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03/18/2016

Cultural Expectation and Prenatal Risk – A Matter of Justice

Leslie Ann McNolty
I recently co-authored a peer commentary in the American Journal of Bioethics on gender and the unequal management of pre-natal risks. The argument we made in AJOB has particular relevance to two issues recently in the news.

Zika and the CDC

From public health campaigns to care at the bedside, our culture views women as primarily responsible for physical reproduction. If and when men are assigned any kind or degree of reproductive-related responsibility, it is usually secondary and indirect. Examples of the asymmetrical assignment of responsibility between women and men abound, including two recent stories making headlines. 
In response to the epidemic of the Zika virus which may cause microcephaly in some infants whose mothers are infected with the virus while pregnant, governments in several South American nations formally recommended that women avoid getting pregnant for up to two years. As a public health response, this approach is misguided and frankly disturbing for a number of reasons. First, it attributes all responsibility for managing reproduction to women despite the equal biological role men and women play in procreation. Second, it is starkly at odds with other culturally reinforced norms. Motherhood is the central route to social status for the poor women who have the highest risk of contracting Zika. Third, the countries making this recommendation have overwhelmingly Catholic populations. Catholic doctrine proscribes the use of birth control or abortion. (Though Pope Francis recently made remarks that suggest the presence of Zika may make birth control permissible.) I imagine the response of women in these countries is, “Thanks for the advice. Now how about some real help.”
Meanwhile, in the United States, the Centers for Disease Control (CDC) recently issued recommendations that young women avoid drinking unless they are on birth control to reduce the risk of fetal alcohol spectrum disorders. The thought process in making these recommendations is fairly straight-forward. Almost half of all pregnancies in the U.S. are unintended. Women who drink alcohol in the first few weeks of pregnancy (before they know they are pregnant) expose their fetuses to an increased risk of fetal alcohol spectrum disorders. So, doctors should discuss this risk with patients and recommend that women who drink use birth control.  But where are the recommendations that men avoid unintended pregnancy if they are having sex with a woman who drinks alcohol? Why do men have no responsibility to manage this risk to their potential children despite the fact that men have reliable means for reducing the risk of pregnancy available to them?

Gender, Culture and Moral Responsibility

The assignment of reproductive expectations along gender lines produces deeply gendered differences in moral responsibility. Women are always viewed as potential mothers and their moral responsibilities, in the above examples to avoid pregnancy altogether, are assigned accordingly. Men on the other hand are viewed as independent actors who are responsible only for themselves. As a result, the scope of women’s moral agency is expanded to include responsibilities to potential people. In contrast, the scope of men’s moral agency is much smaller, and, in certain cases, shrinks until it excludes even existing people (often women) who may be harmed by their actions. For example, the CDC’s guidelines for young women included an infographic (that has since been removed) that warned that drinking too much can lead to “injuries/violence,” implicitly suggesting that women are responsible for the violence they face largely at the hands of men.
It is clear, then, that gendered expectations produce and reinforce significantly unequal assignments of moral responsibility to reduce pre-conception and prenatal risks. The practical upshot of the additional moral responsibility that women carry for potential people produces cultural expectations that women will (usually, if not always) sacrifice their present personal interests to protect the future personal interests of their potential children. Men, on the other hand, are largely exempt from such expectations. 
What is socially constructed could be socially deconstructed or reformed, and since the practice of conceiving, bearing, and rearing children is a socially valuable (indeed, vital) practice, the assignment of reproductive-related moral responsibility should be seen as a matter of justice that demands that we evaluate the distribution of the benefits and burdens of sustaining that practice. While men and women largely share the benefits of reproduction and rearing children, the burdens are disproportionately borne by women. These burdens include the (uniquely) expanded scope of moral responsibility that women are assigned for the well being of potential persons, as well as a restricted sphere of autonomy owing to the lower threshold for justifying clinician/state intervention with their decisions. Ideally, the critique offered in here can contribute to the reform of our reproductive-related social practices so that any unequal physical burden of pregnancy necessitated by biology does not also entail unjust violations of women’s bodily integrity or autonomy.
Leslie Ann McNolty is a program associate at the Center for Practical Bioethics.

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