This article examines one of the relevant concepts in the current debate on home birth—autonomy in place of birth—and its uses in general language, ethics, and childbirth health care literature. International discussion on childbirth services. A concept analysis guided by the model of Walker and Avant. The authors suggest that autonomy in the context of choosing place of birth is defined by three main attributes: information, capacity and freedom; given the antecedent of not harming others, and the consequences of accountability (...) for the outcome. Model, borderline and contrary cases of autonomy in place of birth are presented. A woman choosing place of birth is autonomous if she receives all relevant information on available choices, risks and benefits, is capable of understanding and processing the information and choosing place of birth in the absence of coercion, provided she intends no harm to others and is accountable for the outcome. The attributes of the definition can serve as a useful tool for pregnant women, midwives, and other health professionals in contemplating their moral status and discussing place of birth. (shrink)

Minkoff et al.’s contention that Dobbs threatens pregnant women’s right to refuse medical treatments that would risk the embryo’s life offers a bracing set of challenges to ethicists who affirm the...

Howard Minkoff, Raaga Unmesha Vullikanti and Mary Faith Marshall argue that the U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization not only undermines the right to abortion b...

Feminist bioethicists have long shed light on the indignities and injustice of reproductive intrusions, be they coerced gestation or forced interventions during pregnancy and birth. Writing about t...

In this paper, I reflect on an important article by Bob Veatch in the inaugural issue of the Hastings Center Report, entitled “Experimental Pregnancy.” It is a report and elegant analysis of the Goldzieher Study, in which nearly 400 women were randomized to receive hormonal contraception or placebo absent consent or disclosure about placebo use, resulting in several pregnancies. Noting the study’s limited notoriety, I first consider the narratives that have instead dominated bioethics’ approach to pregnancy and research: thalidomide and (...) diethylstibesterol. These narratives have facilitated a narrow focus on avoiding fetal risk, to the exclusion of other ethically relevant considerations. I then revisit “Experimental Pregnancy” and offer two ways in which Bob’s analysis serves as an important corrective, first, by foregrounding research subjects, and second, by normalizing pregnancy and thus foregrounding foundational ethical considerations that are sometimes lost amidst pregnancy’s presumed exceptionalism. (shrink)

I argue that public officials and health workers ought to respect and protect women’s rights to make risky choices during childbirth. Women’s rights to make treatment decisions ought to be respected even if their decisions expose their unborn children to unnecessary risks, and even if it is wrong to put unborn children at risk. I first defend a presumption of medical autonomy in the context of childbirth. I then draw on women’s birth stories to show that women’s medical autonomy is (...) often ignored during labor. Medical interventions are performed during childbirth without women’s consent. Childbirth is risky and some coercive medical interventions may be understood as attempts to protect children and to prevent mothers from acting impermissibly. However, even if it is wrong to make risky choices during childbirth, women have rights to do wrong in these cases. Therefore, coercive medical interventions are impermissible during childbirth and institutions should adopt specific protections for obstetric autonomy. (shrink)

The US Food and Drug Administration (FDA) is fraught with controversies over the role of values and politics in regulatory science, especially with drugs in the realm of reproductive health. Philosophers and science studies scholars have investigated the ways in which social context shapes medical knowledge through value judgments, and feminist scholars and activists have criticized sexism and injustice in reproductive medicine. Nonetheless, there has been no systematic study of values and gender norms in FDA drug regulation. I focus on (...) three questions about values in regulatory science. First, how have societal values and gender norms shaped the way that the FDA regulates drugs in the realm of reproductive health, specifically with drug labels? Second, what are the ethical, epistemic, and social consequences of these influences on regulation for women and other marginalized groups? Third, which societal values and gender norms ought to influence drug regulation about reproductive health, and how ought this happen? Integrating philosophical analysis with historical archival research and in-depth interviews, I conduct three case studies of drug labeling about reproductive health: (1) the “drug fact” about the mechanism of the morning-after pill; (2) the package inserts for patients about the health risks of oral contraceptives; and (3) the special physician labels made for prescribing drugs to pregnant women. I identify three challenges for the FDA and suggest ways to reduce the influence of sexist values and facilitate feminist alternatives. First, across these cases, I have found that there are many ways in which other concerns in reproductive medicine (such as zygotic life, fetal health, and population control) have devalued women’s health. Second, both knowledge and ignorance xvi about their reproductive health have contributed to women’s oppression, especially poor women and women of color. Finally, by avoiding the epistemic dimensions of ethics, powerful, mostly male parties in medicine (such as doctors, pharmaceutical companies, and religious institutions) have misused “informed consent,” “religious freedom,” and “paternalism” for unethical purposes. For improvement, I suggest extracting sexist values and gender norms from regulatory science that cause epistemic injustices, and I point to success stories for reforming sexism with feminism at the FDA. (shrink)

As a feminist bioethicist, I have frequently wondered why the exclusion of pregnant women has been the default position for most clinical research and how social values have influenced this decision. Relatedly, I wonder what responsible research involving pregnant women would look like. As a theorist who conducts research on the concept of vulnerability, I have often wanted to know why there has been so little research into the harmful effects of the routine exclusion of pregnant women, including questions such (...) as: What do pregnant women actually think about participating in research? How should we treat pregnant women and their fetuses for the purposes of consent (are they two separable persons or one complex... (shrink)

In this article, we discuss decision making during labor and delivery, specifically focusing on decision making around offering women a trial of labor after cesarean section. Many have discussed how humans are notoriously bad at assessing risks and how we often distort the nature of various risks surrounding childbirth. We will build on this discussion by showing that physicians make decisions around TOLAC not only based on distortions of risk, but also based on personal values rather than medical data. As (...) a result of this, we will further suggest that the party who is best epistemically situated to make decisions about TOLAC is the woman herself. (shrink)

The Women's Movement has greatly benefitted women in the workplace. What about in their encounters with medicine? This paper reviews the history of physicians’ attitudes toward women and then considers three contemporary areas of medicine in particular: health research relevant to women, health policies, and women's success at working their way into the medical profession. The picture that emerges is somewhat less than rosy. The androcentrism that has been so glaring in the history of medicine has not entirely gone away. (...) Women and their concerns are still considered less important than men's, and women are valued more for what they provide than for who they are themselves. These problems are mostly not the fault of specific physicians or other individuals; they are, rather, systemic problems—the result of social practices and institutions that work together quite impersonally to favor the interests of men over women. Correcting them requires listening to women's voices better than medicine, or bioethics, has so far managed to do. (shrink)

Subpart B of 45 Code of Federal Regulations Part 46 (CFR) identifies the criteria according to which research involving pregnant women, human fetuses, and neonates can be conducted ethically in the United States. As such, pregnant women and fetuses fall into a category requiring “additional protections,” often referred to as “vulnerable populations.” The CFR does not define vulnerability, but merely gives examples of vulnerable groups by pointing to different categories of potential research subjects needing additional protections. In this paper, I (...) assess critically the role of this categorization of pregnant women involved in research as “vulnerable,” both as separate entities and in combination with the fetuses they carry. In particular, I do three things: (1) demonstrate that pregnant women qua pregnancy are either not “vulnerable” according to any meaningful definition of that term or that such vulnerability is irrelevant to her status as a research participant; (2) argue that while a fetus may be vulnerable in terms of dependency, this categorization does not equate to the vulnerability of the pregnant woman; and (3) suggest that any vulnerability that appends to women is precisely the result of federal regulations and dubious public perceptions about pregnant women. I conclude by demonstrating how this erroneous characterization of pregnant women as “vulnerable” and its associated protections have not only impeded vital research for pregnant women and their fetuses, but have also negatively affected the inclusion of all women in clinical research. (shrink)

Despite increasing recognition of the ways in which ethical and social values play a role in science (Kitcher 2001; Longino 1990, 2002), scientists are often still reluctant to acknowledge or discuss ethical and social values at stake in their research. Even when research is closely connected to developing public policy, it is generally held that it should be empirical data, and not the values of scientists, that inform policy. According to this view, scientists need not, and should not, endorse non-epistemic (...) values related to their research, as doing so may bias their assessment of what the evidence is. As a result, debates over science-based policy tend to be construed solely as empirical discussions to be .. (shrink)

Among feminist philosophers, there are two lines of argument that sexist values are illegitimate in science, focusing on epistemic or ethical problems. This article supports a third framework, elucidating how value-laden science can enable epistemic oppression. My analysis demonstrates how purported knowledge laden with sexist values can compromise epistemic autonomy and contribute to paternalism and misogyny. I exemplify these epistemic wrongs with a case study of the morning-after pill during its 2006 switch to over-the-counter availability and its new drug label (...) from the US Food and Drug Administration that it “may prevent implantation.” Antiabortion science advisers created this label to protect zygotes based on debated value judgments that were later concealed. This zygote-centric knowledge enabled them to shape potential users by instructing “good mothers” that they ought to protect zygotes and punishing “bad mothers” by refusing their requests for the drug. Therefore, I argue that the sexist values and gender norms of antiabortionists that prioritize zygotic health are illegitimate in this context because they cause epistemic injustices and perpetuate epistemic oppression. Furthermore, I advocate against blanket protections for the “right to conscience” and “religious freedom” of healthcare providers because they reinforce the epistemic oppression of women, especially those on the margins.Content Warning: This article discusses sexual assault and refusals to provide contraception to patients, including survivors. (shrink)

ZusammenfassungDieser Artikel beleuchtet die tragende Rolle, die Umweltdenken und Umgebungswissen für die Legitimation traditioneller Geschlechterrollen im 20. Jahrhundert spielten. Gezeigt wird, auf welche Weise einflussreiche psychologische und psychoanalytische Konzepte der Kindes- und Persönlichkeitsentwicklung Frauen dazu anhielten, sozio-naturale Umwelten herzustellen, ja, selbst Umwelt zu sein. Expertinnen und Experten verschiedener Denkrichtungen und Generationen propagierten ein ganz ähnliches Bild femininer „Environmentalität“, das heißt: der Disposition und Bestimmung der Frau, Umwelten zu erzeugen und zu verkörpern, die eine gesunde Kindesentwicklung ermöglichen und das Wohlbefinden und (...) den Erfolg des Mannes, gar den Erhalt der gesellschaftlichen Ordnung begünstigen sollten. Dieses Konstrukt weiblichen Umwelt-Seins verpflichtete Frauen auf Ehe und Vollzeitmutterschaft und fixierte sie in Raum und Zeit. Sein reaktionärer Gebrauch in Auseinandersetzungen über alternative weibliche Lebensentwürfe demonstriert, dass leitende Konzeptionen von Entwicklung, Wohlergehen und Identität nicht nur androzentrisch, sondern antifeministisch waren. (shrink)

This article shows how environmental and ambient constructions were used to legitimate traditional gender roles in twentieth-century Europe and the United States. It demonstrates the normative and reactionary character of influential psychological and psychoanalytic theories of childhood and personality development, which instructed women to create, even embody social and emotional environments. This body of thought spanned diverse psychoanalytic schools and extended across generations of psychological experts. They put forth a notion of feminine “environmentality” postulating a woman’s disposition to create, even (...) personify an environment that facilitated normal child development as well as a man’s professional success—and, ultimately, sustained the social order. This construction of women as essentially environmental beings bound them to matrimony and full-time, at-home motherhood, fixing their lives in space and time. It provided a powerful weapon against alternative life-styles and feminist critiques, suggesting that leading conceptions of development, well-being, and identity were not just androcentric, but indeed anti-feminist. (shrink)

At no time in recent decades has more attention been paid to ethical issues in pregnancy. Particularly riveting—and alarming, to many—was the passage of Senate Bill 8, a Texas law banning abortion...

Drawing on sociological and anthropological studies, the aim of this article is to reconstruct how obstetric technologies contribute to a moral conception of pregnancy and motherhood, and to evaluate that conception from a normative point of view. Obstetrics and midwifery, so the assumption, are value-laden, value-producing and value-reproducing practices, values that shape the social perception of what it means to be a “good” pregnant woman and to be a “good” mother. Activities in the medical field of reproduction contribute to “kinning”, (...) that is the making of particular social relationships marked by closeness and special moral obligations. Three technologies, which belong to standard procedures in prenatal care in postmodern societies, are presently investigated: informed consent in prenatal care, obstetric sonogram, and birth plan. Their widespread application issupposed to serve the moral goal of effecting patient autonomy. A reconstruction of the actual moral implications of these technologies, however, reveals that this goal is missed in multiple ways. Informed consent situations are marked by involuntariness and blindness to social dimensions of decision-making; obstetric sonograms construct moral subjectivity and agency in a way that attribute inconsistent and unreasonable moral responsibilities to the pregnant woman; and birth plans obscure the need for a healthcare environment that reflects a shared-decision-making model, rather than a rational-choice-framework. (shrink)

International media have reported cases of pregnant women who have had their children apprehended by social services, or who were incarcerated or forced into treatment programs based on a history of substance use or lack of adherence to addiction treatment programs. Public discourse on the biology of addiction has been criticized for generating stigma and a diminished perception of self-control in individuals with an addiction, potentially contributing to coercive approaches and criminalization of women who misuse substances during pregnancy. We explored (...) whether this is the case based on literature from social psychology, ethics, addiction research, science communication, and philosophy. The literature shows that the relationship between public discourse on biological aspects of addiction and issues such as stigma and perceptions of diminished self-control are unclear, largely due to the complexity of these phenomena. However, concerns about the biological approach are nevertheless legitimate given the broader social and policy context of women’s health. (shrink)

Despite the fact that the requirement to obtain informed consent for medical procedures is deeply enshrined in both U.S. moral and legal doctrine, empirical studies and anecdotal accounts show that women's rights to informed consent and refusal of treatment are routinely undermined and ignored during childbirth. For example, citing the most recent Listening to Mothers survey, Marianne Nieuwenhuijze and Lisa Kane Low state that "a significant number of women said they felt pressure from a caregiver to agree to having an (...) intervention that they did not want during birth". Specifically, Nieuwenhuijze and Low cite that "19% of women who did not have epidural analgesia felt... (shrink)

Several factors related to fetal risk render it more or less acceptable in justifying constraints on the behavior of pregnant women. Risk is an unavoidable part of pregnancy and childbirth, one that women must balance against other vital personal and family interests. Two particular issues relate to the fairness of claims that pregnant women are never entitled to put their fetuses at risk: relative risks and relatives' risks. The former have been used—often spuriously—to advance arguments against activities, such as home (...) birth, that may incur risk; the latter implicate the nature of relationships in determining the acceptability of coercing or precluding activities. Motivated reasoning by clinicians and judges leads to inaccurate risk assessments, and judgments based on false claims to objectivity. Such judgments undermine the moral and legal standing of pregnant women and do not advance the interests of fetuses, pregnant women, families, or states. (shrink)

I argue that the American Congress of Obstetricians and Gynecologists (ACOG), as an organization and through its individual members, can and should be a far greater ally in the prevention of violence against women. Specifically, I argue that we need to pay attention to obstetrical practices that inadvertently contribute to the problem of violence against women. While intimate partner violence is a complex phenomenon, I focus on the coercive control of women and adherence to oppressive gender norms. Using physician response (...) to alcohol use during pregnancy and court-ordered medical treatment as examples, I show how some obstetrical practices mirror the attitudes of abusive men insofar as they try to coercively control women's behavior through manipulation and violence. To be greater allies in the prevention of violence against women, obstetricians should stop participating in practices that inadvertently perpetuate violence against women. (shrink)

Many pregnant women use pregnancy related mHealth applications, encompassing a variety of pregnancy apps and wearables. These are mostly directed at supporting a healthier fetal development. In this article we argue that the increasing dominance of PRmHealth stands in want of empirical knowledge affirming its beneficence in terms of improved pregnancy outcomes. This is a crucial ethical issue, especially in the light of concerns about increasing pressures and growing responsibilities ascribed to pregnant women, which may, in turn, be reinforced by (...) PRmHealth. A point can be made that it would be ethically askew if PRmHealth does not lead to improved pregnancy outcomes, while at the same time increasing maternal duties to closely monitor fetal development. We conclude that more research is needed to get a view on the benefits and burdens of PRmHealth in order to ethically assess whether the latter are proportionate to the former. If not, there is a case in saying that endorsement of PRmHealth is overdemanding. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 64-65, December 2011.