Culpability and blame after pregnancy loss

Abstract

The problem of feeling guilty about a pregnancy loss is suggested to be primarily a moral matter and not a medical or psychological one. Two standard approaches to women who blame themselves for a loss are first introduced, characterised as either psychologistic or deterministic. Both these approaches are shown to underdetermine the autonomy of the mother by depending on the notion that the mother is not culpable for the loss if she “could not have acted otherwise”. The inability to act otherwise is explained as not being as strong a determinant of culpability as it may seem at first. Instead, people's culpability for a bad turn of events implies strongly that they have acted for the wrong reasons, which is probably not true in the case of women who have experienced a loss of pregnancy. The practical conclusion of this paper is that women who feel a sense of guilt in the wake of their loss have a good reason to reject both the psychologistic and the deterministic approaches to their guilt—that they are justified in feeling upset about what has gone wrong, even responsible for the life of the child, but are not culpable for the unfortunate turn of events.

After a pregnancy loss, many women feel a sense of responsibility or guilt for what has happened with their child. These feelings of responsibility can lead to a host of unpleasant emotions that bereaved mothers and their partners carry around for years.¹,²,³,⁴,⁵,⁶ It might be thought that only two clear approaches exist to such claims of guilt: (1) to associate this guilt with blame, or self‐blame, and chalk it up to a deep attachment to the child, to an emotional reaction that is only natural in the face of loss; or (2) to associate the guilt with a misunderstanding about medical fact. The natural response to the psychologistic reading is to urge bereaved parents to accept guilt as an irrational but nevertheless normal reaction to bad outcomes. The natural response to the deterministic reading is to attempt to console mothers by explaining medical probabilities, by suggesting that “sometimes bad things just happen” and that the mother “could not have prevented the outcome”. Both approaches seek to overcome the mother's feelings of self‐blame by playing down her emotion as somehow an irrational response to events outside her control. In a sense, however, neither approach deals with the main concern. A mother who feels this sense of guilt has a good reason to reject both standpoints—to feel upset about what has gone wrong, even responsible for the life of the child, but not culpable for the unfortunate turn of events.

It is my aim in this paper to encourage practitioners—in settings such as pregnancy loss support groups, maternity wards, counselling offices and doctors' offices—to use the terms “guilt”, “blame”, “responsibility” and “culpability” carefully when dealing with cases of pregnancy loss. Those who do not, but who offer consolations along deterministic or psychologistic lines, ignore the will of the mother by implying that the mother had little or no role in the life of her child, which is clearly not true. Women are the providers of a safe environment for their babies. They are autonomous self‐legislators carrying the moral burden of another life. When disaster strikes, they have every reason to be confused about how their actions may have changed the destiny of their child. Moreover, and perhaps more importantly, consoling along deterministic or psychologistic lines overwhelms the mother's sense that she can act differently in the future to avoid complications in subsequent pregnancies.

Blame after pregnancy loss: a moral problem

The standard and near‐natural response to a mother's grief and guilt about a pregnancy loss, whether from medical practitioners, psychologists, social workers or sometimes even the grieving parents themselves, is to take an objective, third‐party look at the mother and to posit her as either tossed about on a sea of emotion or lost in a vast and churning network of medical wheels set in motion. It is to turn our back on the moral question, to deny in many senses that women have any role in the outcome of their pregnancies, and many reasons why we would respond like this. One of the primary reasons is simply that it sounds better if we do not go blaming the victim. Women who have lost their children are quite seriously victims of fate, in so far as fate is a folksy way of talking about bad luck; sensitive practitioners therefore naturally seek to avoid any suggestion that the mother may be responsible for what has occurred. It sounds crass and insensitive to suggest such a thing. A serious drawback to such psychologistic or deterministic responses is that the grieving mother must reconcile these mollifications with (a) her own feelings that things might have turned out differently, or that she could have acted differently and (b) the medical advice of her doctors earlier in the pregnancy that she should act differently (by going on bed rest, exercising regularly, eating a healthy diet, and so on). So, although these attempts may seem valiant and appropriate to the practitioners and relatives who proffer them, they inevitably invoke a conflict.

The problem here is that the pregnancy may well have turned out differently. Until the point that the pregnancy had gone awry, the mother had understood (correctly) that her actions could affect the outcome of the pregnancy. In the mother's mind, it was only a matter of time before her efforts would guide the pregnancy to a healthy outcome. What “could have been otherwise” in this case is what could have been better—much better—and the loss here is a loss that we cannot make sense of without attending to the mother's role in that loss. When comforters compartmentalise this loss into the crude and mechanistic banging around of medical rules, or of mind‐event psychological talk, they play down the value of the child and the role of the mother in that child's life. When they speak of the feelings of guilt as if they are misplaced sadness, they turn their attention away from the question of what has been lost—the “what could have been otherwise”—and speak instead of the mother as though her guilt is neither rational nor reasonable.

Normative ethicists are not always careful about distinguishing between culpability and responsibility, but they tend to be more careful than non‐philosophers. For our purposes, it will suffice to define responsibility technically, as “fulfilling one's duty”. This definition of responsibility bears on parents and future parents in an important sense. For instance, it is a relatively uncontroversial assertion that parents have duties to their children. In this case, it is their duty, their responsibility, to protect their children and keep them safe. This notion of a duty makes it possible for us to talk about blame in the first place. Without responsibilities or duties, we would not be able to blame ourselves for acting improperly. We may define culpability, by contrast, as “deserving blame”. In this case, a mother may be found to deserve blame if she has violated her responsibilities. More on this later. What is interesting is that we often use the word responsibility interchangeably with culpability. We say, “John is responsible for having mown over your daffodils”, when what we really mean to say is that he is culpable for having mown over your daffodils. We mean that we know where to point the finger, not that he has a duty, a responsibility, to mow over your daffodils.

This distinction becomes incredibly important for women who experience the loss of their children. Mothers (and fathers) hold themselves responsible for the lives of their babies. If something terrible happens to their children, they rightly believe that they have not fulfilled their duty to protect them. As the parents, and mostly the mothers, are the only people who have any real control over the life of their child, it stands to reason that they may believe they are responsible for the loss. Simply not having succeeded in fulfilling their duties, however, does not imply that the parents are culpable for the loss or that they somehow acted wrongly. This is yet another matter. To establish this, we need to dig a little deeper. We need to understand what makes the parents culpable.

Before we do, however, let us notice the part that reasoning plays here. If a mother is blaming herself for the loss, she is probably looking for a cause for this loss. “What happened here?” she may be saying. And what is perhaps most important is that looking for the cause is perfectly rational, not just “normal”. Rationality beseeches us to find a reason: we seek to understand why the pot has fallen on the floor, why the Tacoma Narrows Bridge collapsed, why the car will not start. But human causes are slightly different from natural causes. At any given juncture we face many possible courses of action—say, between route A and route B—and we must choose between options. We must decide, “Shall I take this route over the other route? Which is the better route?” The fact that we can make deliberate choices in most cases is empowering. It is what makes it possible for us to be responsible in the first place. When the chosen route, however, does not lead where we thought it would lead, it is easy to imagine that we have failed in our responsibility and that we are therefore culpable. Rationality in this case urges us to evaluate not just different causes, but also different courses of action.

In so far as we have the choice of acting otherwise, or acting according to multiple possibilities, choosing one course of action over another puts a value on the choice of actions. The choice of one course of action over another involves prescriptive, if not fully normative, and moral values. Often these values are tied directly to the health and welfare of those for whom we are responsible, such as our children. It is hardly a wonder then that mothers blame themselves for what has gone wrong: they could have done otherwise; they did not do otherwise; and their world has come tumbling down on them. Their valued and preferred decisions have yielded great hardship.

Culpability and blame

What is most interesting about blame, then, is that it carries with it the understanding that we might have acted otherwise. It is often thought that moral responsibility carries with it the Principle of Alternative Possibility: “that one is not culpable for an action if one could not have acted otherwise”.⁷ Further, it is sometimes argued that moral responsibility requires the Principle of Possible Prevention: “a person is morally responsible for a certain event … only if he could have prevented it”.⁸,⁹ It seems in fact that both the deterministic and the psychologistic approaches function along these lines. But many prominent moral philosophers are sceptical of these two principles. Harry Frankfurt,⁷,⁹ among others, argues in numerous articles that the principles of alternative possibility and of possible prevention are misleading because they do not account for acting for the right reasons. Frankfurt gives many examples to support his claim.

Here is a Frankfurt‐type example that can be related to pregnancy loss. Imagine two people who cannot act otherwise, the outcome of whose actions is the same regardless of their chosen courses of action. Imagine two experienced mountain climbers, Jones and Smith, who have been climbing with their respective climbing partners for years. Both Jones and Smith stand to earn a large sum of insurance money on their partner's death. As the pairs have been climbing for years, their equipment is on the older side, and thus carries with it known risks. One sad day, fate is written for both climbing parties; according to this fate unbeknownst either Jones or Smith, the lifelines supporting both partners will snap, causing Jones's partner and Smith's partner to plummet to their deaths.

Before the eventual playing out of fate, both Jones and Smith are engaged in the project of preparing for the climb. Jones, knowing that he stands to gain an immense insurance pay‐off on his partner's death, and feeling no particular compunction to protect the life of his partner, wilfully neglects to check his lines and his gear, hoping that, through his negligence, his partner will take a fall and he will collect the insurance. He is a selfish sort, and, given the pay‐offs, such actions seem acceptable to him. Smith, unlike Jones, knowing that he stands to gain this immense insurance pay‐off, but also knowing that he stands to lose his climbing partner and friend, checks his lines and his gear carefully, and hopes sincerely that his partner will not be injured during their climb. Despite Smith's hopes, both Smith's and Jones's partners take the fall, die, and both Smith and Jones can now collect on their insurance.

It seems then, despite the original observation regarding the inevitability of the outcome, that we really do have two possible courses of action: either to willfully neglect, as Jones did, or to take precautions to prevent the outcome, as Smith did. These two courses of action differ in an important moral sense. The question here is whether Smith is responsible for his actions in the same way that Jones is responsible for his.

It is pretty clear to me, at least, that although we may excuse Smith for taking the appropriate precautions to protect his partner's life, we may blame Jones for his unseemly enthusiasm over and negligence in enabling his partner's death. This is true even though the outcome could not have been otherwise: the fate of both men's climbing partners was predetermined. It seems to me that the clearly blameworthy party here is Jones, who acts with bad intent, and it is this that makes him morally culpable for his actions. Although the outcome of his actions is an outcome that could not have been prevented, we may nevertheless want to hold him culpable, or morally responsible, for his decision to take delight in the death of his climbing partner. In fact, in both cases, the outcome is the same and could not have been otherwise, but the bare difference that makes all the difference is that one climber, Jones, acts for bad reasons, whereas the other climber, Smith, acts for good reasons. The principles of alternative possibility and of possible prevention ought to be rejected, because they propose that a person is not culpable when an outcome could not have been prevented and also because they ignore the reasons for a person's actions.⁹,¹⁰,¹¹,¹²

Now, rejecting the principles of alternative possibility and possible prevention may not seem the sort of thing that we would want to do in the face of a problem such as pregnancy loss. After all, it sounds like it makes more room for the mother to blame herself, as simply having a result forced on her does not rule out the possibility that she could still be responsible for the loss. But women who blame themselves for their loss talk as though they are subscribing to just this notion of moral responsibility, and look to find an explanation for what has gone wrong. When they blame themselves, they introduce innumerable possibilities about what could have been, and they rightfully hold on to their belief that they could have acted differently.

Although pregnancy loss is not necessarily a case of predetermined outcomes, we can learn at least one thing from Frankfurt's analysis of the principles of alternative possibility and of possible prevention: being culpable and being morally responsible for a bad outcome implies strongly that a person has acted for the wrong reasons. And it is this point that must be reinforced with the mother who blames herself for her loss. Bereaved mothers want to figure out where they went wrong and are looking for answers as well as indicators of how they may act differently in the future. This means that they are evaluating courses of action and are clearly not viewing themselves as the passive recipients of a medical fate. They need to be reassured on numerous fronts that they are not culpable for the loss that has occurred, and this cannot be done by denigrating their autonomy. Practitioners can do this if they bear in mind the fine distinction between responsibility and culpability, and urge their patients that to be culpable for an action a person must have acted for the wrong reasons. In most cases, I assume, women will already have taken an active role in making the right decisions for their children and will already have accepted responsibility for the outcome of their child long before the child is lost. This acceptance of responsibility may well be what drives them mad when the loss occurs. In their minds they are responsible for the loss as well as mind‐numbingly not responsible.

So long as it can be understood and shown that, within a reasonable degree of medical certainty, the mother was acting with the best interests of the child at heart, she should be able to separate her responsible actions as a mother and the real moral problem of culpability. She can, in other words, be responsible for the life of her child but not culpable for the child's loss.

To put this in more formulaic terms, the mother must be reaffirmed in her belief that

1. There is little way that she could have known that the path she chose was the path that would lead to a negative outcome.

2. Her actions were those of a mother seeking to do good by her child.

Also, she must be assured that

1. Whether or not there is reason to believe that this outcome could have been prevented by taking another path is irrelevant to her culpability.

2. Her emotional upheaval in the face of this loss—in other words, her feeling of guilt—is also an irrelevant indicator of culpability.

The first and second concerns deal with the epistemic problem—that culpability requires intentionality, and intentionality requires having correct beliefs. The third and fourth concerns relate to the more understandable descriptive or psychologistic problem—that culpability requires that a person could have acted differently. If these two issues are not considered in tandem, the mother will probably find a way to blame herself, for the very reason that she is, and was, responsible about her role as a mother throughout the pregnancy. She had already taken responsibility to care for her unborn child long before the child disappeared.

In the practical realm, this means that counsellors in support groups, or doctors treating women after a pregnancy loss, may benefit from understanding the guilt of a grieving mother in this two‐pronged way. They can reassure her of medical facts about her pregnancy, while also being mindful that her intentions for her child—that she meant to be a great mother, for instance—play an important part in determining her culpability. In other words, it should be suggested to the mother that she was responsible for her child, but not culpable for the loss. If practitioners do not consider the intentionality issue inherent in culpability questions, struggling mothers cannot release themselves from a nagging sense of guilt and from their belief that they are still somehow responsible for the negative outcome.

That many women have a nagging sense of guilt is our tip‐off to this conclusion. The word “guilt” is often used to refer to the emotion of feeling responsible, which is quite different from the “guilt” when it is used to refer to the state of being culpable, as when we pronounce a criminal guilty. The term “blame” is the flip side of this. Blame in the psychology literature refers to feelings of guilt. It is a psychological construct tied to movements and effects that bodies have on the world. Culpability means deserving blame. Culpability is a moral construct, meant to make sense of actions that can be taken for good or bad reasons, to bring about morally good or bad ends. To be free of morally bad culpability, we need to have good intentions, and we also need to have good reasons for acting in the ways that we act. This is where well‐meaning practitioners often misunderstand the plight of the mother who has lost her child.

Women who blame themselves for their pregnancy loss are raising moral claims, and it is important for medical practitioners, psychologists, social workers and philosophers alike to bear this in mind when dealing with these women. Moral culpability is different from psychological guilt or self‐blame, although it may seem that guilt is a feeling, and not a fact, about what happened. Not only is it true that simply feeling guilty does not make a person guilty, but also that guilt is much more complex than a simple emotion that follows in the wake of a loss. Moreover, moral culpability is different from physical causality, and although one physical action does certainly cause a subsequent reaction, this is not enough to establish culpability, and hence not enough to establish blame. Much more must be in place for this to be so.

A fair bit more can be said on the matter of culpability and pregnancy loss but space constraints do not allow for such discussions. Topics that are worth exploring further include the claim that mothers are also not necessarily culpable for an action that they undertake assuming that it will turn out for the best, but which eventuates in disaster. Simply having a good intention does not release them from culpability. It is equally important to observe, as one referee suggests, that many women do not experience guilt after their loss, and other women even take active steps to terminate the pregnancy, which suggests that, in some cases, responsibility and guilt are not as out of sync as they may appear. Empirical researchers wishing to follow up on the clinical implications of the distinction may study the degree to which such a distinction improves or affects the coping responses of bereaved mothers.

The important point discussed in this paper relates to culpability and blame after pregnancy loss. Whether a child dies because of some action that a mother takes does not alter the responsibility that she must and does own for having taken the action in the first place. If a bad outcome arises as a result of some action that she takes, then it is only more unfortunate that this action has given rise to that bad outcome. To put it in the words of Michael Zimmerman,¹³ “There is no fresh injection of responsibility.” Mothers are not any more culpable for the bad turn of events, precisely because, as I have been arguing, culpability implies strongly that a person has acted for the wrong reasons. The responsibility for their actions stands as it always did: independent of an outcome that could not have been otherwise.