[Feature: Thinking About the "Mass-Death Society"] Takiko Fujii: The Reality of the "Mass-Death Society" from Future Projections

Japan's population peaked in 2008 and turned toward a decline, continuing to decrease consistently since then. What is particularly important is that the cause of the current population decline is a natural decrease, where the number of deaths exceeds the number of births. The total fertility rate, which was 4.54 in 1947 shortly after the war, fell below the replacement level (then 2.1) in 1974 and has remained at a very low level below 1.5 ever since. The current population decline is the result of this ultra-low birth rate over more than half a century, which has changed the population structure over time. Even if the total fertility rate were to recover to the replacement level immediately, the population decline would not stop right away. It takes several decades for an increase in the number of births to be reflected in the population size. For this reason, at least during this century, Japan is highly likely to remain a "mass-death society" where deaths constantly exceed births. This is because it is certain that generations with large population sizes will pass away over the next few decades. Therefore, it can be said that the core of Japan's currently progressing population-declining society lies in the transition to a "mass-death society where death occurs in large numbers on a daily basis" (Figure 1).

Looking at future population projections at the national level, the actual number of people aged 65 and over will peak around 2043. While this is often discussed as the "peak of the elderly population," it is important to note that the peak of the elderly population and the peak of the number of deaths do not coincide.

When considering the future number of deaths on a timeline, Japan's "mass-death society" is expected to show at least two peaks.

The first peak will occur in the early 2040s, when the baby boomer generation born between 1947 and 1949 reaches their early 90s. In 2041, two years earlier than the peak of the elderly population, 1,574,000 people are projected to die in a single year. The discrepancy with the peak of the elderly population occurs because the large generation born in the early 1970s will transition into the elderly group one after another after 2035, but since the mortality rate is not yet that high in the late 60s, the population transitioning into the 65-and-over group is larger than the number of deaths within that total (Figure 2). The baby boomers passing away in the early 2040s have a high marriage rate and a high rate of having children. Therefore, during this period, "deaths attended by family" will occur in large numbers throughout society. This will likely also be the period when the number of "elderly caring for elderly" households reaches its peak.

The children of the baby boomers were born in the 1970s and 80s, and this generation has a higher percentage of unmarried individuals compared to previous generations. For example, as of 2020, about one-third of men born in 1970 (who were 50 at the time) and about one-fourth of women were unmarried. In addition, about 10% of couples in this generation do not have children even if they are married, so after they have seen off their own parents, they are highly likely to become so-called "elderly people with no next of kin." Figure 3 shows the projected percentage of single-person households aged 65 and over by marital status for men and women based on estimates up to 2050. Among male elderly single-person households, about one-third were unmarried as of 2020, and a similar proportion were divorced; by 2050, about 60% will be unmarried single-person households. For women, because their average life expectancy is longer than men's, about 70% were widowed as of 2020, and just over 10% were unmarried. However, by 2050, it is projected that widowhood will decrease to just under half, while the unmarried will increase to over 30%.

This means that during the second peak of deaths in the early 2060s, there will be an increase in deaths where there are no family members to attend, or where family is extremely limited. During this period, there will be far more "elderly people with no next of kin" than can be compared to the present.

While I have discussed this based on national-level projections so far, this alone does not reveal the true image of the mass-death society. When discussing the mass-death society, the perspectives of "when" and "where" are extremely important.

According to regional population projections, the number of municipalities where the population aged 65 and over has already peaked and turned toward a decline has reached 858 (45.5%) (Figure 4). Particularly in rural areas, nearly half of the local governments have already entered a declining phase even for the elderly population. This may be a phenomenon that differs from the general image that "aging will continue consistently in the future." In these municipalities, along with the decrease in total population due to low birth rates and the outflow of young people, even if the "rate" of elderly people is rising, the actual "number" of elderly people is decreasing. In such regions, right now, along with the rapid reduction in population size due to the deaths of the elderly, it is becoming difficult to maintain not only medical and nursing care but also administrative services. On the other hand, in 319 municipalities (16.9%) centered on urban areas, the peak of the population aged 65 and over is projected to be after 2050. In these areas, in addition to the need for home-based medical care, the increase in "elderly people with no next of kin" is expected, so the need for facilities will increase further. Furthermore, from the perspective of "when" and "where," the number of "elderly people with no next of kin" will likely increase rapidly from around the late 2030s in urban areas where there are many unmarried single-person households currently in their 40s and 50s, and from around the late 2040s in suburban areas centered on the 30km zone where there are many ultra-aged nuclear family households consisting of parents currently in their 70s and 80s and children in their 40s and 50s. The "mass-death society" is not a uniform phenomenon nationwide, but one that progresses at different speeds and scales for each region, and the gap will continue to widen.

Issues that come into focus when focusing on "death" rather than "aging" include post-death procedures, funerals, organizing personal effects, inheritance, and shortages of graves and crematoriums. Currently, the Ministry of Health, Labour and Welfare is considering the establishment of a "new Type 2 social welfare business" to provide not only daily life support and support for hospital admission/facility entry procedures but also post-death administrative support as a "response to elderly people with no next of kin." However, what I consider most important is decision-making support for the individual. For example, a person's assets become an issue of inheritance after they die, but while they are alive, it is naturally an issue of asset disposal based on the person's own will.

When thinking about this issue, there is a case I always remember. From December 2018 to March 2023, I worked at the Nakano Ward Office on elderly welfare and the promotion of community-based integrated care. I would like to introduce one case from that time.

Nakano Ward has a very high number of single-person households. Looking at all ages, single-person households account for 62.3%, and even narrowing it down to those aged 75 and over, single-person households account for 47.9% of households where the head is 75 or older (both based on the 2020 Census). It is an area where the trend toward single-person households is progressing ahead of the rest of the country. In the promotion of community-based integrated care in Nakano Ward, one of the most important issues is the construction of monitoring and mutual support systems for elderly single-person households and the creation of community gathering places. Since various resident-led activities are developed in Nakano Ward, centered on elderly community centers, it is relatively easy to make new friends even if living alone.

When I was working in Nakano Ward, there was a woman in her late 70s (let's call her Ms. A). She was an unmarried single-person household, but because the business she had been involved in until recently was successful, she was very wealthy financially. After retiring from her business, she started attending a local elderly community center. However, due to higher brain dysfunction, she could not control her emotions and caused trouble in various places, leading to her being banned. She was wandering through several elderly community centers looking for a place to belong.

In the midst of this, she met Mr. B, a man in his early 60s, at a hobby club activity and they became close. Ms. A began going out frequently with Mr. B. However, Ms. A's younger brother, who lived nearby, began to feel suspicious about her behavior. When he checked her bank passbook, he found that money was being withdrawn in units of 1 million yen every month. When questioned, Ms. A said she was giving the money to Mr. B so they could go on trips together. The brother advised her, "You're being deceived by Mr. B. I want you to wake up," but Ms. A would not listen, saying, "I have fun when I'm with Mr. B. What's wrong with using the money I earned myself however I like? Besides, I might have higher brain dysfunction, but I don't have dementia, and I understand everything I'm doing."

Afterward, Ms. A's brother went to a Community General Support Center for consultation. On the grounds that her assets could not be protected this way, he had a doctor write a medical certificate, and the brother became the petitioner to use the adult guardianship system. The brother became the guardian, and Ms. A could no longer withdraw money without his consent.

I was not the direct person in charge of this case, so I learned about it in the form of a follow-up report. Certainly, there is no doubt that Ms. A's assets can now be protected. From the brother's perspective, if Ms. A, who has no next of kin, dies, those assets will go to him, so protecting Ms. A's assets also leads to protecting his own inherited property. However, from Ms. A's perspective, her autonomy was lost. I still wonder now if there was a way to support Ms. A's decision-making through accompaniment-style support while gaining her trust, rather than suddenly connecting her to the adult guardianship system.

Among the issues highlighted by the mass-death society, some begin while the person is still alive, and decision-making support is a prime example. In addition to the disposal of personal assets mentioned earlier, issues of business succession for self-employed individuals or company owners also make decision-making support extremely important. When interests are involved within narrow human relationships such as family, it is a very difficult problem to determine who should provide decision-making support and in what form. However, considering that in the 2040s, "elderly people with no next of kin" will appear in large numbers, and a certain percentage of people who cannot communicate their intentions or emotions well due to dementia or who find it difficult to accurately grasp the situation will increase more than ever before, it is important to position decision-making support as an important professional job, similar to medical and nursing care, and to build a support system.

In Japan, preparations for an aging society have been underway from an early stage, with 2025—when the baby boomer generation becomes late-stage elderly aged 75 and over—as a target point. The symbol of this is the Long-Term Care Insurance system established in 2000. Along with this, the construction of a "Community-based Integrated Care System" that provides medical care, nursing care, prevention, lifestyle support, and housing integrally within the community has been promoted.

Through the efforts of this quarter-century, institutionalization and cooperation have progressed regarding professional medical and nursing care, and an environment where home-based care is possible is being established to a much greater extent than before. However, on the other hand, in areas such as contractual acts, various procedures, detailed daily life support like money management, and the decision-making support mentioned in the previous section, the reality is that the portion handled by family remains large. It can be said that while support through systems has been expanded, the "existence of family" has been implicitly incorporated as a premise.

However, with the increase in single-person households, the rise in the percentage of unmarried individuals, and the diversification of family relationships, these premises have gradually ceased to hold. For this reason, since around 2015, there has been a major shift toward dispersing the informal care that families had previously provided for free and comprehensively to various entities in the community to support those in need as a whole community. This flow from "family care to community care," under the broad philosophy of a "Community Cohesive Society," targets everyone in need of support—not just the elderly, but also people with disabilities, children, and those in poverty. It indicates that the policy focus has shifted toward a concept of mutual support in the community, where the relationship is not one-sidedly supporting/being supported, but sometimes supporting and sometimes being supported.

As a measure to surely materialize that direction, the Project for Developing a Multi-layered Support System began in 2021. This enables the construction of a support system that transcends the silos of fields and systems. However, it requires local governments to take the lead in implementing mechanisms suited to the actual conditions of the region. Perhaps because the hurdles are high, the number of municipalities implementing it in fiscal 2025 is 473 (the planned number based on a survey as of October 2024), remaining at just under 30% of all municipalities.

"Death" is no longer an event to be undertaken only by individuals or families. A mass-death society is a society where the number of deaths increases, but it is also a society where the entire community is questioned on how to accept, support, and connect death. Within this, the role played by local governments will become broader and heavier than ever before.