This article caught my eye for a couple of reasons. Firstly I think the input from the National Childbirth Trust is a classic case of letting rights dialogue get in the way of discussion of the real problems. Saying that expectant mothers should have the same rights as any other patient misses the fact that they are really two patients. It also begs the question of whether other patients should have a right to refuse treatment that is good for them. We wouldn't allow a mother to intentionally harm herself or her child at the point of Birth, why should we allow her to do so by picking the wrong kind of treatment?
Secondly if we do try and deal with this issue in a utilitarian way we encounter some pretty fundamental issues within utilitarianism itself. Obviously we want the Utility maximising outcome. At first glance this seems pretty obvious, home births are bad, we need less homebirths. When we try and construct a more complicated rational behind that thought we start running in to problems.
Some might suggest that the a big problem for utilitarians (or consequentialists1 in general) is that the article shows how difficult it is to make empirical calls on problems. We have a study which might mean that we're inadvertently causing lots of infant deaths here in the UK, or it might just mean that the medical services of the USA are bad at providing care for at home births. This has a massive bearing on the course of action that we're going to proscribe. Of course that's bad and it might mean we make what is ultimately the wrong decision but it doesn't impact on our philosophical stance much. We should still make our best attempt at maximising utility, even if we know we'll fail sometimes because of bad information.
So let's assume for the sake of argument that the study really does reveal something about the risks of home birth, what problems remain?
Problem 1:
What do we mean by utility? Do we mean pleasure or the absence of pain? Perhaps we mean both but in that case we have to work out how to weigh the two against one another. Or we might suggest some other measure entirely, a common one is Preference satisfaction. In this case we don't try to impose our view of what someone's utility is, we let them decide what they want and then try to make sure that happens. This brings us on to...
Problem 2:
Whose utility counts? If we were talking about the preference satisfaction of two identical humans the weigh up would be pretty simple. Human A wants to undergo the birth in familiar surroundings, Human B wants to survive the birth. I feel safe in saying that Human B's preferences win by a pretty large margin. Unfortunately we really have no idea what Human B's preferences are because babies are bad at both forming and communicating preferences about medical procedures. Peter Singer suggests that the preferences of unborn babies really don't matter much at all because they can't actually form them. I'm inclined to think we might make preference decisions on the baby's behalf given the normal animal impulse to survive but we're certainly getting in to quite speculative territory here.
Problem 3:
What's actually wrong with death? Given the problem with preferences we might fall back on an alternative utility definition. Perhaps we could use hedonic utility, that is maximising the pleasure and minimising the pain of the individual. This generates another set of problems entirely though. We think that a home birth increases the baby's risk of death by 0.1% but how much negative hedonic utility is that. Dying is normally quite painful but if we just take in to account the direct pain that dying causes we undervalue how big a problem it is. Imagine I were to slip you a poison that caused you to fall in to a blissful sleep and then die peacefully. That wouldn't actually register on our hedonic scales at all because you didn't suffer any actual pain.
We can get round that by saying that dying minimises your future utility. Unfortunately that's also a bit shaky, partly because it assumes that everyone is, on balance, going to have a pleasurable future life and partly for other reasons we'll ignore at the moment.
Problem 4:
Should we even be interfering in the first place? Some forms of utilitarianism are direct, that is they seek to directly affect the best outcome in each case. On the other hand we might seek a morality that is to some extent indirect. That is it recognises we can't agonise over every single event and therefore lays down some kind of rule of thumb. This might be that births should, if at all possible occur in a hospital or it might be that the decision should be left up to someone directly involved. Perhaps the mother. After all who is better placed to weigh up the risks to both the baby and herself?
Anyway that's by no means an exhaustive list of the problems we might encounter trying to deal with the issue, but it does give an idea of the lines of thought that various utilitarians have explored in an attempt to deal with practical ethical issues. Hopefully I'll be able to explore some of them in more depth in future posts.
1 Consequentialism is the overarching moral or political theory to which utilitarianism belongs. It argues that consequences are what define the morality of acts, for example murder is wrong because it has the bad consequence of someone dying. It stands opposed to deontological ethical theories which argue that certain acts are intrinsically wrong or right, thus murder would still be wrong even if it had good consequences (to use a particularly hoary example let's say you murdered Hitler). As I said Utilitarianism is a kind of consequentialism, specifically it's consequentialism where the only consequence that matters is how much utility you create.
