Fallacy of rights-based reductionism

The fallacy of rights-based reductionism can be understood by analogy to the fallacy of biologic reductionism or oversimplification of scientific models of disease and health. As an antidote to biologic reductionism in medicine, George Engel made a sentinel contribution with his introduction of the biopsychosocial concept of health and disease. In his classic paper in Science , Engel summarized the biomedical model:

The dominant model of disease is biomedical, with molecular biology its basic scientific discipline. It assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. … the biomedical model embraces both reductionism, the philosophic view that complex phenomena are ultimately derived from a single primary principle, and mind-body dualism, the doctrine that separates the mental from the somatic. Here the reductionist primary principle is physicalistic; that is, it assumes that the language of chemistry and physics will ultimately suffice to explain biologic phenomena. ^{, pp. 39-40}

The history of biologic reductionism stands in contrast to traditional Chinese medicine, based on the concept of qi , which was understood to have both physical and spiritual components in an “incessant process of transformation.” This history also stands in contrast to more holistic strands in the history of Western medicine, eg, naturopathy and homeopathy. In this study, we sketch a complicated history.

Ancient Hippocratic physicians understood all diseases to be an interaction of the 4 humors. According to the Hippocratic or Coan school of medicine, diseases resulted from imbalances among blood, phlegm, black bile, and yellow bile. This theory recognized the existence of environmental factors, such as prevailing wind direction, but the explanation of the direct causes of disease and of their subsequent clinical management, mainly by modest changes in diet and exercise and the use of mild medications, appealed to what they took to be the biologically fundamental realities, the humors. Later anatomy became fundamental and the focus shifted to the skeleton and organs as the seat of diseases. Debates arose about more aggressive or “heroic” treatment, especially surgery, to correct abnormal anatomy. Physiology, the science of the functions of organs and then organ systems, then displaced anatomy as fundamental. Medications and potions to correct symptoms of abnormal function became increasingly important. The discovery of microbes led to a dramatic conceptual shift. The seat of disease was now understood to be microscopic, which led to an increased understanding of the pathophysiology and treatment of infections. We are now well into the era of genomic medicine, in which the genome supersedes the microbe as a senior partner in explaining the biologic basis of health and disease.

Engel’s concern was that equating health and disease with biologic fundamentals commits physicians to a clinically inadequate model of health and disease that results in inadequate diagnosis, prevention, and treatment. For example, a married woman of child-bearing years presents with a complaint of infertility. The biomedical model focuses on the mechanisms of ovarian, tubal, uterine, and sperm function. The biopsychosocial model includes this focus but rejects it as the exclusive focus, because it is clinically incomplete and could result in unneeded, invasive, and expensive workup and assisted reproduction. A psychosocial assessment goes on to identify psychologic and social factors such as stress in the workplace or household, which would be elicited only by a more complete history and would be missed by a workup for impaired anatomy of reproduction. The biopsychosocial model is clinically crucial because it reminds the obstetrician that psychosocial, as well as anatomic and pathophysiologic factors can result in reproductive failure.

As this example illustrates, Engel’s concern was not the limitations of our scientific knowledge at any given time about what is assumed biologically fundamental in obstetrics. His point was that even a very sophisticated scientific fund of knowledge about, for example, human reproduction, will be scientifically and therefore clinically fallacious if it focuses only on the biologic aspects of health and disease, eg, the basic science mechanisms of reproduction, mistaking these mechanisms of disease for an adequate model of the totality of the disease. Incorporating the psychologic and social dimensions is required to have a clinically adequate model to guide obstetric care and thereby avoid clinical tunnel vision. Fulfilling the requirements of the biomedical model by finding an anatomic cause for infertility, may be very fulfilling for the physician on a narrowly scientific basis, but not for the patient, whose complaint will remain inadequately addressed if her infertility is also a function of unidentified and therefore unmanaged psychosocial factors.

Engel’s main point remains germane: the biomedical model becomes a fallacy when it is assumed to be complete. The remedy is to recognize that it is scientifically and clinically incomplete and misleading. Comprehensive clinical judgment requires attention to the clinically relevant biomedical and the clinically relevant psychosocial aspects of pregnancy.

There is an analogous fallacious reductionism in obstetric ethics. The phrase, “ethical reductionism,” has been used, but not in a way that makes this analogy explicit. The fallacy of ethical reductionism occurs when a model for ethics appeals to one ethical concept in complex clinical circumstances that by their very nature require consideration of complementary concepts. Rights-based reductionism in obstetric ethics bases it exclusively on the rights of either the pregnant woman or the fetus and ignores other clinically relevant ethical concepts ( Table ).

The fallacy of rights-based reductionism shapes the current abortion controversy. Consider first the model of obstetric ethics based on unconditional fetal rights, especially the right to life. The logic of this concept means that fetal rights always override the rights of the pregnant woman. Termination of pregnancy at any gestational age or for any reason is therefore impermissible, regardless of whether the pregnancy is voluntary or not. Consider, next, the concept of the woman’s unconditional rights, especially the right to control her body. The logic of this concept means that the pregnant woman’s rights always override fetal rights. Termination of pregnancy is therefore permissible at any gestational age ( Table ).

Rights-talk has an undeniable appeal, because rights-talk seems so clear-cut: one either has rights or one does not and, if one does, others must respect one’s rights. This is a false veneer of certainty masking the fact that there is significant controversy about the nature and limits of fetal and maternal rights. Debating rights results in intractable disputes, because rights are based on so many factors, including cultural, political, and religious beliefs that do not lend themselves to compromise and are peripheral to the physician-patient relationship.

It is obvious that a pregnant woman has rights, including an unconditional right to control what happens to her body. There is enormous dispute about whether that right should be understood to come with limits or with no exceptions throughout the entire pregnancy. Professional integrity, for example, sets justified limits on the preferences of pregnant women.

Claims that the fetus has rights, especially an unconditional right to life, are in endless dispute. Some take the view that the fetus has no rights whereas others assert strong rights of the fetus. Those who assert that the fetus has rights must–but often in fact do not–recognize that the world’s religions and their moral theologies are not in agreement. Nor are philosophers. Indeed, there is no single authoritative perspective from which the incompatible differences of these diverse views on fetal rights can be resolved. Such an authoritative source would have to be acceptable to all of the competing accounts and conceptual frameworks. This is not achievable because of an unavoidable fact. There is profound and irresolvable disagreement between different religious and cultural traditions, within such traditions, and between religious and secular views on fetal rights.

The pregnant woman’s rights reductionism model appears in the literature on intrapartum management. This model asserts the unconditional right of the pregnant woman to control her body and the implicit position that the fetus has no rights. The pregnant woman has rights and her rights control performance of cesarean delivery: “… the moral and legal primacy of the competent, informed pregnant woman in decision making is overwhelming.” A recent expression of this model takes what at first seems a nonreductionist approach. Its authors acknowledge patient safety as a “first-order issue” and support what they call “restrictive guidelines” based on protecting the life and health of pregnant women. However, they abandon this more nuanced approach in favor of an exclusive emphasis on the pregnant woman’s rights reductionism model when they assert: “Crucially, even when restrictive guidelines are warranted the rights of pregnant women to bodily integrity must be maintained.” Some express the model in explicit terms, eg, that “women have fully endowed rights that do not diminish with conception, nor progressively degrade as pregnancy advances to viability and birth.” Another example is the assertion of the pregnant woman’s autonomy as an “unrestricted negative right,” ie, an unconditional right to noninterference with refusal of cesarean delivery: “autonomy is an interrelational right–ultimately there is no circumstance in which someone should be brought to an operating room against their will.” The pregnant woman’s rights reductionism model also grounds claims to the rights of pregnant women to have a clinically nonindicated cesarean delivery.

Rights-based reductionism models invite the unwary obstetrician to be satisfied with an oversimplified solution: deciding whose rights win out in a zero-sum game–those of the pregnant woman or those of the fetus. This solution, however it might appeal to us in its simplicity, is ethically and clinically inadequate. Rights-based reductionism in obstetric ethics is a fallacy.