ethics, and DVD supplements,3 5–8 as well as an internet search9 10 produced an initial list of 10 films we considered suitable for this study (Box 1).
Box 1 Ten films about dementia made in Japan in the past 30 years
The Twilight Years (Kôkotsu no hito), directed by Shiro Toyota, written by Zenzo Matsuyama, performed by Hisaya Morishige et al, 1973.
Three-Seventy Five Gram of Flower (Hana Ichimonme), directed by Toshiya Itoh, written by Hiroo Matsuda, performed by Minoru Chiaki et al, 1985.
Human Promise (Ningen no Yakusoku), directed and written by Yoshishige Yoshida, performed by Rentaro Mikuni et al, 1986.
Will in the Afternoon (Gogo no Yuigonjou), directed and written by Kaneto Shinto, performed by Haruko Sugimoto et al, 1995.
Yukie (Yukie), directed by Hisako Matsui, written by Kaneto Shinto, performed by Mitsuko Baisho et al, 1998.
A Day in the Summer (Ano Natsu no Hi), directed by Norihiko Ohbayashi, written by Shiro Ishimori and Norihiko Ohmori, performed by Keiju Kobayashi et al, 1998.
Way of Acacia (Akashia no Michi), directed and written by Joji Matsuoka, performed by Yui Natsukawa et al, 2000.
Picked Japanese Apricot (Oriume), directed by Hisako Matsui, written by Hisako Matsui and Akane Shiratori, performed by Emiko Harada et al, 2002.
Half a Confession (Hanochi), directed by Kiyoshi Sasabe, written by Toshiyuki Tabe and Kiyoshi Sasabe, performed by Akira Terao et al, 2004.
Memories of Tomorrow (Ashita no Kioku), directed by Yukihiko Tsutsumi, written by Ryo Sunamoto and Yuiko Miura, performed by Ken Watanabe et al, 2006.
Of these, our study focused on two films, The Twilight Years and Memories of Tomorrow (boxes 2, 3). While we do refer to other films produced within Japan and abroad where relevant, we do not attempt to provide either a systematic analysis of dementia in film nor to compare and contrast the two films from the standpoint of film studies. Instead, the primary objective of this paper is to explore the ethical problems raised by the care of dementia patients as depicted in these films.
Box 2 The Twilight Years11
The setting is Tokyo in 1972. Eighty-four-year old Shigezo Tachibana lives with his 75-year-old wife and their son, daughter-in-law and grandson. One day, his wife suddenly dies, and this leads to a sudden progression of Shigezo’s dementia, which his family had not been aware of previously. Shigezo cannot comprehend his wife’s death. He does not recognise his daughter when she visits, wanders aimlessly and experiences insomnia and nocturnal delirium. He is always hungry and is continually asking for food. Eventually Shigezo eats his wife’s ashes in the middle of the night. Akiko, the wife of Shigezo’s eldest son, takes complete responsibility for his care in addition to her own work and becomes physically and mentally exhausted. She receives little or no support from her husband. Yet gradually Akiko and Shigezo bond as human beings. Even as Shigezo’s condition deteriorates, he is able to recognise Akiko until the very end. One day, Shigezo wanders aimlessly for a long time in a torrential downpour, becomes utterly exhausted and dies.
Box 3 Memories of Tomorrow12
This film, set in contemporary Tokyo (2005), traces the lives of a man with early-onset Alzheimer disease and his wife as they fight the disease over several years. The main character, 49-year-old Masayuki Saeki, goes to see a neurologist after he begins to experience episodes of forgetfulness and difficulty with mental processes: he cannot remember the names of clients at his advertising agency, forgets meetings and buys the same thing numerous times. Masayuki is diagnosed as having dementia of the Alzheimer type with early onset. The Saekis are devastated. The film goes on to depict the unrelenting advance of the disease and the wife Emiko’s efforts to care for him at home, along with the wedding of their only daughter, the birth of their first grandchild and Emiko’s professional independence. When Masayuki is finally unable to recognise his wife, Emiko resolves to place him in an institution.
The ethical and social problems associated with dementia form a major focus of both films. Shiro Toyota, the director of The Twilight Years, has said that he wanted to focus on the emotional ties between Shigezo, who has dementia, and his daughter-in-law, Akiko.13 Novelist Sawako Ariyoshi, on whose book The Twilight Years14 is based, wrote her book to share her view that the serious problems associated with ageing, which can destroy a family, should not be regarded as someone else’s problem or just ignored; rather, people should recognise that they too will age, and think about how they want to be treated when they get older.15 Perhaps reflecting widespread discomfort at this self-evident truth, film critic Ken Masubuchi pointed to the scenes of caring for older people in The Twilight Years in his review entitled “On the depiction of old age”, noting that “The very essence of the ageing problem is that what is on the inside a hopeless tragedy appears from the outside to be a side-splitting comedy.”13 16
Hiroshi Ogiwara’ s novel Memories of Tomorrow, which was the basis for the 2008 film of the same name, sold over 230 000 copies, winning the 18th Yamamoto Shugoro Award in 2005 and taking second place for the Japanese Bookstore Grand Prize. 17 Director Yukihiko Tsutsumi and Ken Watanabe, the producer and star, describe Memories of Tomorrow as a story in which all sorts of things are forgotten. Its message is that there are some things that must not be forgotten, and the film aims to inform society about the difficulty of early-onset Alzheimer dementia, the importance of human ties, and love between a married couple.18
A number of factors influenced our choice of these two films. First, both films were pioneering in that they were the first Japanese films to straightforwardly depict the problems faced by patients with, respectively, senile dementia and early-onset Alzheimer-type dementia. Second, both films resonated with Japanese society, achieving both commercial and critical success with the release of The Twilight Years followed by an unprecedented period of renewed interest in public policy on treatment and care of older people and dementia patients.19 Third, The Twilight Years is the oldest and Memories of Tomorrow is the newest of the 10 films identified by our search, thus giving an (admittedly limited) chronological range to this analysis. Fourth, both films are widely available in DVD or video and are thus easily accessed by public and professionals alike.
JAPANESE ATTITUDES TO GIVING PATIENTS BAD NEWS
In Japanese society, although patients’ self-determination is seen as important, there is also a strong desire to protect them from the harsh truth and there continues to be resistance to attempts to inform patients of serious diagnoses such as cancer.20 Nevertheless, within medical practice, informing demented patients about their condition is becoming more widespread.21–23 Within some dementia-related films made in Japan, scenes related to the disclosure of the patient’s condition highlight and reflect the complex social position and unresolved debates over whether to inform patients of their dementia.
Memories of Tomorrow, set in present-day Tokyo, contains a dramatic scene in which the Saekis are informed of Masayuki’s condition. While explaining the results of the medical tests, the neurologist informs Masayuki and Emiko that Masayuki has Alzheimer disease. After being told of his condition, Masayuki suddenly becomes agitated and blames the physician, stating that after working as a doctor for 10 years, he must have become accustomed to breaking the news to patients and can no longer understand how it feels to be told you have dementia. He even accuses the doctor, saying, “You probably think it’s none of your concern, don’t you?” and “Are you happy to have found a disease?”
Masayuki subsequently runs to the hospital’s roof and prepares to jump. In response, the doctor explains that his own father had the same illness, so he wants to do everything possible to save people with the condition. He tries to persuade Masayuki not to give up, and ultimately Masayuki agrees.
In the South Korean film A Moment to Remember, which was also very popular in Japan, the main character, 27-year-old Su-jin, visits the hospital and undergoes several tests without telling her husband. After a few hospital visits, she has a diagnosis of early-onset Alzheimer disease.24 She feels hopeless and falls into a state of depression. When her new husband, Cheol-su, learns she has gone to the hospital alone and has been told of her illness, he is furious with the doctor. “Are you out of your mind? What do you hope to accomplish by telling her?” he demands of the doctor. But a nurse who hears this defends the physician, explaining, “The doctor’s wife died of the same illness. He’s devoted everything to this research.” At this point, the doctor explains that he had to tell Su-jin the truth so that she could prepare herself emotionally, but Cheol-su refuses to listen.
These scenes suggest that in Japan, and elsewhere in Asia, physicians who tell their patients the truth may become objects of criticism. It also suggests that doctors who inform patients of their conditions need personal reasons to justify their conduct. Masayuki’s words reflect a way of thinking whereby a doctor who really considered the patient’s feelings and was not jaded would never disclose the illness to the patient. It appears that the Western ethical view—that the doctor has a duty to tell patients the truth about their condition—holds little sway with either Cheol-su or Masayuki.
In addition, there is the suggestion that only doctors who have experienced the same situation—for example, having a family member with the same disease—are qualified to speak. In other words, only in special circumstances is the physician permitted to tell patients that they have dementia, with the honest disclosure of diagnoses such as dementia continuing to be seen, or in this case portrayed, as a cruel act. In fact, some families in Japan today try to prevent their family members from being told the truth about their conditions, and this practice is not limited to cases of dementia.25 Perhaps the filmmakers felt that their Asian audiences would not be satisfied unless the doctors gave a sufficient reason for disclosing the harsh truth to their patients.
Contrast this with the British film Iris,26 which does not include any special scenes regarding “disclosure,” but instead shows the doctor matter-of-factly explaining the disease to the patient. In response to Iris’s question about her condition’s prognosis, the doctor clearly answers, “It will win.” Iris thanks him, saying, “That’s very kind.” Although troubled and saddened, neither Iris nor her husband feels the slightest bit angry about being told the truth.
The Twilight Years, which presents the main character in the middle to late stages of dementia from the outset, does not touch on the issue of disclosure.
WISHING FOR DEATH
In films depicting dementia, the patient and the care giver frequently are revealed as wanting the patient to die. In The Twilight Years, which presents almost no insight into the inner thoughts of the demented patient, it is the psychological anguish of the patient’s family members that is frankly expressed. When the sleeping medication given to Shigezo no longer has any effect and he begins to experience night-time delirium, Shigezo’s son screams at his wife, “Kill him already!” As her father no longer has any idea what is happening around him, his daughter casually remarks to another member of the family that “there’s no point in him living anymore”. One of Akiko’s colleagues at work talks about her bedridden, 90-year-old grandfather. “He’s on a liquid diet, which goes into his nose through a rubber tube … the insurance won’t pay so its really hard”, the coworker says, calmly adding that her family wonders, “Why won’t the hospital just kill him?” In the Japanese film Half a Confession, which was released 31 years later, the desire of families for the suffering to be over is echoed by the daughter-in-law caring for her demented father-in-law, who quietly confesses to her husband that at times “I wish he would go out for a walk and never come back. I want him to die on his own.”27
The characters making such statements are regular people, not heartless scoundrels or villains, and are no different from us. They are people struggling to support themselves and their families. As already mentioned, there have been numerous cases of murder and collective suicides involving the families of elderly demented patients.2 Watching these films, it is not difficult to imagine that one might be driven to thoughts of murder when the psychological, physical and economic burdens of caring for someone with dementia are exacerbated by that person’s problematic behaviour. By openly portraying the burden placed on families, these films may perhaps go some way towards encouraging discussion within Japanese society about the need for comprehensive social countermeasures.
In other films, it is the demented person who pleads for death. In Memories of Tomorrow, when Masayaki is informed of his condition he flees from the examination room and tries to jump from the roof of the hospital. As his condition progresses and he is left unable to do anything but wait at home for his wife to return from work, he sees himself as nothing but a nuisance and wants her to divorce him. “Tell me to die!” he screams at his wife. These thoughts are once more echoed in Half a Confession, where the 51-year-old wife of the main character has early-onset Alzheimer disease. Each time she regains her senses she pleads, “As a mother, I just want to die while I still remember my son.” Her husband listens to her and complies with her wishes to kill her. In the Japanese film Oriume, the main character’s dementia worsens, making it impossible for her son and his wife to care for her at home. The day before she is to enter an institution, the protagonist Masako grabs a knife and says, “There’s no point in living anymore,” and urges her daughter-in-law Tomoe to kill her.28
In the American film The Notebook, an elderly couple joined by ties of intense love live in the same institution. The wife has Alzheimer disease and can rarely recognise her own husband. On the last night in the movie, the wife, then able to recognise her husband, asks if their love can bring about a miracle. “Do you think our love could take us away together?” she asks him. In the film, their love does create a miracle. Fully cognizant of one another, the husband and wife fall asleep holding each other and die peacefully the next morning. The end of this film is very moving. For this couple, dying together is preferable to continuing to live with the dementia.29
While depression sometimes accompanies dementia, the demented person’s sense of worthlessness often seems to be at the root of these cries for help. In real life, there is evidence to suggest that the disintegration of sense of identity, loss of independence and inability to fulfil a social function can all contribute to a demented patient’s sense of worthlessness.30
THE ABSENCE OF THE PORTRAYAL OF TERMINAL MEDICAL CARE IN JAPANESE FILM
Interestingly, none of the films considered here realistically present the lives of the main characters with dementia after they have become completely bedridden and require assistance to eat and relieve themselves. In The Twilight Years, produced more than 30 years ago, Shigezo suddenly weakens and dies comfortably at home after his final wandering about. In Iris, the protagonist dies peacefully after entering an institution, following a scene in which she dances in a trance-like state. Medical action taken in the course of events leading up to death is not depicted at all.
In the films Memories of Tomorrow, Oriume and A Moment to Remember, the stories end before issues such as confinement to bed, complete assistance or the inability to take sustenance by mouth become serious problems. In real life, as ageing and the symptoms of dementia progress, these issues become serious obstacles, which Japanese filmmakers have so far chosen not to portray.8 As a result, many important questions are left unexplored. What kind of medical treatment do Masayuki, Masako and Su-jin want during their final days? How can their human dignity be preserved? Additionally, what sorts of medical treatment will their family members Emiko, Tomoe and Cheol-su accept for them?
In reality, when demented patients in Japan become bedridden and are no longer able to feed themselves, life-sustaining action is usually taken, for instance by feeding patients through a stomach or nose tube.31 32 If patients get pneumonia, antibiotics are administered, and if they become dehydrated, they receive a fluid transfusion. In Western countries, on the other hand, patients who can no longer eat are often allowed to die peacefully, without artificial hydration or nutritional support.32 33 As Japanese society ages and the number of demented patients increases, the question of what medical actions should be taken at the end of life is an issue that must be seriously discussed, considering both individual dignity and medical costs. Even in Japan, there are patients who, given the option, want to die naturally without intervention if they are bedridden and unable to feed themselves.31 On the other hand, there is a deeply held belief that allowing patients to die by not providing nutritional support through a stomach or nose feeding tube is equivalent to starving the patient to death, which cannot be permitted under any circumstances. Thus, from this perspective, giving no treatment is impermissible.32
Medically, dementia results in the impairment of short-term memory; impairment of the ability to recognise people, times, or places; incontinence; indifference and apathy and pronounced overall memory impairment. In the end, the patient may well be bedridden, requiring complete assistance to live.34 The films discussed above present dementia as a vanishing of the light of the soul, death of the spirit and a slow demise. Patients lose the ability to recognise themselves or others, as well as their independence, autonomy and connection to society—what Yoshimura calls “the destruction of the human being”.8 Evidence suggests that a significant number of people would choose or have chosen death when faced with the prospect of being bedridden and unable to understand what was happening.31 35
Films have the capacity to reflect and portray many aspects of a country and its times: culture and ideology, morality and religion, medical treatments, societal views on life and death, social conditions, and those issues viewed by society as problematic. Japanese films depicting the lives of demented patients and their carers leave audiences with a vast array of messages about what it means to live with and die from dementia and what is and isn’t morally acceptable behaviour at this time. The films often end by providing the characters with a form of salvation. Sometimes this salvation takes the form of a quick death, while in other films it is a mercy killing. The form of salvation and the message may differ but the suffering and stress of the care givers and families is almost always a major theme running through these films. Another recurring theme reflects concerns within Japanese society about whether or not patients should have bad news withheld from them. By contrast, Japanese films typically do not explore medical treatment at the end of life, an issue that may reflect Japanese sensibilities about human dignity. The best of such films have the capacity to provide us all with an opportunity to think deeply about the ethical and social implications of dementia. We commend their study to medical educators and bioethicists.
Competing interests: None declared.
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