Fertility Control: II. Social and Ethical Issues

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The status of contraception, sterilization and abortion services in the United States has always been linked to the various social and political movements that have been engaged with issues of women's role in society, reproduction and sexuality. Different groups have advocated for and against family planning for different reasons and with different levels of success. While issues pertaining to reproductive control have always caused some degree of social conflict, this has been especially true since the 1970s when the abortion debate intensified and spilled over to other reproductive health services. The emergence of HIV and rising rates of other sexually-transmitted diseases have also contributed to the controversy surrounding fertility control in the United States and abroad as the new millennium dawns.

This entry begins with a discussion of fertility control in a historical context. One must be aware of this history in order to understand the current ethical debate and controversies surrounding family planning and abortion. The article then continues with discussions of the social, political, religious and moral perspectives. Although the circumstances may change, the issues surrounding fertility control will always be with us and will remain among the most unresolved in bioethics.

Historical Context

It is often said that if we are unaware of our history, we are doomed to repeat the mistakes of the past. Mistakes and dilemmas regarding birth control are particularly apparent when looked at from the perspectives of the women involved, rather than as a success of technology developed by the great men of medicine.

Advocates for birth control generally intended it to be an option for all women, regardless of race or class. The reality, however, was often that poor, otherwise unempowered women, often from minority backgrounds, were most in need of such advocacy, education and access to contraception. Upper-class women had greater access to information and methods of contraception through their private physicians and other social contacts. They could also pay for whatever was available at the time. They voluntarily reduced the number of children they had. The well-intentioned, beneficent efforts on the part of advocates for women and for birth control to improve access for poor minority women and empower them often had the effect of targeting these women for efforts to reduce the numbers of children they had. The ability of a woman to choose the number of children she had and when she had them might allow her to control other aspects of her life and family and to improve the quality of life for herself and others. It could also come dangerously close, on a population basis, to achieving the desires of eugenicists to reduce the numbers of poor minority, or otherwise undesirable people, in the population. One example of this tension is that involving immigrant Irish and Eastern European women in the late nineteenth century. There was a real concern on the part of eugenicists that the immigrant population was growing and reproducing while educated, upper class American women were successfully reducing the size of their families. Eugenicists may have wanted to control the fertility of immigrant women in order to maintain population proportions, especially those of the "desirable" component of the population. On the other hand, early advocates for birth control might have wanted to improve access to birth control in order to empower these women to control their own destinies to a certain extent. Promoting the autonomy of women and acting beneficently on their behalf, in this case, comes dangerously close to the less ethically acceptable motivation of the eugenicists.

The history of the birth control movement in this country over the past 125 years provides clear examples of the tensions which have always existed between empowering women to control their fertility and promoting limitations on fertility for the disadvantaged. Several important developments in the history of the American birth control movement have been chosen to illustrate these tensions and provide a context within which to analyze contemporary social, ethical and political issues (Powderly).

CONTRACEPTION IN LATE NINETEENTH CENTURY AMERICA. Victorian beliefs regarding sexuality accepted promiscuity as a fact of life for men who were either not expected to or were unable to control their sexual urges. Women, on the other hand, were expected to control or even deny their sexuality (Gordon, 1981). Prostitutes were a common and accepted solution to this dichotomy. Despite the view that female sexuality was viewed as inextricably linked to reproduction, contraception was widely practiced among all social classes. The methods of contraception varied by class, however, due to cost and availability. The upper classes were more likely to use relatively expensive methods of contraception such as condoms, spermicides, and douches. They might also have had access to diaphragms and cervical caps smuggled in from Europe at a high cost. Withdrawal and rhythm were often the only methods available to the poor. At a time when menstrual cycles were only partially understood, pregnancies often resulted. Abortion, often self-induced and always dangerous, was resorted to frequently. It is estimated that one out of every five to six pregnancies in America ended with an abortion by the 1850s (Chesler). Mortality from septic abortions was extremely high. In 1888, it was estimated as being fifteen times greater than maternal mortality (LaSorte, Powderly).

During this era, American feminists supported the concept of "voluntary motherhood" (Gordon, 1981). Far from empowering women and providing them with sexual freedom, however, voluntary motherhood sustained traditional family roles for women. Limitation of family size enhanced their ability to fulfill their societal roles as wives and mothers according to this view. These feminists were joined by moral reformers who were concerned about excessive breeding among the lower classes. Immigrants were particular targets of this concern. Focusing efforts toward reduction of fertility on the lower class and members of minority groups has strong historical roots in the late nineteenth century (Powderly).

Although contraception was widely practiced in private and abortion was accepted as a necessity when it failed, many were not willing to risk expressing support for them in public or admitting to their use. This Victorian reluctance influenced public policy. Abortion was declared illegal for the first time in the United States in 1830. A majority of states had declared it so by 1870 (LaSorte). A great legal blow was dealt to contraception in 1873 with the passage of the statute that came to be known as the Comstock law. This federal statute made it illegal to transport obscene materials through the mail. Contraceptive devices such as condoms and diaphragms as well as literature were confiscated under this law, which was in effect until 1936. It lost its power in a case in which Margaret Sanger established the right of doctors and other qualified professionals to use the mail for such distribution. Contraceptives themselves remained in the obscenity statutes until 1971 (Wardell, Powderly).

MARGARET SANGER AND THE AMERICAN BIRTH CONTROL MOVEMENT. Perhaps no name is more associated with birth control, family planning, and reproductive freedom for women than Margaret Sanger's. Sanger was born in 1879, the middle child in an Irish immigrant family with eleven children. She was impressed at a young age with the effect of frequent pregnancies on her mother, who suffered from tuberculosis and died at the age of fifty. Her mother's frequent pregnancies and their ultimate role in her early death angered Sanger. She went on to play a strong role in the birth control movement in the United States and abroad until her death in 1966. While her decision to devote her life to the promotion of access to birth control for all women was influenced by many factors, her own family background and experience certainly played an important role.

Sanger was trained as a nurse, although she left her training program early to marry William Sanger. Because of prohibitions against married nursing students in this era, she could not remain in the program once she married. She would remain conflicted throughout her life between her obligations to her family and the demands of her passionate cause—access to birth control for all women. This is a conflict that remains for many working mothers today in an era where there is often no choice.

Margaret Sanger's experience as a visiting nurse and midwife on New York City's Lower East Side provided the stimulus for her crusade. She often cited the case of Sadie Sachs, a twenty-eight year old Jewish immigrant and mother of three who was married to a truck driver named Jake. Unable to deal with another pregnancy and an additional child, Mrs. Sachs nearly died from a self-induced abortion. Sanger nursed her for weeks and listened to her pleas for reliable contraception. It is likely that Sanger offered her personal experiences with condoms and coitus interruptus, the common methods readily available at the time. Mrs. Sachs knew another pregnancy would kill her. The only advice her physician could offer her was to "tell Jake to sleep on the roof." If only these immigrant men could control their sexuality, there wouldn't be so many problems! There was no better or more constructive advice available to her. Three months later, Mrs. Sachs died of septicemia after another self-induced abortion. Her husband was distraught and her children left motherless. Margaret Sanger called it "the dawn of a new day in my life … I knew I could not go back merely to keeping people alive.…" (Chesler; Wardell; Sanger, 1931, 1938; Powderly).

Early in her crusade, Margaret Sanger used her connections to the Socialist Party to promote her cause. She published a column entitled: "What Every Girl Should Know" in The Call, a New York Socialist daily, in 1912 and 1913. The columns elicited a range of responses and were ultimately challenged by Anthony Comstock. Early in 1913, one of the columns was entitled "What Every Girl Should Know—Nothing; by order of the U.S. Post Office" and was followed by a blank space. Several weeks later the censored column appeared (Chesler; Sanger, 1938). Birth control was not to become a priority issue for the Socialists, however. It couldn't compete with suffrage and labor issues. Sanger was disillusioned and disappointed that birth control was not viewed by her comrades as a priority issue for women.

In 1914, Sanger abandoned her own failing marriage and devoted herself to the development of The Woman Rebel, a magazine for working women that would cover issues of sexuality and contraception. She was indicted under the Comstock laws for sending the first issue of this magazine through the mail. While awaiting trial, she wrote Family Limitation, a practical pamphlet on birth control methods. The world was about to go to war and Sanger's arrest and cause were not receiving as much publicity as she had hoped for. She decided to flee the country and her children and go to Europe until she could command more visibility. While she continued her research on contraceptive methods, her husband, still a supporter, went to jail for dispensing one of her pamphlets. Sanger returned to heightened publicity for her cause and the charges against her were ultimately dropped (Chesler; Powderly).

Sanger began a cross-country speaking tour to promote the importance of knowledge for women regarding sexuality and birth control. While she promoted access to birth control for all women, she focused primarily on the poor. Sanger believed that uncontrolled fertility and large families were inextricably linked to poverty. Her efforts to empower poor women, however, would be viewed by some as racist and by others as having eugenic propensities. While many eugenicists supported the ideas of limiting population growth, particularly among those they viewed as undesirable (e.g. the poor, immigrants, those with mental problems or disabilities), they were greatly troubled by the idea that the upper classes would use birth control and the lower classes would continue to breed.

Margaret Sanger brought birth control directly to the poor women of Brooklyn on October 16, 1916, when she opened a free-standing clinic in Brownsville. Immigrant women from many cultures lined up with their baby carriages to learn how to prevent future pregnancies. In the few weeks the clinic was open, 464 women were provided with sex education and contraceptive information (Chesler; Powderly). The clinic was raided by the New York City Vice Squad and Sanger and her sister, Ethel Byrne, the clinic's nurse, were jailed. The trial produced an important legal victory for birth control. The New York State Court of Appeals interpreted the law to allow for prescription of contraceptives by physicians not only to prevent or cure venereal disease—an interpretation largely applied to men—but also for any health reason. This opened the door for physicians to prescribe contraceptives for women. It also produced another dramatic effect, however. Birth control from that point on was a physician-dominated enterprise. While Margaret Sanger's Brownsville clinic brought contraception to the community level and to poor women, it did so at a price. Nurses, and to a large extent, women, were not to control the provision of contraceptives. This is a legacy that lingers today. In populations with limited access to physicians, it is a clear disadvantage (Chesler; Powderly).

The compromises struck with the medical community are evident in Margaret Sanger's interactions with Robert Latou Dickinson. Dr. Dickinson, a Brooklyn gynecologist, was a champion of studies of female sexuality, fertility and contraception. While he was not a strong supporter of contraception early in his career, he became one of its strongest supporters and was on the Board of Planned Parenthood at the time of his death in 1950 at the age of eighty-nine. Dickinson and Sanger fought for the right to contraceptives, but he viewed her techniques as propogandist. He sought initially to evaluate the effectiveness of contraceptive counseling and techniques, using more traditional scientific methods. Influential in his field, Dickinson used his platform as president of the American Gynecological Society to promote professional interest in birth control. He set up a committee on maternal health at the prestigious New York Academy of Medicine to promote contraceptive research. He found, however, that without Sanger's "propoganda" he had trouble recruiting patients. While he had access to the medical establishment, she had access to the women who would be the subjects of the research and the users of contraceptives. Dickinson also, ultimately, sought Sanger's assistance in securing diaphragms for his own patients. He had been unable to acquire enough diaphragms through legal channels. Sanger had been smuggling them into the country, sometimes in "Three-in-One oil boxes." She had married the millionaire head of the Three-in-One oil company and used his fortune and resources to promote her cause (Wardell; Powderly). Sanger and Dickinson often disagreed vehemently on strategy, but also cooperated to achieve their mutually desired goals. Dickinson ultimately joined Sanger's Birth Control Clinical Research Bureau's advisory board. Together, they assured that birth control would be available to American women. It was, however, to be a male-dominated enterprise constructed on the medical model (Powderly).

STERILIZATION. Tubal sterilization was first proposed in the early nineteenth century for effective long-term contraception in women undergoing operative deliveries (C-sections). The first reported tubal sterilization was performed in 1880 (Lungren; Siegler and Grunebaum). While technology had evolved enough to attempt these procedures, it is important to recognize that they were still quite risky. A paper delivered at the Brooklyn Gynecological Society in 1891 reviewed the sixty-eight sections that had been performed in the United States from 1882–1891. The Brooklyn maternal mortality rate of 33 1/3 percent compared favorably with the national mortality rate of 40 percent (Powderly). Surely, if a woman survived one section, avoidance of another would be an important consideration. Many of the early tubal ligations were recommended to protect the life or health of the woman.

In the early twentieth century, however, eugenics was a dominant reason for tubal sterilization, particularly involuntary sterilization. Compulsory sterilization began to be recommended for individuals with hereditary disease, the "feebleminded" (i.e. the insane and demented) and the mentally retarded. There were also racial overtones, as undesirable characteristics were perceived to occur more often in Negroes, Orientals, and the foreign-born. In addition, there were some moves to sterilize habitual criminals—a move that some promote to this day for repeat sex offenders. While recommendations for habitual criminals dealt largely with men, efforts to control hereditary and mental illnesses were most often directed at women (Reilly; Powderly). Efforts to "train" female inhabitants of mental institutions gave way to a priority to keep them from reproducing. The view that deviance was hereditary was supported in large part by studies of two families—the Jukes and the Kallikaks.

Richard Dudgale, a social reformer, studied 709 people over five generations in a family he called the "Jukes." Although Dugdale believed both heredity and environment were to blame for the propensity of the Jukes for crime, intemperance and prostitution, he gave real credence to heredity (Dugdale). He estimated that their care had cost society well over a million dollars. In 1912, Henry Goddard added to the belief that deviance was hereditary with his publication of The Kallikak Family. Goddard had been studing feeble-mindedness when he discovered the family, which he traced back over six generations. The progenitor had produced both a legitimate and an illegitimate line. The legitimate line produced upstanding citizens, while the illegitimate line produced large families with a disproportionate number of feeble-minded individuals (Reilly; Powderly).

Already concerned with the effects of immigration on population demographics, eugenicists were given superb ammunition with these two studies. The eugenics movement also received financial support from some of the country's most prominent philanthropists. Even Theodore Roosevelt supported the movement, urging Americans to avoid "racial suicide"—the upper classes must not be outnumbered in their progeny by immigrants and the lower class.

The nation's first involuntary sterilization law was passed in 1907 and 14 states had laws allowing involuntary sterilization by 1914. The effect of the laws varied. From 1907 to 1921, there were 3233 documented sterilizations performed under state laws. These sterilizations were seen by many within the mental hygiene movement as beneficial to society and, at the very least, as not harmful to the individual (Reilly). While there was much popular and professional support, eugenic sterilization was still controversial. Some statutes were drafted with more concern regarding constitutional constraints and more care about guardians'consent. Ultimately, however, the Supreme Court provided a boost for involuntary sterilization with its decision in Buck v. Bell in 1927. Oliver Wendell Holmes wrote: "It is better for all the world, if instead of waiting to execute degenerative offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind." Sterilization programs were active through the 1940s and 1950s and not influenced by reaction to the Nazi sterilization programs (Reilly; Powderly; Lombardo). Eugenic sterilization virtually disappeared, however, in the 1960s in an era of awareness of patients' rights and the need for society to protect the vulnerable.

BIRTH CONTROL AND THE MODERN ERA. The 1960s and 1970s saw great technological advances in birth control, albeit all dependent on women. The development and approval of oral contraceptives, after controversial research on women in the third world, finally provided a highly effective form of contraception that was not associated with individual sex acts. Intrauterine devices (IUDs) also became popular choices for women and couples who wanted to control their fertility. Although IUDs would later become less available because of legal challenges related to side effects of the Dalkon Shield, they remained a method of choice for many women. By the end of the twentieth century, contraceptive rings and patches and long-acting contraceptives like Norplant, in addition to safer doses of oral contraceptives, would provide many accessible and affordable options for fertility control. The reduction in the use of barrier contraceptives, however, would increase concern about transmission of sexually transmitted diseases, including HIV.

In addition to technological advances, there were legal and policy victories for birth control. A significant victory in this regard occurred in New York City in 1957 when Dr. Louis M. Hellman fitted a severely diabetic postpartum woman with a diaphragm in violation of the policies of the commissioner of hospitals. The media had been notified in advance and the resulting coverage precipitated a policy change that allowed women to receive contraceptive counseling and devices in municipal hospitals in New York City (Hellman). Dr. Hellman went on to serve as deputy assistant secretary for population affairs in the Department of Health, Education and Welfare under President Nixon. He oversaw the Title X family planning initiatives that provided family planning services to five million women who desired them but could not afford them (Powderly).

The Supreme Court declared contraception a constitutional right for married couples in 1965 in the case of Griswold v. Connecticut. The Comstock laws were finally repealed in 1971 and the Supreme Court guaranteed a woman's right to abortion in Roe v. Wade in 1973. Women were now entitled to access to contraceptives and abortion services. This, however, did not ensure that they would have access. Some women did not have access to Title X funded services and could not afford contraceptives. Barriers to health care in general often extended to family planning services. For others, partners or spouses prohibited the use of desired contraceptives. Cultural and religious beliefs and prohibitions may also prove problematic. In addition, the fight against legalized abortion rages on and has escalated to violent outbursts that threaten the providers and users of abortion services. Coercion and social pressure may also result in women who do not desire contraception being forced to use them (Powderly).

Social and Political Issues

Numerous social and political issues have influenced fertility control in the modern world.

INTEREST GROUPS AND FAMILY PLANNING. Providers of Family Planning Services. Family planning services in the United States are offered by both private and public agencies. Public providers of family planning services at the local level include public health clinics in hospitals or neighborhood health centers, school-based clinics, Medicaid managed-care organizations and hospital-based clinics. At the county, state, regional and national levels, various arms of government are involved with the setting of policy for these publicly supported clinics and in devising formulas to disburse funding. The major conduit for public funding of family planning services is Title X of the Public Health Act of 1970. Title X has never allowed funding for abortion services, however.

In the private sector, abortion and family planning services are offered both by for-profit and not-for-profit clinics, managed care organizations and by private physicians. The not-for-profit Planned Parenthood Federation of America, Inc., with affiliates across the country, continues to be one of the most important providers of family planning services in the private sector.

In theory, the public and private components of the family planning delivery system share similar goals: the dissemination of contraceptive services and education under a public health model, which includes the prevention of HIV infection and other sexually transmitted diseases as well as services specifically rendered to control fertility. The relationship between the public and private components is quite complicated and intertwined, however. Family planning services, like other publicly provided social services in the United States, are typically delivered through a system that relies at least partly on private agencies, or "subcontractors," rather than directly by the government itself.

In addition, family planning became intensely politicized in the United States after the election of Ronald Reagan in 1980. Since then, the agendas of public and private providers of family planning services have often been at odds. Difficulties with Title X-funded programs illustrate these contradictions. A significant proportion of Title X-funded services in many communities across the country is provided by Planned Parenthood, which is also a prime target of those who are politically conservative because of the organization's visibility as an abortion provider. Political appointees within the Department of Health and Human Services, which oversees Title X and related services, have, at times, been aligned with political groups committed to the defunding of this program, because of some conservatives' opposition to family planning programs. The number of publicly funded family planning programs and clinics across the country has declined; this decline reflects the bitter ideological wrangling over the concept of publicly funded family planning (Ettinger, 1992; Scott).

In 2002, nearly five million women received health care services at family planning clinics funded by Title X. They were predominantly young, poor, uninsured, and had never had a child. Seventy-one percent of women using Title X-funded clinics are 20 years of age or older and 63 percent are white. Sixty-five percent have incomes at or below the federal poverty level. It is estimated that these clinics are the only source of family planning services for more than 80 percent of the women they serve (AGI, 2002a; Kaeser et al; Planned Parenthood).

The Women's Movement. Since the re-emergence of a visible women's movement in the United States in the late 1960s, various groups associated with the movement have been forceful advocates for family planning and abortion services. The new feminists have demonstrated a keen interest in issues of reproductive rights and sexuality (Joffe, 1986). The campaign to make abortion legal and accessible was a major focus of the feminist movement in the 1960s. During the 1980s, when a woman's right to a legal and safe abortion was threatened, women's organizations played a highly visible role in pro-choice activities, working closely with such organizations as Planned Parenthood and the National Abortion Rights Action League.

With respect to other reproductive issues, however, the relation of sectors of the women's movement to its abortion allies has been more complex. At times, the responses of some feminist health activists to prevailing contraceptive practices and new contraceptive innovations have conflicted with sometime allies, such as Planned Parenthood. These activists, for example, raised doubts early on about the safety of oral contraceptives, objected to testing new contraceptive technologies on women in developing nations and, more recently, voiced reservations about the likely social abuses of Norplant, a long-acting, implantable contraceptive device (Seaman; Gordon, 1976; Moskowitz and Jennings).

The Pro-Family Movement. Beginning in the 1970s, a movement of sexual conservatism—the "pro-family" movement—became a significant presence in family planning politics (Petchesky; McKeegan). This movement's main concern has been the breakdown of sexual morality in contemporary society, as evidenced by high rates of abortion, adolescent pregnancy, out-of-wedlock births, and sexually-transmitted diseases. For sexual conservatives, widely available family planning services—especially those supported by public funds—represent a temptation to break with traditional morality (Marshner). Though the profamily movement is most visible in anti-abortion activity, its interests and interventions extend to a broad range of reproductive and sexual matters—contraceptive services, sex education, adolescent pregnancy prevention efforts, and HIV prevention (Joffe, 1986; Nathanson).

Family planning services for adolescents have been a major focal point of pro-family activity (Joffe, 1993). Conservative activists have persuaded legislators in a number of states to adopt parental notification and consent rules for teenagers seeking abortions, and have sought regulations that would include parental notification policies for federally funded clinics providing contraceptive services.

The "gag-rule" controversy, which has spanned the presidencies of Ronald Reagan through George W. Bush, is further illustration of the efforts of conservatives to link attacks on abortion to those on family planning. Originally written as an administrative guideline during the Reagan administration, the gag rule forbade employees in Title X-funded family planning clinics to provide counseling about abortion options, even when women asked for such information. For many within the healthcare community and the public at large, this ruling raised concerns about free speech for health professionals. In the space of several years, the gag rule was upheld by the Supreme Court, overturned by congressional legislation, and promptly vetoed by George H.W. Bush, under intense pressure from conservatives. In one of his first acts after taking office in 1993, Bill Clinton abolished the gag rule, under similar pressure from the prochoice and family planning communities. On his first day in office, George W. Bush restored the Reagan–era gag rule for international family planning programs. This is a pattern that is likely to continue, illustrating the strong relationship between politics and women's health issues, especially those involving fertility control (Planned Parenthood; RowBoat).

Welfare Conservatives. In contrast to the pro-family movement, whose defining issue is the breakdown of sexual morality and traditional families, "welfare conservatives" are concerned about the rising welfare costs resulting from adolescent pregnancies, illegitimate births and failure of fathers to make child support payments. Welfare conservatives have made a number of policy proposals that either mandate use of contraception as a condition of receiving welfare or other financial incentives for such contraceptive use, that penalize recipients financially for having additional children and that forbid adolescent mothers from receiving welfare assistance directly, providing instead that the grant go to their parents or guardians (Nathanson; Peirce).

The contraceptive implant, Norplant, introduced in the United States in 1990, quickly became implicated in a number of policies advocated by welfare conservatives. Once inserted, the implant prevents pregnancy for up to five years. Both the insertion and the removal, however, must be done by a trained health professional. After the insertion, no further "user compliance" is required, making this a far more effective contraceptive device than other birth control methods. Within eighteen months of the introduction into the United States of this new method, virtually all states approved the public funding of Norplant insertion for welfare recipients. The potential for coercion is evident. There have been instances where judges have required Norplant use as a condition of probation or child custody for women convicted on drug-related charges or of child abuse (Forrest and Kaeser). Provision of access to Norplant for adolescents has also raised ethical concerns (Moskowitz and Jennings). In addition, lack of access to providers trained to remove the implant may restrict choice for some women.


Minority Communities. Minority communities in the United States have long had a wary relationship with family planning advocates and services. The previously cited historical links between the founders of the birth control movement, such as Margaret Sanger, and those in the eugenics movement with an avowedly racist ideology created a lasting sense of distrust in minority communities as to the intentions of some within the family planning movement (Chesler; Gordon, 1976). Such distrust reached a height in the late 1960s and early 1970s when many of the Title X clinics appeared to be targeted specifically at African-Americans, leading some African-American leaders to accuse family planners of "genocidal" intentions (Littlewood). More recently, some community leaders—most notably, black clergy—have joined forces with the pro-family movement, arguing against such measures as condom distribution in inner-city high schools and offering Norplant to adolescent mothers (Moskowitz and Jennings).

At the same time, the rates of premarital sexual activity, sexually-transmitted diseases, adolescent pregnancy and abortion have been disproportionately higher for minorities than for others. Thus, there is a need for culturally-sensitive family planning and abortion services, and many minority organizations argue forcefully for their retention and expansion.

Adolescents. In the early 1990s, adolescents were entitled to receive low-cost or free confidential contraceptive services at Title X sites. Adolescents, as a group, did not receive any public funds for abortion. The field of adolescent medicine recognizes the need to provide education and family planning services to sexually active adolescents (American Academy of Pediatrics, 1999). The rising rates of sexual activity among adolescents, particularly young adolescents, has increased concern within the family planning community about adolescent pregnancy and this group's vulnerability to HIV and other sexually-transmitted diseases (Alan Guttmacher Institute, 1991). In the 1980s, a major response to both these issues was the establishment of school-based clinics on the theory that while few teens would make their way to a free-standing clinic, clinics located within the school would reach a much larger public. Programs were also established for pregnant adolescents and those with children to try to keep them in school. Predictably, such school-based programs were controversial from the start, strongly opposed by conservatives and just as strongly advocated by health professionals and public health advocates (Kirby et al; Moskowitz and Jennings).

A number of school districts, particularly those in large urban areas, began distributing condoms to students in response to the HIV epidemic. There has been massive controversy here as well, with many parent and church groups opposing such efforts. Generally speaking, however, HIV-related interventions in schools seem to be more acceptable to the public and to educators than specific efforts for pregnancy prevention. A national study of sex education in U.S. schools in the late 1980s found far more attention paid to HIV and sexually-transmitted diseases than to family planning education (Forrest and Silverman). While most would advocate abstinence for adolescents, particularly young ones, the alarming rate of unprotected sexual activity in this age group warrants realistic education and confidential access to safe, appropriate family planning services.

In October of 1998, there was an attempt to pass legislation restricting minor's access to family planning services. The proposed amendment would have mandated that parents of dependent adolescents be notified before their children received contraceptives from Title X-funded clinics (Congressional Record). Supporters of parental consent feel that available, confidential family planning services encourage sexual activity in adolescents and undermine parental authority. However, research has demonstrated that confidentiality is crucial to teens' willingness to seek services related to sexuality (American Academy of Pediatrics, 1999; Reddy et al; Planned Parenthood). Moreover, Planned Parenthood states that the fact that the average teen does not visit a family planning clinic until 14 months after she has become sexually active provides clear evidence that clinics do not encourage sexual activity. Requiring parental consent may not deter adolescents from having sex, but it could keep them from seeking reproductive health care in a timely fashion or at all. This could contribute to an increased rate of pregnancies as well as sexually transmitted diseases (AGI, 2000; Planned Parenthood). While the 1998 amendment was not passed, there is an ongoing attempt by political conservatives to fight access to family planning services for adolescents and even punish them for having sex. In a recent NYC case, a group of eighth graders who skipped school to attend a party where they allegedly had sex were forced to submit to pregnancy and other gynecological testing and to provide the results before they could return to school. A suit has been filed on their behalf by the New York Civil Liberties Union (Williams).

Services to the Disabled. Case law in the United States generally recognizes that developmentally disabled individuals have the same fundamental rights regarding procreative choice as those who are not disabled. There are, however, difficulties in implementing family planning services for disabled persons. The issue of informed consent for mentally disabled individuals is particularly relevant and remains ethically problematic. Is the individual capable of giving informed consent, and if not, who is the appropriate surrogate empowered to make such decisions (Stavis).

In spite of legal decisions supporting provision of such services, relatively few disabled persons are served in Title X clinics (Moore and Lieber). Few clinic staffs have received the specialized training necessary to work effectively with this population. In addition, many caretakers, particularly parents, have difficulty dealing with sexuality in this population and are reluctant to ensure that these individuals receive such services. In addition, disabled individuals and caretakers are often not aware of the entitlement of the disabled to family planning services, which implies a need for more outreach to this population.

In light of the compulsory sterilization programs of the past, the major ethical conflict regarding sterilization today is balancing the rights of a mentally retarded or mentally disabled person to sexual freedom with a protection of their best interests regarding childbearing. Many writings deal with the sterilization of the mentally retarded who are somewhat incapacitated or even totally incapable of giving informed consent (Macklin and Gaylin). The Committee on Ethics of the American College of Obstetricians and Gynecologists has issued a statement on "Sterilization of Women Who Are Mentally Handicapped," which urges all possible attempts to communicate with the person involved on whatever level is possible. Even in cases where it is clear that the individual has no ability to comprehend a pregnancy and childbirth and may be harmed by the experience, it is difficult to obtain a court order for sterilization because of the history of abuses. Perhaps it is more beneficent to take the middle ground in these cases. While routine sterilization of a mentally impaired individual without her consent is clearly wrong, restricting the sexual expression of a profoundly impaired individual who cannot comprehend her sexuality, much less pregnancy or coitus-related conception, is also not justified. In carefully considered circumstances, advocates for the patient may conclude that sterilization is in the patient's best interest. The decision should be made by an appropriate surrogate or proxy, based on the best interests of the patient after considering alternative methods of dealing with the situation. The prominence of this issue in the Senate confirmation hearings of Dr. Henry Foster as Surgeon General in the Clinton administration illustrates the importance of this issue and the lack of societal consensus (Powderly, 1996).

Religious and Moral Issues

Most people today, along with philosophical ethicists, religious ethicists and organized religions, generally accept the morality of contraception within marriage, often appealing to the need for family planning. While recognizing a link between marital sexuality and procreation, many concede that marital sexuality also has other significant purposes such as expressing and enhancing the love union of the partners and thereby the good of the marriage. Unlimited procreation, or at times any procreation, could be harmful to one of the spouses, the marriage itself, the good of already existing children or the needs of the broader society. Judgments about the ethical use of contraception outside of marriage depends upon one's understanding of the morality of extramarital sexual activity. As a matter of fact, many unmarried people today are sexually active. Indeed, the majority of adolescents in the United States have had sexual intercourse by the time they are nineteen years old (Demetriou and Kaplan; American Academy of Pediatrics).

Many feminists emphasize reproductive rights, freedom, control of one's body and autonomy to support their stand that women have the right to make contraceptive decisions in all cases (Harrison). Although society at large in the United States no longer condemns all extramarital sexuality as immoral and irresponsible, the mainstream churches and religions still generally maintain the immorality of sexual relations outside marriage (Lebacqz). The use of condoms enters into the discussion of extramarital sexuality not only because of the desire to prevent procreation, but also because condoms can help to prevent the transmission of HIV and other sexually-transmitted diseases. If one believes that extramarital sexual relations are morally responsible, then the use of contraception to prevent unwanted procreation is morally acceptable.

No perfect contraception exists, but most ethical reasoning sees no significant moral differences among the various means, provided they are not harmful to the individuals who use them or others. One could justify contraception on the basis of an absolute autonomy, giving the individual control over her body and the right to make all decisions concerning it, but most justifications of family planning, which by definition concerns more than the individual, avoid such a radical individual autonomy. The official teaching of the Roman Catholic church constitutes the strongest and the primary contemporary moral opposition to the use of contraception.

The widespread moral acceptance of contraception has taken place well within the twentieth century. Individuals do not make moral judgments in the abstract. As indicated previously, a number of significant social factors have influenced the acceptance of contraceptive practices. These include the increased life expectancy of all human beings, the massive improvements in infant and child health resulting in more survival, the realities and pressures of an increasingly urban and industrialized society, the changing role and function of women in society, the wider and more accurate understanding of the physiology of human reproduction, the recognition of the population explosion and the need to limit population, and the development of accessible, effective methods of contraception.

The Christian religions have played a significant role in ethical views on contraception in the West. The ancient world of both East and West knew the reality of contraception either by avoiding insemination of the female or by using potions or magic. In the Greco-Roman world, some philosophers and physicians apparently accepted attempts at contraception. On the other hand, the Roman Empire tended to encourage childbearing. Some influential philosophers insisted that procreation constituted the only purpose of sexual intercourse and thus, logically condemned contraception. The Hebrew scriptures contain no law condemning contraception.

The Christian approach to contraception also developed in a context in which contraception was associated with prostitution and extramarital sexuality, which Christians strongly opposed. In addition, early potions used for contraception (and some modern methods such as IUDs) could not clearly be differentiated from abortifacients and abortion was even less tolerable than contraception. The Christian condemnation of contraception followed from its understanding of human sexuality and the belief that the purpose of sexuality was procreation. Some medieval theologians and their successors, however, including Thomas Aquinas, maintained that procreation was not the only lawful purpose for sexuality, at least within marriage. The church, for example, accepted the marital sexuality of the sterile and those no longer able to procreate. The procreation of offspring also included the responsibility for the wellbeing and education of the children—some would extend this to justify not having so many children that you could not care for the pre-existing ones. However, the condemnation of contraception remained, with emphasis on its violation of the order of nature calling for the depositing of the male seed in the vagina of the female. This nature-based rationale also served as the basis for the condemnation of sodomy, oral and anal sex, and masturbation. This view is closely related to the Hebrew prohibition on "spilling" seed.

Although some Protestant laypersons were involved in the Anglo-Saxon countries, the Christian churches remained firm in their condemnation of artificial contraception, as distinguished from abstinence, well into the twentieth century. The Church of England became the first Christian church to accept officially the morality of artificial contraception for spouses. In 1930, the Lambeth Conference, by a vote of 193 to 67, adopted a resolution recognizing a moral obligation to limit or avoid parenthood and proposing complete abstinence as the primary and most obvious way while also accepting other methods (Fagley).

The Committee on Marriage and Home of the U.S. Federal Council of Churches issued an influential statement in 1931 in which the majority of its members accepted the careful and restrained use of contraception by spouses. Subsequently, the major Protestant churches and the most significant Protestant theological ethicists accepted contraception as a way to ensure responsible parenthood. The proponents of change pointed to aspects in the Christian tradition supporting such a move. Christians had gradually come to recognize the loving or unitive aspect of marital sexuality in addition to the procreative aspect. The procreative aspect itself included not only the procreation but also the education of offspring. This called for the good health of the parents. Protestantism justified the use of contraception as a way for spouses to realize responsible parenthood (Fagley).

Roman Catholic official teachings continue to steadfastly oppose artificial contraception, even within marriage. Some Catholic theologians have advocated the use of the infertile period for sexual intercourse, or the rhythm method. In 1951, Pope Pius XII taught that serious medical, eugenic, economic and social indications justified the use of the sterile periods even on a permanent basis. Unfortunately, the rhythm method often proves to be a rather ineffective method of contraception. This can have devastating consequences, especially if there are serious medical contraindications to pregnancy. Pope John XXIII and Pope Paul VI established a commission to study the question. The majority of the commission favored changing the teaching to allow for artificial contraception, but Pope Paul VI and Pope John Paul II have reiterated an absolute condemnation of artificial contraception. In Humanae Vitae, Paul VI states that the natural law "teaches that each and every marriage act must remain open to the transmission of life" and refers to "the inseparable connection, willed by God and unable to be broken by man on his own initiative, between the two meanings of the conjugal act: the unitive and the procreative meaning" (Paul VI). In practice, the vast majority of Catholic couples use contraception (Curran). The Catholic Church's continued prohibition of any method of artificial contraception is especially problematic in poor, overpopulated developing countries with large Catholic populations. In such countries, uncurtailed childbearing can have dire consequences for women and children.

The Catholic Church also opposes voluntary sterilization for contraceptive purposes. As far as therapeutic sterilization is concerned, the principle of double effect is generally applied. Therapeutic sterilization is that done for the good or health of the individual and not primarily for contraceptive purposes. Direct sterilization is that which aims at making procreation impossible either as a means or as an end and is always considered wrong. Indirect sterilization aims directly at the health or good of the individual and the actual procreative effect is secondary. Thus, a cancerous uterus can be removed, but hysterectomy to prevent harm to the pregnant woman would be considered direct and morally wrong (Boyle).

The fact that there is little or no discussion of punitive sterilization in the more recent literature hints at a consensus against the practice. However, Francis Hurth, a conservative Roman Catholic theologian in the 1930s, proposed limited cases in which punitive sterilization might be justified. Pope Pius XI went out of his way not to directly condemn punitive sterilization. This is interesting in light of the absolute prohibition on sterilization for contraceptive purposes in women desperate to limit the size of their families. Proponents of punitive sterilization maintain that if the state can inflict capital punishment for certain crimes, it can also inflict the lesser punishment of sterilization in limited, appropriate cases. Critics reply that punitive sterilization does not achieve the purposes of punishment and does not even inhibit future sex crimes (McCarthy). Punitive sterilization is virtually unsupported (Mason).

Other religious bodies today generally support artificial contraception in the context of responsible parenthood. The Eastern Orthodox church accepts responsible contraception while condemning abortion and infanticide. The multiple purposes of marriage, the lack of any definitive statement against contraception by the church, a synergistic cooperation between God and humans, and the need for responsible parenthood serve as the basis for the responsible use of contraception within marriage (Harakas; Zaphiris).

Orthodox Judaism gives a limited acceptance to some forms of contraception. Jewish law puts the duty of procreation on the male, and this obligation militates against the use of condoms or coitus interruptus. In this view, the most acceptable contraception is that which interferes the least with the natural sex act (Rosner). Conservative and Reform Judaism fully accept and endorse contraception provided it is not harmful to the parties involved.

Islam accepts contraception if it does not entail the radical separation of procreation from marriage. All forms of contraception are acceptable provided they are not harmful and do not involve abortion. Justification for contraception in Islam rests on reports that the Prophet Muhammad did not forbid the contraceptive practices of some of his companions (Hathout).

Ancient Hindu medicine and Hindu tradition did not contemplate contraception, but did sanction means to enhance contraception. In time, medical texts began to address contraception by advising a few oral preparations to prevent conception. When India embarked on a national family planning program after its independence in 1947, the discussions accepted the morality of contraception, but the main focus was the relative population size of the higher and lower castes (Desai).

Contemporary popular morality—the behavior and values of ordinary people—as well as contemporary philosophy, theological ethics, and religious bodies (with the major exception of the Roman Catholicism), accept the morality of contraception for spouses in practicing responsible parenthood. General agreement exists that on the microlevel of the family, the decision about contraception should be made by the spouses themselves in the light of their own health, the good of their marriage, the education and formation of their children, and population and environmental needs, both local and global (Curran). In fact, with the exception of those who are politically conservative and/or pro-family, most accept the right to fertility control even for those who are unmarried.

International Population Control

The highly politicized nature of family planning in the United States has had major implications for the developing world. In response to pressures by conservatives, the emphasis of U.S. population programs abroad shifted heavily to programs promoting natural family planning rather than the more reliable methods of artificial contraception. Most notably, the "Mexico City policy" adopted by the Reagan administration in 1984 stipulated that no U.S. aid would go to any international organizations that supported abortion, even if the U.S. funds were separated and used only for nonabortion services. The Mexico City policy was overturned in the early days of the Clinton administration in 1993, thus renewing a commitment on the part of the United States to international family planning efforts after a period of marked decline. The policy again became an issue in the administration of George W. Bush who withheld $34 million in funding for birth control, maternal and child health care and HIV prevention from the United Nations Population Fund in 2002 (Rosenberg; Planned Parenthood; UNFPA Funding Act, 2003). The loss of U.S. funding has a grave impact on UNFPA programs and the people they serve. UNFPA estimated that the $34 million loss would lead to two million unwanted pregnancies, 800,000 induced abortions, 4,700 maternal deaths, and 77,000 infant and child deaths. Restoration of U.S. funding would also save lives through HIV prevention campaigns. The $34 million would provide one-third of the annual needs for mass HIV prevention information campaigns aimed at behavior change. It would also cover the cost of 13 per cent of the condoms needed worldwide to prevent sexually transmitted infections, including HIV. President Bush also reversed the U.S. position in support of the 1994 global agreement that affirmed the right of all couples and individuals to determine freely and responsibly the number and spacing of their children and to have the information and means to do so (United Nations; RowBoat). Walking a political tightrope, he then announced major programs to deal with HIV infection abroad.

Family planning issues are an increasingly high priority for many developing nations. Concerns about the ability to feed rapidly growing populations, the dramatic spread of HIV infection and AIDS in the Third World, especially in parts of Africa, Asia, and Eastern Europe, and the large number of deaths that occur each year from illegal abortions create constituencies for family planning services within these countries. There are, of course, also often significant religious and cultural objections.

The rise of indigenous women's movements in the developing world has also served as a particularly important stimulus for additional family planning services which must be provided in a culturally sensitive manner (Bruce; Dixon-Mueller). The International Women's Health Coalition has been one of the most successful international population groups in terms of its ability to work closely with local, grass roots women's organizations in the design and delivery of family planning programs.

Current and Future Controversies

The future of accessible family planning services in the United States and abroad is unclear. During the administration of Bill Clinton, the influence of political conservatives in public policy debates about family planning was greatly diminished. Clinton's appointments to key health policy positions of individuals strongly committed to family planning, especially in the area of adolescent pregnancy prevention, sharply reversed the trends of the Reagan-Bush era. Ideological battles were temporarily muted, but they will never entirely disappear because of a change in presidential administration. At the state and local levels, many of the bitter struggles over the public provision of reproductive health services continued. Bill Clinton attempted to reform health care in general and largely failed. The election of George W. Bush signaled an immediate return to the ideologically conservative policies of his father.

The abortion issue remains among the most politically explosive and unresolved issues in bioethics. Provision of abortion services has endangered funding for other family planning services and endangered the lives of providers and consumers alike. Concerns of political conservatives and anti-abortion groups have affected policy debates as diverse as end of life decision-making in New York State and Federal regulation of embryonic stem cell research. In August of 2002, George Bush revealed his decision on stem cell research. Had it not been for the terrorist attacks that occurred shortly thereafter, stem cells might have been the defining issue of his presidency. Bush allowed future work with stem cell lines already produced, but his policy did not allow for the development of additional cell lines. By sitting on the fence, Bush did not satisfy either side in the debate. Anti-abortion forces were not happy that the existing cell lines, obtained from aborted fetuses, would still be used. Those in favor of stem cell research did not think that the existing cell lines would be adequate to study the possible benefits of stem cells for those with diseases such as Parkinson's Disease, Alzheimer's Disease, and diabetes.

The historical context is important for the current ethical and policy debates related to fertility control. Efforts to empower all women, including poor women of color, must be balanced with a keen sense of the abuses evident in the history of the birth control movement. Racism and eugenic concerns have been consistent issues in debates about controlling fertility, and our targeted educational programs and initiatives must be sensitive to community concerns. Empowering women to make their own reproductive choices is a praiseworthy goal, but it is not a desirable one for some.

kathleen e. powderly

SEE ALSO: Abortion; AIDS: Public Health Issues; Autonomy; Coercion; Conscience, Rights of; Embryo and Fetus; Eugenics; Family and Family Medicine; Genetic Testing and Screening: Reproductive Genetic Screening; Infanticide; International Health; Law and Morality; Maternal-Fetal Relationship; Natural Law;Population Ethics: Religious Traditions; and other Fertility Control subentries


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