Straw Man: an intentionally misrepresented proposition that is set up because it is easier to defeat than an opponent's real argument.
We are living in amazing but very confusing times. While we have the unbelievable luxury of access to infinite data from a multitude of sources, we also have the dilemma of not knowing whether what we read and hear has been vetted for accuracy. And when some data is repeatedly disguised as fact, not the opinion that it so often is, it can be confused for a truth of sorts. Ideologies or nefarious motives such as power or profit do not value truth. So, when an opinion is spoken in eloquent language or written in prestigious publications it can be very misleading. Repeatedly referencing disputed science, ignoring data that is contrary to their thesis and ridiculing those who disagree is a tried and tested tactic of those who wish to deceive. On occasion they believe what they are saying. But more often the self-declared experts and ethicists are, in fact, ideologically driven and their mendacity and obtuse opinions masquerade as elitist and ethical proofs that simply confound those of lesser expertise on the matter discussed.
Home birth is accepted in many parts of the world. Encouraged in some. Discouraged elsewhere. There are those that disagree with the option of home birth. And an honest discussion can be had with some about the reason women choose home birth’s support systems and safety in comparison to the pros and pitfalls of hospital birth. Good people can disagree honestly. And then there are those who despise home birth and the midwives who support it that repeatedly recycle misinformation, create new theories of ethics, never apply the same scrutiny to options they approve, insult their opponents and create straw man arguments in their zeal to support their narrative. Two such men are Amos Grunebaum, MD & Frank Chervenak, MD out of Cornell University and Lennox Hill Hospital in New York. They have repeatedly suggested that support for home birth is unprofessional conduct. Their condescension towards midwives, OB colleagues who dissent and the women they serve is really what is unprofessional. And they need to be called out once again as no one in academia has the courage, and very few others the platform, to do so.
I have editorialized on these men before. In the American Journal of Ob/Gyn (AJOG) in 2011 and on my blog in 2013 (Please read). I even have a power point presentation I put together called, “Dissecting the Ethics of the Ethicist”. Please bear with me as I try to apply common sense and logic to once again dissect their latest home birth clinical opinion hit piece, “Critical appraisal of the proposed defenses for planned home birth”, in the July 2019 issue of the AJOG.
(As a side note, pretty much every article these two publish on this subject is in the AJOG. Dr. Chervenak sits on the AJOG advisory board with the subtitle of “ethics”. It makes a curious person wonder if they have ever had a submission rejected from that journal.)
From the very beginning the authors conjure up two arguments they attribute to proponents of home birth. The first is the very low absolute risk of planned home birth justifies its support. The second, is an argument I have never heard from anyone supportive of home birth. The authors state that a defense of planned home birth invokes an analogy of similar relative risks between trial of labor after cesarean (TOLAC) delivery and planned home birth. They conclude these arguments are flawed and obstetricians should respond to expressions of interest in planned home birth with a respectful explanation of the inadequacies of pro home birth arguments, the failure to commit to patient safety, and a recommendation for planned hospital birth.
In order for their critical appraisal of these points to be valid one has to assume their arguments can withstand simple logical scrutiny. Logic is a topic that most of us have heard of but do not really understand the meaning in the context of making a logical argument.
Generally, there are two types of logical reasoning, inductive and deductive. In order for an inductive logical argument to sustain itself it must be built on reliable observations. It gives probability but never certainty. For example, if Cinderella’s shoe fit perfectly, then why did it fall off? Ergo, if there is never certainty then that needs to be expressed and explained when giving informed consent. Beneficence based ethics has long been the standard on which medical ethics is built. Simply put, it balances reasonable options with patient autonomy. Dr. Chervenak has rejected this form of ethics in favor of professional responsibility ethics. Where responsible medical science can override patient autonomy and the physician is the arbiter of what is responsible. I would also add that any form of ethics allows for informed consent and mandates the importance of expressing the risks and benefits of all options, including those unique to the hospital setting, which our authors do not do.
If at any step in the creation of a deductive logical argument, a fact or component of that argument is false, reveals bias or exhibits a leap of faith then the entire subsequent premise falls under a veil of suspicion. So, to be true, a deductive logical argument must for all intents and purposes be perfect. This is a very high bar, rarely met in our profession.
In this context lets analyze what the authors state is their opposition to point number one, very low absolute risk. And, let’s assume they are expressing a logical opinion and not an emotional one. To me, logic dictates that no real scientist would forego logic in making an argument. They state, “Professionalism in medicine requires all physicians to commit to patient safety.” Well, here’s a can of worms already. Which patient? What is their definition of safety? Can there be more than one definition? Who decides?
The authors then state that planned home birth has been associated with significantly increased relative and absolute risk of neonatal death and morbidity. For proof they cite five references. Interestingly, four of the references are to their own papers and the fifth is the notorious Wax, et al paper. (Many subsequent analyses of the Wax paper have discredited its legitimacy. Here’s one: https://www.medscape.com/viewarticle/739987 and yet these authors continue to cite it every time). They conclude that the only way to reduce the preventable increased relative risks of planned home birth is to remove the variant setting and put all births in the hospital. They go on to state “Professionalism requires the absolute commitment to patient safety. Because the commitment to patient safety requires the reduction of variation when such reduction improves outcomes, planned home birth….is not consistent with the commitment to patient safety.” Wouldn’t analogic reasoning here suggest that because the staffing, size and resources in some hospitals are suboptimal that patient safety would require the reduction of this variation and therefore they should be shut down?
I would propose that hospital birthing in the United States over the past 50 years has not led to an increase in patient safety or improved outcomes. In fact, while neonatal mortality has risen slightly, cesarean section, which consensus agrees is less safe for the mother and her future babies than vaginal birthing, has risen 500%. And maternal morbidity and mortality has risen accordingly. Using the authors logic, since 99% of births take place in the hospital setting should we still say that is the safest place to give birth? Or can we at least say that the current model of hospital birthing is not safe? I think so and so do many other well-informed people which may explain the increasing interest in alternative choices. It’s only logical.
The second argument: that the comparison of planned home birth safety to TOLAC safety is faulty analogic reasoning, baffles me. I have been connected to the home birthing world in some form for 33 years and have never heard this argument. It would seem this is the classic straw man. The authors pose this as a legitimate argument of home birth proponents and then proceed to tear it down. I would encourage everyone to read their full article (referenced earlier) to understand the scope to which the authors go to defeat an argument that no one makes. It’s even more confusing when they argue, as an example of their reasoning, for the use of influenza vaccine in pregnancy. “Although the absolute risk of pregnancy-related maternal mortality ratio for influenza A infection deaths is low (1/454,545), this mortality rate can be reduced significantly with vaccination against influenza during pregnancy.” How much lower risk can you go than 1/454,545? So, to the author’s logic, we should give every woman a vaccine never tested in pregnancy to lower the risk from near zero to a little closer to near zero. To inform a woman of this information and support her choice would be professionally unethical in their model.
The article finished with suggestions for “directive counseling”. I’m thinking euphemism here. “When the evidence is strong (strong not defined), the physician should engage in directive patient counseling in the form of making recommendations. Fulfilling this professional responsibility is essential for achieving patient safety… Failure to undertake such directive counseling is an egregious clinical ethical error.”
They also suggest that some caregivers view making recommendations as incompatible with the ethical principle of respect for patient autonomy. Again, I don’t know who they are talking about but the use of the word caregiver rather than obstetrician or physician as used throughout the article would suggest they are implying midwives. I don’t know of any midwives who are against making recommendations, hence I see this as another straw man because they go on to dissect this position that no one has by saying, “These objections should not be considered persuasive because they assume that women are helpless pawns who affirm whatever their obstetrician recommends.” Who thinks like this? Knowing these authors well leads me to believe what they are really saying is skewed counseling disguised as recommendations is a sound ethical practice and standard in their institutions. Their previous abandonment of beneficence in favor of professional responsibility gives them away.
They conclude this opinion piece by reaffirming their position that there are two proposed defenses for planned home birth, its very low absolute risk and the TOLAC analogy. “In response to women who express the belief that the very low absolute risk of planned home birth is acceptable to them, the obstetrician should recommend, respectfully, but firmly, against planned home birth….”. But even this premise is a straw man argument as one of these is not an argument used in favor of home birth by its proponents and the other should remain a decision that belongs to the informed woman. Therefore, their supposition that these two reasons are not consistent with patient safety and are no longer justification for the support of home birth is flawed. Plus, they ignore the myriad of other reasons women might choose an out of hospital birth. Rare increases in neonatal morbidity and mortality, while always of concern, is not the only endpoint of concern to some women. Obstetricians should be wary of any recommendation from these authors that violates beneficence and the respect for patient autonomy in reasonable decision making.
Subtle coercion is still coercion and, in this case, paternalistic. Using false arguments and relative risk to imply that home birth is unsafe and to advise physicians to discourage this reasonable choice is not professionally responsible. There is enough evidence in the accepted world literature to suggest that properly selected mothers can safely have their babies in the home setting using skilled practitioners with higher success rates and higher levels of patient satisfaction. The authors have a long history of antipathy towards home birth and the midwives who support it. This opinion piece, published in a prestigious American journal to which they are connected, is simply a new iteration of the same refuted logic. They are displaying a high level of arrogance, paternalism and cognitive dissonance in reaching their conclusion.
Daniel Patrick Moynihan was credited with the quote, “Everyone is entitled to his own opinion, but not his own facts.” When making a logical argument to ascertain truth certain rules must apply or the arguments fall apart. We all have our biases on the topic of home birth and autonomy in decision making. Given honest informed consent, patients rarely make decisions that are foolish or irresponsible (i.e. choosing not to have a cesarean with a complete placenta previa). The reasoning used by the authors of this paper is convoluted, unnecessarily complicated and fails to satisfy the requirements of inductive or deductive logic. By their own reckoning, they would conclude that Cinderella should never have gone to the ball because her shoe might fall off.
Stuart J. Fischbein, MD FACOG
August 9, 2019