Wang’s film covers a wide range of topics in its 89-minute runtime. Starting from the one-child policy, she examines related issues such as forced abortions and sterilizations, cultural preferences for male offspring, and corruption in state-run orphanages. As Wang works through these storylines, we begin to appreciate their deep connections and see how cultural beliefs exacerbated by policy lead to unforeseen abuses and loss of life. Wang approaches these sensitive topics through the people who lived under the policy: those charged with enforcing it, those who suffered under its draconian measures, and those who fell into both categories. Particularly poignant interviews include a midwife who exclusively treats infertility as penance for decades of performing abortions and sterilizations, and a family planning official who was initially horrified by her work but was ultimately convinced that the strict enforcement was necessary. Though their careers took opposite directions, both women repeat the mantra that they had no choice, that it was a matter of putting country over self. Wang highlights this sense of helplessness as a result of intentional social molding by the Communist Party through the copious use of propaganda. Nevertheless, it’s worth considering the collectivist mindset that enables this idea to more easily take root.

Though it’s not obvious from the film, the one-child policy underwent various relaxations in enforcement during its 35-year history. Prior to the policy’s unceremonious annulment in 2015, upwards of fifty percent of couples were legally allowed to have a second child. Wang’s family received such an exemption: rural families could have a second child five years after the first, if the firstborn was a girl. Wang enjoyed growing up with a younger brother but became the subject of other children’s taunts and disapproval when they found out she had a sibling. Her experience suggests a difference between theoretical permissibility and on-the-ground realities: although exemptions existed, the strong belief that one was not putting the country’s interests first by having multiple children could result in stigmatization and even retaliation from one’s neighbors and community.

The brutal, on-the-ground realities that Wang uncovers change her feelings toward the policy from a naïve acquiescence to disillusioned anger. She notes the importance of documenting the policy’s consequences, because, as artist-turned-activist Peng Wang states in the film, “the most tragic thing for a nation is to have no memory.” Recent events suggest that the Party would like its populace to forget and move on.

The one-child policy was replaced with a two-child policy in 2015. Yet another population crisis incited the change: men vastly outnumbered women (by an estimated 33.6 million at the time) and declining birth rates meant that the elderly population was growing beyond the working population’s capacity to care for them. Without missing a beat, government messaging began touting the greatness of the new national policy, adorning walls with slogans like “xiao you ban, lao you kao”—the young will have companions and the old will have caretakers. The new policy led to a short-lived boost in births, but rates subsequently settled at level lower than what it was in 2015. Currently, the government is studying whether population control measures should be phased out altogether.

Fuller accounts of the human cost paid for the one-child policy are all the more crucial as controls are eased. They serve as a caution against using Malthusian rationales as the major determinant of policy, and while Wang never outright addresses the underlying justifications of the policy, viewers must wonder if the economic doom without it was in fact so certain.

This film raises important bioethical questions for medical trainees to consider:
To what extent should medical procedures like abortion and sterilization be intertwined with the goals of the state? Wang notes that it’s an irony for her to move from a country where abortion is forced to one where abortion is restricted. However, her conclusion that both policies are primarily about “controlling women’s bodies” comes off as perfunctory given her intense focus on the plight of children under the Chinese policy. These issues deserve and require deliberation that weighs individual rights, consent, and ethics.

How do clinician independence and conscientious objection operate in non-democratic contexts? The limitations of life in a propaganda state are brought to bear repeatedly throughout the documentary. The penitent midwife vowed to treat infertility alone, but only after she had retired from the family planning corps. Would she have been allowed to make such a decision prior to retirement? Could she be forced by the government to resume work she found morally unbearable? Clinicians working in close proximity to the precipices of human life and death ought to work without undue coercion.

How does a globalized world address the international ramifications of bioethical failures? Wang’s film makes a compelling case against an isolationist attitude toward abuses overseas: she features Brian and Longlan Stuy, a couple in Utah who, through their own adoption experience, expose a network of human trafficking in China’s orphanages. The Stuys, and the many other families adopting from China, cannot ignore the exploitative practices of the one-child policy. We shouldn’t either.