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Book Review   |    
Susan Stefan
Psychiatric Services 2009; doi:

by Paul A. Lombardo; Baltimore, Johns Hopkins University Press, 2008, 384 pages, $29.95

Ms. Stefan is senior staff attorney for the Center for Public Representation, Newton, Massachusetts.

Paul A. Lombardo's new book, Three Generations, No Imbeciles, is both a fascinating history and a thoroughly modern cautionary tale about the problems that society has always had imagining people with disabilities both having sex and having families. It is the in-depth story of the deceptions, pressures, and paradoxes behind the sterilization of Carrie Buck and the path to the infamous Supreme Court decision of Buck v. Bell. In 1927 Justice Oliver Wendell Holmes upheld the sterilization of Carrie Buck and others like her with the infamous sentence, "Three generations of imbeciles are enough" (1).

Lawyers are supposed to protect citizens from this kind of overreaching by the government. Carrie Buck was assigned a lawyer and an expert witness, and she had hearings all the way to the Supreme Court, but, as Lombardo shows, the outcome of her case was never in question. Her lawyer was a prominent sterilization advocate with ties to the institution petitioning for her sterilization. The expert witness had a eugenics agenda. Neither Carrie Buck nor her child, Vivian, was an "imbecile" at all, but evidence supporting her, and known at the time, was suppressed. Buck v. Bell gave the imprimatur of authority to the sterilization of thousands of people with disabilities, many of whom were in mental institutions. Sterilization for social purposes continued well into the mid-1970s, when, as Lombardo discusses, between 100,000 and 150,000 welfare recipients with low incomes, belonging to racial or ethnic minority groups, and often having disabilities, were coerced unknowingly into sterilization.

Like most outstanding history books, this one has lessons for modern readers, whatever their profession. For mental health professionals, it raises stark questions about the lines between protection of vulnerable people with mental disabilities and interference with and suppression of some of the most fundamental aspects of being human. Today only a small fraction of people with disabilities live for years in institutions, but their sexuality and opportunities for romance continue to be strictly controlled and limited. Parents with mental disabilities have their parental rights terminated at a very high rate.

This book also resonates with policy questions about the tension between individual autonomy and protecting people with disabilities. Lombardo sees Buck v. Bell and Roe v. Wade as fundamentally opposed because the former gives the power over reproductive decision making to the state and the latter reserves it to the individual. But Roe v. Wade was used to overturn protective state legislation banning sterilization of people with mental retardation and enabling guardians to impose sterilization on their wards (2). Thus each case has been used to support sterilization of people with mental disabilities. Our continuing social ambivalence about these issues makes Lombardo's book starkly relevant today, when women are using the rights they gained under Roe v. Wade to abort fetuses found to have Down's syndrome and the Supreme Court protects hospitals that follow parents' direction to provide only palliative care to infants born disabled when those infants could have been treated and lived (3). Is it hypocritical to criticize the statement that "three generations of imbeciles are enough" when individuals today decide that even one generation is too many?

This is a meticulously detailed and researched history that should be read not only by those who enjoy history but also because, as Lombardo says, "one of the important lessons of the Buck story [is that] a small number of zealous advocates can have an impact on the law that defies both science and conventional wisdom." As Lombardo shows, the move to sterilize "social undesirables" is far from extinct today. This book is enjoyable, thought provoking, and troubling in equal measure. I highly recommend it.

The reviewer reports no competing interests.

Buck v Bell, 274 US 200, 207 (1927)
Stefan S: Whose egg is it anyway? Reproductive rights of incarcerated, institutionalized and incompetent women. Nova Law Review 405:413–427, 1989
Bowen v American Hospital Association, 476 US 610 (1986)


Buck v Bell, 274 US 200, 207 (1927)
Stefan S: Whose egg is it anyway? Reproductive rights of incarcerated, institutionalized and incompetent women. Nova Law Review 405:413–427, 1989
Bowen v American Hospital Association, 476 US 610 (1986)

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