On Pregnancy, Prudence, and Zika – Lorraine Cuddeback

As the geographical scope of the Zika virus spreads, and researchers further examine the evidence surrounding its connection to microcephaly, women who are currently pregnant (or trying to be) are awash in misinformation and fear-mongering. Fearful for their children and for themselves, they need advice on what to do. When information remains uncertain, the best approach is not one of absolute mandates, but of discernment — that is, the virtue of prudence.

Unfortunately, most discussions about Zika’s effects on pregnancy seem to have a common theme: control. Reproductive control is presented as a necessary measure to manage the impact of the virus. Or better yet, we can control the virus with the optimistic belief that there will be a vaccine soon. This desire for control was echoed again, not long after the Zika emergency was announced, when the CDC released a statement that women who could be pregnant (that is, not on birth control) shouldn’t drink. At all. Maybe ever. In the CDC announcement, the Principal Deputy Director Anne Schuchat, asks: “The risk is real. Why take the chance?”

Why take the chance, indeed. But the hard truth we like to avoid, the truth that Zika is calling us to face yet again, is that our bodies are vulnerable, contingent. Control is an illusion; chance is always at play. Control is not a virtue. Prudence, by contrast, offers a necessary tool in navigating the line between caution and paranoia, between isolating ourselves out of fear and willful disregard of health.

Prudence Part I: What are the Facts?

In the quintessential definition given by Thomas Aquinas, prudence is “right reason applied to action” (ST II.II.47.8). Thus, the first step is to gather facts. This is a process already underway, beginning with the epidemiological investigations in Brazil.

While the research goes on, fear continues to be fueled by theories that remain circumstantial, theories which the new investigation by the CDC is hoping to strengthen or discredit. At stake in the raised concern about Zika is the connection with Guillain-Barré Syndrome (an autoimmune disease), and the possibility of microcephaly in children born to infected pregnant women. While one case-control study strongly indicates a connection between Guillain-Barré and Zika, such studies have limited generalizability until further research is done. However, Guillain-Barré is not what has prompted the WHO to call Zika an international health crisis. Rather, it was the correlation of infection with Zika with heightened rates of microcephalic births in Brazil. A similar connection is being uncovered in the U.S.

But as the refrain goes: correlation does not equal causation. For Zika, there are a few data problems for proving causation. FiveThirtyEight and FactCheck.org have both done more detailed breakdowns of the actual data at hand, but suffice it to say that the causal connection between Zika and microcephaly will be difficult to prove in the traditional sense, that is, by disproving all other causes. As Christie Aschwanden explains for FiveThirtyEight: “What’s easy to forget about the oft-cited scientific mantra, correlation is not causation, is that causation is incredibly difficult to prove.” The evidence compiled concerning Zika and its link to other health problems may only ever be circumstantial (this ambiguity inherent in science would be good for those who want to jump to pro-choice conspiracy theories to keep in mind).

The bulk of the problem faced with establishing a causal relationship between Zika and microcephaly or Guillain-Barré is access to data. This may be due to the under-reporting of Zika because of mild symptoms in most infections; less often discussed is that, given Zika’s primary impact on communities with extremely limited access to healthcare (and even more limited healthcare records), the number of microcephaly cases is underreported, too.

In short, we know a lot more about what we don’t know, than what we do.

Prudence Part II: Speculation and Action

Returning to Aquinas, the second part of the process of prudence is “to judge of what one has discovered” (ST II.II.47.8), or what Aquinas calls speculative reason, in order that a right action might be determined. So, while the causal connection between Zika and microcephaly or Guillain-Barré is being questioned and examined (as it should be), the limitations on data should not mean disregarding the threat.

Zika is hardly the first disease linked with problems during pregnancy. In the U.S., I can’t help but think that our fear of Zika feels so extreme because we have forgotten the dangers of pregnancy itself. Prior to the 20th century, pregnancy and childbirth was the cause of death for almost 1 out of 100 women in the U.S. To this day, on a global scale, it remains the most common cause of death for adolescent women between ages 15 and 19. And the rate of maternal mortality for the U.S. remains high compared to other developed countries. In short, pregnancy is still a dangerous undertaking for women, and most especially for poor women without access to healthcare.

In addition to the risk of pregnancy for mothers, we have forgotten that there have been many other diseases that posed dangers to mothers and unborn children alike. Mumps and Rubella could cause impairment and disability in mothers and unborn children even until the 1970s, when we virtually eliminated the diseases in our country thanks to vaccines.

Pregnancy is a vulnerable state for women and the children they bear. The health of one impacts the other, in both directions. The ever-present dangers of pregnancy defy any discussion of Zika that centers solely around control — of people, of pregnancy, of bodies. The actions we decide to take in light of prudence have to reflect the embodied reality of vulnerability in pregnancy. They also have to reflect thoughtful acknowledgement of the limits of the knowledge we have, and what kinds of actions are feasible and practical.

Prudence Part III: Willing

And so we come to the final step of prudence: moving from judgment to command, from reason to action. Or in Aquinas’s words, “applying to action the things counselled and judged” (ST II.II.47.8). This is a combination of both reason and will, of thoughtful reflection and actually taking effective next steps.

Some actions have been suggested already: El Salvador has told women to avoid pregnancy for two years; the CDC in the U.S. is recommending against travel for pregnant women (or those trying to get pregnant) to the areas most affected by the virus. Unfortunately, in these examples the onus of prevention rests on individuals, and on women in particular. The only example of a communal response so far is insecticide spraying and releasing genetically modified mosquitoes that cannot reproduce. But the attempt to eliminate all the mosquitoes that carry the virus is certainly a Sisyphean task.

So women are told to avoid pregnancy, but men (also necessary for conception) are not addressed. Access to birth control and limitations on travel are all addressed to individuals, suggested to them but laid out apart from attention to the community that surrounds them. Such suggestions are not prudent if there are no structures of support for women (or men) who wish to follow them. We cannot ask women to avoid pregnancy without also asking men to respect women’s choices about their sexual activity. In fact, we cannot make any demand of women about their pregnancies, sexual activities, or travels without also assessing what is happening around them. Prudence requires attention to these things even more so than to individual actions.

Zika is not just an individual problem, nor is microcephaly or Guillain-Barré. No matter how cautious we are, no matter what vaccines we develop against the Zikas, Rubellas, and Mumps of the world, we are born into bodies shaped by our environment, by chance, and by risk, for better or for worse. Microcephaly and paralysis will not disappear if we eliminate Zika. Moreover, the dangers of pregnancy remain for women across the globe, from any myriad of causes: disease, accidents, and violence. Part of prudence is having a good response to even these contingencies.

So yes, be prudent, avoid exposure, try not to willfully endanger yourself. But also know that such cautions may still fail, and that such failure is not your fault. Our knowledge is incomplete, our options limited. To try and control the uncontrollable is imprudent. Rather, prudence should recognize that disability and illness are not going away anytime soon. Prudence calls us to develop structures of support for our inevitable fragility, rather than to wish that fragility away.

Lorraine Cuddeback is a PhD candidate in moral theology at the University of Notre Dame. Her research is in social ethics, particularly disability and theology, Catholic social teaching, and feminist ethics. Her dissertation is about ethics, practices, and theologies of inclusion for people with intellectual and developmental disabilities.