Japan in Quandary on Fertility
Junko Ito’s mother-in-law decided that it was time for her son to get a divorce, and she broke the news to Ito with an old Japanese proverb: “A woman barren after three years of marriage should leave.”
Her husband did not defend her against his heir-obsessed parents, so she left.
Now 37 and remarried, Ito is at last expecting a child, conceived through in vitro fertilization. But the doctor who helped her become pregnant is expected to be expelled from the prestigious Japan Society of Obstetricians and Gynecologists, which has convened a special meeting today to discuss his case.
His “crime,” which has set the Japanese medical establishment on its ear and triggered a wave of debate, was to help three couples conceive children through in vitro fertilization with eggs or sperm donated by siblings--and then dare to announce it to the media.
The procedures violated an ethical--but not legally binding--ban by the powerful obstetricians society on what one Japanese headline termed “extramarital fertilization”: the use of genetic material from anyone other than a spouse for in vitro conception.
Medical ethicists, doctors and lawyers say the case of rebel fertility expert Dr. Yahiro Netsu underscores the need for legislation in Japan on sensitive reproductive matters.
Japan has no laws or government guidelines covering such issues as the sale of genetic material, surrogate motherhood, human cloning or even the use of sperm or eggs without the donor’s permission. In a widely publicized scandal in California, doctors at a UC Irvine fertility clinic were accused of taking eggs from some women and implanting them in others, prompting several lawsuits.
More broadly, however, the Netsu case has highlighted Japan’s immense, unresolved conflicts between fast-developing reproductive technologies and conservative social mores.
For example:
* Birth control pills are banned here, but abortion is legal, easy to obtain and ends almost one in four Japanese pregnancies. Abortion is considered undesirable, but most Japanese have no religious objections to it.
* At least 10,000 babies have been born since 1949 through artificial insemination with donor sperm (not the husband’s), but the obstetricians society adopted a rule eight years ago forbidding doctors to use that same donor sperm to fertilize an egg in a test tube.
“It is extremely illogical,” Kiyoko Kinjo, a medical ethicist at Tsudajuku University in Tokyo, said of the rule. The obstetricians society said the procedure is “not acceptable to the Japanese public.”
* Japanese are heading abroad to get infertility treatments denied them at home. Yuki Sumi, director of the Surrogate Mother Birth Information Center in Tokyo, said she has been arranging to send infertile couples to San Francisco for the past six years. So far, 39 Japanese babies have been born to American surrogate mothers, and 80 more children were conceived with donated eggs or sperm, she said.
* Amniocentesis is performed in Japan, but the obstetricians society forbids doctors to tell the parents the sex of the fetus, citing fears of sex-selective abortions. The guidelines also do not allow parents to know the sex of their child even after the 21st week of pregnancy--the legal limit for abortion in Japan.
Netsu said he decided to publicly challenge the society’s ethical guidelines because he has already been branded as a “problem doctor” by the group--and so has less to lose than his colleagues--and because he believes that no one is standing up for the patients’ rights to medical treatment.
“It’s fine for the society to decide all sorts of things in a theoretical sense, but when you are faced with a patient in front of you begging for help, it’s a different story,” Netsu said in an interview in the hospital he founded, the Suwa Maternity Clinic in Nagano prefecture.
Protection Under Law Questioned
Dr. Kazuo Sato, medical professor at Nihon University in Tokyo and chairman of the obstetricians society, charged that Netsu is making babies who will fall outside the protection of Japanese family and inheritance law.
“The society cannot permit procedures after which the children’s parental rights will not be legally guaranteed,” Sato said.
The society plans to mete out “the strictest possible punishment”--meaning expulsion--for ethics violations, other officials said. In a rather atypical Japanese development, Netsu said he will sue if ousted.
However, the society may not revoke Netsu’s medical license, and Netsu said he will continue to perform the procedures as long as they are legal, so it is unclear how much effect any sanctions by the obstetricians society would have on Netsu’s practice.
Netsu favors revision not only of the society’s guidelines but also of the group’s monopoly on the ethical decision-making process.
“I think it’s a big mistake for the society to be making such rules,” Netsu said.
“These are 95% social issues, not medical issues,” and should be decided by lawmakers after broad public debate, with the input of ethicists, doctors and patients, he said.
The Health and Welfare Ministry has said it will convene a committee in August to discuss the ethical issues raised by in vitro fertilization.
Netsu has a number of well-placed defenders.
“Women are marrying later, and we are also seeing more male infertility, but hospitals are bound by outdated guidelines,” said Dr. Masakuni Suzuki, a former chairman of the obstetricians society.
Suzuki was the first Japanese to succeed at in vitro fertilization in 1983, and he agreed to restrict the procedure, using only the genetic material of married couples, in order to quell the ensuing controversy.
“It’s time to come up with clearer standards,” Suzuki said, adding: “The people who have money now go to America, and those who don’t have money don’t get the treatment.”
Although most Japanese have no religious objection to the high-tech reproductive technologies, the public tends to frown upon them as being “unnatural,” ethicist Kinjo said.
“Unnatural” is equivalent to “immoral” for many Japanese.
Organ Transplants Are Also Restricted
That kind of mind-set has also restricted organ transplants in Japan, which has the medical sophistication to perform such operations. Although Japan passed a law last year allowing organ transplants from brain-dead patients, the law is so narrow and has proved so difficult to implement that so far not a single such transplant has been performed here, according to the Japan Organ Transplant Network.
The government has announced plans to loosen some of the restrictions, but meanwhile, Japanese patients continue to stream abroad in hopes of finding organs.
The controversial organ transplant law was passed after years of public debate. But patients’ desire to keep their infertility a secret has hindered the public’s understanding of the new reproductive technologies.
“If just one person would speak up about it, public opinion would change,” Suzuki said. “They all want to have it done, but they think somebody else should speak up.”
Because there has been so little discussion of issues raised by reproductive technology, it is unclear what kind of a law might be acceptable to the Japanese public. Kinjo, Suzuki and Netsu all agreed that the sale of sperm, eggs or human embryos, surrogate motherhood for pay and other financial transactions are repugnant and should be banned in Japan.
A recent Yomiuri newspaper poll of the nation’s 226 infertility clinics found that nearly 33% of the doctors believe that the obstetricians society’s guidelines should be revised, 26% believe that a broader national debate is needed, and 21% agree with the society’s current policy.
Drop in Birthrate Coincides With Debate
In the wake of Netsu’s disclosure, the newspaper reported, two other clinics, which were not named, had performed “extramarital” fertilizations, one of them using the sperm of the infertile husband’s father.
Ironically, just as the debate over infertility treatments burst into the public eye for the first time, the Japanese birthrate plummeted again.
The Health and Welfare Ministry reported that the birthrate fell to a record low of 1.39 births per woman last year, far below population replacement level. In the same year, the U.S. birthrate was 2.06 per woman.
Prime Minister Ryutaro Hashimoto has begun warning in recent speeches of the serious social and economic impact of the birth dearth.
The Health and Welfare Ministry’s 1998 annual White Paper is devoted entirely to the topic of “Thinking About a Low-Birthrate Society.”
A special government panel will be convened next month to ponder remedies, including revision of the employment system, which tends to force mothers out of the workplace, and better child care. And the ruling Liberal Democratic Party has been discussing plans for special tax deductions for parents or for child care.
Some Decry Effort to Boost Fertility
Some feminists and environmentalists decry the government’s efforts at population-boosting, and they say the idea that a tax break will promote fertility is nonsense.
“There is a population explosion in the world, and we don’t necessarily need more people,” feminist attorney Mizuho Fukushima said.
If fertility is to be encouraged, she said, the only way would be to end the Japanese system in which “men work like maniacs and can’t participate in child rearing, and women have to do all the housework and are excluded from the work force.” A majority of Japanese professionals, however, believes that the low birthrate is a problem, according to a Health Ministry survey.
In the poll, 49.5% said the problem was “very serious,” 34.1% deemed it “serious,” 7.3% believed that it was not a problem, and 1.8% said it was desirable.
However, encouraging treatment for the estimated one in 10 infertile couples has not been a priority.
Infertility treatments are not covered by Japan’s national health insurance; infertile couples continue to be stigmatized; and although the rate of childless couples is increasing, more than half of Japanese in a recent survey declared that couples should produce children.
‘Barren’ Women Still Being Rejected
Childlessness is still often considered to be the woman’s personal or moral failure, doctors and patients said.
“People who have no children are seen as handicapped,” said Ito, who was divorced eight years ago and says “barren” wives like her continue to be rejected today.
Ito conceived “ethically” in a test tube with her husband’s sperm but decided to tell--for the first time--the painful story of her 13 years of attempts to become pregnant, in order to defend the embattled Netsu, because the “extramarital” families are too ashamed or afraid to speak out.
“The people who are bashing--well, who are criticizing--Dr. Netsu have not experienced infertility in themselves or perhaps in their daughter,” she said. “They should listen to the voices of the patients.”
Chiaki Kitada in The Times’ Tokyo Bureau contributed to this report.
