To Have, or not to Have


There are two worlds out there, two Magisteria. Two contrasting inclinations that pass each other on the street without a wave. Strangers who sometimes know each other well. They sit, unwittingly close to each other, in the waiting room of my office. They chat and smile obligingly, trusting that their ignorance of the other is no impediment to friendship, however brief. Indeed, there is no barrier, only a perspectival boundary: Weltanschauung.

And yet, I don’t want to make too much of the difference; it is often in flux, and can mutate even as we watch –Time has a way of adjusting viewpoints,  justifying decisions. We all try to vindicate ourselves in the end. Validation requires exculpation, does it not? Absolution in the eyes of those who matter…

So the stronger the tradition, the societal apologue, the more the justification and guilt assigned to those who stray from it. There is a sort of canniness in the collective –or at least strength. Acceptance… And it is easier to regress to the mean, than defy the group. Especially when it comes to attitudes towards pregnancy –or more specifically, the decision whether or not to have a baby.

I’ve just read an incredibly powerful  book, whose title captures some of the agony and guilt attending those who dare to deviate from societal expectations: Selfish, Shallow, and Self-Absorbed. It is a collection of 16 well-written and generally thoughtful essays -13 from women, and 3 from men- about choosing not to have children. None are from paedophobes; and only a few are from those who decry the notion of pregnancy in others. They are not outliers –except perhaps on a carefully constructed Bell Curve- nor could they be construed as deviant. Each has merely made a personal decision not to accept the tyranny of the Norm.

The essays took me back to the early days of my practice, when, as a newly minted obstetrician, the very idea that someone would not want to have a child at some stage in her life, was anathema… Well, perhaps curious would describe it better –memorable, at any rate. And yet, it was not unknown. It was always a difficult decision in those faraway times to accede to a request for sterilization in a young woman. Contraception, yes, and although this closed the door effectively, it did not lock it. We were suffocatingly parental in those days: we knew she might change her mind –she was young and inexperienced, after all. Like a child, she had to be protected; it was our responsibility to keep her future mutable and open. We –society- were the guardians of that door…

But there are surely two issues at play here. It is one thing to criticize a decision made prematurely –before the kaleidoscope of life has fully displayed, when the future is more chiaroscuroid, more obscure and uncertain- and another developed in that fullness of time when a considered, even retrospective analysis of the factors leading to the choice can bear fruit.

This, too, can seem arbitrary, I realize. Is there a difference between a thoughtful twenty-five year old woman who -in her mind at any rate- has weighed the risks and benefits of having a baby and decided against it, and a forty-five year old who, on looking back at the way her life has unfolded, is grateful and reconciled to never having a child? It is a vexing question on several levels, I think.

In these days of autonomy and non-maleficence when it is considered medically paternalistic and politically incorrect to suggest that a decision need not be vetted by experience, we forget the other ethical duty of a health care provider at our –her- peril: beneficence –serving the best interests of the patient. It seems to me that this entails both a mature and non-directive dialogue and a list of other, more malleable options that would not only adequately serve her needs, but would also allow for change at any stage. Some form of reliable and non-intrusive contraception, for example, might respect her desire to avoid pregnancy, and yet enable some flexibility should she change her mind, or harden her decision for a permanent solution.

But I have to confess that I am still troubled. On the one hand, it seems to me that wisdom is the ability to judge a situation based both on knowledge of what it entails, as well as experience of how it usually turned out in the past. It is why elders were revered in the days before the plethora of information technology that assails us today. I am trying not to be Ludditic here but what the elders contributed, that Google often does not, is digestion. Analysis over time and place. Evaluation. Information can be coloured by current trends and bent by traditional assumptions –but of course so can needs. We must not forget that.

I have always been leery of ‘facts’ divorced from context. Are they then still facts or do they inhabit some terra incognita we have yet to fully occupy? A territory of collation, a thesaurus that is able to list endless variations on whatever theme we decide applies to us, so we can pick and choose the reality we prefer?

It is not the decision to have, or not to have a child that should preoccupy us, but rather the reason it has been chosen. And for such an important life-changing resolution, the depth and –dare I say- maturity of  thought that has gone into the consideration is paramount. It is not, nor should be allowed to fall under, the purview of political correctness and thereby escape a more cautious and examined approach. There is no correct answer, no unquestionable myth that can justify any position. We may have a spur to prick the sides of our intent, to paraphrase Hamlet, but it is a different one for each of us. We must take care that we, and those we counsel, are not –Hamlet again- hoisted with our own petards.

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