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W1578852891 abstract "Pregnancy loss occurs more frequently than many realize. Although documented losses vary in differing countries, and early losses are frequently undocumented, an estimated 30–40 percent of pregnancies do not end in live birth (Michels and Tiu 2007). In the United States, if we exclude abortions, one quarter of women of childbearing age will experience a miscarriage1 (Jones 2001, 228). Losses can happen before a woman knows she is pregnant or occur as late as during childbirth.2 Some women choose to end unwanted pregnancies; other losses occur to women who did not want to be pregnant but strove to remain so, and others to women who wanted to become pregnant and give birth to a child. Pregnancies may end in loss because of injury (sometimes deliberately caused) to the pregnant woman, or because of exposure to environmental toxins or illness. Women who initially wanted to be pregnant may later choose to terminate a pregnancy. This could be because of changes in health, financial resources, or social support. Decisions to terminate may reflect prenatal test results that reveal anomalies that a woman believes will compromise either quality of life for the potential child, the prospective parents' ability to care successfully for that child, or both. In this essay, I aim first to give a sense of the complexity of the ethical terrain connected with pregnancy loss and then to discuss early pregnancy loss in the light of this complexity and variability. By early loss, I mean loss that occurs before an embryo or fetus is believed to be either sentient or able to survive outside the womb.3 What I lose in depth of focus on any one issue I hope to gain in breadth, ensuring that attention to the moral significance of early pregnancy loss in one context considers other types and contexts of loss. This approach should help me avoid making assumptions about what is entitled to moral consideration to arrive at desired results, for instance to cohere with pro-choice politics or express sympathy with those who have experienced much lamented pregnancy loss. My research is drawn from a wide variety of disciplines but has focused on pregnancy loss in industrialized secular democracies, and should be interpreted in that context. Reflection on the ethical significance of pregnancy loss should discuss multiple contexts and multiple actors. The contexts include different stages of pregnancy, different reasons for pregnancy loss, and different attitudes toward the pregnancy by those involved. The actors include pregnant women, their partners (male or female), individuals, or couples for whom pregnant women act as surrogates, and extended family members of pregnant women (or other expectant parents). They also include individuals and groups whose actions contribute to pregnancy loss, and medical professionals who provide care for pregnant women or who participate in procedures aimed at providing medical treatment to a fetus or terminating a pregnancy. Others who confront pregnancy loss include acquaintances and coworkers who wonder how to respond to others' losses, funeral directors, social workers, and support group members. Finally, pregnancy losses represent an end, chosen or not, to a human life (viable or not) and so raise questions about the moral status of beings located along the continuum between immediate products of conception and fetuses on the cusp of birth at full term. As a feminist, I wish to acknowledge the widely varying significance pregnancy losses have to pregnant women while recognizing that others may have very different attitudes toward those losses. Many women who lose a pregnancy believe that loss of an embryo (a stage of development from conception to eight weeks gestational age4) or fetus (a stage of development from eight weeks until birth) is loss of a child and is morally significant not only because of their loss of hopes and dreams but also for that child. They believe that factors that lead to avoidable pregnancy loss should be struggled against, and that their losses should be socially acknowledged as losses of children. Efforts to receive this social acknowledgment may take the form of participating in pregnancy support groups (Layne 2005) or creating or visiting pregnancy loss memorialization websites (Keane 2009) or memorial gardens (Woodthorpe 2012). Other pregnant women do not believe that an embryo or fetus is a child and will terminate pregnancies without seeing those terminations as morally significant at least if they occur relatively early or perhaps at any stage. Still others may regard termination of pregnancy, at least at certain stages of fetal development, as loss of a child but believe it is the right thing to do because of their own situation, or because they believe the fetus is unlikely to have a future of value. Some feminist scholars attempt to resolve potential tensions between supporting women's right to terminate pregnancies (either at every or at some stages), with fighting for resources to prevent pregnancy loss, and social and institutional changes that acknowledge the importance of pregnancy loss by arguing that fetal personhood is constructed socially. Laury Oaks writes: “Borrowing from the pro-choice position, women's health advocates can promote a fetal politics by asserting that, in disputes more than the fetus-as-subject, the pregnant woman's judgment is to be respected. This support would entail a steadfast foregrounding of women's agency by privileging their notions of their fetuses” (2000, 97). Annemarie Jutel similarly argues that we must make pregnant women's attitudes central and focus on whether or not a pregnant woman regards loss of the pregnancy as loss of a child (2006, 431–433). Linda Layne claims that feminists can reconcile sympathy for those grieving the loss of their pregnancies with support for those who choose abortions by acknowledging that if one accepts an “anthropologically informed view of personhood, that is, that personhood is culturally constructed … one can see that the process of constructing personhood may be undertaken with some embryos and not others” (1997, 305). These feminist scholars seek to create a rhetorical space in which pregnancy losses can be acknowledged in a manner that allows both support for some women's choices to abort pregnancies and other women's response to miscarriage or stillbirth5 as tragic loss of a child. This feminist strategy, however, may falsely suggest that pregnant women only construct their embryos and fetuses as babies, persons, or potential children in pregnancies they intend to keep. Jeannie Ludlow notes that many of the women she encounters in the abortion clinic where she works refer to their fetuses as babies (2008, 43) and wish their life circumstances had permitted them to have and rear these potential children. She observes that some pregnant women who have abortions have developed emotional connections with the embryo or fetus and some choose, after the procedure, to hold the body, say goodbye, and “grieve for a child” (41). I take this as evidence that undermines Julie Palmer's contention that one must be anti-abortion to speak of babies in utero or unborn children (2009, 181). Recognizing that pregnant women—including those who choose abortion—may or may not construct their fetuses as persons can help us deal sensitively with their losses. But they are not the only ones who construct fetuses as persons, and hence are not the only ones whose losses require sensitive response. Grief counseling or more informal emotional support could appropriately be offered to those whose words, actions, and emotional responses suggest they feel a person has been lost while not to those who would feel morally judged by these kinds of offers. Mary Ann Hazen notes how important it can be to respond sensitively in the workplace to pregnancy loss experienced by one's colleagues (2006). However, it is important to avoid assuming that all who experience pregnancy loss will feel the same way. Many hospitals have developed protocols for dealing with pregnancy loss, but some pregnant women and their partners consider encouragement to hold the body of the dead fetus and grieve as adding to their emotional discomfort, and dictating how they should feel rather than responding to their actual feelings which may be mixed (Corbet-Owen and Kruger 2001, 422; Letherby 1993, 177; Graham et al. 2012). According to the approach taken above by Oaks and others, fetal personhood is constructed socially, and therefore, some fetuses and some embryos (those desired by pregnant women and regarded as their children) are persons. By contrast, other fetuses are not persons on this view because not constructed as such by a pregnant woman. Clearly this approach suggests that respect for a pregnant woman's autonomy should extend not only to her control more than her own body but also to others' attitudes toward whether or not the loss of a pregnancy is a loss of a person. I disagree and discuss first the claim about the social construction of persons and next what respect for reproductive autonomy should instead entail. A person is typically taken to have moral status equivalent in most respects to adult humans with normal capacities but, as Bonnie Steinbock points out, we can mean different things by talking about persons (2011, 30). Melinda Roberts, for instance, takes a person to be any being with moral status, and so for her a kitten (capable of experiencing pain and pleasure) is a person, whereas an embryo or early fetus (one not yet capable of sentience) is not (2010, 147). Many would find this way of talking counterintuitive. It seems clearer to refer to moral status (had by all beings worthy of moral consideration for their own sake), rather than invoking personhood. This may help avoid confusion and also enables acknowledgement that beings can be entitled to different types of moral consideration. Many people who encounter pregnancy loss think of at least some embryos or early fetuses as people in their own right, as children (not only potential future children) and as morally considerable. Some of these people are a pregnant woman's partner, an individual or couple for whom she is undertaking a pregnancy (Berend 2012), medical professionals who regard a fetus as a patient (Wyatt 2001), members of a pregnant woman's social network, and members of her society more broadly (including people who believe, for religious or other reasons, that personhood and hence moral status begins at conception). As Palmer notes, with the increasing sophistication of ultrasound technology, people she terms “citizen voyeurs” (2009, 186) have constructed fetal personhood on the basis of ultrasound images, which, because persons have moral status, has resulted in calls for earlier gestational age limits to abortions (182). Diffuse social construction of the personhood of fetuses can be an impetus for legal and policy changes such as provision of birth certificates in stillbirths (Cacciatore and Bushfield 2008). Jenny Hockey and Janet Draper observe that “the social identities of the unborn” are constructed by people in varying ways (2005, 54), often by looking at and sharing ultrasound images, telling friends and extended family members about the pregnancy, and making preparations to welcome the anticipated child [see also Weaver-Hightower (2012) for a personal account of this process]. In their interviews with expectant fathers, Hockey and Draper found that whether or not a man constructed a fetus as a social person and himself as a father he could “find his view either supported or contested by other interested parties” (2005, 46). In her study of male participants in pregnancy loss support groups, Bernadette McCreigt found that expectant fathers can experience considerable grief while feeling pressure not to express it, either to conform to a masculine identity or to support their female partner (2004, 329). This suggests the grieving men regard the fetus lost as both a child and morally considerable. Sometimes a pregnant woman's life partner is another woman, and these women may equally grieve pregnancy loss and often do not have their feelings acknowledged or addressed (see Peel and Cain 2012). If social construction of a fetus's personhood/moral status gives sufficient ground for others to recognize an entity as morally considerable, then we are left on relativist grounds, as some will construct fetuses as social actors worthy of moral consideration and some will not, often with respect to the same fetus. Clare Williams notes that in fetal medicine units “the same fetus might, at varying stages, be conceptualized at different points along this human/non-human continuum, by women, partners and practitioners” (2006, 13). Given that people may also socially construct other non-human entities as persons and indeed as their children (while writing this essay I saw a bumper sticker that read: “My children have four paws”), recognition that various people may or may not socially construct different fetuses as persons/children/morally considerable would hardly settle the matter of how others should regard them. We have a long history of denying moral status to beings who should, on the basis of their properties, be recognized as morally considerable: slaves, women, people with cognitive disabilities that do not prevent them from having beliefs and desires, entering into relationships, caring about others, and/or responding to reasons. [For a discussion of the moral status of children with cognitive disabilities, see Mullin (2011)]. It is, therefore, problematic to conclude that those constructed by some others as morally considerable have moral status, and those that are not so recognized lack it. It is important to reflect on features that could affect the moral status of a human embryo or fetus at different stages of its development, beyond the value it may have to others. These features may include viability (or the ability to live outside a woman's body, if provided other forms of care), sentience (or the current capacity to be conscious and feel pain that appears to emerge no earlier than the third trimester6), and the potential to develop other morally significant capacities. However, determination of the moral status of a developing human would not settle the matter with respect to how we should respond to those that cause, contemplate, or suffer its loss. We need to consider the other actors involved, especially but not only the pregnant woman. Before discussing the moral status of fetuses I will, therefore, discuss the autonomy of pregnant women, and women's reproductive autonomy more generally. It is important to be clear that respect for reproductive autonomy should constrain some actions and inspire others, and that deference to the pregnant woman's attitude toward her loss should affect interactions with her, but need not determine others' attitudes toward pregnancy loss. I assume that pregnant woman's bodily and reproductive autonomy is of value because autonomy (or self-determination) is generally of value, and so are women, and further assume that bodily and reproductive autonomy are important forms of autonomy, with typically far greater significance for people than the freedom to make decisions about what to wear, or eat on any particular association. I take this to be true even though decisions about how we clothe ourselves and how, what, and with whom we eat are also important to people. I assume, therefore, that the moment of birth is ethically significant, because before then fetuses can only be accessed (treated, monitored, or terminated) through intervening on the pregnant woman, and when this is done without her consent, it violates her autonomy. I disagree, however, with Mary Anne Warren's contention that birth is also morally significant because it marks the beginning of the possibility of social interactions with a child who may be cared for as a particular individual (1989, 62). I have already suggested that a variety of actors may construct an embryo or fetus as a baby or person, and characterize their own interactions with it in social terms. For example, physicians and other medical practitioners may care for fetuses as patients. Wyatt gives a moving account of the tension this represents for doctors (and their medical teams) who are expected both to try to engage in treatments that may save a fetus or improve the quality of life it may have once born, and to terminate a pregnancy during its later stages (2001; see also Williams 2005; Williams 2006, 11–12). Fetuses may be constructed as children both before birth and after death by a variety of social actors whose identities are shaped by being in a family relationship with them (Morgan 1996, 53; Keane 2009, 156). Birth is instead significant because before it a fetus can only be harmed or helped by affecting a pregnant woman. The ability of a fetus to live outside the body of a pregnant woman (something that shifts with changes in medical technology) is similarly significant because it marks the point at which people other than her can begin to assume responsibility for its care. This means that a unique burden would not need to be imposed on her for the fetus, once born, to live. If we seek to enhance women's reproductive autonomy, it will be important not only to protect their abilities to choose not to have children but also to acknowledge limits to women's abilities to choose to have children, whether because of features of their bodies, their luck, or their circumstances that lead to unwanted pregnancy loss. Autonomy is increased when we are well informed about our options, about the potential need to make difficult decisions, and are also informed about the limits to what we can control, so as to avoid inappropriate self-blame, a common response to unchosen pregnancy loss (Layne 2003, 1888; Letherby 1993, 170). It is also increased when we have the social, financial, and emotional resources that make options to have children and raise them in safe and supportive environments real possibilities (Price 2010, 56). Respect for reproductive autonomy suggests we should devote resources to help men and women become more informed about what can go wrong and what they might face when things go wrong (Layne 2006, 610). We should encourage discussion of potential problems in public discourse. In McCreigt's study of male grief after pregnancy loss, many of the men expressed being unprepared for loss, uninformed about what they could expect, and unsupported in dealing with it (2004, 338, 341). Serene Jones's work reveals that for pregnant women miscarriage can be deeply emotional, combining “lost agency and guilt” (2001, 233). Autonomy is also enhanced by provision of support (when it is desired) to women and their partners when they need to make decisions connected to pregnancy loss, decisions that are often very emotionally laden (Howard 2006). Finally, if we are to enhance men and women's reproductive autonomy in the face of potential or actual pregnancy loss, it will be important to avoid assuming that all individuals or couples need the same kinds of support in the face of loss (Graham et al. 2012). We can respect autonomy without agreeing that particular choices autonomous persons make—or the attitudes they manifest—are either moral or definitive of how others should respond to what they experience. We need not, therefore, allow a pregnant woman's attitude toward her fetus shape how we respond to others either devastated by or indifferent to her loss, or to shape what we determine has been lost. Furthermore, we can value autonomy without believing that it is the only legitimate factor to be taken into consideration in ethical decision making (or policy-making) as harm to others with moral status should also be considered. It will, therefore, be important to consider whether/when a fetus may acquire moral status, and to recognize all who are affected by pregnancy loss. Recognition of the importance of pregnant women's autonomy should not end all ethical debate about their actions and decisions with respect to their pregnancies. However, we might find ethical fault with people's autonomous decisions without seeking to prevent them from making those decisions, and indeed while supporting the importance of their being able to make them. This does not mean we must avoid discouraging some kinds of decisions (for instance, with respect to termination of pregnancy because of the sex of the fetus, or because of fetal anomalies that do not appear likely to prevent a fetus, once born, from having a life worth living). In the next sections of this essay, I focus on early pregnancy losses, before a fetus is either sentient or able to survive outside the womb—two features that are often taken to be morally significant. This way I can explore what else might be morally significant in pregnancy loss, including the worth of a being with potential to develop morally valuable properties. In choosing to focus on early pregnancy loss, I should not be taken to assume that time of loss is the only or chief factor in determining how we should regard pregnancy loss or respond to those who have lost a pregnancy.7 As discussed above, sensitive responses need to take into account the attitudes of the pregnant woman and others involved with the pregnancy. Many early pregnancy losses are in the category of blighted ovum and are presently unavoidable (Pearce and Easton 2005). In blighted ovum pregnancies, a fertilized egg implants in the uterus but does not develop into an embryo, sometimes because of a chromosomal problem with a sperm or egg or sometimes because of early problems with cell division. Even though an embryo never existed, these losses are memorialized on pregnancy loss websites “in the same ways as other early miscarriages” (Keane 2009, 69). Others early losses are avoidable—sometimes they result from someone's actions (for instance the embryo or early fetus is damaged by something that happened to or was chosen by the woman). We know that pregnant women sometimes face domestic violence, and that a pregnant woman's abdomen is often singled out for violence (Layne 2006, 611), leading to placental abruption, fetal loss, premature labor, and maternal and fetal fractures (Bacchus et al. 2001, 251). If a pregnancy would have been viable and wanted, then someone who caused the loss did something to damage the woman (and others who hoped to parent the expected baby) beyond the damage to the woman's body. If a blighted ovum pregnancy was ended due to accident or injury, then no embryo or fetus was lost. But in other cases of early pregnancy loss, an embryo or fetus was lost. Is the loss caused to the embryo or early fetus morally considerable for its sake and not only because of the expectant parents hopes and plans? I will discuss these questions by first reviewing variations in feticide8 laws in the United States. In the first decade of the twenty-first century, federal law in the United States made it a separate crime to harm a fetus in an assault on a pregnant woman, and many states followed suit (Fleming 2008–09, 44). The federal legislation (The Unborn Victims of Violence Act of 2004) proscribes the same punishment for killing or harming a fetus in an assault on its mother as if the injury or death had occurred to her (except the death penalty cannot be imposed). The law applies to an embryo or fetus at any stage of development (Fleming 2008–09, 50–51). It does not apply to abortions women seek, to medical treatment for woman or fetus, or to any conduct of the woman herself. These exceptions protect a pregnant woman's autonomy and privacy. State laws differ in how they treat harm to fetuses. Some consider harm to a fetus only in effects on pregnant women (Fleming 2008–09, 52). Others recognize any embryo or fetus as a person whose killing is homicide (53). Some indicate that gestational age affects whether or not a fetus is a legal victim of a crime (56). Others stipulate that fetal harm is a crime only it if could have survived birth (54) or only if the attacker knew the victim was pregnant (55, 59). As with the federal legislation, most states do not apply their laws to acts of the pregnant woman (68). However, some prosecute pregnant women for harming their fetuses (Layne 2006, 606). Although it is morally problematic for a pregnant woman to harm a fetus she intends to keep, criminal prosecution for such acts would enable considerable intrusion on pregnant women's autonomy and privacy. It would also discourage them from seeking health care during pregnancy, potentially damaging both the woman's health and that of the child to be (Fleming 2008–09, 72; Layne 2006, 606). These legal approaches to acts that harm or kill a fetus (aside from abortion undertaken with a woman's consent) provide varying reasons for considering these acts morally problematic. The reasons range from recognizing them as acts that harm a pregnant woman (because of her emotional attachment to the fetus), acts that are equivalent to harming or killing an adult person, no matter what stage of development the embryo or fetus is at, or acts that are punishable only if they harm fetuses at a more advanced stage of development. How can this review of legal responses to harming or killing directed at a fetus without a pregnant woman's consent help us think more broadly about the moral significance of early pregnancy loss? Clearly one type of loss is the suffering of the pregnant woman and others who cared about the pregnancy and/or expected to be involved in the life of the expected child. For the pregnant woman, this can include loss of hopes and plans for a relationship with a child, loss of an identity as a mother, a challenge to her understanding of herself as a woman, and a potentially traumatic emotional and physical experience of the miscarriage itself (Engelhard et al. 2001). Women who have agreed to act as surrogates for others are sometimes expected to feel the losses less, but Berend's work shows that they can be keenly felt by surrogate mothers as losses of projects of meaningful acts of care and sacrifice for others, and as losses of valuable children (Berend 2012). Expectant fathers, expectant female co-parents, or those who expected to parent a child in a surrogate pregnancy, and their extended family members, may also lose hopes and plans for a relationship, and aspects of their identity (as prospective grandparent, or father, or co-mother). This strand of fetal harm laws is, therefore, well supported by research on experiences of pregnancy loss (both studies that focus only on pregnant women and those including other prospective parents). The emotional aspects of pregnancy loss can be very significant (Bonnette and Broom 2011; McCreigt 2004; Säflund et al. 2004; Weaver-Hightower 2012). When a fetus is constructed as a person and then a pregnancy is lost, those who experience the loss not only lose a being they found morally considerable but may also lose aspects of their identity, as well as hopes and plans for the future. As a result, Layne suggests that very early detection of pregnancy, via home pregnancy tests, may avoidably increase the pain of those who might otherwise not have realized they were pregnant with a nonviable pregnancy (2009).9 If an early pregnancy was not viable, then it is better that the pregnant woman (and others involved) never learn about the loss. What about fetal harm laws that equate harming or killing a fetus with harming or killing a pregnant woman? Some early and otherwise viable pregnancies are not wanted or accepted. If they are lost either through the pregnant woman's actions (in seeking an abortion or actions that made loss more likely) or through others' actions then we may think any loss of future for the embryo or early fetus is outweighed by gain to the pregnant woman. Given uncertainty about the potential of the embryo or early fetus to have developed into a live birth (a potential contingent on the pregnant woman's consent), equation of loss or death suffered by the embryo or early fetus (a being not yet capable of consciousness and not yet able to live outside the pregnant woman's body) with loss or death suffered by the pregnant woman seems unmerited. When a pregnancy was wanted and viable, however, uncertainty around its potential to develop into a live birth is greatly decreased, and loss suffered by those who planned a relationship with the child is significant. Having critiqued feticide laws that equate damaging a fetus, at any stage, and whether in a wanted pregnancy or not, with damaging the pregnant woman, does that mean that I support those that focus only on the losses caused to the pregnant woman, or those that punish only acts that damage fetuses once sentient and/or viable? Is there room instead to regard the loss of an early fetus as morally considerable, apart from the losses experienced by expectant parents and others? I now end my discussion of feticide laws to explore a possibility they missed. When an embryo or early fetus dies, is that a morally considerable loss apart from the attitudes and plans of others? If the being was not viable, and would never have had experiences, it has not lost a future of value. Furthermore, since we are discussing pregnancy losses before a fetus is sentient, then it was not a loss experienced by the embryo or early fetus, as the capacity for conscious experience emerges in the third trimester (Lee et al. 2005, discussed in endnote 3). If one believes that even unviable embryos and early fetuses are beings with dignity because human (Pullman 2010) or ensouled, then even in these cases, loss of a being with dignity or a soul has occurred. It seems appropriate to treat unviable embryos with dignity out of respect for the value of humani" @default.
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W1578852891 title "Early Pregnancy Losses: Multiple Meanings and Moral Considerations" @default.
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