POPULATION POLICIES, STRATEGIES FOR FERTILITY CONTROL IN

Population wide fertility control has a history of both success and failure. That history has been fraught with ethical dilemmas rooted in issues of autonomy, responsibility, choice, community, the significance of reproduction, and the meaning of life, among many others, that have occurred in the context of a wide range of practical policies designed to limit or sometimes increase human reproduction.

Many early cultures, both Western and non-Western, have been aware of population pressures and have made attempts to prevent excessive population growth. However, the contemporary history of fertility control, responding to the economist Thomas Malthus's 1798 warnings, began in earnest in the mid-1960s, when some of the world's most populous nations, especially India and China, became aware of skyrocketing growth rates. From the mid-nineteenth century on, death rates had begun to decline. Developments in public sanitation, immunization, antibiotics, and medical technology began to reduce infant and child mortality and lengthen the average life span. Average family size in many cultures increased, and more offspring survived to reproductive age. In the latter half of the twentieth century, the world's population doubled in two generations, increasing from 3 billion in 1960 to 6 billion in 1999, and estimates of the population in 2050 ranged from 9 billion to 12 billion.

Despite these estimates of uncontrolled growth, in the early years of the twenty-first century global population growth rates began to decline, particularly in Europe, where by 2003 at least fourteen countries had below-replacement rates (that is, below 2.1 children per woman), in some cases well below that number. Average fertility rates in the less developed countries also fell, declining from 6.0 in the late 1960s, when fears of a "population explosion" were coming to the fore, to about 2.9 in 2003. Disputes over population policies and strategies for fertility control have continued to rage, although they have been tempered in the developed countries in recent years by the mistaken popular perception in which declining growth rates are conflated with declining growth. Despite declining fertility rates, absolute population growth remains high as a result of both above-replacement birthrates in many populous parts of the world and enormous population momentum.

Ethical Issues in Population-Control Programs and Policies

The ethical issues raised by population-control programs are of two principal kinds: those concerned with specific means for controlling population growth and those which challenge the objective of limiting human fertility. The earlier population-control programs have been more vulnerable to criticism about the means used for limiting fertility; contemporary policies raise questions about the overall objectives of fertility control.

EARLY PROGRAMS: INDIA AND CHINA. In 1975, concerned by the prospect of uncontrolled population growth in an already very poor country, India launched a vigorous population-control program that encouraged vasectomy, a comparatively simple and inexpensive method for permanent fertility control. The program in India employed a broad system of incentives and penalties to secure cooperation. Its critics often focused on the violations of individual rights and procreative liberty it seemed to involve, especially when nonvoluntary or semivoluntary means were used to elicit consent, for example, "bribing" men with transistor radios, middle-of-the-night roundups coupled with fines, denial of benefits and wages, denial of educational opportunities, and other penalties. Hostility to the sterilization program was so substantial that it contributed to the downfall of Indira Gandhi's government in 1976, and the program essentially was dropped without an effective replacement.

In China concern with population growth also began in the mid-1960s, but it was not until 1979 that that country instituted an effective, if controversial, population-control program. Dubbed the "one-child" policy, that program introduced a system of birth limitations that were imposed in both urban areas and, less effectively, rural areas: With some exceptions couples were permitted to have only a single child. The few exceptions were made for couples whose first child died or was disabled and in some rural areas if the first child was a girl or the couple were members of a non-Han minority group. The one-child policy was imposed by means of a system of birth permits and local supervision of the menstrual cycles of village women, separate residences for young couples in different cities, delayed marriage ages, and the required use of indwelling contraceptives (especially the intrauterine device [IUD]) and required or forced abortion for supernumerary pregnancies.

Observers outside China typically identified two principal moral problems in the one-child policy: the sometimes draconian means by which regulations and penalties were imposed and the consequences for females in a culture with strong preferences for male offspring, including selective female abortion, female infanticide, and female abandonment and out-adoption. Although China has permitted considerable relaxation of the one-child policy—in particular, couples in which both the husband and the wife are only children are now allowed two children and couples who are able to pay a fine for a second child are often permitted to do so—but the one-child policy is still officially in force.

Although India's and China's population-control programs appear to have involved similar ethical abuses, including mandatory contraception and severe penalties for extranumerary children, there is a substantial ethical difference between them. India's system was a targeted system that worked by profiling categories of individuals on whom pressure for nonreproduction was to be put and was satisfied when a preset proportion of "acceptors" complied. China's policy, in contrast, has been imposed in a comparatively egalitarian way: The few exceptions aside, China's policy stipulated that at least in principle all couples were limited to having only one child. While China's policy was not easy to impose, especially at the outset, and the total fertility rate did not drop below 2 children per woman until 1990, the policy was egalitarian in intent. However, outside critics, in their haste to expose excesses such as forced abortion and female abandonment, typically have failed to notice the ethical conundrum at the center of China's policy: Although it is the most restrictive coercive population-limitation policy in any country, it is also the most fair.

Population policies in the developed world typically but not always have stressed voluntary fertility reduction. Zero population growth (ZPG) became a rallying cry as well as the name of an influential organization and an international family-planning movement dedicated to encouraging couples to have only two children; indeed, average family size in the United States and other developed nations declined dramatically to just above the replacement level. There has been some concern in the United States about manipulative and coercive fertility-control programs that have been suggested, recommended, or put into practice for various minority groups (for example, sterilization programs for Puerto Rican and Native American women that involved inadequate consent and proposals for bonuses or bribes to encourage black women on welfare to accept Norplant), but in general the developed nations have proceeded through the stages of the demographic transition, going from high birthrates and death rates, to high birthrates and low death rates, to low birthrates and low death rates at which population growth again stabilizes, largely as a result of voluntary fertility control.

DEVELOPMENT-BASED POLICIES. After denouncing abuses in policies such as those of India and China as well as other nations that attempted to limit population growth by nonvoluntary means, international attention turned to the pronounced association between more developed economies and lower fertility rates. With the once-a-decade United Nations Conference on Population and Development that was held in 1994 in Cairo, population policy began to shift toward encouraging development, which was understood as involving both macroeconomic changes such as moving from agrarian to industrial economies, improving infrastructure, and shifting the balance of trade to greater proportions of export commodities as well as changes in social agendas, especially more education for girls and improved economic status for women. With that shift would come the benefits of a modern consumer society, it was argued, with its advanced healthcare, social security policies, and other institutions, and people no longer would need to have many children to provide farm labor, foraging, or care and economic support in their old age.

The effort in the new development-based policies was understood as being aimed at stimulating mechanisms that would bring about the demographic transition in countries that had not undergone it, and so birthrates would drop, as death rates already had, and population growth would "level out" at a low, steady, globally supportable rate of about 2.1 children per woman. Because women in underdeveloped countries with high birthrates routinely reported having on average about two more children than they wanted, changes in the economic environment would make it possible for them to reduce fertility to accord with their desires.

Development-based fertility-lowering policies counted among their ethical advantages the fact that people in advanced industrial nations were willing to share a lifestyle—higher development with low fertility and small family size—that had brought them material advantages and were willing to foot much of the bill. Developed societies offered better nutrition, better healthcare, better infant and child survival rates, better education, better jobs, longer life spans, and better security in old age; those advantages were to be made possible for developing countries as well, and in the process fertility rates would decrease. Development-based population policies also seemed to have another moral advantage: They were aimed not at directly controlling population or restricting individuals' fertility but at changing people's background circumstances for the better, thus allowing them to choose to have fewer children. Thus, they seemed to have the moral advantage of favoring individual choice rather than manipulation (as in the Indian vasectomy-targeting scheme) or coercion (as in China's one-child policy).

However, development-based strategies for fertility reduction have raised at least three moral dilemmas. First, they function by disrupting existing cultures, changing traditional agrarian lifestyles into wage-labor ones, often leading rural villagers into the cities and the life of the urban poor and in the process changing gender roles, parent–child relationships, and community structures. Second, they move resources from developed countries into the economic restructuring of less-developed, high-fertility countries, not always in efficient ways, and in doing so often bring with them alien cultural and economic values.

Third, those models may have counterproductive results: Even if they reduce fertility, they may increase consumption, thus undercutting the Malthusian argument for population control. They exacerbate rather than reduce the so-called tragedy of the commons, in which individuals in economic competition exploit resources for their own self-interest and thus make communal restraint impossible. In terms of global resources and environmental impact, the original Malthusian rationale for population control, China's success with its one-child policy, for example, will be negated if all those single children want refrigerators and cars.

REPRODUCTIVE-HEALTH MODELS. Currently favored in programs in many countries, reproductive-health models of fertility control attempt to avoid many of the ethical problems associated with the early population-control programs and the development model. They avoid the targeting of "acceptors," instead attempting to provide access to contraception and reproductive healthcare to everyone; avoid birth ceilings and after-the-fact penalties for excess births; and do not attempt to change existing cultures' economic patterns, occupational roles, domestic relationships, and community structures.

Instead, the reproductive-health model attempts to provide women with full-range reproductive healthcare, including access not only to modern contraception but also to disease prevention; prenatal, perinatal, and postnatal healthcare; and other forms of healthcare and education that affect reproduction. They are designed to satisfy unmet needs for contraception rather than to force conception on unwilling users, keeping in mind that women in less developed, high-fertility societies routinely say that they would have wanted on average about two children fewer than they have. Many of these programs also seek to extend reproductive healthcare to men, including the provision of male contraception and the prevention of sexually transmitted diseases. Many programs that provide reproductive healthcare in less developed nations have been inventive in devising new, more effective forms of healthcare delivery: In Bangladesh, for example, healthcare workers are aware that village women may have difficulty reaching public clinics or may be prevented from visiting them and have developed systems of home delivery of contraceptives and other forms of reproductive healthcare.

Although reproductive-health models of fertility control have avoided many of the ethical problems of earlier programs, they have had other problems. Some nations with conservative administrations, including the United States, have refused to support programs that provide safe abortion services even when those services are recognized by local providers as essential to reproductive healthcare. Other points of dispute that have been raised primarily by the Catholic Church include the provision of condoms for disease prevention as well as contraception and the supplying of contraception and other reproductive-health services to unmarried adolescents and women. Those issues differ from the ethical dilemmas raised by the earlier programs in that they are politically freighted, occurring at the intersection of conservative political and religious thinking with progressive public-health-oriented concerns. Some view the fact that reproductive-health programs may involve contraception, abortion, and the provision of services to unmarried persons as an issue of troubling moral significance; for others there seems to be no moral problem.

Ethical Issues Concerning Fertility Encouragement

The most thoroughly explored issues in fertility theory involve global population growth and ways to control it without violating individual reproductive rights. In some parts of the world, however, including Europe and Japan, fertility rates have declined so dramatically that they are well below the replacement rate. Some of the apparent decline is an artifact of later-onset childbearing and longer child-spacing intervals, but some of it is real. Subreplacement societies are "graying," it often is said, and social security, health insurance, and other social systems are being stressed as very low birthrates coupled with much longer average life spans have produced comparatively few children but many elderly people.

The ethical issues that arise in this context involve fertility encouragement, usually in preference to more liberal immigration policies, and what measures a society may or should take to increase birthrates, if any, and for what reasons. It is becoming fashionable to speak of "population collapse," associating the prediction of population decline, particularly in Europe, with predicted economic collapse.

Some countries offer bonuses, generous maternity and paternity leave, and/or child support for having a baby. Some engage in public advertising that promotes childbearing: "Sterben die Deutschen aus?" ("Are the Germans dying out?") asked one German subway poster. Although none of these programs repeat ethical abuses such as the requirement the former dictator Nicolae Ceausesçlu imposed on Romanian women that they bear at least five children, some attempt to influence individual reproductive behavior in many of the same ways in which advertising attempts to influence consumer choice.

The ethical issue here is whether individuals' reproductive lives should be influenced in the same ways and by the same means that manufacturers sell automobiles or laundry soap. There is also the question of whether public-service advertising to increase fertility is ethically analogous to public-service advertising to decrease fertility, as in "stop at one or two" billboards in Vietnam, soap operas favoring small family size in China, and similar measures in many other countries.

Averting "population collapse" is not the only motivation for a state, ethnic group, or religious group to encourage fertility increase. Many earlier societies and some contemporary ones, such as early Maoist China and contemporary Iraq, have encouraged high fertility as a source of military might and/or productive power: More children mean more soldiers and workers. Some religious groups have encouraged high fertility to, as detractors see it, increase denominational strength. It might be considered appropriate for some groups that have suffered genocide or other calamities to practice high fertility to recover their demographic strength. Examples include Armenians after their expulsion by the Turks, Jews after the Holocaust, African Americans after slavery, and New World Amerindians after European contact, when indigenous groups in North, Central, and South America were reduced not so much by warfare but by epidemics of European diseases such as measles, typhus, yellow fever, and smallpox that in many areas killed 80 to 90 percent of the population or resulted in complete extinction. In what sense a group may or should attempt to regain its earlier population size, when and how compensatory population gain should be measured, and what impact it may have on other groups inhabiting the same region are issues that invite further discussion.

Ethical Issues Concerning Technology in Fertility Control

New reproductive technologies play a major role in issues involving fertility control, especially new forms of contraception and pregnancy interruption. Three pose particularly complex ethical issues.

MALE CONTRACEPTION. With the exception of India's vasectomy program, virtually all programs for fertility control have focused on women. While a wide variety of modern contraceptive methods have been developed for women, until recently sexually active males had only three methods for controlling their contribution to reproduction: withdrawal, condoms, and vasectomy. A number of modern male contraceptive methods are under development, including vas-blocking methods, heat-based methods, and hormonal methods, and several can be expected to reach the market soon.

These methods raise a variety of ethical issues. Are different degrees of control over whether conception can occur appropriate to non-abstinent males and females? At least in areas where women have free access to it, female-controlled contraception has given women veto power over their own reproduction, something that is often held to be appropriate because reproduction occurs within women's bodies. Should males also have veto power over reproduction even though it does not affect them physically in the same way? Might the development of effective long-acting but reversible methods of male contraception herald an ethically problematic change in male/female reproductive roles, especially in roles that often are considered essential to female identity?

POSTCONCEPTION CONTRACEPTION. Among the various methods of female contraception, some function by preventing conception and others function by preventing implantation or interrupting an early pregnancy. Generating particularly vigorous ethical controversy have been "morning after" contraceptive modalities, not only "emergency contraception" that is effective for up to 120 hours but in particular abortifacient methods that interrupt pregnancy at up to seven weeks of gestation.

As with reproductive-health programs for fertility control, the problems here are the subject of political dispute, involving disagreements between those who oppose abortion altogether and those who do not or who find moral issues of abortion appropriately resolved privately or over-ridden by other moral concerns. Another issue posed by postconception technologies involves the timing of decisions about pregnancy: Should those decisions be made before conception, when one is not yet pregnant—that is, should they deal with a condition not yet established—or is there a moral and epistemological advantage to allowing conception and pregnancy to occur and then deciding whether to continue it? Opponents of abortion would insist on the former; the latter might be supported on the grounds that it gives the woman or couple a more realistic opportunity for full-fledged consent: Once pregnancy has begun, she can understand more fully the step she is taking, including the changes it brings about in her body, and then decide whether she wants to continue. Although this issue may seem bizarre to Western theorists of reproduction, it is pressing in countries, such as Soviet-era and post-Soviet Russia, in which abortion has been a principal method of fertility control. The total induced abortion rate for Moscow is about 6 (though for Russia as a whole it is 2.5) and decisions about pregnancy continuation often are made after rather than before the fact.

LONG-ACTING CONTRACEPTION. The ethical implications of the difference between short-acting, "time-of-need" contraceptive modalities such as the condom; the diaphragm; spermicidal foams, gels, and sponges; and other forms that require use at the time of sexual exposure as distinct from long-acting modalities that have a contraceptive effect over an extended period, such as the IUD, the subdermal implant, and the depot injection, also have been explored inadequately. The central theoretical difference involves the degree of user cooperation required to prevent conception. Short-acting, time-of-need modalities require user awareness and cooperation each time, every time, as do nontechnological methods of contraception such as withdrawal and the "rhythm method" of scheduled abstinence. In contrast, true long-acting contraception requires no user cooperation beyond the initial emplacement. This difference is obscured, however, by a variety of technologies that have a long-term chemical effect but require repeated dosing, such as oral contraceptives ("the pill"), as well as by permanent or difficult-to-reverse methods such as tubal ligation, quinacrine sterilization, and vasectomy.

The ethical issue that arises here concerns whether it is morally appropriate to "reverse the default" in human reproductive biology. Currently, sexual contact between a fertile male and a fertile female may permit conception unless that is prevented; if the default were reversed by having long-acting, indwelling but reversible contraception in place and if everybody used it, sexual contact would not permit conception unless that were chosen. The consequences of such a reversal for fertility control are potentially enormous: If everybody did it all the time—that is, used long-acting, reversible contraception except when he or she wanted to have a child—fertility rates would decline dramatically without a violation of reproductive rights.

Societal Interests in Fertility

The issue of societal interests in individual fertility has a greater scope than any of the issues discussed above. Society in general—that is, the global population as a whole—is composed of individual human beings, all of whom are the product of reproductive activity between earlier human beings: their parents, the providers of the male and female gametes involved. A very small proportion of this reproductive activity, at least in the developed world, involves artificial reproductive technologies such as in vitro fertilization, embryo storage and transfer, surrogacy, and cloning, and some involves arrangements between nonheterosexual couples, but most reproductive behavior takes place between a man and a woman, whose reproductive roles are influenced by the wide range of cultural settings in which their conjunction occurs.

The overarching ethical question is what weight the interests of their society or society in general should be given over people's personal choices about reproduction. Should concern about global population growth take precedence over individual reproductive behavior? Should the risks of population decline take priority over individual choice? Are pressures for increased fertility more or less defensible than pressures for fertility limitation? These larger issues invite extended exploration.

Population control measures are motivated principally by the Malthusian specter of global crowding, which traditionally is formulated as the threat that a population will outrun the carrying capacity of its site, that is, will consume more than can be replaced in its environment and thus eventually will exhaust its resources and die. The urgency of global fertility control often is underestimated by those who confuse declining growth rates with declining growth: Growth rates are falling in virtually all areas of the world, but as a result of immense population momentum in the latter decades of the twentieth century, total global population is still increasing rapidly. Nevertheless, the Malthusian specter does not answer the question of whether it is better to have fewer people with a higher standard of living or more people in far more modest circumstances. What should be the aim of population control?

As the philosopher Derek Parfit has discussed, different future scenarios may involve fewer people with a higher quality of life or more people with a lower quality of life, but as long as the quality of life is not so low that life is not worth living, it is not easy to say why a larger population of less fortunate people is not preferable to a smaller population of people with a higher quality of life. Parfit entertains what he calls the "repugnant conclusion" that for a large population with a high quality of life there always could be a much larger population with a much lower quality of life, a life barely worth living, but that such a future would be better.

Similarly, fewer people consuming more is not obviously better in terms of global environmental impact than more people consuming less and also is not obviously morally preferable to the opposite situation, assuming that the effect on environmental sustainability is equal. This philosophical puzzle raises deep cultural, political, and religious questions and perhaps will be the central challenge for theorists of fertility control in the future.

margaret pabst battin

SEE ALSO: Abortion; Autonomy; Eugenics; Eugenics and Religious Law; Family and Family Medicine; Feminism; Race and Racism; Sexism; Sustainable Development; Women, Historical and Cross-Cultural Perspectives

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