Eugenics and human rights

Toward a More Just System of Care in Molecular Pathology

Policy Points American health care policy must be critically assessed to establish the role it plays in sustaining and alleviating the health disparities that currently exist in molecular genetic testing. It is critical to understand the economic and sociocultural influences that drive patients to undergo or forgo molecular testing, especially in marginalized patient populations. A multipronged solution with actions necessary from multiple stakeholders is required to reduce the cost of health care, rebalance regional disparities, encourage physician engagement, reduce data bias, and earn patients' trust.

CONTEXT

The health status of a population is greatly influenced by both biological processes and external factors. For years, minority and low socioeconomic patient populations have faced worse outcomes and poorer health in the United States. Experts have worked extensively to understand the issues and find solutions to alleviate this disproportionate burden of disease. As a result, there have been some improvements and successes, but wide gaps still exist. Diagnostic molecular genetic testing and so-called personalized medicine are just now being integrated into the current American health care system. The way in which these tests are integrated can either exacerbate or reduce health disparities.

METHODS

We provide case scenarios-loosely based on real-life patients-so that nonexperts can see the impacts of complex policy decisions and unintentional biases in technology without needing to understand all the intricacies. We use data to explain these findings from an extensive literature search examining both peer-reviewed and gray literature.

FINDINGS

Access to diagnostic molecular genetic testing is not equitable or sufficient, owing to at least five major factors: (1) cost to the patient, (2) location, (3) lack of provider buy-in, (4) data-set bias, and (5) lack of public trust.

CONCLUSIONS

Molecular genetic pathology can be made more equitable with the concerted efforts of multiple stakeholders. Confronting the five major factors identified here may help us usher in a new era of precision medicine without its discriminatory counterpart.

Discussions of the "Not So Fit": How Ableism Limits Diverse Thought and Investigative Potential in Evolutionary Biology

AbstractEvolutionary biology and many of its foundational concepts are grounded in a history of ableism and eugenics. The field has not made a concerted effort to divest our concepts and investigative tools from this fraught history, and as a result, an ableist investigative lens has persisted in present-day evolutionary research, limiting the scope of research and harming the ability to communicate and synthesize knowledge about evolutionary processes. This failure to divest from our eugenicist and ableist history has harmed progress in evolutionary biology and allowed principles from evolutionary biology to continue to be weaponized against marginalized communities in the modern day. To rectify this problem, scholars in evolutionary research must come to terms with how the history of the field has influenced their investigations and work to establish a new framework for defining and investigating concepts such as selection and fitness.

You can't keep a bad idea down: Dark history, death, and potential rebirth of eugenics

"Be careful what you wish for": This adage guides both how this project came to life, and how the topic covered in this review continues to unfold. What began as talks between two friends on shared interests in military history led to a 4-year discussion about how our science curriculum does little to introduce our students to societal and ethical impacts of the science they are taught. What emerged was a curricular idea centered on how "good intentions" of some were developed and twisted by others to result in disastrous consequences of state-sanctioned eugenics. In this article, we take the reader (as we did our students) through the long and soiled history of eugenic thought, from its genesis to the present. Though our focus is on European and American eugenics, we will show how the interfaces and interactions between science and society have evolved over time but have remained ever constant. Four critical 'case studies' will also be employed here for deep, thoughtful exploration on a particular eugenic issue. The goal of the review, as it is with our course, is not to paint humanity with a single evil brush. Instead, our ambition is to introduce our students/readers to the potential for harm through the misapplication and misappropriation of science and scientific technology, and to provide them with the tools to ask the appropriate questions of their scientists, physicians, and politicians.

Experiences of forced sterilisation and coercion to sterilise among women living with HIV (WLHIV) in Namibia: an analysis of the psychological and socio-cultural effects

The forced and coerced sterilisation of women living with HIV (WLHIV) is a phenomenon reported in several countries. In Namibia, litigation efforts for cases of forced and coerced sterilisation were successful, yet the psychological and socio-cultural well-being of those affected has not been adequately investigated and addressed. To determine the psychological and socio-cultural effects of involuntary sterilisation on WLHIV in Namibia, qualitative data from seven WLHIV were collected through face-to-face interviews. Our analysis showed that, firstly, there are negative psychological effects manifesting in psychological symptoms associated with anxiety and depression. Secondly, there are negative socio-cultural effects including discrimination, victimisation and gender-based violence. Patriarchal cultural values regarding reproduction, marriage and decision-making contribute to negative psychological and socio-cultural effects. Finally, negative psychological and socio-cultural effects of involuntary sterilisation are long-lasting. For participants, coping remains difficult, even over a decade after the sterilisations. Given the considerable long-lasting negative psychological and socio-cultural effects, psychological interventions to expedite positive coping and well-being must be prioritised.

A social history of serious mental illness

Despite medical, technological, and humanitarian advances, the criminalization of those with serious mental illness continues. This is not an isolated phenomenon. The benefits of treatment reform and innovation are difficult to maintain or sometimes outright harmful. Across time and geography, the care of those with serious mental illness tends towards maltreatment, be it criminalization or other forms of harm. We present a social history of serious mental illness, along with the idea that the treatment of serious mental illness is a Sisyphean task-perpetually pushing a boulder up a hill, only for it to roll down and start again. The history is provided as a basis for deeper reflection of treatment, and treatment reform, of those with serious mental illnesses.

Representações do discurso médico-eugênico sobre a descendência: a eugenia mendelista nas teses doutorais da Faculdade de Medicina e Cirurgia de São Paulo na década de 1920

Resumo A eugenia representou um movimento de grande repercussão a partir do final do século XIX e pretendia o melhoramento e aprimoramento da espécie humana, abrangendo ações de educação e de restrições à reprodução, contribuindo para a construção da ordem e da civilidade, baseada no progresso e na superioridade moral e física dos indivíduos. Este artigo visa apresentar e discutir elementos extraídos das teses doutorais da Faculdade de Medicina da Universidade de São Paulo na década de 1920, especificamente relacionados ao tema da eugenia mendelista, sob a ótica da produção discente da época. O período escolhido representa um momento de grande influência da medicina na sociedade, em ações de controle e normatização dos indivíduos, influenciadas pelas teorias eugênicas. As teses doutorais representam o início da produção discente da Faculdade e contêm influências das teorias em voga no período - teorias evolucionistas, positivistas e eugenistas. Foram selecionadas para apresentação neste artigo oito teses doutorais, analisadas a partir do conceito de representações como técnica de leitura de documentos. Nas teses analisadas, pôde-se observar uma preocupação dos autores com a formação de uma descendência eugênica, defendendo o estabelecimento de medidas como restrição de casamentos, exame médico pré-nupcial e, em alguns casos, esterilização compulsória.

Rational subjects, marriage counselling and the conundrums of eugenics

Against the background of degeneration and the perceived threat to the nation's health and stock, family politics came to constitute an important site for eugenic discourses and interventions. Eugenic regulation of reproductive sexuality and marriage was not only pursued through 'negative' eugenics but also through educational policies targeted at young adults and youth. Switzerland serves as a useful case to explore a general idea, namely the limitations for eugenicists of exploiting the concept of a rational subject in order to achieve their ends. Practices of 'positive eugenics' crucially hinged on the utilitarian principle of rationality underpinning positive eugenics which this paper seeks to elaborate. Eugenicists devised tools to deal efficiently with social problems on a collective as well as an individual basis by deploying technologies of government which conceived individuals to be members of a population who were each held responsible for the generation of healthy future generations. As a form of 'sustaining, multiplying and ordering life' eugenics thus relied on the premise that its ideas would be adopted through an appeal to rationality and, where this was insufficient, through a series of coercive measures. Relying on conviction and education about the merits of eugenics, however, posed particular problems to positive eugenic thinking and practice.

The sterilisation of people with intellectual disabilities in England and Wales during the period 1988 to 1999

BACKGROUND

In England and Wales, if a person is thought to lack capacity to make a decision to undergo a sterilisation operation, a specific process occurs. A Judge sitting in the Family Division of the High Court receives evidence from relevant parties including psychiatric and gynaecological experts and subsequently decides on the lawfulness of the sterilisation operation. We have investigated who was referred and by whom, the reasons given, and the outcomes of the legal process during an 11-year period.

METHODS

A retrospective case note study was undertaken of all referrals to the Official Solicitor's Office for sterilisation between 1988 and 1999. Using an established protocol, information was obtained from legal and clinical notes relating to the initial referral to the Official Solicitor, the opinions of experts, the court proceedings and the outcome.

RESULTS

Seventy-three people, only three (5%) of whom were men, were referred over the 11 years. They were aged between 12 and 41 years. All but one had an intellectual disability (ID). Seventy-five per cent were living at home and did not have partners. Full applications were made for 50 of the 73 (68.5%), 39 proceeding to a court hearing. For 31 of the 39 (79.5%) cases, the court ruled that sterilisation would be in the person's 'best interests'. An additional six women probably had operations resulting in sterilisation without court authorization.

CONCLUSIONS

Referrals for sterilisation are almost always for people with IDs. In the case of the majority, it was thought that it was unlikely that they had had or will have in the future a sexual relationship. Care needs to be taken in interpreting the results in this case note study. We hypothesize that the request for sterilisation is the consequence of a complex process reflecting concerns about the future, but in the context of other family issues. The relationship between lacking the capacity to consent to sterilisation and the capacity to consent to sexual intercourse needs further exploration. Future studies including interviews with those involved are required.

Off the map: a critical geography of intellectual disabilities

A "critical geography of intellectual disabilities" is outlined. Drawing on personal experience and borrowing poetic inspiration, claims about the end of the institutional era for intellectual disabled people are disputed, and the continuing eugenic legacy, complete with its multiple stigmatizing effects, is emphasized. The extent of the social exclusion experienced by many people with intellectual disabilities in the wider community, linked to various poor quality of life indicators, is also given attention. Finally, speculations are raised about how to move beyond the "asylum" and the "ghetto", empowering intellectually disabled people in the process.

Nuremberg and Tuskegee: lessons for contemporary American medicine

The activities of German doctors during the Nazi regime are well known and documented. They include efforts at eugenic sterilization and euthanasia, gruesome medical experimentation, and contributions to genocide. The German medical profession embraced the Nazi ideology of racial superiority. Nazi doctors enthusiastically perverted traditional medical mores of viewing each patient as a full individual towards a misguided sense of protecting the racial well-being of the nation from the perceived threat of certain groups of people. Similarly, some 20th-century American physicians engaged in activities prompted by a misguided sense of patients' worth as individuals. This essay will examine the ethical problems of Nazi medicine and ethical missteps in the United States in the context of challenges for contemporary physicians, particularly the way in which we refer to our patients.

Ethnicity and the politics of the new genetics: principles and engagement

Identifying the genetic basis of disease is not a straightforward medical procedure but implicates the broader social, cultural and political context. Ethnicity represents an important part of this context, particularly given the confused and poorly informed debate about genetic differences among supposedly different 'racial' populations. Debates about the 'new genetics', however, have not engaged fully with the issue of ethnicity and racism. This paper, by reviewing a mix of empirical and theoretical debates, explores the discursive practices that inform current thinking on genetics, ethnicity and race. The account begins by exploring some of the philosophical tensions inherent in providing genetic testing. In doing so, the paper argues that current debates about genetics are not neutral but evoke a specific set of received ideas and codes of intervention, embodying social and power relationships. The paper then broadens the discussion by exploring the general meaning of screening and counselling for the 'lay' population, before focusing on the process of providing information and identifying people as carriers. The paper concludes by suggesting that the social space in which the 'new genetics' is enacted, understood and given meaning raises generic concerns, irrespective of ethnicity. These include the potential tension between prevention and informed decision making, whereby ideas about empowering individuals to exercise choice exist alongside a more general societal concern with minimising impairment and illness. In more practical terms, individual choice is compromised by poor-quality care, inadequate information, insensitivity to an individual's worries and concerns and a more general failure to meet his or her needs. At the same time, however, the often racialised perspectives articulated through the activities of service professionals can further complicate the choices and decisions available to minority ethnic populations. The failure to recognise and respond to diversity; blaming minority ethnic populations for their health problems; and the pervasiveness of racist myths and stereotypes in service provision, serve to disadvantage minority ethnic populations. This explains why themes such as equity and access, political engagement as well as more general notions of deservingness based on the construction of citizenship and identity emerge as fundamental in making sense of the relationship between ethnicity and the politics of the 'new genetics'.

Eugenics and its relevance to contemporary health care

Recently there has been a revival of interest in the theory and practice of eugenics by both academics and lay people. The ongoing revolution in biology and the increasing ability to acquire genetic information has led to concerns about genetics being used again for sinister eugenic ends. Although the goals behind traditional eugenics--the minimization of disease and the improvement of human health--remain unchanged, the means by which these goals should be achieved have altered significantly. However, in debates about the impact of human genetic research, eugenics is sometimes viewed as a purely historical phenomenon and its relevance to the current situation is minimized. This article outlines the history of the eugenics movement, describes some eugenic practices, and explores why an appreciation of these historical debates is important for nurses.