The Moral Meanings of Miscarriage

Abstract

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.11 Throughout this article, I refer to those who are pregnant as “women.” I want to acknowledge that this language regrettably excludes those occupying other locations on the gender identity spectrum, and more specifically people in the trans* community on the female-to-male (FTM) spectrum who have experienced or are considering experiencing pregnancy. Additional analysis is required to properly address the meanings of miscarriage for this community. 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.22 As the Mayo Clinic notes, the actual number of miscarriages is likely much higher because manywomen miscarry early in their pregnancies before realizing that they have conceived. “Miscarriage,” Mayo Clinic, July 9, 2013. Retrieved October 2, 2014, http://www.mayoclinic.org/diseases-conditions/pregnancy-loss-miscarriage/basics/definition/con-20033827. Nearly one million miscarriages occur in the United States every year.33 “Miscarriage Perceptions vs. Reality: Public Understanding Not in Sync with Facts,” Albert Einstein College of Medicine of Yeshiva University, October 16, 2013. Retrieved October 15, 2014, http://www.einstein.yu.edu/news/releases/945/miscarriage-perceptions-vs--reality-public-understanding-not-in-sync-with-facts/. 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.”44 Zucker, Jessica, “ Saying It Loudly: I Had a Miscarriage,” The New York Times, October 15, 2014. Retrieved October 16, 2014, http://parenting.blogs.nytimes.com/2014/10/15/saying-it-loudly-i-had-a-miscarriage/. 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.55 Herman, Judith Lewis, Trauma and Recovery ( New York: Basic Books, 1992) , 212ff. 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.66 We can understand what miscarriage means in multiple registers, including social, emotional, legal, cultural, and political registers. Far from existing in isolation from one another, these categories of meanings are interwoven. While mapping their interrelation is important (and a task for another day), each category also requires independent investigation. 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.77 I focus here primarily on North American contexts. 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).88 Important exceptions to this rule exist. Though the philosophical and related literature on miscarriage is small, it contains some excellent work. See the following: Cahill, Ann, “ Miscarriage and Intercorporeality,” Journal of Social Philosophy, this issue ; Hale, Benjamin, “ Culpability and Blame after Pregnancy Loss,” Journal of Medical Ethics (2007): 24– 27 ; Layne, Linda L., Motherhood Lost: A Feminist Account of Pregnancy Loss in America ( New York: Routledge, 2003) ; McLeod, Carolyn, Self-trust and Reproductive Autonomy ( Cambridge, MA: MIT Press, 2002) ; Morgan, Lynn M., “ Fetal Relationality in Feminist Philosophy: An Anthropological Critique,” Hypatia 11, no. 3 (1996): 47–70 ; Parsons, Kate, “ Feminist Reflections on Miscarriage, in Light of Abortion,” International Journal of Feminist Approaches to Bioethics 3, no. 1 (2010): 1– 22 . 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 liminality99 On the concept of the liminal in the context of miscarriage, cf. Layne, Motherhood Lost.—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.1010 Ethics and bioethics do deal with other complex liminal phenomena, such as brain death. Here I aim to explain the specific nature of liminality associated with miscarriage. Note, however, that this particular liminality is also relevant to discussions of abortion, as I indicated earlier. 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.1111 Self-betrayal and guilt are only two possible responses. There is no one experience of miscarriage and certainly no “right” interpretation or reaction. The meanings of miscarriage are multiple not only within the inevitable variegation of any given societal context, but also within a single woman's perception—shifting over time, sometimes quite rapidly. 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)ethics1212 I understand perinatal bioethics to differ from the existing subfield of prenatal bioethics in several important ways: Perinatal ethics covers a wider expanse of time than does prenatal bioethics. Perinatal ethics stitches together several conceptually interrelated periods: pre-pregnancy, pregnancy, and post-pregnancy, which is not the case with prenatal bioethics. Whereas prenatal bioethics frames the ethical issues in terms of the importance of the embryo/fetus (the focus, after all, is on that which is prenatal), perinatal ethics opens up the focus to include both woman and embryo/fetus, as well as others affected by and involved in the pregnancy. is an emergent subfield of philosophy that addresses the moral issues that arise before, during, and after pregnancy.1313 While there have been a limited number of contributions to the subfield of perinatal bioethics, especially within the dedicated clinical obstetrics literature, further cultivation of and involvement in this subfield by philosophers would be beneficial. For some examples of earlier discussions of perinatal ethics, see Harris, Lisa H., “ Rethinking Maternal–Fetal Conflict: Gender and Equality in Perinatal Ethics: In Reply,” Obstetrics & Gynecology 96, no. 5 (2000): 786– 91 ; Schenker, Josephe G., “ Codes Of Perinatal Ethics: An International Perspective,” Clinics in Perinatology 30, no. 1 (2003): 45– 65 . 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.1414 For a critical discussion of recent feminist work on relationality in the context of philosophical approaches to miscarriage, as well as a engaging discussion of the role generosity might play in our understanding of pregnancy's intersubjective nature, see Cahill, “Miscarriage and Intercorporeality.” 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.1515 Traditional bioethicists also have not tended to consider the implications of such matters for one's moral relation with oneself or one's moral self-regard, a matter that I consider later in this article. 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.1616 Cf. Parsons, “Feminist Reflections” and Cahill, “Miscarriage and Intercorporeality.” 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.1717 See Sherwin, Susan, “ A Relational Approach to Autonomy in Health Care,” in The Politics of Women's Health, ed. Susan Sherwin ( Philadelphia: Temple University Press, 1998), 19– 47 ; Carse, Alisa and Nelson, Hilde Lindemann, “ Rehabilitating Care” in Embodying Bioethics: Recent Feminist Advances, ed. Anne Donchin and Laura Purdy ( Lanham, MD: Rowman and Littlefield, 1999), 17– 31 ; and Tong, Rosemary, “ Just Caring about Maternal–Fetal Relations: The Case of Cocaine-Using Pregnant Women,” in Embodying Bioethics: Recent Feminist Advances, ed. Anne Donchin and Laura Purdy ( Lanham, MD: Rowman and Littlefield, 1999), 33– 43 . 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.1818 Women who ultimately welcome the ending of their pregnancy also experience a lack of agency, though perhaps one that is less psychologically or emotionally upsetting. There is a similar gap of agency for women who are ambivalently oriented toward their pregnancies. 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 loss1919 For a discussion of this matter see Morland, L. A., Leskin, G. A., Block, C. R., Campbell, J. C., and Friedman, M. J., “ Intimate Partner Violence and Miscarriage: Examination of the Role of Physical and Psychological Abuse and Posttraumatic Stress Disorder,” Journal of Interpersonal Violence 23, no. 5 (2008): 652– 69 .). 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,2020 It is true that mind/body dualism brings with it a certain solution to miscarriage: the body, as separate from your self, which is identified with your mind, is that which miscarries. Thus, on this account you are decidedly distanced from miscarriage as a bodily phenomenon, and therefore, your sense of guilt or self-betrayal does not compute. Following many feminist philosophers of the body, this is an account that I reject. 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,2121 A few examples from these literatures include: Bartky, Sandra Lee, Femininity and Domination ( New York: Routledge, 1990) ; Gatens, Moira, Imaginary Bodies ( London and New York: Routledge, 1996) ; Grosz, Elizabeth, Volatile Bodies ( London: Routledge, 1994) ; Butler, Judith, Gender Trouble ( London: Routledge, 1990) ; Butler, Judith, Bodies that Matter ( London: Routledge, 1993) ; Alcoff, Linda Martín, Visible Identities ( New York: Oxford University Press, 2006) ; and Barad, Karen, Meeting the Universe Halfway ( Durham, NC: Duke University Press, 2007) . 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 co