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The Moral Meanings of Miscarriage

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

10.1111/josp.12091

1467-9833

Sarah Clark Miller,

Patient Dignity and Privacy

Miscarriage is a confounding phenomenon. Often spoken about obliquely and other times shrouded in silence, we are not sure what to make of it and even less sure how to respond to those who experience it. Women who miscarry can find themselves with few resources to help decipher the meaning of their loss.1 Whereas in the case of pregnancy our collective consciousness is overcrowded with multitudinous meanings, the analogous space for miscarriage is a relative void. This emptiness is particularly curious given the prevalence of miscarriage: an estimated 20 percent of all pregnancies end in spontaneous abortion.2 Nearly one million miscarriages occur in the United States every year.3 Thus, many women experience pregnancy loss firsthand. It also touches the lives of their partners and other family members. Why, then, the neglect of this unfortunately common event? Another way to pose this question is to ask, “Why the silence surrounding miscarriage?” Jessica Zucker, a clinical psychologist specializing in women's reproductive and maternal mental health, recently provided one response in a Motherlode column for the New York Times. She writes, “We shouldn't feel ashamed of our traumas, nor should we hide the consequent grief. … I … feel compelled to question why it seems as if we rarely talk about pregnancy loss, though the statistics are staggering. Is it resounding cultural shame? Speckles of self-blame? Steadfast stigma? The notion that talking about ‘unpleasant’ things is a no-no? It's a hard topic. But if every woman who has lost a pregnancy to miscarriage or stillbirth told her story, we might at least feel less alone.”4 Determining the meaning of pregnancy loss represents one important way for women to move beyond both neglect and silence, as well as hopefully to lessen associated trauma through the construction of meaning understood as a mode of recovery.5 In this article, I seek to address an aspect of the general inattention to miscarriage by examining a pressing issue: the moral meanings of pregnancy loss. I focus primarily on the import of such meanings for women in their ethical relationships with themselves, while also finding significant the meaning of miscarriage in community, that is, for our shared moral lives. Exploring miscarriage as a moral phenomenon is critical for figuring out miscarriage's impact on our ethical self-conception—on how we understand ourselves as moral agents—and in forming and deforming how we understand one another in the broader context of our moral communities—in intimate realms, in public realms, and in various realms in between.6 While the modes of silence that tend to surround miscarriage are multiple—cultural silences, interpersonal silences, historical silences—the silence that serves as a main impetus of this article is scholarly silence. Reviewing the literature on miscarriage in philosophy and closely related disciplines is far from an arduous task.7 Of particular interest here is the lack of discussion about miscarriage in the ethics and bioethics literatures, where scholars have amply theorized other prenatal events and conditions (e.g., pregnancy, genetic testing, and abortion).8 As a result of this scholarly silence, or at best minimal conversation, the moral meanings of miscarriage remain philosophically and ethically underdetermined. I believe there are at least two main reasons for this scholarly silence—one political and one intellectual. Politically speaking, discussions of miscarriage can easily become entangled with the politics of abortion, making miscarriage perilous political territory. Miscarriage and abortion both address the subject of the not-yet-human, which may explain the reluctance of some feminist scholars to enter the fray. The impetus to grant a degree of moral standing to the embryo/fetus in an effort to acknowledge the weightiness of what women lose when they miscarry can inadvertently and unhappily add fuel to the anti-choice fire, generating unintended and inaccurate implications for abortion politics. Political turmoil can make good theorizing about the not-yet-human difficult, which is all the more reason for feminists to take on the task of careful consideration of the matter. It is essential that academic and public discussions of miscarriage include a wide variety of voices and perspectives, especially those most likely to represent women's interests. Avoiding the complexity of the human liminality9—be that complexity moral, political, emotional, or other—will not make it go away and reinforces a culture in which miscarriage is not to be discussed. Ultimately, while engaging in ethical consideration of pregnancy loss risks the unwitting support of anti-choice efforts, the risks of not entering the conversation are greater. In addition to this significant political reason for silence, I suspect that there is also a leading intellectual one. Discerning the moral meanings of pregnancy loss presents a challenge because miscarriage tends to exceed the extant conceptual resources and language we have at the ready. As a liminal event, it involves entities and conditions that slip between recognized categories—a growing entity that is not quite human, yet not other, or a woman's identity as somewhere between mother and not as she faces fetal demise and transitions to not being pregnant while waiting for the fetal heartbeat to wane.10 The implications of miscarriage's inbetweenness for ethics are thorny and profound, rendering standard conceptual resources wanting and requiring the development of additional resources, which I consider below under the guise of perinatal ethics. The usual suspects—agency, intention, act, outcome, responsibility—fail to fully capture the nuances of the shifting nature of the experience and moral content of miscarriage. Through a process of refashioning and amendment, we can begin both to tweak existing ethical concepts, as well as to generate new concepts better suited to the task of comprehending the phenomenon and its import for our shared moral lives. In what follows, I first till the ground of inquiry by articulating the need for a dedicated perinatal ethics, then developing an overview of this approach. It is against this backdrop that miscarriage's complex moral meanings can best emerge. I then consider a few promising yet problematic concepts for comprehending the moral meanings of miscarriage, including moral agency, reactive attitudes (in this case, betrayal and guilt), moral responsibility, and moral standing. Throughout, I place women who miscarry and their relationship with themselves at the center of the analysis. In doing so, I do not mean to deny the importance of the experience of partners and other family members who may be similarly invested in the outcome of a pregnancy. I do intend, however, to acknowledge the moral centrality of those who contain the embryo/fetus within their own bodies, which I take to be a fact of foundational moral significance. In addition, I focus on women who experience miscarriages of “wanted” pregnancies (itself a strange term), and more specifically, those who experience a sense of self-betrayal and guilt in the wake of their miscarriages.11 A conventional interpretation characterizes these reactions as inappropriate, misplaced, or irrational feelings of responsibility functioning as an expression of grief. While this may hold in some cases, in this article, I consider how we might otherwise make sense of this kind of reaction. Could we understand it as a reasonable way of discerning the moral meanings of a miscarriage? Perinatal (bio)ethics12 is an emergent subfield of philosophy that addresses the moral issues that arise before, during, and after pregnancy.13 A decent ethical approach to miscarriage will consider the full arc of experience of miscarriage rather than focusing on one discrete, crystallized moment of the overall experience. Perinatal ethics encourages this more expansive view, as well as a fluid approach, incorporating the changes in a woman's identity from the time before she is pregnant, during the pregnancy, while miscarrying, and after. Perinatal ethics includes some familiar territory, such as how best to make decisions about the use of new reproductive technologies or genetic diagnostic testing. Other issues addressed under this umbrella term might also include which course of treatment to pursue when a baby is born too soon or very ill. Generally speaking, many perinatal ethical quandaries call for a balanced evaluation of the potential for benefit versus the possibility of risk. This more standard ethical formulation, however, does not make sense for the condition of pregnancy loss, thus again demonstrating the distinctiveness of this reproductive event. While miscarriage may contain some morally idiosyncratic features, how contemporary ethics and bioethics fail to do it justice serves as a microcosm of how many perinatal issues are inadequately addressed by standard ethical concepts. Perinatal ethics thus opens the door to a more expansive approach to ethics and bioethics and provides vital resources for creating an adequate approach to the ethical quandaries arising in the general areas of subfertility, pregnancy loss, and fetal death. Recognition of the importance of thinking through the philosophical implications of miscarriage gives rise to a broader opportunity: to draw attention to, and therefore better theorize, the distinctive ethical nature of the perinatal realm. In so doing, we can begin to fill in the gaps of our ethical understanding. In considering the very possibility of perinatal ethics, one could wonder whether pregnancy, birth, and early infancy require a distinct approach. Are what we might consider to be standard or traditional bioethical frameworks adequate and appropriate for treating perinatal ethical issues? Is there something about the nature of pregnancy, abortion, miscarriage, birth, and early infancy that goes beyond what the conceptual resources already provided by current mainstream theories of bioethics can capture? Why ought we consider perinatal ethics to be special in any significant sense? While this is perhaps not the place either to offer a full theory of perinatal ethics or to mount a complete defense, I will offer a few observations to address these questions. Several features of perinatal relationships challenge the adequacy of traditional bioethics, thus creating a conceptual need and space for what I am arguing should be the subdiscipline of perinatal ethics. A profound intertwining and intercorporeality characterizes multiple stages of the perinatal, including the interdependent nature of woman and embryo/fetus, of woman and emerging child, and even of parents and infants. This challenges the individualistic orientation of most mainstream approaches to bioethics, opening space for a more significantly relational form.14 While more traditional strains of bioethics offer resources to analyze the moral issues that arise in interpersonal relationships, those resources may prove inadequate for sorting through the moral murkiness that relationships with nascent entities—such as a growing fetus—present.15 In addition, feminist bioethicists remain uncertain about the conceptual adequacy of the resources that more standard models of bioethical theory provide for analyzing the morality of relationships. The conceptual facets of relatedness—intertwining, interdependence, and complicated reliance—are a plentiful assemblage from which to fashion the structure of perinatal ethics.16 As one example, such resources are already extant in the literature arguing for a relational account of autonomy in bioethics. This approach can be found, for example, in the work of Susan Sherwin, Hilde Lindemann, and Rosemary Tong.17 An explicitly relational bioethics could offer reconceptualized and reinvigorated models of interest, responsibility, and responsiveness that differ from those currently on offer by their attention to intertwined subjectivities. In addition, the ever-shifting boundaries of self/other, subject/object, and agent/patient in the evolving relationship between woman/mother and fetus/child require augmented theoretical resources. While certainly bioethicists are aware of the need to acknowledge the emergence of personhood (as well as its retreat), a dedicated perinatal ethics could generate better normative formulations to address the ever-changing moral landscape of the perinatal period. In this section, I explore two promising, yet also limited standard ethical concepts for grasping the moral dimensions of miscarriage: agency and reactive attitudes. Agency is a common feature of many ethical theories. One way ethicists understand agency is as the ability to bring about meaningful ends for yourself; it is sometimes also rendered as the concept of acting in the world so as to achieve your self-determined ends. The related term, moral agency, is the ability to act in accordance with the moral values and principles you take to be important. Moral agency also involves self-determination in the specific form of determining the values or principles that guide you and then acting in accordance with them. When you are a moral agent in these senses, others can hold you morally accountable for your actions. You can be blameworthy for actions you perform that are morally impermissible, that is, so long as they were not actions beyond your control in the sense of being coerced. In many schools of ethical thought, rationality rests at the center of moral agency in that those who are moral agents enjoy full rational powers. Those moral agents also have the greatest degree of moral standing. In what ways are the concepts of agency and moral agency relevant to an analysis of miscarriage? Can the concept of agency help us grasp its nuances? Are there specific features that the lenses of agency and moral agency bring into focus? Which features do these concepts obscure? And finally, how might we need to tweak the concept of moral agency to get to the heart of the moral meanings of miscarriage? To begin by focusing on the concept of agency, if your self-determined end is to have a child (a significant component of many people's life plan), miscarriage clearly thwarts that end. Pregnant women who wish to have children may experience the sense of a distinct loss of agency when miscarrying. Conceived as such, miscarriage is one's body doing that which one most wants one's body not to do. When it is a pregnancy that a woman wishes were not the case, perhaps a miscarriage can feel like luck, like one's body working in favor of one's desired ends. Luck, however, is a far cry from agency.18 Miscarriage is a complicated loss of agency and a loss of control, because it typically lacks an external causal agent. In most cases, no one external to you bears responsibility for thwarting your agency and causing the miscarriage (setting aside cases in which psychological and/or physical abuse induce pregnancy loss19). Yet it is incorrect to say that you bear the responsibility for doing this to yourself. There is no moral culpability to be assigned. It can seem like it is both you and not you who acts. This kind of moment confounds how philosophers tend to think about agency. It exhausts the standard distinction between moral agent and moral patient. Arguably, you retain aspects of your moral agency, though not with regard to the actual miscarriage. You are also definitely a moral patient in that you are being harmed (or benefited if the pregnancy is not wanted) by the miscarriage. But it seems incorrect to say that when you miscarry there is no actor at all involved and certainly wrong to say that you lack moral agency entirely. Yet the circumstances of there being no moral culpability differ from other usual ways in which this is the case. For example, you may set the self-determined end and life goal of building a home for your family with your own hands as an expression of the way in which you value the bonds of relationship. During a violent storm, a massive oak tree falls on your mostly constructed home, smashing it to pieces. You were the moral agent responsible for building the home as a way of seeking your self-determined ends and expressing your values. You are the moral patient who has been harmed by the tree falling and wrecking the external expression of your moral values, but clearly there is no moral culpability to be assigned to the tree. The tree cannot be held morally responsible. A force of nature has acted on you and although the results interact with the representation of your moral values, there cannot be said to be a moral agent who has directly harmed you. In the case of miscarriage during a wanted pregnancy, you are a moral agent like the house builder is in that the pregnancy is a self-determined end that you are seeking, as well as a representation of the values of significance to you. You are a moral patient in that you experience harm that destroys a representation of your values. The tragedy that befalls you, however, does not come from the outside. In some sense, it is you—your embodied self—who brings it about, but not as a traditional moral agent does and not even as a non-moral agent, like a force of nature does. Understanding the role of the body in this scenario is important. The claim that your self as embodied is intimately involved in the miscarriage may be contentious both because it risks assigning moral culpability to women for causing miscarriage and for the view of the relationship between mind, body, and self on which it relies. While it is the case that in the vast majority of situations women who miscarry are not morally culpable, it is also the case that women often feel morally responsible for the demise of their embryo/fetus. Rather than diagnose this as a mistake or misconception, we can instead explore how to make sense of this citation of moral meaning and embodied agency. By drawing on feminist philosophical resources that reject mind/body dualism,20 which I can only characterize briefly here, we see that a corporeal ethics attuned to the implications of embodied subjectivity for the self fosters this consideration by providing resources not found in canonical accounts of ethics. Various stripes of feminist philosophers of the body, be they phenomenologist, materialist, or new materialist,21 would understand miscarriage as an embodied experience of the self—not a “natural” or unmediated biological phenomenon, but rather one thoroughly informed by social formation and discourse and mediated by cultural representations. Such an account opens up a space in which moral agency—and perhaps to some extent moral responsibility itself—can be embodied. With this background in mind, we can break down the elements of the ethical puzzle miscarriage represents. There is a moral patient—this is a woman in the ways that she can be benefited or harmed by the miscarriage. There is an event or a series of actions, that is, miscarriage. There is an outcome, namely, the loss of the pregnancy. When we rethink selfhood as thoroughly embodied, it seems inadequate to say that women have nothing to do with miscarriage. Even if it is a matter of chromosomal abnormality, a woman as embodied is at least the means of miscarriage. It may be simpler to say that she does not cause the miscarriage, even embracing a mind/body dualism to accomplish this task. Such a move, however, renders incomprehensible the sense some miscarrying subjects have of being part of the miscarriage, while not performing it in a more traditional agential sense, as I noted earlier. It is the woman as embodied who carries out these actions, though she holds no intention of accomplishing this end through those actions. In fact, her self-determined and desired end is likely the exact opposite state of affairs. As another indication of the way in which miscarriage exceeds the standard categories of ethical analysis, consider the following: in the moment of miscarriage, you are a complicated blend of both moral agent and moral patient. Moreover, these two categories fail to capture the sum total of your experience: you are something beyond or between agent and patient—a quasi-moral agent, if you will. This observation further supports the important idea that it is incorrect to characterize the betrayal and guilt that women often feel after a miscarriage, which I will explore in detail below, as irrational or misplaced psychological or emotional responses. It is not that women misunderstand how the concepts of guilt and betrayal work and then misapply them en masse. They are using the moral concepts and categories they have at their disposal, inadequate as they may be, to describe their experience of miscarriage. It should come as no surprise that those concepts and categories cannot accurately capture the full extent of their reaction. What they may be attempting to capture is this very sense of being a quasi-moral agent and of having been in the process of developing moral responsibility for their future child, only then to be thwarted. Making matters murkier, it is not only women who are directly ensnared in the harm of miscarriage. The embryo/fetus is harmed in a way that the house destroyed by the oak tree above is not. It was not yet a full-blown house, though it had the potential to provide shelter and comfort to a family for years to come. We cannot run a parallel line of thought for the embryo/fetus. That the embryo/fetus lost in a miscarriage was not yet a full-blown person, yet had the potential to become one, involves a very important loss of future possibilities that far outstrips the harm of losing a house. Similar to the quasi-moral agency of the pregnant woman, the embryo/fetus exists as a quasi-moral entity—an entity on its way to developing full moral standing. The extent of moral standing grows along with the development of the embryo/fetus, a concept that I consider in the next section. Generally speaking, however, miscarriage clearly demonstrates that there are circumstances in which moral responsibility and moral standing do not toggle on and off like a light switch. Philosophical accounts that render moral standing in this way are wholly inadequate for grasping miscarriage's moral dimensions. I turn now from agency to reactive attitudes. In the case of wanted pregnancies (and sometimes even when women have some negative or ambivalent emotions regarding their pregnancy), miscarriage can give rise to reactions that have tended to be understood purely in emotional or psychological terms, but that should be read in a moral register, too. Two common reactions are betrayal and guilt. Contemporary moral philosophers use the term “reactive attitudes” to refer to such moral reactions. P. F. Strawson inaugurated the concept in 1962 in his well-known article, “Freedom and Resentment,”22 which has been widely influential in contemporary debates about moral responsibility. Analysis of miscarriage in terms of reactive attitudes proves illuminating in some perhaps unexpected ways, while also butting up against certain conceptual limitations that require refashioning and extension to uncover the deeper moral meanings of miscarriage. A brief summary of reactive attitudes will set the stage for further consideration. Participant reactive attitudes are interpersonal moral attitudes. Strawson writes, “What I have called the participant reactive attitudes are essentially natural human reactions to the good or ill will or indifference of others towards us, as displayed in their attitudes and actions.”23 We hold one another responsible, Strawson argues, not through the theoretical judgments we make about others, but instead through this form of participation in interpersonal relationships in which we judge how we treat one another and ourselves. Reactive attitudes can concern how I treat others (self-reactive attitudes), how I treat myself (also a self-reactive attitude), how others treat me (personal reactive attitudes), or how others treat others (vicarious reactive attitudes). Strawson's self-reactive attitudes involve an expression of holding myself accountable or morally responsible for my actions and attitudes toward others. They express an assessment of whether the extent of goodwill I grant others is morally appropriate. I want to emphasize an expansion of Strawson's work that can increase our understanding of an important moral meaning of miscarriage. In the context of self-reactive attitudes, I would like to highlight what I call “self-referential reactive attitudes,” which represent an important feature of our moral relationships with ourselves, namely, how we hold ourselves accountable or morally responsible for our actions and attitudes toward ourselves. Self-referential reactive attitudes express an attitude of evaluation concerning whether the goodwill we grant ourselves is morally appropriate. Self-referential reactive attitudes underscore the dimension of the moral relation with oneself that is not about evaluating our own degree of proper moral regard for others, but rather for ourselves. Further exploration of this concept proves vital for making sense of the morality of miscarriage. An example may help to clarify the nature of this important concept. A classic Strawsonian self-reactive attitude is guilt. Guilt represents an attitude I hold toward myself when I steal my child's Halloween candy. I have wronged him by taking it without his permission. I feel badly within myself about myself for how I have acted toward him. But the question arises of whether I can feel something analogous to guilt as an expression of how I feel about myself when I wrong myself, not another. This would be an example of a self-referential reactive attitude. Take a situation in which you fail to respect yourself: Initially unbeknownst to you, your good friend manipulates you in ways that are deeply disrespectful. After several months you become aware of her manipulative tendencies but neither call her out on them nor end the friendship. In this case, a self-referential reactive attitude of moral self-disgust is appropriate. It represents an attitude you hold toward yourself with regard to how you act toward yourself, rather than toward another. Women who miscarry can evidence a mixture—perhaps even a hybrid—of self-reactive attitudes involving others and self-referential reactive attitudes. We can see this in the attitude of betrayal that women articulate post-miscarriage, which I will treat first, then moving on to the reactive attitude of guilt. After a miscarriage, many women report experiencing a sense of betrayal of themselves.24 This betrayal functions as a twisted inversion of agency, delivering the unsettling impression of being undermined by one's own body. This represents a difficult challenge to a person's agency, especially as an embodied agent, where the ability to control your own body is paramount. On the one hand, there is the desire to have some control over the situation, to imagine oneself as more than a passive recipient of a biological action that one desperately does not want to happen. That biological action occurs within oneself, is oneself, if we take seriously the fully embodied view of the self articulated earlier. Your own body betrays you, though inadvertently; it renders your agency impotent. That the betrayer is the embodied self has profound implications for a woman's moral relation with herself and in this regard evidences a self-referential reactive attitude. It is perhaps trust that suffers most. One salient aspect of what has been betrayed in the context of miscarriage is a woman's trust of her own body. During a crucial time—that of gestation—her body lets her down, failing to do what it is supposed to do, thus ending a chance to bring forth life. Miscarriage can shatter the trust women have in themselves as embodied agents with the ability to carry a pregnancy to term. Though more often thought about in terms of the trust that exists between ourselves and others (interpersonal trust), Carolyn McLeod emphasizes the moral importance of “self-trust” or what we might call intrapersonal trust.25 What breaks down post-miscarriage is trust as an intrapersonal function, as an aspect of knowing oneself and believing in one's reproductive, as well as moral and epistemic, competence. Miscarriage, especially if it is a repeated occurrence, can render women less likely to deem themselves worthy of their own reproductive trust in the future. This problem amounts to the dismantling of a mode of intrapersonal positive regard. While some part of this attitude relates to their biological competence, so to speak, for many women it also includes moral and epistemic components. They feel that they have let themselves down in an ethical (as well as possibly an emotional or psychological) sense and have perhaps in a different sense also let down the embryo/fetus. In addition, they may feel that they have disappointed others who were invested in the pregnancy. Epistemically, a woman may no longer trust her competence as one who knows the status of her pregnancy. Feeling that she cannot count on herself in these ways can ultimately result in a compromise to her moral integrity and can have a cascading effect, as respecting yourself becomes much more difficult when you do not trust yourself and when you question your own moral integrity. Miscarriage is not the only bodily event that can carry with it a strong sense of betrayal. Something similar can happen with other bodily failures—in heart attacks, for example. A major organ in your body, your heart, fails to function as you wish it to. It betrays you and arguably your trust by malfunctioning and placing your life in danger. But in this scenario, there are at least two key differences from the sense