Margaret Olivia Little

Risk and the Pregnant Body

November-December 2009 The first trimester of pregnancy had not been an easy one for Andrea—mornings brought waves of nausea and vomiting, and afternoons, debilitating fatigue.1 What got her through were two things: the hope that her symptoms would start to lift when she got past her first trimester, and, of course, the promise of a baby in December. Unfortunately, neither of these came to pass. Andrea had just reached fifteen weeks’ gestation when she arrived in the emergency room at a major academic medical center. After a short week of relief, her nausea had returned, accompanied by a lowgrade, persistent, gnawing abdominal pain, and— perhaps of more concern—a conviction that something was badly wrong. Given the signs, her attending obstetrician ordered a CT scan, the gold standard for ruling out what would be inexcusable to miss: appendicitis. Yet the medical imaging team, nervous about radiation exposure with a pregnant patient, resisted the CT scan. First they attempted to image without radiation, but an ultrasound and an MRI yielded no useful information. The team then requested extra layers of documentation verifying that risks of radiation exposure to the fetus were discussed with the Reasoning well about risk is most challenging when a woman is pregnant, for patient and doctor

Abortion, Intimacy, and the Duty to Gestate

In this article, I urge that mainstream discussions of abortion are dissatisfying in large part because they proceed in polite abstraction from the distinctive circumstances and meanings of gestation. Such discussions, in fact, apply to abortion conceptual tools that were designed on the premiss that people are physically demarcated, even as gestation is marked by a thorough-going intertwinement. We cannot fully appreciate what is normatively at stake with legally forcing continued gestation, or again how to discuss moral responsibilities to continue gestating, until we appreciate in their own terms the goods and evils distinctive of gestational connection. To underscore the need to explore further the meanings of gestation, I provide two examples of the difference it might make to legal and moral discussions of abortion if we appreciate more fully that gestation is an intimacy.

Defeasibility and the Normative Grasp of Context

In this article, we present an analysis of defeasible generalizations — generalizations which are essentially exception-laden, yet genuinely explanatory — in terms of various notions of privileged conditions. We argue that any plausible epistemology must make essential use of defeasible generalizations so understood. We also consider the epistemic significance of the sort of understanding of context that is required for understanding of explanatory defeasible generalizations on any topic.

On Knowing the ‘Why’: Particularism and Moral Theory

If particularism is right, the broad moral claims we make are usually riddled with exceptions. But such generalizations can still be a useful, even necessary part of moral life. They help us show what we should do, and they are essential for understanding why we should do it.

Reframing the Framework: Toward Fair Inclusion of Pregnant Women as Participants in Research

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A Critique of the ‘Fetus as Patient’

Reasoning about the fetus is a complex, often vexing, challenge. Indeed, at the center of the some of the most provocative and difficult bioethical debates in the last decade are questions about the responsibilities of society, physicians, policymakers, scientists, and pregnant women to embryos and fetuses. Having noted the problems particular to use of the pervasive term ‘unborn child,’ McCullough and Chervenak propose ‘patient’ as a clarifying alternative for discourse about the fetus (McCullough and Chervenak 2008), at least for questions in the realm of clinical medicine. According to McCullough and Chervenak, shifting to this language avoids certain connotations brought by ‘unborn child,’ helpfully highlighting, for instance, the beneficence- rather than rights-based nature of obligations toward early life, as well as what they call the “dependent status” of that life. While we concur with McCullough and Chervenak in rejecting the language of unborn child, we have concerns that the alternative they propose brings dangers of its own.

The national children's study: A golden opportunity to advance the health of pregnant women

With a

Toward an ethically responsible approach to vaginal birth after cesarean.

3 billion investment by the federal government, the National Childrens Study (NCS) recently began recruitment. The NCS is a golden-and potentially missed-opportunity to study one of the most underrepresented populations in clinical research: pregnant women. As the nations largest-ever study of childrens health, the NCS will examine the effects of the environment on children from before birth to 21 years of age, with participants sampled primarily through women during pregnancy. Thus the NCS presents a rare opportunity to study the health of women during and after pregnancy, in addition to the health of their children. On both moral and policy grounds, we make the case for inclusion of womens health outcomes in the NCS.

Advancing HIV research with pregnant women: navigating challenges and opportunities.

Determining approach to delivery after a previous cesarean is among the most contentious areas of obstetrics. We present a framework for ethically responsible guidelines and practice regarding vaginal birth after cesarean. We describe ethical complexities of 3 key issues that mark the debate: the cesarean delivery rate, safety, and patient autonomy. We then describe a taxonomy of considerations that should inform a responsible framework for guideline development and highlight critical distinctions between types of guidelines that have been blurred in the past. We then forward 2 central claims. First, in otherwise uncomplicated birth after a single previous cesarean, both vaginal birth after cesarean and repeat cesarean should be regarded as reasonable options; women, rather than policymakers, providers, insurance carriers, or hospitals, should determine delivery approach. Second, in complicated cases, providers and policymakers should carefully calibrate the strength of evidence to ensure differential risk and cost are adequate to justify directive guidelines given important variations in values women bring to childbirth.

Ethics and Research with Pregnant Women: Lessons from HIV/AIDS

Objective:Concerns about including pregnant women in research have led to a dearth of evidence to guide safe and effective treatment and prevention of HIV in pregnancy. To better understand why these evidence gaps persist and inform guidance for responsible inclusion of pregnant women in the HIV research agenda, we aimed to learn what HIV experts perceive as barriers and constraints to conducting this research. Methods:We conducted a series of group and one-on-one consultations with 62 HIV investigators and clinicians to elicit their views and experiences conducting HIV research involving pregnant women. Thematic analysis was used to identify priorities and perceived barriers to HIV research with pregnant women. Results:Experts discussed a breadth of needed research, including safety, efficacy, and appropriate dosing of: newer antiretrovirals for pregnant women, emerging preventive strategies, and treatment for coinfections. Challenges to conducting research on pregnancy and HIV included ethical concerns, such as how to weigh risks and benefits in pregnancy; legal concerns, such as restrictive interpretations of current regulations and liability issues; financial and professional disincentives, including misaligned funder priorities and fear of reputational damage; and analytical and logistical complexities, such as challenges recruiting and retaining pregnant women to sufficiently power analyses. Conclusion:Investigators face numerous challenges to conducting needed HIV research with pregnant women. Advancing such research will require clearer guidance regarding ethical and legal uncertainties; incentives that encourage rather than discourage investigators to undertake such research; and a commitment to earlier development of safety and efficacy data through creative trial designs.