• Obstetrics
• Women
• Women's rights

Neil Postman used the term ‘technopoly’ to describe societies where people seek to achieve their goals primarily through the use of technology and where human progress and other ideals have been supplanted with the ideal of technological progress. In a technopoly where culture is ‘surrendered to technology’, healthcare too is transformed such that the urge to develop and use medical technologies is supported by the idea that medicine is ‘about the disease not the patient’.1 When this shift is accompanied by a cultural inclination to expand the jurisdiction of medicine and view life through the lens of pathology,2 there is a danger of reducing people to their ‘disease state’ in order to focus on matters of technical management. We point to this in order to highlight some of the potential implications of Smajdor and Rasanen’s argument that there are both ‘normative and pragmatic reasons to consider pregnancy a disease’.3 Here, we question some of the purported benefits of accepting their view that pregnancy (and childbirth) should be formally classified as ‘pathological’.

Underpinning their claim that pregnancy itself is pathological, Smajdor and Rasanen say that ‘to be pregnant is to experience symptoms and face significant risks to life and health’.3 Indeed, in Smajdor’s elsewhere expressed view, pregnancy is ‘barbaric’4 given the risk of physical harm and pain it can pose (particularly during childbirth itself) and ‘to expose oneself to risks comparable to pregnancy and childbirth would be deemed foolish and pathological in any other context’.5 But failing to imagine how exposing oneself to risk could be anything but pathological neglects to see a much fuller range of meanings attached to risk, harm and pain within people’s lives. Exposing oneself to risk can be many things—brave, worthwhile, reckless, ignorant, etc—without invariably being ‘disordered’. Smajdor and Rasanen’s view effectively requires us to relocate all the experiential aspects of risk in our lives to the jurisdiction of medicine.

In support of their argument, much is made of an apparent analogy between pregnancy and measles (which they refer to as an example of a ‘bona fide disease’).3 Smajdor and Rasanen3 argue that the risks of pregnancy (potential harm and pain) mean it ought to be considered a disease ‘on the basis that it shares important features with other diseases, such as measles’.3 This conceptual claim has been made previously by Smajdor to support the normative view that pregnancy, like measles, ought to be ‘eradicated’5:

‘…in a comparison between pregnancy and measles, pregnancy comes out considerably the worse in terms of morbidity and mortality. Yet concerted medical efforts are focused on ridding ourselves of measles, while women are expected to submit themselves to the greater risks of pregnancy and childbirth almost without thinking about it. Measles is a notifiable disease whose eradication is an avowed goal of medicine. It follows that pregnancy should–all other things being equal—also be regarded in this light, since it is riskier than measles’.

We think this is an incredibly impoverished view of pregnancy and childbirth, which for many women can be an inherently valuable experience that is decidedly unlike being diseased. The proposal to eradicate pregnancy is supposed to be achieved by developing various technological alternatives to pregnancy, including gestational biobags or ‘extracorporeal uteruses’, which in their view would add weight to the claim that pregnancy is a disease.3 Smajdor has elsewhere expressed the view that ‘there is a strong case for prioritising research into ectogenesis as an alternative to pregnancy’6 and even advocated a moral imperative to avoid the risks of pregnancy by allowing brain-dead women to be impregnated as whole-body gestational surrogates.5 The prospect of artificial-wombs-for-all so that human pregnancy is not required for reproduction is probably still the kind of enhancement-like scenario that many people see as fanciful and doubt the need for. In many ways, this line of argument parallels the claims of life-extension enthusiasts for whom ageing per se is also considered a risky ‘tractable medical problem’.7 In trying to garner the public’s support for Methuselah-making technologies claiming to stop or reverse the ageing process, some have argued that ageing kills many people, just like cancer—and so if cancer is a bona fide disease that we try to cure, why shouldn’t the same be true of ageing itself8? But in claiming that we have good reason to classify pregnancy as a disease by showing that its risks may be comparable to diseases like measles,3 we suggest that Smajdor and Rasanen have just shifted the question: if disease status is based on risk of harm, then what determines the level of risk and severity of harm that is constitutive of pathology, be it for measles, cancer or anything else? This doesn’t appear to be answered.

Engaging in speculative bioethics is sometimes rightly criticised for hyping new technologies (eg, ectogenesis) that seem to straddle the line between therapy and enhancement. Advocates can sometimes unrealistically assume the real-world feasibility of proposals that lack current relevance to most people’s lives. However, we are concerned that accepting Smajdor and Rasanen’s view that pregnancy is pathological may foster a number of proximate, problematic outcomes for pregnant women now. They claim that for women who are pregnant, ‘pathologising pregnancy could, in fact, lead to better treatment’.3 They don’t convincingly say how this is supported by evidence, but their concern is that pregnant women are routinely denied medical treatment ostensibly because the normalcy of pregnancy means they aren’t considered diseased. In their view, they ‘tend to be deprived of patient status’3 and this is what increases their vulnerability to harm. For Smajdor and Rasanen, pathologising pregnancy may facilitate a more direct moral obligation to medically intervene in pregnancy and childbirth:

‘Among women who are pregnant, their preferences in terms of pain relief, mode of delivery, are frequently ignored precisely because the ‘normalness’ of these conditions mean that their detrimental effects on women are disregarded and the norms of medical ethics that govern doctor/patient interactions are often swept aside’.3

We agree that there is a problem being identified here: pregnant women are often not listened to. But if we think healthcare providers aren't listening to pregnant and birthing women who are suffering, why would classifying them as ‘diseased’ be the solution? Smajdor and Rasanen assume that the ‘norms of medical ethics’ are swept aside because of the notion that pregnant women aren’t really patients. They think that when pregnancy is considered normal, it leads to ‘a failure to recognise and respond to its disease-like features’.3 Not receiving required or desired treatment may indeed result in harm and classifying pregnancy as a disease could conceivably help some women who want more intervention; however, Smajdor and Rasanen’s explanation of women being ignored solely because pregnancy is seen as normal comes into question once we acknowledge that women are also frequently ignored when they ask for less medical intervention. The current medicalisation of pregnancy indicates how often doctors do see pregnant women as ‘patients’,2 and the problem can be that doctors also mistakenly see themselves as having jurisdiction over pregnant women and ownership of the decision-making process.9 Smajdor and Rasanen’s proposal doesn’t seem to take seriously enough how many women suffer harm from unnecessary and unwanted medical attention and intervention during their pregnancy and childbirth. Formally classifying pregnancy as a disease is not likely to help these women if it emboldens clinicians to think that women (and the foetus) invariably receive better outcomes when the process, including childbirth, is entirely medically orchestrated. We suggest that Smajdor and Rasanen’s view could encourage the assumption that more ‘medical’ intervention in pregnancy and childbirth is necessarily a better standard of care. We urge caution in accepting this. No doubt some medical complications during pregnancy and childbirth pose a serious threat of death and morbidity to women and the foetus and so require medical intervention. But pregnancy and childbirth are not emergencies per se, and there is good evidence that for many pregnancies, a higher rate of medical intervention isn’t necessarily associated with less maternal or neonatal harm.10 Many women want less medical intervention during their pregnancy and birth but report being ignored or not even consulted before undergoing procedures, resulting in birth trauma.11 The problem is that the medical model too frequently results in a cascade of medical interventions that were perhaps not necessary—formally classifying women as diseased patients may simply embolden a perceived need to enact these interventions.12 Curiously, Smajdor and Rasanen don’t discuss how evidence for the considerable benefits of continuous care midwifery supported birth13 might cast doubt on the view that pathologising pregnancy may lead to better treatment for women. The midwifery model of care is philosophically grounded in the view that pregnancy is a ‘critical, vulnerable, but normal part of women’s lives’,14 and Conrad points to midwifery as one of the only successful attempts at de-medicalisation.2

What’s needed is a more dedicated focus on addressing the underlying gendered reasons why many pregnant and birthing women feel disempowered, have their preferences ignored and have their consent for interventions not sought. It’s not clear that pathologising pregnancy would result in better treatment for women, facilitate women being listened to, or reconfigure care in ways that benefit women. It may only beget the increased use of medical intervention where it is not necessarily needed and entrench the misguided view that the best way to achieve our goals is through technological intervention.