Introduction: Japan is known as a country with very few donor PMPs (fewer than 1.2 ever) over the past three decades. However, the Cabinet Office’s research indicates that over 40% of the general public is affirmative to deceased donations. Therefore, it is essential to analyze what hampers the development of organ donation in Japan.
Method: For twenty years, the author, an emergency neurosurgeon who tries to promote awareness about organ donation, has given over three hundred lectures to medical university students, the general public, and emergency and transplant medical personnel. Through these activities, the author has observed and analyzed the reasons for the scarcity of deceased organ donors in Japan.
Results:
1. Dark History: Media coverage has created significant unrest and fostered distrust regarding transplantation medicine and the definition of brain death among the general public since the failure of the first heart transplantation in 1968 and throughout subsequent turning points. Also, Japanese individuals often perceive the proactive promotion of donations as coercive. These distrusts persist today, even within medical societies in Japan. 

2. Passivity in participation: In Japan, brain death is not generally considered a person’s death. Therefore, the initial step of donation participation relies on ER doctors' subjectivity. A doctor who personally opposes donation can easily evade it. More than 800 of the 900 authorized DBD institutions do not participate.

3. Professionalism in engagement: ER personnel’s primary policy in the donation process is to honor the donor’s wishes, and they are unaware of the recipients' presence. This situation arises from a deficit in proper medical education.

4. Japanese individuals often view the proactive promotion of donations as coercive. This distrust continues today, even within Japanese medical societies. Consequently, neither academic institutions in transplantation medicine nor the government can actively engage in awareness activities for donation.

5. Who coaches Japan, and how? Japan seeks to learn about organ donation from the world's most developed countries, but its goals may be too ambitious. Japan has not referred to the methods used by countries with PMP10 or similar.
Conclusion: Japan has failed to show best practices in organ donation. The stagnation of organ donation in Japan can be attributed to the influence of a dark history, social characteristics, and a lack of proactive awareness-raising in medical societies. Obviously, organ donation is one of the medical procedures in transplantation medicine. We must teach emergency personnel that saving unknown recipients awaiting organs is a fundamental mission for medical professionals and encourage their positive attitudes.