In 1975, concerned by the prospect of uncontrolled population growth in an already 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 Page 2467  |  Top of Articlewith transistor radios (as was alleged) or imposing such penalties as middle-of-the-night roundups coupled with fines, denial of benefits and wages, and denial of educational opportunities. 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 the country instituted an effective if controversial population-control program. Dubbed the “one-child” policy, that program introduced a system of birth limitations that was imposed both in urban areas and less effectively in 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 for couples whose first child was a girl or who 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. The one-child policy is still officially in force, but China has permitted considerable relaxation of it—in particular allowing two children for couples in which both the husband and the wife are only children and for couples who are able to pay a fine for a second child.

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 scheme that worked by profiling categories of individuals on whom pressure for nonreproduction was to be put, and it 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 have 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 two children per woman until 1990, the policy was egalitarian in intent. However, in their haste to expose excesses, such as forced abortion and female abandonment, outside critics 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 has also been at least in principle the most fair.

Population policies in the developed world have typically but not always stressed voluntary fertility reduction. Zero population growth became a rallying cry and 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 (e.g., 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 the hormonal implant 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.

After denouncing abuses in policies such as those of India and China and other nations that attempted to limit population growth by nonvoluntary means, international watch groups turned their attention to the pronounced association between more developed economies and lower fertility rates. With the once-a-decade United Nations Conference on Population and Development in 1994 in Cairo, population policy began to shift toward encouraging development, which was understood to involve 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, and 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 health care, 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 Page 2468  |  Top of Articlebirthrates 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 they were willing to foot much of the bill. Developed societies offered better nutrition, better health care, 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 decline. Development-based population policies also seemed to have another moral advantage: they were aimed not at directly controlling population or restricting individuals' fertility but instead at changing people's background circumstances for the better, thus allowing them to choose to have fewer children. 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 counter-productive 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 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.

Favored in programs in many countries in the early twenty-first century, reproductive health models of fertility control try 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 health care to everyone. They further 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 tries to provide women with full-range reproductive health care, including access not only to modern contraception but also to disease prevention; prenatal, perinatal, and postnatal health care; and other forms of health care 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 health care to men, including the provision of male contraception and the prevention of sexually transmitted diseases. Many programs that provide reproductive health care in less developed nations have been inventive in devising new, more effective forms of health care delivery. In Bangladesh, for example, health care workers are aware that village women may have difficulty reaching public clinics or may be prevented from visiting them, and they have developed systems of home delivery of contraceptives and other forms of reproductive health care.

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 health care. Other points of dispute that have been raised, primarily by the Catholic Church, include providing condoms for disease prevention as well as contraception and supplying 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.

With the exception of India's vasectomy program, virtually all programs for fertility control have focused on women. Whereas a wide variety of modern contraceptive methods have been developed for women, sexually active males have 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 in the early twenty-first century.

These methods raise a variety of ethical issues. Are different degrees of control over whether conception can occur appropriate to nonabstinent 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?

Among the various methods of female contraception, some function by preventing conception and others 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 also 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 overridden 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 may be supported on the ground 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.

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”), and 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. In the early twenty-first century 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 was 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.