Under the guise of what is “best for babies,” the government has wrongly brought its considerable power to bear on promoting breastfeeding. In a fascinating paper entitled State power and breastfeeding promotion: A critique, political philosophers Balint et al. advance a compelling political argument against government promotion of breastfeeding. Simply put, the government misuses its power when it aggressively promotes breastfeeding.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The government misuses its power when it aggressively promotes breastfeeding.[/pullquote]
State-sponsored breastfeeding promotion campaigns have become increasingly common in developed countries. In this article, by using the tools of liberal political theory, as well as public health and health promotion ethics, we argue that such campaigns are not justified. They ignore important costs for women, including undermining autonomy, fail to distribute burdens fairly, cannot be justified neutrally and fail a basic efficacy test… (my emphasis)
I’ve been making these arguments for years: breastfeeding promotion campaigns like the Baby Friendly Hospital Initiative (BFHI) violate women’s autonomy, re-inscribe privilege and are not justified by the trivial benefits of breastfeeding.
Why does the government need to justify itself? This goes to the heart of what we believe about the proper role of government.
One of the roles of liberal institutions is to make it possible for people to pursue their ends; and not to define their ends for them, nor favour some conceptions of the good over others, nor avoidably favour one way of life over others. In relation to breastfeeding promotion, this means that the burden must be carried by the health and welfare argument, and not any view about the goodness of any particular type of motherhood or the natural role of women. That is, only if breastfeeding provides significant welfare benefits for infants or mothers could such promotion be neutrally justifiable.
Breastfeeding promotion programs like the BFHI are unabashedly manipulative. They force women to undergo mandated “education”; they limit women’s feeding choices within the hospital; and they interfere with the free speech rights of medical professionals who believe that aggressive breastfeeding promotion is harmful to mothers and potentially deadly to babies. Manipulation violates women’s autonomy and autonomy ought to be valued very highly by government.
… [M]anipulation, like coercion, bends the will of one to that of another. This invasion of autonomy is severe even when the distortion it causes in a person’s decision making is relatively minor. Here we will argue that in the case of breastfeeding campaigns the quality of the information and the nature of the messages used at a time of particular emotional vulnerability can constitute a form of manipulation and can thus be autonomy-undermining for women …
The government is of course justified in promoting public health but that is subject to limiting principles:
(i) When there is more than one possible way to achieve a goal, we should always choose the least restrictive (i.e. least liberty-infringing) alternative.
(ii) Liberty-infringing interventions should be used in a non-discriminatory way, and we should be particularly cautious about using such interventions when those singled out by it come from the worst-off groups of society.
(iii) The burdens should be as minimal as possible.
(iv) Those who bear the burdens should be compensated.
(v) If a public health intervention is warranted (i.e. it meets the above conditions), an individual should be helped and supported to discharge her duties as much as possible (‘reciprocity’)…
(vi) Respect autonomy as well as doing good…
(vii) Do not cause fear, anxiety and vulnerability unnecessarily…
(viii) A campaign should be efficient in achieving its goals.
How do the BFHI and other breastfeeding programs violate these principles? Let me count the ways:
- It affects only women and is more burdensome for poor women than for rich women.
- The burdens are considerable.
- In the absence of a comprehensive maternity leave policy, the government is imposing the burden without helping the affected women discharge it.
- Fear mongering about the “risks” of formula is central to these campaigns.
- Breastfeeding campaigns don’t actually work and produce only minimal health benefits even when they do (except in the case of prematurity).
The authors are justifiably scathing in their assessment of lactation professionals’ response:
While many of the physical problems … are acknowledged by breastfeeding advocates, the response is usually one of perseverance. The problem – whether it be postnatal depression, multiple births, or severely cracked nipples – can almost always be surmounted with appropriate counselling, management and determination. This is the case even when the problem is one of insufficient milk and the infant itself is not thriving as well as their peers. Hausman, for example, writes that ‘no one disputes that cases of true (or primary) insufficient milk syndrome exist – breastfeeding advocates simply tend to question the idea that there are large numbers of women who physically cannot make enough milk’. And, in response to a woman who, while unsuccessfully trying to breastfeed her infant, had ‘blood dripping down her chest and tears streaming down her face’, the advice was that the issue could be resolved by proper ‘lactation management’…
Perseverance, counselling and management, and not choice, context and individual circumstances, seem to be an all too common response from many public and/or publicly funded health professionals and institutions to those struggling. (my emphasis)
What about the health benefits of breastfeeding? The evidence is weak, conflicting and riddled with confounding variables.
As we argued, if this is true, there remain the problems of autonomy and fairness. And moreover, as we demonstrated, such a claim seems empirically suspect: (a) much of the empirical evidence for breastfeeding is beset with methodological problems, and (b) where positive health effects seem well demonstrated, they are often very small, in non- serious areas, or very rare. Thus, because the scientific evidence for the infant health benefits of breastfeeding is much weaker than is usually claimed, the ethical principle of efficacy (viii) is challenged. It seems then that there is no neutral justification for such a policy given that exclusive breastfeeding is associated with a particular view of child-rearing and motherhood. This means that promoting breastfeeding appears to unjustifiably privilege one conception of the good over others.
In summary, government breastfeeding promotion violates important political principles:
Because of the special role of the state, our argument focused on state power, rather than private organisations. This special role, however, enables the state to act in this sphere. It should provide accurate factual information, and legislate and agitate for more family-friendly workplaces, including for women who want to breastfeed… This is quite different from actively and strongly encouraging, often with quite manipulative and autonomy-undermining messages, a practice, the benefits of which for infants are marginal at best, and under current conditions, the negative effects of which on women’s welfare and autonomy can be strong and long-lasting, and certainly not equally or fairly distributed… Perhaps, breastfeeding is better for a child’s health, but it is certainly not always better, all things considered, particularly when one of the considerations is the health, welfare and autonomy of the woman who is being asked to do the breastfeeding.
Therefore, we should get government’s hands off women’s breasts!
