Challenging the Rhetoric of Choice in Prenatal Screening

1. Challenging the Rhetoric of Choice in Prenatal Screening Victoria Seavilleklein

2. Increases + Autonomy • Increases to number of pregnant women screened and increase in things they are screened for. • Typically justified in terms of greater autonomy for pregnant women. • Seavilleklein’s thesis: Screening does not prtet or promote women’s autonomy in most cases (on various notions of autonomy).

3. Autonomy and Informed Consent • Autonomy in health care achieved through informed consent which is comprised by: person is competent; adequate disclosure about the intervention; adequate understanding about the intervention; voluntary consent. • Lots of evidence to support that in the vast majority of cases, at least one of these conditions is missing.

4. Disclosure • Supposed to disclose details about the conditions being screened for, the liklihood of detection, the method of screening, the meaning of a screen-positive and a screen- negative result, the choices following a screen-positive result, the choices following a a positive diagnosis, and details on how further info can be attained. • Far too little time devoted to this (b/w 2-5 minutes) for it to occur.

5. Understanding • Studies indicate that understanding is rare. • Probabilities difficult to understand. “Increased probability” typically take to mean their child is going to have the disease or they have a 50/50 chance of getting it. But it could be that the chances of their child being inflicted with a particular disease rises from 1 in 400 to 1 in 250.

6. Voluntariness • Stats that women were not asked to consent. E.g., screening was done in conjunction with standard blood tests without the knowledge of the women (284). • Physicians power and their worry about law suits.

7. A Relational View • Standard, individualist view of autonomy vs. relational view. The latter takes into account the context (and, e.g., power relationships) of the decision maker. • Business interests factors and the creation of demand (think of Orgasm, Inc.) Only ‘giving woman want they want’? • More information is better? Contraception and large families • More choice is always good? Choices becoming compulsions. • “Safety” “Usually recommended.” “at risk” (vs. what, “No risk?” • Ultrasonography: now a standard part of pre-natal care despite no evidence of its clinical value.

8. A relational view • Women’s actual choices and options vs. the ones medical profession allows. • E.g., Abortion OK at 20 weeks for Down’s Syndrome, but not sex selection. • Social supports for various decisions – e.g., to give birth to a baby with severe disabilities.

9. Conclusion • NOT opposed to pre natal screening. • But wants us to think more deeply about women’s real choices. • We need to take steps to improve the process of informed consent. • Address contextual factors that restrain choice • Incorporating the offer of prenatal as a standard perinatal care ought to be rethought.