Misfits and Moral Injury: Why Shusaku Endo Matters Today

Shusaku Endo (1923-1996) was a Japanese novelist who, despite receiving his country’s highest literary awards, saw himself as a cultural misfit. Estranged as a child from his father in a deeply patriarchal society, he converted to Catholicism at age twelve, resisted the militaristic education of wartime Imperial Japan, endured loneliness and ridicule while studying in France after World War II, and suffered months of isolation recovering from crude surgical attempts to treat his tuberculosis-ridden lungs. Endo is best known in North America for his historical novel, Silence, translated into English in 1969 and adapted in a 2016 film by Martin Scorsese. Frequent themes in his writing include moral choice vs. social norms, faith and doubt, healthcare and healing, and personal responsibility. Though he set a sizeable fraction of his work during the brutal seventeenth century persecution of Japanese Christians by the Tokugawa Shogunate, it is his contemporary fiction that best reflects his singular biography.

Given Endo’s interest in medicine and morals, I have used his work with medical students and residents to explore the fraught moral landscape of modern healthcare. It would be a mistake, however, to limit the scope of Endo’s ethical inquiry to medical matters. Perhaps all human endeavor affords opportunities for guilt and shame, especially for those implicated in perceived moral lapses or transgressions. Such distress need not be merited or even rational, as in survivor’s guilt or extreme forms of “imposter syndrome.” Yet when life and death is literally at stake—as in war, law enforcement, medicine, and disaster triage—even conscientious persons may commit, fail to prevent, or involuntarily assist in actions they otherwise find morally repellant. In the heat of battle, it is not easy for soldiers to refuse an illegal order. Unscrupulous researchers can persuade well-intentioned professionals to bend ethical guidelines for what they believe to be good reasons. People join ICE with a broad range of motivations.

Endo uses extreme situations to shed light on the murkier corners of human action. There, good intentions and base instincts often coexist, sometimes in the same person. In these untidy outliers, clear moral edges prove scarce. Survivors often bear scars: some physical, some mental, some moral. While Endo’s medical and religious experience rendered him poorly suited for certain aspects of twentieth-century Japanese society, he transformed that marginality into a universal commentary on modern moral injury and healing. Endo’s ethical investigations assume urgent relevance when—as now—prominent individuals, corporations, and government agents excuse egregious behavior with claims to special or emergency authority; follow “protocols” in pursuit of some specious, ill-defined good; or vilify opposing voices, concerns, and cautionary tales. Accordingly, I will review salient moments in Endo’s life, consider three of his novels, and propose ways in which his work matters in these troubled times.

The Making of a Misfit

Shusaku Endo was born in Tokyo in 1923.[1] His father, a bank employee, was transferred to Dairen, a Japanese-controlled city on the Manchurian mainland when Shusaku was three. The boy’s parents separated when he was ten, and his father insisted he choose which parent to live with. Shusaku Endo went with his mother, joining his aunt in a small home in Kobe, Japan. There, he and his mother were baptized as Catholics. In a male-dominated, overwhelmingly Buddhist, and zealously militaristic Imperial Japan, Endo was ostracized and harassed by his classmates and did poorly in school.[2] He received encouragement and consolation from his mother, however, and was accepted to a private university in Tokyo when he turned twenty, as the Second World War turned against Japan. Endo’s father, who had occasionally sent money for the boy’s education, effectively disowned his son when Endo chose not to enter medical school. Choosing to study French literature instead, Endo funded his education with part time work in a munitions factory. Enduring poor working and living conditions as the Japanese Empire collapsed, he was diagnosed with pulmonary tuberculosis at age 22.

After completing what was thought at the time to be curative medical treatment, Endo appeared healthy enough to travel to France five years later as one of the first Japanese scholars to study in Europe following the war. One of three Japanese students at the University of Lyons, he avidly read French Catholic authors such as Georges Bernanos, Julien Green, and Francois Mauriac. At the same time, he suffered frequent racial slurs and social marginalization.[3] After three years abroad, Endo returned to a visibly altered postwar Japan. Dispirited, sick, and convinced that Eastern and Western sensibilities lacked a common ground for meaningful interaction, he began to write fiction contrasting Europe and Japan in a time of radical social change.

His worsening tuberculosis afforded ample time to observe the medical profession firsthand. During long hospital stays, he saw how Japanese physicians focused on treating the body, oblivious to what Endo had learned to call the soul. Efforts to achieve objective benchmarks of cure displaced the more subjective pursuit of personal healing. In Endo’s opinion, Japanese medical schools graduated technicians in pursuit of a career, ill-equipped for ethical decision-making and community responsibility.

As for Endo, the patient, both his tuberculosis and the equally debilitating treatments of the time repeatedly postponed his writing projects. He began a cycle of brutal interventional procedures, including unsedated rigid bronchoscopy (a technique in which the major airways are examined though a straight, hollow metal tube inserted through the mouth of a fully conscious patient), therapeutic pneumothorax (intentional collapse of a lung), and a sequence of operations to remove portions of his ribs.

By the time he turned 39, Endo needed an extended rehabilitation simply to recover from these primitive attempts to cure his tuberculosis. Rather than escaping his predicament through suicide, as his literary predecessors Yukio Mishima and Osamu Dazai had done, Endo wrote about the spiritual life in the face of great suffering. Having come to see his adopted Christianity as, in his own words, “an ill-fitting suit,” he wrote stories about renegade priests, deeply flawed characters inspired by the life of Christ, the survival of hidden Christian communities under merciless suppression, and the possibility of reincarnation. He has a special fondness for the wise buffoon and the holy fool, bumbling outsiders who are the last to get the joke but the first to see and touch the other’s deepest wounds. Though Endo later disavowed his opinion that East and West were irreconcilable polarities,[4] having several times called Japan a “mud swamp” in which Western philosophy and religion could not take root,[5] these themes continued to develop in his fiction, often intersecting with the world of medicine as he had experienced it.

Medicine and Moral Choice

Endo’s life experiences feature significantly in his 1958 novel, The Sea and Poison, which opens with a tuberculosis patient undergoing a therapeutic pneumothorax in a dingy suburban medical office. His physician is a skilled but emotionally distant and visibly distracted man named Suguro. We soon learn that Dr. Suguro interned at a university hospital during the war, during which he participated somewhat halfheartedly in the vivisection of an American prisoner of war. The story is based on a well-documented series of experiments on eight American POWs at the Kyushu Imperial University Hospital in 1945, for which twenty-three persons, including several doctors, were convicted for war crimes. In Endo’s novel, Suguro, clinging to remnants of his compassion in a difficult time, and his fellow surgical intern, Dr. Toda, the jaded son of a wealthy physician, treat tuberculosis patients even as daily allied air raids make Japanese defeat in the war increasingly certain. A member of the surgical faculty, Dr. Hashimoto, hoping to improve his chances of becoming Dean of the Medical School, accepted a request from military medical officers to conduct experiments on living prisoners. A clear research question was presented for each experiment, questions previously unanswered because the procedure will, of necessity, kill the research subject. When the interns were asked to assist, Toda consented immediately. Suguro, unsure at first, ultimately goes along. After the experiments, a horrified Suguro asks Toda what they should do. Toda replies:

“Nothing. Just as we always do. Nothing has changed.”

“But today! Toda, doesn’t it bother you at all?”

“Bother me? What do you mean, bother me?” Toda’s tone was dry. “Was it the sort of thing that should bother somebody?”

Suguro was silent. Finally, as though to himself, he spoke in a still feebler voice. “Toda, you’re strong. As for me . . . I shut my eyes in there. I don’t know what to think. Even now. I just don’t know.”

“What is it that gets you?” Toda felt a painful constriction forming in his throat as he spoke. “Killing that prisoner? Thanks to him, we’ll now be better at curing thousands of TB patients—because we killed him. Should we have let him live, you think? The conscience of a man, is that it? It seems to vary a good deal from man to man.”[6]

So Suguro begins a lifetime of guilt and remorse that Toda neither shares nor comprehends. The bulk of The Sea and Poison moves back and forth in time, exploring the background, motivations, and internal conflicts of Suguro, Toda, and a nurse who also participated in the vivisections. There is little sense of resolution at novel’s end, only troubling unanswered questions: How can a healing professional justify participation in an atrocity? Where and how do freedom and moral responsibility intersect? How does one live with profound moral injury? Michael Gallagher, one of Endo’s English translators, speculates that Endo’s background gave him the tools to fascinate and disturb his readership, noting in an introduction to The Sea and Poison, that “Endo is the only major Japanese novelist who . . . confronted the problem of individual responsibility in wartime.”[7] In my own experience of teaching medical students and residents, this novel serves well as a preface to discussing American medical atrocities such as the Tuskegee syphilis study or the secret Cincinnati radiation experiments, both of which misled African-American patients to believe they were receiving appropriate care.[8]

Collateral Damage

Endo’s 1974 novel, When I Whistle, similarly pairs past with present and freedom with responsibility, this time in a father and son tale. Ozu, a middle-aged businessman, reminisces on his lower-class childhood in pre-war Japan, particularly his friendship with a bumbling middle school classmate who goes by his nickname, Flatfish. Foremost in Ozu’s memory is Flatfish’s earnest, if doomed, attempts to woo Aiko, who attends an elite girls’ academy. The boys are soon drafted for war duty, from which Flatfish never returns. Ozu’s recollections are filled with compassion and acute attention to the erasure of his childhood landscape by postwar construction and development. Ozu’s son, Eiichi, is a young hospital surgeon who resents his father’s humble origins and looks to advance his academic career at any cost. Along the way, he gets one rival fired and bullies another into resigning, all the while calculating which young woman he should date for maximal prestige and influence. Eiichi’s fortunes ultimately rest on the success or failure of a new cancer drug that he tests on a patient without explicit consent. The patient happens to be Aiko, who experiences severe side effects from the drug, a development that brings Ozu’s and Eiichi’s stories together in a denouement that is emotionally satisfying though once again inconclusive. Endo invites comparison to American experiences when Dr. Tahara, a fellow surgeon, confronts Eiichi:

“When you try out a new drug, it’s either got to be because another drug is no longer effective, or when we have the patient’s voluntary consent. One or the other. Do you have her consent?”

“This is hardly the time for you to put the screws on me. In America they test out new drugs on convicts . . . .”

Tahada stared at Eiichi in surprise. Then a look of sadness washed slowly across his eyes. “Do you really believe that?”[9]

Perhaps Endo wrote that last sentence as yet unaware of the ugly truth of Eiichi’s claim, but the history of such unethical trials in the U.S. is now well-documented.[10] When I Whistle explores generational change, professional ambition, and the ethics of medical research from a non-Western perspective. There is much here to trouble us.

Healing and Curing

Endo’s final novel, Deep River, braids several of his recurring concerns into a compelling narrative that weds body to spirit and health to wholeness. The novel follows a group of Japanese tourists visiting Buddhist sites in India, with several of the travelers introduced in vignettes Endo entitles “cases.” Among these is Numada, an author who grew to love animals during his childhood in Manchuria and wishes to repay a debt to a mynah bird he believes died in his stead when he was undergoing a risky tuberculosis operation.[11] Kiguchi hopes to conduct Buddhist rites for soldiers lost on Burma’s Highway of Death in World War II, particularly an army friend, Tsukada, who found deathbed healing from devastating moral injury through the words and prayers of an awkward westerner volunteering at the hospital.[12] Special prominence is given to “The Case of Mitsuko,” a restless divorcee and onetime student of French literature, who hopes to reconnect with Otsu, a college acquaintance and sometime lover. During their toxic college relationship, Otsu’s Christian piety both fascinated and repelled Mitsuko. She has recently learned that Otsu, now a renegade Catholic priest, is caring for indigent patients in the Indian holy city of Varanasi. In finding Otsu, Mitsuko seeks to atone for her abusive behavior.[13] I will not detail Endo’s masterfully orchestrated plot here, but key themes include the need for mercy and compassion and the crucial difference between curing and healing. Yet again, the novel arrives at an ambiguous conclusion, but when Mitsuko wades at last into the sacred waters of the Ganges, her cynicism resolves into belief in:

The sight of all these people, each carrying his or her own individual burden, praying at this deep river. At some point the words Mitsuko muttered to herself were transmuted into the words of a prayer. I believe that the river embraces these people and carries them away. A river of humanity. The sorrows of this deep river of humanity. And I am a part of it.[14]

Do not be put off by the exotic setting or unconventional subject matter. Some of my students found themselves less defensive discussing this meeting of two very different Asian cultures than studying cross-cultural encounters in the U.S. The novel bears indelible marks of Endo’s Catholic upbringing, but the spiritual implications of a truly moral practice of medicine—often difficult to discuss with learners of little or no religious faith—are easier to probe when the conversation is freed from the irritant nodes of dogmatic difference.

Why Endo Matters Today

Endo transforms his trials as a cultural, religious, and medical outsider into keenly observed examinations of manners and morals rather than cartoonish morality plays. His prose is consistently direct and inviting even in translation, making the emotional and spiritual experience of his characters available to the reader. As in life, his fictions leave few things neatly resolved. It would be a category error to read them as parables that illustrate a distinct and readily summarized “moral.” Great moral fiction does not so much instruct as illustrate, reminding the reader what is at stake in every encounter with the other, calling us to account.

What reminders have I stressed when teaching Endo’s fiction? First, he shows the reader how morally dubious practices implicate the good and bad along a spectrum of complicity. A zeal for justice must be tempered with mercy and practical wisdom, since knowing what to denounce is often easier than whom. In a polarized age such as ours, populist heroes propose simple solutions for complex problems, and many go along. All too often, “The best lack all conviction, while the worst / Are full of passionate intensity.”[15] Yet some currently among “the worst” may yet have consciences to prick and conversions to undergo. By nature, feelings of guilt and shame are retrospective, the result of reflection on past action. Historical evils that now appear clear cut—slavery, for example—were once matters of controversy rife with ambiguities, at least to those in power. We can reasonably expect future generations to look on some of today’s moral conundrums and wonder how we, who think ourselves righteous, could have been so blind. For all its surface simplicity, the admonition to “do justice, love kindness, and walk humbly with God,” is a daunting task, indeed.[16]

Second, moral transgressions affect those involved to varying degrees. Many prominent Nazis died in unrepentant certainty. On the opposite extreme, John Newton, a longtime investor and ship’s captain in the transatlantic slave trade, eventually renounced his former life, embraced the British abolitionist movement, and penned the hymn, “Amazing Grace.” In between these polarities lie a broad range of “mixed cases,” some caught between remorse and denial, others hoping to repent and make restitution, but uncertain how to proceed. Here is where therapy, twelve-step programs, and pastoral care can be helpful. Moral injury can be crippling if never named or addressed.

Third, as the cases in Deep River illustrate, ritual or religious practices of repentance and restitution can help heal what cannot be cured. Neither thoughts nor words are sufficient. Healing is a process, a journey over time rather than the action of a moment. Past transgressions cannot be erased, but something like repair can be achieved through acts of apology and restorative justice. Much as a scar both covers and outlines a physical wound, the healing of a moral wound approximates a prior wholeness even as it retraces the extent of the injury.

Finally, it may take an outsider, free of prevailing assumptions, to see through layers of moral pretense in a flawed system and identify a heretofore invisible problem. Courageous outsiders ask impertinent questions and do not accept answers like, “that is the way we always do it.” Endo routinely asked questions about individual and corporate behavior others largely ignored, but did so with nuance and scruple, never reducing his fictions to melodrama. For anyone concerned about responsible action in our unsettled present where power and retribution displace prudence and compromise as guiding lights, there is much to be learned from this self-described misfit.

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