Rebecca Kukla

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

Society: Don't blame the mothers

Careless discussion of epigenetic research on how early life affects health across generations could harm women, warn Sarah S. Richardson and colleagues.

The OHRP and SUPPORT - Another view

A group of physicians, bioethicists, and scholars in allied fields agrees with the Office for Human Research Protections about the informed-consent documents in SUPPORT.

The ethics and cultural politics of reproductive risk warnings: A case study of California's Proposition 65

Public space is filled with reproductive risk warnings, from labels on bottles of alcohol and cigarette packs, to disclaimers on drugs, signs posted in front of amusement park rides, and public health campaigns and advisories aimed at modifying pregnant womens behaviour. Californias Proposition 65 requires that businesses post signs warning of the presence of chemicals that cause cancer, birth defects, or other reproductive harm. In this paper I examine the history of Proposition 65, and demonstrate the gap between its intended and actual effects. I explore the practical and symbolic implications of this law for women who are or think they might be pregnant, and argues that the Proposition 65 risk warnings have ethically troubling consequences for pregnant women. The warnings imply that reproductive risks are more important than other health risks, thereby singling out pregnant women as having a unique responsibility to make choices that minimise risk for others. They locate responsibility for foetal risk management in pregnant ‘consumers’, construed as agents who are free to make the correct choices on behalf of their future children, rather than on those responsible for creating safe public spaces. They offer pregnant women a choice between excluding themselves from public spaces and forgoing basic services, or taking on the identity of the reckless mother willing to ‘voluntarily’ impose ‘unnecessary risks’ on her child. And despite being justified via the rhetoric of informed consumer choice, they impede and distort rather than enable rational, informed decision-making.

The ontology and temporality of conscience

Philosophers have often posited a foundational calling voice, such that hearing its call constitutes subjects as responsive and responsible negotiators of normative claims. I give the name ldquo;transcendental conscience” to that which speaks in this founding, constitutive voice. The role of transcendental conscience is not – or not merely – to normatively bind the subject, but to constitute the possibility of the subjects being bound by any particular, contentful normative claims in the first place. I explore the ontological and temporal status of transcendental conscience, using Heideggers account of conscience in Being and Time as my textual touchstone. I ask what performative structure the call of conscience might have that would enable it to constitute normative responsiveness, and I raise some temporal conundrums surrounding this structure. I argue that it is incoherent to attempt to give a literal, chronological account of the origin of normative grip and response. I suggest that we can best understand the founding calls of conscience, not as literal events occurring in regular time, but as events that can only show up retrospectively, as occurring in an ever-receding, unlocalizable past, and that these calls can only be figured mythically and metaphorically. Appropriating a Derridean term, I claim that the voice of transcendental conscience must be that of a lsquo;ghost,’ whose call binds us by haunting us – a haunting that is no less transcendentally necessary for its inability to be translated into a literal historical event.

“Author TBD”: Radical Collaboration in Contemporary Biomedical Research

Ghostwriting scandals are pervasive in industry-funded biomedical research, and most responses to them have presumed that they represent a sharp transgression of the norms of scientific authorship. I argue that in fact, ghostwriting represents a continuous extension of current socially accepted authorship practices. I claim that the radically collaborative, decentralized, interdisciplinary research that forms the gold standard in medicine is in an important sense unauthored, and that this poses a serious problem in applied social epistemology. It is no easy matter to find procedural or architectural solutions that can secure epistemic trust and accountability for collaborative publishing in biomedicine.

Resituating the Principle of Equipoise: Justice and Access to Care in Non-Ideal Conditions

The principle of equipoise traditionally is grounded in the special obligations of physician-investigators to provide research participants with optimal care. This grounding makes the principle hard to apply in contexts with limited health resources, to research that is not directed by physicians, or to non-therapeutic research. I propose a different version of the principle of equipoise that does not depend upon an appeal to the Hippocratic duties of physicians and that is designed to be applicable within a wider range of research contexts and types—including health services research and research on social interventions. I consider three examples of ethically contentious research trials conducted in three different social settings. I argue that in each case my version of the principle of equipoise provides more plausible and helpful guidance than does the traditional version of the principle.

Equipoise, Uncertainty, and Inductive Risk in Research Involving Pregnant Women

I examine how equipoise and uncertainty ought to be managed in ethically sound and scientifically valid clinical research involving pregnant women. Drawing on recent work in philosophy of science, I argue that it is built into the internal nature of practical reason that equipoise and uncertainty are always relative to a set of values and interests. In brief, this is because a higher evidence bar will raise the risk of false negatives exactly as much as it will lower the risk of false positives, and typically both kinds of errors have costs. Furthermore, interventions during pregnancy are likely to engage sets of values and interests that are deeply held, particularly prone to intense ideological and cultural pressures, and highly variable. Pregnant women have interests and agency of their own, and are caretakers of their foetuses’ well-being. As such, they have an especially important role in determining what counts as legitimate equipoise for the purposes of clinical research in which they may participate. I conclude that for both epistemological and ethical reasons, pregnant women should be given the epistemic tools to make informed, value-relative determinations of scientific uncertainty, and they should be included in the initial process of determining research questions and designing trials.

Living with pirates--common morality and embodied practice.

75 4. Donagan A . The Theory of Morality . Chicago : University of Chicago Press , 1977 . 5. Beauchamp TL , Childress JF . The Principles of Biomedical Ethics . 4 th ed. New York : Oxford University Press ; 1994 , at 6. 6. Beauchamp TL , Childress JF . The Principles of Biomedical Ethics . 5 th ed. New York : Oxford University Press ; 2001 . 7. Beauchamp TL , Childress JF . The Principles of Biomedical Ethics . 6 th ed. New York : Oxford University Press ; 2009 , at 3, emphasis added.

Pregnant Bodies as Public Spaces

Female bodies, and especially pregnant and newly maternal bodies, leak, drip, squirt, expand, contract, crave, divide, sag, dilate, and expel. It is no surprise that historically such bodies have seemed to have dubious, hard-to-fix, permeable boundaries. To the extent that we take the integrity and boundaries of the body as integrally intertwined with the integrity and the boundaries of the self—and we have done so, at least throughout the history of Western culture and probably beyond—these dubious boundaries have been a source of various species of intellectual and visceral anxiety.1 The maternal body has long been seen as posing a troubling counterpoint to the mythical well-bounded, fully unified, seamless masculine body.2