Chinese people's attitudes towards genetic diseases and children with handicaps

Law and Human Genome Review 18 (2003), 191-210.
Author: Baoqi Su and Darryl R. J. Macer

Institute of Biological Sciences, University of Tsukuba,
Tsukuba Science City 305-8572, Japan
Fax: Int+81-298-53-6614
Email: Macer@sakura.cc.tsukuba.ac.jp
Director, Eubios Ethics Institute <http://eubios.info/index.html>

Chinese people's attitudes towards genetic diseases and children with handicaps

Baoqi Su
Research Center for Bioethics and the Department of Social Sciences,
Chinese Academy of Medical Sciences and Peking Union Medical College,
No. 5 Dongdan Santiao, Dongcheng District, Beijing, 100005, CHINA

Darryl R. J. Macer,
Institute of Biological Sciences,
University of Tsukuba,
Tsukuba Science City, 305-8572, JAPAN

*Address correspondence to D.M.
Tel: Int+81-298-53-4662
Fax: Int+81-298-53-6614
Email: subaoqi2005@sina.com, asianbioethics@yahoo.co.nz
Chinese people's attitudes towards genetic diseases and children with handicaps

Abstract
This paper presents analysis of comments on members of the general public and experts in China on the question of eugenic policy and attitudes towards genetic disease. The Chinese concept of "Yousheng" (healthy birth) is more appropriate than eugenics as an expression of Chinese social policy and public attitudes. This concept is not Chinese eugenics but Yousheng, healthy birth, and it should be clearly distinguished in academic debates on the implementation of medical genetics and policy in China. The widespread support for healthy birth has policy implications. The economic situation of China makes lives for children born with genetic disease generally short and harsh, and needs to be considered when considering the ethical appropriateness of Chinese policies for birth control and healthy birth. We can ask whether medicine should serve the desires of people, which are to avoid births of children with disease.

Key words
Eugenics, healthy birth, genetic disease, prenatal health, China, bioethics.

1. Eugenics and healthy babies
Every human being has a different set of genes, called their genotype. Our genetic information is very important in determining parts of our physical characters and intellectual capacity. All things being equal it is the exception for anyone to want to have a baby born with a genetic disease. People want to have healthy babies. This is true in every culture, although there are wide variations in the definitions of genetic disease, and in the extent to which societies allow individuals choices in prenatal genetics and reproductive selection technology.
The term eugenics was coined by Francis Galton, and is derived from the Greek work "eugenes" which means "good in birth". It meant to him "science of improving stock, not only by judicious mating, but whatever tends to give the more suitable races or strains of blood a better chance of prevailing over the less suitable that they otherwise would have had" (Galton, 1883). Galton later experimented with a variety of different formulations such as "the study of agencies under social control which may improve or impair the racial qualities of future generations", and "the science which deals with all influences that improve the inborn qualities of a race" (Macer, 1990). Negative eugenics means to decrease the proportion of genes that cause disease. Positive eugenics means to take some action to increase the frequency of desirable genes in a population.
For millennia people have had ideas of selective breeding to increase the representation of people with "good genes". Plato had considered the desirability of achieving these ends by subtle, or direct, incentives to control marriage, and/or mating, of supposedly "fit" human beings. Allen (2001) wrote that eugenics defined by Galton meant "truly- or well-born," and referred to a plan to encourage the "best people" in society to have more children (positive eugenics) and to discourage or prevent the "worst elements" of society from having many children (negative eugenics). During the first three decades of the 20th century, eugenics became a popular concept in many countries throughout the world, especially the United States (Pernick, 1996), and, after World War I, in Germany (Kevles, 1985; Macer, 1990). They combined eugenic interests with a focus on persons they judged to be "unfit". Eugenic sterilization laws would allow individuals to be forcibly sterilized if they were judged to be genetically defective. By the 1960s, In the United States more than 60,000 people had been sterilized for eugenic purposes. In Germany, their sweeping sterilization law of 1933, which ultimately led to the sterilization of over 400,000 people.
Eugenics, unlike pure genetic science, involves decision making on various issues, and it involves the risk of making errors, and leading to social change associated with widespread discrimination. Not only are there serious ethical arguments against these types of reproductive policies, but the above attempts have fundamental scientific flaws. All the respective "eugenic" practices, beginning during the twentieth century, have demonstrated that the intention of improving population quality by directive sterilization or abortion can not actually be realized, whether by scientists with kind hearts, or for socio-economic policy (Yang, 2002a). However, there are individual benefits for the reduction of suffering caused by genetic disease, and the involvement of society in these goals depends on culture.

2. The Chinese concept of "Yousheng" and eugenics
In the 1990s Europeans accused China of enacting a eugenic law, questioning the role of the state in individual reproductive decision making (Editorial, 1994; Beardsley, 1997; Doering, 1998ab). To quote a Lancet editorial (1995), "Totalitarian states are attracted to eugenics, and too often are able to force their population to conform, as a quick means to a 'better life for all'..." One lesson taught by the history of eugenics in the past is that there should be a proper balance between the public interest and individual rights. Europeans tend to focus on individual rights. Especially many Asians believe that individual rights should not be at the cost of public interest (Shao, 1999).
The Chinese Encyclopedia of Medicine (1994) defines eugenics as: "a science for the improvement of human heredity, prevention defects of births and raising the quality of the population by research applying genetics theories and approaches." In fact, most such eugenic practices pay attention to the prevention the defect of the births. Social policy interventions associated with genetics measures exist in many countries. Such social policies intervention should be based on the individual's informed consent. This science can be called "negative eugenics" (Wang, 1999).
The Chinese word "Yousheng" is same as the Greek work eugenes meaning "good in birth", also it is consistent with Galton's eugenics core doctrine of improving the stock of humankind by application of the science of human heredity. In this sense, the Chinese word "Yousheng" can be translated to eugenics. But it is different from the US and German "eugenics" in the twentieth history (Wang, 1999; Tang, 2002).
In 1986 a Leading Group for drafting a law on healthy birth and rearing healthy children under the leadership of the Ministry of Public Health, involving the participation of 23 ministries and NGOs led to the establishment of an Expert Advisory Committee. In April 1987 the first draft of the law called "China's law on Healthy Birth and Health Care" was written. In 1988 the draft was called "China's law on Health Birth and Protection". In 1988 a national feasibility survey was conducted in thirty provinces and municipalities. There were many revisions during 1988-1993. In 1994 the draft of the Law on Healthy Birth was submitted to the People's Congress by Professor Chen Minzhang, who was Minister of Public Health. On October 27, 1994 the law with the new name as Law on Maternal and Infant Hearth Care was adopted by the People's Congress and promulgated by President Jiang Zemin (Qiu, 1996). The law went into effect in 1995. Some articles are discussed later in the paper.
Foreign critics of China focused on articles 10 and 18, which are (Doering, 1998a):
Article 10: Physicians shall, after performing the pre-marital physical check-up, explain and give medical advice to both the male and the female who have been diagnosed with certain genetic disease of a serious nature which is considered inappropriate for child-bearing from a medical point of view: the two may be married only if both sides agree to take long-term contraceptive measures or to take a ligation operation for sterility. ...
Article 18: The physician shall explain to the married couple and give them medical advice for a termination of pregnancy if one of the following cases is detected in the prenatal diagnosis: (1) the fetus is suffering from genetic disease of a serious nature; (2) the fetus is with defect of a serious nature; and (3) continued pregnancy may threaten the life and safety of the pregnant woman or serious impair her health due to the serious disease she suffers from.
The intention of the Chinese government in enacting the law is that people in China should be warned of the risks of inheriting heritable genetic diseases, and helped to avoid them among their children (Wang, 1999). In China about 20 million people get married every year, after passing the premarital examination. There are actually guidelines or laws that prohibit the marriage between close relatives in many countries. This can also be called a type of eugenics. Even though involuntary is included in such eugenics, almost few persons object to it.
Doering (1998a, 1999) argued that many international critics had not studied thoroughly even the English translation of the law. He noted that there has not been any similar objection against the Taiwanese 'Eugenics Health Care Law' of 1984 ('Yousheng baojian jiating jihua fa'), nor the remnants of eugenics laws in some 'Western' states. This anti-Chinese view stands in the way of a fair and balanced judgment, and it does not help Chinese physicians and patients. As many have noted there were new and encouraging concepts in the law inventing new standards for medical personnel, stipulating patient's informed consent, and forbidding sex-related abortion in China. The Minister of Public Health, Chen Minzhang, explained the political background by giving the reason that, "the cost of looking after those with hereditary handicaps was enormous, imposing a heavy burden both on the state and on millions of families. There was therefore wide popular support for the rapid enactment of a eugenics law containing effective measures to reduce inferior-quality births." (quoted by Wang, 1999).
The issue of healthy babies is a very broad topic, covering not only issues from the Chinese eugenics debate, as it relates to genetic screening, sterilization, and marriage laws (Hesketh, 2003), but generally maternal and infant health. In our daily lives, few of us can escape from the eugenic thinking "good in birth". Couples shall decide to delay having a child until they were financially and emotionally ready to be a qualified parent. Most modern governments hope that their people will be energetic, ingenious and enterprising. But eugenic thinking and practice in Chinese thinking should balance the interests of all sides (Wang, 1999), individual, community or society. There is actually a written tradition of universal love as fundamental ethical principle in China for three millennia (Macer, 1998a).

3. Methodology of interviews
What is lacking in the English language literature is adequate representation of the views of Chinese citizens, and academics. There have been some accounts from anecdotal experience (Hesketh, 2003) but we wanted to clarify what ordinary citizens think in China, and investigate the way that future studies may be conducted. Interviews were conducted in 2001 with both the general public and bioethics researchers in cities and countryside with an emphasis on qualitative study. The data collection in Mandarin Chinese was followed by interpretation of the results considering ethical principles that the respondents were using and translation of words and concepts into English.
The 36 respondents from the general public included 28 women and 8 men aged between 20 to 65 years (Table 1). A range of people in different social positions was interviewed, rather than just focusing on family composition. They were from four different regions in China. The locations were Beijing city and Changping county and Changzhi city and Yangcheng county in Shanxi province. Beijing has a population of approximately 13.8 million persons, and Changping county includes 431,000 persons, among whom 119,000 are childbearing women. Shanxi has a total of 130 counties and prefectures with a population of 33 million, among whom 15.6 million are women. Its rural population is 21 million, among whom 5.5 million are childbearing women (The Fifth National Population Census, 2000).
A fundamental question about conducting social research in a country where people have some risk of persecution from authorities is whether they will give honest answers to interviews, and fully trust that their privacy will be maintained when tape recorded. The interview subjects for the general public study in this paper were chosen through personal acquaintances or subsequent introductions, because an unknown person will not discuss freely some personal opinions. Further attention should be developed if quantitative studies are needed on how to really get a random sample rather than a representative sample as we concentrated on here.
The women in the survey (N=28) ranged in age from 20 to 60, with an average age of 35 years in Beijing and 36 years in Shanxi province (Table 1). Educational attainment for women differed between the four groups. More than two thirds of the women were of reproductive age. The average age of women was 35.5 years. The rate of illiteracy was 8%, the same to the rate of persons with a qualification above college level. There were also 6 men in the survey. Among the total interviewees there were two unmarried women, two married women who had have no children, and one divorced man with no child. One woman (49-year old) had three daughters and two families (55-year and 60-year old) had four children.
Interviews with 23 persons in the expert group (Table 1), included 10 bioethics researchers; 4 gynecology and obstetrics doctors; 3 health workers for maternal and children health; 3 policy bureaucrats; and 3 members of the All-China Women's Federation. Persons were also met through attendance at an International Scientific Symposium on Genomics and Biotechnology in Hangzhou, China, August 2001, and at the Sixth and Seventh Tsukuba International Bioethics Roundtables in Japan.

4. Public attitudes to genetic disease and handicap
We can see a summary of people's attitudes towards handicapped in Table 2 and towards genetic diseases in Table 3. The respondents who are listed as uncertain include the people who could not understand the questions and could not give the clear answers. Table 2 shows that the majority (53%) thought that handicapped persons had a right to come into this world, while also 19% of respondents disagreed. A majority, 61%, believed that the government should provide for their care and 67% considered it was difficult for the community. At the same time most (83%) said that they would like to help the handicapped.
When asked personally, 78% of respondents would not consider childbearing with the risk of handicap to the child, even only 5% risk, and 83% of they would choose abortion when diagnosed with a 5% risk of handicapped.
Table 3 tells us that most of respondents had some basic knowledge of genetic disease and prefer to consult a doctor when there was any such suspicion. The majority knew that heredity could be the cause of diseases (83%), especially for congenital disorders (72%). All of them were against consanguineous marriages. They knew the marriage law in China prohibits it. Two thirds (69%) would perform a prenatal diagnosis if there were the risk of genetic disease, and 89% of the total would perform an abortion if the diagnosis was positive.
From the interviews we may know people's attitudes towards handicapped persons and genetic diseases. It was shown that majority of parents wanted to be given information by a doctor to decide whether to risk passing on unwanted family traits to the next generation. However, the majority of reproductive choices are not to conceive a child with high risk of hereditary disability or to choose abortion. More than half the respondents thought that handicapped children had a right to come into this world, also some of them disagreed. Most of respondents had some basic knowledge of genetic disease and prefer to consult a doctor when there was suspicion.

Table 1: Interviewee characteristics
General public/ Specialist
Number 36 23
Gender Female 30 Female 14
Male 6 Male 9
Average age 37 42
Highest education level M.A. Ph.D
Now married (%) 32 (88.9) 21 (91.3)
Number of children
0 5 4
1 13 10
2 8 6
More 10 3

Table 2: Public attitudes towards the handicapped (N=36, %)
Item (handicapped) Agree Uncertain Disagree
Right to survive 19 (53) 10 (28) 7 (19)
Government should provide care 22 (61) 6 (17) 8 (22)
Difficult for community 24 (67) 3 (8) 9 (25)
Prefer to spend more on healthy people 18 (50) 6 (17) 12 (33)
Difficult to work 19 (53) 2 (6) 15 (42)
Willingness to help 30 (83) 4 (11) 2 (6)
Childbearing with risk (5%) of 2 (6) 6 (17) 28 (78)
Risk (5%) as a reason for abortion 30 (83) 4 (11) 2 (6)

Table 3: Attitudes towards genetic diseases (N=36, %)
Items: Agree/ Uncertain/ Disagree
Heredity as a cause of disease 30 (83) 6 (17) 0
Heredity as the cause of most congenital disorders 26(72) 6 (17) 4(11)
Consanguineous marriage 36 (100) 0 0
Consult a doctor if his/her relative was genetic diseased before marriage 19 (53) 12 (33) 5 (14)
Perform prenatal diagnosis (fetus at risk) 25 (69) 6(17) 5 (14)
Abort if diagnosis was positive 32(89) 4 (11) 0

5. The burden of genetic disease in a developing country
The results of the interviews with academic "specialists" on these subjects were consistent with the public views. While some academics were happy to be personally quoted, in order to preserve privacy we will give only their background to describe the situation in China for readers. An ethics professor said that, "considering the quality of population and the future of the country, a regulation on promoting healthy birth and rearing healthy children should be implemented. The population of handicapped in China amounts to 54 million, 4.5% of the whole population. The disability has not only brought suffering to individuals, misery to the family, but also burdens to community and country."
In China, physicians have responsibility to provide prenatal care, genetic counseling and prenatal diagnosis (Mao and Wertz, 1997). Most of the people in China are quite receptive to prenatal diagnosis. Ethical debates were always raised when the fetus was diagnosed as a disabled one. In China it seems easy to get consensus to abort in most cities and provinces (Nie, 2002), perhaps that is due to the effect of generous propaganda of family planning policy and everyone's responsibility to limit the huge population of China. In Southern China there is also a high frequency of hemoglobin disorders such as thalassemia and there is premarital and prenatal testing in many places (Xu et al., 1996).
In Peking Union Medical College Hospital, Sun (1992) reported from their prenatal diagnostic service the of 420 handicapped and genetically diseases fetuses of pregnant women, 98% of the couples asked for abortion. The couples most common reason was life would be very tough for their lives if they insisted to have the disabled children, and so it was better wait to have a healthy baby next time. Of the babies that were born in their ward there were 14 couples who delivered a "disabled" baby in 1991, the outcome of those babies were as follows: 8 cases died in newborn period because the parent did not ask for treatment. They were very miserable and were discharged. Then they were told that the baby died. Some of those told had asked for surgery, but there were many problems, such as the result was unsure and it was too expensive. At last they all gave up. In another 6 cases the babies were taken care of by parents or grandmothers (Sun, 1992). Maybe it would have appeared different in Western countries, because the government could provide the services for disabled children. But the situation is different in China, because one must take economics into account more than in the Western world. The medical cost of treatment is very expensive and wages are low.
A geneticist influential in the Human Genome Project in China in a international lecture to a Conference to the public session on "The human genome project and its social impact: to educate the educators" (Yang, 2002b), said, "Concerning 'bad genes' and 'good genes', I insist that there is no 'normal genome' or 'disease genome'. There is no good gene or bad gene, no such thing, because all our genes are good." Referring to the Maternal and Infant Health Care Law, he said, "As I said, that law is really terrible. If I can not say terrible, then I should say that it has done more harm than good, I really would like to see more of the internationally acknowledged principles embedded into Chinese practices in this field. That is one of the reasons for me to believe that it is really necessary to again and again debate these issues in the field of ethical, legal and social issues."
At its annual meeting in San Francisco on 25 November 1996, the Ethics Committee of the Human Genome Organization (HUGO) considered the law of the People's Republic of China on Maternal and Infant Health Care. The Committee invited Professor Qui to act as an observer during the Committee's deliberation. The Committee acknowledged that the government and people of China are faced with large problems affecting maternal and infant health care. The solutions to those problems may only be fully understood with an awareness of the cultural values of the Chinese people and medical profession (Knoppers and Kirby, 1997). The Committee noted the strong statements that had been made by geneticists criticizing the Chinese law, and considered there had been too severe criticism of China. China appears to accept the legitimacy of medical conduct that contemplates a termination of pregnancy (Article 18).
The Committee welcomed a number of the provisions of the law that are protective of the rights of mother and child and apparently conformable to international human rights standards and ethical provisions as: Article 21; 22; 27; 31; 32; 34. Unfortunately, there are, in the Committee's opinion, certain provisions of the Chinese law that may infringe international human rights principles. These include: Article 9; 10; 16. These articles conflict with the basic ethical requirement that, before an invasive. The Committee urged the government to revise Articles 9.10 and 16 (Knoppers and Kirby, 1997).
There was reference by several experts to the debate on eugenics and China's Maternal and Infant Health Care Law at the 18th International Congress of Genetics in China in August 1998, and the conference statement. The Symposium on ELSI of Genetic Research at that conference was attended by about 100 participants and the Workshop on Science and Ethics of Eugenics by about 150 persons suggesting significant interest. The statement reads:
"Countries share many ethical principles based on the will to do good and not harm. These principles can be applied in many different ways. New genetic technology should be used to provide individuals with reliable information on which to base personal reproductive choices, not as a tool of coercive public policy. Informed choice should be the basis for all genetic counseling and advice on reproductive decisions. Genetic counseling should be for the benefit of the couple and their family: it has minimal effect on the incidence of deleterious alleles in the population. The term eugenics is used in so many different ways as to make it no longer suitable for use in scientific literature. In formulating policy on genetic aspects of health, international and interdisciplinary communication should be carried out at all levels. It is the responsibility of policy makers concerned with genetic aspects of human health to seek sound scientific advice. It is the responsibility of geneticists to educate physicians, decision-makers and the general public in genetics and its consequences to health."

6. Public support for healthy babies and "Yousheng" in China
The above results of these interviews are consistent with the results of earlier opinion surveys in China, Hong Kong and Singapore. In opinion surveys conducted by Macer (1994) and colleagues, eugenic ideas found both positive support in some developing countries, for example for improving genes by genetic screening; with less negative reaction, for example a few people cited social eugenics programs, or many being against gene therapy for enhancement. The questions regarding genetic screening and gene therapy suggest positive support for eugenics among a significant portion of the population, especially in China (Lo et al., 1994), as well as India and Thailand (Macer, 1994). There was less support for genetic enhancement of genetic screening in Singapore and Hong Kong, but it was still at a higher level than Japan or Australasia (Macer, 1994). A number of specialists disliked the term "eugenics" because it is used in so many different ways as to make it no longer suitable for use in scientific literature.
A survey of attitudes of people to handicapped and genetic diseases in China by Lo et al. (1994), at Peking Union Medical College showed the majority of respondents were willing to perform prenatal diagnosis and even more of them would chose abortion if prenatal diagnosis was positive with the risk less than 5%. This survey was carried among persons with higher education, and half of participants had a medical background in Beijing. Their opinions towards the handicapped and genetic diseases suggest they favor abortion, as 34% said that they would abort even if only a 1% risk of handicapped fetus, and 72% would decide to abort a fetus affected by a serious genetic disease. 87% would abort for Down's syndrome.
The underlying reasons for this support for healthy babies and good birth "Yousheng" may be because Chinese society cannot provide enough facilities, care and welfare for the handicapped. At present the family with a low salary cannot afford expensive health care fees and the expenses to care for a person with a serious handicap. So it could be thought that most Chinese family do not want a handicapped child and from the practical situation they think that it is good for such a child not to come into this world, especially not to come into the country with low economic development and large population. However if someone has an accident and become handicapped they will be looked after, though again resources are limited. It would be an interesting question for future research to compare attitudes to persons with disabilities acquired at different stages of life.
Although a handicapped person is not counted in the government quota for number of children, as the world's most populous nation, China has attempted through the past few decades to curb population growth. The economic burden of looking after persons who need expensive medical care is one that is often too much for persons living in rich countries, let alone for developing countries. The population problem has been viewed very seriously in China, and affects the choices that pregnant women make (Doherty et al., 2001). Socially it touches upon the survival and development of the Chinese nation, the success or failure of China's modernization drive as well as the coordinated and sustained development between the population on one hand, and the economy, society, resources and environment on the other. China's one child family policy, which was first announced in 1979, has remained in place despite the extraordinary political and social changes that have occurred over the past two decades. In the late 1990s, China's 1.2 billion population was growing at a rate of around 1 per cent per year. The population had more than doubled since the formation of the People's Republic of China in 1949.
From 1 September, 2002, the first National Planning Law took effect with the stated intention of preventing arbitrary fining and harsh punishment of families who violate the one child family that have been reported in local communities. Under the new law violators will pay a social alimony based on their income in the local area. The law calls for funding of birth control education from other sources than the collection of fines from violators as been the practice until now. The law requires sex education, which has been neglected until now. Ethnic minorities are allowed to have 2-3 children because of their low number and life in harsh conditions, which is the opposite of some images of social eugenics policies in the past in some countries which restricted the rights of ethnic minorities.
Mao Zedong quoted a traditional saying: "Of all things in the world, people are the most precious". Rapid growth, however, put considerable strain on the government's efforts to meet the needs of its people. Originally with the policy that started in 1970, contraceptive and abortion services were extended into the rural areas, and there was extensive promotion of later marriage, longer intervals between births, and smaller families (Kane, 1987).
Population pressure had arguably contributed to poverty and social crisis since the early nineteenth century. According to the present government it is one of China's most intractable problems. Since the early 1970s the authorities have made a sustained effort to reduce the birth rate; campaigns to popularize contraceptives have raised usage rates to those prevalent in developed countries. In 1979 regulations were announced to restrict families, with some exceptions, to a single child. Studies have found that abortion is a significant means of birth control in China (Rigdon, 1996), which means that there is wide social acceptance of abortion (Nie, 2002). Studies in Hebei province in China found that females have poorer health than men observable during young adulthood (Anson and Sun, 2002), which may be related to neglect of females by parents. There have also been claims of forced sterilization in China (Sills et al., 1998), and it is hoped that the new law will stop these practices being forced upon subjects by local governments.
The number of children that the interviewees had often exceeded one, as older persons did not have to follow these guidelines when they gave birth. There were a few cases of persons breaking the official regulations in those interviewed, having paid a fine. Interestingly, all the persons interviewed were supportive in general of the need for the birth control policy. We did not talk with dissident groups and NGOs who are opposed to the policy, but the support from the general public sample in these interviews conducted with privacy and trust with the interviewer suggests that there is widespread support for the birth control policy among the general public in China.

7. Enthusiasm with science in China
What can we learn from this phenomenon in China? Surveys have found that Chinese people are very interested in science and technology and most believe that science should do more good than harm to human beings (Zhang, 1991). More people in China are receptive to prenatal diagnosis compared to Japan, especially those with a medical background (Macer, et al., 1996). They would receive gene therapy for serious genetic disease for their children. Most of the people surveyed who had basic medical knowledge probably will chose to abort under doctors' advice when there is a chance of a handicapped fetus or serious genetic diseases, even if the risk is very low. The medical staff may have been considering this point in their choices expressed in the survey.
The implementation of the laws to restrict marriage of persons with "serious" conditions is under debate by some of the specialists we interviewed in China and the extent of the practice is unknown as China is a vast country. Hesketh (2003) published the results of her study of ten maternal and child health hospitals to follow the pre-marital health examination. She found between 1-10% of couples were asked to delay following treatment or counseling. The treatment included medicines for tuberculosis, hepatitis and sexually transmitted diseases. Only a few couples (0.03% or less) had to agree to permanent contraception, including some with severe psychiatric disease or of low intelligence who were considered incapable of raising children safely. However in 7 of the 10 counties investigated there was no prohibition to reproduce and even in those which had lacked systematic ways to enforce it. Nevertheless it does raise ethical questions.

8. Medical genetics and disability rights
The advances of the world-wide Human Genome Project and other research in this field have led to the explosion of our knowledge about our genes which are so widely and deeply involved in our lives. Science is only beneficial if it is applied to society in a proper way. Medical geneticists are in the best position to understand that genes and their related technologies would be most dangerous if they were abused or misused. It is the moral, professional and social responsibility to pay serious attention to the ethical, legal and social issues (ELSI) of genetics (Yang, 1999).
There is a close relationship between eugenics and medical genetics. Following the developing of the genetics and the more and more genetics technology applied in the genetics practice, we must justify how to use them, what are the ethical reasons to use them. If a fetus has serious genetic impairment, with a consequence of serious mental deficiency, some people might say that the fetus does not, and will not in the future, have a "life" as "normal" human have a life, it's potentiality is different (Macer, 1998b). Medical geneticists are not out to make superior people, but to combat disease; or even more modestly, to enable individuals to make informed choices in their personal decisions about reproduction. However, there is a debate that medical genetics aims to combat disease not by healing anyone but by preventing the conception or birth of afflicted individuals. It aims to bring about a world less in which fewer people who suffer from hereditary diseases (Wikler and Palmer, 1992). It is argued that children not yet conceived had rights that were being violated.
The quality of life relates to the individual person, and conceptions of it change with time and situation. Those who are disabled children or families with members with a genetic disease, may have their own feelings. They may regard themselves as a social group, no differences to the other groups. They could enjoy their lives although maybe suspected by others. They will feel sad when are separated from others, and will feel happy in the cooperation with others. We should not have negative attitude toward those with hereditary diseases, whether they be one's own children or those of other parents. People agreed that they should not to see the disabled person in the way of their disabilities, whether a blind person or someone who cannot hear. At the same time that we show our sympathy, we need to do our best to help them, to provide the facilities and to remedy the barrier environment, in order to let their lives become close to a normal life. A so-called "normal life" differs between countries.
For the parents who have the hereditary condition and have high risk to conceive a disabled child, we need to respect their own reproductive decisions. The genetic counselors have responsibility to tell the disease, but have no right to help making decision (Macer, 1999). They desire to conceive a healthy child and also not to regret conceiving an unhealthy one. They will wish the best for them, but when it turns out children to be born with a disease, they still love and will take care of them. Studies in Hebei province in China found that females have poorer health than men observable during young adulthood (Anson and Sun, 2002).
However, it is a common desire to have a healthier baby than a diseased one. It claims that the disease is undesirable, the person with the disease is not (Wikler and Palmer, 1992). We could talk about treatment of "sick" babies, for example, those with Down's syndrome. Sun (1992) showed how many babies appear to be neglected when they suffer from a handicap in China leading to their early death. This may be a problem in all countries, especially with limited resources.
It is a reasonable assumption that people do not wish to be diseased, nor do they wish their children to be so (Green, 1997). There are also non-genetic interventions being used to reduce birth defects. One of the simplest remedies that is now being introduced is prenatal and preconception folic acid, to lower the risk of spina bifida; and neural tube defect. This is a very important area of prenatal care, and does not mean we are against persons who suffer from these illnesses.
There was universal disapproval of consanguity. Consanguineous marriages were banned in most of nation of antiquity (Macer, 1990). There are also the laws that prohibit the marriage between close relatives in many countries today. This can also be called eugenics.

9. Conclusion
This paper concludes that people in China wish to promote the idea of healthy babies and will accept the use of medical genetic techniques for prenatal screening and selective abortion of fetuses at risk for genetic disease. The Chinese government policy is concerned with the avoidance of avoidable genetic handicap among future generations. These moves do not appear to be linked to discrimination against the present population of persons with a genetic disease directly (Beardsley, 1997), however there are valid ethical concerns that reproductive rights of those with genetic disease will not be allowed to reproduce, thus facing infringement of reproductive rights. However in practice the implementation of the laws to restrict marriage of persons with "serious" conditions is under debate in China and the extent of the practice is low (Hesketh, 2003) but still unknown. This debate continues in the face of other pressing public health issues in China, such as HIV testing, and disclosure and reporting of sudden acute respiratory syndrome (SARS) in March-April 2003.
The law is not be very different in its effect from the services provided elsewhere, where public health services offer genetic counseling, on occasion, abortion if there is proof that the outcome of a pregnancy will be a seriously handicapped child. The chief beneficiaries of the law, which should be voluntary, are parents and their children. To the extent that seriously handicapped children may be an expense on public finances, there is also a benefit to nation. The eugenics thinking in the law belongs to negative eugenics and may be justified ethically if the parents have choice, given that Chinese society accepts abortion.
From the social point of view, China is a developing country with the biggest population of the world. It has no ability to provide everybody a good social welfare for health care. There are long traditions of virtue and love towards the weak in society, reinforced in some aspects by the communist ideology. Thus sometimes the social's choices are to save the limited resources and to use them in more urgent and effective cases. This idea seems to have been easily accepted by Chinese people, therefore the majority of the couples that were reported to us, and in studies (Sun, 1992) gave up treating the disabled children. We could not blame them in anyway, for there is only sympathy. However, we did not investigate whether they blame those who fail to avoid the births of children with disabilities. That area would enrich the comparison between eugenics and "yousheng" in the future, as in social eugenics there were social pressures and blame for those who did not implement measures to control reproduction.
There is impact on decision making of the one child family policy, the people have strong desire to have a healthy baby, they will easily choose abort or give up treating disabled child and hope for adoption next time. The government cannot provide enough facilities, and care and welfare for the handicapped. The family with a low salary cannot afford to care for a handicapped child. The most important ethical problem is should the couple make the decision to abort a disabled fetus.
To better understand the conditions of persons with disability, future interviews will be made with parents with hereditary conditions. Comparisons of the live of persons in different countries would be useful. While geneticists who assist them in this choice may profess neutrality, studies suggest that many may not leave the decision entirely up to the parents (Mao and Wertz, 1997).

Acknowledgments
The authors wish to thank the participants of the interviews. We also thank Professor Renzong Qiu, Professor Huanming Yang, Dr.Yanguang Wang and Dr. Ole Doering for helpful comments on the research.
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