The Value of Pregnancy and the Meaning of Pregnancy Loss

Abstract

My strategy in this article is to work toward conceptualizing pregnancy loss and reactions to pregnancy loss by considering the meaning and value of pregnancy.1 Motivating this strategy is the assumption, which I do not argue for, that understanding something about the meaning of pregnancy will help us to understand something about the meaning of pregnancy loss. Surprisingly, little philosophical literature touches on the meaning of pregnancy.2 What has been written is mostly in the context of debates about the moral and legal status of abortion and in the limited literature on parenting and child care.3 My focus in this article is on the literature about abortion. In the first part of this article, I argue that the positions set out in traditional debates about abortion are focused on the status of the fetus to the extent that they ignore the value and meaning of pregnancy as something involving persons other than the fetus. Feminist arguments do better than traditional arguments at least to the extent that they recognize the significance of the fact that a developing fetus is inside of, and dependent on, the pregnant woman. Despite this, many feminist arguments defending abortion are, like the traditional arguments, focused on the status of the fetus insofar as they are focused on establishing that the fetus has little or no moral value. In the second part of the article, I consider one account of the value of pregnancy that explicitly acknowledges that pregnancy can and does have meaning for many people in many cases. This account is proposed by Hilde Lindemann.4 According to Lindemann, one source of value in pregnancy derives from the activity of “calling the fetus into personhood.”5 This is the activity by which we come to think of a fetus as a person with a place in our social world. I build on Lindemann's ideas by developing an account of the activities by which people come to think of themselves as being related to, and responsible for, a fetus. Most specifically, I develop an account of what I call the activity of creating an identity as a parent—the activity by which a person, and especially a pregnant woman, comes to think of herself as a parent.6 I argue that recognition of the related activities of calling a fetus into personhood and creating an identity as a parent allow us to make sense of a variety of reactions to pregnancy and pregnancy loss. Traditional debates about the moral and political status of abortion circle around the question of whether a fetus is a person and, as such, a bearer of rights. We find on the one side of these debates the view that abortion is impermissible on the grounds that the fetus is (or will become) a human being or a person and, thus, has a right not to be killed.7 We find on the other side of these debates the view that abortion is permissible on the grounds that the fetus is not a person (in the early stages of pregnancy8) and, as such, need not be treated with the kind or degree of respect or regard owing to persons.9 Attempts to establish that the fetus is not a person are attempts to make room for the idea that, to use a popular formulation, “It's the woman's body, so it's her choice.”10 As they hinge on whether the fetus has moral value, traditional debates about abortion are decidedly fetal-centric. Arguments against abortion rest on the claim that a fetus has some moral status that makes killing a fetus unacceptable except, perhaps, in extraordinary circumstances. Arguments defending abortion rest, primarily, on the claim that the fetus has no such moral status. Feminists have successfully pointed to limits and dangers of fetal-centric approaches to determining the moral status of abortion. When we focus exclusively (or even primarily) on the moral status of the fetus in abstract terms, we overlook the importance of the reality that the fetus is developing inside of a pregnant woman's body.11 By giving proper attention to the perspective of the pregnant woman we succeed in drawing attention to myriad considerations relevant to determining the moral status of abortion. Among these are facts about social expectations that place more responsibility for child-rearing on women than men, structures that give priority and favour to unattached and unencumbered (i.e., childless) professionals, and specific facts about the manner in which being pregnant and bringing a child into the world affect other aspects of a woman's life and well being. By taking seriously the perspective of the pregnant woman, feminist arguments reflect the many reasons a woman might decide to have an abortion.12 Surprisingly, given this broader focus, many feminist replies to traditional debates about the status of abortion are, themselves, fetal-centric. Perhaps feminist authors have, as Susan Sherwin suggests, “felt pushed to reject claims of fetal value to protect women's claims” because of the way in which public debates are fetal-centric like the traditional debates outlined above.13 It is as though we are being pulled back into the same old assumption that it is necessary to show that a fetus lacks moral status to consider a pregnant woman's interests and choices. Feminist accounts of the status of the fetus typically focus on the manner in which a fetus is dependent on the pregnant woman—for basic survival and as an intermediate for relations with other persons—and the manner in which personhood is relational or intersubjective. These accounts recognize that persons are not abstract entities but rather embodied beings in the world and that personhood depends on developing a history with other persons within families and communities with distinctive values and traditions.14 From this perspective, a fetus can be a person only to the extent that it develops a history with other persons. Excepting the relation a fetus has with the pregnant woman in whose body it is developing—which is an asymmetrical relation of dependence and a complex relation in other ways—any relation a fetus can have with another person is mediated by the body and person of the pregnant woman. As an embodied being, a fetus cannot be viewed as a person who just happens to be growing inside of another person in the manner assumed in traditional abortion debates. This is not a matter of mere geography.15 Because anti-abortion activists base their argument on the presence of fetal and, even more importantly, embryonic personhood, feminists have studiously avoided anything that might imply such a presence. The fear in the context of pregnancy loss is that if one were to acknowledge that there was something of value lost, something worth grieving in a miscarriage, one would thereby automatically accede the inherent personhood of embryos/fetuses.16 Whatever the explanation, one is tempted to wonder why we would ever value a fetus or grieve pregnancy loss after considering arguments defending abortion.17 If our goal is to defend reproductive autonomy, and we take this to involve defending a woman's “right to choose,” we need to take seriously the choices available. One such choice is abortion. Another is the choice to continue with the pregnancy.18 While it is necessary in our current political and social climate to defend only abortion (rarely do we ask for a reason to “keep” a child19), accounts of reproductive autonomy should not be so impoverished to obscure or, worse, denounce the ways in which we might think pregnancy can have meaning and value. It would be a disaster if our ways of defending reproductive autonomy make the choice of continuing a pregnancy an absurd choice. Moreover, it would be a disaster if the way in which we conceptualize pregnancy is unable to capture the significance of pregnancy loss. Some accounts of the value of pregnancy in the literature on abortion fare better than others insofar as they leave room to recognize the value of pregnancy in some cases and insofar as they acknowledge the meaning of pregnancy for the many people who are both excited to be pregnant and hopefully awaiting the arrival of a child. One such account is presented by Hilde Lindemann. Lindemann argues that there are two sources of value in pregnancy. The first is the value of the fetus. Lindemann allows that a fetus is not obviously a person in the full sense (what she calls a “paradigmatic person”), but that a fetus is not morally worthless either. On her view it would be “strange” if persons that she takes to have “enormous obvious worth should develop from beginnings worth nothing at all.”20 The moral value of the fetus, then, is established by the fact that the fetus will become something that has moral value and the closer a fetus comes to approximating a paradigmatic person, the greater its value.21 The second source of value in pregnancy derives from what Lindemann describes as the activity of “moving a fetus ever closer to paradigmatic personhood” or “calling a fetus into personhood.”22 The activity of calling a fetus into personhood is a social activity that “consists in the physical expression of human beings' intentions, emotions, beliefs, attitudes, and other manifestations of personality, as recognized by other persons, who then respond by taking up an attitude toward [the fetus] of the kind that's reserved for persons.”23 Calling a fetus into personhood makes “a place in the social world for the developing child to occupy when it is born.”24 Pregnant women often engage in the activity of calling a fetus into personhood. Other people can be, and usually are, involved too.25 The place a fetus occupies in our social world is reflected by our thinking about, and treating the fetus as, the child we expect it to become. We call the fetus by (nick)name, we talk and sing to the fetus, and we prepare a space in our home by decorating a nursery (or, for those of us on a budget, a corner of our own bedroom). Even before birth, a fetus can occupy a place in our social world insofar as we come to think and act as though the fetus is already a baby or child. By the activity of calling a fetus into personhood we come to think of the fetus as a person to whom we are related: as our daughter, son, sibling, grandchild, godchild, or whatever. When our thoughts and actions are recognized by other people, they often come to think of the fetus as a person too. In this way, the activity of calling the fetus into personhood is a source of value and meaning in pregnancy. Lindemann's account of the value of pregnancy is rich insofar as it identifies factors that give meaning to pregnancy in a manner that allows the value of one pregnancy to differ from the value of another pregnancy. It is an advantage of Lindemann's account that it leaves room for the possibility that some pregnancies have little or no meaning and value. When a fetus cannot or does not develop into anything resembling a “paradigmatic person,” the fetus itself has little or no value. Further, and perhaps more significantly, a pregnancy lacks value resulting from the activity of calling a fetus into personhood when, in fact, no person engages in this activity. On Lindemann's account, a fetus cannot participate in personhood or the practice of personhood; it must be called into personhood by other persons.26 When this does not happen, no value accrues. It is also an advantage that Lindemann's account successfully captures at least some of what gives pregnancy value from the perspective of those who experience pregnancy as something that is significant in positive ways. Specifically, what Lindemann calls the activity of calling a fetus into personhood reflects the experience in which many pregnant women and other people come to establish relationships with the fetus that they hope will become their child. Despite these advantages, Lindemann's account is fetal-centric insofar as the value of pregnancy is a factor of the intrinsic value of the fetus and the result of calling the fetus into personhood. Lindemann's account does, however, accommodate a number of related concerns that help us account for responses to pregnancy and pregnancy loss. To show this, I build on Lindemann's work by developing an account of another activity related to the activity of calling the fetus into personhood, specifically, what I describe as the project of identifying oneself as a mother or father, or the activity of calling a person into parenthood. The activity of calling a fetus into personhood often coincides with the process by which the pregnant woman and her partner come to identify themselves as parents. As people come to think of a fetus as their child, they come to think of themselves as its parents. Similarly, as people come to think of a fetus as a child with specific relationships—that is, as a sibling, a grandchild, a niece, a nephew, or godchild—they come to identify themselves as big brothers or sisters, grandparents, aunts, uncles, godparents, and the like. Both the activity of calling a fetus into personhood and the related project of creating an identity as a parent are social activities. As such, they are shaped by social and cultural norms surrounding pregnancy and parenthood. In heteronormative and pro-natalist societies such as many of us experience in Canada and the United States, there is an expectation that younger couples—and younger women especially—desire to have children of their own. In this context, pregnant women are thought to be “expecting” in the sense of looking forward to having a child in their lives. Further, it is assumed that an expecting “mother” should take care of herself and her child. Though the norms lying behind these social expectations are rightly called into question in attempts to promote reproductive autonomy, it remains true that pregnant women and their partners often do look forward to having children in their lives. It is easy to imagine that the activity of calling a fetus into personhood starts with disbelief, excitement, and nervousness in the early days and leads to pregnant women and their partners thinking about the fetus as a child with a place in their family in the final stages of pregnancy. Despite that the activity of calling a fetus into personhood does not always proceed along this path if it happens at all—no two women and no two pregnancies are identical—our expectations inform some common responses to miscarriage.27 Some responses to learning that a woman has experienced a miscarriage reflect the assumption that the woman will be entirely distraught in the manner she would be if she had lost an infant. This assumption is reflected, for example, when a woman is told in consoling tones, “you must have wanted the baby so much.” Paradoxically, other responses reflect the assumption that a woman who miscarries will recognize that she hasn't actually lost a child and that she will recover quickly from her temporary grief and get on with her life. This assumption is seen, for instance, when the significance of the loss is downplayed as being “probably for the best” or “a blessing in disguise.” Further reflecting the assumption that women who experience miscarriages want to have children, a typical response to miscarriage is that “getting on with life” will involve “trying again” or “having another” child when, in reality, some women find the stress of pregnancy loss too much to want to try again and some women discover that they are unable to become pregnant again.28 Moreover, in pro-natalist societies, our social repertoire is found wanting in relation to cases in which a pregnant woman who experiences a miscarriage has no desire to be pregnant either at that specific time or again. When we know or assume that the woman who was pregnant didn't want to be pregnant, there is a tendency to assume that she will feel relief insofar as she has “dodged that bullet” and will now get on with her life. And while she might feel such relief, this is likely to be only one aspect of her experience. If what I have suggested is right, Lindemann's account of the value of pregnancy provides a framework for making sense of common reactions to miscarriage. Of particular note, Lindemann's account allows for us to make sense of confusion surrounding the identity of the fetus and of the would-be parents.29 Where the activity of calling a fetus into personhood is interrupted by miscarriage, there is a sense in which the fetus is a child and the pregnant woman is a mother who loses a child, especially as the pregnancy progresses and there has been sufficient time to both call the fetus into personhood and identify as a parent.30 But, there is also a sense in which the fetus wasn't really a child quite yet and the pregnant woman wasn't a mother quite yet (or that she wasn't yet the mother of this child even if she is already the mother of other children). That the project of calling a fetus into personhood is interrupted before it is completed means that we face some confusion in deciding how to think of both the miscarried fetus and the would-be parents. Perhaps as a result of this confusion (or, perhaps contributing to this confusion) is the fact that we don't have ready conventions for thinking or speaking about women who miscarry—maybe they're mothers, but we're not sure; maybe they're childless,31 but this isn't informative—or their fetuses—whatever medical terms we might use here seem inappropriate and insensitive. If we accept Lindemann's claim that the value of pregnancy has two sources, we are able to explain, in general terms and in a manner that “gives uptake to”32 or makes sense of, many specific reactions to miscarriage including reactions that, on their face, appear contradictory. Focusing on the value of the fetus itself, we have more reason to mourn miscarriage as a loss when miscarriage occurs in the later stages of pregnancy than when it occurs in the early stages. Since a newly formed embryo typically resembles paradigmatic persons far less than a late term fetus, miscarriages occurring in the later stages of pregnancy involve the loss of something with more value than miscarriages occurring in the earlier stages of pregnancy. Focusing on the value resulting from the activity of calling a fetus into personhood, we often find a similar pattern. As a pregnancy progresses, would-be parents find themselves further into the activity of calling the fetus into personhood and are more likely to think of themselves as parents. Unlike the value of the fetus itself, however, the value resulting from calling the fetus into personhood only increases if some person—most obviously, the pregnant woman—actually engages in the activity and this value will be directly proportionate to the extent to which this activity is completed. This allows for different possibilities accounting for what might initially seem to be disproportionate responses to pregnancy loss. A pregnant woman who neither planned for, nor wanted to have, a child might still mourn the loss of a fetus in the final stages of pregnancy just insofar as she thinks that something of value has died.33 In such a case, mourning might be accompanied by a sense of relief. Conversely, a pregnant woman hoping to have a child might mourn the loss of an embryo in the earliest stages of pregnancy. Though this embryo would have little value in its own right, the pregnancy might have value just for the reason that the woman was already engaged in the activities of calling the fetus into personhood and creating her identity as a mother.34 Whereas we might expect the fetus to resemble a paradigmatic person to a greater extent at each successive stage of pregnancy there is no necessary pattern for predicting the meaning and value of pregnancy resulting from the activity of calling a fetus into personhood and the project of creating one's identity as a parent. This is for many reasons. I will note five. First, the activity of calling a fetus into personhood need not coincide with the activity of creating an identity as a parent. There is no fixed relation. This is because the place we make for a child need not be a place in a family of the sort that involves one or more biological (or birth) parents parenting the child as their own. There is a sense in which surrogacy, for example, allows that the pregnant woman is involved in the activity of calling someone else's child into the world.35 In such cases, it is likely that the would-be parents are also involved in the activity of calling the fetus into personhood insofar as they are the ones making a place for the developing child to occupy after birth. Moreover, calling a fetus into personhood is also consistent with the decision to “give a child up” for adoption. At the very least, the decision to give up a child is consistent with the activity of thinking about the developing fetus as a child that will have a place in our social world even when this is not a place in our own immediate family.36 Second, some pregnancies might be devoid of any activity fitting Lindemann's description of calling the fetus into personhood. If they are to be believed, the stories related on TLC's I Didn't Know I Was Pregnant represent cases in which nobody, not even the pregnant woman, was aware of the pregnancy. As such, they represent cases in which no person was engaged in the activity of calling the fetus into personhood. That there were physical changes is undeniable in these cases. Yet, neither the pregnant woman nor her partner came to think of the fetus as their child or of themselves as parents—they simply didn't think about this at all.37 Similarly, a person who did not plan to have a child or to become a parent and does not want a child might actively resist both the idea that the fetus is or will become a child and the idea that she is a mother.38 Third, even persons who engage in these activities engage to varying degrees. Some would-be parents are actively engaged in calling their fetus into personhood. Others are not. Fourth, a person could be actively engaged in calling a fetus into personhood at some times and not others. Circumstances might arise, for example, in which a pregnant woman who didn't originally want a child finds herself later wanting the child (or vice versa) or vacillating back and forth.39 Fifth, the activity of calling a fetus into personhood is not something that is ever or obviously complete. It is true at least that the shaping of a person is an ongoing social activity. Whereas the fetus comes to be seen as a child, it then becomes a child in an undisputed way (at birth), and the process continues toward a time in which the child becomes a paradigmatic person. Moreover, the related project of creating an identity as a parent is never complete and nobody's identity is ever restricted to being a parent only. I can identify as a father, an academic, a some-time sailor, a brother, and so on. Balancing the many aspects of my identity will certainly influence the way and extent to which I identify as a parent. The extent to which pregnancy has meaning for me depends on all of these factors. When I have done little to make a place for a child in my life, pregnancy loss may result in few changes moving forward. But, would-be parents frequently make considerable changes to accommodate the child they are expecting.40 If I have come to think of myself as a father or someone who will soon be a father and I have made arrangements for parental leave from work and I have made career choices to accommodate my being a parent and I have changed my spending habits to better accommodate the costs associated with raising a child, pregnancy loss will be disruptive to the projects that were tied to the expectation that I would become a parent.41 I will end by noting some of the limits of the approach I have taken in this article by highlighting some of the many facts and possibilities that remain to be addressed in providing a complete account of the meaning of pregnancy and pregnancy loss. In building upon Lindemann's account of the value of pregnancy, I have focused on the relations between the fetus and others—especially the pregnant woman. In so doing, I have said little about the possibility that pregnancy has meaning that can be explained in nonrelational terms.42 Moreover, the relational account I have considered might not adequately capture the complex reality of the relationship involving the developing fetus and other persons—most notably the pregnant woman. If what Ann Cahill argues is right, it would be better to think of the relationship as intercorporeal or intersubjective in the strong sense that captures that the identity and essence of subjects (what I am calling persons) are tied to, interwoven with, or implicated in the identity and essence of other subjects (and perhaps other nonsubjects too).43 Though the manner in which I have described the activity of calling the fetus into personhood would need to be reworked, I think the account I have drawn out of Lindemann's work is largely consistent with Cahill's work. Reflecting on the complex relationship between the fetus and the pregnant woman is significant if we are to account for the experiences of women who are pregnant and for the experiences of, and reactions to, miscarriage. Both are experiences of real, embodied, people. [I]n early pregnancy, although the woman's body is undergoing massive changes, the foetus itself is not very physically developed. The foetus' separateness is thus neither physically well established nor is it felt as such by the woman. What happens as pregnancy continues is that, as the foetus develops physically, a triple process occurs. Firstly, from the perspective of the woman, the foetus becomes more and more physically differentiated from her as her own body boundaries alter. Second, this gradual physical differentiation (which becomes very pronounced as soon as the foetus starts moving around…) is paralleled by and gives rise to a gradual psychic differentiation, in the experience of the woman, between herself and the foetus… Thirdly, physical and psychic differentiation are usually accompanied by an increasing emotional attachment of the woman to the foetus, an attachment which is based both in her physical connection with the foetus and in anticipation of her future relationship with a separate being who is also intimately related to her.45 Mackenzie's description is meant as “a normative and reflective apprehension of the way in which conscious experience is structured by our (bodily) situation, perspectives, and modes of perception” rather than as a description of any individual woman's subjective feelings.46 Building on the account of the value of pregnancy outlined above, it seems that the “normative” apprehension outlined by Mackenzie is tied to the activity of calling a fetus into personhood. Where a pregnant woman does not engage in this activity, she is unlikely to experience pregnancy in the manner outlined by Mackenzie. Moreover, and as both Lindemann and Mackenzie would allow, individual women may experience pregnancy in different ways and individual women might experience subsequent pregnancies in different ways. No woman and no pregnancy is the same as all others. The account I have developed in this article is not sufficient to capture the full range of physical, emotional, and psychological responses to pregnancy loss. Certainly, the account I have developed does not address the physical aspects of miscarriage—the cramping, the spotting, the bleeding, the lactation, the exhaustion, the fluctuating hormones, and the other physical realities that are experienced for many days, weeks, or even months.47 The physical realities of miscarriage can give rise to related psychological and emotional responses including a sensed loss of control of body and bodily processes.48 I have managed to say nothing about these responses. By focusing on accounts of the value and meaning of pregnancy as one way to understand the meaning and value of pregnancy loss, I have also managed to say nothing about a host of reactions to miscarriage. Of significant note is the range of emotional responses including guilt, shame, blame, anger, a lack of self-trust,49 and a sense of failure.50 Clearly, there is more work to be done. As a final consideration, I will point to the fact that the literature on abortion upon which I have focused concerns whether abortion can or should be allowed and these sorts of concerns are misplaced in considering the meaning of most pregnancy loss—especially miscarriage. This is for the reason that most miscarriages are not, and do not, involve actions of the sort that are moral or immoral. What I have argued in this article assumes that consideration of the meaning of pregnancy can be separated from consideration of rights,51 responsibility,52 or moral luck.53 I end, however, with the following question: can thinking clearly about the meaning of pregnancy help us reframe abortion debates? I expect that we will be in a better position to re-engage with debates about the moral status of abortion once we have fleshed out a richer account of meaning in reproductive contexts.54 That, however, is an argument for another paper. Thank you to Professors Ann Cahill and Kathryn Norlock, participants at the 2012 meeting of the Canadian Society for Women In Philosophy in Calgary, and the anonymous referees for the Journal of Social Philosophy for providing insightful and constructive suggestions for improving the ideas presented in this article.