Ethical problems with breastfeeding promotion

I’ve written extensively about the misguided attempts of breastfeeding activists (lactivists) to promote breastfeeding.

The dirty little secret about the latest efforts to promote breastfeeding (prohibiting formula gift bags, denying bottle feeding WIC mothers the same benefits as breastfeeding mothers, hiding formula in hospitals) is that they are purposely punitive, vindictive and serve only to bolster the self image of those implementing them…

This is just one reason why contemporary efforts at breastfeeding promotion are ethically problematic. Dutch philosophy professors Jessica Nihlen Fahlquist and Sabine Roeser have written a fascinating paper on the topic entitled Ethical Problems with Information on Infant Feeding in Developed Countries.

The authors argue:

… current breastfeeding policies have ethically problematic consequences for individual women, e.g. for women who experience physical and emotional difficulties when trying to breastfeed and for women who have other good reasons not to breastfeed. These arguments are strengthened by the fact that there are scientific studies in respected journals that cast doubt on the commonly accepted claims that breastfeeding is more beneficial to the health of babies and mothers than formula. Our discussion is based primarily on insights provided by literature on the
ethics of risk.

The authors address many ethical problems including:

1. Lactivists are not honest about the very real difficulties and drawbacks of breastfeeding.

… [E]ven though most women plan to breastfeed for a substantial period and think it is the best food for infants, many new mothers experience physical challenges at least in the beginning and some for the whole breastfeeding period. Many mothers give up breastfeeding. For example, in the Netherlands, although 81% of the women breastfeed exclusively after birth, only 48% do so after 1 month, 30% after 3 months and 23% for at least the recommended 6 months. The most important reasons mothers stated for giving up breastfeeding within or after the first month was that it was painful and that they did not have sufficient milk. Other commonly mentioned reasons for stopping were, concerning the mother: tiredness, weight loss, use of medication and better sleep at night; concerning the baby: tummy aches and restlessness, dissatisfaction, hunger and that it did not grow well. Some women mention work as a reason to stop breastfeeding. In the Netherlands, maternity leave lasts until three months after the baby is born, and many mothers take prolonged parental leave afterwards, so only after 2 months this becomes an important argument for a larger percentage of women to stop breastfeeding.

The unfortunate truth is:

Although problems with breastfeeding happen frequently, this is hardly ever mentioned in official documents, giving women the feeling that they are alone with their difficulties. Rather, it is generally emphasized that ‘all women can breastfeed’—implying: ‘if they want’. Stating that all women can breastfeed and combining it with statements like the following: ‘Every day
you breast feed makes a difference to your baby’s health now and in the future’ (UK NHS, 2011) are likely to have negative effects on non-breastfeeding mothers. The implication for these women is that they are not trying hard enough and that they are not sufficiently concerned with their child’s current and future health.

2.  Lactivists point to a small decrease in the risk of respiratory and diarrheal illnesses in the first year, and ignore the many factors that individuals consider in risk assessment.

Social scientists and psychologists have shown that most people use a broader notion of risk that includes additional factors, such as available alternatives, whether an activity is freely chosen, and whether risks and benefits are fairly distributed.

Lactivists completely ignore fact that the benefits of breastfeeding are seen across large populations, and do not necessarily apply to individual mother-infant pairs. According to lactivists, every mother, regardless of her circumstances, should breastfeed.

Mothers are basically told that unless they have HIV, they ought to breastfeed and what they may consider reasons to stop are not ‘acceptable’ reasons. Although emotions are
mentioned in the documents concerning breastfeeding, it is only the positive emotional experiences of bonding and being close to one’s baby that count… [N]egative emotions should also be considered valid …

3. Lactivists are not honest about the acceptability of alternatives to breastfeeding. In particular, they like to pretend that the risks of formula feeding in developing countries can be extended to first world countries.

There may of course be good reasons to promote breastfeeding in certain contexts, for example, in developing countries, where clean water is not available or parents are poor and might dilute formula, which means that babies will run the risk of becoming undernourished. However, a problem arises when a policy to promote breastfeeding to prevent children in underdeveloped countries to die or become sick is generalized to apply to all contexts and all families. The availability of alternatives is very different in developing versus industrialized countries.

4. The assertion that breastfeeding is “natural” is ethically meaningless.

A common fallacy in thinking about risks is to assume that nature is benign, and technology is malicious. However, this view of nature is empirically false …

Naturalness is usually considered and presented as a good thing, something which we ought to strive for and want… However, in spite of the positive connotations of naturalness, there are many philosophical problems with the concept of naturalness. The concept is vague, value-laden and even political. First, it is extremely difficult to say for sure what is natural and what is unnatural. Second, many things we appreciate today would not be considered natural, yet we prefer the new unnatural instead of the traditional, natural thing. For example, people today see glasses,
central heating, means of transportation … as necessary tools which facilitate daily life tremendously… That breastfeeding is natural and bottle feeding not is in itself not an argument in favor of the former. To say that something is natural is not really to say anything, since that could be good or bad. If breastfeeding is said to be natural and therefore preferable, this is a fallacious argument in which the descriptive and the prescriptive dimensions are blurred.

5. The lack of balanced information.

For example, it is said that breastfeeding is more convenient than bottle feeding… However, women who experience physical and emotional challenges when trying to breastfeed are not likely to perceive it as convenient…

It is often emphasized that breast milk contains more optimal nutrients than formula milk and that it always adjusts itself to the development of the baby. This information has to be nuanced by the fact that mothers who breastfeed need to give their babies the supplemental vitamins K and D, which are contained in the right doses in formula milk. Furthermore, studies have shown that breast milk can contain chemical contaminants…

The claim that breastfeeding helps mothers get back into shape should also be nuanced. Some women only start losing weight after having stopped breastfeeding…

6. The refusal to acknowledge that many of the purported medical benefits are not back by solid scientific evidence.

… [T]here are scientific studies in respected journals, including metastudies, that actually cast doubt on claims about the medical benefits of breastfeeding.

The authors’ conclusion is that the current message sent by public health authorities is unacceptable:

The way breastfeeding is currently promoted by WHO, UNICEF and the national health authorities does not respect mothers as autonomous beings capable of making good decisions
for themselves and for their families. Breastfeeding is a very personal matter and women who have physical and emotional problems with it or, for other completely valid reasons, prefer not to breastfeed, are made to feel inadequate as mothers, and perhaps even as women, and made to feel that they are not doing what is in their child’s best interest. This is a powerful message to vulnerable mothers, especially first-time mothers… We have argued that the current message sent by public health authorities is unacceptable. Public health policy should be compassionate and take the negative as well as the positive emotions associated with infant feeding into account. It is the responsibility of providers of information on infant feeding and of health care providers to encourage parents to make an informed individual choice.

In other words, contemporary lactivism isn’t merely based on inaccurate factual claims, it is also ethically suspect.