Is it ethical to lie to patients when you are doing it in their best interests?

I suspect most of us would answer ‘no.’ Lying to patients deprives them of moral agency, impairs their ability to give informed consent and is shockingly paternalistic. The liar imagines that he or she knows better than the patient herself. The liar may even be correct in this assumption, but lying to patients is unethical nonetheless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivist dishonesty is deadly not just because lactation professionals lie to patients, but because they lie to each other.[/pullquote]

Curiously, both natural childbirth advocates and lactivists, who would be rightly appalled if a doctor lied to them about the risks of childbirth interventions or the benefits of breastfeeding, have no problem lying to women to promote their own ends. Indeed, efforts to promote both natural childbirth and breastfeeding rest on the assumption that telling women the truth will scare women away from doing what is best for them.

Of course activists don’t call it lying. They drape their falsehoods in finery, calling their efforts ‘The Positive Birth Movement’ and ‘Trust Birth’ or the ‘Baby Friendly Hospital Initiative’ and ‘Breast Is Best.’ These sound lovely, but they are lies and paternalism nonetheless.

Consider Milli Hill’s justification for lying to women about the excruciating pain of childbirth.

Most pregnant women are very scared of labour. But by putting all the focus on how painful it is, are we failing to give them the full picture? And in doing so, could we actually be making labour worse – in some sense, setting them up to fail?

Fail? If the baby that’s inside her uterus ends up in her arms alive and healthy, she’s succeeded. When Milli Hill talks about failing at labor she means failing at the conceit of a specific performance of labor — vaginal birth without pain relief or other interventions.

The full picture? What does that even mean in the context of pain? When we tell women that cosmetic surgery involves pain are we depriving them of the ‘full picture’ of face lifts? Or are we giving them what we are ethically required to give them: the truth without which they cannot give informed consent.

The lying and paternalism in lactivism are even worse. Under the guise of promoting what is best for babies, lactation consultants and their organizations aren’t merely lying to women, they are letting babies die. Their motto appears to be ‘Better Dead than Formula Fed.’

Many of the tenets of the Baby Friendly Hospital Initiative are lies. Pacifiers not only don’t interfere with breastfeeding, they prevent SIDS. Judicious formula supplementation not only doesn’t reduce the likelihood of breastfeeding success, it actually increases it. Locking up formula in hospitals doesn’t improve breastfeeding rates, but it does increase the psychological distress of women who can’t or don’t wish to breastfeed.

Lactivist dishonesty is particularly deadly not simply because lactation professionals lie to patients, but because they lie to each other. Lactation consultants are ostensibly medical providers and like all medical providers, they are responsible for preventing, diagnosing and managing medical problems.

There’s an aphorism about diagnosis that has relevance for all providers: ‘what is rare is rare and what is common is common.’

That’s what’s known as a heuristic:

…any approach to problem solving, learning, or discovery that employs a practical method not guaranteed to be optimal or perfect, but sufficient for the immediate goals.

Heuristics are short cuts to diagnoses. Brain tumors are rare; tension headaches are common. When a patient complains of a headache, it’s much more like to be a simple tension headache, not a brain tumor. Sure some people with headaches will have brain tumors, but that represents only a tiny percentage of people with headaches. That’s why most people who have headaches can be reassured and sent away.

In contrast when someone starts coughing up blood, odds are high that something is wrong with their lungs and they should not be simply reassured and dismissed. Doing so can easily result in missing a deadly pneumonia or a deadly lung cancer.

Imagine then if we erroneously taught providers that pneumonia and lung cancer are vanishingly rare and that patients who cough blood from their lungs should be sent home and told to call if they’re still coughing blood a few days later. Many cases of pneumonia and other serious lung ailments would undoubtedly be missed at the moment when they are easiest to treat. Providers would be falsely reassuring patients with deadly conditions because the providers themselves have no idea just how common those conditions are.

That’s precisely what is going on with lactation professionals at this moment. Because they are taught that insufficient breastmilk is rare when in fact it is quite common (affecting up to 15% of women or more), they are falsely reassuring the mothers of critically ill newborns that their babies are fine when, in truth, they are actually dying of jaundice, dehydration, starvation or all three.

Babies are dying because lactivists are lying. And lactivists are lying because they believe that telling women the truth about the risks of breastfeeding as well as the benefits may lead them to ‘fail’ at breastfeeding. But the goal of providers should never be promoting a specific process; that’s unethical. The goal should always be promoting the wellbeing of patients regardless of how that outcome is achieved.

Lying is never justified, whether it is lying about the pain of labor or the risks of breastfeeding.

Natural childbirth isn’t best. Breast isn’t best.

Honesty is best.

What natural childbirth advocates like Milli Hill don’t know about the neurophysiology of pain could fill a book — or several.

Hill recently wrote The myth of the painful birth – and why it’s not nearly so bad as women believe. It is a typical paean to ignorance and disrespect — implying that childbirth pain is culturally conditioned and due to lack of support.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.[/perfectpullquote]

At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable. We simply don’t know what it would be like if all women were given one-to-one support from a midwife they really trusted, or if we created birth rooms, even in hospitals, that were dimly lit, homely and uninterrupted.

Since the beginning of time women have described childbirth as agonizing because they always gave birth in hospitals with bright lighting and unsympathetic male physicians. Oh, wait! Up until very recently all women gave birth in dimly lit, homely surroundings complete with one-to-one support from a midwife.

Obviously Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.

When it comes to sport, we all seem to understand just how much negative thoughts can affect your performance both physically and mentally. We know how powerful a confident attitude can be. Perhaps it’s time to consider that with birth, things are no different.

Wrong! The neurophysiology of sports pain is very different from the neurophysiology of childbirth pain.

Let’s start with the most basic difference. Most sports pain is somatic pain whereas labor pain is visceral pain. The distinction is critical.

According to Wikipedia, somatic pain can be deep or superficial:

Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.

The pain of crowning, when the baby’s head stretches the vagina, is somatic pain, but the pain of uterine contractions is visceral pain:

Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.

The neurophysiology of the visceral pain of uterine contractions is very different than that of somatic pain. Most importantly, visceral pain activates the autonomic nervous system, the nerves which control the automatic functions of the body like heart rate and blood pressure. In other words, visceral pain — unlike somatic pain — has a variety of effects that go beyond the conscious sensation of pain. These include elevated heart rate, elevated blood pressure, nausea and vomiting, and profuse sweating. Visceral pain — whether it originates in the heart, the gall bladder, or the uterus — is often perceived as “sickening.”

In her piece, Hill claims:

…[E]ven in ‘the nightmare labour from hell’ – 36 hours of contractions coming thick and fast – she can still expect to be without pain for around 60 per cent of the time.

That statement might be true if we were talking about the limited nature of somatic pain. If you poked someone with a pin for 20 seconds out of each minute they would feel fine for the 40 seconds that you aren’t poking them. But it’s definitely not true for visceral pain like uterine contractions. Even when the pain recedes the elevated heart rate and blood pressure as well as the nausea, vomiting, sweating and overall sickening sensation often do not recede completely before the next contraction begins. So women in labor do not spend most of the time feeling well except for intervals of pain. They spend most of the time feeling awful.

That has important implications for the philosophy of natural childbirth. The pain of uterine contractions is very different from the pain of athletic endeavor. The idea that the pain of labor is socially conditioned is nonsense; we can identify the receptors and trace the pain pathways. Most importantly, the pain of uterine contractions triggers a cascade of neurological responses that are not under conscious control.

No amount of support in labor is going to prevent women from having a profound physical response to uterine contractions that goes far beyond the sensation of pain itself. In contrast, an epidural, which blocks the neural pathway by which uterine pain reaches the brain does more than merely eliminate the pain. It also eliminates the autonomic nervous system response. When the pain goes away, the nausea, sweating and sickening feeling usually go with it.

The bottom line is that natural childbirth advocates promote a philosophy based on wholesale ignorance of neurophysiology. Childbirth pain doesn’t come from lack of support or lack of confidence. It comes from pain receptors, neural pathways, and the activation of the autonomic nervous system. Telling women about the excruciating pain doesn’t set them up to fail as Hill would have us believe. It’s simply telling them the truth.

The title of her piece is the first giveaway, The myth of the painful birth – and why it’s not nearly so bad as women believe.

You might have thought that the hours you spent in labor were agonizing, but Milli Hill knows better.

Most pregnant women are very scared of labour. But by putting all the focus on how painful it is, are we failing to give them the full picture? And in doing so, could we actually be making labour worse – in some sense, setting them up to fail?

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Denying the reality of women’s experience of agony and trauma in labor is a form of psychological abuse.[/perfectpullquote]

Milli’s done the math:

… In an average eight hour labour, a woman can expect to be ‘in pain’ for only around 23 per cent of the time. The other 77 per cent is ‘pain free’.

Is this woman an idiot? Would she tell a man that passing a kidney stone isn’t painful because only around 23% of the time is spent writhing in agony and vomiting. The rest of the time is “pain free!” I doubt it.

No, Milli is not an idiot. Like many people who make their money promoting the philosophy of natural childbirth, she’s a psychological abuser. Her abuse technique of choice is known as gaslighting.

According to Wikipedia:

Gaslighting … is a form of psychological abuse in which a victim is manipulated into doubting their own memory, perception, and sanity. Instances [include] the denial by an abuser that previous abusive incidents ever occurred …

The term comes from the play Gas Light:

…The plot concerns a husband who attempts to convince his wife and others that she is insane by manipulating small elements of their environment, and subsequently insisting that she is mistaken, remembering things incorrectly, or delusional when she points out these changes.

As practiced by Milli Hill and her colleagues, gaslighting means responding to stories of agony, desperation and trauma by denying the reality that most women experience.

Classic gaslighting phrases include:

That never happened!

You’re overreacting!

It’s all in your head!

You’re so sensitive!

Think your pain was excruciating? You’re overreacting!

And even in ‘the nightmare labour from hell’ – 36 hours of contractions coming thick and fast – she can still expect to be without pain for around 60 per cent of the time.

Still traumatized by 36 hours of agony? It’s all in your head!

When it comes to sport, we all seem to understand just how much negative thoughts can affect your performance both physically and mentally. We know how powerful a confident attitude can be. Perhaps it’s time to consider that with birth, things are no different.

Performance? Childbirth is not a performance anymore than passing a kidney stone is a performance. How powerful is a confident attitude in treating the pain of a kidney stone or a migraine or a broken leg? It has no effect at all. Why then would it have any effect on labor pain?

Look back on your labor as endless hours of intense suffering? That’s not what happened!

The importance of words is also emphasised by childbirth expert Penny Simkin, who stresses the vital distinction between ‘pain’ and ‘suffering’.

“Many women ‘suffer’ in childbirth, and it’s because they’re not respected, or kindly treated, they don’t have the tools to cope, or they feel unloved, or alone. If a woman crosses the line from ‘pain’ into ‘suffering’ in childbirth, we’ve failed her.”

Unloved? Unloved??!! These women are peddling pure bullshit.

At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable. We simply don’t know what it would be like if all women were given one-to-one support from a midwife they really trusted, or if we created birth rooms, even in hospitals, that were dimly lit, homely and uninterrupted.

Does Milli Hill ever listen to herself? We simply don’t know? What about what millions upon millions of women have told us since oral tradition and written language came into being? What about the fact that the people who wrote the Bible were so impressed by the agony of childbirth that they concluded it could only be explained as a punishment from God? What about the childbirth prayers from the Middle Ages and women’s own accounts from colonial times to the present?

According to Milli Hill and her colleagues: They were overreacting. It was all in their heads. It never even happened.

Milli Hill makes her money by gaslighting women, denying the reality of their experiences of excruciating pain and trauma. And that’s psychological abuse.

In a fascinating paper in the Journal of Medical Ethics, philosophers Fiona Woollard and Lindsey Porter conclude that mothers do not have a moral duty to breastfeed.

The paper is Breastfeeding and defeasible duties to benefit. The authors begin by quoting colleagues Lee and Furedi who deftly summarize the current moral milieu.

A process of cultural transmission seems to have turned provision of health information about the benefits of breastfeeding into hostility about formula use. This has a detrimental effect on relationships that are very important for new mothers, namely with health professionals and with other mothers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The moral duty to feed a baby does NOT imply a moral obligation to breastfeed just as the moral duty to educate a child does not imply a moral obligation to pay for private school.[/pullquote]

Or, as Woollard and Lindsey explain:

For many women experiencing motherhood for the first time, the message they receive is clear: mothers who do not breastfeed ought to have a darned good reason not to; bottle feeding by choice is a failure of maternal duty.

That’s certainly what professional lactivists believe, but they’re wrong.

We argue that this pressure arises in part from two misconceptions about maternal duty. First, confusion about the scope of the maternal duty to benefit and second, conflation between moral reasons and duties.

Indeed:

While mothers clearly have a general duty to benefit their offspring, we argue that this does not imply a duty … to carry out each particular beneficent act. Mothers do not have a moral duty to carry out each and every act that would benefit their baby. Mothers do have moral reason to perform each beneficial action. However, not complying with a moral reason, unlike failure to comply with a duty, is not an accountable matter. Therefore, the act of holding mothers to account for individual beneficent act omissions, and the demand that individual omissions be justified, is unwarranted. The expectation that mothers who bottle feed should have a ‘darned good reason’ is morally unwarranted, in addition to being demonstrably harmful.

We generally take this for granted in the day to day business of parenting. Mothers (and fathers) have a duty to protect children. Skiing is a potentially dangerous leisure activity. If mothers had a moral duty to carry out each and every act that might possibly protect their children, they would be morally required to forbid their children from skiing. But though everyone recognizes a mother’s duty to protect her child, very few people think that duty encompasses forbidding any activity that raises the possibility of injury.

Similarly, in many areas of the country private schools offer better education than public schools. If we believed that mothers have a moral duty to provide what is “best” for children, we would be forced to conclude that those mothers have a moral duty to provide the private school education regardless of the cost, but we don’t.

Though mothers have a general moral duty to provide “the best” for their children, they does not imply specific moral duties to provide every possible advantage in education or any other sphere. No one expects mothers to provide a ‘darn good reason’ for sending their children to free public schools.

Many lactivists are also natural childbirth advocates. Curiously they have no difficulty recognizing that the general moral imperative for mothers to protect babies does not imply a specific moral duty to give birth in exactly the way that doctors recommend. They argue — correctly in my view — that mothers have a right to autonomy over their own bodies and that, therefore, the moral duty to protect babies must be balanced against the moral right of women to give birth in the way that they choose.

For example, homebirth in Oregon has a perinatal mortality rate 9X higher than comparable risk hospital birth, yet very few believe that any Oregon mother who chooses homebirth must justify her desire to have a homebirth to other healthcare providers, other mothers or society at large.

The benefits of breastfeeding are far smaller than the benefits of hospital birth, yet lactivists routinely invoke a maternal moral duty to breastfeed. Diane Weissinger, in her seminal paper on the language that should be used to counsel new mothers, recognized this problem:

When we … say that breastfeeding is the best possible way to feed babies because it provides their ideal food, perfectly balanced for optimal infant nutrition, the logical response is, “So what?” Our own experience tells us that optimal is not necessary. Normal is fine, and implied in this language is the absolute normalcy and thus safety and adequacy-of artificial feeding …

In other words, Weissinger acknowledges that there is no moral duty to breastfeed … but then goes on to ponder how women can be browbeaten into believing that such a duty exists regardless.

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.

The mantra of the lactivist movement, “Breast Is Best,” is understood as invoking a moral duty to breastfeed. That’s why lactivists generally feel superior to mothers who formula feed, and feel justified in shaming those other mothers.

And that’s why they vehemently hate the phrase “Fed Is Best.” “Fed Is Best” embodies the very real maternal moral duty of making sure that babies are adequately fed while implying correctly that there is no moral duty to breastfeed.

It is both sad and ironic that the natural childbirth movement, which is supposed to empower women, has ended up disempowering them. Organizations like Human Rights in Childbirth and the Orgasmic Birth movement imagine that they are liberating women to experience the fullness of natural birth. In truth, they are imprisoning women in a view of birth that is in its own way every bit as constraining and unnatural as the medical model of birth.

Psychologist Helena Vissing addresses this irony in the chapter A perfect birth; The Birth Rights Movement and the idealization of birth in the new book A Womb of Her Own; Women’s Struggle for Sexual and Reproductive Autonomy. The chapter is dense with the language of psychoanalysis, but is worthwhile reading in full nonetheless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The birth rights movement has replaced one oppressive model of birth with another equally oppressive model: the idealization of birth. [/pullquote]

Vissing starts with an analysis of what she terms the “birth rights movement.”

… In the Birth Rights Movement, birth is seen as a decisive moment in a woman’s life and is viewed as having crucial impact on the baby and the attachment process. Mainstream obstetrics and hospital birth practices are fiercely criticized and understood as oppressive, profit-oriented, and inhumane.

Sadly, while the birth rights movement has empowered some women, it has disempowered many more. How?

I assert that the idealization of birth is an illusory solution …. On the individual level, it serves to protect against anxieties about the body. On a cultural level, this defense fuels the ideological fight. When the rightness of birth choices is debated in a heated atmosphere, it happens at the expense of maternal subjectivity and emotional integration. Mothers’ subjective experiences of their reproductive rights are used as testimonies in current discourses on birth rights and thereby become underpinnings in an ideological debate…

Simply put, in its insistence on idealizing childbirth, the birth rights movement ignores the experiences of a substantial proportion, perhaps the majority, of women. And it doesn’t merely ignore them, it actively derides them.

Indeed:

… [T]he Birth Rights Movement may be reproducing the oppressing tendencies it sets out to fight.

The primary problem is that the birth rights movement replaces what it views as the faulty model of “industrialized” labor with the equally faulty model of idealized labor.

I suggest that the idealization is fueled mainly by two elements of the Birth Rights Movement’s philosophy: bio-essentialism … and the use of (maternal) subjective accounts…

Vissing articulates the fundamental principles of natural childbirth:

The term “natural” is widely used in the Birth Rights Movement, coined in the term “natural childbirth” by Grantly Dick-Read. In the idea of “normal” or “natural” birth, the birth process is seen as an inherently natural biological, psychological, and potentially also spiritual process, that, if left undisturbed, will unfold itself. Natural childbirth proponents have argued that the unnecessary or questionable interventions, like excessive fetal monitoring and induction that can lead to a cascade of interventions, are disturbing to the natural process of birth.

This idealized view of birth has nothing to do with the reality of birth:

What is understood as the “natural” and “normal” here is quite far from the realities of general childbirth practices. Using the terms “normal” and “natural” create an implicit judgment of women who need or chose to use medical technology and interventions in birth.

Birth stories are used to reinforce this unnatural view of childbirth.

The challenge of asserting maternal subjectivity becomes further problematic when there is idealization at play, as it is namely the idealization of the maternal that makes it hard to connect with the reality of the mother subject (Benjamin, 1988; Parker, 1995). I therefore find it concerning to see mothers’ subjective experiences widely used in literature of an ideological nature. Mothers’ subjective experiences risk getting lost in the ideological discourse because they are fitted into a specific narrative and used as underpinnings. With that we lose the voice of the individual mother’s intrapsychic and complex experience.

How does this hurt women?

In the idealization of birth, the negative aspects are split off and understood explicitly as the result of an unhealthy and/or abusive obstetric system and implicitly as a woman’s failure to assert and empower herself. In the Orgasmic Birth narrative, we are offered the fantasy that childbirth and motherhood without any boundary pressure is possible. From feminist psychoanalytic perspectives, this has dire consequences for maternal subjectivity. A woman will have a hard time expressing ambivalence and anxieties in a philosophy that understands negative feelings as symptoms of an oppressing system that should be resisted. A childbirth philosophy that places responsibility on the mother, whether directly or indirectly, as in the exaggerated focus on a woman’s potential control over the birth, is concerning.

In promoting an idealization of birth, in rejecting the real experiences of the majority of women, in pretending that those who don’t experience an idealized birth have themselves to blame, and in refusing to acknowledge that different women have different views and values, the birth rights movement has become everything is claimed to despise in the medical system. They have merely replaced the patriarchy with the matriarchy and used their power to oppress rather than to liberate.

I recently wrote about the way that lactivists, including lactation professionals, invoke “lack of support” as a rationale for ignoring women who can’t or don’t want to breastfeed.

Tell lactivists that you don’t want to breastfeed and they’ll insist that you would want to breastfeed if only you received support.

Tell lactivists that breastfeeding is painful and they’ll insist that it wouldn’t be painful if you had received support.

Tell lactivists that you don’t produce enough breastmilk and they’ll tell you that is a misperception due to lack of support or, alternatively, that you would be producing enough if only you had the correct support.

That explains why lactation professionals feel perfectly justified in ignoring both women who have breastfeeding difficulties and the infant disabilities and death that result in ignoring those difficulties.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In the best case scenario they are deluded; in the worst case scenario, they are lying.[/pullquote]

But that doesn’t explain why lactation professionals feel justified in ignoring and vilifying me. Consider this recent Twitter exchange.

I had been taking Prof. Amy Brown to task in the wake of baby Landon’s death from dehydration due to insufficient breastmilk. Although Brown was willing to acknowledge that breastfeeding can be deadly, she refused to acknowledge just how often insufficient breastmilk occurs. The incidence is not rare; it is common. Brown didn’t give a small number; she knew I would ask for proof and she wouldn’t be able to provide any. She refused to give any number at all.

Pediatrician Dan Flanders parachuted in to offer what he presumably thought was a witty response:

I consider it an honor to be the target of Amy’s trollery.

Trollery?

Not to put to fine a point on it, but my academic credentials are likely superior to either those of Dr. Flanders or Prof. Brown. Moreover, since I breastfed my own four children I probably have as much or more experience breastfeeding as Prof. Brown and infinitely more than Dr. Flanders. Neither knows more about breastfeeding than I know, yet they feel free to dismiss my writing and my warnings.

Why? Because like most lactivists they are ideologues and the fundamental tenet of their ideology is that breastfeeding is perfect. How dare I point out that not only is breastfeeding imperfect like any other bodily function, but that it has real risks of injury and even death?

In many ways professional lactivists like Prof. Brown and Dr. Flanders undermine their own cause. Pretending that there are no risks to breastfeeding is like pretending there are no risks to pregnancy. No matter how much they want to believe in the Tinkerbell theory of childbirth and breastfeeding — you can only be successfully if you believe — no amount of believing prevents miscarriage. Similarly, no amount of believing increases milk supply.

In the best case scenario they are deluded; in the worst case scenario, they are lying. In either case, they demonstrate themselves to be untrustworthy, not to mention heartlessly cruel. Baby Landon is dead because lactation professionals insisted that everything was going well when Landon’s mother told them she thought he was starving. Rather than address that issue, both Brown and Flanders prefer to whine about me.

Sadly, they are recapitulating the behavior of an earlier generation of physicians whom they presumably despise. Those physicians believed that formula was the perfect food because it was “scientific.” They discouraged women from breastfeeding as a result. They were wrong, but they had the best of intentions. They truly believed what they said and that their paternalism was thereby justified.

Similarly, professional lactivists like Prof. Brown and Dr. Flanders sincerely believe that breastmilk is the perfect food because it is natural. They discourage formula feeding as a result and feel it necessary to demean anyone, no matter how personally and professional qualified, who dares to disagree with them. They are wrong, even though they appear to have the best of intentions. They truly believe what they say, but their paternalism is just as ugly as that of the generation of providers who promoted formula.

Let me speak directly to Prof. Brown and Dr. Flanders:

Breastfeeding is NOT perfect!

Believing breastfeeding is perfect is NOT the key to successful breastfeeding.

Informing women of the risks of breastfeeding does not undermine breastfeeding.

Idealization of breastfeeding harms, indeed kills, babies and mothers.

To the extent that you ridicule anyone who disagrees with you, you aren’t merely acting like heartless fools. You are harming both babies and mothers.

And that’s not funny.

Contemporary breastfeeding promotion is based on two lies. The first lie is that breastfeeding is critical to infant health when it isn’t and, in fact, can actually be harmful or deadly. The Fed Is Best Foundation has been doing tremendous work in exposing the lack of scientific evidence for this lie and the injuries to infant health and maternal mental health caused as a result.

The second lie beloved of lactivists is even more pernicious. It is the lie that women who can’t or don’t breastfeed are suffering from lack of support. As I wrote a few days ago, Prof. Amy Brown routinely deploys this lie. Brown’s own research showed that 80% of women stop breastfeeding because of pain and difficulty. She routinely ignores her own findings and substitutes the lactivists’ preferred explanation for any and every breastfeeding problem, “lack of support.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Simply disagreeing with lactivist orthodoxy marks you as disabled by false consciousness. Lactivists will ignore everything you say.[/pullquote]

The substitution is ludicrous on its face. There has never been more institutional and professional support for breastfeeding. Indeed there is an entire cadre of women, lactation consultants, who are paid for no other reason than to support breastfeeding. In other words, the idea that women are suffering a lack of support is a bald-faced lie.

The most pernicious aspect of the lie is not the fact that it is patently false, but that it is in effect an accusation of false consciousness. Therefore, it serves as an all purpose reason for ignoring anyone who claims to have difficulty with breastfeeding and anyone who criticizes lactivism and its dangerous excesses. Lactivists cry “lack of support” in an effort to disempower any woman who dares disagree.

False consciousness typically refers to political beliefs. According to Dictionary.com, false consciousness is:

a Marxist theory that people are unable to see things, especially exploitation, oppression, and social relations, as they really are; the hypothesized inability of the human mind to develop a sophisticated awareness of how it is developed and shaped by circumstances.

For example, Marxists insisted that working people who opposed Communism suffered from false consciousness. That inevitably led to the conclusion that the opinions of anti-Communists could be ingnored and that Marxists’ opinions were more valuable than those of people who opposed them.

As political theorist Steve Cook explains in Why calling “False Consciousness” is dangerous and unreasonable:

The moment that someone believes that another agent suffers from false consciousness, then they risk denying the equality of citizens. If someone believes that another suffers from false consciousness, then they can discount any reasons the other gives. The agent believes that they have special access to the truth, which others do not. Once you have special access to the truth … then your reasons automatically count and another’s can automatically be discounted…

Tell lactivists that you don’t want to breastfeed and they’ll insist that you would want to breastfeed if only you received support.

Tell lactivists that breastfeeding is painful and they’ll insist that it wouldn’t be painful if you had received support.

Tell lactivists that you don’t produce enough breastmilk and they’ll tell you that is a misperception due to lack of support or, alternatively, that you would be producing enough if only you had the correct support.

Hence Dr. Amy Brown, in her polemic entitled Why Fed Will Never Be Best: The FIB Of Letting Our New Mothers Down, insists:

Of course we must ensure that babies are fed. However, although the message may sound comforting on the surface, ‘fed is best’ is simply putting a sticking plaster over the gaping wound that is our lack of support for breastfeeding …

Brown’s claim perfectly illustrates the danger of accusing those who disagree with false consciousness. Brown and her colleagues feel completely justified in ignoring what women who can’t or don’t wish to breastfeed tell them. Their reasons for not breastfeeding (pain, insufficient breastmilk, inconvenience) don’t count. The only views that count are those of lactivists.

It does not matter how eloquently you explain that your baby died or nearly died of starvation. Your personal experiences are meaningless. Simply disagreeing with lactivist orthodoxy marks you as disabled by false consciousness. They will ignore everything you say.

As Cook notes:

The only way to prove that you don’t suffer from false consciousness is to wholeheartedly agree with the one who believes that you suffer from it. Effectively, you are regarded as fallible, and they as infallible. This kind of thinking can easily provide a justification for them to impose their will upon you…

In other words, it is deployed to disempower anyone who disagrees.

The bottom line is this: There has never been more institutional support for breastfeeding than there is today. To argue that current breastfeeding difficulties are due to lack of support is an empirical lie. But it’s also a tactic that lactivists use to disempower anyone who disagrees with them. That’s not merely wrong, but it can be deadly.

Lactation professionals are beside themselves with fear.

The story of a baby Landon who died from dehydration as a result of exclusive breastfeeding has become a tipping point. For years they have been exaggerating the benefits of breastfeeding, denying the risks and contributing to a wave of newborn deaths from both breastfeeding complications and deaths resulting from breastfeeding promotion efforts that have led to hundreds of smothering deaths and falls of maternal hospital beds each and every year.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals believe that it is okay to withhold critical information in order to convince women to breastfeed.[/pullquote]

Baby Landon’s death has brought lactation professionals face to face with the biggest lie they espouse: the lie that insufficient breastmilk is rare when in truth it affects up to 15% of women or more.

Many lactation professionals are simply ignorant. They only know what their teachers — other lactation professionals have told them — which means they don’t know anything about the very real and very deadly risks of insufficient breastmilk. When you live and work inside an echo chamber, it’s hardly surprising that your knowledge is limited.

In contrast, there are quite a few prominent lactation professionals who do know the truth and are desperately trying to hide it. That is both unethical and profoundly paternalistic. They are literally afraid that if they tell women the truth about the risks of breastfeeding, as well as the benefits, women won’t make the choice they prefer.

Their goal is NOT to empower women with accurate information and hope they will choose to breastfeed. Their goal is to hide accurate information from women to ensure that they will breastfeed. They are no different from anti-choice activists who spread scientific falsehoods in an effort to dissuade women from choosing pregnancy termination. It’s unethical and it’s paternalistic.

Consider Prof. Amy Brown. I have engaged with her on the Facebook page of The New Scientist. She absolutely refuses to state a number for the incidence of insufficient breastmilk. Why? I’m going to guess that it’s because she knows that she has no scientific evidence for the typical lactivist lie that insufficient breastmilk is rare. I suspect that she knows as well as I do the the real incidence is 15% or more — and she doesn’t want to be caught telling women the truth. That’s shockingly unethical and disturbingly paternalistic.

I wrote about Brown last fall in connection with the naked misogyny of pressuring women to breastfeed. Brown’s research showed that 80% of women stop breastfeeding because of pain and difficulty. Brown then proceeded to ignore her own findings and substitute the lactivists’ preferred explanation of “lack of support.”

Brown is also the author of the charmingly titled Why Fed Will Never Be Best: The FIB Of Letting Our New Mothers Down. The title is in keeping with what appears to be the cardinal rule of lactivism — never miss an opportunity to shame women who can’t or don’t breastfeed.

Brown repeats the preferred lactivist fairytale that physiological problems are rare and “lack of support” accounts for low breastfeeding rates.

Of course we must ensure that babies are fed. However, although the message may sound comforting on the surface, ‘fed is best’ is simply putting a sticking plaster over the gaping wound that is our lack of support for breastfeeding and mothering in general. We cannot afford to say that how babies are fed does not matter…

Brown offers the standard lactivist lie.

Physiologically speaking only around 2% of women should be unable to breastfeed, but in reality less than half of mums in the UK breastfeed at all past six weeks.

In our discussion on The New Scientist Facebook page, Brown simply refuses to answer the simple question about the real incidence of insufficient breastmilk. I noted that you can tell the the difference between real medical professionals and lactation consultants in the way they deal with this issue. When informed of a preventable death, real medical professionals ask, “How can we avoid this happening to another baby?” Lactation consultants ask, “How can we avoid blame?”

Brown then proceeds to prove my point by trying to deflect attention:

Babies can also die from dehydration if bottles are not properly made up eg too much powder provides too much sodium.

Now … is that the fault of the formula or a lack of awareness that it is an issue …

In both cases better support and education should be given!

I asked Brown a direct question:

What is the failure rate for breastfeeding? Please quote an actual number since this discussion is about the fact that lactation professionals lie about the rate of breastfeeding failure.

She didn’t bother repeating her previous lie of 2%.

Watch her try to wriggle out of giving an actual number.

…[I]t’s Friday night in the UK and I’ve gone out for dinner.

You know it gets increased by what happens at birth and in early days. I recognise that. Better support would reduce that. Some will need formula. The data is different across countries which confirms this.

So … better recognition when things are not working. Formula if needed. I think we can agree on that?

I asked:

Would you agree with Alison Stuebe, MD of the Academy of Breastfeeding Medicine that as many as 15% of newborns can benefit from formula supplementation?

More comments from Brown, but no answer. I can only conclude that she doesn’t want women to know the truth because that might discourage them from breastfeeding. That’s just as paternalistic as the gynecologist who recommends hysterectomy but refuses to tell the patient the complication rate because that might discourage the her from choosing surgery.

It’s unethical when a gynecologist does it and it’s equally unethical when a lactation professional does it.

The goal of lactivism ought to be empowering women to breastfeed successfully if they can and if they want to do so. The goal should not be getting all women to breastfeed. That harms (and even kills) babies and the only people it empowers are lactation professionals.

One of the greatest ironies of contemporary lactivism is how lactation professionals have eagerly adopted the very traits that they so disparaged in doctors. They believe they know better than women themselves what is right for those women. They believe that it is okay to withhold information in order to convince women to do what they want them to do.

That’s why Amy Brown refuses to give a number for the incidence of insufficient breastmilk. The truth would reveal that breast is not best for a substantial proportion of mothers and babies.

Better to lie and let babies die.

I’ve been writing about the issue of US maternal mortality for years, and for years I’ve argued that most of the supposed increase is a result of improved reporting of maternal deaths, not more deaths.

That view was confirmed by the recent paper Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues by MacDorman et al.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”The overall picture is not consistent with any serious deterioration in maternal health or maternal health services in the United States.”[/pullquote]

Studies based on data from the 1980s and 1990s identified significant underreporting of maternal deaths… To improve ascertainment, a pregnancy question was added to the 2003 revision of the U.S. standard death certificate…

However, there were delays in states’ adoption of the revised death certificate … This created a situation where, in any given data year, some states were using the U.S. standard question, others were using questions incompatible with the U.S. standard, and still others had no pregnancy question on their death certificates.

Due in part to the difficulties in disentangling these effects, the United States has not published an official maternal mortality rate since 2007…

While raw data suggested that US maternal mortality had more than doubled since 2000, MacDorman and colleagues found that the real increase was only 26.4%, a much smaller increase, but an increase nonetheless.

Now a new paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States by Joseph et al., questions even the smaller increase.

The authors note:

Recent publications on global trends in maternal mortality have reported substantial increases in maternal deaths in the United States … The maternal mortality ratio in the United States in 2013 was higher than that in Azerbaijan, Iran, Kazakhstan, Libya, Saudi Arabia, and Uruguay (among others)… Such reports have led to considerable dismay in the United States and pleas for prompt clinical action to reduce maternal deaths.

It is difficult to reconcile the maternal mortality ratios in the United States with the lower estimates of these rates in less industrialized countries. Several explanations have been offered to explain the observed temporal increase in maternal mortality including an increase in chronic diseases among reproductive-aged women (especially obesity) and increasing rates of cesarean delivery. However, an alternative narrative, which views the rising rates of maternal mortality in the United States as an artifact of improved surveillance, implicates several different changes in maternal death surveillance …

The authors analyzed changes in both the overall rate of maternal mortality from 1999-2014 and cause specific mortality rates. They found that deaths from traditional causes actually DECLINED while deaths in new categories increased substantially.

Maternal mortality ratios (excluding late maternal deaths) increased from 9.88 in 1999 to 21.5 per 100,000 live births in 2014 (RR 2.17, 95% CI 1.93–2.45). However, maternal deaths resulting from complications of labor and delivery declined significantly over the same period (RR 0.43, 95% CI 0.27–0.68). There was no significant change in maternal deaths resulting from abortive outcomes (O00–O07), edema, proteinuria and hypertensive disorders, maternal care related to the fetus and amniotic cavity, and complications predominantly related to the puerperium. However, deaths resulting from other maternal disorders predominantly related to pregnancy and deaths resulting from other obstetric problems not elsewhere classified increased substantially between 1999 and 2014 (RR 10.0, 95% CI 6.85–14.7 and 5.88, 95% CI 4.38–7.89).

The difference was even more pronounced for late maternal deaths, many of which were not captured before the changes in reporting requirements;

Late maternal deaths, that is, obstetric deaths greater than 42 days and less than 1 year after delivery and deaths from sequelae of obstetric causes, increased from 0.38 in 1999 to 6.69 per 100,000 live births in 2014 (RR 17.7, 95% CI 10.5–29.7). Exclusion of codes O26.8 (other specified pregnancy-related conditions) and O99 (other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium) and late maternal deaths (O96 and O97) abolished the temporal increase in these maternal mortality ratios.

The authors explain:

Our study suggests that the reported substantial increase in maternal mortality in the United States between 1993 and 2014 was likely a consequence of improvements in maternal death surveillance and changes in the coding of maternal deaths. Regression adjustment for the separate pregnancy question on death certificates, ICD-10 codes, and the standard pregnancy checkbox on death certificates eliminated the increase in maternal mortality rates between 1993 and 2014. Exclusion of maternal deaths associated with the four new ICD-10 codes that identified late maternal deaths (O96, O97), other specified pregnancy-related conditions (O26.8), and other maternal diseases classifiable elsewhere (O99) also abolished the temporal increase in maternal mortality between 1999 and 2014.

Most other countries have not instituted new maternal mortality guidelines. Therefore it is hardly surprising that US maternal mortality ranking has dropped in relation to other countries that aren’t recording all maternal deaths.

The authors conclude:

Although there may have been some increase in maternal deaths resulting from chronic diseases (such as diseases of the circulatory system, diabetes, and liver disease) and definite reductions in maternal death resulting from obstetric causes (such as preeclampsia, eclampsia, and complications of labor and delivery), the overall picture is not consistent with any serious deterioration in maternal health or maternal health services in the United States.

Which is what I have been saying all along.

There is something morally grotesque about watching Republican legislators — all of whom get free Obamacare Plus on the public dime — compete with each other over designing the most unjust healthcare insurance system for others who may rely on the public dime.

I have a simple suggestion. Let’s mandate that Republican legislators get only the healthcare insurance that they give to the most vulnerable among us including the unemployed and those employed in blue collar work. If poor people get lousy Trumpcare, Republican legislators should get lousy Trumpcare too. That’s what justice requires.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If poor people get lousy Trumpcare, Republican legislators should get lousy Trumpcare too.[/pullquote]

How can we determine what a morally just healthcare insurance plan might look like? It’s not as hard as you might imagine. John Rawls, the greatest political philosopher of modern times wrote that if we want to know what justice requires of us, we ought to imagine the world we would want if we didn’t know the position that we would occupy in that world. In other words, justice is what we would choose if we didn’t know if we were rich or poor, black or white, brilliant or plodding, talented or talentless. Or, expressed colloquially, what’s good for the goose is good for the gander.

Since it is unlikely that Republicans are going to create a Trumpcare that copies their high end insurance plans, the changes to Obamacare that Republican legislators propose must apply equally to them.

This is especially simple for Republican legislators who rely on the taxpayers to fund their health insurance. Justice means providing for others what legislators mandate that taxpayers provide for them. If they get government funded insurance — beef Wellington for every meal — it is immoral to force their poorest constituents to subsist on dry cereal without milk. Going forward, Republican legislators ought to get dry cereal without milk, too.

Since Trumpcare doesn’t mandate that employers provide insurance for their employees, the Federal government should not provide health insurance for Republican legislators. They should be forced to buy their health insurance on the open market. That will surely be very expensive, but it would save the a fortune for taxpayers. Of course if they think they are entitled to comprehensive health insurance, that’s what they should provide for the poorest among us.

Obviously Republican legislators wouldn’t qualify for any insurance subsidies since they make $174,000/yr, and they wouldn’t qualify for the new tax credits, either. Of course if they think that their comprehensive health insurance ought to be free from them, justice requires that it be free for everyone else.

Mandate that Republican legislators who are older be required to pay up to 5X more for insurance coverage than their younger colleagues. Not to worry, though; they could contribute up to $13,100 to pre-tax health savings accounts. That should be super helpful since self-insuring their families will cost about $6000 per year … before extras. If Republican legislators think that’s too onerous for them, it’s obviously too onerous for anyone else.

There would be no maternity benefit. That’s extra. If a Republican legislator wants to have children, he or she will have to pay for coverage with an expensive maternity rider or out of pocket, just like poor constituents. Babies might die as a result? Big deal. Republican “pro-life” legislators don’t give a damn if babies die, just so long as women are forced to give birth to them first.

Ironically, many Republicans are howling that the new plan is too generous! Surely if it’s too generous for poor people, their health insurance is far too generous for them.

If they want to exempt pre-existing conditions for others, their insurance shouldn’t cover pre-existing conditions. Child was an insulin dependent diabetic before Dad was elected to Congress? Now Dad will have to pay for insulin out of pocket.

If Republicans want to deny health insurance coverage to children between 22-26 that ought to apply to Republican legislators as well. And the same thing goes for lifetime caps. Legislator’s husband gets diagnosed with metastatic cancer? We’ll cover the first $1,000,000; after that they can pay the tab.

Don’t forget religious exemptions. No birth control on the public dime. Republican legislators and their spouses can just pay for it out of pocket.

Wait, what? Republican legislators think they’re entitled to better health insurance than their constituents who might be coal miners, factory workers, or stock boys at the local supermarket? Why? It can’t be because they are providing a more valuable service than those who work in mines, factories or supermarkets. Republican legislators just sit around and talk.

If a lousy Trumpcare plan is good enough for poor people and blue collar workers than it’s good enough for Republican legislators. Mandating that the government pay for Obamacare for legislators but not for constituents would be morally grotesque, wouldn’t it?