脳死臓器の提供広げる道を 矢永勝彦(論壇)

(1998年10月13日)

015871998年10月13日朝刊オピニオン00401713文字昨年十月に臓器移植法が施行されたが、その特徴は、生前に文書で脳死後の臓器提供を認めた人の場合だけを合法化し、一方で提供意思が不明の場合に近親者からの忖度(そんたく)による提供を禁じた点にある。
その背景として、一九九〇年から二年間におよぶ脳死臨調の審議で、大多数の脳死容認派と少数の否定派の間で、最も基本的な「脳死は人の死か否か」について合意が得られなかったことがある。
最終答申の一本化を目指す容認派は、否定派の「本人の生前意思がある場合には違法性を棄却して臓器提供を認める」との考えを尊重し、生前の本人意思重視の姿勢をとった。だが結局、答申は一本化されず、「生前の本人意思」だけが独り歩きして、移植法成立の最終段階で、本人の書面による提供意思が不可欠とされた。さらに施行細則では、臓器提供施設の数が極端に限定された。
本人意思のみによる臓器提供は理想的だが、脳死の大半は突然発症するため、臓器移植先進国である欧米ですら、生前に臓器提供の意思を表示している可能性は低いのが実情である。わが国では、このあまりにも厳しい提供要件のため、法施行後一年が過ぎようとした今も、提供は一件もない。
ドナーカード(提供意思表示カード)を所持した事例はあったが、その多くは死に直面した自殺者、あるいはがん患者であり、脳死段階での提供は実現しなかったと聞く。また、臓器提供の意思表示は十五歳以上とされるため、現行法では心移植の必要な小児への対応はできない。
諸外国では提供促進のためにドナーカードを普及させる一方で、遺族による提供意思の忖度を広く認めており、さらには西欧諸国の過半数は「臓器は社会の資源」との考えから、原則として脳死者イコール臓器提供者としている。また米国では、病院管理者に脳死者の家族への臓器提供の打診を法律で義務付けている。最近では、費用がかさむにもかかわらず、臓器提供者の登録制を敷く国が出てきはじめた。これらの諸外国に共通しているのは、移植でしか救命できない患者の治療を推進するため、行政が中心となって脳死者からの臓器提供の促進に真剣に取り組んでいることである。
わが国では行政主導で臓器移植のシステム自体は確立したが、まさに「肝心」な臓器提供がない現状では、移植以外に救命手段のない心・肝の移植希望者は国内で死を待つか、海外で移植を受けるか、肝の場合は生体移植へ転換するしか道はない。私は昨年度、厚生省の研究班で海外渡航肝移植の全国調査を行ったが、患者と家族の多くは移植費用の工面、現地での言葉や文化のハンディなど大変な苦労をしていた。
近代医学では脳死は人の死とみなされ、日本でも過半数の国民がそれを肯定している。だが、一方で脳死移植に反対する人々は声高に医療不信や、わが国の独特の文化などを唱え、脳死者の臓器提供とそれによる臓器移植の推進を阻んできた。そして妥協産物としてできた現行法は、個の独立性が高くない日本人に、唐突に臓器提供ヘの自己決定を要求しており、日本人の文化・習慣にすぐなじむとは考えにくい。わが国では他人に迷惑をかけぬことが美徳とされるが、その点で現行法は理想的で限りなく潔い一方で、移植以外に救命手段がない患者らにはあまりにも冷酷ではないのか。
わが国では脳死者数そのものは年間約三千八百人と推定されるが、実際の臓器提供は、心停止後に約百人と極めて限られている。これは、人口がわが国の二倍の米国で、昨年一年間の死体臓器提供者数が約五千五百人、そしてそれに基づく心・肝移植がそれぞれ二千三百件、四千二百件という現状と好対照である。
臓器移植法はあと二年余りで見直しの時期を迎える。望むらくはその際、臓器移植以外に救命手段のない末期臓器不全患者を思いやる、温かい法律に改めていただきたい。その具体策として、オランダのように国民一人ひとりに臓器提供の意思を確認する登録制か、あるいは諸外国では常識で、世界保健機関(WHO)も認めている脳死者の家族からのインフォームド・コンセントによる臓器提供に道を開くか、選択肢はこの二つに一つしかないと考える。
(やなが・かつひこ 松山赤十字病院外科部長=投稿)

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