Life, Death and Choice

Author: Dr Martin Leet

Date: 01 October 2009

A central narrative of modern culture is the liberal tale of increasing individual autonomy. Freed from many of the restrictive social hierarchies and inhibiting values of the past, individuals now have, by and large, more scope for choice. But there are also countervailing trends that mould and thwart the freedom of the individual. Martin Leet reflects on two sites where individual choice is exposed to tension, one at the beginning, the other at the end of our worldly existence.

The federal Health Minister, Nicola Roxon, recently announced a package of reforms called “Providing More Choice in Maternity Care”. The new measures will supply “eligible” midwives with far more government support in terms of access to Medicare and the Pharmaceutical Benefits Scheme. As the debate ensuing from the Minister’s decision suggests, however, it is questionable whether the reforms will truly give women more choice in birthing. For the government support to midwives is made conditional upon their collaboration in a team in a hospital setting. Effectively, from the middle of next year, midwives will be unable to attend home births.

The Maternity Services Review and the policy flowing from it are a response to increasing pressure on the system. It is an attempt to boost the “system” but it does so by further increasing the power and authority of that system. There is already a longstanding, institutionalised prejudice against the practice of home birthing in Australia. The rate of home birthing, here, is low compared to many other countries. And it is interesting to note how the local history of a practice produces the evidence to confirm the underlying prejudices. In its participation in the consultation process of the Review, the Australian Medical Association noted that while choice is important, “Women need to understand that studies have shown that their babies are three times more likely to die in a home birth compared to a birth in hospital”.

Studies have indeed shown this, but they have been conducted in Australia, where home birthing receives little support. In contrast, the available, and considerable, international evidence – published in several large-scale studies covering thousands of births – shows that, for low-risk pregnancies, there is no difference at all in the health of babies between home births and hospital births. In countries such as Canada and the Netherlands, where home birthing is seen as equally as valid as hospital birthing, the evidence demonstrates that the practice is safe.

Individual choice is never exercised in a vacuum. It takes places within a context, within a set of social values and institutional practices. Women in Australia do not have the same set of choices in regards to birthing as women do in some other countries. A local history establishes the range of choices and how they can be exercised, and it seems difficult to break out of that history once its momentum has been established. The momentum against home births has been heightened by the federal government’s latest vision of maternity services. As a result, it is likely that the “evidence” against home births in this country will become more persuasive. After recently completing an investigation of a baby’s death following a home birth, Byron Bay coroner, Nick Reimer, urged the government to rethink its approach. He argued that home birthing “will not go away” with the decision but instead will be “driven underground with disastrous ramifications”.

To reiterate the point, the liberal story of expanding individual freedom is a very general and often illusory one. In every domain, as the instance of home birthing illustrates, “choice”, “autonomy”, “freedom” – whatever word is preferred – exists only within a set of values and institutions, and not in some abstract realm. Likewise, the incredible and advancing power of medical knowledge and technology exists within a context. The manner in which it is applied, if applied at all, depends upon the nature of social and political relationships. The authority of the “medical model” over birthing in Australia is very strong and that has consequences for the freedom of those wishing to have a family. Judging by the comments made by the AMA, the minimisation of risk is the lone issue at stake. But it is only one value, among others, to consider in the debate.

The attempt to dominate discussion with reference to a single value often characterises debates such as these. A similar thing happens in deliberations over the question of voluntary euthanasia, at the other end of our worldly existence. At other times and in other places, the question, while always difficult and complex, was approached from a different cultural point of view. The Hippocratic Oath, for example, was formulated in a culture where choosing a “good death” or “dying well” was seen as a natural and desirable value. In other words, the ancient Greeks and Romans could think, at the same, that life is precious and important, but it is also only one value among others.

Modern, western culture seems to have developed a more exclusive and absolute sense of the value of life, human life in particular. In his book Straw Dogs, British philosopher John Gray observes that, “Until a century or so ago, it was common for people to let themselves be carried off by pneumonia (‘the old man’s friend’) or to step up their daily intake of opiates until they fell asleep for ever. The men and women who did this turned towards death, sometimes consciously, but more often in an instinctual movement no different from that in which a cat seeks a quiet place to see out its end. As humanity has become more ‘moral’, it has put such deaths beyond reach”.

A cultural outlook blinded to the value of “dying well,” allied with the power of modern medicine, is a potent combination that can take away from individuals the choice of a good death. It is a combination that often prevents the introduction of legislation to make voluntary euthanasia available. Any such legislation, like all laws, is fraught with difficulties. But we could approach it from a more balanced and dispassionate point of view by putting aside a dogmatic and excessively moralised commitment to life.

The medicalisation of life and death, then, is far from being an unambiguous development. Its desirability is undeniable. But it is worth maintaining a strong vigilance of its potential erosion of individual choice and autonomy. We should be particularly watchful of a medical system overreaching its limits at a time when it has become increasingly litigation-wary and risk-averse while simultaneously being overburdened and under-resourced. In an attempt to avoid some of the perils of individual autonomy, it may end up creating much greater ones.

Dr Martin Leet is Senior Research Officer with the Brisbane Institute. He studied political science at the University of Queensland and was awarded a BA (Hons) and PhD. Over the last ten years, he has taught and researched in the fields of political economy, public policy and political theory. Martin has published two books, as well as numerous journal articles and book reviews. His most recent book, Aftereffects of Knowledge in Modernity (State University of New York Press), examines the ambivalent cultural consequences of the search for knowledge in the modern western world.