Perhaps this will lay the accusation that I am a shill for ACOG to rest.
The president of the American College of Obstetrician Gynecologists (ACOG) wrote a letter in response to my recent piece in The Washington Post, Five myths about pregnancy, in which he vehemently disagreed with me. He seems to think we disagree on what the science shows; in truth, we disagree on what professional ethics demands of doctors.
I wrote:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women deserve to have the same information that doctors have and medical autonomy means that they can decide for themselves whether the risk is worth it to them. [/pullquote]
Studies on alcohol are … ambiguous. Although it is quite clear that large amounts of alcohol can cause fetal alcohol syndrome, the limit of safe consumption is unknown. There are some doctors who insist that if we don’t know the exact limit, women should avoid any alcohol. But most believe that an occasional glass of wine or beer will not cause any problems.
These sentences are undeniably true, yet in a Letter to the Editor, Tom Donaldson, president of the National Organization on Fetal Alcohol Syndrome and Haywood L. Brown, president of ACOG, vehemently disagree.
By writing that studies are “ambiguous” in “Five myths about pregnancy” [Outlook, May 14], Amy Tuteur framed the issue of a safe level of alcohol use during pregnancy as an ongoing debate between opposing sides, each with scientific validity. In fact, the science is settled: There is no amount of risk-free alcohol use during pregnancy. This is the position of every scientific and public-health institute and medical and behavioral health association in the United States …
They claim:
[No study] has found any level of prenatal alcohol consumption that is non-toxic to human development.
This is the logical fallacy known as the “argument from ignorance,” often colloquially expressed as “Absence of evidence is not evidence of absence.”
According to Wikipedia:
It asserts that a proposition is true because it has not yet been proven false (or vice versa). This represents a type of false dichotomy in that it excludes a third option, which is that there may have been an insufficient investigation, and therefore there is insufficient information to prove the proposition be either true or false.
Yes, it is true that no study has found a safe level of prenatal alcohol consumption in pregnancy, but that does NOT mean that there is no safe level of alcohol consumption, merely that we don’t know what it is.
Why don’t we know? Because the situation is far more nuanced than Mr. Donaldson or Dr. Brown acknowledge and by representing our knowledge as complete and definitive when it is incomplete and uncertain, they infantilize pregnant women.
How?
They write:
Why tempt harm when all risk can be avoided?
But it’s not their decision to make; the decision belongs to each individual pregnant woman.
What do we know about alcohol and FAS?
1. There is no reliable relationship between drinking in pregnancy and FAS. Sure, large amounts of alcohol can lead to FAS, but many women drink moderately without any apparent harm to the developing child. Researchers have noted the “American paradox.” Though alcohol consumption per capita (among women and men) is much higher in European countries than in the US, the incidence of FAS is much lower there. Drinking wine with meals is widespread in Europe, so many women are drinking before they know they are pregnant and when they are pregnant, yet the incidence of FAS is just a fraction of what it is here. Perhaps FAS is more common with some forms of alcohol than with others; we don’t know.
2. The likelihood of developing FAS depends on maternal genetics. Some ethnic groups (like Native Americans) have a much higher incidence of FAS than other ethnic groups even when comparable amounts of alcohol are consumed. In other words, some ethnic groups are “prone” to FAS while others are not.
3. The likelihood of developing FAS also depends on fetal genetics. A study of twin pregnancy in heavy drinkers revealed an extraordinary finding; while there was 100% concordance among identical twins (if one had FAS, the other did, too), there was less than 70% concordance for fraternal twins:
…Sixteen pairs of twins, 5 MZ [monzygotic] and 11 DZ [dizygotic], all heavily exposed to alcohol prenatally, were evaluated. They represented all available twins of alcohol-abusing mothers who were on the patient rolls of the authors. The rate of concordance for diagnosis was 5/5 for MZ and 7/11 for DZ twins. In two DZ pairs, one twin had fetal alcohol syndrome (FAS), while the other had fetal alcohol effects (FAE). In 2 other DZ pairs, one twin had no diagnosis while one had FAE. IQ scores were most similar within pairs of MZ twins and least similar within pairs of DZ twins discordant for diagnosis.
Clearly the issue of alcohol in pregnancy is not straightforward.
Unfortunately, Mr. Donaldson and Dr. Brown have transmuted uncertainty into certainty. Instead of acknowledging that the safe limit of alcohol consumption in pregnancy depends on factors that we don’t yet understand, they imply that NO amount of alcohol consumption is safe in pregnancy and that is almost certainly not true for every woman. To maintain such a stance in the absence of concrete scientific evidence is to treat women like children.
I suspect that if a newly pregnant patient worried aloud about her fears of fetal harm from a glass of Chardonnay she drank before she knew she was pregnant, even Dr. Brown would reassure her that it probably caused no harm at all —because that’s what the existing scientific evidence shows. If it is appropriate to reassure women who have already had that glass of Chardonnay, it is inappropriate to tell another women who hasn’t had the Chardonnay yet that a glass of wine could very easily cause harm.
Women deserve to have the same information that doctors have and medical autonomy means that they can decide for themselves whether the risk is worth it to them.
In my view doctors are ethically obligated to be honest with women — to tell them what is true and to acknowledge what we don’t know — and let them decide for themselves. It is infantilizing to make decision for them and counsel them to do what we might prefer.
