Philosopher: Invoking “harms” of formula feeding is not morally justified

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One of the things I like best in writing about contemporary mothering issues is the cross-fertilization betweeen academic theory found in journals and lived reality represented by media articles and blog posts by and about mothers. The average natural childbirth advocate or lactivist has little idea how her preferred rhetoric, which she believes was promulgated by childbirth and breastfeeding professionals, has actually been shaped by professors. Similarly, women struggling under the crushing imperatives mandated by those professionals have little idea how — fortunately — their anguish is fueling the writing of other academics.

”[W]e should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies.”

Breastfeeding is a case in point. Most contemporary language on breastfeeding can be traced back to an academic paper written in 1996, Watch your language by Diane Wiessinger.

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus”; but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial baby milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

But now a philosophy professor cautions that the use of risk based language around formula is not morally justified. In a new paper in the Journal of Medical Ethics, Fiona Woollard asks, Should we talk about the ‘benefits’ of breastfeeding? The significance of the default in representations of infant feeding.

In an accompanying blog post, Prof. Woollard explains why she wrote the paper.

She was attending a meeting of breastfeeding professionals:

… Then the speaker adds, almost as an aside, “Of course, we know that it is really ‘the harms of formula’ not ‘the benefits of breastfeeding’.” There is a general nodding of heads. It seems to be accepted by almost everyone in the room that this is something that we know. It is ‘known’ that any differences in outcomes between babies fed with infant formula and breastfed babies should be described as ‘harms of formula’.

Woollard begs to differ.

As a philosopher, I feel a sort of territorial annoyance. This is a deeply complex philosophical question. It is not something that we should confidently claim to know as if there were a simple answer.

In her paper she explains why talking about the “harms” of formula is NOT morally justified.

She, too, traces the use of risk language to Weissinger’s piece. And she opposes the use of such language on both philosophical and practical grounds:

Given the detrimental effects that shame surrounding formula use can have on the well-being of new mothers and their neonates, we have strong reasons to avoid the unjustified use of morally loaded terms to describe infant-feeding decisions. There is significant sociological evidence connecting decisions to use formula and feelings of shame, guilt and failure… The use of morally loaded terms … also gives the impression that such guilt and shame is appropriate. If guilt and shame is seen as appropriate, then its effects on maternal well-being may be wrongly dismissed as morally unimportant.

Where did Weissinger go wrong in her invocation to use shaming language around formula feeding?

Wiessinger appeals to an allegedly standard use of language surrounding health to argue that we should treat breastfeeding as the default and formula feeding as deficient and dangerous. She states: “Health comparisons use a biological, not a cultural, norm, whether the deviation is harmful or helpful…

Even if breastfeeding is the biological norm, it is far from obvious that it should be the moral baseline from which the morally loaded calculations of harm and benefit are calculated…

Why not?

Because breastfeeding deeply implicates the mother’s body and agency, positioning breastfeeding as the moral baseline is problematic even if it is the biological norm. To do so takes the mother’s body and agency for granted. It does not fit with our use of the concepts of harm and benefit in other situations…

Woollard reviews a variety of moral accounts of harm and shows why they lead to the conclusion that formula feeding does not cause “harm.”

For example:

If I were to push “Joe” into traffic on a busy highway and he gets hit by a car, I have harmed Joe. But if Joe runs into traffic and I don’t stop him, I haven’t harmed him. Moreover, if a car is heading is our direction and I don’t step in front of Joe to protect him at the expense of myself, I certainly haven’t harmed Joe.

Similarly, if I were to deliberately expose “Sammy” to a diarrheal illness and he gets sick, I have harmed him. But if Sammy gets a diarrheal illness that might possibly been prevented by breastfeeding, I haven’t harmed him. Moreover, if Sammy gets a diarrheal illness because I don’t use my body to offer him the potential protection of breastfeeding, I haven’t harmed him, either.

Therefore, from a moral perspective, not breastfeeding cannot and should not be described as a harm.

Interestingly, Woollard does not question the scientific evidence on the benefits of breastfeeding. Either she is unaware or in the interests of brevity has decided not to mention the fact that the scientific evidence on the benefits of breastfeeding is weak, conflicting and riddled with confounding variables. She does not mention that the promised benefits of increasing the breastfeeding rate have failed to appear and that breastfeeding has risks (of dehydration, jaundice, starvation and death) as well as benefits. She proceeds under the assumption that breastfeeding is indeed beneficial, but even then a mother who doesn’t breastfeed is NOT harming her child.

Woollard concludes:

When it comes to descriptions of maternal behaviour, we should reject the assumption that there has to be a single appropriate default for infant feeding. Breastfeeding is normal and should not be stigmatised or seen as a lifestyle choice that can only be accommodated under ideal circumstances. The phrase ‘breast is best’ should be avoided. But we should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies. Extreme care should be taken before using morally powerful terms such as ‘risk’, ‘harm’ and ‘danger’. Where possible, neutral terms such as ‘difference’ should be used, accompanied by clear information about the outcomes presented non-comparatively.

I strongly agree and I sincerely hope that breastfeeding professionals will take note!

  • What are these alleged “harms” done by formula feeding?

    • seenthelight

      Being UN-natural, of course. And the gut microbiome. Because that research is conclusive. And my formula-fed husband has a sensitive stomach, so obviously that’s related, right?

      And some are saying now that jaundice is a good thing! Formula prevents the newborn from getting to experience that. Why would you rob a newborn of its experience?

      Also, did you hear how Nestle encouraged all those African women to formula feed, and it didn’t occur to them to think about those women’s access to clean water, so a bunch of babies died. So Nestle is evil and all formula producers are in cahoots with them, so they’re all eeeevil and women who can’t produce breastmilk should get it from a milk bank, and the women who don’t want to produce breastmilk, well, they’re just as evil as those formula companies, aren’t they? It doesn’t help the cause to call them that, though, so we’ll just say they must have been caught up in formula marketing, poor dears. But the women who can’t produce get nothing. We have to call them liars. If we admit that some women can’t produce, this house of cards crumbles. Besides, milk banks aren’t too reliably stocked. And you have to store it properly or it becomes far more dangerous than formula ever was. But hey, breast is best!

  • Manly Seadragon

    I had my baby through the public health system in Australia. Overall I had great care but the state government policy is very pro-breastfeeding. I would be happy to hear the (real) benefits of breastfeeding as long as the risks were equally discussed. I only got a very brief discussion of why I shouldn’t formula feed, with all of the ‘risks’ emphasised and no practical advice.
    I remember some snippets from the BF guide, including BF will help me loose weight, reduce chance of cancers, increased baby IQ and immune response etc etc. I was very annoyed that such a poor description of the science was coming from a public health body.
    We should credit women the intelligence to take on all the facts and trust them to make the right decision for their family.

    • Manly Seadragon
      • Danielle G

        That paper you uploaded is horribly offensive and beyond idiotic. Do they think women are stupid or something? Tons of false information and subjectivity (breastfeeding is convenient??) presenter as fact. Thanks for sharing. I can’t wait to have another baby so when the lactation consultant shows me the sheet that shows how small my baby’s stomach is at birth I can laugh in her face.

        • Manly Seadragon

          I know, I was angry for ages after reading this but I didn’t and still don’t know who to complain to. This booklet would be distributed to all women in the public system in my state.

      • RudyTooty

        Yeah. This is garbage.

        Unfortunately, not uncommon in the US, either.

  • Amazed

    I am not sure I agree with this kind of “book wisdom”. I mean, I can accept the two cases with Sammy and Joe at a reasonable level but at the level of my personal comfort? Just no.

    An example from about ten days ago that I mentioned in my comment to another post: about ten days ago, I suffered an accident at a toddler playground. There were some big kids playing volleyball in this place which was tinier and did not have a field. I watched them warily, wondering if I should tell them that this was a place for babies and they can harm someone. Instead, I kept my mouth shut because there were mothers with children much younger than my niece. I decided that I was getting paranoid and if there was something truly dangerous, there mothers would have told the kids to stop long ago. Instead, I focused on my niece alone and lo and behold, I got a head in my throat as one of the big kids lunged for the ball. I am still undergoing treatment. The physician who treats me was shocked what a lucky escape I’d got. It turned out that the mindblowingly strong blow had been centimeters away from my larynx.

    Now that I know what the feeling of this particular harm is like, I feel guilty for not telling the kids to stop. My niece was walking right next to me but the boy who hit me didn’t see me – he just jumped back and up for the ball. He could have easily hit her. Behind me, there was another kid, younger than even her. If I had not been there, the big boy would have just flattened him right upon the spot. The power of the collision was something monstrous even to me, a fully grown woman. I’d rather not imagine what a toddler would feel.

    From now on, I feel I’m potentially harming children if I keep silent. I consider it my moral obligation to warn kids not the appropriate age and with inappopriate ways of playing to stop. I am damned glad that I was there instead of the little boy, although I didn’t do anything to save him.

    It’s the same with the two examples the article provides. Strictly speaking, the author is undoubtedly right. But how many people are this strict? We live in real world, not the world of philosophic theories. If I had seated myself on the bench comfortably and saw my niece – or another kid – being run over by the big boy, even if I had realized what was going to happen and raced towards them, aka did my best to save them, I would have felt immensely guilty for not taking the necessary precations to neutralize the risk although I KNEW I should have. The academic knowledge that I had not harmed them would not have helped.

    This is why I think such articles are going to stay far from the knowledge and mind of ordinary women. We are not all philosophers. Too often, we go with our gut. That’s why I think it’s far more important to bring practical matters to women’s notice. It doesn’t matter if you have theoretically harmed your kid by not breastfeeding – that’s what most mothers are likely to think. But it does matter that not breastfeeding doesn’t have most of benefits claimed. Practically.

    • MainlyMom

      I agree. I think children in our care are a different standard. If i let a toddler walk around a pool and she falls in and downs while i read a magazine, I’ve definitely harmed her. Babies and children don’t have the same agency as adults.

  • Madtowngirl

    A little OT: I had my 20 week ultrasound today, and in the bathroom was that horribly inaccurate “your baby’s stomach is the size of a cherry at birth” poster. Really? My baby isn’t even near birth yet, and you’re inundating me with false information to try and “alleviate” my fear of not producing enough for my child? The BFHI needs to die in a fire.

    • Anna

      My friend with GD came home the other day with the “size of a malteser” crap. They will give her baby some glucose gel if needed and she has been instructed to try to collect colostrum prenatally. Ive tried to subtlely suggest a couple of the little pre-made bottles of formula wont hurt and far better than ending up in special care but given the posters plastered everywhere in the hospital that might as well say “if you dont breastfeed youre shit!” I highly doubt any midwife would dare say the formula is okay as a precaution and it would only be offered too late after problems have developed.

      • Madtowngirl

        It’s so insanely gross that they’re happy to sacrifice a child’s health got the sake of breastfeeding.

      • Danielle G

        I had GD and my baby never had any glucose issues at all in spite of the fact that she was SGA as well (ubder 5.5 pounds but term). She was Totally healthy but small. They basically had me feed her nothing but pitiful drops of colostrum bc her stomach was the size of a coin. Of course by night 2 she was crying and I demanded formula. it was a baby friendly hospital and, to their credit, they did comply with my request and supported me. but when she settled down, I remember being surprised that it was just totally fine for an SGA baby to have nothing but drops of colostrum spooned into her mouth, as she wasn’t latching.

      • Heidi

        Yep, I was told the size of a marble by the nurse, who was wearing a lanyard with a marble on it. Also GD. I was just talking about this on another site:

        Ugh! I’m one of those who didn’t have a choice about whether or not to use formula. It was either combo or fully formula feed or have a dead baby. That’s not an exaggeration. He would have starved to death. I combo fed for 7+ months, giving him all I could pump which was 8 oz. I’m still mad about how I was misled in the first couple of days of his life by the hospital. I was fed lies about how his blood sugar readings. First the nurse told me it wasn’t accurate. Then when the readings came back really low from the lab too, which is actually pretty dang accurate, I was told he wasn’t acting like his blood sugar was that low so he was fiiiiiine. I regret believing her and not telling her to get me a fucking bottle with a fucking nipple ASAP and no fucking lactation consultants. Instead, when his sugar was not going up for a day, they tried syringe feeding and then one of those contraptions you put on your nipple to formula feed. He hated that thing and wouldn’t stay awake for the syringe feeding either. Because his sugar was low! He was acting hypoglycemic and now I clearly see that in retrospect!

        Here’s the kicker – I was already in the fed is best camp and didn’t see anything wrong about choosing to formula feed. I figured I might hate breastfeeding, had it worked, and would gladly switch to formula or combo feeding by choice. But the bullshit propaganda still negatively affected us.

        By the way, a night nurse who had had it with the breastfeed at all costs bullshit her hospital was promoting got us a bottle with a nipple and his next blood sugar reading was good! Imagine that. I still wonder if his brain was injured in the meantime.

    • demodocus

      That crap is everywhere. Fortunately, there wasn’t a copy in the 2 exam rooms my ob usually saw me in.

    • StephanieJR

      What’s insane to me if you tried that argument with animals – oh, your cat’s stomach is the size of a cherry, so they only need a small mouthful a day – you’d very clearly be abusing your pet, but somehow with babies it’s a-okay to starve them? No one seems to be using any logic or common sense to feed an infant.

      (My bunny is about the size of a newborn, and her stomach is definitely bigger than a cherry! She never stops eating, and she doesn’t have to put on weight and keep growing important things like her bones and brains)

    • Charybdis

      I’ll bring the pitchforks if you’ll bring the torches. Any volunteers for the village mob to come along?

  • fiftyfifty1

    I know very little about philosophy and ethics, so I would appreciate the input of those of you who know more. I understand what she is saying about Sammy and Joe above, but is this really the accepted ethics conclusion in all cases? I mean I would feel pretty guilty if I saw Joe headed for the traffic and didn’t even try to stop him! I *would* feel like I had harmed him. Maybe there is no legal obligation to try to stop him, but isn’t there a moral obligation? What if Joe is toddler about to run into the street? What sort of monster would just sit by and let that happen? And don’t parents have even a bigger obligation? For example there is a vaccine against Rotovirus. If I refuse to vaccinate my son “Sammy” and he catches this diarrhea and dies, can I really claim that I have not harmed him just as long as I never deliberately exposed him to the virus (and he doesn’t infect anyone else?)

    • Amy Tuteur, MD

      The arguments in the paper are much more involved and use a lot of philosophical jargon. I tried to reduce one of the arguments to basic, every day experience, but that was far from all that the author discussed.

  • Tina

    Or the reason that she didn’t mention about the very elusive benefits of breastfeeding was that she wanted to focus her attention on her argument, rather running the risk of getting bashed as anti-breasteeding by all the lactivists and her actual message getting drowned out.

    • maidmarian555

      I’ve met Fiona and I would (certainly from my perception) imagine that this would be the case. I definitely believe that her paper has been written in good faith, she’s been doing a lot of research into how language harms mums, has given those mums a space in which to discuss feeding experiences (which was where I met her) and maintains a professional neutrality- which I think is important if her message is ever going to reach the people it really needs to- which would be those who work with new mums and yet insist on using language surrounding infant feeding that is often actively harmful.

  • aurora

    In developed countries with clean water formula helps babies and mothers. Yet, in developed countries the breastfeeding at all costs initiatives are harming babies.