**1. Introduction**

At the beginning of the twenteeth century, when organ transplantation began, the concept of brain death was not widely recognized. Therefore, both the world's first liver transplantation [1] and heart transplantation [2] were performed after cardiac arrest. However, the graft was damaged by ischemia and rejection, and the results were disastrous. On the other hand, the determination of brain death has been discussed since 1957. Then, brain death was proposed as human death, so on June 25, 1968, when the Harvard group announced the definition of brain death, organ transplantation from brain death began in the world.

On August 8 of that year, Japan's first heart transplant was performed at Sapporo Medical University, which caused various controversies. Immediately after the transplant, Professor Juro Wada was hyped up in the mass media for his successful heart transplant. He was started to be accused by the media and public soon after the recipient died 83 days after transplantation. This heart transplant questioned the adequacy of the recipient's indications and the determination of the donor's death. He was indicted in December of the same year but was dismissed after an expert's evaluation was conducted. However, it has caused distrust in transplant medicine based on organ donation after brain death. There were problems with the reaction of the mass media and public opinion, but there were various problems with the Wada heart transplant. It is believed that the fact that these facts were not properly verified has spurred distrust in medical care and has been the reason why organ transplants from brain deaths have become impossible in Japan for many years.

The issues of Dr. Wada's heart transplantation are: (1) whether the recipient was suitable for heart transplantation, (2) whether the donor was truly brain dead, and (3) whether informed consent (IC) had been obtained from the recipient, donor, and their families etc. However, it took more than a decade for the movement to tackle this problem head-on. In 1981, the International Society for Heart Transplantation (ISHT) was established, and in 1982, the Japanese Society for Heart Transplantation was established. Many heart transplants have been performed worldwide, and brain-dead organ transplantation in Japan has come to be actively discussed. In December 1986, the Japan Society for Transplantation published a guideline, "When performing organ transplantation," as a basic provision that should be observed by brain-dead organ transplant recipients in Japan. In October 1987, the Special Committee on Medical Technology and Human Life of the Science Council of Japan announced the "View on Brain Death". In January 1988, the final report of the Japan Medical Association's Bioethics Roundtable was presented and approved by the board of directors, but there were objections from some doctors, and the medical community did not reach a consensus. In 1989, the Japanese Society of Thoracic Surgery established a special committee on organ transplantation to examine problems and solutions in Wada's heart transplantation and published the 1st edition of "Heart and Lung Transplantation - Summary Report on Technical Evaluation and Bioethics" (1991) and the second edition (1992).

As a result of these discussions, it was found that under the current system in Japan, regarding the issue of Wada's heart transplantation (1), to register brain-dead organ transplant patients, the approval of the central indication review committee is required, and strict determination of recipient eligibility is required. This is done so that patients who are not eligible for organ transplantation do not undergo transplant surgery. As for (2), the most stringent legal standards for determining brain death in the world have been established, and brain death is determined by specialists who are neither attending physicians nor transplant doctors. As for (3), IC for recipients and families is maintained at each facility, and IC for donor families belongs to the Japan Organ Transplantation Network, which is independent of donor facilities and transplant facilities, or has received a transplant. The donor coordinator is doing it.
