by Hilde Lindemann Nelson

Although the U.S. now spends close to 15 percent of its Gross Domestic Product for health care-more than any other nation in the world-the Children's Defense Fund reports that the U.S. ranks 20th in infant deaths and 31st in low birthweight rate compared with other developed countries. How can this be?

Data collected by the National Center for Health Statistics indicate that socially disadvantaged women in the United States die in childbirth at twice the rate of middle-class women and bear more than twice as many low birthweight babies, where low birthweight is an indicator that the baby suffers from serious health problems. In addition, the chances that their babies will die are twice as great. So one explanation for the low birthweight rate is poverty. According to the public health literature, the problem arises because of the way health care is financed in the United States. While even babies born below the poverty line have access to Level III neonatal intensive care centers, which can substantially reduce infant morbidity and mortality, their mothers don't always have access to good prenatal care. Since proper prenatal care has been shown to increase babies' birthweight and is considerably cheaper than the intensive care required once a low birthweight baby is born, it's commonly claimed that we have our health care spending priorities backwards. We should concentrate on providing better prenatal care for impoverished pregnant women, since better medical management of pregnancy can prevent low birthweight.

Seems obvious, doesn't it? Get rid of the problem before it starts, save lots of money that can be put to better use, go to a low tech rather than an invasive high tech treatment option-what could be economically or morally objectionable about all that? While the obvious solution to the problem of low birthweight infants is popular and pervasive, I'll argue that it's also dangerous.

Statistics

Low birthweight, which correlates roughly with prematurity, is defined as a weight of less that 2500 grams at birth (under 5 lbs.). Very low birthweight babies, who account for only 1.2 percent of births in the US but 46 percent of infant deaths, weigh less than 1500 grams (under 2 lbs.). The low birthweight rate has been rising over the last 20 years, both in the US and abroad. The pediatrician and ethicist John Lantos reports that in 1997 it was 7.5 percent, the highest rate since 1974 (Lantos forthcoming, p. 81). Nationally, of the 5 million babies born every year, about 53,000 weigh in at under 1500 grams. And twice as many of them are born to poor women as are born to women who don't live in poverty.

What does it cost to take care of VLBW babies? The most recent study we have is one that was published in the journal Pediatrics in 1998. It reports that in California, the average cost for treating VLBW babies for a year in 1987 was $93,800. By comparison, the average first-year medical costs for normal births in 1989 was $2500. If you translate the average cost for treating VLBW babies for a year into 1996 dollars, allowing for the 62 percent inflation in health care costs, it comes to $151,956 (Rogowski 1998).

Now, if you could provide prenatal care so that the babies were born at normal birth weights rather than VLBW, how would the cost of that care compare to the $151,956 spent on average in NICUs for VLBW babies? Nobody knows, because it's extremely difficult to quantify the costs associated with prenatal care for at-risk babies. One study showed that adequate prenatal care was found to be associated with an increase of 197 grams in average birthweight-an increase too small to move even a baby who would otherwise weigh in at 1200 grams out of the VLBW range. Another study showed that prenatal interventions lowered premature birth rates among high-risk patients by 19 percent (Lantos forthcoming, p. 80). And a cost-benefit study surveying 12,023 births in Missouri's Medicaid program for 1988 indicated that for each extra dollar spent on prenatal care, there was an estimated savings of $1.49 in newborn and post-partum costs (Schramm 1992).

Other studies, however, show no results from programs to prevent premature birth. Paneth et al., for example, showed that biological factors, such as race, sex of the baby, and birthweight are all strongly associated with mortality rates, but they found no association between mortality and the number of prenatal visits (Paneth et al.1982, pp. 364-75). Moreover, despite the presence of a National Health Service in Great Britain that provides adequate prenatal care to all pregnant women, babies born into lower income families have significantly worse health outcomes than do babies born into higher income families (Racine et al.1992, pp. 40-55).

Two ways of thinking about the problem of VLBW babies

The popular (but dangerous) solution to the problem reflects the managerial approach that pervades most of bioethics. On the managerial model, the bioethicist begins from the point of view of the health care provider or the health policy analyst, identifies a problem, and figures out an ethically sound way of managing the problem medically. The problem is that NICUs are an expensive way to address the needs of VLWB babies. The solution is to go upstream, preventing low birthweight by managing pregnant women better. This is a top-down model. To a hammer, everything looks like a nail. To a bioethics that too readily assumes a medical perspective, everything looks like a medical problem.

In contrast to the managerial model, I'd like to propose a feminist model. What makes any ethics feminist is that it pays attention to power as it circulates through our practices of morality, noting especially how gender, class, ethnicity, age, and disability mark certain classes of people for disrespectful treatment. What makes any bioethics feminist, then, is that it notes how imbalances of power in the sex-gender system and other social systems play themselves out in medical practice and in the theory surrounding that practice. The feminist bioethicist begins from the point of view of the relatively powerless and asks what various bodily conditions mean for them and for those with whom they are in close relationships. It's a bioethics that tries to get clear about people's needs and vulnerabilities as the people themselves understand them, and then proposes ways of responding sensitively and fairly to those needs. This is not a top-down model, but rather a collaborative one, in which the moral agency of all parties-including that of the very ill-is recognized. A feminist bioethics is suspicious of the view that everything is a nail.

How would a feminist bioethicist think about the problem of VLBW babies? The first thing he or she would notice is that the studies on the cost-effectiveness of NICUs as opposed to prenatal care focus entirely on the well-being of the babies, never the mothers. It's as if the mothers weren't there, or were important only as a kind of biological NICU that offered better health outcomes for the babies than do Level III neonatal intensive care centers. To view women as "maternal background" is to value them only instrumentally-not as ends in themselves, but purely as means to others' ends. This, as Kant points out, is something that we may not do.

The second thing a feminist bioethicist would notice follows from the first: medical care during pregnancy isn't just supposed to produce good health outcomes for babies, but for pregnant women as well. According to a study by the Centers for Disease Control, released in June of 1999, black women are 4 times as likely to die in childbirth as whites. In New York State, 1 black woman dies for every 3484 births, while 1 white woman dies for every 13,160 births. We don't know why, because this truly immense disparity hasn't been studied (Stolberg 18 June 1999). Because there is a strong, socially shared tendency to take the adult male body, unencumbered by other individuals, as the norm for human beings, we don't really have a good understanding of the moral meaning of enmeshed bodies. As bioethics has pretty much adopted moral philosophy's individualistic conception of the moral agent, it lacks the resources for thinking well about pregnancies.

The third thing the feminist bioethicist would notice is that mothers are present in these cost-effectiveness studies only as objects to be managed and monitored. In his famous essay "Freedom and Resentment," the philosopher P. F. Strawson contrasts our ordinary attitudes of interpersonal engagement, such as "gratitude, resentment, forgiveness, love, and hurt feelings," which we display toward people whose actions reveal them to be participants in the moral community, with attitudes that preclude such engagement, because the persons' deeds show them to be morally sub- or abnormal."To adopt the objective attitude to another human being," as Strawson memorably puts it, "is to see him, perhaps, as an object of social policy; as a subject for what, in a wide range of sense, might be called treatment; as something certainly to be taken account, perhaps precautionary account, of; to be managed or handled or cured or trained" (p. 66). The managerial approach to bioethics takes the objective attitude toward impoverished pregnant women, degrading them morally by devaluing their moral agency, seeing them as objects to be managed or handled, if not cured or trained. But to take the objective attitude toward a class of people who are fully developed moral agents is seriously wrong-it's morally disrespectful. And it oppresses women.

The fourth thing the feminist bioethicist would point out is that a policy of improving access to good prenatal care is of no use to women who don't trust the health care system. According to Lawrence J. Nelson and Mary Faith Marshall's report to the Robert Wood Johnson Foundation, more than 240 women in 35 states have been criminally prosecuted since 1985 for using illegal drugs or alcohol during pregnancy. Between 70 and 80 percent of these women are minorities. A landmark study in Pinellas County, Florida, revealed that black women were ten times more likely to be reported to criminal justice agencies for testing positive for drugs when pregnant than were white women. And a survey published in NEJM in 1987 showed that of 18 cases (out of 21 cases petitioned) in which court orders allowed coercive obstetrical interventions, all of the pregnant women were either receiving public assistance or were treated at a public hospital. Why should women who have been medically policed in these ways be eager for more policing?

Feminist therapies for low-birthweight babies

A feminist bioethics, then, would propose three solutions to the problem. First, it would surely advocate for better access to effective prenatal care for impoverished pregnant women. This requires better studies of what works and what doesn't, including a better understanding of black women's health. But it also requires better theory. We need conceptions of the self that include physically enmeshed selves, so that we can get better moral understandings of pregnancy.

Next, rather than adopting a managerial model of prenatal care, a feminist bioethics would call for a collaborative model, one which recognizes that impoverished pregnant women are fully developed moral agents in their own right who must be accorded moral respect.

And finally, it would call for making the health care system more trustworthy. This is a particular problem for African Americans, but it's also a problem of class and gender. The solution isn't just to provide universal access to health care, though that is surely necessary, or even to provide more social services. The solution is to become a more hospitable society-one that doesn't marginalize certain classes of people or see them as fit only for others' purposes. If we as a society aren't willing to work toward that goal, we will continue to have an unacceptably high number of low birthweight babies born in grossly disproportionate numbers to women who live in poverty.

References:

Lantos, John. Forthcoming. A Tiny Baby in a Court of Law. Baltimore: Johns Hopkins University Press.

Nelson, Lawrence J., and Mary Faith Marshall. 1998. "Ethical and Legal Annalyses of Three Coercive Policies Aimed at Substance Abuse by Pregnant Women." Robert Wood Johnson Foundation Grant 030790.

Paneth, N., S. Wallenstein, J.L. Kiely, and M. Susser. 1982. "Social Class Indicators and Mortality in Low Birth Weight Infants." American Journal of Epidemiology 116 (2): 374-75.

Racine, A., T. Joyce, M. Grossman. 1992. "Effectiveness of Health care Services for Pregnant Women and Infants." The Future of Children 2:40-55.

Rogowski, Jeannette. 1998. "Cost-Effectiveness of Care for Very Low Birth Weight Infants." Pediatrics 102: 35-43.

Schramm, Wayne F. 1992. "Weighing Costs and Benefits of Adequate Prenatal Care for 12,023 Births in Missouri's Medicaid Program, 1988." Public Health Reports 107:647-52.

Stolberg, Sheryl Gay. 18 June 1999. "Racial Divide Found in Maternal Mortality." New York Times.

Strawson, P. F. 1982. "Freedom and Resentment." In Free Will, ed. Gary Watson. New York: Oxford University Press.