The first Nebraska bill, LB1103, is deceptively called the “The Pain-Capable Unborn Child Protection Act.” The true goal of the bill is to directly challenge the Roe v. Wade decision, which extended legal protection for abortion for any reason to the point of fetal viability (approximately 24 weeks) and thereafter to protect the health or life of the pregnant woman. In making the claim that the fetus can feel pain prior to viability, abortion opponents hope to change the boundaries of legal abortion.

Those who advocate for abortion restrictions based on the notion of fetal pain make three central claims: the fetus has the physical structures for pain; the fetus withdraws from stimulation in response to pain; and anesthesia is used on similar-age fetuses during fetal surgery to prevent pain. None of these claims, however, is supported by objective science.

In 2005, a group of scientists at the University of California, San Francisco (UCSF) conducted a review of the available evidence related to the question about when a fetus is capable of feeling pain and published their findings in the Journal of the American Medical Association.[1] They explain that while the brain circuitry responsible for relaying some types of sensory information begin developing around 23 weeks’ gestation, the circuits must be connected to the brain in specific ways for a fetus to experience pain. That connection does happen until later in the pregnancy and not sooner than 29 weeks of gestation, well into the third trimester.

The second claim, that fetal responses to stimuli are evidence of an ability to feel pain, is also without merit. Reflex responses occur independent of pain sensation, such as the “knee jerk” reflex. Thus studies demonstrating the presence of fetal movement in response to stimuli (potentially harmful or not) do not establish the existence of fetal pain.

Finally, in response to the claim about anesthesia, the authors of the UCSF study note that performing surgery on a fetus and providing an abortion are two very difference scenarios. For fetal surgery, analgesia/anesthesia is primarily used to prevent possible adverse surgical outcomes, to relax the uterus to prevent premature contractions, to immobilize the fetus, and to prevent possible long-term neurological developmental problems resulting from the hormones released during surgery. None of these objectives is applicable to an abortion.

Opponents of abortion stress the “scientific controversy” over fetal pain and highlight the few outsiders who support their agenda to make abortion illegal. This focus on doubting established science is a common tactic of the conservative right which has politicized science in areas from evolution, to climate change, to sexuality education.[2] And journalists eager to cover a new controversy over abortion take the bait; potentially out of a desire to “balance” their coverage of abortion they suggest that the science is unresolved. The controversy, however, is resolved—fetuses cannot feel pain at 20 weeks gestation.

Accompanying LB1103 is a companion law, LB 594, requiring a woman seeking an abortion to undergo an elaborate screening process prior to obtaining an abortion. This law, deceptively named the “Women’s Health Protection Act,” perverts science in all kinds of new ways.

First it requires that abortion providers produce a screening tool that includes any risk factor shown to be associated with poor outcomes after abortion. Second, it requires that women be screened for these characteristics and then informed of their individual potential for bad outcomes. These characteristics include demographic factors (i.e. women need to be told that being divorced has been shown to be associated with higher rates of depression after abortion), mental health factors (i.e. having anxiety prior to abortion is associated with higher rates of anxiety following an abortion), and physical health factors (i.e. being obese is associated with higher rates of infection after an abortion). In the eyes of the Nebraska law, there is no difference between those factors shown to be causal and those that are just related (i.e. “associated”).

For the last two decades abortion opponents have undertaken a deliberate effort to publish studies that show a relationship between abortion and poor mental health, i.e. depression, substance use, anxiety, suicide. In these studies researchers use secondary data analysis to conclude that women who have abortions have higher rates of each of these ailments. None of these studies, however, show causality. They demonstrate only associations. Hence the reason for the term “associated” in LB594.

Reviews of the studies of abortion and poor mental health, however, find each of these studies significantly methodologically flawed.[3, 4] For example, these studies include inadequate comparison groups: women who have abortions are compared to those that that have wanted pregnancies, rather than to women with unintended pregnancies who continue their pregnancies to term or to women who wanted abortions and couldn’t get them. These studies often fail to account for preexisting conditions, i.e. women who have depression are more likely to choose abortion so we would expect more women after abortion will have depression.

Helping people understand the difference between causation and association was not a priority of the Nebraska legislature, but it is critically important as a standard for public health law. An analogy helps to explain the difference: Carrying matches is associated with having lung cancer. It is not the cause of the cancer and we don’t suggest that people stop carrying matches as a way to prevent cancer (especially if they just replace the matches with a lighter).

In the context of the Nebraska law, African American women would need to be told that being black is associated with higher rates of substance abuse after abortion. However, having the abortion does not cause the substance abuse, nor does being African American. Other women would need to be told that having relationship problems is associated with higher rates of depression after an abortion. Again, having the abortion does not cause the depression nor would carrying a pregnancy to term reduce the risk of depression.

Conducting the required screening and informing the woman of these associations is not helpful to the woman nor does it improve the care she receives. It does not reduce her chances for having a physical or psychological problem after an abortion, nor does it enhance her decision making related to the abortion. The real intent behind the law is to create a feeling that abortion is risky and to allow women to later sue abortion providers with the claim that they were not adequately warned that they might experience negative outcomes after their abortion.

Ironically what little evidence there is on poor coping after abortion suggests that abortion protesters, lack of social support, and stigma are actually causal.[5-7] Yet the Nebraska legislature is not only unwilling to do anything to reduce these known risk factors—their actions may in fact contribute to poor coping by increasing the stigma woman feel about their abortion and fanning the flames of anti-abortion hostility.

Misuse of science in the name of an anti-abortion agenda is not new. Fetal pain and claims about harms after abortion are just the latest tactics. However, what is at stake in Nebraska is the foundation of the Roe v. Wade decision itself, as well as our ability to craft public health policy with legitimate science.

Dr. Tracy Weitz, PhD, MPA, is Director of the Advancing New Standards in Reproductive Health (ANSIRH) program in the Bixby Center for Global Reproductive Health at the University of California, San Francisco (UCSF).

References

[1] Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA, “Fetal pain: a systematic multidisciplinary review of the evidence,” Journal of the American Medical Association 2005;294(8):947-54.

[2] Mooney C., The Republican War on Science (New York: Basic Books; 2005).

[3] Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C., “Abortion and mental health: Evaluating the evidence,” American Psychologist 2009;64(9):863-90.

[4] Robinson GE, Stotland NL, Russo NF, Lang JA, Occhiogrosso M., “Is there an ‘abortion trauma syndrome’? Critiquing the evidence,” Harvard Review of Psychiatry 2009;17(4):268-90.

[5] Major B, Cozzarelli C, Sciacchitano AM, Cooper ML, Testa M, Mueller PM, “Perceived social support, self-efficacy, and adjustment to abortion,” J Pers Soc Psychol 1990;59(3):452-63.

[6] Cozzarelli C, Major B, Karrasch A, Fuegen K., “Women’s Experiences of and Reactions to Antiabortion Picketing,” Basic and Applied Social Psychology 2000;22(4):265 – 275.

[7] Major B, Gramzow RH., “Abortion as stigma: cognitive and emotional implications of concealment,” J Pers Soc Psychol 1999;77(4):735-45.

Since the 1990s, bioethics commissions have looked closely at scientific advances of breathtaking power, including technologies that have cloned sheep, isolated human embryonic stem cells, and mapped the entire human genome. But commissions working for liberal and conservative administrations have reached different conclusions about the intersection of science and ethics. In this excerpt from the recent book, Progress in Bioethics, editors Jonathan D. Moreno and Sam Berger explain why the progressive approach to bioethics is particularly appropriate, because the core idea of progress is closely associated with the modern idea of science, and bioethics itself embodies a progressive spirit.

The last few years have seen increases in the numbers of self-described progressives and progressive organizations. The new progressive movement is not simply an attempt to abandon the politically compromised label ‘liberal’, but is rooted in certain commonalities between the turn of this century and that of a hundred years ago. Progressives in the early twentieth century faced economic and political changes that seemed to threaten their values and even their very way of life. Similarly today, globalization weakens the ability of the nation-state to regulate its economy, and the global security landscape is dotted with more and more powerful and unpredictable actors, even as we become increasingly aware of growing wealth disparities and of our interconnectedness to people on the other side of the world. The effects of these changes have been felt acutely in the United States; people are concerned about losing jobs in an international marketplace, about the failing social safety net, and about security threats from abroad. The realization that new solutions are needed to confront these issues and many others underlies the modern progressive movement.

In this chapter we will place contemporary American progressivism in historical context and identify some central themes of progressivism in bioethics. As a political philosophy, progressivism complements and builds upon the values of liberalism by emphasizing transparency as an important element of democratic processes, the importance of expertise rather than ideology in public policy, public regulation of concentrations of wealth and power, and activism in the pursuit of social justice. American progressivism is also deeply influenced by pragmatism, which encourages a focus on achieving the goals of social policy by means that work rather than on ideologically based a priori judgments about the efficacy of governmental or private sector solutions to public problems. A progressive approach to bioethics is particularly appropriate because, as we shall explain, the core idea of progress is closely associated with the modern idea of science, and bioethics itself embodies a progressive spirit.

As progressives who work in the field of bioethics, we are interested in the ways these values may guide policies and practices in the life sciences, as well as in pitfalls progressive bioethicists must be careful to avoid. Just as America faces major economic and political changes, the concerns stimulated by modern biology are in important respects unprecedented, and are having a significant effect on Western society as a whole. The cloning of Dolly the sheep, the isolation of human embryonic stem cells, and the mapping of the human genome have catapulted biology, and thus bioethics, onto the national stage. One of President George W. Bush’s first major policy initiatives concerned federal funding for stem cell research, and that issue has been prominent in a number of recent elections. Bioethics has also become a major concern of the conservative movement, particularly among neoconservatives and the religious right (Hinsch 2005). But the need for a progressive bioethics extends beyond simply a political response to the burgeoning public interest in the field. The progressive focus on bioethics represents some- thing greater: a realization that these are significant changes in the life sciences, changes that progressives would do well to pay attention to and address.

While conservatives have devoted significant attention to biotechnology issues, their approach has not been successful. Although admirable in urging a focus on broad philosophical questions, in practice the conservative response to legitimate issues raised by biotechnology has often been ineffectual and shortsighted. Conservatives frequently default to reflexive opposition to new technologies, an opposition that is almost always overtaken by practical events. Worse yet, this all-or-nothing approach leaves them, and the rest of society, unprepared to address the challenges that are raised by the gradual adoption of new technologies. Consider conservative opposition to in vitro fertilization, which culminated in President Ronald Reagan’s decision not to fund IVF research. Rather than smothering the nascent technology, his actions simply allowed it to develop in the private sector, unregulated and self- regulated, which has caused a number of troubling developments we are now beginning to face (Mundy 2007). By preventing the government from regulating cloning and stem cell research through federal funding and other vehicles of public control, research opponents actually help foster similar problems.

Rather than seek to stop change in its tracks, progressives have historically understood that one can view aspects of it as problematic without rejecting it wholesale. Seeing rapid industrialization in the beginnings of the twentieth century, progressives recognized that it was leading to a dangerous accumulation of political and economic power in the hands of a few. But they also saw that it was strengthening the American economy, and that it could not be stopped or reversed. Rather than fight economic and political change in principle or accept it as inevitable, progressives sought to ensure that this change would be influenced and constrained by widely shared values of rewarding hard work, providing economic opportunity, and strengthening democracy.

The changes wrought by biotechnology are in a similar vein—challenging, but potentially very beneficial—and thus require a similar approach. Progressives should not unduly oppose the use of new technologies, but they also should not forget that these technologies must be controlled and regulated so as to comport with our shared values. There is no denying that many find the implications of new biotechnologies disconcerting, and for good reason. Despite their tremendous promise to improve our lives, they also present novel and sometimes unsettling prospects. The synthetic manufacture of deadly pathogens, growing disparities in access to both conventional and newly developed medical care, and the continued commodification of the body are all issues posed by recent medical discoveries. Progressives must be careful to balance enthusiasm for the positive possibilities of new biotechnologies with a healthy respect for their potentially negative effects.

Further, many of these issues cannot be easily addressed with old methodologies. Consider, for example, the tensions facing the reproductive rights movement’s support of reproductive choice when new bio- technologies offer (or will offer) the potential not only to choose when to have a child, but also choose what characteristics it will have (Berger 2007). The issue of reproductive choice takes on new meaning when people can use it in a discriminatory manner, choosing not to bear a child who is a girl or who has a disability. What was once a rallying cry for reproductive rights now seems problematic in certain contexts. These types of novel problems will require equally novel and adaptive solutions. As progressives, we must understand that change will come; the question is what we will do to shape that change.

Progressivism: Past and Future

We can learn much from the original progressives of more than 100 years ago. The Progressive Era was a time of optimism as well as rapid change. Many took seriously the proposition that government could be an institution of reform. At the dawn of the twentieth century, America was feeling the effects of the Gilded Age, a second industrial revolution that made local businesses give way to factories and moved political power from the small towns to the big cities. A small group of businessmen capitalized on these changes, amassing vast wealth and power. With these changes came new problems as ordinary people struggled to adjust to the changing economic realities and government was corrupted by the powerful.

Seeing these problems, and believing in their own ability to fix them, Progressives embarked on one of the most ambitious plans for reform since the Founding. They sought to embrace the potential of these new developments, but also to ensure that this potential was shaped by their shared values. “Progressives arose to bring order to both politics and the economy, but their quest was at least as much about morality as about political economy. The values of the Progressives were rooted in the old virtues, even as they accepted that the tides of industrialism could not be turned back.” (Dionne 1996b, 35) Muckrakers like Upton Sinclair exposed the deplorable working conditions in factories, activists like Jane Addams provided help to the poor immigrants who flocked to urban areas looking for work, and trustbusters like Theodore Roosevelt broke up illegal business monopolies and heightened industry regulation. Academics also joined the fray, realizing that “the function of ‘social science’ wasn’t simply to dissect society for non-judgmental analysis and academic promotion, but to help in finding solutions to social problems” (Moyers 2003). Progressives determined that to limit the deleterious effects of national corporations they would have to give increased power to the national government to protect the interests of ordinary people.

In order to effectively use government as an instrument of the popular will and public interest, Progressives first had to clean it up, rooting out corruption and replacing it with competence and a spirit of public service. Newspapermen like Lincoln Steffens exposed government corruption, while Progressive politicians such as Robert LaFollette and George Norris ran for public office and won. They created fairer labor standards, publicly owned or regulated sanitation, transportation, and utility systems, and better consumer protection. They passed laws barring corporate campaign contributions, and a constitutional amendment allowing the direct election of senators in an effort to clean up the “Millionaire’s Club” the Senate had become. They worked to make government transparent, accountable, and fact-based.

Yet the Progressive Era was not an unqualified boon, particularly in the realm of bioethics. While everyday workers saw improvements in their lives, there was also a resurgence of racism and segregation, encouraged by a “science [that] increasingly endorsed many Americans’ belief that some races were better than others” (McGerr 2003, 192). And the same impetus that inspired academics to fight for workers’ rights also caused some of them to associate themselves with eugenics and social Darwinism. Tainted as it is with the horrors of Nazi Germany, it is hard to imagine eugenics as a progressive movement. Yet eugenics was widely viewed as the progressive biology of the day, justifying a public policy that included the forced sterilization of “inferior” people such as the mentally retarded, the deaf, and certain ethnic and racial groups. No less a progressive leader than President Theodore Roosevelt said “We have no business perpetuating citizens of the wrong type.” (Moreno 2007) Although progressives were not alone in embracing eugenics, and although some of them were among its toughest critics, progressivism must bear its share of the blame for attempting to elevate a biological theory to pubic policy.

The resurgence of progressivism has focused on emulating the economic and political successes of the era while avoiding the moral failures. Contemporary thinkers liken the economic dislocation caused by the rise of transnational corporations and international competition to the prob- lems caused by national corporations in the 1900s, which resulted in similarly dramatic changes in political systems and moral values (Dionne 1996b). These new progressives have taken up the challenge of ensuring that the economy still has a place for the individual, that politics does not become a plaything of the powerful, and that we do not lose our sense of common purpose and values in the face of tumultuous change (Halpin and Teixeira 2006).

But we also face an era of unprecedented biological change. Scientists continue to develop the ability to clone mammals, regenerative medicine seeks to unlock the power to heal ourselves with our cells, synthetic biology may allow us to create new species, and genetic modification offers the potential to radically alter our DNA. As scientific changes challenge and revise our very definition of life (Borenstein 2007), there is a special role for a progressive bioethics. In working to ensure that these changes improve the common good, we must look to hard-won values of respect for persons and protection of human dignity.

Science and Progressivism

A distinctly progressive bioethics is a natural outgrowth of the close connection between progressivism and science. That the words ‘progres- sive’ and ‘science’ gained their modern meanings at the same time was no historical accident, but rather a demonstration of the shared belief inherent in both the scientific method and the notion of progress that the power of knowledge acquired through systematic inquiry can improve the conditions for human flourishing. In many ways, progressivism is simply the application of the method of science to the development of public policy. At its core, “the American Progressive tradition [is] resolutely experimental rather than reflexively ideological, in constant search of new methods, insistent on continuous reform” (Dionne 1996b, 15). Progressivism is predicated on the questioning of assumptions, on openness of inquiry, on reliance on empirical data, and on transparent communal investigation. Policies are to be based on experiment, not belief; Justice Louis Brandeis expressed this attitude when he referred to the states as laboratories of democracy in which new policies could be tested and improved. Just as good science requires a community of informed and empowered researchers reconsidering existing assumptions in light of data, good government requires knowledgeable and capable citizens and legislators doing the same.

The application of scientific principles to governance can be seen not only in the style but also in the substance of progressive policymaking. Progressives brought regulators with greater scientific expertise and adherence to the scientific method into government to ensure food and drugs were safe. They sought to bring empirical analysis to the selection of members of government itself, greatly expanding the number of government jobs given through the merit system. And they sought to replace the old system of nepotism and corruption that had dominated politics with a government that was responsive to hard facts instead of cold cash. Progressives saw the scientific method as a singularly successful mode of objective inquiry, one that would have similar successes when applied to government.

Progressivism’s Promise and Perils

Progressivism is as promising an approach to governing today as it was a hundred years ago. Embracing the spirit of American pragmatism, progressivism focuses on results rather than ideology. Thus, certain problems may require more government intervention, while others may be more amenable to market solutions; only data and experience can deter- mine which is the best means of addressing an issue. Progressives also acknowledge the changing nature of society, understanding that past solutions may not be applicable to current problems. More than that, progressives are hopeful, believing in the capacity of human beings to shape a better world for themselves and their children. They appreciate the possibilities of technology and the use of scientific and technological expertise to achieve our most ambitious goals. Rather than opposing change, progressives embrace the possibility of a new world, seeking to shape it through our shared values into the world we want it to be. And progressivism is mindful of the less powerful, the people in whom political power is and should be vested, ensuring that government works for their interests. This flexible, evolving philosophy is well suited to a quickly changing political landscape in which yesterday’s wisdom is today’s folly.

Like any governing philosophy, however, progressivism has the potential to go awry. Exaggeration of progressives’ support for expertise, belief in our ability to effect positive change, or concern with practical results can lead to impulses that are antithetical to the spirit of progressivism. None of these problems are necessary results of a progressive sensibility, but they do point to potential pitfalls within progressivism that could subvert its effectiveness and its ultimate goals. To avoid these dangers, we must understand the excesses from which they stem.

The belief in the potential of science, evidence, and expertise to solve societal problems can lead to dangerous elitism if not balanced by a keen sense of the limitations of science, as is true for any human endeavor. When relying on expertise and evidence, there may be a tendency to ignore people who are not experts, or to discredit arguments that rely more on moral sentiment than on science. Of course, democracy is based on the notion that individuals can and should make their own political decisions, and creating an environment that allows an engaged citizenry to make these decisions is at the heart of the progressive project. Yet those who strongly support rational, fact-based reasoning may shy away from the messiness of democratic consensus building and gravitate toward the seemingly clearer and cleaner world of elite decision making. This strain of elitism coupled with a belief in the objective truth and power of science was apparent in some progressive reformers in the 1960s, including overzealous social scientists who overestimated their ability to repair social ills. Their perceived failures to fix problems such as de facto school segregation and poverty led to a backlash among intellectuals who “doubted that imperfect and unpredictable human beings could be organized socially on the basis of ‘scientific’ knowledge alone” (Dionne 1991, 60). Many of these critics coalesced around the new journal The Public Interest, which aimed to show that the capacity of social policy to fix intractable problems was limited; eventually, many of those critics would become major figures in the neoconservative movement. Conservatives trace progressive elitism directly back to the optimism of the Progressive Era. The noted conservative intellectual William Schambra erroneously describes Progressives as those who wanted the “transfer of political power away from everyday citizens and their chaotic, parochial, benighted local organizations, often steeped in foolish religious mythology” and who believed that “power should instead be put into the hands of centralized, professionally credentialed experts trained in the new sciences of social control” (2006, 2). While Schambra vastly overstates the undemocratic impulses in progressivism, his critique shows the concern many have for advocating too strongly for expert leadership, particularly in areas where expertise itself is lacking.

Elitism can also lead to a broad utopianism when progressives become too sure of their ability to address any and all of the world’s problems. Not recognizing human limits, they may overreach and fail, thus doing more damage than if they had done nothing. The historian Michael McGerr view today’s impoverished politics as a direct result of the excesses of the Progressive Era, which “offer[ed] the promise of utopianism—and generat[ed] the inevitable letdown of unrealistic expectations” (2003, xiv). Try to do too much and you may convince people they are incapable of doing anything. But the danger lies not only in lowered individual expectations, but also in unexpected negative results from large-scale, poorly understood changes. The neoconservatives termed this the “law of unintended consequences,” arguing that in the 1960s “one well-intended program after another had failed, often by solving one problem only to create another one” (Dionne 1991, 60). In abandoning tradition, conservatives argue, progressives revealed a hubristic belief that they knew better than centuries of painstakingly accumulated human knowledge. Seeing the problems too narrowly, progressives failed to understand the totality of their actions, and at times did more harm than good.

And there is some reason for present-day progressives to be wary of overstepping their bounds. As evidenced by the Progressive Era, the scientific impulse can be abused. Faith in progress inspired protection of workers and accountable, open government, but also was twisted to support eugenic sterilizations stemming from pseudo-science. As long as science carries cultural cachet, people will attempt to justify terrible actions by recourse to it. And there are always limitations to our knowledge and our ability to effect change; the Green Revolution and the war in Iraq are clear testaments to that.

There is also concern that progressives, in their constant efforts to achieve reforms and to solve one problem after another, will lose a sense of the larger picture. Rather than think about the ends, progressives could find themselves too caught up in the means, focusing on the most efficient way to achieve a goal without adequately questioning whether it is desirable. Anticipating the neoconservative critique of mainstream bioethics, this concern was forcefully articulated by Randolph Bourne, a progressive who split with John Dewey over Dewey’s support for American involvement in World War I. Criticizing pragmatists, the philosophical school most closely associated with progressivism, Bourne complained they were elitists who were “hostile to impossibilism, to apathy” and had thus created a generation of young intellectuals “immensely ready for the executive ordering of events, pitifully unprepared for the intellectual interpretation or the idealistic focusing on ends” (1967, 88). The young pragmatists had “absorbed the secret of scientific method as applied to political administration . . . [but] they had never learned not to subordinate idea to technique” (ibid., 88–89). This concern seems surprising in view of other commentators’ suggestions that Progressives were prone to utopian idealism, but it demonstrates that excess has the potential to corrupt underlying goals in many different ways.

There are strong echoes of these worries in the conservative (and especially neoconservative) bioethicists’ project to return to the bioethics of the late 1960s and the early 1970s, when the conversation focused on the moral ends of the life sciences rather than on the appropriate means of utilizing technologies. They worry that in practice bioethical theory has become “thin” with its emphasis on personal autonomy, rather than “thick” with reflection on the goals of medicine, the nature of humanity, and the preservation of human dignity. In particular, Leon Kass, the former chairman of George W. Bush’s bioethics council, has called for a “richer” bioethics that does not have moral consensus as a goal and seeks more than mere procedural solutions to ethical dilemmas. These conservative bioethicists fear that the lack of concern for ends could leave progressivism lifeless, a mechanical pursuit of one goal followed by the next, with no uplifting moral vision. In a sense, Bourne and others worried that Progressives’ focus on science was causing them to forget the poetry, the humanity of their pursuit. Of course, these concerns are directly connected to worries about elitism and anti-democratic impulses stemming from a distancing of professionalized reformers from the “irrational” masses. Their present-day form can be seen in conservatives’ efforts to paint their opponents as “pointy-headed intellectuals” too caught up in the ivory tower of academia to understand ordinary people, and in the left’s perpetual worry that it is so focused on policy prescriptions that it lacks a narrative or vision with which to connect with the common man.

It is no accident that the themes of elitism, utopianism, and excessive concern with means also appear in conservative critiques of science, particularly in the writings of neoconservative bioethicists. Drawing on the distrust of earlier neoconservatives for social science expertise, this later generation has exaggerated their worries to encompass the hard sciences as well. The theme of arrogant scientists, dismissive of the common people and unwilling to accept any of their restraints, is a common one. It stretches at least as far back as Mary Shelley’s Frankenstein. The neoconservative bioethicist Eric Cohen captures the critique in its latter-day form:

From the beginning, science was driven by both democratic pity and aristocratic guile, by the promise to help humanity and the desire to be free from the constraints of the common man, with his many myths and superstitions and taboos. The modern scientist comes to heal the wretched bodies of those whose meager minds are always a threat to experimental knowledge. (2006, 27)

This rhetoric has been extremely strong in the stem cell debate, in which researchers are frequently described almost as if they are mad scientists operating outside the norms of society (Moreno and Berger 2006). Worries that scientists are playing God are partially concerns that they lack a sense of humility—the understanding of human weaknesses and limitations that is the hallmark of conservative thought. Neoconservative bioethicists believe that “humility, alas, is not always a prominent scientific virtue, at least among the most prominent scientists, and especially among many modern biologists” (Cohen 2006, 27).

And neoconservative critics of science also argue that scientists are so caught up in gaining knowledge about the world that they do not stop to think about the morality of their actions, or understand that science itself cannot answer those moral questions. Far from seeing science as value neutral (a widespread view among the general public), neoconservatives see it as value laden in a way that excludes many moral ends. Yuval Levin comments: “In forcing the world into this [scientific] form, science must necessarily leave out some elements of it that do not aid the work of the scientific method, and among these are many elements we might consider morally relevant.” (2006, 35) Leon Kass goes even further, arguing that “modern science rejects, as meaningless or useless, questions that cannot be answered by the application of method” (1993, 8). Echoing Randolph Bourne, Kass describes a cold, remorseless science reminiscent of the opening pages of Aldous Huxley’s Brave New World (a neoconservative favorite), asserting that “the so-called empirical science of nature is, as actually experienced, the highly contrived encounter with apparatus” and that “nature in its ordinary course is virtually never directly encountered” (1993, 7). These neoconservatives argue that scientists are too far removed from the world to properly consider the effects of their actions.

Neoconservatives see science and progressivism as so intertwined that the two are often combined in their minds, concerns about hubristic scientists mingling with old animosities toward leftist reformers. William Kristol (son of neoconservative founding father Irving Kristol) and Eric Cohen made the connection explicit in their discussion of therapeutic cloning supporters, describing them as “an odd mixture of the hubris of the medical researcher seeking to lead his fellow men beyond nature, and the sentimentality of the post-Communist romantic, who sees in genetic science man’s new hope for building a kind, just and liberated heaven on earth” (2002, 300). For neoconservatives, these impulses are one and the same, and both must be vigorously opposed.

Bioethics as a Model of Progressive Public Policy

Bioethics has a close connection to pragmatic progressivism, and is in many ways a progressive strain of the existing medial ethics community. The modern bioethics movement was in part a product of the human rights fervor of the later 1960s, and in part a result of a small group of thinkers’ concerns about the implications of the biological revolution that could be glimpsed over the horizon. What began as an academic conversation about genetic modification, reproductive technologies, replacing organs, sustaining life, and conducting human experiments quickly became a matter of law and public policy.

The new bioethics was distinct from traditional medical ethics not only in the problems it confronted, but also in its emphasis on the rights of patients and their families to make crucial decisions that historically had been made by physicians. In this respect it dovetailed with a growing public desire to open up medical decision making and to vest greater authority in the individual. Institutionally, the movement to create ethics committees at hospitals caught fire after the Karen Ann Quinlan case. Ethics committees represented a practical alternative to legal action when cooperation and communication between patients and caregivers broke down, or when the medical issues were of unfamiliar complexity. In acute clinical situations, academic theories have little leverage; the ethics committee process represents pragmatism at the “micro” level of the individual case (Moreno 1995). Thus, bioethics embodies such progressive values as pragmatic problem solving and the desire to make large, impersonal institutions more responsive to individuals.

At the “macro” level, no academic field has been so closely identified in its early and continued development with governmental advisory bodies as bioethics. Beginning with the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in the 1970s, and continuing through the President’s Council on Bioethics, these panels have attracted a great deal of attention from stakeholders and in some cases have created lasting policy frameworks, including regulations on the use of humans as research subjects, standards for informed consent, criteria for review of human genetic testing, rules on human reproductive cloning, and conditions for research involving human biological materials. To be sure, many of the proposals of these bodies had little or no influence, especially if they seemed to go beyond the readiness of the political system to accept them. From a sociological standpoint, it is important to note that the legitimacy of bioethics as a field was partly conferred by a series of bioethics commissions created by both Democratic and Republican administrations. These panels have not been limited to the presidential level; numerous bioethics advisory committees on special topics, including oversight of recombinant DNA experiments and human testing, have been created by various cabinet-level agencies. This reliance on advisory commissions reflects a progressive sensibility; President Theodore Roosevelt appointed the first presidential advisory committee. More important, the systematic approach taken by commissions—engaging knowledgeable experts in the process of assessing the problem at hand, hearing the views of various stakeholders, gathering evidence, and proposing new policy options—has come to be closely identified with progressive policymaking.

Of course, the pragmatic approach to bioethics has often been criticized as “instrumentalist” or merely means-oriented, and as too easily lapsing into a “thin” discussion about process rather than a “thick” discussion about ultimate goals and moral purposes (Evans 2002; Callahan 1996). Although we grant that in the public policy sphere important ethical considerations can too easily be swallowed up by procedural concerns, we reject the view that serious moral reflection about ends as well as means is incompatible with crafting public policy. The goal of making human beings more fully voluntary participants in research, for example, is embodied in the requirements for informed consent. The value of safety in studies of drugs and devices is realized in formal risk-benefit analysis. And, most important, progressivism respects the foundational value of a liberal polity that individuals should have maximal freedom, consistent with the public interest, to pursue their own vision of the good life. What the critics of bioethics view as succumbing to procedural norms, progressive bioethicists see as efforts to reconcile widely held values with respect for individual rights in a pluralistic democracy.

The justifiable criticism and self-criticism of the bioethics movement should not obscure the constructive innovations associated with the social practice of bioethics. Bioethicists have institutionalized the agenda of patients’ rights in the clinical setting, and they continue to raise concerns about patients’ rights. It would now be unthinkable—and contrary to professional and regulatory standards—for a hospital or a health-care organization to lack a mechanism for addressing ethical issues. Prior review of human research protocols by an ethics board is now a well-established international norm. An international community of scholars has recently launched an energetic movement to address questions of global ethics. And although neoconservatives have urged a thicker rationale for prohibiting human reproductive cloning beyond the risks to the fetus and the mother, the fact remains that the bioethics and life sciences communities have argued for a ban on attempts to clone a human being.

The social practices of bioethics therefore embody core progressive principles: that progress is possible, that pragmatism should prevail over ideology, that both individual rights and the common good can be respected and promoted, and that sound public policymaking requires a respect for evidence and a willingness to change familiar ways of operating. In the coming years, these principles will be needed to address challenges that arise from advances in personalized and regenerative medicine, stem cell research, synthetic biology, and neurotechnology.

In order to adequately address the new biological changes that will be important issues in the twenty-first century, progressive bioethics must reflect the best in both progressivism and bioethics. It must retain progressivism’s optimism and drive, and it must retain a belief in the capacity of individuals and government to work together to solve even the largest of problems. Rather than shy away from challenges or hearken back to a bygone era, progressive bioethicists should engage with the world as it is and contemplate how it might be. But this optimism must be tempered by the lessons of the past and by an understanding of the complexity of many of the social and scientific problems that confront us. Progressive bioethics suggests a cautiously optimistic approach to science that acknowledges uncertainties but is not paralyzed by them.

Progressive bioethics must also remain non-ideological, unwedded to certain policy prescriptions as absolute truths, and not distracted by silver bullets that promise much but deliver little. It should be grounded in the best empirical evidence, staying true to the scientific method. Yet this lack of ideology should be restricted to means. Progressive bioethicists must maintain a clear sense of how they want the world to look, and why they want it to look that way. Furthermore, these goals must be subject to debate as new technologies or other changes alter the world we live in. The answers to these moral questions are not found within science, but they help to define science’s appropriate goals. Progressive bioethics must ensure that the excesses of science do not threaten society’s core values and must remember that the shared moral concerns of the community are as important as medical, economic, and political concerns.

Progressive bioethics recognizes the importance of expertise, particularly in science, and the capacity of a community of experts to be self- correcting. Just as transparency creates the best public policy and ensures accountability of leaders, so too does the openness of the scientific community allow for the best theories to be revealed through constant testing and challenge. Progressive bioethicists must ensure that this openness and accountability remains ever-present in expert communities. But they should also ensure that the limits of expertise are recognized. In a pluralistic democracy, no individual is an expert on how others should lead their lives or how society should be shaped. These determinations are instead made by the people as a whole through their individual everyday decisions, through their elected leaders, and through opportunities to participate in the public dialogue on issues of import. It is crucial that progressive bioethics ensure that opportunities for dialogue continue, whether through the presence of citizens on ethics panels or through active engagement with the citizenry on bioethics issues (as is currently being attempted in Britain in a variety of ways).

Progressive Values in Bioethics

Describing progressive bioethics through a series of specific policy deci- sions is next to impossible. Difficult with any overarching theory, it is even more so with one that is explicitly non-ideological and wedded to the fruits of inquiry with respect to particular cases. But it is possible to describe the sensibility of progressive bioethics—that is, the types of concerns that can and should inform bioethical discussions. The four major values of progressive bioethics are critical optimism, human dignity, moral transparency, and ethical practicality. These values do not lend themselves to any specific policy in perpetuity, but serve to shape the debate in ways that are evident in today’s discussions.

Critical Optimism
Progressive bioethicists are critical optimists. They understand the tremendous potential of science and technology to improve our lives and
our world. They recognize the benefits of penicillin, automobiles, and assisted reproductive technologies. But they also understand that technology and science are not unqualified goods. They remember the lessons of the atomic bomb and of dangerous human experimentation. Thus, they are oriented toward the potential good of the future, believing that on the whole science and technology have been extraordinarily positive forces in our world. Yet they do not forget that this is due in part to our efforts to constrain and shape those technologies, and, at times, to prohibit them. Science and technology are presumptively good, but they do not escape a critical examination of their costs and benefits. Progressive support for nanotechnology, while insisting on adequate safety and environmental standards, reflects such a view.

Human Dignity
The term ‘human dignity’ has recently taken on a new meaning. Conservatives have used it to describe vague concerns about new technologies that force us to reconsider strongly held beliefs. For progressives, ‘human dignity’ has its original meaning: that of supporting the rights of individuals on the basis of our sense of their shared moral worth as members of the human community (Caulfield and Brownsword 2006). Thus, progressive bioethicists do not insist on one vision of the good life, or impose a single moral belief system on everyone. Rather, they protect and promote the ability of individuals to pursue their own ends, provided they do not impede the ability of others to do the same. Progressive support for patients’ autonomy and for access to legal medical treatments and procedures reflects these dignity concerns.

Moral Transparency
For progressives, ethics is not a set of specific, immutable, unchanging laws applied the same way today as a hundred years ago. Rather, our ethics stem from values and beliefs whose expression continues to evolve as they are informed by advances in science, politics, art, culture, and society. New developments cause us to reconsider previously held assumptions, comparing them with our values and, at times, changing our notion of how those values should be expressed. Thus, progressive bioethicists are attuned to these changes, understanding that society may change its opinion on what is right as time passes. We seek to ground bioethical decisions in widely held norms within the community, particularly norms that arise from extensive and informed public debate. The purpose of progressive bioethics is not to impose values, but to help people see how their values can be realized in new contexts within a changing society. Progressive support for in vitro fertilization and other reproductive technologies that are broadly desired and understood reflects a belief in public ethics.

Ethical Practicality
As a type of applied ethics, bioethics must remain closely connected to the actual circumstances of our world. Rather than imagine doomsday scenarios of future dystopias or bright utopian futures that may never come to pass, progressive bioethicists must address the questions of the here and now. Of course, preparation can ease the introduction of future technologies into society, but this cannot distract progressive bioethicists from current problems. And we must not simply address these questions theoretically; we must seek to offer practical, realizable solutions. The medical concerns of the developing world, racial and ethnic disparities in access to health care, and the powerful influence of industry on bio- medical science and regulation are all issues of great importance that may require messy solutions. Hearkening back to our pragmatist roots, progressive bioethicists must seek to productively address questions in the life sciences in ways that affect the actual world. Progressives’ concern with health care as a moral issue, not just an economic one, reflects this concern with practicality.

Toward a Progressive Bioethics

In many ways, there already is a semblance of progressive bioethics. A number of the values described as progressive are among the dominant views of the bioethics academy, including adherence to facts, protection of human dignity, and belief in the potential of science. They are the values that first defined the field, and they continue to hold prominent places in it. But progressive bioethics goes beyond these values. It gives greater prominence to voices that call for a return to concerns with social justice, to the protection of the least among us, and to an engagement with the everyday problems we see around us. It is a call to action, a prompting for bioethicists who share these values to take a more active role in the public and political debate around these issues. Constructively addressing the new moral challenges presented by the life sciences requires an openness to change, an inquiring spirit, and a sense of justice. That is the call of progressivism, one as powerfully inspiring today as it was a century ago.

Sam Berger and Jonathan D. Moreno, reprinted from Progress in Bioethics: Science, Policy, and Politics, edited by Jonathan D. Moreno and Sam Berger, published by The MIT Press.

Works Cited

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Borenstein, Seth. 2007. Scientists struggle to define life. Associated Press, August 20.

Bourne, Randolph. 1967. “The failure of Pragmatism.” In American Thought in
the Twentieth Century, ed. D. Van Tassel. Crowell.

Callahan, Dan. 1996. Is justice enough? Ends and means in bioethics. Hastings Report 26, no. 6: 8–10.

Caulfield, Timothy, and Roger Brownsword. 2006. Human dignity: A guide to policymaking in the biotechnology era? Nature Reviews Genetics 7, January: 72–76.

Cohen, Eric. 2006. The ends of science. First Things 167: 26–30.

Cohen, Eric, and William Kristol. 2002. Cloning, stem cells, and beyond. In The Future Is Now, ed. W. Kristol and E. Cohen. Rowan and Littlefield. Originally published in The Weekly Standard (August 13, 2001).

Dionne, E. J. 1991. Why Americans Hate Politics. Simon and Schuster.

Dionne, E. J. 1996a. Back from the dead: Neoprogressivism in the ’90s. American Prospect 7, no. 28: 24–32.

Dionne, E. J. 1996b. They Only Look Dead. Simon and Schuster.

Evans, John. 2002. Playing God? Human Genetic Engineering and the Rationalization of Public Bioethical Debate. University of Chicago Press.

Halpin, John, and Ruy Teixeira. 2006. The politics of definition. The American Prospect, April 20.

Hinsch, Kathryn. 2005. Bioethics and public policy: Conservative dominance in the current landscape. http://www.womensbioethics.org.

Kass, Leon. 1993. The problem of technology. In Technology in the Western Political Tradition, ed. A. Melzer et al. Cornell University Press.

Levin, Yuval. 2006. The moral challenge of modern science. The New Atlantis 14: 32–46.

McGerr, Michael. 2003. A Fierce Discontent. Free Press.

Moreno, Jonathan. 1994. Deciding Together: Bioethics and Moral Consensus. Oxford University Press.

Moreno, Jonathan. 2007. The clone wars. Democracy 5: 110–116.

Moreno, Jonathan, and Sam Berger. 2007. “Rush” to judgment. http://www.americanprogress.org.

Moyers, Bill. 2003. This is your story—the progressive story of America. Pass it on. Speech at Take Back America Conference, June 4, Washington.

Mundy, Liza. 2007. Everything Conceivable. Knopf.

Schambra, William. 2006. The conservative message machine? Speech at Washington conference titled Building a Better Message Machine: Do Ideas Matter?

Before comparing this potential male contraceptive to others, it is first important to justify the need for male contraception. The dearth of male contraceptives, especially long-acting, reversible contraceptives, referred to as LARCs, contributes to an unjust arrangement in which women bear the majority of the social, economic, and health-related burdens associated with contraception. Today, there are eleven female contraceptive methods but only two male methods: condoms and vasectomy.[1] Women alone contracept 67.3 percent of the time. If we include shared methods as well as male condom use, which women often negotiate, then women are involved in almost 91 percent of all contraceptive use. Men, in contrast, only participate in contraceptive use one third of the time.[2] Moreover, men’s involvement with contraception is usually limited to casual sex, not long-term monogamous relationships where couples tend to prefer LARCs.

The high cost of contraception can affect women’s ability to use contraception, their choice of contraception, and their overall economic situation. The one in five women of reproductive potential who are uninsured have to pay out of pocket for contraception, and, not surprisingly, they are 30 percent less likely to report using prescription contraceptives than women with health insurance. Even having insurance does not obviate financial concerns. Copayments can be high and often add up quickly. Additionally, many insurance companies do not cover contraception. As a result, women pay 68 percent more out of pocket for their routine reproductive health care than men of the same age.[3]

In addition to the economic burdens of contraception, women also suffer from the negative side effects associated with contraception. The side effects of female contraceptives are generally more serious than for male contraceptives in part because there are no hormonal methods for men, and such methods typically carry more risks. Specifically, the side effects of female hormonal contraceptives can include cardiovascular complications, depression, hepatic adenomas, pathologic weight gain, and possible bone loss.[4] The two available male forms of contraception also carry fewer risks than their corresponding female contraceptives, female barrier methods and tubal ligation, respectively. Some dismiss women’s side effects as “minor”; however, to the women who experience them, they often are far from benign. Women most commonly discontinue contraceptives due to side effects[5] and most forms of contraception have discontinuation rates approaching 50 percent after one year of use.[6]

Not being responsible for some or all of these economic, health-related, and other burdens is a significant boon for men. Men typically do not have to dedicate time and energy to contraceptive care, pay out of pocket for the usually expensive and sometimes frequent (often monthly, or at least four times a year) supply of contraceptives, acquire the knowledge about contraception and reproduction needed to effectively contracept, deal with the medicalization of one’s reproductive health, endure the bodily invasion of contraception, suffer the health-related side effects and the mental stress of being responsible for contraception, and face the social repercussions of their contraceptive decisions (such as whether to use a particular contraceptive or to switch contraceptives), and the moral reproach for contraceptive failures. Women who contracept have to devote and sacrifice many aspects of themselves and what they value: their body, health (physical and mental), time, money, etc. These contraceptive burdens and sacrifices limit people’s freedoms. Since men are frequently not responsible for contraception, they are absolved from these burdens and thus their freedom is not infringed upon. In short, men’s autonomy is enhanced by their freedom from contraceptive responsibility.

At the same time, however, men’s autonomy is also diminished by the fact that they are usually not responsible for contraception. For many men, neither of the two currently available male contraceptives is well-suited for their contraceptive needs: they want a long-acting, reversible contraceptive. The lack of such options forces many men in monogamous relationships to rely on their partners to contracept. Even when men choose to use the condom, given its high failure rate of 16 percent for typical use, they are still not able to regulate their reproduction as effectively as women, for many female hormonal methods and IUDs have failure rates under three percent.[7] To further decrease the probability of pregnancy, some couples use both the male condom and a female method. But even if men contracept, they are often dependent on women to also use contraception if they want to use a method with a high success rate (and they are not yet ready for sterilization).

This dependence on women reduces men’s reproductive autonomy. Men have to trust that their partners are correctly and consistently using contraception. If a pregnancy does occur—either unintended by both partners or when the woman decides to stop contracepting without telling her partner—men have no recourse. Men cannot mandate that women get an abortion. Regardless of the circumstances under which the pregnancy transpired, men are still held socially and financially responsible for any children they father. In some ways it seems unfair to hold men responsible for children they did not want when they are ill equipped to prevent pregnancy.

What men need in order to successfully control their reproduction is the one type of contraceptive they are missing (and that women currently have), LARCs. Indeed, the development of male LARCs would enhance men’s reproductive autonomy by enabling them to do what women have been doing since the advent of the female pill: effectively regulate their fertility outside of all sexual activity and without their partner’s participation or knowledge. Scientists have been working on developing male contraception for the last 40 years and keep saying that these contraceptives are just around the corner. So why are there still no male LARCs?

First, dominant understandings of women’s and men’s bodies have played a role. Some scientists claim that it is more difficult to create male contraceptives because men’s bodies are more complex than women’s: women release one egg a month, while men produce millions of sperm a day; women’s fertility is limited to a handful of days each month, whereas men are consistently fertile.[8] At play in these comparisons are implicit and sexist assumptions about the mind/body dichotomy: women’s bodies are more simplistic and closer to nature, while men’s bodies are more advanced and farther from nature. While some scientists still insist that women’s bodies are more controllable and better suited for medical intervention, especially reproductive intervention, other scientists assert that men’s bodies are more easily manipulated and that “if scientists had simply followed nature, they would have developed male contraceptives rather than female methods.”[9] Regardless of the relative ease of developing female or male contraceptives, other factors have contributed to the dearth of male contraceptives. Notably, it was not until the 1970s—50 years after scientists starting researching “modern” female contraceptives—that scientists began researching new types of male contraceptives.[10] Previously, scientists’ work on male contraceptives was limited to improving the condom.[11] Because the female reproductive system has been studied for so much longer, more is known about it and consequently there are more female contraceptives and developing female contraceptives is not as difficult.

Second, much more money is allocated to female contraceptive research. The distribution of research and development money in the 1990s was as follows: 60 percent to high-tech female methods, 3 percent to female barrier methods, spermicides, and natural fertility control methods, 7 percent to male methods, and 30 percent to multiple methods, though mostly for women.[12] Researchers who would like to study male contraception often cannot due to a lack of funding. For example, Richard Anderson, a professor of clinical reproductive science at Edinburgh University, says that “most of the work [on male contraception] has been initiated by university investigators and the World Health Organisation. There has so far not been a lot of money from corporate companies.”[13] Despite positive findings on a male contraceptive pill, Anderson has not been able to conduct trials because no pharmaceutical company will financially support them.[14] The main reason pharmaceutical companies decline to fund male contraceptive research is that they do not think male contraceptives will be lucrative. While nonprofit organizations also research contraception, they typically lack the resources to do on a large scale. The World Health Organization had been one of the more visible and active nonprofit organizations working on male contraceptives, but today they focus entirely on female contraception because they see it as the key to helping women in developing countries.[15]

Third, many do not think there is a market for male contraception because they doubt both the women will trust men to contracept and that men will be interested in using contraception. Yet this reasoning is based on gender ideologies, not fact, and so it is not surprising that empirical evidence shows the opposite conclusions. For example, while mass media articles in the English speaking-world assert women will not trust men (including their partners) with contraception,[16] an international study reveals that only 2 percent of women would not trust their partner to contracept. A gender ideology relating to why men would not be interested in male contraception is that men do not want to participate in private-realm responsibilities like reproduction because they are women’s work. However, empirical studies show that 55 percent of men would be willing to use contraception.[17] Therefore, the data suggest that if those men had access to a long-lasting contraceptive, their female partners would have reason trust they were using it.

Another gender ideology that has inhibited the development of male contraception is that men are not willing to suffer side effects that “minimize” their masculinity. Many of the hormonal male contraceptives currently under research, such as gels, patches, implants, and injections, depend upon testosterone to induce sterility. While most men do not mind increased muscle weight gain, many are troubled by other side effects of testosterone like acne, mood swings, and temporary shrinking of the testes.[18] Additionally, some men are concerned about the effect hormones will have on their libido and their future fertility.[19] A non-hormonal male contraceptive pill currently under research avoids these unpalatable side effects and works by preventing ejaculation. Although the lack of an ejaculation does not affect the quality of orgasm, urologist Harry Fisch claims this side effect will preclude many men from considering this contraceptive: “I don’t think a lot of men are going to take this … The ejaculate coming forward is a significant part of a man’s sexuality.”[20]

A potential male contraceptive based on a genetic defect with the PLC zeta protein would sidestep the aforementioned negative side effects, thereby making it more acceptable to men. This is not to say, however, that this potential contraceptive would not also have problematic side effects. Moreover, a contraceptive that mimics this defect is still in its infancy. Although developing more male contraceptives will make it easier for men to contracept, it is unlikely that men will start contracepting at the same rates women do without any changes in dominant ideas about contraceptive responsibility. The mere existence of a particular technology is not enough to change our current contraceptive arrangement. Permanent contraceptives provides a strong example of this fact.

Unlike the case of reversible contraceptives, permanent contraceptives are equally available for women and men. Both have one option available to them: tubal ligation for women and vasectomy for men. This equality of options might lead one might expect similar rates of tubal ligation and vasectomy. Yet, tubal ligation is practically three times more common in the United States. Worldwide, the same pattern stands. In fact, only two countries, Britain and the Netherlands, have vasectomy rates that are equivalent to tubal ligation rates.[21] These differing rates cannot be attributed to availability of technology nor to the procedures themselves, as vasectomies are quicker, easier, safer, and cheaper than tubal ligations. The alignment of femininity with contraceptive responsibility explains, at least in part, why tubal ligation is much more popular. Before we can expect any male contraceptive to be widely accepted—no matter how objectively attractive it may be—we must first work on changing social norms so that men, as well as women, are expected to assume reproductive responsibility.

Lisa Campo-Engelstein, Ph.D. is a senior research fellow in medical humanities at the Feinberg School of Medicine, Northwestern University and a member of the Oncofertility Consortium.

Endnotes

[1] The eleven female-only contraceptive methods are sterilization (tubal ligation); barrier methods (the diaphragm, the sponge, the cervical cap, and the female condom); hormonal LARCs (the pill, the patch, injectables, implants, the vaginal ring, and a progestin-releasing IUD); and a non-hormonal LARC, other types of IUDs. The two male-only contraceptive methods are vasectomy and the male condom. The two shared methods are withdrawal and the rhythm method.

[2] The Alan Guttmacher Institute. 2008. Facts on contraceptive use. January. http://www.guttmacher.org/pubs/fb_contr_use.html. Accessed June 20, 2008.

[3] Knudson, Lara M. 2006. Reproductive rights in a global context: South Africa, Uganda, Peru, Denmark, United States, Vietnam, Jordan. Nashville: Vanderbilt University Press, 115.

[4] Hatcher, Robert A., James Trussell, Felicia H. Stewart, Anita L. Nelson, Willard Cates Jr., Felicia Guest, and Deborah Kowal. 2004. Contraceptive technology. 18^th Revised Edition. New York: Ardent Media, Inc, 241.

[5] Nass, Sharyl J., and Jerome F. Strauss III, editors. 2004. New frontiers in contraceptive research: A blueprint for action. Washington, D.C.: The National Academies Press, 119.

[6] Nass and Strauss, 125-6

[7] Hatcher, foreword.

[8] For more examples, see Knight, James W., and Joan C. Callahan. 1989. Preventing birth: Contemporary methods and related moral controversies. Salt Lake City: University of Utah Press, 12.

[9] Oudshoorn, Nelly. 2003. The male pill: A biography of a technology in the making. Durham,

N.C.: Duke University Press, 46.

[10] Public Broadcasting Station (PBS). Timeline: The Pill. http://www.pbs.org/wgbh/amex/pill/timeline/index.html. Accessed July 21, 2008.

[11] Oudshoorn, 19.

[12] Yanoshik, Kim, and Judy Norsigian. 1992. Contraception, control, and choice: International perspectives. In Healing technology: Feminist perspectives, ed. Kathryn Strother Ratcliff. Ann Arbor: University of Michigan Press, 70.

[13] Quoted in Moss, Lyndsay. 2007. Hopes for male pill hit by lack of cash. The Scotsman, July 2, 12.

[14] Moss, 12

[15] Oudshoorn 192-3; Dow, Steve. 2005. No pill for him just yet. Sydney Morning Herald, September 29, 6

[16] See for example: Christman, Jennifer. 2006. What’s in a dame? Would he even take the Pill, if he could? Little Rock: Arkansas Democrat-Gazaette. November 7; Levenson, Ellie. 2006. A single dose of a new male contraceptive pill promises “instant” protection from pregnancy and no lasting effects. The Guardian, November 28: 17; Richard & Judy. 2006. Rely on a man to take the pill? Surely they have got to be joking. The Express, December 2: 21.

[17] Glasier, A.F., R. Anakwe, D. Everington, C.W. Martin, Z. van der Spuy, L. Cheng, P.C. Ho, and R.A. Anderson. 2000. Would women trust their partners to use a male pill? Human Reproduction 15 (3): 646-649.

[18] Nuzzo, Regina. 2006. Beyond condoms: Years in the making, male hormonal contraceptives may finally be on track. Los Angeles Times October 16, F3.

[19] Godson and Bourke. Bourke, Fionnuala. 2006. Boys may be offered male pill. Sunday Mercury, May 7, 20.

[20] Macrae, Fiona. 2006. The instant male pill; Scientists unveil contraceptive a man can take before          sex…while hours later his fertility returns to normal. London: Daily Mail. November 27. Fisch quoted in Traister, Rebecca. 2006. Men and the pill. Salon.com December 1.

[21] Ringheim, Karin. 1996. Whither methods for men? Emerging gender issues in contraception. Reproductive Health Matters No. 7 (May), 88, footnote.

Current British law prohibits using the cells for reproductive purposes, and even after the years it may take to improve on the technique, serious safety questions about using them to fertilize a human egg would remain. Some biologists are also questioning whether what the team led by Professor Karim Nayernia have generated are really functional sperm, and others have yet to reproduce the experimental results. But none of this changes the fact that the moment to confront the implications of stem cell research for assisted reproduction is upon us. SP Editor-in-Chief Jonathan Moreno tackled this issue in Science Next, pointing out that conservatives who pushed induced pluripotent cells and reprogramming as alternatives to embryonic stem cells didn’t stop to think about the impact the work could have on procreation. As Moreno points out, coaxing stem cells into sperm may be the first step, but similar techniques might be able to turn stem cells into blastomeres, rendering every cell in the body a potential embryo. The analysis is worth quoting at length:

But scientists and bioethicists alike will have to confront the new possibilities for artificial human reproduction inherent in the rapidly advancing stem-cell biology. Already a British group has reported that it has coaxed human female embryonic stem cells to develop into cells with some of the essential qualities of sperm. Suppose one were to pursue an attempt to transform a diploid cell (a body cell with all forty-six chromosomes) into a haploid gamete (a sperm or egg cell with only twenty-three chromosomes). This might involve first expelling half the genetic complement (as has apparently already been done in mouse cells), and then treating the remainder with factors that are required for gametic processes.

It seems that opponents of embryonic stem-cell research who celebrated the advent of iPS cells have not grasped that the cellular reprogramming technique actually aggravates their greatest concerns about the power of modern biology. For if skin cells can be reprogrammed to become pluripotent and then differentiated into specific somatic cell types, they may also be differentiated into germ (sex) cells.

Since male iPS cells have both X and Y chromosomes, they could be reprogrammed to sperm and eggs. These iPS-derived sperm and eggs could then be used in standard in vitro fertilization procedures. Notably, couples with an infertile male partner may be able to obtain sperm that could then be transferred to the woman’s uterus. The resulting infant would have virtually the full complement of DNA of both members of the couple, though whether the male can be called the father in the traditional biological sense will be a matter of debate. Alternatively, it may be possible for a gay male couple to obtain an oocyte derived from the skin cell of one member of the couple, which could then be combined with the sperm from the second man and the embryo brought to term through the services of a gestational or surrogate mother. The resulting child would be genetically related to both men. Lacking a Y chromosome, a lesbian couple would not be able to reproduce in this way. However, if the genes sort differently during the formation of each of the gametes, there would be grave risks for any resulting embryo. It should not be necessary to elaborate on the extraordinary ethical and social questions that would be raised by such developments. In an overview of the issues raised by pluripotent stem cells, the Hinxton Group, an international consortium on stem-cell ethics and law, urged caution in any new regulatory regime that might be stimulated by these questions: “In the case of PSC-derived gametes, as with all science, it is important to target policy specifically to those dimensions of the research or its applications that have proved to be unacceptable, and that these policies be proportionate to the magnitude of what is morally at stake.”

But that is not the end of the story. If iPS-derived germ cells are in the offing, then so are blastomeres, the cells that constitute an embryo at its very earliest stages. To turn a diploid cell into a blastomere one might either use the induced germ cell in a process of parthenogenesis or spermatogenesis, or introduce factors that skip the gamete stage and turn the iPS cell directly into a blastomere. Thus will come to pass the most astonishing and disorienting result of all: modern stem-cell biology will at that point have made every cell of our body a potential embryo.

All of these scenarios tread the dangerous territory between science and science fiction. The genetic resorting that would take place through several steps of reprogramming from adult cells to iPS cells to gametic cells would almost surely make it too dangerous to attempt human reproduction, so as in the case of reproductive cloning, issues of risk would have to be dealt with before more profound ethical issues would need to be addressed. Yet how many stem-cell biologists, including Thomson and Yamanaka, predicted that reprogramming would be accomplished so quickly?

A more plausible scenario for the use of iPS cells to produce a genetic twin of the cell donor has already been demonstrated in mice by scientists at Advanced Cell Technology, a Worcester, Massachusetts, biotech company. “We now have a working technology whereby anyone, young or old, fertile or infertile, straight or gay can pass on their genes to a child by using just a few skin cells,” a company official said. Moreover, the official added, “the bizarre thing is that the Catholic Church and other traditional stem-cell opponents think this technology is great when in reality it could in the end become one of their biggest nightmares. . . . It is quite possible that the real legacy of this whole new programming technology is that it will be introducing the era of designer babies.”

Widespread appreciation of this technical reality could have profound effects on the divisive abortion debate, but in what directions? There seem to be at least several distinct possibilities, all of which may co-exist. The first and most likely short-term possibility is that prolife groups will split between those that wish to ban such procedures as antithetical to the natural process of conception and those that find it an acceptable alternative along the lines of in vitro fertilization. A second, more extreme, result and far less likely result would be that the human embryo in its early, disorganized state prior to, say, the appearance of the primitive streak (roughly around fourteen days) comes to be seen as no more than another clump of cells. Eventually, something like the traditional view still reflected in Islam, Judaism, and most Protestant denominations may once again be accepted even by those who once held a more elevated view of the early embryo. A third possible outcome of the advent of iPS-derived embryos, and one that is perhaps the most distant, is that a growing proportion of the public comes to view the tissues and organs that compose the human body as the remarkable systems they are, rich with life and the potential for independent life. Cults that worship every cell and even every sloughed cell can be imagined.

What is clear is that our society is unprepared for breakthroughs in the life sciences that we can foresee just over the horizon. For some, the new dawn of mastery over our own biology that will follow from the technology of induced pluripotency will seem like a cruel joke and confirm their worst fears. Some may even be reminded of the myth of Prometheus, whose punishment for stealing fire from the gods and sharing it with humans was to be tethered to a rock where his liver was consumed by an eagle. Thus we may conclude that, though humans may suffer for their knowledge, neither will it consume them, for the liver happens to be the only organ in the human body capable of complete regeneration, a definitive property of pluripotent cells.

(Jonathan Moreno, from “Stem Cells and the Betting of Moral Milestones” in Science Next)