AMA Journal of Ethics^®

The ability to make choices about whether, when, and how to have a family is a goal that people have sought since antiquity. For example, written records of contraceptive methods and techniques for performing abortions dating back to 1550 BCE have been found among artifacts of ancient Egyptian civilizations [1]. Of course, as our understanding of reproductive science has increased, newer, safer, more effective technologies for family planning have been developed and introduced. Regulation of fertility is now very common: between 2006 and 2008, 73 percent of Americans women aged 15-44 (or their sexual partners) were using a “modern method” of contraception, such as pills, condoms, intrauterine devices, injectables, and implants [2]. With the help of these methods, some people are choosing to delay having children or not to have children at all. In fact, the average age at which American women have their first child increased from 21.4 years in 1970 to 25 years in 2006 [3]. Despite this, about half of American women have an unplanned pregnancy and nearly one in three women are projected to have an abortion by the age of 45 [4].

The opportunity to make choices about family planning and access to safe and effective methods to carry out those choices are surely welcomed by many. It seems, however, that the development of these methods has outpaced our ability to reach consensus on what constitutes their ethical use. In halls of government, at kitchen tables, on blogs, and around the water cooler, debates rage about who should have access to emergency contraceptives, whether abortion should be legal, and who should or shouldn’t be having children.

This month, we take a broad view of the ethical issues in family planning, past, present and future. We look back at the history of government intervention in childbearing with an article by Susan P. Raine, JD, MD, LLM, on the history of the federal sterilization program. We touch on a current hot-button issue in Rebecca C. Thilo’s review of a journal article exploring the attitudes of emergency room clinicians about emergency contraception. Timothy F. Murphy, PhD, looks forward to the future in his op-ed, which explores whether it might be acceptable, or even ethically obligatory, to use prenatal genetic selection methods to ensure desirable traits in children.

Our clinical cases this month focus on some of the fundamental principles of medical ethics as they relate to family planning. Xiomara M. Santos, MD, examines how physicians can protect the confidentiality of a minor whose parents demand information about her sexual activity. Frank A. Chervenak, MD, and Lawrence McCullough, PhD, provide guidance on counseling a patient who desires a pregnancy but whose ability to care for a child is in question. Lastly, Lusine Aghajanova, MD, PhD, and Cecilia T. Valdes, MD, comment on the obligations of a physician to a couple who desire a child of a particular sex.

Family planning is often thought of primarily or solely as a women’s health issue, in part because fewer contraceptive options are available for men than for women. In her medicine and society article, Lisa Campo-Engelstein, PhD, examines the development and social implications of this disparity. In addition, Mara Y. Roth, MD, provides an update on the current state of research in the development of long-acting reversible contraceptives for men.

Finally, we look at the role of law and government in regulating access to family planning services. Recent policies have raised several ethical questions in this area, as we see in the review by B. Jessie Hill, JD, of recent legislation restricting access to abortion services and an article by Adam Sonfield, MPP, on the conscience exemption to new requirements for health insurance coverage of family planning services. Kristina Tocce, MD, MPH, and Britt Severson, MPH, examine the impact that federal funding restrictions on abortion services have on the training of medical residents.

With so many options for family planning, and education about these issues often lacking, patients turn to their health care clinicians for information, guidance, and support as they make decisions about whether, when, and how to start or expand their families. Although many of the questions explored in this issue have no single right answer, we hope that these articles spur you to reflect on your own beliefs and opinions concerning what are often emotional subjects for both patient and physician and that they may provide a starting point as you guide your patients toward their decisions.