Hope Itself   /   Fall 2022   /    Essays

The Right to Care

On the Unruly Body, Abortion, and the Limits of Choice.

Adin Lears

Spring Pregnancy (detail), 2012, by Julie Held (b. 1958); © Julie Held. All rights reserved, 2022/Bridgeman Images.

Shortly after a surgical procedure to treat my second pregnancy loss in a year, I read a passage from a fifteenth-century English medical treatise that describes a condition called “ache of the womb”:

Ache of the womb comes of a dead-born child that is born earlier than his time, wherefore the mother has a great liking and a great comfort of the child that is within her, and when she loses it, she makes a natural mourning and sorrowing, just as a cow does when she has lost her calf; and that sorrowing is ache of the womb.

This passage opens a section of text that offers various abortifacient recipes, and it is striking for two reasons. First, its placement presents abortion as a necessary and common treatment for pregnancy loss. Second, it recognizes a form of suffering shared by human and nonhuman animals. The twinned physical and emotional pain of the patient acknowledges an experience of animality in the human. The treatise considers abortion a necessary form of care more than a choice.

In a 1972 memorandum to colleagues, the abortion rights advocate and Episcopal priest Jimmye Kimmey proposed “Right to Choose” as a pithy counterpoint to “Right to Life,” noting that “choice has to do with action—and it is action we are concerned with.” Significantly, for Kimmey this phrase was provisional: She added that “I hope someone can clearly think of a better one.” Yet choice remains foundational to contemporary frameworks of abortion rights advocacy and to movements seeking to protect the autonomy and self-determination of women.

But since the decision in Roe v. Wade was handed down in 1973, feminist scholars and activists have also highlighted the harm of framing reproductive health care in terms of choice. Led by feminists of color, the reproductive justice movement, which began in the 1990s, objects to the framework of reproductive choice in part because it assumes that all women have access to the same choices. In contrast, reproductive justice emphasizes that abortion cannot be considered in isolation from economic inequality, toxicity and environmental threat, race and sexuality-based discrimination, and other issues of social justice that impede many women from obtaining informed access to reproductive health care.

Other critics have highlighted how a choice-centered framework also runs the risk of reproducing the same habits of thought that pervade antiabortion rhetoric. Just as abortion opponents vilify those seeking abortion, claiming that they seek to evade the consequences of their promiscuous sexuality, proponents of abortion access who frame their advocacy solely in terms of the values of rational choice and freedom ignore and obscure the realities of reproductive health, which depend on social and biological contingencies beyond the patient’s individual control. The choice-centered framework and its emphasis on rational judgment lends itself to a conflation of the sexual and biological with the moral: For the individual patient, some choices are better than others—a perspective that is disproportionately deployed against the economically disenfranchised, including many women of color. The language of choice further corresponds to a consumer model of subjectivity reinforcing market-driven forms of health care, which tend to transfer medical responsibility from the provider to the patient.

A closer look at the language historically used to describe involuntary pregnancy loss will reveal careful and complex attributions of agency or action. The term spontaneous abortion, used among medical professionals for decades to draw a distinction between it and induced abortion, conjures hysteria: the notion of the uterus as a compulsive entity with its own interests and agency, that ejects its contents at will, “an animal within an animal,” in the nineteenth-century Scottish physician Francis Adams’s translation of the Greek physician Aretaeus. By contrast, miscarriage, which gathered traction in Britain and the United States beginning in the 1970s, attributes a certain agency to the patient, though it is an agency that is botched or blighted. For centuries, miscarriage had a patina of morality. Before it was widely adopted as a term for pregnancy loss, it referred to instances of misconduct or misbehavior and more generally to a mistake or failure. In the context of reproductive health care, then, the term miscarriage implies that the patient has carried the pregnancy, but badly, with its failure as the result.

A prime mover behind the shift to the term miscarriage in Britain was Dr. Richard William Beard, head of the Department of Obstetrics and Gynecology at St. Mary’s Hospital, London, from 1972 to 1996. In 1985, Beard and two colleagues wrote a letter to the medical journal The Lancet highlighting the great distress among women upon hearing their early pregnancy loss called abortion. The letter called for doctors to use the term miscarriage rather than abortion out of compassion for patients. This call for compassion has remained a major rationale for keeping pregnancy loss distinct from abortion, both in medical and public discourse.

Yet as the public health writer and historian of medicine Andrew Moscrop has shown, the widespread adoption of the term miscarriage among medical professionals can also be attributed to a range of other developments in medicine as well, highlighting the political and personal interests involved. Prior to legal decisions like Roe, which eased restrictions on abortion, the criminalization of abortion created conditions that made it difficult to distinguish between spontaneous and induced abortion, especially in the absence of ultrasound technology. Many patients who sought treatment for pain and infection after illegally obtained abortions attributed their condition to spontaneous rather than induced abortion. But increasing use of ultrasound technology through the 1980s made it possible for doctors to diagnose varieties of early pregnancy loss, and thus to distinguish miscarriage as a set of conditions with their own causes and treatments different from those of more ambiguous endings to pregnancy that may or may not have been voluntary.

Within this context of advancing scientific knowledge about early pregnancy loss, the subfield of perinatology emerged as a part of obstetrics and gynecology. Between the mid-1970s and the mid-1980s, Beard published multiple letters in The Lancet, many of them with the goal of improving women’s experience of health care. Yet these letters also delineated the contours of perinatology as a discipline and established Beard’s own authority within it. As Moscrop notes, the letters evince a “selective empathy,” demonstrating enormous compassion for those who experience early pregnancy loss but none for those who undergo voluntary abortion. For Beard and others, a harder distinction between miscarriage and abortion allowed those who experienced pregnancy loss—and the doctors who treated them—to distance themselves from abortion’s lingering associations with criminality and stake a claim for the morally upright nature of an emerging medical field.

Moscrop notes that as the shift from “spontaneous abortion” to “miscarriage” was taking place, the phrase “pregnancy loss” was frequently used by doctors writing to an audience of other doctors. Yet medical texts still maintained that doctors should use “miscarriage” when speaking to patients. For Moscrop, this disjunction suggests an effort among doctors to maintain a measure of professional control by denying the uncontrollable nature of pregnancy loss. Despite attempts to maintain a terminological and conceptual separation between voluntary and involuntary pregnancy loss, the widespread adoption of “miscarriage” in place of “spontaneous abortion” still attributes agency, control, and responsibility for the end of a pregnancy to the patient.

Yet the idea that reproduction goes exactly according to plan is absurd, as anyone who has ever tried it can tell you. Unplanned pregnancies number nearly half of those occurring in the United States, and as many as one in five known pregnancies end in pregnancy loss. Understanding volition as the governing principle of reproductive health care harms patients who are seeking abortion. As the historian Rickie Solinger writes, “Choice has masked the ways that laws, policies, and public officials punish or reward the reproductive activity of different groups of women differently.” Despite the best intentions of progressives, activists, and medical practitioners, framing abortion in terms of choice opens the door for moral judgments, which are disproportionately leveled at impoverished women of color. Patients without the financial means for contraception or those who seek abortion because they lack the means to support a child are judged to be irresponsible for getting pregnant in the first place.

An emphasis on choice has also been harmful to women of color seeking medical treatment for pregnancy loss. In 2018, Adora Perez gave birth to a stillborn baby in a California hospital and was subsequently convicted of murder because she admitted using methamphetamine during her pregnancy. In 2020, Brittney Poolaw sought treatment in Oklahoma for the loss of her pregnancy at four months and was convicted of manslaughter in 2021 because of a similar admission. Casting reproductive health care only or primarily in terms of choice makes patients vulnerable to the same conflation of the physical and the moral that structures antiabortion arguments. It creates the conditions for the heartbreaking injustices suffered by Perez, Poolaw, and others, in which a patient undergoing a spontaneous medical event is made to assume responsibility for it.

Though less urgently damaging, a choice-centered model of reproductive health is also harmful to the mental and emotional experience of individual patients. Over the course of my multiple pregnancy losses, the specter of choice has been a burden, not a boon, carrying with it the weight of sometimes unbearable personal responsibility. Several days after an ultrasound performed by technicians, without the presence of a doctor, I learned over the phone that my first pregnancy had ended. I had to decide, despite never having been to medical school myself, and in a state of shock and grief, whether I wanted to have a surgical procedure at a hospital or take drugs to expel the remaining products of conception at home. I was prescribed mifepristone and misoprostol. Because of the restricted availability of abortion drugs in Virginia, I was only able to obtain misoprostol. I had to decide whether to carry on with the treatment or switch to an alternative, despite the diminished effectiveness of taking misoprostol alone. When I looked at the bottle, it displayed a standard warning: “Do not take if you are pregnant.” I thought, “I’m pregnant and I don’t want to take this.” But I did, as prescribed. Six months later, I finally found out why my pregnancy hormone was still hovering at a level just above clinical pregnancy, despite my body’s apparent return to pre-pregnancy stasis: The misoprostol had not worked on its own, and my uterus had retained products of conception. I felt the burden of personal responsibility: I had made the wrong choice.

After my second pregnancy loss I was given the same choices. The morning of the surgical procedure, I recalled how three previous ultrasounds had shown the matter inside me growing steadily each week, though doctors told my partner and me it would never develop a heartbeat or become viable. I became paralyzed with fear that I was making the wrong choice.

To the extent that I have made choices about my own reproductive health care through these experiences, they have stemmed from a reaction to circumstances beyond my control, not an active assertion of my own agency as a self-determined liberal subject. Placing personal choice at the center of reproductive health care places the burden of choice squarely on the patient, and so dilutes the relationship of care that should be foundational to medicine, through which doctors and patients communicate and make decisions about treatment plans together, without the influence of insurance and hospital bureaucracy. Instead, the word choice highlights a consumer-based model of subjectivity at the center of health care. Within this model, as the physician Haran Ratna has written, “consumers can make the right decision for their health. Or they can make the wrong decision for their health. And if the healthcare they receive does not meet standard of care, they can sue for malpractice in an attempt to recoup money for services that were improperly rendered. This is analogous to how you might return a defective product to Walmart.”

“Right to Choose,” then, advances a narrow understanding of action and agency, in which the subjectivity of the individual depends strictly on reasoned choice. This framework accords with neither the extreme physical vulnerability of the experience of abortion nor the ambivalence many patients feel about the process. Instead, “Right to Choose” extends Enlightenment values—which persist today—that assert the supremacy of rational thought over the experiences of the body.

Such values have been subject to critique from scholars working across a range of disciplines, including the theories of the new materialisms. Loosely set against the rational scientific materialism associated with the philosophical values of the Enlightenment and the emergence of “modern” science, the new materialisms seek to challenge rationally bound forms of subjectivity associated with the human, which have historically been perceived to be superior to nonhuman and creaturely consciousness. In her influential book Vibrant Matter: A Political Ecology of Things (2010), the political theorist Jane Bennett writes of the “vibrancy” of the nonhuman world and calls for a reconceptualization of the self that embraces the strangeness of the body in order to accentuate the material affinities between human and nonhuman life. Advocating an approach to ecology based on “vital materiality” rather than “environment,” she writes that “vital materiality better captures an ‘alien’ quality of our own flesh and in so doing reminds humans of the very radical character of the (fractious) kinship between the human and the nonhuman.” For Bennett, the bacteria that live on human skin indicate that “my ‘own’ body is material, and yet this vital materiality is not fully or exclusively human. My flesh is populated and constituted by different swarms of foreigners…it is thus not enough to say that we are ‘embodied.’ We are, rather, an array of bodies.” (Emphasis in this quotation and the preceding is in the original.)

Bennett’s aim, along with that of many other scholars working in the same vein, is to reconceptualize human subjectivity in order to conceive of more sustainable modes of production and consumption. It is worth noting that this emerging brand of materialism is “new” only from a Western perspective. Native American conceptions of matter and the natural world, for example, have long been grappling with similar concerns, often complicating the idea of the body as a boundary between self and other, embracing its openness and vulnerability as a crucial locus of affinity and contact with the nonhuman world.

From such perspectives, absolute bodily integrity—along with absolute control over bodily processes and functions—is a fantasy. This is not to say that medicine should not seek to understand how the external world influences individual health and well-being, including social and cultural forces as well as organic and chemical ones. But it is to say that we might do well as a culture to keep in mind that our control over our own bodies is limited.

If the impulse to assert mastery over the material world, including our own bodies, aligns with “modern” Enlightenment ideals in the West, premodern thought may offer flickering glimpses of an alternative. The European Middle Ages are not without influence on the contemporary evangelical culture of life behind the Supreme Court’s decision to overturn Roe with Dobbs v. Jackson. As the historian Wolfgang Mueller has shown, the criminalization of abortion in the West arguably emerged from the schools of twelfth-century canon law where medieval scholars and theologians sought to pinpoint the exact moment of ensoulment. In the predominant Aristotelian view, the arrival of the soul took place when the fetus was understood to take on human form through the development of limbs, usually thought to occur forty to eighty days after conception, but also sometimes at conception. This focus on ensoulment is easily recognizable as a precursor to current pro-life evangelical arguments, which seek to protect the sanctity of human life, as defined by the presence of a soul. With their emphasis on defining the moment at which matter attains humanity, these perspectives elevate the ontological status of the human over and above all other forms of life.

Yet premodern books of practical medicine evince a more complex perspective. Whereas scholastic works were the domain of literate, university-educated men, medical texts straddled realms both theoretical and practical, literate and oral. Medical texts like The Sicknesses of Women operated in the realm of what the historian of medieval medicine Monica Green has called “literate medicine,” which she defines as “the realm of medical thought and practice that involves medical knowledge that has been written down, knowledge that has been committed to a textual and not simply oral mode for its transmission.” Those who wrote down recipes were most likely men, although these formulations may have circulated orally among women practitioners as well.

What emerges from these texts is not by any means a golden age of women’s health care, in which women were in charge of reproductive medicine and voluntary abortion was more freely available and not maligned, as some historians have claimed. The Sicknesses of Women and another fifteenth-century English text, The Knowing of Woman’s Kind in Childing, are based largely in the same sources, but they vary in their perspective on abortion. The Knowing author acknowledges that some women “use a thing so that they should not conceive and that causes abortion.” But he refuses to name or describe it on the grounds that “some cursed whore would use it.” The Sicknesses author is preoccupied with abortifacient herbs. He considers retained products of conception or a “dead child” that cannot be delivered as a grave danger to maternal health and outlines a program of medical care according to which, in his words, “it is better that the child be slain than the mother of the child die.” In one recipe, the Sicknesses author instructs practitioners to make an herbal tincture and give it to a woman to drink, explaining that “this medicine brings forth both dead child and quick, wherever it be in the woman’s womb, and that soon.” As Green notes, abortifacient herbs could be used as purgatives and even as birthing aids. But their inclusion in such texts could also indicate how cultures “flip technologies,” taking what was used for one purpose (maintaining fertility through uterine purgation) and using it for another purpose (ending a pregnancy).

Premodern practical medicine may not provide a straightforward model for integrating abortion into a holistic program for reproductive health care, but it does offer a vision of medicine in which the patient’s body is unruly and must be cared for in its unruliness. The Sicknesses author shows an interest in the shared physical experience of human and nonhuman animals, all of whom suffer pregnancy loss and react to it in ways that are audible and palpable to others.

Aching of the womb, the Sicknesses author explains, can also come from a “hardness” of the womb, which develops after the birth of the child. To prevent this condition, the author recommends that the patient soak in a bath infused with various herbs, then have an herbal plaster applied to her abdomen. “Otherwise, when the woman is delivered of the child, the uterus walks in the belly from one place to another and aches, since she is suddenly emptied of the child that made her full before.” Other passages attribute similar movements and personalities to the “matrice,” or uterus. The author frequently refers to the organ as “she” and makes it the subject of various verbs as it “walks,” “falls,” and “grows” hard or soft.

Such personifications and attributions of uterine agency are consistent with ancient and medieval notions of the “wandering womb” drawn from ancient Greek medicine and persisting in medical theories of hysteria. Ancient Greek medical texts describe “suffocation of the womb” and other maladies as the result of uterine restlessness and movements around the body: When the humors are balanced, the uterus remains in place; when they are out of balance, the uterus roves, causing a range of physical symptoms. The notion of the wandering womb was based on a misogynistic understanding of sexual difference that held that female bodies were inherently inferior to male bodies, a physical condition reflecting women’s moral inferiority.

Sigmund Freud’s influential articulation of hysteria mirrored the model of the wandering womb, yet instead of a vagabond organ wreaking havoc on the patient’s physical and psychological well-being, the unconscious was to blame. Like an animal within an animal, the unconscious mind operating outside the patient’s conscious control caused neurotic behavior. In the case of Dora, Freud’s ur-hysteric, these included headache and “nervous coughing,” along with fidgeting, suicidal depression, and a complete loss of voice, brought about by enduring sexual abuse and rape at the hands of an acquaintance of her father’s. For Freud, problems of the unconscious could be brought to consciousness only through psychotherapy, as the psychoanalyst unearthed fragments of the patient’s unconscious and pieced them back together on the patient’s behalf. In analyzing Dora, Freud saw himself as an archaeologist reassembling the “mutilated relics” of her unconscious and translating her silence and fidgeting—the “chattering” of her fingertips—into rational narrative form. As numerous scholars have shown, the concept of the unruly uterus, and later the unruly unconscious, justified centuries of benevolent patriarchy through which authoritative men sought to control women in the name of a perverse kind of care.

The language of choice, then, is an understandable corrective that confers agency and self-determination on patients who are able to become pregnant—but this language has its limits. The model of the wandering womb expresses a medical reality: the unruliness of bodies and their resistance to the wills and desires of patients and doctors alike. The solution to the harmful legacy of hysteria is not only for patients to assert their right to make decisions about their own bodies. It must also be to acknowledge that bodies—all bodies—continue to operate outside anyone’s individual will or control. It is to acknowledge that the decisions in health care—for all bodies—are made as much (and maybe even more) in reaction as in premeditated and willed action. Recognizing the involuntary character of such decisions may require us to reconsider our attachment to the supremacy of the human and acknowledge the creaturely nature of human life.

Jimmye Kimmey’s proposed “Right to Choose” as a provisional slogan for abortion rights advocates is not capacious enough to accommodate the lived experience of many patients. And its emphasis on individual self-determination and freedom can be harmful, in ever-proliferating ways. It is no surprise, for example, that “My Body, My Choice” has been appropriated by right-wing and libertarian opponents of vaccination, or that New Age wellness influencers are developing narratives about manifesting the desires of the individual will to heal autoimmune disorders, cancer, and more.

It is time to accentuate other frameworks centered on collectivity and the right to care along with individual agency. In her Cancer Journals (1980), Audre Lorde addresses another area of reproductive health care, accentuating the external forces that influenced the course of her disease. For Lorde, arguably the mother of self-care, this meant acknowledging her enmeshment with others, both human and nonhuman: It meant confronting and fighting the social and environmental circumstances of pollution, radiation, and other factors that contribute to higher rates of cancer in communities of color. It also meant loving herself and accepting the “careful tending” of others in her life.

Lorde’s perspective is consistent with reproductive justice in its emphasis on environment and circumstances. It also anticipates a new materialist perspective accentuating how individual bodies are physically enmeshed in vital materiality with external forces. We might extend this to internal forces as well. For decades, the movement to protect abortion has overlooked pregnancy loss, in part because it ran the risk of acknowledging fetal value, a slippery slope toward the antiabortion promotion of fetal personhood. But personhood need not be the sole litmus test for value. As the legal scholars Greer Donley and Jill Weber Lens wrote this past August in a New York Times op-ed, “If we ground fetal value in the pregnant woman’s attachment, and commit to defending her conception of pregnancy, we can recognize loss without threatening abortion rights” (emphasis added). To recognize value though attachment—through care and cooperation—rather than ensoulment acknowledges how we are dependent on and vulnerable to nonhuman matter both around and within us.

After Roe, defenders of abortion might more wisely reframe their case around the central importance of care. A care-centered approach would align with the commitments of reproductive justice, working toward policies directed to mitigating social conditions like poverty and environmental toxicity that affect reproductive health care. Such an approach would also work toward health-care reform that would allow medical professionals to make decisions about care, in consultation with their patients, without having to conform to the bureaucratic parameters required by insurance companies and hospital administration. And it would acknowledge the strangeness of the body, its entanglement with other matter and its persistent tendency to operate beyond rational control. The action in “right to care” extends in two directions: It acknowledges a patient’s right to care—actively—for oneself, one’s family, the potential lives one may create. It equally acknowledges patients’ right to receive care from others: to accept and work with social contingencies and the unruliness of one’s own body in all its creaturely vulnerability and need.