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Miscarriage and the Stories We Live By

2015; Wiley; Volume: 46; Issue: 1 Linguagem: Inglês

10.1111/josp.12087

1467-9833

Hilde Lindemann,

Short Stories in Global Literature

The stories by which English-speaking societies constitute one of the identities arising from pregnancy—the “expectant mother” identity—connect loosely to form a narrative tissue. Some of the stories and story fragments in that tissue are the socially shared master narratives familiar to us all. They include the one of Mary and Joseph arriving in Bethlehem to find there is no room at the inn, so they shelter for the night in a stable. Or the one in Lady and the Tramp, where Darling sits humming in her rocking chair and knits tiny garments while her doting husband, Jim Dear, asks her anxiously if she is feeling well. Master narratives are culturally specific and sometimes specific as well to certain demographics within the culture; you have to be rich enough to have access to HBO, for example, to appreciate references to First Comes Love. While many people within a culture may distance themselves from certain master narratives (think of feminists who roll their eyes at Cinderella), what makes a story a master narrative is not that everybody agrees with it, but that everybody knows it (Nelson 2001). Because master narratives depict people behaving in certain ways that allow us to categorize them, these stories serve as hermeneutic resources we draw on to make sense of ourselves and other people (Nisbett and Ross 1980). For each of us, the narrative tissue that constitutes the various aspects of our identities also includes personal stories, such as my memory of getting up very early one morning and watching the day break as I sipped my coffee in the delicious new knowledge that I was growing my second child inside me, or the stories of my daughter's struggles with gestational diabetes and high blood pressure both times she was pregnant. The stories I weave around the things about me that matter most to me constitute my self-conception, and I act on the basis of them. The stories others weave around the things about me that matter most to them constitute the rest of my personal identity, and they treat me on that basis (Lindemann 2014). These are the stories we live by (McAdams 1997; Lakoff and Johnson 2003). They allow the expectant mother to make sense of herself and to navigate her social world; they allow others to understand who she is and how they are supposed to behave toward her. Although the stories are multiple and differ from one another, they all converge on the birth of the child-to-be. The baby is wanted, the mother-to-be grows it, so the baby comes. Because the plot is, at bottom, that simple, it's easy for family, friends, and society at large to make sense of who the woman is. She expresses who she is by what she does (more about that later) and this expression is recognized by others who respond accordingly. Matters are very different for the woman who has miscarried. In the first place, miscarriage is not in itself an identity, although if it mattered enough to the woman, the stories by which she makes sense of it can enter into her identity. In the second place, her attitude toward the pregnancy that preceded the miscarriage can affect how she sees herself in relation to it. The miscarriage might have happened even before the woman knew she was pregnant, so the “expectant mother” identity—if that is how she would have seen herself—was taken away from her before she even had a chance to try it on. Or she might have been unwillingly pregnant, not wanting to become a mother, so the “expectant mother” identity was never one she took to be her own in the first place. Or she might indeed have thought of herself as an expectant mother and now that identity has been thrown into irretrievable confusion. For others, too, matters are more complicated. It can be difficult for friends, family, and colleagues to select the stories that show how they are supposed to respond to the woman. If they were unaware that she was pregnant, she may not have told them she miscarried, leaving open the possibility that they might say or do something they would not have said or done had they known. If they were aware of her pregnancy, they may misjudge how much or little it mattered to her that she lost the pregnancy, leaving open the possibility that they might respond clumsily or uncaringly because they got it wrong. They might offer sympathy when all she feels is relief, or tell her it was for the best when all she can see is the inexpressible worth of the entity who has been taken from her. It's not, then, that we don't have the stories that let us understand what miscarriage means. Rather, the problem is knowing which, among all the many stories, are the ones that let us understand this miscarriage, undergone by this particular woman. In what follows, I make an argument that might help us get a handle on this problem by giving us a standard to assess at least some of the stories by. I argue that miscarriage is the loss of something valuable, such that any story that does not somehow represent the loss is a defective story. This standard only takes us so far, as the woman who miscarried and those around her still have to find stories that don't paper over important particulars and get the proportions wrong, but it's a start. I begin in a narrative fashion, by looking at the story that comes before the miscarriage—a story about what the woman was doing. I'll then show how having to stop doing it necessarily involves a loss. Although the community, the woman's partner, and the rest of her family would also be affected by a (known) miscarriage, I narrow my scope to two kinds of losses in particular, loss to the woman and loss to the fetus, and argue that at least one of these is always implicated in a miscarriage. Often, both are. After suggesting a way of constructing the stories needed for a good response to the woman who has miscarried, I end by considering stories that might best remain unspoken. A widespread but arguably misogynistic view of human pregnancy is that it is a purely biological condition that a woman undergoes: the embryo implants in the uterine wall, it grows for nine months, and a baby emerges. This account (yes, a story) of pregnancy is misogynistic because it completely effaces the woman's agency during pregnancy. It depicts her as a flowerpot, oven, or incubator—merely a passive receptacle housing the entity that is growing into a born child. To apply Marx's famous distinction between the architect and the bee (Marx 1930, 169–70), in which the bee constructs a honeycomb by following its own preordained patterns while the architect uses his creativity to make new patterns, the common view of pregnancy sees the pregnant woman as a bee, who cannot help what she is doing. Sustaining a human pregnancy, however, is no more purely biological than any other human behavior, which is to say that in important ways the pregnant woman is more like the architect than the bee. As is typical for her species, the pregnant woman both obeys the laws of nature and improves on them, ordering and shaping the natural world through her own intentional, creative activity (Jaggar 1983). She transforms many natural processes not only by giving thought and care to how she performs them, but by valuing them in certain ways or by giving them meaning. In response to the biological phenomenon of hunger, for example, she makes dinner: she takes raw foodstuffs and cooks, bakes, or roasts them to create food that is appetizing, attractive, and nourishing. Often she makes more of it than she needs so that she can feed her family or friends in the social ceremonies we call the family meal or the dinner party. Like the architect's, her constructions of food are purposeful and deliberate, and they go far beyond what is biologically necessary to sustain her body. So too in pregnancy. In non-human animals, for all we can tell, pregnancy is a process that occurs in the female without any purposive contributions on her part: she passively suffers the fetus to grow in her rather than actively shaping it, so the relationship that ensues is a purely biological one. In human pregnancies, by contrast, what begins as a purely biological condition is transformed into a recognizably human one in all sorts of ways. For starters, women, unlike other animals, are often pregnant for a reason: they may conceive and carry a fetus because they want a special relationship that will last over time, or they hope the baby's bone marrow will be a lifesaving match for a dying family member, or they want an existing child to have a sibling, or without children they would feel less firmly rooted in the world. Even if the woman is unwillingly pregnant, many aspects of her pregnancy are purposeful. If abortion is ruled out or she has no access to it, she, like every other pregnant woman, must come to terms with the fact that she is now in profound and ongoing physical intimacy with another human being. To be pregnant, of course, is to be occupied, by an entity that is both you and not you, and that makes use of your heart, liver, lungs, other organs, blood, hormones, enzymes, and metabolism for its survival. And just as it makes use of your body, so too it makes itself felt in and on that body, changing its contours and the coloration of some of its parts, shifting the organs as it grows to make room for itself, producing nausea, weight gain, euphoria, and varicose veins, and sometimes causing life-threatening diseases such as diabetes, high blood pressure, and preeclampsia. To gestate, as Margaret Olivia Little puts it, is to engage in “a particular, and particularly thoroughgoing, kind of physical intertwinement” (Little 1999, 296). Adjusting to that intertwinement, particularly if she did not want to be pregnant, can involve difficult emotional work. In addition to that work, the woman must now take responsibility for herself and the child-to-be; even if she is unwillingly pregnant, she has a prima facie responsibility to put neither herself nor what will be a born child deliberately into harm's way. The woman may need to manage her nausea by what she eats or chooses not to eat. She may need to manage high blood pressure or gestational diabetes, or drug addiction. She may consult a physician to make sure that she and the fetus are healthy and take steps, when something is wrong, to correct the problem. She will have to adapt herself to her growing body, making or buying or borrowing clothes that will accommodate her swelling belly, perhaps taking extra rest when needed, learning to walk with the swaying gait that supports her new center of gravity. Indeed, in recent years, I note that greater numbers of middle-class women are likely to make a full-blown project of their pregnancies: they do online research, visit mommy blogs and pregnancy chat rooms, read What to Expect When You're Expecting, buy ergonomically designed baby paraphernalia, hire midwives and dulas, take pregnancy yoga classes, and on and on ad infinitum. The social pressure for women to take full control of their pregnancies is not all to the good, however. If a woman thinks of herself as the sole master of her fate, then if she should miscarry, she may well feel that she was to blame because it was all her own doing. It wasn't, of course. Human pregnancies are not purposeful in every respect, even though they are more than a purely biological process. There is one other kind of activity that women who know they are pregnant engage in. It is a practice that I have elsewhere described as calling the fetus into personhood (Lindemann 2014). As I understand it, personhood is not a matter of capacities or characteristics that constitute an individual as person (see, among many others, Tooley 1983, Strawson 1959, Dennett 1976, Schechtman 1996). Rather, it is conferred by a social practice into which humans are initiated at a very early age. It consists of four elements: (1) a human being has sufficient mental activity so that the succession of mental states constitutes a personality, (2) aspects of this personality are expressed bodily, (3) other persons recognize it as the expression of a personality, and (4) they respond to what they see. Recognition and response are often a matter of understanding who someone is and treating them accordingly. Whether these understandings are self-conceptions or others' sense of who we are, they consist of a web of stories depicting our most important acts, experiences, characteristics, roles, relationships, and commitments. This narrative tissue constitutes our personal identities. The bodily expression of a personality and its uptake by others in the form of recognition and response makeup what can be called the social practice of personhood, the practice on which all other social practices rest. If this is right, then fetuses are not persons, as they haven't yet developed the personalities to which they will give bodily expression when born, and in any case the pregnant woman couldn't recognize that expression even if it existed, much less respond to it. So what she does instead is call the fetus into personhood, by making physical arrangements for it, creating social space for it within her family and the wider community, and, in an imaginative projection, conceiving of it as if it were already the born child she hopes it will become. In this act of imagination, she draws on or creates the stories that constitute that child's proto-identity. William Ruddick has usefully called the forward-looking relationship established in this way a proleptic relationship (Ruddick 2000, 97). Prolepsis, as a literary device, is the treating of a future state of affairs as if it already existed. It's achieved by means of an anticipatory adjective, as in the poetic “While yon slow oxen turn the furrowed plain,” where the plain won't actually be furrowed until later, after the oxen have finished turning it. Proleptic pregnancies also anticipate the future in this way, because the mother-to-be treats the fetus as if it had already attained personhood. It's not uncommon in the course of a pregnancy, for example, for the woman to give the fetus a nickname (my first fetus was Oscar, although the baby turned out to be a girl) and all sorts of other activities, from furnishing a nursery to starting a college fund, are apt to take place in the months before the child is actually born. Ruddick dubs the proleptic view of pregnancy the “maternalist” conception, because the gestating woman thinks of the pregnancy as a maternal project. Note how, in accepting the pregnancy and beginning the process of calling to her fetus, the woman adds an important set of stories to her own self-conception. She now not only bears the identity of a pregnant woman but also becomes a particular kind of pregnant woman: she is a (fittingly proleptic) expectant mother. The stories surrounding pregnancy, then, are mostly forward looking: many of the pregnant woman's activities anticipate the birth of the child. These considerations about what the pregnant woman is doing give us some insight into what is lost when a miscarriage occurs. As the woman and those around her continue to call the fetus into personhood, it takes on more and more of the worth of paradigmatic persons—the worth that Kant called “beyond price.” So one thing that is lost in a miscarriage is this thing of growing pricelessness. As the woman nears her due date, her work of imaginative projection also nears completion; what was once proleptic has now almost caught up with itself. If the woman miscarries then, she may have been calling to her fetus so long and steadily that, for her and the others who have been calling to it (grandparents, siblings, friends, even strangers), the fetus is her child and she grieves for it as if it had already been born. Indeed, even if it's an early miscarriage, she may mourn the loss of the child that is not to be. The obstetrician Anne Drapkin Lyerly writes of a woman, Janine, who lost one of the twins she was carrying early in the pregnancy and clearly conceived of her loss in that way. After the surviving twin was born Janine reported that she just “didn't feel ready to meet this new baby because she hadn't really felt like she'd said good-bye to the other one that wasn't being born” (Lyerly 2013, 247). How the woman conceived of herself with respect to the fetus can be another source of loss. If it was a first-time pregnancy, she may nevertheless have thought of herself as a mother, and now feels the loss of that identity. If she is already a mother, she may still experience the loss as a blow to her identity: she will not be this child's mother. For other women who have miscarried, although, the sense of loss isn't so much about their identities as about their bodies. Raquel, another woman Lyerly interviewed, described the loss as “the feeling that your body has failed you” (Lyerly 2013, 86). Bound up with this feeling can be a loss of trust: a woman may feel that the body that has served her well up to now is no longer reliable, not to be counted on to perform properly. There are other possible losses to the woman as well. One has to do with the intimate intertwinement of the fetus with the woman's body. At birth, of course, there is a physical separation of the two, but this is usually followed by attachment as the woman holds her new baby in her arms. In a miscarriage, there is only the separation. This can be felt as a loss of connection—a loss that extends to connection with others who don't know how to respond to the woman. Lyerly tells how Molly's husband left to feed the dog (and perhaps to grieve by himself) just after she lost a set of twins in a miscarriage. “A nurse or somebody probably told the chaplain at the hospital that I was alone, because somebody suddenly shows up,” Molly reported. “And that was awkward … he didn't really know what to say to me. He did his best. But I felt like I had to put him at ease in his discomfort more than his awkwardness over it. I think at that point I would have preferred to have been left alone” (Lyerly 2013, 114). A fourth kind of loss to the woman centers on neither the child that is not to be, the woman's lost connection to herself, nor the woman's lost connection to others, but on a connection she has lost to the world. Like birth, miscarriage can alter how the world looks to a woman—make it seem less safe, more open to chance, no longer a place of security. As Lyerly puts it, “Women with a history of reproductive loss or infertility may feel not only that they can't trust birth's normalcy, but that risk, in their life, will not pay attention to the odds” (Lyerly 2013, 89). The universe can seem hostile and uncaring, full of dangers that strike capriciously or lurk around every corner. Now let's consider the losses that miscarriage might inflict on the fetus itself. It is not clear just what, exactly, fetuses experience. Younger ones cannot have experiences of any kind, and won't until their cerebral cortexes are well enough developed to register them. Older ones—those in the third trimester, say—can feel pain, sense the woman's heartbeat, stretch their limbs, suck their thumbs, and so on, but the precise content of their experience is another question. I raise this point because it might be thought that if fetuses cannot experience loss, they cannot sustain loss. It's the claim that what you don't know can't hurt you. That claim, however, is surely incorrect. Consider the rich aunt, de rigueur in the best detective novels, who dies and leaves her impoverished but beautiful niece half her estate. Due to the machinations of the elderly woman's evil nephew, who was also her lawyer, the will is suppressed and all the money goes to him. The niece has no expectations in the matter and is delighted by his good fortune, but it seems clear that she has sustained a loss even though she will never know it. By the same token, I submit, the fetus can sustain loss without knowing it. An objection presents itself. It might be argued that the fetus—at least in its early stages of development, before its cerebral cortex is formed—more closely resembles someone in a persistent vegetative state (PVS) than it resembles the impoverished but beautiful niece. Lacking a functioning cerebral cortex, a person in a PVS can have no interests, and if she has no interests, she has nothing to lose. So she can sustain no losses. By the same token, the objection goes on, fetuses lacking a cerebral cortex can have no interests and nothing to lose. So they cannot sustain loss. The trouble with the objection is that it misses the different directions in which the stories depicting the respective situations of the fetus and the person in a PVS are facing. The stories that represent the person in a PVS are mostly backward looking. They enter her identity because they depict her former acts and experiences, earlier roles and relationships, bygone characteristics and commitments, now suspended forever by the trauma that caused the PVS. By contrast, the stories that represent the fetus are mostly forward looking, entering its identity by depicting the child who is yet to come, anticipating his acts and experiences, roles and relationships, characteristics, and commitments. If the persistent vegetative state takes away from a person everything she has to lose—all of what Frances Kamm calls “the goods of experience and action” (Kamm 1993, 18)—the fetal state holds the potential for precisely those goods, to be enjoyed after the child is born. If this is correct, then although both the person in PVS and the fetus lack a functioning cortex, only the person in PVS has no interests. For her, death is no harm. But fetuses that are being called into personhood do have interests. Should a miscarriage occur, they have a lot to lose. What do fetuses have to lose? Why, everything. Fetuses have, to borrow a phrase from Don Marquis, “a future like ours”1 (Marquis 1989, 191). If it is possible for the fetus to be called into personhood, and if it is given the right kind of parental, familial, and social support (a point on which Marquis is conspicuously silent), the fetus can live the life that is distinctive of human beings. The person she or he becomes can have a self and a self-concept, can acquire moral, rational, and other sorts of agency, can play, work, love, make friends, create art, enjoy the world, and do many of the other things that make a human life so valuable. In a miscarriage, the fetus loses all of that potential. Whatever its life as a person would have contained, for good or ill, can no longer be. The person who was being called into existence will never exist, for all of eternity. Death deprives every living being, including the human fetus, “of all the experiences, activities, projects, and enjoyments that would otherwise have constituted [its] future” (Marquis 1989, 189). Existing persons, before they die, have the chance to enjoy at least some of the experiences and activities that make a human life so valuable. A miscarried fetus doesn't even get that. All the futures that were possible for it are closed off before it began to live its life. I find problematic many of the arguments and assumptions Marquis makes in working this insight into his argument for why abortion is immoral, but for all that, the insight itself is a valuable one. Death inflicts the same loss on fetuses set to become persons that it inflicts on people like us. Only I'd add that fetuses lack even the taste of a life lived as a person that might otherwise lessen death's sting. They don't know what they've missed, of course, so whatever they may feel, they won't feel that sting. But they have lost something precious, all the same. Note that while the fetus can only sustain this loss but not experience it, matters are different for the pregnant woman. In the earliest stages of the pregnancy, of course, when the embryo might yet divide into twins, there is no distinct entity that can sustain the loss of its future, no discrete individual the woman can call into personhood. And if the woman does not know she has miscarried such an individual, she cannot be conscious of what it has lost. But if she knows she has miscarried, she knows that loss, just as the wicked nephew knows what the beautiful niece has lost. Even things without consciousness can suffer loss: a book, for example, can lose some of its pages through rough handling. But such a loss is no loss to it, although it may be to the reader of the book. For something to be a loss to something, that thing must possess a consciousness or at least the potential for consciousness. The niece could have been aware of the loss, even though she wasn't, and the fetus could have felt the loss had its consciousness been fully evolved. The difference is that the fetus is intertwined with the woman and the woman is a conscious being, so the loss, while not felt by the fetus, is one that the woman can feel and can proleptically project onto her fetus. In fact, it could be argued that the farther along in a wanted pregnancy the woman is when the miscarriage occurs, the greater is the loss, in that the fetus itself is nearing consciousness. Then, the fetus sustains the loss of an individual being whose consciousness has almost evolved, and that of an intertwined proleptic union that is desired and valued by the mother and perhaps also the others around her. The stories that accurately depict the woman who has suffered a miscarriage, then, may or may not represent her as having suffered losses of various kinds; that depends on how she viewed the pregnancy. Any story depicting her viable fetus, however, must represent the loss of its future, or it's a bad story. That is why, even if the pregnancy that ended in miscarriage was unwanted, some doubt would be felt about a woman who, to paraphrase Bernard Williams, too blandly or readily moved to a feeling of pure relief (Williams and Nagel 1976, 124). If she feels the miscarriage as she ought, that relief will be touched—even if just a little—by darkness. In that way she registers the loss to the fetus itself. Now, perhaps, we are in a better position to see what a family member, friend, or colleague might do to respond well to the woman who has had a miscarriage. The stories of loss to the fetus and the woman that I have catalogued here—of a future like ours, of her baby-to-be, of an important part of her identity, of trust in her body, of trust in the universe—cannot guide action in specific cases, but they might give us a sense of the narrative possibilities. Because any miscarriage can be epistemically opaque, it's often wisest for others not to assume they know how to understand a given one, much less how to respond to it. Here as elsewhere, the best thing the third party might do is to ask the woman, “What are you going through?” (Weil 1973, 75) The question is both an invitation to the woman to tell her story and a promise that the person asking will listen to the story. Attentive listening is an integral part of any narrative exchange, and it can be morally crucial for interactions with people who have experienced a traumatic event (Brison 2003). Part of what can be upsetting for the woman, however, is an inability to articulate a story that captures what this is like for her. If it is clear the woman wants to tell such a story, but does not know herself how the story goes, it might be possible for the listener to help her co-construct it. Then, the listener might begin by asking if the woman is grieving a loss, and the story could be constructed around the focus of her grief. If the woman says she is not grieving but is taken aback by the sense that she doesn't know how she feels, the listener could ask if perhaps that sense comes from the fact that the fetus has lost all its possibilities, and the story could go on from there. I offer these suggestions with great trepidation, knowing that conversations about miscarriage can be emotionally fraught. Perhaps they ought not to be. Perhaps we should call for a shift, on feminist grounds, in the social attitudes toward miscarriage that relegate it to the private and purely personal sphere and give women who have had one a sense of inadequacy and failure. Until that shift comes, however, these attitudes can complicate whatever else the woman might be feeling. Given the current state of affairs, the best those around her may be able to do is to leave unspoken the stories that are too painful for her to tell. Some sorrows go too deep for words, and others are too fragmentary or chaotic or fleeting to be captured by words. Here is a final thought. Many of the stories of loss reported by women who have had a miscarriage center on some kind of broken connection, whether to the child to come, to the woman's own self, to the people around her, or to the world. Some of those connections are gone for good, but others can be repaired. If people responding to the woman can contribute to the work of repair, they might want to give it a try. But even if repair is impossible, those who listen to the woman can always connect. My thanks to Kate Norlock and Jamie Lindemann Nelson for discussing these matters with me.