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Winter 2008/09 | Vol 12 No 2

Review

Nancy Poole

Conceiving risk, bearing responsibility: FASD as social construction

Sociologist Elizabeth Armstrong has written a provocative book. Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder offers a compelling and important critique of how complex health-related problems such as fetal alcohol syndrome become medicalized. It also challenges questionable prevention guidelines that stigmatize women and ignore the social and structural determinants of women’s drinking. In the book, originally published in 2003, Armstrong builds this critique by analyzing historical medical literature, drawing insight from in-depth interviews with doctors and evaluating U.S. epidemiological data.

Conceiving risk. In a very readable way, Armstrong traces the history of the construction of alcohol’s effects on fetal development, from the 19th-century debates on heredity and eugenics, through its construction during prohibition, to modern individualized, medicalized conceptions. All along, she illustrates how this has not been a progressive, cumulative evolution of medical knowledge, but one very much influenced by sociocultural forces and historical context, including moral preoccupations and concerns about women’s societal roles. Today we recognize alcohol as a teratogen; yet we still do not have answers on the exact relationship between fetal development, alcohol use and a wide range of determinants of pregnant women’s health, such as malnutrition and social and environmental stressors. Exaggeration of risk still often characterizes our prevention responses, and health and morality become so intertwined in these responses that pregnant women who have even a single drink are still considered to be at risk and face reproach.

Bearing responsibility. In Canada we are making significant strides in increasing fetal alcohol spectrum disorder (FASD) diagnostic capacity to ground our understanding of risk and prevalence. Yet this initiative is beset with the concerns identified by Armstrong and current women’s health researchers of reinforcing a false maternal/ fetal conflict of interest and decontextualizing women’s alcohol use pre-, during and post-pregnancy. Diagnosis is done in the child health system without linkage to the health needs of birth mothers, who most commonly have lost custody by the time children are of an age to be diagnosed. We continue to ignore how issues of poverty, violence, isolation and fear of losing custody can characterize women’s lives and interact with alcohol use to create adverse outcomes for mothers and their children. Women of childbearing years with alcohol problems, pregnant women who drink and birth mothers of children with FASD continue to face opprobrium, while comprehensive, welcoming, respectful health care is lacking and structural inequities go unaddressed.

The diagnosis of moral disorder. Armstrong poses important questions regarding our approach to maternal drinking: How do we construct the risk of alcohol use in pregnancy and justify our warnings to women? Why do we continue to characterize people with alcohol/substance use problems as lacking self-control and expect cessation of use, all the while ignoring the roots of these problems? How does the medical model serve to enforce social control? How can we make our policy responses more grounded in evidence and less punitive? And in Armstrong’s words, “How might we close the gap between the uncertainty of our medical knowledge about the relationship between alcohol and reproduction and the need to take action at a societal level to prevent adverse birth outcomes?” (p. 219). Armstrong’s fascinating critique needs to be widely considered, discussed and acted upon.

Conceiving Risk, Bearing Responsibility: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder. Elizabeth Armstrong. Johns Hopkins University Press, Baltimore, 2008, 296 pp., $25 US.

Nancy Poole is a research associate with the British Columbia Centre of Excellence for Women’s Health.