Book Review

Women, Pregnancy, and Health Care

At Women's Expense: State Power and the Politics of Fetal Rights

N Engl J Med 1994; 330:648-649March 3, 1994

Article

At Women's Expense: State Power and the Politics of Fetal Rights
By Cynthia R. Daniels. 183 pp. Cambridge, Mass., Harvard University Press, 1993. $19.95. ISBN: 0-674-05043-6

The December 5, 1993, Sunday New York Times Magazine had an exceedingly disturbing picture on page 63: a woman, obviously in an advanced state of pregnancy, smoking crack cocaine. It was a picture calculated to drive a few to pity, some to horror, others to fury, and all to despair.

Physicians are among the crack troops in the crack wars. They see addicted men and women come to emergency rooms over and over again, bringing the same problems and leaving with the same nostrums. Rehabilitation programs are too few, too crowded, and too likely to fail. Perhaps it is not surprising that in their frustration many physicians have put their faith in the criminal law, urging prosecutors to arrest women whose drug use threatens their fetuses. This reliance follows from a similar surge of support among physicians for using the civil law to force recalcitrant women to follow a physician's advice when cesarean section is indicated to forestall fetal injury or death. And it is consistent with the views of occupational health physicians working for heavy industry, which excludes all fertile women from areas of the workplace considered dangerous to fetuses, because such women might have early, undetected pregnancies.

Cynthia Daniels, an assistant professor of political science at Rutgers University, is not unsympathetic to efforts to ensure that children are born free of avoidable environmental injuries. But in this lucid, well-organized book, she discusses why these efforts are often self-defeating and are usually insensitive to the tragic aspects of the mothers' lives. Daniels attributes much of the attention given to protecting the fetus, as opposed to the mother, to two coinciding phenomena: medical advances that permit increased visualization and treatment of fetuses, and the efforts of the antiabortion movement to expand its political agenda to include all aspects of maternal-fetal relations.

Her book focuses on three tales. They concern forced treatment, exposures in the workplace, and addiction. The first is the case of Angela Carder, a young woman whose planned pregnancy was almost but not quite at full term when her cancer became imminently life-threatening. Although she had previously expressed a desire to have her baby saved by cesarean section if necessary, she now refused to have the surgery, because the fetus had only borderline viability and the procedure was likely to kill her. Over the objections of the baby's father and grandparents, George Washington University Hospital obtained a court order to force Carder to undergo surgery. The baby died two hours after birth, and Carder two days later.

Daniels notes that an article in the Journal in 1987 (V.E.B. Kolder, J. Gallagher, and M.T. Parsons. “Court-Ordered Obstetrical Interventions.” New England Journal of Medicine 1987;316:1192-6) found that nearly half the obstetricians surveyed supported such court orders. Although this position was subsequently renounced by both the American Medical Association and the American College of Obstetricians and Gynecologists, their opposition seemed to stem in part from a fear of judicial interference with the doctor-patient relationship. Daniels argues instead that opposition should stem entirely from a resistance to splitting off the fetus from the mother as a second patient and to a tendency to elevate fetal rights above children's rights. By making the mother an invisible host to the fetal patient, forced surgery conscripts women in a way men are never conscripted, even when their donation of blood or marrow would be the only possible way to save their children.

Daniels bemoans the increasingly prevalent image of mothers' bodies and wills at war with their unborn babies. This perceived conflict leads to desperate solutions that are ineffective and insulting: among them, the prosecution of pregnant addicts who may be driven from the medical care they and their fetuses desperately need by the fear of criminal action, and the exclusion from the work force of fertile women, possibly forcing them to work at other jobs whose wages and benefits are not sufficient to meet the needs of the women and the children they already have.

The insult lies in the dismissal of the mothers' interests. A pregnant woman addicted to drugs should not be pregnant -- not only because of the danger to the fetus, but also because of the danger to herself. This is clearly not a good time to face additional nutritional needs or the strain of added child care. By focusing entirely on fetal protection, physicians, lawyers, and policy makers act as if the mother were no longer an independent citizen, but merely a means to the end of producing a new generation.

At Women's Expense breaks no new legal ground. Nor is it a theoretical or comprehensive treatment of the fetal-rights movement. But it is an informative, well-written journalistic introduction to the politics of fetal protection, with special attention to the part played by physicians in creating the littlest patient. The book therefore deserves at least a little attention from physicians.

R. Alta Charo, J.D.
University of Wisconsin Law School, Madison, WI 53706