Sunday, September 7, 2008

Criminality versus Dumb Decisions

Earlier this week Lynn Paltrow, executive director of National Advocates for Pregnant Women, published an open letter to Sarah Palin in Alternet, asking her to reconsider her position on abortion:
According to press reports your water broke while you were giving a keynote speech in Texas at the Republican Governors' Energy Conference. You did not immediately go to the hospital – instead you gave your speech and then waited at least 11 hours to get to a hospital. You evaluated the risks, made a choice, and were able to carry on your life without state interference. Texas Governor Rick Perry worried about your pregnancy but didn’t stop you from speaking or take you into custody to protect the rights of the fetus.

After, Ayesha Madyun’s water broke, she went to the hospital where she hoped and planned to have a vaginal birth. When she didn’t give birth in a time-frame comfortable to her doctors, they argued that she should have a C-section. The doctors asserted that the fetus faced a 50-75 percent chance of infection if not delivered surgically. (Risks of infection are believed by some health care providers to increase with each hour after a woman’s water has broken and she hasn’t delivered).

The court, believing, like you that fetuses have a right to life, said, "[a]ll that stood between the Madyun fetus and its independent existence, separate from its mother, was put simply, a doctor's scalpel." With that, the court granted the order and the scalpel sliced through Ms. Madyun's flesh, the muscles of her abdominal wall, and her uterus. The core principle justifying an end to legal abortion in the US provided the same grounds used to deprive this pregnant and laboring woman of her rights to due process, bodily integrity, and physical liberty. When the procedure was done, there was no evidence of infection.

(Read the whole thing here.)
Paltrow doesn't specify how many hours passed before Madyun's doctors pressed for a c-section. An old New York Times article says she'd been in labor for two days and in the hospital for 18 hours. Rachel Roth's excellent study Making Women Pay: The Hidden Costs of Fetal Rights states it had been 48 hours since her water broke. That's long enough that Madyun's decision starts to look fairly foolish by my standards and by most medical guidelines.

But here's the thing: People do lots of things that are stupid, risky, macho, or otherwise blameworthy. Some of these risk other people's lives as well as their own. Not all of these things are illegal. One example would be driving while very sleepy or distracted.

This is naturally true for childbearing, as well. Some people choose unassisted home birth, where the father catches the baby and no midwife or other trained assistant is present. Many of the people who propagandize for unassisted birth believe that birth, like sex, should only involve the couple; some of them also subscribe to right-wing religious ideologies. This is loony and irresponsible, in my view. (Not to mention it's asking a hell of a lot of the father!) Still, it's not illegal. Nor should it be. Imagine the mess if every baby born after a precipitous labor triggered a court case.

Another example Paltrow cites is of a woman who insisted on a VBAC at home. There are good reasons that no reputable doctor should condone this. If you give birth vaginally after a cesarean, there's a heightened chance of uterine rupture, which endangers the mother's life as well as the child's. If that occurred at home, odds are great that you'd bleed out before you could get help.

This woman, too, was forced by court order to have a c-section. This goes against our law on medical treatment in every other instance. A person cannot be forced to have surgery or undergo radiation even if they would surely die without the treatment. No one can be forced to donate a kidney - even if he or she is the parent of the patient needing a transplant.

If you believe humans have a right to bodily integrity and autonomy, you cannot legislate women's childbearing decisions. You certainly can argue that these people have an ethical obligation to make wise decisions and that some decisions are so irresponsible as to be unethical. However, unless you want to reduce the woman to an incubator and deprive her of basic rights of personhood, the law has no place intruding on ethics.

This is a long-winded way of saying that it's possible to fully agree with Paltrow's arguments and still maintain that Sarah Palin's choice to board a plane while she was at astronomical risk of going into active labor was a foolish decision. She wasn't taken to task for it legally, nor should she be. Her privilege protected her from any legal action. (Women subjected to forced childbearing decisions have been disproportionately young, poor, unmarried, and non-white.) If we trust women to make their own reproductive decisions, we have to acknowledge that while most women are remarkably altruistic and sensible, there will always be some who make decisions that we personally would never countenance.

But Palin's privilege shouldn't stop us from regarding her choice as 1) reckless and 2) completely hypocritical for someone who preaches the sanctity of fetal life. What's legal - and should remain legal - is not always ethical in every situation. We have a right to demand leaders that understand this distinction.

11 comments:

M.R.Ambrose said...

I hadn't heard about this. Thanks for publishing the letter.
oh!press pass

M.R.Ambrose said...

Thanks for the insight about Kimmel. I was more critiquing the New York Times article than his actual work. I have not read his work, but got the feeling that he was a pretty pro-feminist guy. The writer of the article, Wesley Yang, criticized Kimmel for bringing up cases like Spur Posse too often.

Perhaps if I remove the last paragraph about Kimmel, the essay would speak more about the NY Times piece instead of Kimmel's work. What do you think?

Hope you keep reading oh!press pass

Sungold said...

Hi Madeline. I responded to your Kimmel post at your blog.

Thanks for stopping by my place!

M.R.Ambrose said...

Hope you don't mind, and I don't think you will...but I like to link other blogs from mine that I like and in the same genre as mine. So I am putting a link to your blog on my blog! Feel free to return the favor. ;)

Sugarmag said...

Amen, sister!

Sungold said...

Madeline - Thanks very much for the link. I'll be happy to reciprocate if you're still blogging regularly in a few weeks and I like what I see - which is too hard to gauge with just the two posts so far. So maybe remind me again?

Sugarmag - A lot of this argument could be applied to breastfeeding as well. I think there's a strong ethical imperative to try and make it work. Some people encounter major physical obstacles; for others socioeconomic factors get in the way. I will not judge people in these groups. But a woman who's prosperous, educate, and healthy has an obligation to give it a serious try. I do think less of someone who has all these advantages and still goes straight for the bottle. Obviously I would never want to see the law get involved in enforcing breastfeeding, however!

Sugarmag said...

Hey Sungold! Absolutely! I feel strongly that mothers "should" breastfeed, but I also know that there are lots of reasons why they don't and these reasons are often things that are not the "fault" of the mother, including misinformation, especially from medical professionals, and lack of support. Do I think there should be laws mandating breastfeeding? Of course not!!! But there should be laws that say that mothers have a right to breastfeed in public and there should also be legal guidelines for how artificial milk can be marketed.

Laura Shanley said...

Paltrow makes some good points, as do you. The state does not own our bodies. But why be so hard on those of us who choose to give birth unassisted? Many of us are pro-choice (me included). And if you read my birth stories on my site - http://unassistedchildbirth.com - you'll see that my husband only caught one of our babies. I birthed the others into my own hands. I gave birth unassisted because I believed in my own abilities and did not want anyone telling me how to give birth. Midwives in most states are required by law to intervene - check dilation, time contractions, transfer a woman to the hosptal if she doesn't give birth within a certain time frame, etc. (a time frame that is determined by the state). I believe I have a right to give birth in my own way and in my own time.

As far as Palin, regardless of how anyone feels about her politics, I think there are misconceptions about her "labor." Her water didn't break. She was leaking amniotic fluid, but this is not necessarily an emergency. Waterbags can and do reseal. She said she had been in labor before and knew that while she was feeling some mild contractions, she wasn't in labor. People seem to think she would have been safer giving birth in Texas with doctors she had never met. She knew she felt more comfortable going home. So she did. After returning home she went to a doctor she knew and felt comfortable with - a GP not an OB/GYN (who are often quick to do c-sections and perform other unnecessary and often dangerous interventions). Once home, she was induced and gave birth soon after. If the birth had been truly imminent, she wouldn't have needed to be induced (of course perhaps she didn't need to be induced at all).

I support Sarah Palin in her decision to give birth in the way that felt right to HER. But yes, I agree with you - she should support women who know there are times when carrying a child to term is not in their, or the child's best interest.

Sungold said...

Sugarmag, we are totally on the same page here - especially regarding laws guaranteeing the right to breastfeed in public places. It's barbaric to expect women to do it in bathrooms - no adult would eat there!

Laura, I will say I think your approach to birth is absolutely fascinating. I also don't want to make you stand in for everyone who chooses unassisted birth; I linked to you because you are perhaps the most prominent spokeswoman. I've read the stories on your site and I found them very interesting, even if it's a choice I wouldn't make myself.

I would fiercely defend your right to make the choices you've made - again, even though I wouldn't make them.

I'm also aware that there are better ways to deal with midwives - I had my first baby in Germany, and while midwives are formally subservient to doctors in that doctors take over whenever anything "abnormal" occurs, midwives do have a fair amount of latitude there. And I think that's a good thing. They're also required to have strong formal training, and while I respect women's experience, I do think that this training is a good thing - even though it does definitely place the midwives within a medicalized model of birth.

I'm a historian of childbirth, so I'm very attuned to the various things that can and do go wrong - this includes medical error and meddling - but also the fact that nature really doesn't care if some mothers and babies don't survive, or come through only with serious injuries.

So - to be slightly less polemical than I was in my post - unassisted childbirth goes *way* beyond my risk tolerance. I think there's a strong case to be made for having a trained attendant present. But again, I would strongly defend your *right* to made decisions, as you have.

As for Palin - the problem is she got on an airplane for a very long flight. I'm aware that a slow lead of amniotic fluid is not in itself an emergency - I have a post from a few days ago where I make clear that the risk of infection was not a major factor. But her odds of going into labor were quite high. Most airlines won't allow women to fly at 36 weeks, and for good reason - the pressure change also promotes premature contractions. Giving birth on an airplane is just not a good idea when you're four weeks premature and carrying a child with a known health issue - 50% of Down syndrome babies have cardiac problems.

So, waiting *on the ground* would have been perfectly reasonable. Getting on an airplane - much less so.

Thanks for stopping by and contributing a point of view that would otherwise not be heard. I may disagree with some of your points, but I very much appreciate your taking the time.

labortrials said...

Another example Paltrow cites is of a woman who insisted on a VBAC at home. There are good reasons that no reputable doctor should condone this. If you give birth vaginally after a cesarean, there's a heightened chance of uterine rupture, which endangers the mother's life as well as the child's. If that occurred at home, odds are great that you'd bleed out before you could get help.

Actually, many women who have undergone an unnecessarian (and even some who had necessary ones) believe that their chances of having a VBAC in a hospital setting are quite slim. Cesarean surgery is marvelous when used appropriately; the 31% c/s rate and declining maternal-fetal outcomes point to the fact that cesareans are overused MAJOR medical procedures.

Most homebirth midwives have the necessary skills and tools to deal with complications away from the hospital. Certainly a major rupture might end poorly at home, but it might also end poorly at a hospital where the "decision to incision" time is around 30 minutes. And women with one transverse lower uterine incision are only at SLIGHTLY greater risk of rupture (statistically insignificant, actually) than your average low-risk first time birther.

There are alarming potential consequences of medicalized birth. Have a look at http://www.childbirthconnection.org and http://www.ican-online.org for starters if you're not already aware of these organizations.

Sungold said...

Labortrials: We're agreed that 31% is too high, for sure. What's driving this is largely the fear of malpractice suits. (I know it's not the only factor, but it's the biggest one.)

A similar trend is decreasing women's chances to have a VBAC. My local hospital no longer offers it as an option. Again, it's the fear of malpractice suits.

As you may have noticed in my last comment, I'm a historian of childbirth, so I'm very well versed in this stuff (and of course familiar with the resources you linked). I realize that hospitals are also often unequipped to handle a true emergency - which is part of the problem here locally - but if you're at home and need to be transferred, you've got an even greater delay.

Last study I saw on uterine rupture indicated a real (not statistically insignificant) increased risk. However, it must be said that certain medical interventions (Pitocin, Cytotec!!) increase the risk, too, and I don't know offhand whether the study I have in mind controlled for that.