A Short History of Reproductive Medical Problems in Japan

- Shinryo N. Shinagawa, M.D.
Emeritus Professor of Hirosaki University School of Medicine
Institute on Public Issues Relating to Healthcare and Medicine
Fujimi-cho 32-3, Hirosaki 036, JAPAN

Eubios Journal of Asian and International Bioethics 6 (1996), 158-9.

Several topics related to reproductive medicine in Japan were presented in this paper from the 2nd Tsukuba Bioethics Roundtable. A call is made for more debate on the protection of the human embryo in Japan; and the recent changes in law are contrasted with the attention given to the Embryo in Europe.

1. Population in Japan and the policies of the Japanese Government since the Tokugawa Period

Based on the reliable records and demographic statistics, Japanese history can be divided into three stages. They are the pre-modern stage of the Tokugawa Shogunate (from 1603 to 1868), the westernizing/modernizing stage from the Meiji Restoration to the defeat of World War II (from 1868 to 1945), and the post-war stage since 1945.

In pre-modern Japan, the Tokugawa Shogunate Government took a policy of isolation from Euro-American countries, except the Netherlands, for more than 200 years up to 1858. In this pre-modern period of the Tokugawa Shogunate, although the birth-rate in Japan was high, in other words probably more than 35 per 1,000 population, Japan's population stayed at a fairly constant 31-32 million people. This stabilization was a result of a variety of socioeconomic reasons, including frequent famines, natural disasters such as great earthquakes, and recurrent epidemics of acute infectious diseases such as smallpox, typhoid, dysentery, and measles. Besides these reasons, it is widely speculated that induced abortion and the practice of infanticide were quite common especially among poor peasants.

The Meiji Restoration Government, on the contrary, set up a complete family registration system throughout Japan, and adopted a policy of increasing the population banning induced abortion and infanticide. Therefore, since the 1870s Japan's population began to increase very markedly, and on the other hand, vital statistics on birth rates, death rates, causes of death became very reliable and available. The Population Increasing Policy of Japanese Government was strengthened in the 1930s especially by the promulgation of National Eugenic Law.

From the 1930s to 1945, the population of Japan is said to be around 70 million. However, when the people who lived in Korea, Formosa, Sakhalin and the Kuril Islands were added, the total number of people was estimated to reach a level of 100 million.

2. Eugenic Protection Law (EPL) and induced abortion in postwar Japan

After World War II, the Japanese Government changed the population policy into "to stabilize and not to increase" from "to increase". How to popularize family planning became the No.1 policy in health care of postwar Japan, and at the same time, the Eugenic Protection Law was promulgated in 1948, and Japan became the second largest populated country after the Soviet Union in the semi-liberalization of induced abortion.

The EPL was a combined law of a modification of Preventive Law of Offspring with Hereditary Diseases (das Gesetz zur Verhuetung erbkraanken Nachwuchses), 1933 of Germany under Hitler, with a semi-liberation of induced abortion. This law was written at a time of confusion right after the defeat in the war prior to the enormous development of fetal medicine afterwards, and in today's perspective was not necessarily appropriate. One thing is a fact that almost nothing is written on the embryo and the fetus.

In June 1996, however, another inappropriate part of this law was amended by the omission or elimination of eugenic articles, and the title of this law changed from Eugenic Protection Law to Mother's Body Protection Law.

3. Uncontrollable lowering of birth rate in the 1990s

According to the results of the 1990 national census released from the Japanese Government in June 1991, the Total Fertility Rate or number of children Japanese women bear in their lifetime was only 1.53 in 1990, and dropped to a low of 1.48 in the year 1993, and the nation's population will begin to decline from 2010. The Japanese Government and leaders of industries were shocked very greatly by this census, and the number of this census led to the nickname, the "1.53 shock".

A great reason for the birth rate drop is that, I guess and think, more women are putting careers before marriage, and the government is studying twofold measures to cope with the situation. One is the revision of policies in a wide range of areas such as medical care and pensions, and the other concerns measures to encourage women to marry early, and also be able to bear children and work at the same time. Among the steps considered are revision of the regulations on maternity leave and raising children, late night child care at nurseries managed by enterprises, and the establishment of paternal leave.

However, I think and believe that the more important, probably the greatest reason is that today, most large cities in Japan which attract young women and men, and give them jobs, lack the conditions to bear and raise children. Similar phenomena can be seen in many industrialized countries. But the extent and exaggeration are more marked in Japan than in most Euro-American countries. Unless the trend of unplanned urbanization and inhuman industrialization is not stopped, and unless the situation mentioned above is not improved, most women will not want to have more children and the birth rate will never rise again in Japan.

4. Contraception

As discussed previously, since the 1870s the Japanese Government banned contraception and induced abortion except in women with life-threatening medical complications, and until 1948, unless seriously ill, the Japanese women could not have induced abortions. Even birth control was not welcomed much by the government. The only thing that the government reluctantly recognized was natural contraception. Consequently this next episode took place. In 1922, one of the pioneers in birth control, Mrs. Margaret Sanger arrived at the Yokohama port, invited by her friends in Japan, only to find that the Japanese government was very reluctant to allow her to enter the country. Only after promising the Japanese government to give no lectures on birth control during her stay in Japan was she finally (a few days later) given permission to land. It seems that it was not for ethical or religious reasons that the Japanese government prohibited induced abortion and birth control. It is likely that the main reason for this, was carrying out their policy for population increase. Still, that does not mean that before the war there were no campaigns among the Japanese requesting the adoption of induced abortion and birth control. Especially intellectual people well informed about America and the post-revolution USSR, tried to appeal to the public. But the government at the time considered these to be radical ideas and suppressed such discussions and campaigns.

5. AID

In the year 1948, when induced abortion was legalized in Japan, another major bioethical event was taking place. At the time, this too, was rarely the subject of ethical discussion. It only came to the extent of a few lawyers making an issue of the matter. The mass media, also, hardly ever took up this matter. This new problem was the fact that artificial insemination with semen collected from a donor (AID) had started being practiced at a university in Tokyo. Many Japanese obstetricians took a negative stand toward AID, but in Japan, campaigns strongly opposing AID did not advance at all. And so, even after that, AID was practiced widely, mainly in and around Tokyo, and children born by AID in Japan already number over 6,000. Because of this, there is the opinion among obstetricians and the mass media that it is not too late yet for the government to formally recognize AID and to protect the rights of the children born by AID and make their legal standing a more stable one. But the most important government and lawyers, for some reason have not done very much.

6. IVF/ET and the mass media

The Japanese mass media and general public opinion showed hardly any interest toward the legalization of induced abortion and AID, but in August of 1968, after the first heart transplantation was performed in Japan, there was a sudden great response towards ethical problems. Subsequently in 1983 there was a great disturbance when the first baby by in vitro fertilization and embryo transfer (IVF/ET) was born. It is interesting that both events took place, not in Tokyo or in Osaka, but at the universities of the northern cities, Sapporo and Sendai. At first the Japanese mass media and general public treated the doctors, who performed the first heart transplantation and IVF/ET as heroes. But in no time, with talk that the young man who had been a donor in a heart transplantation had still been alive, there was a convulsion concerning heart transplantation. This, in turn, touched off an active dispute concerning brain death. And as for IVF/ET, whether the process was safe and whether it was good or bad for doctors to interfere with reproduction to such extent, became the source of great dispute.

The way that the Japanese mass media took up these two subjects was bigger than almost any other political and economical event. Compared to the indifference toward the legalization of induced abortion and aid in 1948, this was a really favorable contrast. The cause for this, I feel, is the next three reasons: 1. Japanese society quickly escaped the disorder following the defeat in the war and many Japanese people found spare time to debate bioethical problems; 2. Discussions over brain death/organ transplantation in Europe and America had already spread widely among the Japanese people through the mass media. And so, preparations for social dispute was complete; 3. Criticism toward the recent advances among doctors and medicine has risen among the Japanese people.

Putting the issue of brain death/organ transplantation aside for a while, IVF/ET's success has had great influence over Japanese society, especially sterile and infertile women. And, lawyers and religious teachers fearing the abuse of IVF/ET were greatly alarmed. The Japan Society of Obstetrics and Gynecology (to which most Japanese obstetricians belong) in April of 1983, rushed to form an ethical committee concerning IVF/ET. This committee consisted of 14 members of Japan Society of Obstetrics and Gynecology. While listening to the opinions of representatives from the mass media and highly educated, in October 1983, they wrote and announced a statement to the society of Obstetrics and Gynecology. Even though it was a little too late, this was probably the first time that a medical society made and announced ethical guidelines for its members. The statement is as follows:

1. The Method should only be used for women who are judged unable to become pregnant by any other medical method.

2. The individual implementing this Method must be a qualified doctor who has mastered a high standard of knowledge and technology in the field of reproductive medicine. Every procedure and treatment should be carried out with the utmost care. The procedures and expected results of the Method should be sufficiently explained to the applicants concerned prior to implementation of the Method. Upon obtaining consent from the applicants, and acknowledgment should be filled out and signed by the applicants and retained by the doctor.

3. The applicant receiving the Method should be married, have a strong desire for a child, and be in satisfactory mental and physical condition for pregnancy, delivery and raising of a child. It must be possible to successfully conduct retrieval of mature ova, implantation into the uterus and maintenance of pregnancy.

4. The fertilized ovum should be carefully handled in respect to the basic moral values of life.

5. When implementing the Method, no gene manipulation is permitted.

6. The privacy of the couple and their delivered child should be respected and protected according to relevant laws and regulations.

7. Considering the importance of the Method, the organization using it should provide opportunities to hear opinions from individuals other than those directly concerned."

The number of babies born through IVF/ET is about 14,000 since the first case in 1983 in Japan. A total of 22,000 couples underwent procedures for IVF/ET at 236 medical facilities by autumn 1995 according to a recent report from the Japan Society of Obstetrics and Gynecology.

7. Preconceptional Sex Selection of Embryo/Fetus

While leaving AID to be practiced freely, it allows for only married couples to receive IVF/ET. However, in Japanese society it is common for there to be such inconsistency in laws and regulations. And the Japanese people seem to be sort of illogical or perhaps optimistic, in that the do not find it too much trouble to live with these inconsistencies.

In May 1986, when children were being born by IVF/ET not only in Sendai, but all over Japan, another complicated problem came up. This next problem was the preconception sex selection of the fetus. In other words, the doctors of a certain old university in Tokyo adopted a method called the Percoll Method and announced that they had been successful in separating layers of sperm where boys are easily conceived and layers of sperm where girls are easily conceived, causing a great controversy. Postconception sex selection (where after becoming pregnant, the fetus' sex is diagnosed as soon as possible and if it is of the desired sex, the pregnancy is continued) apparently is practiced in other Asian countries, but scientific procedures for sex selection of the fetus before conception (preconception) had not been given too much publicity in Japan until then and caused a great commotion.

The Japanese mass media, especially, handled this in a big way. And, opinions for and against this preconception sex selection came up against each other. People approving expressed the following: 1. It would help to prevent the birth of children with severe sex-linked recessive genetic disorders; 2. It would benefit people who were hoping for a specific sex in their next child; 3. There is a possibility, that it might control population increase; 4. There is a possibility that this procedure could be abused by militarists.

This problem was taken up right away by the Ethical Committee of the Japan Society of Obstetrics and Gynecology. And at the same time, the Ethical Committee of the Japan Medical Association took up the problem of preconception sex selection as their first task. These two ethical committees came to about the same conclusion in September 1986. That is, that it was decided that this procedure should only be adopted to prevent the conception of conceptuses with severe sex-linked recessive genetic disorders.

The detail of the Ethical Committee of the Japan Society of Obstetrics and Gynecology's statement are as follows:

1. Any individual implementing the Method must be a qualified physician who has mastered a high standard of knowledge and technology in the field of reproductive medicine.

2. A physician intending to implement the Method must be previously registered with the Society according to the specified format. It is also desirable that the results be reported to the Society.

3. Before application of the Method, the physician should sufficiently explain the procedures and expected results to the individual(s) concerned, and should obtain their written consent.

8. Embryo Protection

In Germany, in December of 1990, the Embryo Protection Law (Embryonenschuetzgesets) passed the Diet. This law is protecting embryos from their improper use and improper use of modern reproductive technologies such as transfer of more than three embryos or eggs within one treatment cycle, sex selection, artificial alteration of human germline cells, cloning, creation of chimeras and hybrids.

Needless to say, embryos are the weakest potential human being. Therefore, embryos should be protected most highly and most intensively not only from abuse of modern technologies but also from today's environmental hazards of all kinds.

I am of an opinion that issues of embryos should be discussed more widely and seriously in Japan not only from viewpoints of moral and ethics, medicine, science, law, ideology but from the viewpoint of the environment effects that may harm them.

Commentary on Shinagawa - Yutaka Tejima
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