Milk for Thought: Balancing Parental Choice with the Health of the Baby

by Dr. Nileema Conlon Vaswani in

Breastfeeding has been in the news in the UK not only this week but also has featured regularly in some context or other over the past few months. As we marked National Breastfeeding Awareness Week in May, figures became clear once again, that barely one in five mothers were breastfeeding their babies for the recommended six months. In June, it was proposed that the legal issues surrounding breastfeeding in England needed re-examining; currently it is legal to ask a woman who is breastfeeding in a cafe or restaurant to leave if other customers are put off by the sight of her breastfeeding. This legislation is not on a par with what is done in Scotland or in other European countries where women have the legal right to breastfeed in public.

Last week, the National Childbirth Trust (NCT), along with Save the Children and UNICEF UK, published a document called "A Weak Formula for Legislation: How Loopholes in the Law are Putting Babies at Risk" that called for companies that produced formula milk to be banned from advertising these products. Their argument was that although the advertising of infant milk formula is illegal, manufacturers are advertising so called "follow on" formula milk that looks so similar to the infant formula that they are indirectly also advertising the latter. Some may argue that a blanket ban is appropriate; others may suggest making the advertising more honest. Regardless of one's position, this is a debate in itself and not one that I will be able to consider in any detail here. The reason I mention this debate is to point out that the issue of breastfeeding spans many domains.

This week, the UK is considering adopting growth charts that show how breastfed babies ought to be growing, a rate of growth that is slower than that of formula fed babies. At present, growth charts are based on formula fed babies, making those parents who breastfeed their babies worry that their babies are not putting on as much weight as they should. With all these moves to promote breastfeeding over formula feeding, it is time to consider the moral implications of each choice as well as an appropriate moral role for the experts in this decision.

Should a group of experts be telling us to breastfeed our babies or is this a choice that should be left for parents to make? It is widely accepted in the medical community that breastfeeding is better than formula feeding for both mother and baby but does this medical "fact" give the experts the right to tell us what to do?

Let us start with the impact of breastfeeding on the mother. If a mother chooses to breastfeed, she supposedly improves her chances of not developing certain illnesses and, likewise, if she chooses not to breastfeed, she lowers her protection against these illnesses. As an adult, the protection to herself is optional. Arguably, many of us could do more to protect ourselves from various illnesses in the long term but not all of us take steps to do so. If a mother who could breastfeed chooses not to, her decision not to protect herself in this way from certain illnesses is one that we ought to respect. Forcing her to breastfeed for the sake of her own protection would be morally equivalent to forcing her to undergo a course of treatment for an illness that she had already developed. There is a fine line between encouragement and information, on the one hand, and force, on the other hand, and we should be careful not to cross it in the case of an adult who has the right to make her own medical decisions.

The question is whether it is morally appropriate to cross this line if the health of a baby is at stake, even if the repercussions of not breastfeeding will only be seen in the future. Consider an example where parents refuse to give their children important immunisations or where they don’t give them medicines when they are ill. Would these cases be morally acceptable? Imagine now that all parents were given a tablet that they were encouraged to give their children for six months which was meant to decrease the child’s chances of developing various illnesses not only in the short term but also in the future. Parents who did not give this tablet to their children might be considered negligent. So what is the moral difference between our imaginary case of the illness-preventing tablet and breastfeeding? Are women who choose not to breastfeed negligent because by making this choice they also indirectly choose to expose their children to illnesses they might otherwise not develop? And, more importantly, does the State have a moral duty to protect its babies and thereby make breastfeeding compulsory?

Although it might be possible for the State to insist that children are protected from disease and receive treatment in general, the moral issues assume a greater complexity in the case of breastfeeding. There is no moral difference between the case of a parent who chooses not to give their child the tablet that is meant to prevent illnesses and the case of a parent who chooses not to breastfeed, yet our response to these cases ought to be different. Breastfeeding involves the woman’s body and for this reason the legal and moral power the State has to legislate on its use is limited. Just as the State cannot require that women avoid certain foods during pregnancy or that they not smoke, etc., it cannot and ought not to require that a woman breastfeed even if the health of a child is at stake. The imaginary case of a tablet that prevents future illnesses could be made compulsory in the same way that it is morally appropriate for childhood vaccinations to be compulsory because it does not involve the use of the woman's body against her will.

It is important to point out that certain women should not be breastfeeding and for this reason, they are excluded from the debate that asks whether they ought to. They include those who are on medication, have certain strains of hepatitis, or those who are HIV positive. For this reason, the moral issues surrounding breastfeeding do not apply to these women, as breastfeeding is a choice that is not open to them. 

Related to this category of women are those who find it difficult to breastfeed. This is perhaps a more complex category because many of them feel obliged to try to breastfeed and feel guilty if they are unable to do so. Since the interests of the baby are paramount, in the case of mothers who choose not to breastfeed, or who would like to but find it difficult to breastfeed, appropriate support ought to be extended. This could be either in the form of helping them to breastfeed or by directing them towards the best alternative in the range of formula milk. We could also encourage mothers to breastfeed initially, even if they want to switch to formula milk later. This way, the baby will be given colostrum or "first milk", the most important feeds. A change in our breastfeeding laws with regard to breastfeeding in public places would also make it easier for women to breastfeed. Whatever we do, we ought to aim towards maximising health for our babies and support for their parents. Making people feel guilty will only make them resentful and, eventually, the very babies we aim to protect will be the ones to suffer because we have made their mothers feel guilty.