THE JEREMIAH METZGER LECTURE: A BRIEF HISTORY OF EUGENICS IN AMERICA: IMPLICATIONS FOR MEDICINE IN THE 21^ST CENTURY

Abstract

In the first half of the 20^th century, the US was swept up in a multifaceted movement to enhance the genetic makeup of the country's population. This eugenics movement, based on flawed scientific principles promulgated by Galton in the UK and Davenport in the US included legally mandated compulsory sterilization in 27 states in the US and sharply restricted immigration from many parts of the world. Compulsory sterilization legislation was upheld by the Supreme Court in 1927. The American eugenics movement was a model for the compulsory sterilization implemented by the Nazis after they took power in Germany in 1933. The movement waned in America only following World War II when the US public became aware of the full extent of the Nazi Aryan racial superiority program. With the advent of major advances in molecular and cellular biology that are already being applied to clinical medicine in the 21^st century, we have entered a new eugenics era. It is critical that we learn the lessons of our earlier eugenics movement if we are to avoid making the same flawed decisions now.

INTRODUCTION

Major advances in molecular and cellular biology over the past few decades hold extraordinary promise for revolutionizing the way medicine is practiced in the 21^st century (Figure 1). First, following completion of the “draft” Human Genome in 2001, there has been a dramatic reduction in the cost of DNA sequencing combined with major increases in speed and scale. This has enabled practical application of DNA sequencing in clinical settings, most notably in oncology where comparison of germline and tumor DNA sequence to identify molecular treatment target(s) has become routine in major cancer centers. While evidence that such approaches increase patient survival are still lacking, oncology and diagnosis of rare genetic diseases are viewed as the leading edge of a coming era of genome sequencing-based “precision” medicine.

Fig. 1.

A listing of major advances in molecular and cellular biology and their current and potential applications in medical practice. Next-Gen, next-generation sequencing; WES, whole-exome sequencing; WGS, whole-genome sequencing; Dx, diagnosis; IVF, in vitro fertilization; Rx, therapy.

DNA sequencing has also been applied to carrier screening (typically for rare recessive disease gene mutations) before marriage, to prenatal screening, not only for trisomy but also genetic diseases, in blood samples from pregnant women containing fetal DNA, to preimplantation genetic diagnosis by DNA sequencing of embryo-derived cells in the context of in vitro fertilization (IVF), and in screening of newborns (by DNA sequence rather than conventional biochemical tests) for treatable genetic disorders. Other striking applications of recombinant DNA technology and of stem cell biology are gene therapy which is finally showing promising results in treating diseases such as hemophilia and inherited forms of blindness, in utero fetal therapy using a number of modalities, and so-called “three-parent” IVF for prevention of diseases caused by mitochondrial DNA mutations. Reproductive cloning has already been performed in various mammalian species, including nonhuman primates. This changes the prospect of cloning humans from a fantasy (as in cloning Hitler in the novel and movie, The Boys from Brazil) to technically feasible reality. And genome editing (of somatic as opposed to germline DNA) is being vigorously pursued as a treatment method for a number of diseases by several biotechnology companies.

All of these developments raise profound bioethical questions because of their effects on the human “gene pool,” with both preservation and elimination of “deleterious” genes as a downstream consequence of the foregoing diagnostic and treatment advances. It is reasonable therefore to ask whether we are entering (or have already entered) a new 21^st century eugenics era. George Santayana's dictum: “Those who cannot remember the past are condemned to repeat it” suggests that a careful examination of the American Eugenics movement of the early 20^th century should provide valuable lessons as we enter this new 21^st century eugenics era.

FRANCIS GALTON: “FATHER” OF EUGENICS

Before we consider the American Eugenics movement, we must first introduce Francis Galton (1822-1911), the “father” of eugenics. Charles Darwin's first cousin (and greatly influenced by his cousin's work on evolution and natural selection), Galton was a polymath, a pioneer in statistics (he developed regression analysis), in psychology, and meteorology (1). But his major passion was heredity. The inscription on a plaque in Claverdon Church near where he is buried reads: “Many branches of Science owe much to his labours but the dominant idea of his life's work was to measure the influence of heredity on the mental and physical attributes of mankind.” In a series of magazine articles and books (Hereditary Talent and Character, MacMillan's Magazine 1865; Hereditary Genius: An Inquiry into its Laws and Consequences, 1869; English Men of Science: Their Nature and Nurture, 1874), he expounded his ideas on the heredity of intelligence. Perhaps we should not be surprised that in documenting multiple highly intelligent and high-achieving members of leading English families, he largely discounted the “environmental” advantages enjoyed by the upper class, and instead attributed this familial clustering of “genius” to heredity. From such conclusions, it was a small step to advocating for positive steps to be taken to improve mankind; what Galton initially termed “viriculture,” and by 1883 called “eugenics.”

Galton's advocacy for a eugenics program drew from the longstanding human practice of animal breeding, something that would also feature prominently in the American Eugenics movement. Galton proclaimed (in his article in MacMillan's Magazine in 1865): “If a twentieth part of the cost and pains were spent in measures for the improvement of the human race that is spent on improvement of the breed of horses and cattle, what a galaxy of genius might we not create! We might introduce prophets and high priests of civilization into the world, as surely as we can propagate idiots by mating cretins.”

At the International Health Exhibition in London (1884), Galton set up an Anthropometric Laboratory “for the measurement in various ways of human form and faculty” (Figure 2). The data obtained from subjects voluntarily submitting to these measurements would be analyzed by Galton along with information obtained from psychological testing questionnaires he first developed. Subjects were charged a small fee for the laboratory's service, a practice foreshadowing the business model of genetic testing companies like 23andMe (Mountainview, California). The fundamental problem with Galton's interpretation of the “scientific” data was that his conclusions largely confirmed his own preconceived bias regarding genetic determinism and the innate superiority of the English upper class. The veneer of science which was in fact often pseudoscience was used to justify eugenic practices that would find their most ardent support and implementation first in the US, and later in Nazi Germany.

Fig. 2.

Poster and photograph showing Galton's Anthropometric Laboratory at the International Health Exhibition (London, 1884).

THE AMERICAN EUGENICS MOVEMENT: ITS ORIGINS AND CONTEXT

While the American Eugenics movement was rooted in the same racial bias (in favor of those of Anglo-Saxon or more generally, Northern European, origin) and pseudoscience promulgated by Galton, it arose in a unique context. First, there were several purportedly inferior racial groups in America that were either indigenous (Native Americans) or had been forcibly brought to the US (African slaves and Chinese imported to work on the railroads). Second, during the late 19^th and early 20^th centuries, relatively permissive immigration policies saw large waves of immigrants to the US from Southern and Eastern Europe. The perception that these immigrants of “inferior” racial stock brought with them infectious diseases and crime, and that they reproduced at rates far greater than that of the more refined upper classes, fueled fears that the nation was in danger of becoming “mongrelized.”

Studies of extended families such as the Jukes (2) and Kallikaks (3) in which criminals and/or the feeble-minded were disproportionately represented in multiple generations were cited as evidence for the heritability of mental disability, criminal behavior, and pauperism. Environmental factors were ignored or minimized, thus providing a rationale for a eugenics program rather than social programs aimed at improving the environment. Leading intellectuals and academicians were at the forefront of the American Eugenics movement with those from Harvard University playing a particularly prominent role (4). Charles Benedict Davenport, educated at Harvard and on the faculty, became Director of the Department of Experimental Evolution at the Cold Spring Harbor Station (now Laboratory) in Long Island (5). He collected and studied numerous pedigrees with hereditary diseases such as retinoblastoma, but also purportedly genetic conditions such as pauperism and thalassophilia (literally “love of the sea” in a multigenerational family of sea captains).

A eugenics program was justified on public health grounds. Henry Fairfield Osborne, President of the 2^nd International Congress of Eugenics held at the American Museum of Natural History in New York in 1921, stated: “The right of the state to safeguard the character and integrity of the race or races on which the future depends is, to my mind, as incontestable as the right of the state to safeguard the health and morals of its people. As science has enlightened government in the prevention and spread of disease, it must also enlighten government in the spread and multiplication of worthless members of society, the spread of feeblemindedness, of idiocy, and of all moral and intellectual as well as physical diseases.”

The proposed program consisted of positive and negative eugenics. In the US, the former program was largely symbolic with contests at state fairs for “fitter” families (Figure 3) and “better” babies. In contrast, the negative eugenics program was multipronged and widely implemented. It comprised three main elements: anti-miscegenation laws in multiple states which criminalized inter-racial marriage; compulsory sterilization of men and women considered genetically inferior; and severe restrictions on immigration from geographic areas (Asia and Southern and Eastern Europe) harboring what were considered inferior racial types.

Fig. 3.

Winners of a Fitter Family contest at the Kansas State Fair (1920s).

FORCED STERILIZATION

Indiana in 1907 was the first state to pass a law mandating compulsory sterilization of those deemed unfit to reproduce. Eventually 27 other states passed similar laws, defining “unfit” variously as mentally defective, feeble-minded, imbeciles, idiots, habitual criminals, and epileptics. This led to an estimated 60,000 sterilization procedures with California leading the country in the number performed. Virginia's law was contested in the case of Buck V. Bell which came to the Supreme Court in 1927 (4). Chief Justice Oliver Wendell Holmes Jr. rendered the verdict in favor of sterilizing Carrie Buck with the infamous dictum: “three generations of imbeciles is enough.” In fact, Carrie Buck had apparently been raped in a foster home, and to cover up the crime was labeled an imbecile (as were her mother and daughter), then forced to undergo sterilization. Subsequent investigation revealed that both Carrie Buck and her daughter were of average intelligence.

An editorial in the New England Journal of Medicine in 1934 (6) conceded that forced sterilization of those deemed unfit to reproduce is “a very complicated problem … because it is an invasion of personal rights, but even so, the general scheme of civilization is the right of the community as against that of the individual, and as a general proposition, the individual must give way before the greater good.” This statement epitomizes the two flawed ideas forming the basis of the negative eugenics program of forced sterilization: 1) the erroneous assumption that one could determine unequivocally who was and who was not genetically “fit” to reproduce; and 2) putting the public good ahead of respect for individual rights. The latter argument has been invoked on more reasonable grounds but still with some controversy to justify mandatory isolation of individuals with highly contagious infectious diseases (as in the 2015 Ebola outbreak which reached the US) and to justify mandatory vaccination for childhood infectious diseases in order to achieve “herd immunity.” Invoking improved public health to justify forced sterilization of those deemed unfit to reproduce violates fundamental bioethical principles.

IMMIGRATION RESTRICTIONS

In addition to reducing the reproduction of “inferior” individuals by forced sterilization, the negative eugenics program in the US used harsh restrictions on immigration of individuals deemed to be of inferior quality. In 1894, the Immigration Restriction League was founded in the US by three Harvard graduates (4). The hypocrisy of those who were themselves often only a single generation removed from immigrant forebears advocating current immigration restrictions was well depicted in a contemporary cartoon (Figure 4). Their efforts culminated in passage of the Johnson-Reed Immigration Act of 1924 which set highly limited quotas on immigration to the US of Southern and Eastern Europeans and Asians.

Fig. 4.

“Looking Backward” by Joseph Keppler in Puck, January 11, 1893.

Charles Davenport, cited above, championed such restrictions, asking “Can we build a wall high enough around this country so as to keep out these cheaper races…” (7). In Chapter V (titled “Migrations and their Eugenic Significance”) of his 1911 book, “Heredity in Relation to Eugenics,” Davenport observes: “The proper way to classify immigrants for admission or rejection is on the basis of the probable performance of their germ plasm. In other words, immigrants are desirable who are of ‘good blood’; undesirable who are of ‘bad blood.’ Since ‘blood’ cannot be judged by inspection of the individual, what practical method remains for separating the sheep from the goats?” His answer: a proposal for creating an army of “field workers” who would be deployed abroad to vet the family and personal history of those seeking admittance to the US. Needless to say, nearly a century later our country is still struggling to develop a coherent immigration policy.

THE NAZI CONNECTION

The relationship between the American Eugenics movement and the race-based policies implemented by the Nazis following Hitler's ascent to power in 1933 is a feature of our nation's history that has been underappreciated, if not actively suppressed (8). The Nuremberg race laws passed in 1935 denying citizenship to Jews and criminalizing intermarriage between Jews and ethnic Germans were modeled in part on US laws banning miscegenation, depriving Blacks and other groups of voting rights, and restricting immigration of those deemed inferior.

The Nazi program of compulsory sterilization and “euthanasia” of those deemed unfit (as opposed to the Holocaust per se) was unequivocally inspired by the American Eugenics movement (9). Evidence for this includes the granting of an honorary degree from Heidelberg University in 1936 to the head of the American Eugenics Record Office for his work on behalf of the “science of racial cleansing,” and statements such as this one by the California eugenics leader, C.M. Goethe: “You will be interested to know that your work [the California eugenics program] has played a powerful part in shaping the opinions of the group of intellectuals who are behind Hitler in this epoch-making program. Everywhere I sensed that their opinions have been tremendously stimulated by American thought.” Nazi propaganda prominently invoked the US example to prove that their own state-sanctioned victimization of innocent men, women and children was not some egregious violation of ethics and human decency (Figure 5).

Fig. 5.

Nazi propaganda poster from 1936 supporting Germany's 1933 Law for the Prevention of Hereditarily Diseased Offspring. The title: “Wir Stehen Nicht Allein” translates to “We Do Not Stand Alone,” and displays flags of other countries with purportedly similar laws and eugenics programs (with the American flag prominently shown at upper left).

As the full dimensions of the Nazi atrocities became apparent in the later 1930s, and eventually with the US declaration of war with Nazi Germany, support for eugenics programs in America weakened. The Supreme Court ruled in Skinner v. Oklahoma in 1942 that forced sterilization of incarcerated criminals was unconstitutional, but only on the narrow basis that it violated the equal protection clause of the 14^th amendment because compulsory sterilization was not ordered for “white collar” criminals (10). In 1967, Virginia's anti-miscegenation law was overturned by the Supreme Court (Loving v. Virginia), and it was not until 1974 that Virginia repealed its compulsory sterilization law. It became convenient in subsequent years to minimize the history of the American Eugenics movement, and to the extent eugenics was touched on at all, it was primarily as a manifestation of the Nazis' warped racial policies. But in confronting the ethical challenges posed by recent biomedical technology progress, we would do well to appreciate our own eugenics history. And one need only look at current controversies surrounding Confederate monuments or the statue formerly in Central Park of the pioneering gynecologic surgeon, J. Marion Sims, who experimented without consent on African slave women (11) to realize that our own views regarding race are far from resolved. In that regard, the next section provides a new perspective on the biology of “race” based on the most recent advances in human genome sequencing.

ANCIENT DNA STUDIES RESHAPE OUR VIEWS OF HUMAN ORIGINS AND OF RACE

Historically, the study of human origins and evolution was centered in the disciplines of archeology, anthropology, and linguistics. The advent of relatively low-cost, large-scale DNA sequencing coupled with refinements in techniques for isolation of DNA from ancient (thousands of years old) human bone remains (and critically, excluding contamination with DNA from modern humans) has dramatically altered these studies. Long-held hypotheses based on classical methods have been disproved, and a new, more complex picture of human origins featuring major migrations and intermingling has emerged. This fascinating story is the subject of a recent book by David Reich, a Harvard Medical School human geneticist, and one of the pioneers of the study of ancient human DNA (12).

Data from Reich's studies and those of other leaders in the field lead him to conclude that the origins of modern humans are far more complex than the previously held view that Homo sapiens emerged “out of Africa” and spread across the globe into discrete clusters like branches from a tree. Evidence for admixture of a small percentage of Neanderthal DNA in the genome of modern Europeans is just one example. He further shows that earlier racial classification based on physical features: Caucasoid (West Eurasia), Mongoloid (East Asia), Negroid (sub-Saharan Africa), and Australoid (Australia and New Guinea) do not reflect pure “units of biology,” but instead are recent phenomena, the result of repeated mixing and migration. Classic “Nordic” features (light skin, blond hair, and blue eyes) actually derive from a mixture of early European hunter-gatherers (blue eyes and dark skin and hair), early European farmers (light skin and dark hair and eyes) and ancient North Eurasians with a blond hair mutation. Reich concludes: “Mixture is fundamental to who we are.”

How do the data from studies of ancient (and modern) human DNA inform our understanding of America's past eugenics era and help us approach the difficult issues raised by recent technologic advances in disease treatment and prevention? After the disclosure of the horrors perpetrated by the Nazis by the end of World War II, eugenics and the racial classifications on which it was based [see for example Montagu (13)] were widely discredited in the US and elsewhere. Population geneticists such as Richard Lewontin argued, based initially on studies of blood protein variations and later on DNA polymorphisms, that variation within races exceeds that between races, and therefore racial classification is of no social value and virtually no genetic significance (14). In contrast, some contemporary “authorities” [perhaps most famously James Watson of DNA double-helix fame; see Reich (12), page 263] have argued for genetic differences between races in intelligence among other features (15-17). Reich points out that most such views are grounded in bigotry and have no basis in reality, but he also rejects “the idea that any biologic differences among populations are so modest that as a matter of social policy they can be ignored and papered over. It is time to move on from this paralyzing false dichotomy and to figure out what the genome is actually telling us” (12). Reich's prescription for how to deal with the likely future discoveries of substantial differences across populations is that “as a society we should commit to according everyone equal rights despite the differences that exist among individuals … or across populations” (12). His prescription, in my view, is highly relevant to how we should approach the bioethical challenges posed by advances in 21^st century medicine.

THE NEW EUGENICS ERA

The advances in DNA sequencing and in molecular and cellular biology briefly described in the introduction (Figure 1) have dramatically altered medicine's ability to prevent and to treat disease, while at the same time posing difficult social, legal, and ethical questions. Paradoxically, some advances have enabled us to eliminate or at least reduce the prevalence of deleterious “disease” genes in the population, whereas others have the effect of preserving such genes in the population gene pool. We are therefore simultaneously practicing negative eugenics and its opposite, depending on the disease. These disparate practices vary between different countries, and in the US between different ethnic/cultural groups. Premarital carrier screening of Ashkenazi Jews in New York City (using biochemical assays in the pre-DNA sequencing era circa 1960-1980) to prevent birth of offspring with early lethal Tay-Sachs disease was an early example of a form of negative eugenics. Amniocentesis and chorionic villus sampling to detect trisomy followed by abortion in cases testing positive is another example. As DNA sequencing technology advanced, leading to lower cost and increased availability, this method began to supplant earlier non–DNA-based methods in premarital carrier screening and in prenatal diagnosis. With the development of DNA sequencing technology, several states and the federal government began to consider and in some cases pass legislation calling for DNA screening for certain diseases. Application to sickle cell anemia in African-Americans raised serious questions regarding discrimination, and the constitutionality of mandatory genetic screening statutes (18). Indeed, in groups such as African-Americans and Hispanics historically subject to discrimination in the US, there is often a mistrust of DNA testing because of conflation with issues related to paternity and criminal data-bases rather than health. Attitudes to application of DNA sequencing for premarital carrier screening in contrast are positive in the ultraorthodox Jewish community in New York City where a program (“Dor Yeshorim”) of extensive premarital screening for Mendelian disease genes disproportionately found in Ashkenazi Jews guides marital decisions in a culture where traditionally all marriages are “arranged.”

Newborn screening for genetic diseases is mandatory in all states in the US. Although specific programs vary, the general practice uses biochemical methods and focuses on diseases with profound health implications (congenital hypothyroidism; phenylketonuria) for which early diagnosis allows implementation of therapies that effectively mitigate and in some cases eliminate the disease burden. Next-generation DNA sequencing (whole-exome and whole-genome) has now become a feasible alternative to current methods, but its implementation will bring a number of ethical challenges (19). First, there is the problem of detecting variants of unknown significance. Second is the problem of detection of genetic variants known to cause late-onset disorders such as Huntington's disease. How (and whether) to convey such results to parents or the offspring at some later date is unclear. A further problem relates to use of such genetic data not solely for addressing agreed upon serious diseases, but to enable some forms of “enhancement” that are not clearly disease treatment. The latter dilemma has been raised in mainstream media regarding another DNA-based method, preimplantation genetic diagnosis used in conjunction with IVF. Implantation only of embryos that do not harbor mutations in genes causing diseases such as cystic fibrosis is an example of simultaneous positive and negative eugenics, but is generally viewed as ethically acceptable. In theory though, this method could also be used to select embryos for implantation that have genes specifying desired hair color or other desirable traits that are not health-related in the strict sense of the term.

Other recent technical advances in medicine such as gene therapy and in utero fetal therapy are remarkable testaments to application of modern science to ameliorating human disease. Although some will argue that they have the “anti-eugenic” effect of maintaining deleterious genes in the gene pool, most would agree that this concern is outweighed by medicine's imperative to alleviate human suffering whenever possible. However, there are examples that highlight the difficulty in balancing conflicting ethical considerations. Down syndrome is arguably one of the most challenging conditions with respect to opposing views. For some parents, the decision to undergo prenatal testing and abort the fetus if the test is positive for trisomy is clear, and presumably based on the view that the affected child's disability would pose unacceptable demands. Others will espouse exactly the opposite view, and the fact that there is a phenotypic spectrum of extent of disability in affected subjects sharpens the ethical dilemma. Within this already complicated landscape, some states (e.g., Ohio in 2017) have passed laws banning abortions in cases where the parents' decision is based on a diagnosis of Down syndrome in the fetus (20). In this case, to the issue of reproductive rights of women, already the focus of culture “wars” in the US, is added the difficult ethical issue of our attitudes toward children with disabilities such as those found in Down syndrome.

One consequence of the conflicting views on reproductive rights and related matters in the US was that IVF was initially banned in the US, and first introduced in 1978 in the UK, where the government's independent regulator, the Human Fertilization and Embryology Authority (HFEA) oversees IVF practices, as well as research on embryos. Because no such entity was established in the US, IVF, although eventually accepted in the 1980s, is essentially unregulated. Among the consequences of this lack of oversight are reports of single sperm donors fathering as many as 44 children (see Washington Post, September 2018). Such cases represent a unique example of “positive” eugenics because the frequent selection of a particular sperm donor was presumably based on desirable characteristics (height and hair and eye color) in the donor file. “Three-parent” IVF, performed to prevent birth of a child with severe disease due to mutations in the mitochondrial, maternally transmitted genome, is another example of a reproductive advance first performed in the UK under the oversight of the HEFA, and still banned in the US.

Research on human embryos was explicitly banned by the Dickey-Wicker amendment to the 1996 Federal Appropriations bill for the department of Health and Human Services (which covers the National Institutes of Health [NIH]). As a result, federal support for research on human embryonic stem cells (hESC) became a controversial issue in the early 2000s following creation of the first hESC lines. One application of hESC research, so-called “therapeutic cloning” likewise became a subject of controversy with Senate hearings held on the subject. Following Ian Wilmut's cloning of Dolly the sheep in 1996, many mammalian species have been successfully cloned (“reproductive” as opposed to “therapeutic” cloning), but most scientists and members of the public recoil at the prospect of reproductive cloning of humans. Nonetheless, technical advances and the lack of regulation in the US leaves open the possibility of some “rogue” practitioner attempting to clone a human.

Genome editing, the ability to make precise alterations of even a single base change in the 3 billion base-pair human genome, is the most recent technical advance to raise profound bioethical questions. The use of the most advanced method, clustered regularly interspaced short palindromic repeats (CRISPR)–caspase, has already been shown to ameliorate a serious disease, Duchenne muscular dystrophy, in a large animal (canine) model (21). As this method is further refined (minimizing “off-target” genome changes, increasing efficiency and ability to access organs such as the brain), there will be enormous opportunities for correcting many genetic defects, as well as treating nongenetic diseases such as HIV infection. At least two conceptual issues that must be addressed are whether genome editing should be limited to disease treatment as opposed to “enhancement” (however that is defined), and whether editing the genome in embryos as opposed to somatic cells, with resultant germline transmission of any edits, should be permitted.

ISSUES TO CONSIDER IN OUR NEW EUGENICS ERA

Figure 6 lists a number of key issues to be considered in our new eugenics era. First is the question of scientists' responsibility to consider the “downstream” consequences of their discoveries and technical advances. Some would contend that scientific discoveries per se are neither “good” nor “bad”; only the way in which they are applied. But public alarm over nightmare scenarios of recombinant DNA research led to the Asilomar meeting in 1975 that as Paul Berg, one of its organizers, stated: “set standards allowing geneticists to push research to its limits without endangering public health” (22). Berg, writing in 2008 in reference to controversies over fetal tissue research, hESC research, and somatic and germline gene therapy, worries that “nearly irreconcilable ethical and religious conflicts and challenges to deeply held social values” might doom any effort by scientists to create consensus on these issues. But he concludes that: “the best way to respond to concerns created by emerging knowledge or early-stage technologies is for scientists from publicly-funded institutions to find common cause with the wider public about the best way to regulate” (22). A “set-aside” of NIH funding for ethical, legal and social implications (ELSI) projects was implemented as part of the Human Genome Project in this spirit. Likewise, the National Academies of Sciences, Engineering, and Medicine of the US commissioned a report published in 2017 to discuss and make recommendations regarding ethical considerations of human gene editing (23). Among the report's recommendations are principles shown in Figure 7 including “respect for persons” that reflects lessons learned from America's earlier eugenics era with its program of forced sterilization justified by flawed science. Another recommendation calls for “transnational cooperation” reflecting the globalization of science in the 21^st century. An International Summit on Human Genome Editing held in Washington, DC, in 2015 and another scheduled for Hong Kong in November 2018 show the commitment of the global scientific community to confront difficult questions and to engage the public in their deliberations.

Fig. 6.

A list of issues to consider in our new eugenics era that should be informed by the history of America's 20th century eugenics era.

Fig. 7.

Recommended principles for governance of human genome editing from the report of the Committee on Human gene editing of the National Academies of Science, Medicine, and Engineering (2017).

Such deliberations are vital if contemporary scientists are to avoid the mistakes made by Galton, Davenport, and others who promulgated America's 20^th century eugenics movement on what were in retrospect flawed racial theories. Two related issues are what constitutes “promoting well-being” (all would agree that amelioration of serious disease qualifies, but what about enhancement of human capabilities such as athletic and intellectual ability?), and how to balance individual rights and the public good. Forced sterilization in the US was justified by its proponents as benefiting society as a whole. That this argument was based on flawed concepts such as heritability of criminal behavior was only part of the problem. Equally problematic was the fact that forced sterilization was largely applied to segments of the US population that were deemed inferior by racial and ethnic criteria that themselves reflected pseudoscience. The same pseudoscientific theories about racial superiority drove the passage of federal legislation sharply restricting immigration to the US from select geographic regions. The fact that proponents of such policies managed to get Congress to pass highly restrictive immigration laws and many states to pass legislation mandating sterilization should be a warning regarding the need for a scientifically informed public and elected representatives. Sadly, current distrust of science by large segments of the American public hardly provides encouragement, but still should not dissuade efforts by leaders in science and medicine to engage the public in an open and noncondescending way about the important issues raised by the stunning advances of the 21^st century. Only in this way can we hope to avoid repetition of the mistakes of our 20^th century eugenics movement.