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Early Pregnancy Losses: Multiple Meanings and Moral

Considerations

Amy Mullin

1. Introduction: Contexts of Loss

Pregnancy loss occurs more frequently than many realize. Although docu-
mented losses vary in differing countries, and early losses are frequently undo-
cumented, an estimated 30–40 percent of pregnancies do not end in live birth
(Michels and Tiu 2007). In the United States, if we exclude abortions, one quar-
ter of women of childbearing age will experience a miscarriage1 (Jones 2001,
228). Losses can happen before a woman knows she is pregnant or occur as late
as during childbirth.2
Some women choose to end unwanted pregnancies; other losses occur to
women who did not want to be pregnant but strove to remain so, and others to
women who wanted to become pregnant and give birth to a child. Pregnancies
may end in loss because of injury (sometimes deliberately caused) to the preg-
nant woman, or because of exposure to environmental toxins or illness. Women
who initially wanted to be pregnant may later choose to terminate a pregnancy.
This could be because of changes in health, financial resources, or social sup-
port. Decisions to terminate may reflect prenatal test results that reveal anoma-
lies that a woman believes will compromise either quality of life for the
potential child, the prospective parents’ ability to care successfully for that child,
or both.
In this essay, I aim first to give a sense of the complexity of the ethical ter-
rain connected with pregnancy loss and then to discuss early pregnancy loss in
the light of this complexity and variability. By early loss, I mean loss that occurs
before an embryo or fetus is believed to be either sentient or able to survive out-
side the womb.3 What I lose in depth of focus on any one issue I hope to gain in
breadth, ensuring that attention to the moral significance of early pregnancy loss
in one context considers other types and contexts of loss. This approach should
help me avoid making assumptions about what is entitled to moral consideration
to arrive at desired results, for instance to cohere with pro-choice politics or
express sympathy with those who have experienced much lamented pregnancy
loss. My research is drawn from a wide variety of disciplines but has focused on
pregnancy loss in industrialized secular democracies, and should be interpreted
in that context.

JOURNAL of SOCIAL PHILOSOPHY, Vol. 46 No. 1, Spring 2015, 27–43.

C 2015 The Authors. Journal of Social Philosophy Published by Wiley Periodicals, Inc.
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This is an open access article under the terms of the Creative Commons Attribution-
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modifications or adaptations are made.
28 Amy Mullin

Reflection on the ethical significance of pregnancy loss should discuss mul-

tiple contexts and multiple actors. The contexts include different stages of preg-
nancy, different reasons for pregnancy loss, and different attitudes toward the
pregnancy by those involved. The actors include pregnant women, their partners
(male or female), individuals, or couples for whom pregnant women act as sur-
rogates, and extended family members of pregnant women (or other expectant
parents). They also include individuals and groups whose actions contribute to
pregnancy loss, and medical professionals who provide care for pregnant
women or who participate in procedures aimed at providing medical treatment
to a fetus or terminating a pregnancy. Others who confront pregnancy loss
include acquaintances and coworkers who wonder how to respond to others’
losses, funeral directors, social workers, and support group members. Finally,
pregnancy losses represent an end, chosen or not, to a human life (viable or not)
and so raise questions about the moral status of beings located along the contin-
uum between immediate products of conception and fetuses on the cusp of birth
at full term.
As a feminist, I wish to acknowledge the widely varying significance preg-
nancy losses have to pregnant women while recognizing that others may have
very different attitudes toward those losses. Many women who lose a pregnancy
believe that loss of an embryo (a stage of development from conception to eight
weeks gestational age4) or fetus (a stage of development from eight weeks until
birth) is loss of a child and is morally significant not only because of their loss
of hopes and dreams but also for that child. They believe that factors that lead to
avoidable pregnancy loss should be struggled against, and that their losses
should be socially acknowledged as losses of children. Efforts to receive this
social acknowledgment may take the form of participating in pregnancy support
groups (Layne 2005) or creating or visiting pregnancy loss memorialization
websites (Keane 2009) or memorial gardens (Woodthorpe 2012). Other pregnant
women do not believe that an embryo or fetus is a child and will terminate preg-
nancies without seeing those terminations as morally significant at least if they
occur relatively early or perhaps at any stage. Still others may regard termina-
tion of pregnancy, at least at certain stages of fetal development, as loss of a
child but believe it is the right thing to do because of their own situation, or
because they believe the fetus is unlikely to have a future of value.

2. Social Construction of Fetal Personhood/Moral Status

Some feminist scholars attempt to resolve potential tensions between sup-

porting women’s right to terminate pregnancies (either at every or at some
stages), with fighting for resources to prevent pregnancy loss, and social and
institutional changes that acknowledge the importance of pregnancy loss by
arguing that fetal personhood is constructed socially. Laury Oaks writes:
“Borrowing from the pro-choice position, women’s health advocates can pro-
mote a fetal politics by asserting that, in disputes more than the fetus-as-subject,
 Early Pregnancy Losses 29

the pregnant woman’s judgment is to be respected. This support would entail a

steadfast foregrounding of women’s agency by privileging their notions of their
fetuses” (2000, 97). Annemarie Jutel similarly argues that we must make preg-
nant women’s attitudes central and focus on whether or not a pregnant woman
regards loss of the pregnancy as loss of a child (2006, 431–433). Linda Layne
claims that feminists can reconcile sympathy for those grieving the loss of their
pregnancies with support for those who choose abortions by acknowledging that
if one accepts an “anthropologically informed view of personhood, that is, that
personhood is culturally constructed . . . one can see that the process of con-
structing personhood may be undertaken with some embryos and not others”
(1997, 305). These feminist scholars seek to create a rhetorical space in which
pregnancy losses can be acknowledged in a manner that allows both support for
some women’s choices to abort pregnancies and other women’s response to mis-
carriage or stillbirth5 as tragic loss of a child. This feminist strategy, however,
may falsely suggest that pregnant women only construct their embryos and
fetuses as babies, persons, or potential children in pregnancies they intend to
keep. Jeannie Ludlow notes that many of the women she encounters in the abor-
tion clinic where she works refer to their fetuses as babies (2008, 43) and wish
their life circumstances had permitted them to have and rear these potential chil-
dren. She observes that some pregnant women who have abortions have devel-
oped emotional connections with the embryo or fetus and some choose, after the
procedure, to hold the body, say goodbye, and “grieve for a child” (41). I take
this as evidence that undermines Julie Palmer’s contention that one must be
anti-abortion to speak of babies in utero or unborn children (2009, 181).
Recognizing that pregnant women—including those who choose abortion—
may or may not construct their fetuses as persons can help us deal sensitively
with their losses. But they are not the only ones who construct fetuses as per-
sons, and hence are not the only ones whose losses require sensitive response.
Grief counseling or more informal emotional support could appropriately be
offered to those whose words, actions, and emotional responses suggest they
feel a person has been lost while not to those who would feel morally judged by
these kinds of offers. Mary Ann Hazen notes how important it can be to respond
sensitively in the workplace to pregnancy loss experienced by one’s colleagues
(2006). However, it is important to avoid assuming that all who experience preg-
nancy loss will feel the same way. Many hospitals have developed protocols for
dealing with pregnancy loss, but some pregnant women and their partners con-
sider encouragement to hold the body of the dead fetus and grieve as adding to
their emotional discomfort, and dictating how they should feel rather than
responding to their actual feelings which may be mixed (Corbet-Owen and
Kruger 2001, 422; Letherby 1993, 177; Graham et al. 2012).
According to the approach taken above by Oaks and others, fetal person-
hood is constructed socially, and therefore, some fetuses and some embryos
(those desired by pregnant women and regarded as their children) are persons.
By contrast, other fetuses are not persons on this view because not constructed
30 Amy Mullin

as such by a pregnant woman. Clearly this approach suggests that respect for a
pregnant woman’s autonomy should extend not only to her control more than
her own body but also to others’ attitudes toward whether or not the loss of a
pregnancy is a loss of a person. I disagree and discuss first the claim about the
social construction of persons and next what respect for reproductive autonomy
should instead entail.
A person is typically taken to have moral status equivalent in most respects to
adult humans with normal capacities but, as Bonnie Steinbock points out, we can
mean different things by talking about persons (2011, 30). Melinda Roberts, for
instance, takes a person to be any being with moral status, and so for her a kitten
(capable of experiencing pain and pleasure) is a person, whereas an embryo or
early fetus (one not yet capable of sentience) is not (2010, 147). Many would find
this way of talking counterintuitive. It seems clearer to refer to moral status (had
by all beings worthy of moral consideration for their own sake), rather than invok-
ing personhood. This may help avoid confusion and also enables acknowledge-
ment that beings can be entitled to different types of moral consideration.
Many people who encounter pregnancy loss think of at least some embryos
or early fetuses as people in their own right, as children (not only potential
future children) and as morally considerable. Some of these people are a preg-
nant woman’s partner, an individual or couple for whom she is undertaking a
pregnancy (Berend 2012), medical professionals who regard a fetus as a patient
(Wyatt 2001), members of a pregnant woman’s social network, and members of
her society more broadly (including people who believe, for religious or other
reasons, that personhood and hence moral status begins at conception). As
Palmer notes, with the increasing sophistication of ultrasound technology, peo-
ple she terms “citizen voyeurs” (2009, 186) have constructed fetal personhood
on the basis of ultrasound images, which, because persons have moral status,
has resulted in calls for earlier gestational age limits to abortions (182). Diffuse
social construction of the personhood of fetuses can be an impetus for legal and
policy changes such as provision of birth certificates in stillbirths (Cacciatore
and Bushfield 2008).
Jenny Hockey and Janet Draper observe that “the social identities of the
unborn” are constructed by people in varying ways (2005, 54), often by looking
at and sharing ultrasound images, telling friends and extended family members
about the pregnancy, and making preparations to welcome the anticipated child
[see also Weaver-Hightower (2012) for a personal account of this process]. In
their interviews with expectant fathers, Hockey and Draper found that whether
or not a man constructed a fetus as a social person and himself as a father he
could “find his view either supported or contested by other interested parties”
(2005, 46). In her study of male participants in pregnancy loss support groups,
Bernadette McCreigt found that expectant fathers can experience considerable
grief while feeling pressure not to express it, either to conform to a masculine
identity or to support their female partner (2004, 329). This suggests the griev-
ing men regard the fetus lost as both a child and morally considerable.
 Early Pregnancy Losses 31

Sometimes a pregnant woman’s life partner is another woman, and these women
may equally grieve pregnancy loss and often do not have their feelings acknowl-
edged or addressed (see Peel and Cain 2012).
If social construction of a fetus’s personhood/moral status gives sufficient
ground for others to recognize an entity as morally considerable, then we are
left on relativist grounds, as some will construct fetuses as social actors worthy
of moral consideration and some will not, often with respect to the same fetus.
Clare Williams notes that in fetal medicine units “the same fetus might, at vary-
ing stages, be conceptualized at different points along this human/non-human
continuum, by women, partners and practitioners” (2006, 13). Given that people
may also socially construct other non-human entities as persons and indeed as
their children (while writing this essay I saw a bumper sticker that read: “My
children have four paws”), recognition that various people may or may not
socially construct different fetuses as persons/children/morally considerable
would hardly settle the matter of how others should regard them. We have a
long history of denying moral status to beings who should, on the basis of their
properties, be recognized as morally considerable: slaves, women, people with
cognitive disabilities that do not prevent them from having beliefs and desires,
entering into relationships, caring about others, and/or responding to reasons.
[For a discussion of the moral status of children with cognitive disabilities, see
Mullin (2011)]. It is, therefore, problematic to conclude that those constructed
by some others as morally considerable have moral status, and those that are not
so recognized lack it.
It is important to reflect on features that could affect the moral status of a
human embryo or fetus at different stages of its development, beyond the value
it may have to others. These features may include viability (or the ability to live
outside a woman’s body, if provided other forms of care), sentience (or the cur-
rent capacity to be conscious and feel pain that appears to emerge no earlier
than the third trimester6), and the potential to develop other morally significant
capacities. However, determination of the moral status of a developing human
would not settle the matter with respect to how we should respond to those that
cause, contemplate, or suffer its loss. We need to consider the other actors
involved, especially but not only the pregnant woman. Before discussing the
moral status of fetuses I will, therefore, discuss the autonomy of pregnant
women, and women’s reproductive autonomy more generally. It is important to
be clear that respect for reproductive autonomy should constrain some actions
and inspire others, and that deference to the pregnant woman’s attitude toward
her loss should affect interactions with her, but need not determine others’ atti-
tudes toward pregnancy loss.

3. Reproductive Autonomy

I assume that pregnant woman’s bodily and reproductive autonomy is of

value because autonomy (or self-determination) is generally of value, and so are
32 Amy Mullin

women, and further assume that bodily and reproductive autonomy are impor-
tant forms of autonomy, with typically far greater significance for people than
the freedom to make decisions about what to wear, or eat on any particular asso-
ciation. I take this to be true even though decisions about how we clothe our-
selves and how, what, and with whom we eat are also important to people. I
assume, therefore, that the moment of birth is ethically significant, because
before then fetuses can only be accessed (treated, monitored, or terminated)
through intervening on the pregnant woman, and when this is done without her
consent, it violates her autonomy.
I disagree, however, with Mary Anne Warren’s contention that birth is also
morally significant because it marks the beginning of the possibility of social
interactions with a child who may be cared for as a particular individual (1989,
62). I have already suggested that a variety of actors may construct an embryo
or fetus as a baby or person, and characterize their own interactions with it in
social terms. For example, physicians and other medical practitioners may care
for fetuses as patients. Wyatt gives a moving account of the tension this repre-
sents for doctors (and their medical teams) who are expected both to try to
engage in treatments that may save a fetus or improve the quality of life it may
have once born, and to terminate a pregnancy during its later stages (2001; see
also Williams 2005; Williams 2006, 11–12). Fetuses may be constructed as chil-
dren both before birth and after death by a variety of social actors whose identi-
ties are shaped by being in a family relationship with them (Morgan 1996, 53;
Keane 2009, 156). Birth is instead significant because before it a fetus can only
be harmed or helped by affecting a pregnant woman. The ability of a fetus to
live outside the body of a pregnant woman (something that shifts with changes
in medical technology) is similarly significant because it marks the point at
which people other than her can begin to assume responsibility for its care. This
means that a unique burden would not need to be imposed on her for the fetus,
once born, to live.
If we seek to enhance women’s reproductive autonomy, it will be important
not only to protect their abilities to choose not to have children but also to
acknowledge limits to women’s abilities to choose to have children, whether
because of features of their bodies, their luck, or their circumstances that lead to
unwanted pregnancy loss. Autonomy is increased when we are well informed
about our options, about the potential need to make difficult decisions, and are
also informed about the limits to what we can control, so as to avoid inappropri-
ate self-blame, a common response to unchosen pregnancy loss (Layne 2003,
1888; Letherby 1993, 170). It is also increased when we have the social, finan-
cial, and emotional resources that make options to have children and raise them
in safe and supportive environments real possibilities (Price 2010, 56).
Respect for reproductive autonomy suggests we should devote resources to
help men and women become more informed about what can go wrong and
what they might face when things go wrong (Layne 2006, 610). We should
encourage discussion of potential problems in public discourse. In McCreigt’s
 Early Pregnancy Losses 33

study of male grief after pregnancy loss, many of the men expressed being
unprepared for loss, uninformed about what they could expect, and unsupported
in dealing with it (2004, 338, 341). Serene Jones’s work reveals that for pregnant
women miscarriage can be deeply emotional, combining “lost agency and guilt”
(2001, 233). Autonomy is also enhanced by provision of support (when it is
desired) to women and their partners when they need to make decisions con-
nected to pregnancy loss, decisions that are often very emotionally laden
(Howard 2006). Finally, if we are to enhance men and women’s reproductive
autonomy in the face of potential or actual pregnancy loss, it will be important
to avoid assuming that all individuals or couples need the same kinds of support
in the face of loss (Graham et al. 2012).
We can respect autonomy without agreeing that particular choices autonomous
persons make—or the attitudes they manifest—are either moral or definitive of
how others should respond to what they experience. We need not, therefore, allow
a pregnant woman’s attitude toward her fetus shape how we respond to others
either devastated by or indifferent to her loss, or to shape what we determine has
been lost. Furthermore, we can value autonomy without believing that it is the only
legitimate factor to be taken into consideration in ethical decision making (or pol-
icy-making) as harm to others with moral status should also be considered. It will,
therefore, be important to consider whether/when a fetus may acquire moral status,
and to recognize all who are affected by pregnancy loss. Recognition of the impor-
tance of pregnant women’s autonomy should not end all ethical debate about their
actions and decisions with respect to their pregnancies. However, we might find
ethical fault with people’s autonomous decisions without seeking to prevent them
from making those decisions, and indeed while supporting the importance of their
being able to make them. This does not mean we must avoid discouraging some
kinds of decisions (for instance, with respect to termination of pregnancy because
of the sex of the fetus, or because of fetal anomalies that do not appear likely to
prevent a fetus, once born, from having a life worth living).

4. Early Pregnancy Loss

In the next sections of this essay, I focus on early pregnancy losses, before a
fetus is either sentient or able to survive outside the womb—two features that
are often taken to be morally significant. This way I can explore what else might
be morally significant in pregnancy loss, including the worth of a being with
potential to develop morally valuable properties. In choosing to focus on early
pregnancy loss, I should not be taken to assume that time of loss is the only or
chief factor in determining how we should regard pregnancy loss or respond to
those who have lost a pregnancy.7 As discussed above, sensitive responses need
to take into account the attitudes of the pregnant woman and others involved
with the pregnancy.
Many early pregnancy losses are in the category of blighted ovum and are
presently unavoidable (Pearce and Easton 2005). In blighted ovum pregnancies,
34 Amy Mullin

a fertilized egg implants in the uterus but does not develop into an embryo,
sometimes because of a chromosomal problem with a sperm or egg or some-
times because of early problems with cell division. Even though an embryo
never existed, these losses are memorialized on pregnancy loss websites “in the
same ways as other early miscarriages” (Keane 2009, 69). Others early losses
are avoidable—sometimes they result from someone’s actions (for instance the
embryo or early fetus is damaged by something that happened to or was chosen
by the woman). We know that pregnant women sometimes face domestic vio-
lence, and that a pregnant woman’s abdomen is often singled out for violence
(Layne 2006, 611), leading to placental abruption, fetal loss, premature labor,
and maternal and fetal fractures (Bacchus et al. 2001, 251).
If a pregnancy would have been viable and wanted, then someone who
caused the loss did something to damage the woman (and others who hoped to
parent the expected baby) beyond the damage to the woman’s body. If a blighted
ovum pregnancy was ended due to accident or injury, then no embryo or fetus
was lost. But in other cases of early pregnancy loss, an embryo or fetus was lost.
Is the loss caused to the embryo or early fetus morally considerable for its sake
and not only because of the expectant parents hopes and plans? I will discuss
these questions by first reviewing variations in feticide8 laws in the United
States.
In the first decade of the twenty-first century, federal law in the United
States made it a separate crime to harm a fetus in an assault on a pregnant
woman, and many states followed suit (Fleming 2008–09, 44). The federal legis-
lation (The Unborn Victims of Violence Act of 2004) proscribes the same pun-
ishment for killing or harming a fetus in an assault on its mother as if the injury
or death had occurred to her (except the death penalty cannot be imposed). The
law applies to an embryo or fetus at any stage of development (Fleming 2008–
09, 50–51). It does not apply to abortions women seek, to medical treatment for
woman or fetus, or to any conduct of the woman herself. These exceptions pro-
tect a pregnant woman’s autonomy and privacy.
State laws differ in how they treat harm to fetuses. Some consider harm to a
fetus only in effects on pregnant women (Fleming 2008–09, 52). Others recog-
nize any embryo or fetus as a person whose killing is homicide (53). Some indi-
cate that gestational age affects whether or not a fetus is a legal victim of a
crime (56). Others stipulate that fetal harm is a crime only it if could have sur-
vived birth (54) or only if the attacker knew the victim was pregnant (55, 59).
As with the federal legislation, most states do not apply their laws to acts of the
pregnant woman (68). However, some prosecute pregnant women for harming
their fetuses (Layne 2006, 606). Although it is morally problematic for a preg-
nant woman to harm a fetus she intends to keep, criminal prosecution for such
acts would enable considerable intrusion on pregnant women’s autonomy and
privacy. It would also discourage them from seeking health care during preg-
nancy, potentially damaging both the woman’s health and that of the child to be
(Fleming 2008–09, 72; Layne 2006, 606).
 Early Pregnancy Losses 35

These legal approaches to acts that harm or kill a fetus (aside from abortion
undertaken with a woman’s consent) provide varying reasons for considering
these acts morally problematic. The reasons range from recognizing them as
acts that harm a pregnant woman (because of her emotional attachment to the
fetus), acts that are equivalent to harming or killing an adult person, no matter
what stage of development the embryo or fetus is at, or acts that are punishable
only if they harm fetuses at a more advanced stage of development.
How can this review of legal responses to harming or killing directed at a
fetus without a pregnant woman’s consent help us think more broadly about the
moral significance of early pregnancy loss? Clearly one type of loss is the suffer-
ing of the pregnant woman and others who cared about the pregnancy and/or
expected to be involved in the life of the expected child. For the pregnant
woman, this can include loss of hopes and plans for a relationship with a child,
loss of an identity as a mother, a challenge to her understanding of herself as a
woman, and a potentially traumatic emotional and physical experience of the
miscarriage itself (Engelhard et al. 2001). Women who have agreed to act as
surrogates for others are sometimes expected to feel the losses less, but Berend’s
work shows that they can be keenly felt by surrogate mothers as losses of proj-
ects of meaningful acts of care and sacrifice for others, and as losses of valuable
children (Berend 2012).
Expectant fathers, expectant female co-parents, or those who expected to
parent a child in a surrogate pregnancy, and their extended family members,
may also lose hopes and plans for a relationship, and aspects of their identity (as
prospective grandparent, or father, or co-mother). This strand of fetal harm laws
is, therefore, well supported by research on experiences of pregnancy loss (both
studies that focus only on pregnant women and those including other prospec-
tive parents). The emotional aspects of pregnancy loss can be very significant
(Bonnette and Broom 2011; McCreigt 2004; S€aflund et al. 2004; Weaver-
Hightower 2012). When a fetus is constructed as a person and then a pregnancy
is lost, those who experience the loss not only lose a being they found morally
considerable but may also lose aspects of their identity, as well as hopes and
plans for the future. As a result, Layne suggests that very early detection of
pregnancy, via home pregnancy tests, may avoidably increase the pain of those
who might otherwise not have realized they were pregnant with a nonviable
pregnancy (2009).9 If an early pregnancy was not viable, then it is better that the
pregnant woman (and others involved) never learn about the loss.
What about fetal harm laws that equate harming or killing a fetus with
harming or killing a pregnant woman? Some early and otherwise viable preg-
nancies are not wanted or accepted. If they are lost either through the pregnant
woman’s actions (in seeking an abortion or actions that made loss more likely)
or through others’ actions then we may think any loss of future for the embryo
or early fetus is outweighed by gain to the pregnant woman. Given uncertainty
about the potential of the embryo or early fetus to have developed into a live
birth (a potential contingent on the pregnant woman’s consent), equation of loss
36 Amy Mullin

or death suffered by the embryo or early fetus (a being not yet capable of con-
sciousness and not yet able to live outside the pregnant woman’s body) with loss
or death suffered by the pregnant woman seems unmerited. When a pregnancy
was wanted and viable, however, uncertainty around its potential to develop into
a live birth is greatly decreased, and loss suffered by those who planned a rela-
tionship with the child is significant.
Having critiqued feticide laws that equate damaging a fetus, at any stage,
and whether in a wanted pregnancy or not, with damaging the pregnant woman,
does that mean that I support those that focus only on the losses caused to the
pregnant woman, or those that punish only acts that damage fetuses once sen-
tient and/or viable? Is there room instead to regard the loss of an early fetus as
morally considerable, apart from the losses experienced by expectant parents
and others? I now end my discussion of feticide laws to explore a possibility
they missed.

5. Embryos, Early Fetuses, and Loss of Future

When an embryo or early fetus dies, is that a morally considerable loss apart
from the attitudes and plans of others? If the being was not viable, and would
never have had experiences, it has not lost a future of value. Furthermore, since
we are discussing pregnancy losses before a fetus is sentient, then it was not a
loss experienced by the embryo or early fetus, as the capacity for conscious
experience emerges in the third trimester (Lee et al. 2005, discussed in endnote
3). If one believes that even unviable embryos and early fetuses are beings with
dignity because human (Pullman 2010) or ensouled, then even in these cases,
loss of a being with dignity or a soul has occurred.
It seems appropriate to treat unviable embryos with dignity out of respect
for the value of humanity. However, in the absence of either present or future
value, the loss of the unviable embryo is not a loss in itself, even though there
may be a loss of hopes and dreams for those who hoped to be its caregivers. If
the embryo or early fetus could have survived and had a future including sen-
tience and experiences of value, then it was deprived of a future of value, but it
is hard to evaluate the moral significance of this loss. It is unclear how much
weight we should give to potential when the being does not yet have interests of
its own. I now explore several different approaches to this problem before pro-
posing my own.
Steinbock argues that beings do not acquire moral standing because of their
potential alone—only the potential of sentient beings has moral weight (2011,
59–71), because only such beings have interests (2011, 46). Roberts similarly
argues that a fetus acquires moral status when it first becomes sentient—when it
has its first thought, with thinking conceived very broadly (2010, 147). It is plau-
sible that a being that has moral status of one sort would be a good candidate for
a being whose potential is also morally significant. Such a being’s potential (to
have future experiences of value, and to develop other morally relevant
 Early Pregnancy Losses 37

capacities, such as the ability to have a good of one’s one, to reason, and to
develop caring relationships) would be morally relevant. This would help us to
make sense of why the potential of infants to develop morally relevant capaci-
ties is important, such that failure to develop that potential when it exists (Mullin
2011) is a significant moral problem. Requiring that a being already have moral
status in order for its potential to develop other morally considerable properties
to be morally relevant would also explain why we do not have obligations to
create beings that could enjoy futures of value. However, one could instead
argue that we do not have obligations of this sort because we need not consider
the potential of a being to develop morally considerable features until it actually
exists. On Roberts’s view already existing entities (such as embryos) that lack
moral status in virtue of existing properties but have potential to develop
morally considerable properties have no moral value at all. She argues that an
early abortion (before a fetus has its first thought) “has no moral significance
whatsoever” (2010, 156, italics in the original).10
Steinbock agrees that embryos and early fetuses have no moral standing,
but argues that early pregnancy loss can still have moral significance. She sug-
gests we may give moral value to the potential of a being to acquire moral stand-
ing in the future. The moral value may be symbolic value (in the same way that
we should treat a dead body with respect) or it may have to do with the interests
others have in the being (for instance parents’ interests in what could have been
their child being treated with respect). For Steinbock, beings that lack moral
standing in virtue of present capacities but have the potential to acquire it have
importance only because of what they mean symbolically or in particular cir-
cumstances to others.
Although Steinbock offers one alternative to Roberts’s view, Pullman’s is a
more extreme contrast. He argues that dignity belongs to all human entities,
whether or not they have other moral properties (such as being agents). His
argument, therefore, does not depend on potential, as it applies to embryos that
are unable to survive until the point when sentience is acquired, as indeed dig-
nity is even for him a property of all human tissue (2010, 361). In so far as we
are talking about symbolic value, potential does not need to be invoked, as
many would see it as an equal affront to human dignity to treat an unviable
embryo or early fetus disrespectfully as a viable one. Symbolic value depends
on the meaning the entity has for others and, unless potential alters the meaning,
it is not relevant.
So far I have discussed views that (a) an embryo or early fetus has no moral
significance because a fetus only acquires such significance once it has its first
“thought,” (b) an embryo or early fetus matters morally only insofar as it matters
to others or has meaning for them, and (c) an embryo or early fetus has dignity,
in virtue of being human, whether it has the potential to survive until infancy or
not. I now postulate a fourth alternative—those embryos and early fetuses that
have the potential to survive until infancy and develop morally significant
powers deserve moral consideration for that reason.
38 Amy Mullin

Potential of a being to become morally considerable depends not only on its

own features but also on the willingness and ability of others to act to support it.
An embryo or fetus can only develop subject to the willingness of a pregnant
woman. It has the potential to develop into a being with moral standing only
subject to her agreement (or by others unacceptably coercing her in violation of
her autonomy). But should its potential (supposing she is willing to consider
remaining pregnant until it is born or viable outside her body) be a ground for
her to entertain agreement? This does seem reasonable to me. Furthermore, the
fact that many pregnant women who did not want to be pregnant decide to carry
a child to term suggests this potential does carry moral weight in the decision
making of many women.11 In addition, respect for fetal life demonstrated by
some women who have abortions (and the fact that some use grief counseling
afterwards) indicates that the potential of an embryo or fetus to develop into an
infant is given weight not only by those who choose to continue with a preg-
nancy but also by some who do not (Ludlow 2008, 43).
To think more clearly about the moral value of the potential of a being to
acquire moral status, I consider the following hypothetical situations. Imagine a
woman who enjoys being pregnant. Perhaps she ordinarily has some difficulty
falling asleep, but falls asleep easily when pregnant. Perhaps she just enjoys
how she feels when pregnant. She does not want to rear a child herself, and is
concerned about overpopulation, or feels there are enough children waiting for
adoption and so does not want to give birth to a child for someone else to raise.
She would never want a sentient being to suffer, and so gets pregnant and ends
her pregnancies through abortions well before any scientific experts think a fetus
could be sentient. Let us, moreover, imagine that she has the financial means to
pay for the abortions, and suffers no ill health effects from them, physical or
mental. Furthermore, she knows that some people desperately want to have a
child and are either infertile or experience unwanted pregnancy loss, and so she
does not disclose her pregnancies to others, and let us furthermore suppose that
her male sexual partners have no concerns about her pregnancies and abortions.
According to my hypothesis above, she has ended her pregnancies before
any fetus was sentient, and so none have suffered, and the fetuses did not have
moral status because of their own manifested properties. She has been sensitive
to the concerns of others and has not demonstrated a lack of respect for the
moral value of humanity in a manner that could offend or distress others as she
keeps her pregnancies secret (except from abortion providers). Has she done
anything prima facie morally wrong or failed to give due weight to any morally
relevant factor? There are two potential reasons to say yes. The first concerns
the potential of the fetuses she carries to develop into morally considerable
beings. The second concerns symbolic moral value of genetically human beings.
To remove the first reason, we might further assume that she knows she has
a medical condition that means she will not be able to carry a fetus to term or
indeed to the point of sentience, as she can count on miscarrying spontaneously.
The fetuses in question (again we must suppose her knowledge is secure) do not
 Early Pregnancy Losses 39

have the potential to develop into children who could be born and become moral
actors. Now the only reason to think she has done something morally wrong
would concern the symbolic value of human beings (including those with no
potential to develop the capacity to be sentient, become moral agents, engage in
morally significant relationships, or indeed survive pregnancy). Even reasons
based on religious views about a soul being created on conception would not
apply, as the woman would not be choosing to end the pregnancies, but instead
merely knowing that they would end and hence choosing not to prevent
conception.
Are the two cases relevantly different? If so, potential has moral signifi-
cance. It would clearly be morally wrong for a woman who finds it easy to get
pregnant to flaunt her pregnancies and the lack of (other than instrumental) value
she gives them to those who yearn to become or stay pregnant. An entirely sepa-
rate concern is related to taking a purely instrumental attitude toward becoming
pregnant with beings with the potential to become morally considerable, even if
that potential would depend on her involvement. So long as we have imagined
that there are no health-related consequences, it is hard to see what is wrong
with someone who does little to prevent pregnancy out of knowledge that no
pregnancy would continue beyond its earliest stages, and may bring her some
minor benefits. The only moral issues here would concern the symbolic value of
human tissue, or the feelings of others who may have experienced painful losses
of their own. The moral issues are more complex in the former case, where the
fetus is viable. I, therefore, consider potential in this case to have moral
significance.
This is not to say that a pregnancy must be viable for its loss to be morally
significant. Women who wanted to be pregnant (and those close to them or who
expected to care for the children once born) and who experience early losses,
even unavoidable losses of beings that could not have developed into infants,
have suffered serious losses. This includes instances of complete hydatidiform
molar pregnancies, in which a grapelike mass develops instead of an embryo
(Moglabey et al. 1999). The losses concern their hopes and dreams, their identi-
ties as prospective mothers (and fathers or co-mothers, or other family members)
and experiences of miscarriage that can involve feelings of loss of agency, self-
blame, anxiety, trauma, and horror at the appearance of a fetus especially if rec-
ognizably human, as well as uncertainty as to how to dispose of fetal remains. In
a large scale prospective longitudinal study (thus avoiding the bias of only inter-
viewing only those who, for instance, attend a pregnancy loss support group)
Engelhard and colleagues demonstrate that pregnancy loss can involve more
than grief and depression, and can also involve significant anxiety and trauma
(2001). Horror, fear, and feelings of helplessness were common among women
who experienced pregnancy loss (at any stage), and one quarter of all partici-
pants met criteria for a posttraumatic stress disorder diagnosis one month after
the loss (64)—with a moderate association between gestational length and
severity of symptoms (65). Thus, I am by no means discounting the significance
40 Amy Mullin

of loss of unviable pregnancies. Instead I stress that when a pregnancy was also
viable and the woman intended to continue with it, there is another morally sig-
nificant loss. This is loss of a being with potential to become morally consider-
able, to become a member of the moral community.

6. Conclusion

In summary, beyond the need to be sensitive to the feelings of people who

have suffered a loss that is very significant for them, what are the implications
of early pregnancy loss for ethics? The large number of unavoidable pregnancy
losses that occur very early suggest that it could be better for women not to take
pregnancy tests as early as they frequently do (Layne 2009) to reduce the pain
pregnant women (and their partners) often feel on those early losses. At the
same time, the value that viable pregnancies have for many pregnant women,
others in their lives, and for social reproduction (at least when overpopulation is
not a concern) warrants more investment in research into factors that avoidably
lead to the loss of viable pregnancies. In addition, we have reason to condemn
those who harm pregnant women and cause or contribute to early pregnancy
loss of wanted pregnancies, not only for direct harm to women but also for the
loss of their hopes and plans, and perhaps loss of identity to the pregnant woman
and to others in her life with respect to the longed for future with a child.
Respect for reproductive autonomy suggests that we should devote more resour-
ces to letting prospective parents know about the likelihood of pregnancy loss,
and of decisions they may face in this context. Finally, loss of a being with
potential to develop into a member of the moral community (a potential that
depends on the pregnant woman’s plans) can also be recognized as a morally
considerable loss.

Notes
1
Miscarriages are spontaneous terminations of pregnancies that occur before fetal viability. The
majority of them occur during the first trimester of pregnancy (up to twelve weeks) (Gerber-
Epstein et al. 2009). Miscarriages are sometimes called spontaneous abortions, but women who
experience pregnancy losses in a context where these losses were not sought typically prefer the
term miscarriage.
2
In the United States approximately 1 in every 110 pregnancy losses occur during or just before birth
(Cacciatore and Bushfield 2008).
3
Different jurisdictions define early pregnancy loss differently. Given that sentience and viability are
two of the features that figure prominently in many discussions of the moral status of a fetus, I
define early loss in a way that allows me to focus on what may be morally significant about these
losses before the fetus is either viable or sentient.
4
The gestational clock for a pregnancy starts with the beginning of a woman’s last menstrual period,
and so is dated to before conception. A fetus of ten weeks gestation was, therefore, typically con-
ceived eight weeks ago.
5
Stillbirth is defined differently depending on the political jurisdiction. In the United States, stillbirth
is defined as fetal death that occurs after twenty weeks gestational age in which the fetus weighs
 Early Pregnancy Losses 41

at least five hundred grams (Cacciatore and Bushfield 2008, 380). In the United Kingdom, a still-
birth is death of a fetus that takes place after twenty-four or more weeks of pregnancy (Godel
2007, 253).
6
In an extensive review of evidence, Lee et al. conclude that conscious perception (including any
perception of pain) requires “presence of functional thalamocortical circuitry” (2005, 949).
Nociception, in contrast to pain, is a reflex response to a noxious stimulus and does not require
“cortical involvement or conscious pain perception” (949). Thalamocortical fibers (not those
specific for pain) develop between twenty-three and thirty weeks gestational age. Thalamocorti-
cal pathways need to both be present and functional in order for pain perception to occur, and
evidence from neonates suggests that normal electroencephalograms may occur as early as
twenty-four weeks post conception, although continuous activity appears to occur at around
thirty-four weeks, and patterns indicating wakefulness appear first around thirty weeks (950).
Evidence for thalamic connection with the somatosensory cortex occurs at twenty-nine weeks,
and behavioral evidence of fetal response to pain occurs at twenty-eight to thirty weeks (950).
The authors conclude that evidence suggests that fetal perception of pain does not begin until
the third trimester (952).
7
Layne notes that those who experience late loss participate in pregnancy loss support groups more
often than expected based on the proportion of pregnancy losses that occur late (1997, 295–96).
This suggests grief occurs more often in later losses—but early losses are often greatly grieved.
Cosgrove urges therapists to avoid assuming for any particular woman that gestational age at
time of loss will correlate with severity of distress (2004, 16).
8
Feticide, or actions that deliberately or negligently result in death of a fetus, may be taken to
exclude or include abortion. Feticide laws in the United States exclude abortion (Fleming 2008–
09). By contrast, in the United Kingdon late termination due to genetic anomaly is sometimes
referred to as feticide (see Graham et al. 2008).
9
Layne further argues there is no evidence that home pregnancy tests have led to better prenatal care
(2009, 69).
10
Roberts takes a very different attitude toward late abortions. She recognizes almost no moral rea-
sons for a pregnant woman to have a late abortion since she compares the loss of future value to
the fetus to the losses suffered by the woman, and has the former almost always trump the latter
(2010, 161). I cannot support giving this kind of weight to potential loss in comparison to losses
suffered by the pregnant woman but that is a topic for another essay.
11
Bermudez’s statement of what he terms “The Moral Irrelevance of Potentiality Principle” (1996,
379) shows it is controversial among philosophers to give weight to the potential of a fetus or
embryo to develop into a morally considerable being. However, I read his attempt to give
derived moral value to what he terms the primitive state of a more fully fledged property as an
attempt to fill the void left by denying the relevance of the potentiality of a being that already
exists to develop morally relevant properties. I have argued for the ethical significance of child-
ren’s moral potential elsewhere (Mullin 2011).

References

Bacchus, Loraine, Bewley, Susan, and Mezey, Gill. 2001. “Domestic Violence in Pregnancy.” Fetal
and Maternal Medicine Review 12 (4): 249–71.
Berend, Zsuzsa. 2012. “Surrogate Losses: Failed Conception and Pregnancy Loss Among American
Surrogate Mothers.” In Understanding Reproductive Loss: Perspectives on Life, Death and Fer-
tility, ed. Sarah Earle, Carol Komaromy, and Linda Layne, 93–104. Burlington, VT: Ashgate.
Bermudez, Jose Luis. 1996. “The Moral Significance of Birth.” Ethics 106 (2): 378–403.
Bonnette, Shari, and Broom, Alex. 2011. “On Grief, Fathering and the Male Role in Men’s Account
of Stillbirth.” Journal of Sociology 48 (3): 248–65.
Cacciatore, Joanne, and Bushfield, Suzanne. 2008. “Stillbirth: A Sociopolitical Issue.” Affilia: Jour-
nal of Women and Social Work 23 (40): 378–87.
42 Amy Mullin

Corbet-Owen, Carina, and Kruger, Lou-Marie. 2001. “The Health System and Emotional Care: Vali-
dating the Many Meanings of Spontaneous Pregnancy Loss.” Families, Systems and Health 19
(4): 411–27.
Cosgrove, Lisa. 2004. “The Aftermath of Pregnancy Loss.” Women and Therapy 27 (3–4): 107–22.
Engelhard, Iris M., van den Hout, Marcel, and Arntz, Arnoud. 2001. “Postraumatic Stress Disorder
After Pregnancy Loss.” General Hospital Psychiatry 23: 62–66.
Fleming, Marka B. 2008–09. “Feticide Laws: Contemporary Legal Applications and Constitutional
Inquiries.” Pace Law Review 29: 43–74.
Gerber-Epstein, Paula, Leichtentritt, Ronit, and Beniamini, Yael. 2009. “The Experience of Miscar-
riage in First Pregnancy: Women’s Voices.” Death Studies 33: 1–29.
Godel, Margaret. 2007. “Images of Stillbirth: Memory, Mourning and Memorial.” Visual Studies 22
(3): 253–69.
Graham, Ruth H., Robson, Stephen C., and Rankin, Judith M. 2008. “Understanding Feticide: An
Analytic Review.” Social Science and Medicine 66: 289–300.
Graham, Ruth, Embleton, Nick, Farnworth, Allison, Mason, Kathy, Rankin, Judith, and Robson,
Stephen. 2012. “Experiences of Reproductive Loss: The Importance of Professional Discretion
in Caring for a Patient Group with Diverse Views.” In Understanding Reproductive Loss: Per-
spectives on Life, Death and Fertility, ed. Sarah Earle, Carol Komaromy, and Linda Layne,
205–20. Burlington, VT: Ashgate.
Hazen, Mary Ann. 2006. “Silences, Perinatal Loss and Polyphony.” Journal of Organizational
Change and Management 19 (2): 237–49.
Hockey, Jenny, and Draper, Janet. 2005. “Beyond the Womb and the Tomb: Identity, (Dis)embodi-
ment and the Life Course.” Body and Society 11 (2): 41–57.
Howard, Elizabeth. 2006. “Family-Centered Care in the Context of Fetal Abnormality.” Journal of
Perinatal and Neonatal Nursing 20 (3): 237–42.
Jones, Serene. 2001. “Hope Deferred: Theological Reflections on Reproductive Loss.” Modern The-
ology 17 (2): 227–45.
Jutel, Annemarie. 2006. “What’s in a Name? Death before Birth.” Perspectives in Biology and Medi-
cine 49 (3): 425–34.
Keane, Helen. 2009. “Foetal Personhood and Representations of the Absent Child in Pregnancy Loss
Memorialization.” Feminist Theory 10 (2): 153–71.
Layne, Linda L. 1997. “Breaking the Silence: An Agenda for a Feminist Discourse of Pregnancy
Loss.” Feminist Studies 23 (2): 289–315.
. 2003. “Unhappy Endings: A Feminist Reappraisal of the Women’s Health Movement from the
Vantage of Pregnancy Loss.” Social Science and Medicine 56: 1881–91.
. 2005. “Pregnancy and Infant Loss Support: A New Feminist, American, Patient Movement?”
Social Science and Medicine 62: 602–13.
. 2006. “A Women’s Health Model for Pregnancy Loss: A Call for a New Standard of Care.”
Feminist Studies 32 (3): 573–600.
. 2009. “The Home Pregnancy Test: A Feminist Technology?” Women’s Studies Quarterly 37
(1&2): 61–79.
Lee, Susan J., Ralston, Henry J. Peter, Drey, Eleanor A., Partridge, John Colin, and Rosen, Mark A.
2005. “Fetal Pain: A Systematic Multidisciplinary Review of the Evidence.” Journal of the
American Medical Association 294 (8): 947–54.
Letherby, Gayle. 1993. “The Meanings of Miscarriage.” Women’s Studies International Forum 16
(2): 165–80.
Ludlow, Jeannie. 2008. “Sometimes, It’s a Child and a Choice: Toward an Embodied Abortion
Praxis.” NWSA Journal 20 (1): 26–50.
McCreigt, Bernadette Susan. 2004. “A Grief Ignored: Narratives of Pregnancy Loss from a Male
Perspective.” Sociology of Health and Illness 26 (3): 326–50.
Michels, Thomas C., and Tiu, Alvin Y. 2007. “Second Trimester Pregnancy Loss.” American Family
Physician 76 (9): 1341–46.
 Early Pregnancy Losses 43

Moglabey, Yolla Bou, Kircheisen, Renate, Seoud, Muhieddine, El Mogharbel, Nisrine, Van den
Veyver, Ignatia, and Slim, Rima. 1999. “Genetic Mapping of a Maternal Locus Responsible for
Familial Hydatidiform Moles.” Human Molecular Genetics 8 (4): 667–71.
Morgan, Lynn M. 1996. “Fetal Relationality in Feminist Philosophy: An Anthropological Critique.”
Hypatia 11 (3): 47–70.
Mullin, Amy. 2011. “Children and the Argument from ‘Marginal’ Cases.” Ethical Theory and Moral
Practice 14: 291–305.
Oaks, Laury. 2000. “Smoke-Filled Wombs and Fragile Fetuses: The Social Politics of Fetal Repre-
sentation.” Signs 26 (1): 63–108.
Palmer, Julie. 2009. “Seeing and Knowing: Ultrasound Images in the Contemporary Abortion
Debate.” Feminist Theory 10 (2): 173–89.
Pearce, Christine, and Easton, Karen. 2005. “Management of Complications in Early Pregnancy.”
Nursing Standard 19 (34): 56–64.
Peel, Elizabeth, and Cain, Ruth. 2012. “Silent Miscarriage and Deafening Heteronormativity: A Brit-
ish Experiential and Critical Feminist Account.” In Understanding Reproductive Loss: Perspec-
tives on Life, Death and Fertility, ed. Sarah Earle, Carol Komaromy, and Linda Layne, 79–93.
Burlington, VT: Ashgate.
Price, Kimala. 2010. “What is Reproductive Justice? How Women of Color Activists are Redefining
the Pro-Choice Paradigm.” Meridians: Feminism, Race, Transnationalism 10 (2): 42–65.
Pullman, Darryl. 2010. “Human Non-Persons, Feticide and the Erosion of Dignity.” Bioethical
Inquiry 7: 353–64.
Roberts, Melinda A. 2010. “Abortion and the Moral Significance of Merely Possible Persons: Find-
ing Middle Ground in Hard Cases.” Philosophy and Medicine 107: 1–166.
S€aflund, Karin, Sjogren, Berit, and Wredling, Regina. 2004. “The Role of Caregivers after a
Stillbirth.” Birth 31 (2): 132–37.
Steinbock, Bonnie. 2011. Life Before Birth: The Moral and Legal Status of Embryos and Fetuses,
2nd ed. New York: Oxford University Press.
Warren, Mary Anne. 1989. “The Moral Significance of Birth.” Hypatia 4 (2): 46–65.
Weaver-Hightower, Marcus B. 2012. “Waltzing Matilda: An Autoethnography of a Father’s
Stillbirth.” Journal of Contemporary Ethnography 41 (4): 464–91.
Williams, Clare. 2005. “Framing the Fetus in Medical Work: Rituals and Practices.” Social Science
and Medicine 60: 2085–95.
. 2006. “Dilemmas in Fetal Medicine: Premature Application of Technology or Responding to
Women’s Choice?” Sociology of Health and Illness 28 (1): 1–20.
Woodthorpe, Kate. 2012. “Baby Gardens: A Privilege or Predicament?” Understanding Reproduc-
tive Loss: Perspectives on Life, Death and Fertility, ed. Sarah Earle, Carol Komaromy, and
Linda Layne, 143–54. Burlington, VT: Ashgate.
Wyatt, John. 2001. “Medical Paternalism and the Fetus.” Journal of Medical Ethics 27: ii15–ii20.