Last Friday, Noah Millman voiced his objection to Michael Brendan Dougherty’s warnings against eugenic thinking.

Dougherty referenced back to America’s dark 20th century, when mandatory sterilizations of the poor and infirm were given the Supreme Court’s seal of approval with the line, “three generations of imbeciles are enough,” when Progressivism often meant eliminating the poor for impeding progress, and when compulsory sterilization continued, in my home state of North Carolina, into the late 1970s. American eugenics has been swept under the rug of our cultural and medical memory in a manner reminiscent of how Native Americans were once inconvenient supporting characters in the heroic settling of the West, and Southerners once sighed about how the races used to get along just fine before the Yankees came in and ruined everything.

Yet Dougherty doesn’t fear a new eugenics coming in “the explicitly racialist terms of the biodiversity-obsessed right. Liberal societies have the antibodies against that.” Instead, “it will come to us in terms of ‘quality of life,’ and ‘health and safety.'” In fact, “In the case of babies with Down syndrome, we are already eugenicists,” as up to 90 percent of Down syndrome pregnancies are aborted. Echoing the language of the white lesbian couple suing a sperm bank for accidentally giving them a black man’s genetic material, prospective Down families recognize “that the world is a difficult place for people with intellectual disabilities.” Preventing children from having to struggle through a difficult world is the sheep’s clothing in which eugenics makes its reentry, in Dougherty’s telling, as our cultural commitment to health erases those who do not live up to our societal self-image.

That is where Millman’s objections come in. Noah says Dougherty doesn’t have an objection to eugenics as such, but to abortion. Because the eugenic means are illegitimate, the ends are tainted. Millman presents the common Ashkenazi Jew premarital ritual of being tested for genetic markers for Tay-Sachs, a terribly painful, fatal, and incurable childhood degenerative disease. Had Noah and his wife discovered that they were both carriers for the recessive genes,

we could have chosen not to marry; or to marry but not to have children; or to marry and adopt children; or to marry and have children using either donor sperm or donor eggs; or we could have taken our chances and aborted any children who tested as having the disease. Those would all be ways of preventing what we didn’t want to happen: having children who suffered from Tay-Sachs.

Millman goes on to say that if a person objects to any of those options because it would be eugenics, then “you would logically have to object to all of them. Because that is what they have in common: they are all ways of making sure that our children won’t be born with a genetic disease.” Millman in fact claims that “eugenic motivations aren’t suspect as such, but perfectly normal,” so long as they are properly tempered with humility and a recognition of the inner life of others not like us. For “everybody wants their kids to be healthier, including being born healthier. There’s nothing wrong with trying to ensure that—unless there’s something wrong with what you are doing to ensure it, or unless you take your standards of what constitutes ‘health’ to unreasonable extremes.”

The problem is, taking “health” to unreasonable extremes is just what is at issue in this discussion. Dougherty doesn’t object to Tay-Sachs carrier couples adopting or even parting ways, after all. He voices concern over social policy and social stigma turning against those who fall short of an increasingly healthy society’s increasingly stringent expected standards. A moral abhorrence at abortion is certainly at work in his defense of Down children, as is no secret to anyone familiar with his work. But resisting the prenatal extirpation of the Down community is about more than the abortion wars. It is precisely about how poorly our society is equipped to understand health reasonably, and what consequences flow from that shortcoming.

In a different context in 2012, Yuval Levin wrote an essay for The New Atlantis entitled “Putting Health in Perspective,” which remains one of the best descriptions I have encountered of what he describes as “an old and very complicated problem for our kind of liberal democracy: our inability to properly rank health in relation to other public goods.” While I will condense the full genealogy, Levin argues, in essence, that modern political philosophy and modern science were both born out of a shift towards elevating health and bodily security above the more soulful goods in favor in Dante’s time and before.

Rene Descartes argued in his Discourse on Method for “the conservation of health, which is without doubt the primary good and the foundation of all other goods of this life.” Francis Bacon pursued “the relief of man’s estate” in his torturing of nature to reveal her secrets. Following these fathers of modern science, modern political philosophy and liberalism were birthed by Thomas Hobbes (Bacon’s secretary) and John Locke, each of whom emphasized the natural law’s grounding in the pursuit of security and freedom from death’s early arrival.

It is worth quoting the next part of Levin’s argument at some length:

If nature is above all the source not of a desire for excellence but of a desire for relief, then society must be directed to relief first and foremost—relief from danger, fear, and pain. In that way freedom, another word for relief, became the aim of politics, while power and health became the goals of the great scientific enterprise.

The preservation of life—and not just any life but a healthy life as free as possible from pain and suffering—is thus at least implicitly taken to be the primary good and the foundation of all other goods by our kind of society. We have accepted Descartes’s premise and acted on it, even if we rarely consider it explicitly. (As Alexis de Tocqueville observed of our republic in a different context in the 1830s, “America is the one country in the world where the precepts of Descartes are least studied and best followed.”)

The dual pursuit of health and liberty has served us very well. Modern science is a marvel that has itself transformed childhood from a source of braced dread for parents during times of elevated infant mortality to a cherished (albeit sleep-deprived and still anxious) celebration. Liberalism has democratized the West, enshrined a discourse relatively suspicious of state coercion, and, at least historically in America, provided the room for a rich and active civil society to ceaselessly chase after problems to solve.

But as biomedical advances have taken the tools provided by the previous centuries’ advances in physics and chemistry and applied them to the human form, we have gained the power to manipulate that necessarily accompanies the power to heal. And now we have to discern how to use the tools science provides us.

Levin describes how the embryonic stem cell research debate gave a very pessimistic peek into what could be our biotechnological policy future. Media, politicians, and physicians united in urgent hyperbole as John Edwards toured the country promising that lifting a partial ban on federal funding of human embryonic stem cell research would cause Christopher Reeve to stand up and walk again, and Arlen Specter claimed it held “the potential to conquer … all the maladies we know.” Those raising ethical questions were berated and blamed for the suffering of the sick. So far, we have found that “when the pursuit of health through science and medicine conflicts with even our deepest commitments—to equality, to the protection of the weak, or to responsible self-government—science and medicine typically carry the day.”

So what happens when science and medicine tell us that we have the ability to avoid bringing children into the world who would suffer all the many maladies associated with trisomy 21—Down syndrome? Apparently, we terminate the child along with the suffering. Does the calculus change if one is performing pre-implantation genetic diagnosis on embryos created in an IVF cycle to select for a normal set of chromosomes? Of course. But the families of Down children, not to mention people with Down themselves, might object to the idea that resolving the abortion issue resolves all the issues. The “disappearing faces” those families fret over still disappear, and the transformative gift of a Down child that (pro-choice) Martha Beck describes in her book, Expecting Adam is permanently denied to a new family.

The medical establishment has traditionally not performed well in appreciating disabled children as transformative gifts. As Caitrin Nicol Keiper related in her essay “At Home with Down Syndrome,” “One physician had the gall to lecture a shaken father, his baby in his arms, for not getting an amnio and ‘terminating.'” Beck herself describes the pressure her Harvard University Hospital doctors brought upon her to terminate her pregnancy. Ignorance often starts at the top, here.

Balancing health against other goods does not come easy to contemporary Americans, and fear in the face of suffering is rooted deep in the very philosophies that have shaped our world, and our minds. For Down syndrome, obstetrician Adam Wolfberg notes that termination rates seem to have declined or at least stabilized (and may never have been as high as they appeared in the first place), likely as a result of improving medical support and a widespread movement to give prospective Down parents better information, including access to other Down parents who carried to term.

What is clear is that this balancing, this discernment, will have to be a discussion at once society-wide and patient-specific. Most experts will be of little to no help, for as Helen Andrews (nee Rittlemeyer) recently recounted, the professional bioethics discipline is in most respects an abject failure, embodying the very worst of credentialist academic formalism, presenting a wide-ranging philosophical menu of Rawls, Mill, or Kant (if you’re feeling adventurous), and being willing to tell practitioners of biomedicine nearly anything except no.

Tay-Sachs is a cruel, fatal, degenerative disease that almost all would agree is best avoided by any licit means available. Down syndrome is a difficult chromosomal disorder that presents significant burdens to caregivers and precludes a “normal” life for the child, but avoiding it even by licit means is a much more complex question (but certainly not comparable to a father giving up a gambling habit). How do we navigate the differences, and obtain a proper definition and valuation of health? It won’t be easy, especially since, as Levin notes, “our regard for health, it seems, can easily coexist with a society that we would not otherwise be proud of.”

As Christine Rosen wrote on this very intersection of Tay-Sachs and eugenics,

Not all eugenic practices are equal, and often the same practices can have very different meanings when pursued in a different spirit or governed by a different moral purpose. Perhaps some forms of eugenics are sacred and some profane. But we ought never allow good intentions (or claims of holiness) to blind us to moral realities—especially the ways a new privatized eugenics, directed by individuals or specific communities, will affect the range of human possibilities for everyone.

Eugenics can be read in Francis Galton’s original light, as the pursuit of better, healthier genes, just with all the racist claptrap stripped out. But it cannot be understood apart from a liberal society’s unbalanced obsession with health, and the struggles such a society will have bringing its other wisdoms to bear.