The Road to Fukushima Dai-ichi Part 2: The Prolonged Death of the Victims of the Tokaimura Criticality Accident

Review of A Slow Death: 83 Days of Radiation Sickness, NHK-TV “Tokaimura Criticality Accident” Crew, Vertical Books, 2008

In Part 1 of these two posts about the Tokaimura criticality accident in 1999 (which should be read first to get the background for Part 2), I wrote that there were suspicions about the reasons for the prolonged treatment of the two terminally ill victims of the accident. Many people who watched the frequent news reports wondered if the treatment was carried out as an experiment or as a desperate attempt to delay the bad news that there had been fatalities from radiation poisoning in the Japanese nuclear complex. The NHK report provides no indication that such motives had anything to do with the treatment received by the two victims. Although one of the nurses interviewed said she had regrets and feelings of guilt, she was the only person in the book to raise the issue, and she did it in a rather indirect manner.

No, it's not a cover from 2011. TIME Magazine, October 11, 1999

The decision to undertake an all-out effort to save the patients, rather than give them palliative care, was made, as far as we can tell, by the leader of the medical team, Dr. Maekawa. A Slow Death centers on the story of only one of the patients, Mr. Ouchi. The reason is not explained, but we can assume it is because the family of Mr. Shinohara or the medical staff involved in his care declined to participate in the report.
Dr. Maekawa was an emergency medicine specialist and a professor at the University of Tokyo Department of Medicine. He had only recently become involved with nuclear energy, but he had been appointed chairman of the Nuclear Safety Research Association’s Radiation Emergency Treatment Task Force. Radiation emergency medicine was not his specialty, but he had become involved in it at the insistence of a Nuclear Safety Commission member.
He knew that previous victims of criticality accidents had died within a few days of exposure and could not be saved by any medical intervention, but he believed there was a chance that his patients could be saved with the latest drugs and treatments. If he had thought things through a little more carefully, he might have been able to admit to himself that even the best treatments available would not allow these men to ever leave the intensive care unit. The neutron beams had destroyed the chromosomes of cells throughout their bodies. If one or two vital functions could be restored, others could not. However, instead of deciding on palliative care, Dr. Maekawa decided that there was only one way to know for sure. He proceeded to do everything possible for the next eighty days until the truth became unavoidable even for him.
From this much we can conclude that yes, he was conducting an experiment, and it is one which he decided to carry out on his own with no ethics committee or public prosecutor to answer to. There was not even a second medical opinion to take into account. He went completely unchallenged by colleagues and staff throughout the eighty-three days. Mr. Ouchi’s family placed complete trust in him.
One striking element of the doctor’s thinking was that he resembled a military general stuck in the quagmire of an unwinnable war. By the time it was obvious that victory was not possible, he was too deep into the battle. He felt he had to go on. Otherwise, all the efforts until the present moment would have been wasted. Thus, instead of letting Mr. Ouchi pass away sometime in the middle of his ordeal, it lasted another forty days or so. It was the dilemma of sunk costs so similar to what is found in the nuclear industry itself. The Japanese nuclear establishment was desperate to carry on even after the Fukushima catastrophe had made it clear that Japan is one of the least suitable places to operate nuclear reactors. The nuclear establishment could not admit to itself that it was dealing with a terminal problem and inflicting unnecessary damage on the people it pretended to be saving with an energy policy that they believed was essential for Japan.
The essential question of Mr. Ouchi’s story is how people involved determined what he really wanted. The phrase “he did his best” (gambatta, in Japanese) is repeated ad nauseum by the witnesses interviewed for the book, as was the phrase “He really wanted to live.” However, the skeptical reader must ask what lies behind such subjective interpretations. There is little evidence in the book that he expressed a desire to live and carry on with the treatments, but there is evidence that he wanted them to stop. One of the most curious things about this story is the way the witnesses forgot the patient’s explicit request stop treatment then made up a narrative that rationalized the way he was actually treated.
In the final pages of the book, several of the people involved share their thoughts about the ordeal. The voices of key persons, such as Dr. Maekawa himself, are also conspicuously absent in this chapter.
Mr. Ouchi’s wife questioned the nation’s nuclear policy: “This might be pessimistic, but as long as we continue to use nuclear energy, a similar accident will likely occur. After all, it is handled by human beings, and I cannot shake my mistrust.” (p. 134) It is tellingly sad that she felt she had to preface her statement with an apology for seeming pessimistic, then could not explicitly state her opposition to the nation’s nuclear energy policy.
Several members of the nursing team also shared their thoughts about their experience caring for Mr. Ouchi. Ms. Nawa said, “Only those individuals themselves can know if they want to live, or if they no longer want to live in pain. That’s why you shouldn’t entrust your life to someone else. (p. 125)
Ms. Shibata stated, “Dying is just like living. That person should be able to decide how to face death... Caring for Mr. Ouchi made me realize this.” (p. 125-126)
Ms. Hosokawa was one of the people who, based on her own inferences, decided that Mr. Ouchi wanted to fight to live until the bitter end. She expressed mild doubts about whether he really wanted to live, but said, “... after meeting Mr. Ouchi, my perspective changed. Regardless of their situation, patients don’t want to die and be relieved of their suffering.” (p. 126)
Ms. Hanaguchi was the only person involved in the case to clearly express remorse and imply blame lies on herself and others, whom she didn’t name specifically. This is to be expected for someone in her position in Japanese culture. She could not explicitly blame the esteemed Tokyo University professor, Dr. Maekawa. However, he had unchallenged, sole authority over Mr. Ouchi’s care, so Ms. Hanaguchi’s words can be considered as directed squarely at him. To her credit, she shares the blame herself and avoids saying she was only following orders:

I still don’t understand the meaning of that treatment because I don’t know how Mr. Ouchi felt. Looking back now, I still wonder if anyone benefitted from all the effort we put into continuing the treatment. Were we just forcing Mr. Ouchi to suffer? We’ll never be able to ask his feelings, so I feel regret and guilt for what I did. I fear that Mr. Ouchi suffered, and that he would have preferred not to suffer so much. This makes me think terrible things because I wonder if I unknowingly helped to prolong Mr. Ouchi’s life for the benefit of people who didn’t understand his suffering whatsoever, and not for the benefit of Mr. Ouchi. I have to convince myself that Mr. Ouchi persevered for his family because he loved them so much. Otherwise, I won’t be able to forgive myself. If I consider myself one of the causes that forced Mr. Ouchi to live, I’ll feel guilty for the rest of my life. (p. 126)

For reasons that the authors do not explain, Dr. Maekawa was not interviewed. His thoughts about this issue are never revealed. In spite of Ms. Hanaguchi’s frank admission of feeling guilt, there is a contradiction in her statement that Mr. Ouchi’s feelings were not known. On the ninth day of his treatment during a painful procedure, seventy-four days before his death, the medical staff in his room heard him say clearly:

I can’t take it anymore. I don’t want to do this anymore. Forget the treatment. I’m leaving. I’m not a guinea pig. (p.54)

These words, witnessed by several members of the staff, could have served as a clear expression of the patient’s will, made while Dr. Maekawa himself described him as lucid and of sound mind. After this, Mr. Ouchi spent most of his time sedated with propofol (the general anaesthetic that became famous in the death of Michael Jackson) and fentanyl, a powerful pain killer, so it is questionable that anyone could conclude that he "did his best" after that, or "really wanted to live." Such statements are pure conjecture.
Another serious ethical breach is evidenced by the fact that they isolated the patient from television and radio reports that were truthfully describing his exposure as a fatal dose. His exposure was far above those of other patients in criticality accidents that had proven fatal. This deception was a deliberate attempt to keep him from having the information he would need to give informed consent. This was done with the common excuse that it was meant to not stress his mind or body during his so-called “recovery.”
They persisted with the treatment while he uttered his protest and asked him to bear with it a little longer, but no one ever followed up on the wish he expressed. This was the time to ask him to elaborate on what he really wanted, and to have the serious talk with the family, but the medical team pushed on and ignored the episode. At this point in the story, an outside observer, especially a professional in the field of caring for the terminally ill, would want to scream out, “Where was the hospital’s ethics committee? Where was the external review, the counsellors, or even a second impartial medical opinion?” As for the patient’s family, they could have got more actively involved in questioning the doctor’s approach. The internet existed in 1999, although they might have had to understand English in order to read up on the outcomes of other criticality incidents.
In spite of a couple of positive developments from the medical treatment, all hope proved to be false, and there were undoubtedly many experts in this field of nuclear medicine who would have known that this patient’s vital organs were like eggs that can’t be un-fried. There was massive chromosomal damage to cells throughout the body. Even if his blood could have been made healthy again, muscles, skin, liver, intestines and kidneys were all damaged beyond repair. Some of the damage was from the treatment itself, but primarily it was due to neutron bombardment. Dr. Maekawa’s reasoning had been that new medical treatments might lead to an outcome that wasn’t possible in previous criticality accidents. If the patient could be kept alive until his blood and immune system were restored, then other problems could be repaired on that foundation. The esteemed professor went unchallenged in this view for the entire eighty-three days, even by the foreign specialists who visited briefly around day 10 and day 29.
These experts perhaps hesitate to criticize and speak frankly because they all belong to the same club. They empathize too strongly with a colleague in a horrible situation that they imagine they themselves could be in someday, so they defer and keep their thoughts to themselves. Nuclear engineers behaved the same way after Fukushima. They might have been privately angry at TEPCO and the Japanese government for doing so much damage to the nuclear industry’s reputation, but as long as they remained pro-nuclear, they closed ranks and expressed no criticism. It is perhaps only in those scenes in TV medical dramas where we can see two hot-headed, opionated doctors hollering and having it out in front of the nursing station. In real life, everyone keeps his head down even when they know a disaster is looming.
These top experts also seem to hold back their criticisms because they are accustomed to being called on by the powerful whenever there is an emergency. Dr. Peter Gale was one of the experts who came to Japan in the Tokaimura case, and he also came in March 2011 to advise the Japanese government. Once someone has been greeted warmly and respectfully in the halls of power, he tends to become allied with the powerful and unwilling to criticize them. They are now friends, after all. At Dr. Gale’s press conference at the Tokyo Foreign Correspondents Club in March 2011, journalists tried but could not draw from him any criticisms of the government response to the disaster. He maintained his stance as an impartial advisor, but in fact his willingness to always come as a first responder to nuclear emergencies (he played a role in Chernobyl also) amounts to his approval and enabling of the nuclear industry which he believes “can help, even save, mankind or lead to its destruction.” (back cover of the book)
Shogo Misawa, professor of Forensic Medicine at the University of Tsukuba, performed the autopsy that was necessary for the criminal case against JCO, the deceased man’s employer. Professor Misawa was stunned to see the damage that radiation had done to throughout the body, especially to muscles cells, which he didn’t expect to be affected. He noted that only the heart muscle was not affected, and took the unusual step for a man of science of inferring special meaning and occult messages in this outcome. He said:

From the pitiful condition of Mr. Ouchi’s internal organs, I could see that Mr. Ouchi had lived with all his might. He really had done his best. And from his heart, the one internal organ that remained vividly intact, I think I heard Mr. Ouchi’s message that he wanted to continue living. It even occurred to me that Mr. Ouchi’s heart was unaltered by the radiation and continued functioning because of his determination to live. (p. 121)

If it seems odd that a forensic scientist would resort to such magical thinking, making this bizarre interpretation based on his idiosyncratic theory that the dead leave messages in their organs, we must remember that it served an important purpose in the sociological phenomenon that was taking place. This judgment by Dr. Misawa did much to absolve his colleague, Dr. Maekawa, of guilt, and it erased from collective memory the words of Mr. Ouchi on his ninth day of treatment that expressed his desire to be released. It’s unfortunate that the “NHK team” (no author is credited on the cover) let Dr. Misawa’s pathetic fantasy pass without harsh comment. And this is the greatest flaw in this otherwise valuable historical account of this tragedy. This book takes the traditional “objective” approach to reporting and makes only the most oblique criticism of Japan’s nuclear village and other possible targets, and in doing so it becomes a subjective endorsement of the status quo. It tells a horrifically sad and tragic tale, and asks the reader to reflect seriously on these events, but it pulls too many punches when the occasion calls for a knockout strike aimed at the nuclear village, the corporate malfeasance of JCO, and the serious breaches of medical practice and ethics. But what more could one expect from NHK, the staid and conservative national broadcaster? They are allowed to deal with sensitive topics, but they must handle them only in a sensitive manner. People are invited only to ponder and reflect on the “serious questions” raised by the events surrounding the Tokaimura accident.
Some might say my assessment of Dr. Maekawa is unfair. He dedicated his life to his patient during those eighty-three days, sleeping at the hospital and taking part in many of the unpleasant tasks he could have left to nurses. He was well-intentioned, wasn’t he? Of course he was, but if good intentions were an excuse, all crimes could be excused. Intentions are completely irrelevant in a court of law or for an inquiry into professional misconduct. People are responsible only for the knowable and predictable consequences of their actions, and by this criterion we can say that Dr. Maekawa should have been forced to at least defend himself in an investigation as to whether his treatment amounted to two months of unjustifiable torture. Why this never happened is a question that was never asked, let alone answered.

No comments:

Powered by Blogger.