A moral duty to breastfeed implies a moral duty to vaccinate and reject co-sleeping and homebirth

Volvo XC40

Philosophy professor Fiona Woollard has written a fascinating paper on the issue of breastfeeding and maternal duties entitled Is It Okay to Let My Child Be Stung by a Wasp?

New mothers report feeling shamed for not breastfeeding, and constantly having to defend their use of infant formula from strangers on social media or in public places like cafes. Coming at a time when new mothers are extremely vulnerable, such guilt and shame can have devastating consequences…

Something that might help would be if we recognised that the health benefits of breastfeeding give mothers a reason, but not a defeasible duty to breastfeed. Defeasible duties are associated with guilt, blame and requirements to justify our behaviour. If you have a duty to do something then you are required to do it; if you don’t, other things being equal, you should feel guilty and people with appropriate standing can blame you.

Defeasible duty is a technical philosophy term; colloquially we might call it a moral imperative. So the question becomes: do the purported health benefits of breastfeeding lead to a moral imperative for a mother to breastfeed? Woollard believes that the answer is “no” because not all reasons reach the threshold of moral imperatives.

Is there a moral duty to do what is safest for a baby?

Woollard notes:

We treat mothers and pregnant women as if they have a defeasible duty to perform each action that might benefit their child. That’s why we tend to act as if it follows from the fact that breastfeeding has health benefits that the mother has a defeasible duty to breastfeed. I call this a maximal maternal duty to benefit.

Most lactation professionals claim to believe, and craft their language to promote, the idea of maximal maternal duty to benefit. For them, the fact that breastfeeding has any health benefits is not merely a reason to breastfeed but a moral imperative to breastfeed.

But most of us, including lactation professionals, do not believe in a moral imperative to do anything that benefits a child regardless of other factors. For example, I doubt lactation professionals would claim that there is a moral duty to buy a Volvo, the safest car on the road.

If you do the math, the risk of a child dying in a car accident is far greater than the risk of being “harmed” by formula feeding, regardless of what magical benefits you ascribe to breastfeeding. But wait, you say. Volvos are expensive, many people cannot afford them and they might destroy the family budgets of even those who could scrape together the money. In other words, the benefits to the child can be balanced or even outweighed by the harms to the family. Therefore, while the fact that it is safer might be a reason to buy a Volvo, it does not lead to a moral imperative to buy a Volvo.

In other words, there is not a maximal maternal duty to benefit. Yet if reducing the greater risk of dying in a car accident isn’t a moral imperative, why would breastfeeding be a moral imperative?

The Volvo example is a bit outlandish but there are several situations a lot closer to breastfeeding that pose the same moral conundrum.

Is there a moral imperative to avoid co-sleeping with infants?

There is simply no question that co-sleeping increases the risk of sudden infant death. True, not every breastfeeding pair has the same risk but the risk exists for everyone. In other words, there is a measurable benefit to a baby to sleep outside its mother’s bed. Any theory of a maximal maternal duty to benefit creates a moral imperative for mothers to reject the practice of co-sleeping.

Most lactivists and lactation professionals are appalled at the thought. Co-sleeping makes breastfeeding more convenient, and although they would be the first to lambaste a mother who chose formula because it is more convenient, they rate their own need for convenience in breastfeeding very highly.

Besides, they claim, breastfeeding itself reduces the risk of sudden infant death. So what? If there is a moral imperative to breastfeed because of the health benefits, then surely there is the SAME moral imperative to reject the practice of co-sleeping.

How about homebirth? If a maximal maternal duty to benefit leads to a moral imperative to breastfeed, then the same principle creates a moral imperative to give birth in the hospital.

Homebirth in the US dramatically increases the risk of perinatal death. The best analysis to date, conducted by Judith Rooks, CNM MPH shows that homebirth with a licensed homebirth midwife increases the risk of perinatal death by 800%.

But wait, homebirth advocates say, homebirth provides benefits for the mother. So what? If mothers are morally required to do what is best for babies, regardless of the impact on themselves, then it doesn’t matter how mothers might benefit from homebirth. They have a moral duty to deny themselves those benefits in order to maximize the health and survival benefits to the baby.

Is there a moral imperative to vaccinate?

Every pediatric health organization promotes vaccination even more aggressively than breastfeeding. If they were forced to choose between them, they would undoubtedly choose vaccination as far more beneficial to babies than breastfeeding. Even their absurd claim that higher breastfeeding rates could save more than 800,000 lives per year pales into insignificance compared to the hundreds of millions of lives saved by vaccination.

Anyone who insists that there is a moral imperative to breastfeed because the WHO says it saves lives must acknowledge that there is a greater moral imperative to vaccinate because it saves far more lives. Yet millions of parent insist that what they personally believe about the benefits and risks of vaccination should carry greater weight than WHO recommendations. If that’s the case, then how can there be a moral imperative to breastfeed when many women believe the risks to their babies, themselves and their families outweigh the benefits?

Where does that leave us?

At a minimum, we must acknowledge that we do NOT believe in a maximal maternal duty to benefit. We don’t believe that mothers are obligated to drive Volvos or nothing else. Moreover, many passionate advocates of natural mothering do NOT believe that the fact that co-sleeping, homebirth, and refusal to vaccinate increase the risk of death means that mothers are obligated to avoid co-sleeping, homebirth and vaccine refusal. They recognize and respect that fact that there are other factors (convenience, finances, parental beliefs) that are involved.

Now they just need to recognize and respect that there is more involved with breastfeeding than benefits to babies.

  • alongpursuit

    Has anyone ever taken their sick baby/toddler/kid to the doctor’s and been asked whether you breastfed them? (Implying that your kid wouldn’t be sick if they were breastfed?)

    On the topic of moral duty, maybe I’m too sensitive but I worry about being shamed for having a sick kid because I couldn’t EBF for 6 months. I have a lot of mom-guilt about “failing” at breastfeeding (I had very low supply and managed to combo-feed for only 5 months before quitting because I had gone insane with sleep deprivation from a triple-feeding schedule). My partner has taken our baby to the doctor’s since she was 6 months old because I couldn’t handle being hounded about breastfeeding by the nurses and seeing all the BF posters in the clinic. She’s almost 2 now. At her 18-month checkup the doctor asked my partner if baby was still breastfeeding. How long are they going to ask this question? Why does it even matter?

    My toddler has only seen the doctor for regular vaccination/checkup appointments, once for an ear infection, and once for a mild case of hand, foot and mouth disease. She seems pretty healthy to me (though she does have the daycare runny nose most of the time).

    • Lurker

      For a toddler with a stomach virus, I think I’ve been asked if they were still breastfeeding, not to imply that they wouldn’t be sick if they were still nursing but just for the purposes of ensuring adequate hydration/managing intake so as not to aggravate the vomiting. That’s the only time it’s ever come up in terms of illness. In terms of asking during a well visit, I would think it mostly impacts nutritional recommendations – my pediatrician told me a toddler should have breast milk OR whole milk OR formula until 2. If they’re still nursing, whole milk isn’t as crucial. If they can’t tolerate dairy (like mine), they should get non-dairy formula if weaned before 2. I’m pretty sure my pediatrician asked at 12 and 15 months, but that might be because my kids can’t have dairy, so their diets need a little more attention. I can’t remember if we were asked at 18 mos or 2 years, but I know certainly no later than that.

    • Griffin

      “I have a lot of mom-guilt about “failing” at breastfeeding”

      Well, you didn’t fail anything. You have in fact succeeded and continue to succeed. You fed your kid beautifully and I’m sure your love and nurturing means that she’s happy and thriving. The daycare runny nose indicates that she’s getting all the infectious exposure that is needed to build up a strong immune system. You’re being a great mother! Really!

      I had no problem breast-feeding but didn’t want to. I wanted my body back and my nights uninterrupted, and my husband was more than happy to do the night and other feeds. I wasn’t untouched by all the breast-feeding pressure, it did cause me to second-guess myself sometimes. But I had a strong suspicion that it was some sort of mania designed to stuff women back into a biological drawer so I resisted by avoiding it, like you.

      So my husband did all the baby health check ups because he’s a bit left-brained and was completely impervious to all the breast-feeding furor. He would answer questions like “Is your wife still breast-feeding?” with a bored “No”, which always stumped the maternal health nurse. Once she pressed some BF pamphlets onto him and he gave them back to her before he left.

      By the time our third kid came along, the maternal health nurse had given up.

      I also avoided mother’s groups because they were hotbeds of gossip and societal pressure (and frankly boring).

      It’s hard to escape all the brainwashing, we women are bombarded with it from day one. If it’s not how we look, it’s how we act and the life’s decisions we make. None of those things are anybody else’s business. In my view, the only way through that morass is to think, “What works for ME (and my family)?” and work from that base point.

      • Heidi

        It’s always puzzled me when they try to push breastfeeding after the fact, as if most women can just put a baby to their boob and milk will be produced in plentiful amounts despite having exclusively formula fed. Just from what I’ve read I’ve read of other women’s experiences, it seems to take most a week to dry up.and really just a few days to really get past engorgement. But I’ve seen it presented like it’s never too late. So much better things to do with one’s time and energy than trying to re-establish lactation.

    • rational thinker

      They usually ask anytime up to age 2 just to make sure the kid is getting all the nutrition he/she needs. Formula has all the stuff baby needs for growth but sometimes breastfed babies need vitamin supplements like vitamin D ect. So yes it is normal for them to ask.

      When my son was born he had jaundice and was pretty yellow on day two. When the pediatric doc came to check him he was extremely happy I was formula feeding so he was not too concerned about the jaundice. But if I was breastfeeding he would of had to monitor the baby a lot more to make sure he was getting enough and gaining weight.

  • The Bofa on the Sofa

    Aren’t c-sections safer for babies but riskier for moms?

    • rational thinker

      Maybe but c section is much safer for mom compared to vaginal birth.

      • AnnaPDE

        Especially if we include not just risk of death but serious damage to pelvic floor etc.

      • Griffin

        Well, compared to *attempted* vaginal birth. The last I looked at the medical lit, it was quite clear that women who have uncomplicated vaginal births have less perinatal morbidity (infections, hemorrhage, etc) than women who have elective CSs. HOWEVER women who are aiming for a vaginal birth – trial of labor (TOL) – but end up with an emergency CS (or instrumental delivery) have much worse perinatal morbidity than the women with elective CSs. As a result, the TOL group overall has worse perinatal outcomes than the elective CS group. And we can’t dissect off the successful TOLs from the unsuccessful TOLs because we still can’t properly identify the women who are going to need an emergency CS.

        And as AnnaPDE said below, if you add long-term morbidity outcomes (incontinence, sexual dysfunction, psychological trauma) to the perinatal morbidity outcomes, elective CS ends up markedly safer for women than TOL.

        • AnnaPDE

          Given that the “uncomplicated vaginal birth” group is explicitly selected to not have encountered any of the adverse outcomes, this kind of risk balance is not entirely surprising.
          For fairness of comparison, we might then also divide the elective CS outcomes into the much cited “mum walked around happily the same evening, and was fine on some panadol the next day” cases from all the rest, and marvel at the excellent outcomes of the first group.
          (I for one had the majorly uncomfortable “feel like my insides are falling out for a week despite serious painkillers” version, but at least the scar is invisible by now, and in hindsight it would have been next to impossible to get bub out the other way, so that’s a net plus I guess.)

          • The Bofa on the Sofa

            This discussion is all well and good, but remember, the outcomes for mothers are irrelevant. What matters is the outcomes for the babies. And if the outcomes for babies with c-sections are better than those for vaginal delivery, then that means there is a moral imperative for c-sections.

        • rational thinker

          I guess for moms it depends on circumstances my first birth was 24hrs two were spent pushing and I had 4th degree tears. I should have had a section with my first. My second was only 3hrs pushed 3 times and she was out no tearing and I got out of bed less than an hour later.
          With regards to the baby I think a c-section would be safest for baby every time.

          • Griffin

            Yes, CS is safer for the baby, and that’s long been clear. It’s one of the facts about CS that can’t really be disputed so the NCBers try to ignore it and hope that mothers-to-be don’t learn about it.

            I discovered this when I was considering (and eventually fighting for) an elective CS in the Netherlands 18 years ago. I wanted to discuss the pros and cons of elective CS and in my naivete I sort of coerced a Dutch obgyn into seeing me (at that time in the NL, low-risk women never ever saw an obgyn – only midwives, home birth without painkillers was the norm, and routine ultrasounds or blood tests for abnormalities were not practiced). At the mention of elective CS, the doc looked like he had just swallowed a fly. He said loftily that it was too dangerous for me and he refused to talk about the comparative maternal morbidity/mortality analysis I had conducted. He just kept repeating that no one would give me an elective CS in NL.

            I then asked, “Do you at least agree that CS is safer for the baby?” He tried to avoid answering until I pointed out that 6 months earlier, the head obgyn honcho in NL (who was very pro home birth) had acknowledged in a journal editorial that CS was safer for the baby. Then the doc got all red and angry and stood up and tried to (literally) push me out of his office.

            (I made him give me an ultrasound to date the pregnancy and then I went across the border to another country for an elective CS. And we now know that Dutch women have massively abandoned home birth in recent years. I speculate that the truth could only emerge in NL after head obgyn honcho died).

            You know, if a hospital really wants to be labeled “BABY-friendly”, they should be routinely advising pregnant women to get elective CSs! This is yet another example of how politicized the whole birth and babies thing is.

          • Alia

            You can’t get a elective C-section in Poland, at least not officially. So if you really, really want it, you either pay the obgyn under the table (illegal and unethical) or you go to a psychiatrist and convince them that you suffer from tocophobia (fear of giving birth) and then you present it to the obgyn and you have a “valid medical reason” for elective CS.

          • Griffin

            That sucks 🙁 The European country I went to for my first elective CS was also somewhat resistant to them at the time but I knew of the doc and his midwife: they had readily consented to a CS when my BIL’s wife was in labor for four agonizing days and my BIL asked desperately, “Can’t you just cut the baby out?”

            But we still had to pretend heavily pregnant me was driving through the country, started labor that had stalled, and needed an emergency CS.

            I think attitudes to elective CS in that country have relaxed considerably since 2000.

          • Alia

            Generally it sucks to be a woman of childbearing age in Poland. Emergency contraception is prescription-only, obgyns are allowed not to prescribe birth control for “religious reasons” and pharmacies are allowed not to sell it. Oh, and abortion is illegal in most cases and even in the cases when it’s legal, it’s often very hard to find a hospital that would do it.

            Of course, if you’re wealthy enough, you can go to Germany, Slovakia or the Czech Republic and have it done in a hospital – or pay a doctor under the table to have it done in secret.
            It’s so bad that when I had to undergo a surgery for a valid medical reason, I was a little afraid that the surgeon would choose not the option that was the best for me but one that would preserve my ability to have children (even though it’s not important for me).

            Sometimes I hate this country.

          • Griffin

            I’m sorry. I’ve been keeping an eye on Poland since the present reactionary government got in. I was heartened by the 2016 protests that got them to back down on restricting the abortion law further but it seems they’re trying to chip away at it piecemeal now. What a ghastly situation 🙁

            What is the system like regarding NCB and breast-feeding?

          • Alia

            It depends on the hospital, I guess. There was a movement serveral years ago to make hospitals more mother- and baby-friendly, getting away from routine episiostomies, letting fathers take part in birth and generally doing away with paternalism (and other stuff that was mostly the legacy of communism). And then, as it happens, in some hospitals they went to the other extreme.

            Women also have 20-weeks long paid maternity leave, so if they want to stay at home and breastfeed, they can at least do it without losing income.
            Personally, I know a few lactavist moms and if you start sharing things like SkepticalOB on social media, you may get shouted down. But I still do it.

          • EmbraceYourInnerCrone

            4 days? Who lets a woman labor for 4 days before doing a C-section??? that amount of time leaves the baby and the woman at risk for serious infection and a host of other complications…

          • Griffin

            Yeah, I was pretty “wow, was that safe?” when I heard the story, even though at the time I knew nothing about having babies. And when we visited BIL and SIL 10 days after the birth, I was frankly shocked at the appearance of my nephew. He had massive swelling and bruising around his eyes and ears. He’d been squeezed head down into the pelvis for way too long. It took weeks for the swelling to subside and for nephew to be able to open his eyes. They didn’t include a photo in their birth announcement card because of it. That poor kid 🙁

            The obgyn who did the CS (and mine, later) was only brought into the situation when BIL requested to see someone else other than the midwives who were attending to SIL. SIL was very very keen on having a vaginal birth, so I have the feeling that the long delay to CS was partly due to her decision-making.

            She was also very very keen on breast feeding and turned out to be unable to do so fully. So when we came to see nephew, he was also constantly crying and mewling and fussing and nursing. BIL and SIL were hysterical with exhaustion and anxiety.

            I was just pregnant with my first then and it was my first taste of the nuttery that surrounds pregnancy, birth, and child rearing.

          • EmbraceYourInnerCrone

            Sorry if it seems like I am being mean to your SIL. I just don’t understand OBs or midwives who let things like “the patient is very keen on vaginal birth” keep them from making REALLY clear the danger and possible permanent damage that can result from delaying delivery. I guess I take it personally because my mother and my brother only got to live long health lives because of modern medicine and C-section. Nothing like being 4 and watching mommy hemorrhage all over grandma’s living room floor to bring home the possible dangers of pregnancy and childbirth…

          • Griffin

            I agree with you. If you look at my history, you will see that I am a staunch proponent of informed choice, and that that information should come from properly trained impartial professionals.

            I myself, 18 years ago, fought for an elective CS as a low-risk pregnant woman and got it with some trickery, contacts, and help from sympathetic docs/midwives. It should NOT be like that. The nonpartisan information should be provided and the woman makes her choice. That’s how it SHOULD be.

            The events of which I spoke were 20 years ago. I do think we’ve come along a little bit from then, but it’s really still very unsatisfactory.

          • Griffin

            And I didn’t really address your comment. I don’t actually know what the obgyns and midwives were thinking to allow my SIL to labor for 4 days before CS (they kept sending her home). I do know there was a lot of woo going on at the time from the side of my SIL but on the other hand, my sympathetic doc/midwife pair told me to lie to the other staff at the same hospital about my real reasons for being there (to get an elective CS) because “otherwise they will make trouble”. Which suggests there was a political/ideological agenda on the part of many in the hospital.

            I just know that it was all very traumatic and terrifying for my SIL and BIL. Fortunately, nephew seems to be OK. But it could so easily have gone irretrievably wrong.

          • AnnaPDE

            There were noises in a “we don’t do elective” direction in Germany when I had my IUD removed. The doctor asked about my plans while chatting through the procedure, and then offered to take an ultrasound measurement of my pelvis (for free) that would prove it incapable of letting out anything larger than a mouse. “Just in case someone insists on a medical reason”, she said.
            It sucks when this kind of thing is necessary, and even more when it’s not easy to find.

        • Cat

          I actually lost a friendship because I said (fairly uncontroversially, I thought) that unsuccessful TOL plus emergency c-section was the worst-case scenario, compared to successful vaginal birth and scheduled c-section. She seemed to take that as an insult to her successful, uncomplicated vaginal birth. No idea why. Mind you, she was also annoyed with me because she was trying to claim the fact that her (male) toddler liked playing the drum as evidence that boys and girls are fundamentally different from babyhood, and I pointed out that my female toddler loved her drum kit. So maybe that friendship wasn’t meant to be!

          • Who?

            Sounds like you’re well out of it!

          • rational thinker

            I would say you are well rid of that friendship. Also I would say toddlers in general love drums, they like anything they can bang on to make noise at that age.She sounds like the type that would constantly find any reason why her child is more perfect than yours and try to one up you all the time regarding the children.

        • Shawna Mathieu

          This, plus how hard a failed TOL can be on a baby, is why, even though I planned through my whole pregnancy with my daughter to VBAC, when I was 39 weeks and I heard the doctors remarking they couldn’t see both her shoulders at the same time in the ultrasound, I immediately said, “No, if you’re going to have to use a crowbar to get her out, I’m not putting her through a VBAC. How soon can you schedule the C-section?” My wish for a VBAC was not worth putting her health at risk. 24 hours later, she was in my arms in perfect health.

  • fiftyfifty1

    So is it okay to let my child be stung by a wasp or not? I followed the link but it allows me to read only the first page!

  • Cartman36

    This what makes the lactivist obsession with breastfeeding so bizarre. There is quite a bit of data to support that children in high quality preschools have better outcomes into adulthood than children who are not. Yet we would NEVER insist everyone send their children to preschool. Nor would we tell parents to stay together in a bad marriage because on a population level children from two parent homes have better outcomes than those from single parent homes. We recognize that what is best for each family is unique to their situation.