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Leaders and societies have committed atrocity in the name of plans to improve the public’s genetic inheritance. In Western political and philosophical history, from Plato to Aristotle to Hobbes, our deepest ideas about human nature have been rooted in crude, non-molecular accounts of human heredity, many of which have been used to explain or fortify education, health, and political practice. Those acting in the name of purifying public health or hygiene have made some of the most significant ethical mistakes of our lifetimes. Eugenics was taught as scientific fact in the world’s finest universities until 1945, sanctioned in global court decisions, and led to the sterilization in the 1920s and 1930s of more that 20,000 in the U.S., 45,000 in the U.K. and 250,000 in Germany.4

Eugenics turned public opinion against public control of reproductive choices or communal control over what kind of children will be born. However, in fighting against eugenics, we have only one, highly ineffective safeguard, so-called “non-directive” genetic counseling. Most genetic professionals take the wise lesson that it is wrong to attempt to persuade families about genetic choices. It is a meritworthy ideal. However, not only has the ideology of non-directive counseling been ineffective in preventing counselor or physician bias (as study by Wertz and Fletcher suggests5), it has completely ignored the role of economics and social context in pressuring families. If the genetic counselor is available only for families who can pay for the testing, such counseling is by definition directive, namely directed at helping those who can pay. Likewise, how are genetic counselors to protect us from eugenics in a future where state-sponsored genetic screening seems unavoidable? A genetic counselor cannot be non-directive about a test if the test is mandated. The genetic counseling role is likely to expand in importance, whether genetic counselors are around or not. However, the chief sin to be avoided is not directiveness but rather inappropriate pressure.

None believe that we will return to the sterilization practices of eugenics. But public sponsored genetic testing programs will make it likely that more parents will use genetic tests as a part of planning for birth. The public in many nations will begin to pressure families to avoid births where discrete genes can be identified as disease-related. How is the public to be defined for such a purpose? Who will choose which traits to include in screening efforts?

Before we can answer such questions there must be a comprehensive global public health effort to regulate the spread of genetic testing, and in particular an effort to establish global cooperation in assessing the efficacy of genetic tests and the relationship between particular genes and environments. There must also be a new emphasis on retraining journalists, politicians, and ministers about genetics so that genetic testing will not always result in hysteria about eugenics. The debate about eugenics is not helpful in thinking about genetic testing, and in fact has resulted in the development of institutions that hardly protect us from anything, least of all eugenics. Careful, cautious progress into the future of genetic public health policy depends on the establishment of new institutions whose task is to link environmental, genetic, and policy information. Genetic counseling is great, but there are only 1,300 genetic counselors in the United States and a scant few elsewhere. It is thus more important that we ensure that the conceptual resources of genetic counseling are present in clinical services of all kinds. Families must be able to turn to someone, even if only a minister, to interpret and cope with the new issues. These professionals will be directive, reflecting the culture and meaning of their professions and societies. However they must bring concern for the family and individual liberty to the table as well.

The third issue for the future is perhaps the most difficult one. It is clear that the maldistribution of public resources in health care cannot continue in the U.S. or other countries. The U.S. spends billions on genetic research and biotechnology, yet still is unable to spend pennies on public health prenatal services for all pregnant women. Americans spend millions on genetic research concerning intelligence, but find their institutions unable to spend pennies to educate the world’s children to the point where comprehensive understanding of, and informed consent for, genetic services is possible. This is dangerous because it suggests that we hope for a future in which nutrition, education and environmental issues are sublimated to genetics or genomics or gene therapy.

Perhaps the key and overriding institutional issue in the future of human genetic science and medicine has to do with what we might call “genetic exceptionalism.” To allow the mapping of the human genome to occur quickly and auspiciously, several governments created special programs for mapping and sequencing. To allow gene therapy to be separately examined, at least two countries created special regulatory bodies. In the U.S., more than 10 states have laws prohibiting genetic discrimination, but not non-genetic discrimination. These programs and others create the idea that genetics is exceptional, different, and meriting its own category of analysis and regulation.5

At times genetic issues are exceptional. Genetic predictive information is different than cholesterol testing. Giving a child gene therapy in

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